by Dr. Marel Ver
The obesity epidemic has been around much longer than other world health crises like SARS and COVID.
However, we may not fully recognize being at a healthy weight as a major world health priority, as we often accept weight gain as a natural part of living.
The 2023 update of the Obesity Medicine Association states that:
“Obesity is defined as a chronic, progressive, relapsing, and treatable multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences.”
A convenient way to measure weight is by a number called the BMI, or Body Mass Index.
The BMI is calculated with the formula kg/m2. The normal BMI range is 18 to 25. A BMI of 26 to 29 is considered overweight. BMI 30 to 34 is obese class 1. Obese class 2 is BMI 35 to 39. Obese class 3 is BMI 40 and over.
Health problems, like hypertension (high blood pressure) or prediabetes (elevated blood sugar) usually start when patients are overweight.
When the BMI hits over 40, the risks of developing health problems go up exponentially.
These conditions include heart disease, Type 2 diabetes, cancer, hypertension, stroke, liver and gallbladder disease, respiratory problems, and osteoarthritis.
In fact, the chances of developing diabetes or heart problems are 20x higher in BMI >40 compared to a normal BMI person.
Obesity is now considered a disease. Therefore, if you have a higher BMI, your doctor may document overweight or obesity in your medical chart as a medical problem.
In the United States, health and life insurance companies use the BMI number as a predictor of overall health. Being obese carries significant economic costs due to increased healthcare spending and lost earnings.
A limitation is that the BMI is just a raw number. It does not take into consideration the body’s percentage of fat versus muscle mass.
Athletic celebrities like Dwayne “The Rock” Johnson or John Cena, have “overweight” BMIs due to high muscle mass, but are in top health.
Also, under-appreciated and not well known, is that in Asia, there is another BMI scale, in which the ranges are lower. Normal BMI is 18 to 22. Overweight is 23 to 26. BMI >27 is obese.
This is significant in Hawaii, as our Asian population is over 37%. Although physically ‘smaller,’ Asians have higher health risks at a lower BMI.
Genetically, Asians have a higher percentage of body fat mass, which lowers the threshold for developing health problems.
Filipinos make up 25% of the population in Hawaii. Hawaii Health Data Warehouse reports that in 2020-2022, 21.4% of Filipinos were considered obese. 41% of Native Hawaiians were obese.
The Hawaii Department of Health (DOH) reports that 19% of Filipinos and 13% of Hawaiians have diabetes. Also reported is that Filipinos and Japanese have the highest prevalence of high blood pressure.
The DOH health initiatives including the Hawaii Health Disease and Stroke Plan 2030 and the Hawaii Diabetes Plan 2030 are published online at https://hhsp.hawaii.gov .
We all know that it is not easy to lose weight. It is even more challenging to maintain a healthy weight.
Moreover, when the BMI reaches the obese range, the body’s metabolism ‘resets’ as the body’s chemistry changes to ‘protect’ the body at a higher BMI, thus making weight loss even harder.
Although globally seen as one of the healthiest states, living in Hawaii has its challenges too. Hawaii’s culture of social gatherings with a variety of savory foods contributes to increased caloric intake. Working multiple jobs and being stuck in Hawaii traffic contributes to decreased exercise.
High-stress levels, lack of restful sleep, and not eating on a schedule all increase stress hormone levels, again pushing the body to ‘protect itself’ from starvation, and so the body prefers to store rather than burn calories.
As we learn and know more about the science of obesity, the saying “eat less, exercise more” may not be as significant.
Simply, the food we eat is broken down into chemicals and nutrients and alters the biochemical signaling and metabolism of the body.
Therefore, when recommending a ‘diet,’ I ask providers to identify the primary goal they are trying to achieve for that individual patient. There are several types of diets out there for different goals.
For instance, the Ornish diet focuses on heart health. The Atkins diet and ketogenic diet focus on weight loss. A diabetic diet aims to lower blood sugar levels.
Diets are only one aspect of weight loss which is a billion-dollar industry. There are diet plans, exercise programs, health coaching, and other options available.
With the expansion and ease of the online market, there is increased access to programs, specialized foods and vitamins, and medications.
One of the newest class of medications is the GLP-1 agonists. These drugs mimic the action of a hormone called glucagon-like peptide 1 (GLP-1), which stimulates the body to produce more insulin which lowers blood sugars after eating.
GLP-1s also stimulate other biochemical signaling pathways that decrease inflammation and improve the efficiency of other organs.
Weight loss is a known side effect of these medications. Weight loss is from decreased hunger and overall improved metabolism. With weight loss and decreased BMI, overall health improves.
These GLP-1 medications include Dulaglutide (Trulicity), Exenatide (Byetta), Semaglutide (Ozempic), Liraglutide (Victoza, Saxenda), and Semaglutide (Rybelsus).
With the exception of oral semaglutide, these medications are weekly or daily self-administered injections.
These brand medications are protected by multiple patents and are very expensive. Subsequently, many health insurance companies have limited coverage to diabetics only.
Otherwise, out-of-pocket costs can be as high as $500-1400 for a month’s supply. Weight loss is an off-label use for these medications.
Because of the somewhat decreased access to GLP-1 medications due to cost and prescription, the latest trend is the availability of compounded formulations.
These medications are marketed online and through smaller health clinics as a weight loss prescription. They may be more ‘affordable’ but still have significant costs.
Compounded medications are made by specialty pharmacies and are not FDA-approved. The prescription and use are not regulated so I advise caution when choosing to take compounded medications.
One can expect to lose about < 20% of excess weight with the GLP-1 meds.
Dosing needs to be titrated up slowly. While most patients tolerate these medications, common side effects include nausea, vomiting, food intolerance, and gastroparesis (slow stomach emptying).
Long-term health effects and complications of GLP-1s are still unknown because these medications are so new.
Weight loss plateaus in 12-18 months. If stopped, patients typically regain the weight lost within the year.
Therefore, maintenance dosing may be necessary to keep the weight off. In the long run, the use of GLP-1s for weight loss is not cost-effective.
In one large study, only 27% of patients remained on the GLP-1 after one year.
When using a GLP-1 medication for weight loss, I always recommend dietary and lifestyle counseling, which may or not be provided by the prescriber.
If insurance coverage runs out or a patient decides to stop taking the meds, optimally, the patient has reached a healthier BMI for maintenance.
If efforts for proper eating habits and a healthier lifestyle were not made, then weight regain is faster, and then we’re back to the original problem.
Obesity medicine physicians advocate for a Food is Medicine (FIM) approach for weight loss maintenance after GLP-1 meds are stopped.
Bariatric (weight loss) surgery is a surgical option covered by most insurance companies for patients BMI >35 with significant medical conditions including diabetes or sleep apnea and for patients BMI >40 with or without medical problems.
The most common bariatric surgeries performed in the US are the sleeve gastrectomy (GS) and the Roux-en-Y gastric bypass (RNYGB). These surgeries are performed laparoscopically through small incisions.
Most centers keep patients in the hospital post-surgery for 1-2 days. Some centers even send patients home on the same day after surgery.
There are over 20 years of data supporting the safety of surgery and improved health and health maintenance of bariatric patients in the short and long term.
In 2017, my mentor from the Cleveland Clinic, Dr. Philip Schauer authored the groundbreaking manuscript that the Roux-en-Y gastric bypass surgery surpasses intense medical therapy for the treatment of diabetes.
Hawaii is one of the few states where HMSA covers an RNYGB for BMI >30 with diabetes.
Preoperatively, patients will need to complete mandated assessments and therapies with dieticians and behavioral health to meet insurance approval. Additional specialist consultations, like sleep medicine or gastroenterology, may be requested.
Preop requirements take several months to complete, but if compliant, the patient will lose weight in the process.
Bariatric surgery is also considered metabolic surgery since it changes the body’s chemical signaling. Interestingly, one of the effects is stimulating the body’s GLP-1 signaling.
At one year post-surgery, the average is about 60% of excess weight lost. This means that if a person is 100 pounds over from a BMI of 25, then they will lose an average of 60 pounds.
Maintenance is key after two years post-surgery as the body will reset again, hopefully to a near-normal BMI.
Overall weight loss improves diabetes, sleep apnea, and heart health since these are considered weight-related diseases. There is also less inflammation in the body which improves conditions including gout, asthma, fatty liver, and depression.
Cancer risks also go down. It is reported that there is resolution or at least improvement >90% in weight-related diseases. 10-year mortality is decreased by 30-40%. It is also reported that quality of life is improved in 95% of patients. These percentages are reproducible and consistent with my patients in my bariatric program.
On a side note, as the only female bariatric surgeon in Hawaii, I have a handful of referrals from ObGyn specialists. Fertility is decreased with obesity and immediately improves with weight loss.
I welcome consultations for younger women so that they have healthier child-bearing years.
There are six bariatric surgery programs in the state of Hawaii. Our providers collaborate with the Hawaii Bariatric Society. We have varying experiences with increased or decreased referrals for surgery due to the emergence of GLP-1 medications.
In my practice, I welcome the use of the GLP-1s to enhance pre- and post-surgery outcomes.
In summary, obesity is a multifaceted disease in which genetics, environment, psychological, and behavioral factors come into play. Tackling obesity is not as simple as taking a medication or doing a diet.
Successful weight loss and maintenance requires lifestyle changes and should be taken through a multidisciplinary approach.
Self-motivation is key. I recommend to my patients to start with little healthy doable changes. If at a party, consider filling the smaller plate instead of the big one.
When this seems more ‘normal’ and easy, then later, work on better food choices. It can be hard to find and make time for formal exercise given busy everyday work.
Therefore, increase movement by doing things like taking the stairs rather than the elevator, parking the car further away, or paying attention to the pedometer on the cellphone.
Making these small healthy changes is easier to accept and make a routine to sustain a healthier living.
For Filipinos who have a high genetic risk for disease, this should be recognized and action taken earlier in life.
MAREL VER, MD is a general surgeon specializing in bariatric surgery and is the previous PMAH president.
+ There are no comments
Add yours