Is obesity really a disease?

Much ado was made last June about the American Medical Association (AMA) officially classifying obesity as a disease -- it continues to be hotly debated. Specifically, many people argue that obese people who are free from other metabolic problems like diabetes, high cholesterol, or high blood pressure are just as healthy as lean people, and should not be targeted for obesity treatment.

But just today, a study published in the Annals of Internal Medicine lends support for the concept that obesity really is a disease. A large systematic review an meta-analysis was done using 8 different scientific studies (including over 61,000 people) that looked at whether obese people who are otherwise healthy have similar rates of cardiovascular events (like heart attacks or strokes) or death from any cause when compared to lean people who are similarly healthy.

The authors found that the people who were "healthy obese" had a 24% higher chance of having a major cardiovascular event or death over the next 10 years than the lean people did. They suggest that even when obese people may seem to be healthy based on lab tests and blood pressure checks, that they probably have small differences that turn into bigger problems over time.

What does this mean? Well, it may be worth trying to lose weight if you're above the "normal" BMI range of 18.5 - 24.9, even if everything else about your health seems to be intact... because a few years down the road, you might not find yourself so lucky.

The timing of food intake might affect your weight loss efforts!

OK guys, first of all, I am sad to say that I missed the symposium on alternate-day fasting at Obesity Week! I know I talked it up last week, so I feel terrible that I can't report back to you about it this week. I was so upset -- I (and many others) kept wandering around the area where it was *supposed* to be held, only to fail to find it. So I can't tell you yet what was presented there -- I'll have to wait until the audio and slides become available for me to view online next month.

BUT.

I *did* attend a symposium that dealt with the timing of food intake in a slightly different way, and discovered something new: that increasing your calories at breakfast and decreasing your calories at dinner might have a significant impact on your weight loss success! A study just published in July in Obesity examined the effects of two parallel diet groups: each group ate 1400 kcal per day for 3 months, but the first group ate most of their calories in the morning (700 kcal at breakfast,  500 kcal at lunch, and just 200 kcal at dinner), while the second group ate a more traditional American pattern with the most energy intake in the evening (200 kcal at breakfast, 500 kcal at lunch, and 700 kcal at dinner).

You can read the study itself here.

The results were striking: the big-breakfast group lost more weight, more inches off their waists, had greater improvements in insulin and fasting glucose levels, and even had drops in their triglyceride levels (while the big-dinner group's triglycerides actually increased). Perhaps most importantly, the mean satiety scores were significantly higher in the big-breakfast group, and hunger scores were lower -- so they felt more satisfied on the same amount of calories! Food for thought....

I'm in Atlanta for Obesity Week! ...about to hear evidence behind intermittent fasting....

This is the first time ever that The Obesity Society and the American Society for Metabolic and Bariatric Surgery are coming together for a combined annual scientific meeting. I've perused the program and am particularly interested in attending several of the sessions, including one at 1:30pm tomorrow about alternate-day fasting for weight loss and cardio-protection in humans, fasting to reduce cancer risk, and intermittent fasting and brain health. I am really looking forward to hearing the current scientific evidence behind this concept after hearing on The Diane Rehm Show this past March about Dr. Michael Mosley's diet sensation, "The Fast Diet."
http://thedianerehmshow.org/shows/2013-03-13/dr-michael-mosley-fast-diet

He promotes severe calorie restriction (under 500 kcal/day for women, 600 for men) on two non-consecutive days every week, claiming that it will help promote weight loss, decrease the risk of dementia, and increase longevity. But this concept has largely been based on animal studies, and the UK National Health Service posted information (updated in May) about the limited research supporting it:
http://www.nhs.uk/news/2013/01January/Pages/Does-the-5-2-intermittent-fasting-diet-work.aspx

The session here at Obesity Weeks tomorrow is supposed to outline research in humans, so I am quite curious to see what will be presented, and whether it will support intermittent fasting!

This just in: bariatric surgery leads to better sex

It may not come as a surprise to you that obesity is associated with increased body image dissatisfaction and decreased sexual satisfaction, but a study that was just published online yesterday in JAMA Surgery (doi:10.1001/jamasurg.2013.5022)  found that women lost about 33% of their body weight at the end of one and two years after surgery, and that they reported "significant improvements in overall sexual functioning and specific domains of sexual functioning: arousal, lubrication, desires, and satisfaction." Given that about half of women who seek bariatric surgery to treat their obesity report sexual dysfunction and psychosocial distress, these findings are really promising. Also of note, the women experienced significant improvements in reproductive hormone levels, as well as in body image.

We have known for some time now that bariatric surgery is associated with improvements in medical diseases like diabetes and obstructive sleep apnea, but now there's proof that it's good for your sex life, too!

How do they lose so much weight on The Biggest Loser?!

Even though I was a contestant on The Biggest Loser during season 3, I didn't actually get to live on the ranch and compete like the contestants do on most seasons, since there were 50 of us and only 14 stayed on the ranch. I was one of the "36ers" who lost the weight on our own at home. So how people managed to lose 30 pounds or more in one week, I had no idea... until I was the doctor for the show on seasons 4 and 5, that is.

First, it turns out that a "week" on TV is sometimes filmed over 7 days, but sometimes the filming schedule is longer and it might be up to 14 days before the next episode is filmed. They all say "this week" and make it seems as if every episode occurs 7 days after the last, but that's just not the case. So, those 30 pounds might have been lost over 2 weeks, not just one.

Second, the contestants pretty much universally dehydrate themselves before weigh-ins. They cut out carbs (which makes them deplete their glycogen stores, which also makes them lose water with it) and cut out salt to lose as much water weight as they can through diet, and then they exercise and sweat without drinking water to replace their losses. This drops an enormous amount of weight due to water losses without actually requiring any fat to be lost.

Finally, they actually do lose a lot of fat. They might work out up to 8 hours in a day, and are watching their caloric intake closely. So a good amount of the weight lost is real fat loss. Just don't be discouraged if you can't lose the same amount of weight at home, since you don't have 8 hours a day to dedicate to exercise and you're not taking extraordinary measures to drop water weight.

Is willpower a muscle?

When trying to watch what you eat, have you ever noticed that it's easier to stick to your guns early in the day, but by late afternoon or evening you find it 10 times harder to resist those chips or that brownie? One of the most important factors in someone's ability to lose weight is self-control, or willpower. An obese person's ability to resist the impulse to eat calorie-dense foods, especially with junk food available around every corner, is critical to his or her weight loss success.

Researchers have found that willpower may be more like a muscle than we realized. And just like a muscle that fatigues after being used repetitively, willpower can fatigue with use, too. Muraven, Tice and Baumeister did a series of experiments in 1998 that found that people reported feeling fatigued after making an effort to control themselves, and the more difficult the challenge to their willpower, the more fatigue they reported. Then these people actually did worse when they were confronted with a subsequent unrelated test of self-control. Muraven, Tice and Baumeister speculated that, like physical exertion, someone’s capacity for self-control might draw on a limited resource and become depleted with short-term use, just like a muscle becomes fatigues after short-term use -- but they also suspected that willpower might actually increase over time with repeated use much as someone's physical fitness increases over time with repeated bouts of exercise.  

In fact, Mark Muraven did an experiment in 2010 that confirmed this theory: people who practiced unrelated tasks that actually required them to exert their willpower did better in the real-life challenge of quitting smoking.

This can have important implication for those of us trying to change our eating habits. Practicing small instances of willpower on a regular basis might actually improve our ability to control ourselves around junk food later on. And trying to face challenges to our self-control when we are already fatigued might be a recipe for disaster. Could this be why recent research has found a correlation between sleep deprivation and weight gain/obesity? Something to think about….

References

 Muraven, M. (2010). Practicing self-control lowers the risk of smoking lapse. Psychology of Addictive Behaviors, 24(3), 446-452. doi:10.1037/a0018545

Muraven, M., Tice, D. M., & Baumeister, R. F. (1998). Self-control as limited resource: Regulatory depletion patterns. Journal of Personality and Social Psychology, 74(3), 774-788.

 

Stuff yourself to lose weight!

Some of you might have heard of the "Volumetrics" diet -- the original book was published in 2000 by Barbara J. Rolls, PhD (a professor of nutrition at Penn State) after she had discovered in lab experiments that people naturally eat fewer calories when they eat foods that are low in energy density. Energy density is the amount of energy, or calories, in a food compared to how heavy the food is -- the lower the energy density, the lower calories per measure of weight. So for example, celery, which is made up of a lot of fiber and water, has a low energy density; cheddar cheese -- mostly fat and no fiber or water -- is very high on the energy density scale. By adding some lower energy-dense foods to your diet (foods high in fiber and water, like fruits and vegetables), you may fill up more quickly and end up eating fewer calories overall -- even though you consume MORE food by weight. The most recent iteration of the diet was published in 2012:
http://www.amazon.com/Ultimate-Volumetrics-Diet-Science-Based-Strategies/dp/B00ASP9JO0/ref=sr_1_2?s=books&ie=UTF8&qid=1381256952&sr=1-2&keywords=volumetrics
Dr. Rolls' diet has won widespread acclaim from scientists and nutritionists, and is always listed as one of the best diets available.

While I did not specifically follow Dr. Rolls' Volumetrics diet plan when I lost my 120 pounds back in 2006, I definitely DID subscribe to her philosophy and ate the way she recommends. I love to eat. I feel comforted when my belly is full. I feel a lot of anxiety if my belly is empty; when hunger pangs start, it might as well be a full-on emergency. I know that's crazy, but that's me (and many other people who have weight issues). So in order for me to feel satisfied while also significantly lowering my caloric intake, I had to start stuffing myself with veggies. LOTS of veggies. One of my favorite recipes that I made up is a hearty low-calorie vegetable soup that I make without any added fat. I eat it for lunch pretty much all winter; adding half a cup of kidney beans to 2 cups of the soup provides extra protein and fiber, and I truly feel stuffed after eating it. Broth-based soups are one of the stars of Volumetrics, so if you're interested in trying this eating style, give my homemade vegetable soup a try!

----------------------------------------------------------------------------------------------------------
Makes ~10 2-cup servings

2 tsp Herbes de Provence
1 tsp fennel seeds, crushed with a mortar & pestle (optional)
1 medium onion, chopped
8-10 ounces sliced cremini ("baby bella") mushrooms
1 10-16 ounce bag of chopped kale
2 large or 3 medium zucchini, chopped
2 28-ounce cans diced tomatoes in juice
2 T Better 'n' Bouillon soup base (I use beef, but chicken or vegetable works too)
splash of red wine vinegar
water
salt/pepper to taste

Heat 1 cup water in a large stockpot over medium heat. Add the Herbes de Provence and fennel seeds and simmer while you chop the onion. Add the onion and simmer for a minute or two (until translucent), then add mushrooms and kale (picking out very large stems). Continue simmering over medium heat and stir intermittently while you chop the zucchini. Then add the zucchini and the tomatoes. Fill each empty tomato can with water and add that too. Then add the soup base and vinegar, turn the heat up to high and bring to a boil, then turn down to low-medium to simmer for 10 minutes, stirring intermittently. Taste the broth and add salt and pepper as desired. (I often add more soup base, too, but that adds a lot of sodium, so if you're trying to watch your salt intake, be cognizant of this ingredient!)

Will eating olive oil reduce heart attacks?

On my drive in to work on Monday morning, I listened to a story by Allison Aubrey on NPR's Morning Edition about the benefits of eating olive oil, and that fresh-pressed oil provides the most benefit:
http://www.npr.org/blogs/thesalt/2013/09/30/226844915/to-get-the-benefits-of-olive-oil-fresh-may-be-best
Ms. Aubrey referred to a large randomized controlled trial that was published in The New England Journal of Medicine in April 2013
http://www.nejm.org/doi/full/10.1056/NEJMoa1200303
that found a benefit when people in Spain who were at high risk of heart attacks and strokes added 4 tablespoons of olive oil a day to an already Mediterranean-type diet (that is, a diet high in fruits, vegetables, legumes, nuts, olive oil, and cereals and low in dairy products, red and processed meats, and sweets).

Ms. Aubrey stated in her story, "And what researchers found was that a Mediterranean diet rich in olive oil cut the risk of heart attacks and strokes by 30 percent. The nut group, which was consuming olive oil as well, did well, too." This is a touch misleading, though -- and a classic problem with how journalists interpret and report data from clinical trials to the general public.

What the study actually found was that there was a small decrease in the number of strokes in people who consumed the added amount of olive oil, but that there was NO DIFFERENCE in the number of heart attacks, or in the number of deaths (see Table 3 in the paper for the actual numbers).
http://www.nejm.org/doi/full/10.1056/NEJMoa1200303#t=article
But because the study combined all three of these endpoints (stroke, heart attack, and death) into a single endpoint, they have been grouped together by the authors of the study -- and by journalists, who are inferring that the olive oil decreased the number of heart attacks and giving this misinterpretation to the public.

This isn't to say that olive oil doesn't have benefits. I just believe it's important that research findings don't get twisted when they are interpreted by journalists.

I also think we should keep in mind that 4 tablespoons of olive oil is a LOT of oil! Adding that much olive oil to your diet would provide an additional 480 calories a day -- and for people trying to watch their total energy intake in order to maintain or lose weight, this can be a significant amount of calories! If you kept your diet and activity levels the same and added 4 tablespoons of olive oil a day, you could pack on a pound of fat every week! So it's important not to just go out and start sucking down the olive oil from the bottle.

I personally think that the sensible thing to do would be to DECREASE the calories in your diet by decreasing other foods containing saturated fats (like butter; high-fat dairy products like cream, half-and-half, cheese, or ice cream; or red and processed meats like sausage or steaks containing a lot of fat) and simultaneously increase the amount of olive oil in your diet (by cooking with it or using it in place of butter or cream on bread or in sauces and dressings). This could provide the healthy monounsaturated fats and other healthy substances like polyphenols without adding extra calories to your diet: a win-win.
 

Can you lose weight by taking prebiotics?

Last Tuesday, my horrified dad called me and told me to take down my "poop transplant" post because he thought it was disgusting and not a funny joke. I told him I wasn't joking. I really wasn't!

But, for those of us who prefer not to put other people's poop into our bodies just yet, is there another way to change our own bowel flora to create a microbiome that could help promote weight loss?

The research is still in it's infancy, really, but several studies have shown that diets with a high amount of fiber (mostly from fruits, vegetables, legumes, and whole grains) are associated with gut flora that do a better job of wasting calories. Prebiotics, which are fiber substances that are indigestible (ultimately reaching the colon where they are fermented by the gut bacteria there), help stimulate the beneficial bacteria. They are found naturally in foods like wheat, asparagus, Jerusalem artichokes, garlic, onions, leeks, and chicory root, and also come in supplements (e.g., the fiber contained in Metamucil Clear & Natural is inulin, which is the fiber derived from chicory root). They can stimulate the "good" bacteria, but can they help abolish the calorie-hoarding bacteria that are found in the colons of obese people, and actually help with weight loss?

As I mentioned last week, there have been studies that have demonstrated that obese people have higher Firmicutes (which have been shown in mice to be better at energy-harvesting -- or keeping calories in the body and increasing fat [1]) and fewer Bacteroidetes in their systems than lean people. What is notable is that these alterations can be abolished after a year of diet-induced weight loss, with the degree of change in microbes being proportionate to the amount of body fat lost [2].
Now the question for future research in humans is whether giving obese people prebiotics that will help people lose more weight than they would lose otherwise just from calorie restriction or increased exercise. It's hard to separate the effect, because many of the foods that people eat when they are trying to lose weight are vegetables that naturally contain prebiotics, so researchers might need to provide one group of dieters a prebiotic in a supplement form while the other dieters get a placebo to see whether there is a difference in weight loss. A promising preliminary study just published in Gut found that obese women who were given a prebiotic supplement containing inulin and oligofructose for 3 months (vs. placebo) had subtle changes in their gut bacteria that could impact obesity and/or diabetes [3]. Now, longer-term studies are needed to evaluate whether prebiotic supplements could actually lead to long-term weight loss and perhaps help prevent the development of diabetes.


References

1. Turnbaugh, P.J., Ley, R.E., Mahowald, M.A., Magrini, V., Mardis, E.R., and Gordon, J.I. (2006). An obesity-associated gut microbiome with increased capacity for energy harvest. Nature 444, 1027–1031.

2. Ley, R.E.; Turnbaugh, P.J.; Klein, S.; Gordon, J. Microbial ecology: Human gut microbes associated with obesity. Nature 2006, 444, 1027–1031.

3. Dewulf, E. M., Cani, P. D., Claus, S. P., Fuentes, S., Puylaert, P. G., Neyrinck, A. M., . . . Delzenne, N. M. (2013). Insight into the prebiotic concept: Lessons from an exploratory, double blind intervention study with inulin-type fructans in obese women. Gut, 62(8), 1112-1121. doi:10.1136/gutjnl-2012-303304; 10.1136/gutjnl-2012-303304
 

Want to lose weight? Get a poop transplant.

OK, so maybe the title of this week's post is a bit sensationalistic, but the future of medicine may truly lie in the transfer of beneficial bacteria from a healthy person's colon into the colon of a person afflicted with a disease or illness -- one of which is obesity. This general idea isn't exactly new, as doctors have been performing fecal transplants for a particular type of infectious diarrhea that we call "C. diff colitis" (because the infection is caused by the overgrowth of a bacterium called Clostridium difficile) for decades with dramatic success.

In a 2006 landmark paper in Nature, Turnbaugh et al. described the differences in gut bacteria (or the "microbiome") of obese vs. healthy mice as well as obese vs. healthy humans, and found that the obese mice and people had an abundance of bacteria that were found to have an increased ability to absorb energy from the diet (meaning, they help the person absorb all the calories eaten rather than lose some of the calories that would've otherwise been indigestible).
http://www.nature.com/nature/journal/v444/n7122/full/nature05414.html
What was striking, though, was that the investigators took the bacteria from the obese or thin mice and transplanted them into the colons of bacteria-free mice, and found that the recipients of the bacteria from obese mice soon gained significantly more fat than the bacteria-free mice who received a stool transplant from the thin mice. This showed that the bacteria could actually CAUSE weight gain rather than just happened to be associated with weight gain.

There have since been scores of fascinating studies that are being done to evaluate the human microbiome, how it affects our health, and how we might be able to manipulate it to help treat medical conditions and diseases -- including obesity. If you've been struggling to lose weight with little success, is a poop transplant in your future?

Is obesity contagious?

You might've heard news reports that obesity might be contagious. What's all this about?

A study published in the New England Journal of Medicine a few years ago followed over 12,000 people for 32 years to help determine whether being socially linked to someone was a more important determinant of developing obesity than being genetically or geographically linked: 

http://www.nejm.org/doi/full/10.1056/NEJMsa066082

The study found that if your friend becomes obese, you have a 57% higher chance of becoming obese yourself (and if you are close/mutual friends, your risk increases to a whopping 171% higher than strangers!).

They also found that next door neighbors' obesity did NOT increase your risk of gaining excessive fat yourself, and that good friends who are very far away geographically still DO increase your risk of gaining weight. This helps rule out exposure to something in the environment (like a virus or a poison) as an explanation, and suggests that it is a change in your thought processes -- in your perception of social norms

and the acceptability of obesity -- that is to blame.

What does this all mean? If you are more likely to gain weight when you have friends who gain weight, then it is reasonable to assume that surrounding yourself with healthy-weight friends may keep you from gaining eight yourself. This can have enormous implications on the obesity epidemic in America. Public health programs

might focus more on weight loss programs that include peer support, since both bad and good behaviors

might spread over social ties/friendships.

The bottom line: if you want to maximize your chances of losing weight and keeping it off, surround yourself with like-minded people. Join a weight-loss community, such as Overeaters Anonymous or Weight Watchers, or start your own fat burners' club at work. Spending too much time with friends who are overweight and who continue to eat unhealthfully and remain sedentary might influence you without you realizing it. Try to spend a little more time with people who make healthy eating choices and get out there and exercise with you!

Who am I??

Who am I?
I am a doctor.
Double board certified in obesity medicine as well as internal medicine, I have been practicing for over 20 years now. The George Washington University Medical Center was home -- I went through medical school and residency training there; I was honored to be asked to serve as Chief Medical Resident and delighted to be inducted into the Alpha Omega Alpha medical honor society there before moving to California in 2003 to join the medical faculty at the University of California San Diego. I was an Assistant Clinical Professor of Medicine at UCSD for four years, caring for patients and teaching medical students and residents. In 2007 I had the opportunity of a lifetime: I moved to Los Angeles to work with Dr. Rob Huizenga and serve as a medical consultant for NBC’s hit reality TV show, “The Biggest Loser.” My time in Los Angeles was spent watching over the contestants during their weight loss journey, making appearances on the show, writing a blog about the behind-the-scenes medical aspects of the show for NBC.com called "Dr. Jen's Journal," and running a private weight loss group in Beverly Hills with Dr. Huizenga. After three seasons of filming the show, Dr. H asked me to buy into his practice and stay on permanently, so I was forced to choose between staying in Hollywood long-term and returning home, and there's just no place like home. I decided to return to academia and relocated back to the DC area in 2008, where I am currently Assistant Professor of Medicine at two medical schools: the George Washington University, and the Uniformed Services University of the Health Sciences. I’m on staff at the Washington DC VA Medical Center, caring for our nation’s heroes and running our medical weight management clinic and bariatric surgery program. I’m passionate about helping others learn to manage their weight as successfully as I have. Weight management is sometimes a meandering road, but staying the course (with occasional course corrections!) will get you there eventually.

I am an obesity survivor. 
I understand weight-related issues better than anyone, having struggled with my own obesity since childhood; my weight topped at about 300 pounds in college. I lost over 120 pounds during medical school and kept it off for 3 or 4 years, but the weight gradually crept back on through the stress of residency, a cross-country move, and a less-than-successful first marriage as I allowed my iron will to relax just a bit. What began as gaining "just 5 or 10 pounds" kept recurring, and gradually 5 or 10 pounds turned into the whole 120: by 2005 I was back to my original 270 pounds. Then in 2006, I applied to be one of the 50 contestants on Season 3 of "The Biggest Loser." I was chosen to represent the state of Virginia, and managed to re-lose 108 pounds in just 8 months as an at-home contestant. Yes, those of us who had to lose weight on our own at home seemed to do as well as those who stayed on the ranch and worked tirelessly with the trainers! Since the show's finale in December 2006, I have successfully maintained my weight loss — with a blip of moderate regain during pregnancy and nursing! — and, believe it or not, I am currently 25 pounds LIGHTER than I was when I appeared on the finale of my season of the Biggest Loser 13 years ago!

I am an investigator.
As a physician-scientist, searching out scientific and medical studies to use as evidence to back up my medical decision-making is critical. We are held to this standard in practice and I have become adept at evaluating potential treatments systematically and critically, using the medical literature to lend scientific proof to my therapeutic decisions. I went back to school while working full time and got a Master's degree in Clinical and Translational Research to help me hone my skills in medical research, and had the opportunity of a lifetime to work with Dr. Kevin Hall at the National Institutes of Health investigating the long-term changes in weight and metabolism of a few of my Biggest Loser compatriots, the season 8 contestants. Our research was widely publicized and I have since been interviewed by various media such as Psychology Today, NPR and the New York Times… with a few more articles here and here.
I’m hoping this blog will serve to help me distill the current scientific literature and come up with new ideas and questions to pursue, and more importantly, disseminate whatever insights I gain to the general public. I want to help you outsmart your stomach just like I have! And maybe tell a few stories and opinions from my life and experiences while I’m at it. Care to join me?