Rethinking Obesity

Tammy Dolan had always been a “heavy kid.” Still, she never considered herself “really big.” Then came college and weight gain. She graduated and was ready to face the world. But, “I wasn’t happy with myself,” said the 39-year-old from Centerville, Crawford County. She tried dieting and exercise but couldn’t lose the pounds. After consulting a doctor, she opted to have gastric bypass surgery, only to discover her journey to beat obesity still would be a challenge.

She is not alone.

Obesity is having a body mass index of at least 30. It is a major public health crisis. It affects about 42 percent of Americans, putting them at greater risk of experiencing serious health problems, including heart disease, stroke, type 2 diabetes and certain types of cancer.

Their chances of success are bleak.

An obese man has only a 1 in 210 chance of reaching a healthy body weight, such as a body mass index score of 25 or below, according to an American Journal of Public Health study. Men have a 1 in 12 chance of achieving a 5 percent weight loss, a threshold that lowers the risk of diabetes and heart disease. Women have a 1 in 10 chance. And keeping the pounds off is a struggle: 53 percent regain the weight within two years; 78 percent regain it within five years.

Obesity’s causes are complex, and battling the disease is complicated by stigma and a history of treating the disease as simply a matter of willpower. Health plans have been slow to cover treatment. And the diet industry can influence how people treat obesity on their own.

For most Americans, formal treatment is going to a primary care doctor, whose guidance is often limited, in part, by a lack of specialized knowledge of obesity and training on how to address it.

But as obesity becomes better understood, a broader spectrum of treatment is emerging, ranging from diet and exercise regimens to cognitive behavioral therapies and surgery, in cities with advanced health networks, such as Pittsburgh, with its medical school and two major health systems. Integrative approaches are also emerging that feature diverse therapies and long-term follow-up care.

Part of that evolution is shifting the focus from the numbers on the scale to the dangers they portend. “It’s not about losing weight and how you look, but reducing and eliminating diabetes and preventing heart disease,” said Dr. George Eid, a surgeon and director of Allegheny Health Network’s Bariatric and Metabolic Institute.

Going it alone

Trying to lose weight is a popular American endeavor. Three-quarters of Americans have tried to do it at some time in their lives, according to an American Society for Metabolic and Bariatric Surgery and University of Chicago survey. Diet and exercise are their usual choices of action, and they do it with little or no support from medical professionals. Ninety-seven percent of obese people have tried losing weight by dieting, and 20 percent have tried to shed weight with diet or exercise at least 20 times. About 43 percent have tried meal replacement shakes to lose weight. Only 1 in 4 consult with a dietician.

Americans cite “lack of willpower” as the biggest barrier to weight loss. Lack of knowledge about treatment options, the availability of treatment and insurance coverage are among the reasons people don’t seek professional help. Negative societal perceptions of obesity are another barrier.

“There’s been a lack of knowledge about obesity and obese people, even among health care providers,” Dr. Eid said. “For the longest time, it was this notion that people just need to push the plate away. And even today, the stigma around obesity affects whether many get treatment.”

There is no magic diet. And the verdict on the diets Americans try is mixed: Some people lose a lot of weight by dieting, some don’t lose any and others gain pounds, according to an analysis in the New England Journal of Medicine.

Dieting is one of several “lifestyle interventions.” Others include behavior modification, such as cognitive behavioral therapy to address the psychological roots of weight gain and promote healthy behavior changes; and physical exercise programs. While important in addressing obesity, such treatments don’t often lead to significant weight loss.

But people with obesity don’t have to win America’s Biggest Loser to become healthier. Even modest weight loss can reduce the risk of obesity-related health issues, such as sleep apnea, type 2 diabetes and heart disease.

“When we talk about successful weight loss, we mean 10 percent,” said Marsha Marcus, professor of psychiatry at the University of Pittsburgh. “You will substantially improve your health if you can take it off and keep it off. We’re not talking about turning every American woman into a 100-pounder.”

Lifestyle interventions vary, but the gold standard is considered to be the Centers for Disease Control and Prevention’s National Diabetes Prevention Program (DPP), a public-private initiative to curb type 2 diabetes that includes promoting a healthy diet and exercise with the support of a coach. Studies suggest it can reduce the risk of developing type 2 diabetes by up to 58 percent, and contribute to weight loss and greater physical activity.

The combination of diet and exercise is critical. Each plays a different role in reducing the health risks imposed by obesity. “Diet is the best explanation for weight loss,” said Andrea Kriska, professor of epidemiology at the University of Pittsburgh. “Physical activity is the best for weight maintenance.”

Studies suggest, for example, that physical activity alone doesn’t lead to much weight loss. Its value lies elsewhere, particularly when people dealing with obesity hit the National DPP goal of engaging in 150 minutes of moderate intensity physical activity a week, such as brisk walking.

“Physical activity is important for people who are obese, independent of the weight loss,” said Bonny Rockette-Wagner, assistant professor of epidemiology at the University of Pittsburgh. “It has effects on reducing risk for cardiovascular disease and diabetes.”

When lifestyle change isn’t enough

Drug therapy and surgery are options for taming obesity when lifestyle interventions fail to drop a person’s body mass indexes below 35 and 40—the range where the risk of diabetes, sleep apnea, high blood pressure and other problems becomes seriously elevated.

A variety of prescription weight-loss drugs are available that help some people curb their appetites while trying to lose weight. Using certain medications may help people lose 3 percent more weight in addition to what they lose from dieting and exercise, studies suggest. But the weight loss tends to plateau about six months after taking them. Drugs approved by the U.S. Food and Drug Administration (FDA) for treating obesity include Phentermine hydrochloride (Fastin), Orlistat (Xenica and Alli) and Sibutramine (Meridia).

Surgery is usually reserved as a treatment for severe obesity, which is defined as having a BMI of 40 or higher. And the last decade has seen advances in bariatric surgery and an expansion of options. One of the most common procedures is Roux-en-Y gastric bypass, in which surgeons create a pouch from stomach tissue and connect it to the small intestine. Another is sleeve gastrectomy, which removes part of the stomach to reduce it to about 15 percent of its original size. Other options include endoscopic surgeries, such as gastric balloon, in which a silicone balloon is placed in the stomach to take up space. Another is getting endoscopic sleeve surgery, which involves stitching the inside of the stomach to reduce its size by about 70 percent.

“The real growth in the past 5 to 10 years has been in surgery and the effects of surgery on severe obesity,” said Dr. Anita Courcoulas, chief of minimally invasive bariatric and general surgery at the University of Pittsburgh School of Medicine.

Such surgical advances can result in patients losing up to 35 percent of their weight.

Tammy Dolan’s experience hasn’t been easy. She underwent her first gastric bypass operation in 2005. About a year later, she experienced severe stomach pain due to a hernia above the stomach pouch. She had revision surgery in 2010. But, a few years ago, she developed severe acid reflux. She also never felt full and started gaining back the weight she had lost.

She consulted with Dr. Eid. In August, she had Restorative Obesity Surgery Endoscopic (ROSE) surgery. Done by way of the mouth, it restores the size of the stomach pouch close to its original size from the first surgery. Since then, she said, she’s feeling “the best I’ve felt in years.”

Bypass surgeries also are proving helpful in other important ways. In a study published in the journal JAMA Surgery this March, most patients with type 2 diabetes went into remission within five years after having either a Roux-en-Y gastric bypass or a sleeve gastrectomy. After remission, those who had gastric bypass surgery were 25 percent less likely to have their diabetes reoccur.

An integrated approach

The support patients receive is critical to fighting obesity and improving their health.

When dieting, support matters more than the diet itself, the U.S. Preventive Services Task Force concluded. In one study, people who had 12 sessions with a dietician lowered their cardiovascular risk and rate of prediabetes, a condition in which blood sugar rates are elevated, but not at type 2 diabetes level. Patients who didn’t get support showed little to no improvement.

The reason is that beating obesity also has a psychological element. “One of the biggest challenges after surgery is trying to fit the mold of what your weight loss should be,” said Dolan. “It’s going to be different for everyone. There comes a point when you plateau after the surgery. You need support when that happens.”

Even achieving a healthy weight was an adjustment. “Your mindset changes,” she said. “How do I act now that I can fit into a normal seat? Can I go to this store and shop for these clothes? When I was younger, I’d go to stores and think, ‘I can’t buy these clothes because I can’t fit into them.’ I’d feel like people would stare at me. When I lost that weight, I felt so much better, but it took a long time to feel comfortable with the weight loss.”

Research-backed diet and exercise programs, clinical psychologists who specialize in obesity and weight loss, counseling sessions with registered dieticians and a menu of surgical options are available in many cities, including Pittsburgh. Yet, treatment isn’t often coordinated or managed long term.

But more integrated approaches to treating obesity are emerging.

In southwestern Pennsylvania, for example, the Allegheny Health Network added the AHN Comprehensive Weight Management Center to its Bariatric and Metabolic Institute at West Penn Hospital. The plan of attack includes combining services such as nutrition counseling, support from behavioral health specialists, and consultation with endocrine, bariatric and obesity doctors and surgeons. “The problem with health care is that it is so fragmented,” Dr. Eid said. “You go to a specialist, you get what you need done, then you leave. You might follow up with primary care, or you may not. But obesity is a chronic thing.”