In my sixteen years of family medicine, I think the most frustrating disease I treat is obesity. It’s frustrating because as a doctor I feel great compassion for these patients, trying so hard to lose weight, and yet I feel almost shameful that as a primary care physician I can’t offer much in terms of medicines to help. And now that I’m back in the USA after ten years in China, I’m very concerned that America’s struggle is even worse, with more than two thirds overweight or obese. So now, driven to seriously tackle this epidemic, I’ve scoured the literature for the most up-to-date, evidence-based advice on losing weight. Please feel free to print and share this.
Let me jump right in to perhaps the most controversial point: I think that many, many more people should consider weight loss surgery. It literally is the most effective way not only to permanently cause weight loss, but it also literally can put diabetes in remission, lower your overall death rates, and lower your heart disease risks. A huge percentage of people can stop taking diabetes medicines after surgery. Don’t believe me? Feel free to read up on it, including a 2015 meta-analysis from JAMA, and the Cochrane library review from 2014. There are three major options:
- Sleeve gastrectomy: This involves stapling off much of the stomach, leaving around 25% of the stomach. Average weight loss is 56%. This is now the most popular of the three.
- Roux-en-Y gastric bypass: This is the most radical surgery, with the most complications, but also the most effective, with a weight loss up to 67%
- Adjustable gastric banding: This involves putting a flexible silicone band around the top of the stomach, which essentially limits intake of food and makes you feel full with less food. The average weight loss for this is 44%, less than the other surgeries, and is now less commonly done.
Of course there are risks to these surgeries, and weight loss is disappointing for many afterwards. But in general, this is a far, far better option than the usual lifestyle struggles leading to maybe 10-20% loss at the most, with many gaining the weight back, and still having diabetes and other diseases. In fact, a recent 5-year study comparing weight loss surgery to lifestyle interventions showed a clear winner in the surgery group, with far more people losing much more weight, as well as putting diseases like diabetes in remission — totally stopping insulin injections and diabetes pills.
I seriously hope many people, especially in the high-risk categories, make an appointment with your local bariatric surgery teams and just talk with them, to discuss your options. If you’re in my Swedish system here in the Seattle area, you can sign up for their weight loss seminar and hear them out.
In terms of who should consider bariatric surgery, the current recommendations are:
- Everyone — and I mean everyone — with a BMI (Body Mass Index) over 40, even without any other medical conditions, should consider bariatric surgery.
- Anyone with a BMI 30-40 with diseases such as diabetes, high blood pressure, high cholesterol, sleep apnea, or severe arthritis, can also greatly benefit. Insurance companies usually would cover it if your BMI is over 35.
Do you know your BMI? A BMI over 25 is overweight, over 30 is obese. Here’s a calculator:
My second main point, and perhaps even more controversial among physicians, is that prescription medicines can also help with weight loss. There now are four prescriptions and one OTC supplement which actually are FDA approved for weight loss, and these expanding choices are encouraging for us family physicians on the front lines. Most work by decreasing your hunger urges. All have side effects, of course, and weight loss varies from 7-12% on average, and people often regain the weight after stopping. But since even a 5% reduction in weight loss can greatly help reduce risks for diabetes, heart disease and arthritis, I think these are definitely worth considering, and I’m using more and more of these in my practice. I strongly suggest interested people (and doctors) read the 2016 meta-analysis in JAMA, comparing all five. The take-home message from this review is as follows:
- The medicine phentermine/topiramate (Qsymia) is the most effective at weight loss, losing an average of 8.8 kg over a year, with side effects in the middle of the pack. This is currently my first choice for many. But one side effect is severe: birth defects, so all younger women have to take birth control and get monthly pregnancy tests while on this.
- The combo medicine naltrexone/bupropion (Contrave) was less effective than Qsymia, with an average 5.0 kg weight loss, and more side effects — and also some debate about its safety with heart disease.
- The OTC medicine orlistat (Xenical/Alli) is the least effective (2.6 kg weight loss), but has relatively fewer severe side effects (stomach issues), and also is the only one available without a prescription. You take it with each meal, and it decreases fat absorption.
- The diabetes medicine Liraglutide (Saxenda) is second most effective for weight loss (5.3 kg), but has the most side effects. But it’s certainly a great option for those who have type 2 diabetes.
- Lorcaserin (Belviq) has the least side effects but was second to last in effectiveness (3.2 kg weight loss).
Who’s a candidate for these prescription medicines? The FDA says that anyone with a BMI over 30, regardless of any illnesses, and also those with BMI 27-20 with risks (the usual ones mentioned above) could benefit from trying these medicines, at least for three months to see if you can get to 5% weight loss. If you do, great! Keep going! Hopefully your insurance will cover the cost (many do not).
Besides these medicines, I should also mention metformin. This common prescription medicine for type 2 diabetes also has the great side effect of weight loss, and while the overall loss is less than 5% in the studies, and thus is not FDA-approved for weight loss, it’s still a fantastic first choice for pre-diabetic people who are overweight. The famous Diabetes Prevention Program showed how even after ten years, the overweight group who took metformin 850 mg twice a day had an impressive 18% reduction in developing diabetes. (That’s impressive, but not nearly as impressive as the 34% risk reduction in the group that stuck to lifestyle changes: weight loss of 7%, 150 minutes a week of exercise, and diets focused on fewer calories and less fat.)
And now we finally arrive at the third controversial issue: diets. There’s so much overwhelming confusion out there, but I like to simplify it a lot by saying that it’s not so much what you eat, but how much you eat. In other words, calorie restriction is key. If you want to lose a pound a week, you need to eliminate 500 calories each day. This is basic biochemistry. (check out your specific needs using my weight loss calculator at the top right of this article). If you can do this daily calorie restriction, especially by decreasing simple carbs, great! Keep going!
But there’s an interesting newer option you may have heard about, called intermittent energy restriction (IER; the 5:2 diet). This has been trendy since 2013, with a BBC documentary, best selling book, and a British study showing how a twice a week regimen of cutting your calories (especially carbs) had similar or better results for insulin resistance and body fat than the group that followed daily calorie restriction. When we fast, even if only for 12-16 hours (nothing between dinner and lunch the next day), insulin resistance improves and fat starts to get reabsorbed. A recent review of all IER studies showed that the evidence for IER is promising — but still premature to fully endorse, with much more to learn about which pattern is most ideal, as well as long-term effects. Also, people who aren’t overweight and are trying this actually have a lot more side effects than benefits.
Otherwise, in terms of “diet”, it’s just overwhelming out there for people searching for the “right one”. An excellent review article this year does detail quite convincing evidence that a low-carb high-fat Atkins-style diet not only reduces the hunger urge, but also has clear benefits in insulin resistance, cardiac markers, and weight loss. The DASH diet really does help to lower blood pressure and weight, and the Mediterranean diet also seems to help with heart disease and some weight loss.
But again, the main issue for all of this diet talk is to focus not on food categories, but food quantity. It’s simple biochemistry: you have to have less energy intake to lose weight. Or you could increase energy output, which leads us to:
For decades, the usual doctor spiel is to get 150 minutes a week of moderate exercise. But that hasn’t really translated into any meaningful changes nationally, has it? So here’s where another trendy (uh oh) regimen is gaining popularity, mostly because the growing research is impressive. It’s called High Intensity Interval Training (HIIT), and it basically means you go all out for 30-60 seconds on any activity, getting to maximum exertion, then take a few seconds break, then do another all-out effort, etc etc. You do this 15 minutes tops, twice a week only (typically). Check out an example in the image below from a New York Times article about a 7-minute workout, which I also blogged about in my New York Times column in China. This HIIT routine is great because it requires zero fancy equipment, and you can do it absolutely anywhere. Click here to access the online workout app.
Supplements, Diets and Herbals:
This topic is actually less controversial for me, mostly because there’s an easy answer: most of those supplements have almost no hard evidence that they work well. I’m not confident enough about recommending any of the trendy ones, and that includes CLA, chromium, 5-HTP, and garcinia. I’m sure many of you are already taking some of these. You’re welcome to read the evidence, including some excellent supplement reviews by the Natural Medicines Database (paid); The Encyclopedia of Natural & Alternative Treatments (free); The Cochrane Library; and The National Center for Complementary and Integrative Health (NCCIH).
Personally I’d much rather have my patients focus not on supplements but on calorie restriction. I’d also rather give them one of the prescription medicines above, which all have more evidence than any supplement.
If you must choose a supplement, at least you could try that OTC Orlistat with meals. And you could also consider soluble fiber such as blond psyllium. Used especially for constipation, it also helps lower cholesterol, control diabetes a tiny bit, and also help a bit with weight loss. You’d take it with food, and it absorbs fat from that meal. In fact, it’s now recommended that Orlistat users also take blond psyllium with each dose of Orlistat, as it prevents some of those unfortunate gastric effects.
Yogurt is also one of my favorite recommendations, not just for the way the probiotics help our microbiome and immune system, but also because the literature shows that yogurt helps to manage weight loss and waist circumference. I actually prefer higher fat than the low fat versions, and adding fresh fruit to non-sweetened yogurt is a great way to start your day. Add a pack of instant oatmeal, microwaved with soy milk, and you’ve got a healthy and filling breakfast.
Did you know that sitting all day at work literally is harmful to your health? Recent data, including this 2015 meta-analysis of sedentary lifestyles, shows that the more you sit, the higher your risks for heart disease, obesity, diabetes and overall death rates. I just ordered a standing desk for my office! Here are more tips on how not to be a couch potato.
Use Smaller Plates
Americans definitely have suffered “portion distortion” over decades, as sizes for all types of food creep up and up. Remember how soda machines used to carry 12 ounce cans, and now all have 20 ounce bottles? How about a small popcorn at the movies? If we can’t control these external factors, at least at home we can control portion size, and one interesting step is to replace all of your usual large dinner plates with smaller plates, like the appetizer or salad plates. Recent studies, including the 2016 meta-analysis, do show that when people switch to smaller plates, they actually eat less. How easy is that?
Keeping It Off
It’s actually not super hard to lose weight — it’s keeping it off that’s the problem for most. Unfortunately, that’s a totally normal problem because our “hunger hormones” ghrelin and leptin reset to a new balance when we gain weight, and when we lose that weight, that hormone imbalance doesn’t reset well to the lower weight, and it thinks “I’m starving!” and compels you to eat more. Some tips to control this include healthy carbs, fiber, yogurt and protein (and not a high fat diet). Also, getting a good night’s sleep literally helps to reset those hunger hormones (that’s one reason why people with sleep apnea are at risk for gaining weight).
And for those who are in the higher obese categories with BMI over 35 or 40, gastric bypass surgery actually can permanently improve some of that hunger urge. How? Removing the top of the stomach in these surgeries removes the stomach tissues that secrete grehlin; less grehlin = less hunger signals = less eating = weight loss. That’s another important reason why I urge people to consider weight loss surgery.
My Bottom Line
After writing this article, I personally feel much more empowered as a doctor to help my patients lose weight. There are a lot more options than I had realized, and I’m definitely giving all of my overweight patients this article, and I look forward to working closely with my patients to help them lose weight in a healthy and permanent way. And hopefully I’ve helped you, as well!
Who do you think are healthier: people born and raised in China, or in the USA? I used to generalize that the average person in China was healthier, mostly from observing Beijing’s lively street life, especially at night. On every street corner you see families, friends and neighbors dance en masse, sing along to classic tunes, and chat away while walking — often backwards. This happens every night in every season — in every city I’ve seen across China. It fits with a well known Chinese proverb 饭后百步走，活到九十九 (take a hundred steps after eating, live to be 99). It’s a wonderful cultural tradition!
So from this wonderful nightly visual, I assumed that Chinese exercise a lot more than Americans — but the actual data doesn’t reflect this casual observation. Not even close, in fact. Only 6 percent of people in China aged 20 to 39 got the proper amount of exercise (the goal is 90 minutes a week of moderate activity). This is far lower than the 26% in Americans aged 19-44. This is also lower than their elders, which confirms the commonly noted observation that elderly Chinese get more exercise than the new generation — just the opposite of America. In China, 10% of people aged 50 to 69 carried out regular exercise, more than the 6% of their children and grandchildren. In the USA, 14% of persons age 65-74 got the recommended exercise, much less than the younger adult 26% rate.
The exercise rates in teens and earlier years are better, mostly because of the built-in school activities, but it tails off quickly in the teen years. With Hong Kong teens, for example, 64% of boys and 40% of the girls achieved the recommended 60 minutes of exercise daily after school. These are higher than in the US, with 37% (45.6% in boys and 27.7% in girls) achieving their daily 60 minutes. With weight, around 7.5% of Chinese children are obese and another 13% overweight; this is still much better than in the USA, where 17% are obese.
Why does activity drop off so quickly for kids in China after middle school? One theory is the incredible amount of studying that Chinese students are accustomed to: children in Shanghai and Hangzhou between grades 4 and 8 spend an average of 150 to 160 minutes doing homework every weekday and more than 200 minutes on weekends. In addition, children spend an average of more than 60 minutes every weekday sitting still and playing on computers, cell phones, tablets and watching TV. That’s an astonishing amount of homework, far more than the amounts I and my American friends and relatives ever had. In the UK, 9 to 11 year olds are expected to get 30 minutes a day of homework, going up to 90-150 minutes a day in high school.
A 2010 China Daily article about this issue agreed that “China’s exam-obsessed education system is taking much of the blame for the deterioration in students’ conditions. “It’s the root reason,” said Sun Yunxiao, deputy director of the China Youth and Children Research Center. “The emphasis is on test scores, not physical well-being. Pupils are being assigned too much homework, leaving no time for exercise.” This brings up an interesting and important topic of debate: what provides the better long term health for a child — a good education or proper exercise habits? After all, many studies show that higher education improves long term health, but studies also show that exercising is crucial for lowering lifetime risks of overall death, heart disease, cancers, diabetes and many other diseases. This imbalance is especially concerning since there is no strong evidence that more homework equals more lifetime success. In fact, many experts feel quite the opposite is true, especially during primary school ages. The American Academy of Pediatrics released a report in 2006 stressing that, “the most valuable and useful character traits that will prepare their children for success arise not from extracurricular or academic commitments but from a firm grounding in parental love, role modeling, and guidance.”
This article is in the current edition of Beijingkids magazine. You can read all my previous Beijingkids articles here. It’s an abridged version of an earlier article I wrote last year for my New York Times column.
We parents worry about our children getting enough exercise — but what about ourselves? Are we all leading by example and also getting enough exercise? Surveys show that most adults both here in China and in countries like the USA don’t get the recommended 150 minutes a week of moderate exercise or 90 minutes of strong exercise. So for those of us (including myself) who rarely exercise, what can we do to correct this?
New research shows that short, intense exercise may be just as good for your health as longer workouts. Literally a 4 to 7 minute workout is helpful! It’s called high intensity interval training, which basically includes 30 seconds of all-out exercise followed by 10 second breaks, repeated up to 15 minutes. It could be something as simple as squat thrusts, but you can look up “7 minute workout” on my website or Google and see other routines. This 7 minute workout got a lot of publicity a few months ago after being published in a research journal. It’s a shortened version of circuit training, where you rotate your exercises between focused muscle groups, and finishing the entire routine ideally will have covered all muscle groups. Trust me, the next day your muscles will be feeling both that anaerobic achiness and aerobic burn!
One additional benefit of this particular 7 minute cycle is that you don’t need any weights or machines — just your own body, a wall and a chair. You could also repeat this cycle one of two more times for added benefit. It’s important to take those 10 second breaks between reps as it increases the healthy metabolic response. You will definitely need help keeping track of these seconds, and I found a wide collection of apps for smartphones and tablets which can be custom set to beep at the correct intervals. Just search your app store for HIIT, Tabata or “interval timer” and take your pick. One website at 7-minute-workout.net nicely tracks your 7 minute workout.
The key here for all these HIIT routines is is to really push yourself, not take a leisurely pace. In terms of intensity, most of the research papers’ recommendations mention feeling “unpleasant” or “discomforting” after you finish. Many papers also mention something called VO2max, which generally correlates to 100% of your maximum heart rate. The formula for maximum workout heart rate, calculated in a 2001 research paper, is 208 – .7 * age. You should shoot for at least 80% of your maximum heart rate after finishing your routine.
I think this type of evidence-based exercise research is powerful and certainly has altered my usual speech to patients. I previously would always mention the usual recommended minutes of exercise (150 moderate, 90 intense per week) but now can make it even more appealing: 15 minutes, three times a week. But HIIT definitely isn’t for everyone. I don’t think HIIT would appeal to people who already exercise or play sports. And data is still lacking on the long-term benefits and risk reductions from HIIT. I also don’t think that HIIT is appropriate for most kids — they should be getting their recommended 30 minutes of exercise a day from routine gym glasses and after school activities. But for the silent majority of adults who struggle with exercise or always think they don’t have enough time, HIIT routines could be the perfect solution for you.
My long term readers know that I’m not exactly a fitness fanatic, and my waistline has just jumped over a horrible milestone of over 100 centimeters. (maybe sharing my humiliation will motivate me…) I desperately need inspiration to keep me fitter, and I’m also a tech geek, so I’ve been very excited with the burgeoning quantified self movement. This emphasizes electronic gadgets to track health data, with the goal to encourage you to be more active and live a healthier lifestyle. I recently borrowed a few of these activity trackers from the chief editor of Sports Illustrated’s Chinese version, to help with his upcoming review on them. My wrist was heavy with three popular models: the Fitbit Flex; the Jawbone UP; and the Nike+ Fuelband. Are they worth it, or are they just expensive pedometers? Here’s my review.
(If you’ve never heard of activity trackers before, you may want to read a few reviews first, such as from another doctor at iMedicalApps, or this or this; the New York Times; or follow the blog from Quantified Self.)
Features: all three perform the main function of counting your steps for the day, in varying degrees of success. Some were quite far from each other, but overall I didn’t see any major advantage of any. This begged a larger question from me: is monitoring steps is an accurate surrogate for measuring someone’s health? The good news is that there actually is data showing that pedometers can help; a systematic review of the data published in JAMA in 2007, showed that pedometer use lowered blood pressure and also lowered weight. Both of those are serious health risks in our modern world!
I did find myself trying to reach that magic number of 10,000 steps a day, and pushing more in the evenings to reach that goal — especially with the Nike Fuelband, a clear winner here due to its display showing steps as well as calories and the time.
Regarding other features, all three models also track food and calorie counting, but you have to manually enter every meal, every time. This is definitely a potentially useful feature, but unfortunately it could never be automated too easily. I tried to enter a few meals, especially by syncing with the popular app MyFitnessPal. But I stopped after just a couple days of data entry.
I actually found the sleep tracking features to be the most interesting and useful, especially the Jawbone UP’s easy ability to set up naps and quietly wake you up after a specified time. I really liked this feature for a quick afternoon nap, and its vibrating alarm was much more natural to me than any noisy alarm.
Comfort: I was surprised that all were relatively comfortable, even wearing overnight to take advantage of their sleep tracking (except for the Fuelband, which doesn’t offer this). All are water resistant and worked fine in the shower. In terms of style, I personally prefer something very sedate and small that won’t look silly in my doctor’s coat or in business meetings. I think all are fairly cool this way, especially the Jawbone in black. Perhaps the Fuelband is too thick for me, but it certainly gets attention.
Data Reading: These devices are useless if you can’t access the data in an easy to read manner. Clearly the internet is the key, and all have smartphone apps. While I am happily free of Apple’s ecosystem since last year, I apparently am limiting my app selection via my Android smartphone and tablets. Jawbone’s UP app clearly was the most useful, with outstanding and easy to read graphs on my sleep pattern and steps. Their Trends graphs also are super helpful. The Fitbit app doesn’t look nearly as good, plus I also never got it to sync via Bluetooth. If I can’t set something up easily, I’m not going to use it at all.
There’s a clever English language play on words, “assuming makes an ass out of you and me.” As an American expat straddling two cultures, I confess that it’s all too easy to make sweeping generalizations about differences, usually defaulting to my home country. But when it comes to health, I recently had felt that the average Chinese person is healthier than the average American. I was so convinced of this that I wrote an article on my blog asserting this. But after a chorus of criticism from my long term readers plus a rejection letter from my New York Times editor, I was forced to revisit my assumptions with better data. But I couldn’t find much supportive data at all. In fact, I uncovered much which makes me very worried about the future health of China’s children.
My main argument in favor of China’s health had centered around the sensory splendor of Beijing’s lively street life at night. On every street corner and in every park, generations of families, friends and neighbors dance en masse, sing along to classic tunes, and chat away while walking — often backwards. This happens every night in every season — in every city across China. It fits with a well known Chinese proverb 饭后百步走，活到九十九 (take a hundred steps after eating, live to be 99). There’s simply nothing like this social nightlife in America, and it’s a wonderful cultural tradition which I deeply wish we had in America. In top cities like enlightened and active San Francisco, there may be a few people walking their pets or jogging after dinner, but otherwise most American sidewalks are empty at night.
So from this wonderful nightly visual, I assumed that Chinese exercise a lot more than Americans. Here’s where the “assuming” part comes in: the statistical data doesn’t reflect this casual observation. Not even close, in fact. A 2008 survey, released by China’s State General Administration of Sport, found that only 6 percent of people aged 20 to 39 got the proper amount of exercise (90 minutes a week). This is far lower than the 26% in Americans aged 19-44 reported in the U.S. Health and Human Services report from 2012. This is also lower than their elders, which confirms the commonly noted observation that elderly Chinese get more exercise than the new generation — just the opposite of America. In China, 10% of people aged 50 to 69 carried out regular exercise, more than the 6% of their children and grandchildren. In the USA, 14% of persons age 65-74 got the recommended exercise, much less than the younger adult 26% rate.
What accounts for this striking difference in youth, also an ominous trend for China’s future health? One theory is the incredible amount of studying that Chinese students are accustomed to: a recent survey of 7,000 people in Shanghai and Hangzhou showed that children between grades 4 and 8 spend an average of 150 to 160 minutes doing homework every weekday and more than 200 minutes on weekends. In addition, children spend an average of more than 60 minutes every weekday sitting still and playing on computers, cell phones, tablets and watching TV. That’s an astonishing amount of homework, far more than the amounts I and my American friends and relatives ever had. In the UK, 9 to 11 year olds are expected to get 30 minutes a day of homework, going up to 90-150 minutes a day in high school. A 2010 China Daily article about this issue agreed that “China’s exam-obsessed education system is taking much of the blame for the deterioration in students’ conditions. “It’s the root reason,” said Sun Yunxiao, deputy director of the China Youth and Children Research Center. “The emphasis is on test scores, not physical well-being. Pupils are being assigned too much homework, leaving no time for exercise.”
This brings up an interesting and important topic of debate: what provides the better long term health for a child — a good education or proper exercise habits? After all, many studies show that higher education improves long term health, but studies also show that exercising is crucial for lowering lifetime risks of overall death, heart disease, cancers, diabetes and many other diseases. This imbalance is especially concerning since there is no strong evidence that more homework equals more lifetime success. In fact, many experts feel quite the opposite is true, especially during primary school ages. The American Academy of Pediatrics released a report in 2006 stressing that, “the most valuable and useful character traits that will prepare their children for success arise not from extracurricular or academic commitments but from a firm grounding in parental love, role modeling, and guidance.”
My wife and I love to spend our summer nights biking around our nearby hutongs and sometimes join in a dance. It’s one of the most charming traditions we have in China, and I can’t wait for our little Alex to join in the fun. I can only hope that other young people also join in, but the trend is not encouraging.