Episode Transcript
[00:00:01] Speaker A: Welcome to Obesity a Disease, the official Obesity Medicine association podcast exploring the many facets of the disease of Obesity a Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.
[00:00:25] Speaker B: You.
[00:00:30] Speaker C: A little over 10 years ago, a 32 year old woman presented my office for obesity Care. She had a BMI of 32 and had struggled to lose weight. She started a meal replacement and lifestyle plan and was able to drop to a BMI of 24. She has maintained that weight over the past decade, following a diligent dietary and activity plan.
While I have a number of other patients who have had a similar path, they are the exception, not the rule. In my experience as an obesity medicine practitioner, I've seen patients struggle with weight regain even when they're equally diligent with dietary and physical activity efforts. Which brings us to our topic today, Nutrition for Weight Maintenance after medication.
Hi, I'm Dr. Nick Pennings, professor of Family Medicine at the Campbell University School of Osteopathic Medicine and Director of Clinical Education at the Obesity Medicine Associ.
And with me today is Kirsten Fredrickson, MD, who also serves as a Director of Clinical Education at the oma. Along with me, Kirsten, tell us more about yourself.
[00:01:35] Speaker B: Well, thank you, Nick, for having me. It's great to be here.
I am an obesity medicine specialist. Also, I'm an internist by training and I've been working in the bariatric medical surgical space for many years, but also in obesity medicine, just strictly obesity medicine for years. And I'm currently the director of medical director of the Bariatric center at Mayo Clinic in Jacksonville, Florida.
[00:02:00] Speaker C: Well, that's great. And so I'm sure you've seen similar situations. Some patients can do well with lifestyle, but most patients can't.
And you know, I think there's a difficulty with patient perceptions about weight maintenance. In fact, a common statement will be, patients come in, I just need something to get me started, a jumpstart.
And I know once I lose that weight, I'll be able to keep it off. So why is that wrong?
[00:02:29] Speaker B: It's a great question, and I hear that so often as you do, and I wish that were the case, but this is really just a misunderstanding of what obesity is in that this is a chronic relapsing disease.
There's persistent physiologic change after we start to lose weight and even before we start to lose weight. With initial weight gain, there's physiologic maladaption. And then as we lose weight, our bodies and our hormones and all of that just conspire to have us try to regain weight. And so it's not a temporary problem, it's a chronic relapsing problem. And so having to just get the weight off and somehow it will just stay off just isn't how we physiologically work. So if you look at some of the data, there's a great study from about 15 years ago, it's an older study, but it's a classic study. And it really showed that hormone levels are maladapted to keep the weight off even 12 months after we lose weight, which is to say that we've lost some weight, but our hormones are not happy with that. And that persists for even 12 months after we lose weight. Maybe we've already started to regain weight, but some of our hormones are saying regain weight, get hungry again, start to get back to the weight that you were. Something's not right. And so it's really tough to expect that the weight will just stay off with that in place.
[00:03:58] Speaker C: Right. It's really a very complex situation. You have those neurohormonal responses with increasing in hunger hormones, decreasing in satiety signals.
And so that adds to the challenge. Plus, as you lose weight, your resting metabolic rate goes down. So you're already losing some basal metabolic activity, which is the larger component of our daily energy expenditure. And then you have other metabolic adaptations. So it's very complex. So how should clinicians explain that to patients?
[00:04:31] Speaker B: So I think the first thing is we need to understand this is a chronic relapsing disease, and we need to reframe that for patients as such and give examples of other similar diseases like hypertension or dyslipidemia, where we would perhaps be treating that. We try all the lifestyle changes and that may not be enough. We start medication and we continue the medication. So we treat to a target and not treat to just get to a number and then stop the treatment. So I think one of the key messages is that that we really need to continue treatment. The biology of weight regulation is changed after weight gain, and then it's changed after weight loss or trying to get back to where it was with weight gain. So these, as you said, the satiety hormones are diminished and the hunger hormones increase, and our resting metabolic rate, resting energy expenditure goes way down, even out of proportion to where it should be when we lose weight. So that we really need to consider this chronic and think about that as we're treating our patients. So it's not a one and done.
[00:05:40] Speaker C: Yeah, I think that idea of it Being a chronic disease is one of the things that is important to instruct our patients on and help them to realize that. I know I had a patient, she was a, she is a nurse practitioner and so very educated in medicine, but very resistant to the idea of long term treatment. And she also has a history of hypothyroidism and, you know, explained the hormonal changes and the chronicity of that. And, and I compared it to her thyroid hormone and said, you know, do you feel like you should only take your thyroid replacement temporarily and then be able to go off of it?
That kind of clicked for her.
But I think being able to relate it to other chronic diseases, whether that be thyroid or blood pressure or lipids or other chronic diseases, I think is helpful.
[00:06:34] Speaker B: Yeah, I find a lot of patients understand it much better when you, when you give those examples because many are on antihypertensives or some of these other medications and they don't think that they want to stop. I mean, eventually they would love to stop them, but they know that they can't and why.
[00:06:50] Speaker C: Yeah, and so how do you navigate that? So when you have patients getting to goal and they're, you know, at a, at a kind of steady state, how do you navigate the medications, the use of the medications at that point, increase or decrease the dose, stop, you know, how do you, how do you manage that?
[00:07:15] Speaker B: I really try to individualize it. I do try to tell, we have this conversation at the first visit that really this is not meant to be a life sentence that you're on these medications, but you will be on them long term. And how long that is exactly, I don't know, but at least a couple of years or let's see what's happening with you physiologically with other medical issues that come up and so on. So I try to have that, set those expectations early that I probably won't be stopping them unless there's some reason, maybe severe side effects or they, they've lost, they've gotten to target, maybe they want to be on a lower dose. So that's probably where I would start is, is going to a lower dose of the same medication that was working and see if they tolerate that. But they are going to lose appetite suppression. So being aware of that is important.
And so as we said, these, these hormones, they're still active and they're not quite at the level. So the ghrelin levels are going up and so on, and that that lower dose may not be sufficient and they may end up going back to the higher dose. Again, so there'll be some titration back and forth potentially with patients and hopefully not stopping it.
[00:08:25] Speaker C: I really like to listen to the patient and individualize it as well. But one of the things that I focus on is how their appetite is doing. I often ask what their hunger level is and if they're feeling really hungry still, even though they've gotten to their goal, you know, they're feeling really hungry and struggling, I may increase the dose. If they're feeling good and, you know, they are able to eat regularly, they can moderate their portions and feel satisfied.
I would keep it the same. And if they're struggling to eat, if they're having a hard time getting enough calories in, then I decrease the dose. So I kind of manage their appetite at that point. And I think that kind of makes sense because that's what the medications regulate.
[00:09:13] Speaker B: Right. And then there's also the consideration of cardiometabolic risk factors. So maybe they're hunger is control. Usually I find the hunger and the satiety is what's not quite in order and say their fasting glucose has been normal for a while and they're happy with that. But we haven't quite gotten the hunger part down. But in those patients who they feel their hunger is well controlled, they're at a weight where they feel comfortable, but their blood sugars are not really well controlled, maybe I won't go down on the dose of one of the glucose lowering agents for that reason. So just taking those into account too, some of these other factors and, or if they have some significant stressful event coming up, maybe I won't be as eager to change the dose right away until that is passed and they can focus again on, on their lifestyle modification.
[00:10:01] Speaker C: Yeah, I never, never stop right around or decrease around the holidays. Right. So that's where they were having their challenges.
[00:10:08] Speaker B: So that, that is good disaster.
Yeah.
[00:10:12] Speaker C: So for patients that, you know, are, you know, suddenly have to come off of the medication, maybe it's not covered anymore or they just have decided they don't want to continue. What are some of the dietary strategies that you find that can be helpful to mitigate weight regain?
[00:10:29] Speaker B: Yeah, yeah. We cannot forget that part of treatment is also the dietary strategy. And I think that, you know, we talk a lot about protein and that there's muscle loss with rapid weight loss and we need worry about that. But there is a lot of evidence to support that increasing protein intake can be helpful for satiety. And increasing fiber intake is also really important. So those two are really, really Ones that I focus on. So I give them some measures. And so one goal would be I usually go about a gram, a gram per kilo per day. I know some of the recommendations are higher than that, more like 1 point gram per kilo per day. But I usually don't go that high depending on the patient's needs and you know what their issues are. But really making sure they're getting fiber rich foods and then reducing the ultra processed foods so they're not getting those just over consumption of energy dense food for no reason and then structuring meal patterns so that they're not, if, if they're getting hungrier, they're either not eating all day or they're not eating a large meal once a day. So they try to just stick with a pattern that works for them and, and eat throughout the day to some degree so that they're consistent and they're not skipping too many meals and getting overly hungry.
So that I think is important. But then some flexibility with the portion control and with their plan, you know, so they don't feel it's so strict that they can't adhere to it either. I think that's, that's helpful.
There are some studies and these are older data, but I do think it can help to use some kind of a meal replacement program. Maybe it's for one meal a day. So that could be like a protein shake once a day instead of a, so substituting a whole food meal with a healthy protein shake or a prepared meal, that's a healthy prepared meal that has the portion control already in place. So for those who don't want to cook and they're not great at portion control, maybe that's a way to, to add that kind of a meal replacement system in and then just, and tracking, tracking. I know it's, it can be triggering for some people to track int, but I think really tracking, we have to know what we're doing. We need to know where we've started and where we're going to. And we need to track to some degree how much are we eating and what's our weight doing. And so regularly checking in on those things can help people kind of see when it's not quite when the trend is in the wrong direction. Essentially.
[00:13:03] Speaker C: Those are all excellent points. Certainly prioritizing protein and, and the fiber component I think is, is a, is a key component. So you want to help patients understand that appetite can be regulated in part through dietary efforts, that some certain foods create greater satiety when we eat a larger volume of food that's lower in caloric density. So mostly vegetables tend to have a large volume, low caloric density, high nutrient density that can help to create satiety.
So I think that's a very helpful thing. And then tracking is very helpful. I like to use supplements as well. I, you know, one of the things I'll, I'll tell patients or ask patients, you know, when you were a kid and you want to have a snack before dinner, what were you told?
And typically they'll say, no, I can't, I'll spoil my dinner. And I'm like, well, I want to spoil your dinner.
So, so having a supplement beforehand can help spoil your dinner or decrease your appetite. Right. So I do find that once patients get really hungry, they have a hard time reaching satiety or satiat.
That, that is a, a challenge. So I, I, I encourage them to avoid getting hungry and meal replacements are a great way to do that.
So another important lifestyle component is physical activity. So what, what role do you see physical activity playing in Weight maintenance?
[00:14:35] Speaker B: I would say. Oh, just coming back. One other point I would say is that we often we can confuse hunger for or thirst for hunger. So, so we have to make sure that we're well hydrated. And some water before a meal too can help with some satiety or just this feeling, a little bit of diversion perhaps, and just taking a break, take a breath, have some water, and then having your meal and kind of being more mindful. I think that's, and it kind of ties into the physical activity part too. Staying hydrated with activity is important. And as you increase activity, hydration is, is an important thing to consider.
But in terms of the role of physical activity, I think, yeah, so we can't say that physical activity necessarily leads to weight loss. There are many, many studies that show that our bodies adapt and we don't lose that much weight with, unless it's extreme amounts for a prolonged period of time. But for most of us, we don't really lose a lot of weight. It doesn't mean it's not important to do physical activity. But for weight loss, it's not the best mechanism for weight loss. But to maintain weight loss, it can be very important.
And so I definitely, and as patients are feeling better, I think they're often more eager to do exercise. They know it's important, but they're also wanting to try it. They have more energy, they feel less knee pain or want to go out, run around with their grandkids on the playground. And so all these things they want to do and then so they need some guidance when they get to that point on how to do it. And I think it's one thing that's unfortunate is that we have to do more exercise to keep the weight off than maybe we were doing when we were trying to lose weight with our lifestyle change and medication plan.
So the, yeah, so the recommendations are 2 to 300 minutes per week of moderate to intense activity for weight maintenance as opposed to 150 minutes per week. So we have to really increase that and keep our metabolic rate up by doing more exercise. So that's hard for. It's kind of a, you know, bitter pill to swallow in a way for some people. But I think on the other hand they're feeling better so they're more eager to do get as close to that as they can.
So, you know, so, so at least trying to get 30 minutes a day in, working towards 60 minutes kind of up from there. And what people like to do is really important. And we know that the exercise that people like to do is what they're going to keep doing. So finding. So my telling a patient, you need to go swim 20 laps or something is not going to be for many patients the best exercise because they don't have access to a pool or they don't know how to swim or they don't like to swim. So it has to be that, that exercise that they really enjoy and then maybe adding a little bit, so cardio and then adding some resistance exercises over time several times a week can be really important. And that helps keep our muscle mass up, engages our muscle fibers and keeps those with weight loss engaged and active and hopefully not losing too much muscle as we lose and keep our weight off.
Those are important. Resistance cardio, I think are the main things. And finding what patients really like to do and you know, and having them suggest what they want to do, me not telling them what they should be doing.
[00:18:02] Speaker C: Yeah, that shared decision making process I think is so important for the physical activity component because, you know, one of the things that we say is the, the best exercise is the one you'll do every day. So that is based on what the patient interest is and the importance of it. And it is a key component when we look at total energy expenditure. It's a combination of resting metabolic rate, physical activity and thermal effect of food. But the physical activity activity component is the one that we have the most control over and the most ability to change in a weight maintenance situation. So I think that's where it's Very important.
I also appreciate your comments about hydration. I think that is really key because one of the other challenges that I've seen with patients on GLP1 agents is that they have a decrease in thirst as well as a decrease in appetite. And so some patients will really struggle to maintain the, that hydration and get that fluid in. And I think that's important both in weight loss and weight maintenance.
Yeah, that's good. So weight maintenance is a real challenge. And I think it's important that we discuss weight maintenance with our patients. How should we approach that? And when do you start discussing weight maintenance with a patient?
[00:19:22] Speaker B: That's a great question. I touch upon it a little bit, even at the first visit and I say at some point. So that's part of the treatment. The treatment doesn't end and weight maintenance just is sort of something that you have to do on your own. We're still treating you, we're still taking care of you. And this is again a chronic disease process.
It's not a failure on your part if you're in maintenance and you aren't able to maintain your weight loss. This is not a failure. This is the physiology that we've talked about that a lot of our hormones conspire to have us regain some weight and we metabolically adapt to that weight loss. And, and so we need to kind of be on top of it. And if there's a weight plateau or if you're at maintenance, we just need to really be mindful that this is a chronic process and weight regain is very common. It's not inevitable, but it's really common. And that we need to keep treating it and look for the targets and treat, but not treat and stop.
And I think also when that patients are aware that when we start the program that we're always there for them. So this is a long term relationship. And as things go on with metabolic or sorry, maintenance of weight loss and so on, that we're still there for them. And if they notice weight regain, they shouldn't, they shouldn't wait to come back because the earlier we catch it and the earlier we can address that and what is actually going on?
Do they need to be back on medication? Is it. They need to increase physical activity or what could it be? Or they were started on a new medication that led to weight gain and they didn't realize that one could, could be an offender.
So talking through some of that early is important. So I try to set the stage that this is an ongoing relationship. Your weight may come back to Some degree, and we need to be on it and be in good communication, and our whole team is there for you.
And that's whether they've had bariatric surgery, medication, or even just lifestyle change. Some people don't even want to be on medication. And we see those patients as well. So all of those patients need that advice.
[00:21:36] Speaker C: I would agree that early intervention is really. Early discussion is. Is important. And, you know, one of the challenges that I've seen over the years with patients is that they're happy to come in when they're losing weight, but if they're gaining some weight, then they want to miss their appointment. They say, I didn't even want to come in today. And, and I really emph.
That's when you need me the most. And so having that discussion early and setting that stage and understanding that weight loss is not a straight line down and that there'll be challenges along the way, and I'm here to help you navigate those challenges, I think is an important message early on so patients don't get discouraged and give up too easily or avoid care when they need it the most.
[00:22:22] Speaker B: Right, Right.
And I think that a lot of we have to keep in mind how much bias there is in our healthcare system and how much blame the patients have felt through many encounters in the healthcare system elsewhere. But we're talking about healthcare specifically now. And so they've been told by other providers, well, come on, just eat differently or just go out and exercise more so they don't want to come back. They feel, okay, I did it again, I failed, and that's really not what this is. So I try to set the. One of the things with setting the stage is that we, that they're comfortable with us, that we're not here to shame them, to blame them. We're here to work with them. And this is a medical process and a, and a, you know, shared decision making, as you said. And that's really what it's about. And it's not just, you didn't do it, so we don't want to see you back. You're a failure. No, that's, that's. That's really the wrong message. And they've. 1. They've heard many, many times. Many of our patients have, have heard
[00:23:21] Speaker C: right, which is why they avoid that care because they fear that they're going to be blamed or shamed for having regained weight. And, you know, I'll tell patients that I don't need to shame you or blame you. I know you're doing it yourself. To yourself enough that my, my adding to it isn't going to make it any better.
And, and that the, you know, they are often very hard on themselves and having to navigate that is important.
So one last question. What are two or three most important nutritional principles that providers should be sharing with every patient? Entering in the weight maintenance phase.
[00:24:01] Speaker B: So I'd say three and we kind of touched on them. But I would say prioritizing protein. Try to get it at every meal. I think there's pretty good data that show that we only absorb about 30 grams at a time.
So if you are having, say you're not eating all day and you're having one large meal where you're having 90 grams, most people probably don't eat 90 grams in one meal. But if you're having a huge meal with a lot of the protein that's really supposed to be spread out during the day, you're not going to be absorbing as much as if you spread it out. So consistent meal planning, have some protein during the day. That'll help a lot with satiety. And then that fiber is so important that we talked about non starchy vegetables, cruciferous vegetables really help with those hunger.
Hunger cues and the crunch and so on really helps. So I think that's an important principle and just keeping track of what you're eating and setting a plan in place and then avoiding the ultra processed foods of course, which we talked about. I think that's a big one. And then a consistent structured eating pattern where you're doing some self monitoring. Again, it doesn't need to be super strict. For some people that works very well. For other people that feels triggering and off putting and that's okay too. But some kind of a regular sort of check in with yourself and with your family members too. Right. It's often not you're not doing this in isolation but with family around you. And maybe things have crept into the kitchen that really nobody wanted to be there but they were used to having it so they're buying it again and it just doesn't need. So having these conversations with the family members, look, this food, I'm gravitating towards it, I'm getting hungry and I don't need to have it here. Can help because people just may not be aware. Family members may not be aware about what someone's going through. So having those conversations I think can help a lot with patient support and how they feel doing this.
[00:26:04] Speaker C: Yeah, tapping into support and avoiding saboteurs. There are people that undermine the effort as well. So those are all great points. And we talked about the importance of hydration and maintaining water intake too. So I think those are are all great principles that should be should be conveyed regularly.
Well, this was a great discussion. I appreciate you being on the podcast today.
[00:26:28] Speaker B: Thank you for having me again. It was great to talk to you
[00:26:31] Speaker C: and thank you for being with us today. If you like this podcast, please share it with a friend and help the OMA as we strive advance clinician understanding of the disease of obesity.
[00:26:44] Speaker A: Thank you for listening to this episode of Obesity a Disease. For more information about obesity medicine, podcasts and other valuable resources from the clinical leaders in obesity Medicine, please visit www. Obesitymedicine.org podcasts. If you enjoyed this episode and want to listen regularly, head over to itunes where you can subscribe, rate and leave us a much appreciated review. The views expressed in this episode are those of the host and guest and do not necessarily represent the opinions, beliefs or policies of the Obesity Medicine association or its members.
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