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01/21/2022

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12/30/2021

Although the extent and impact of obesity is widely recognized in the medical community, this level of heightened awareness does not extend to the general populace. A 2019 Gallup poll found ideas about what constitutes “ideal” weight has been on a slow but steady increase. Currently the average weight of American adults is 178 pounds, and although this exceeds perceived ideal weight by more than 10 percent, fewer feel the need to lose weight. Only 38 percent of Americans describe themselves as overweight, but the Centers for Disease Control estimates that over 70 percent of adults over age 20 have overweight or obesity. The numbers just don’t add up!

This increase has been steady over the past several decades. Between 1960 and 2016, obesity rates have risen nearly 30 percent. In addition, more people now say they weigh at least 200 pounds, an increase of 24 percent from the last decade. While men are more likely to be in this category (42 percent), 14 percent of women also indicated they weigh over 200 pounds. Although the number of women is smaller, it is nonetheless a great concern because the average weight of women is 159 pounds, compared to an average weight of 196 pounds for men, so the percentage of increase is notably higher. Clearly we have become more comfortable with our weight.

An argument can be made for the importance of self-acceptance; however, there is an obvious need for greater awareness about the severe, negative health impacts of obesity. Obesity is an epidemic and understanding it as a health issue, versus an image issue, must be elevated beyond the medical community to the greater population.

Addressing the many factors contributing to obesity extends beyond the capacity of the medical community. Poor food options, portion control, food deserts, access to health care and other social determinants require a broader, more comprehensive intervention. However, it is no longer prudent or acceptable to wait for national intervention; change must happen and it must be now. The National Academies of Sciences, Engineering and Medicine recommend major reforms, including a call to health care providers, insurers and other relevant organizations to take a leadership role in making obesity prevention a focus. This makes good sense because primary care physicians have relationships with patients and thus can monitor, educate and, if necessary, refer patients to weight loss centers that can help them deal with the challenges they face.

Obesity is a health crisis with a financial domino effect that impacts everyone in a community, regardless of their individual weight. It is clear that an immediate change is needed on local, national and global levels, and it is incumbent on anyone who has the knowledge and resources to initiate that change, even on a very small scale, to take the initiative.

12/30/2021

A walk along a beach, through a park, or around a neighborhood can be the perfect start to the day, or a way to relive the midday stress of the job or having to monitor stay-at-home school activities. Getting outside in the air and the physical activity of moving acts as a reset button that can go a long way to clearing away anxiety and shifting a mindset to a new perspective.

When a walk is recommended to improve health, however, suddenly it is “exercise” and there’s resistance. While most people are aware of the benefits of cardiovascular exercise, the thought of having to incorporate strenuous effort into a daily routine can outweigh the prospect of greater health benefits. For people with obesity, experiencing a visible or felt difference may occur too slowly to be perceived as a rewarding enough outcome to warrant continuing with an exercise program. What once was an enjoyable activity is now viewed as an obligatory burden.

To encourage a more active lifestyle may require adapting how the addition of physical activity is prescribed. For some, the idea of exercise can conjure visions of weight rooms and machines and way too much effort — not to mention a room full of fit and muscular athletes. Although the perfect body isn’t the reality for most Americans, it can be hard to imagine transitioning from the person in the mirror to a trimmer and healthier future self. Finding activities that are enjoyable and adaptable is the key.

Walking is a good option because it can be done almost anywhere and requires no additional equipment beyond good shoes. The American College of Cardiology, the Centers for Disease Control and other health organizations agree that 150 minutes of moderate intensity over the course of a week is the recommended guideline. Although that equals less than 22 minutes per day, this still may seem unfathomable to someone who leads a primarily sedentary life. Identifying various options that demonstrate that it can be manageable and breaking it down into smaller chunks helps people visualize how it can be incorporated into their day. For example, walking 37 minutes every other day, or even a 10-minute walk before meals each day would meet the guidelines.

Walking with friends adds a social component, as well as the comfort of knowing someone is available for encouragement or to call for help if necessary. For those who prefer to walk alone but may lack motivation, audiobooks or podcasts can be a pleasant distraction and serve as a virtual walking companion. Or, identifying a target location, such as a library or friend’s house establishes a clear distance and goal. This can be helpful because people with obesity are less likely to set weight loss goals even though doing so increases the likelihood of achieving significant weight loss.

Of course, walking isn’t the only option. Riding a bike — stationary or outdoors — strengthens the heart and lungs, and swimming is non weight-bearing so it provides a full body workout with no impact on joints. As strength and stamina build, the level of activity can increase, or new activities incorporated.

The options are unlimited! Weight loss is a journey and each step forward helps reduce multiple health risks, and offers the added benefit of positive psychological well-being. Every day offers a new beginning and each day begins with a first step.

12/30/2021

The 2001 Look AHEAD (Action for Health in Diabetes) trial was groundbreaking for its findings related to weight loss and maintenance through intensive lifestyle intervention, including the use of a Very Low Calorie Diet (VLCD). The purpose of the study was to identify the influence of weight loss on cardiovascular morbidity and mortality in people with obesity that had type 2 diabetes. The outcomes of this trial have served as a foundation for continued research on the efficacy and safety of VLCDs over the past 20 years. In this post we will review some of the foundational and more current (within five years) research supporting the use of VLCDs across populations and the medical continuum of care.

The data collected over the eight year span of the Look AHEAD trial provided invaluable information about medical and quality of life outcomes. Improvements to lipids, blood pressure and glucose management were found, as well as positive outcomes for renal disease, sleep apnea and depression. Importantly, weight loss was significantly higher for the intervention participants, regain was slower and maintenance of loss was higher.

The Diabetes Remission Clinical Trial (DiRECT), which also used total meal replacements, began in 2014 to determine if a weight loss of at least 15kg would lead to diabetic remission without medication for at least two months. The goal was achieved, and 46 percent of the intervention group experienced remission at 12 months, with 36 percent still in remission at 24 months. Additionally, the intervention group experienced significant reduction in systolic and diastolic blood pressure and improvement in triglyceride levels, used fewer medications and reported a significant improvement to quality of life.

These studies spurred further investigations and current research continues to support the benefits of weight loss using a VLCD. Several studies confirm that the reduction or elimination of insulin treatment or other diabetes medications is possible when patients follow a VLCD (e.g., Fatati, 2020; Pareja, etal., 2020). Evert and others (2019) also support the use of VLCD as an option for nutrition therapy as a means of quality diabetes care.

Positive outcomes extend beyond the diabetic population to include those with cardiovascular, nephrological, orthopedic and other issues. Among geriatric populations, for example, VLCDs led to greater weight loss and reduction in waist circumference, fat mass and android fat. There were also significant improvement ins HbA1c and improvements in multiple cardiovascular risk markers (Haywood, etal., 2017 and 2019).

Further, VLCDs have been used safely by patients with kidney disease when medically supervised (Woods, etal., 2019), and led to metabolic and clinical changes in patients with non-alcoholic fatty liver disease (Schwenger, Fischer, Jackson, Okrainec & Allard, 2018). Rehackova and colleagues’ 2017 study took a different approach and looked at patients’ experiences when using meal replacements. Patients indicated that although it required effort, adherence to a VLCD for eight weeks was easier than expected and was perceived as “highly gratifying.”

While there is no “one-size-fits-all” approach to weight loss, these and other clinical trials and secondary reviews suggest that VLCDs are comparable or more effective than other weight loss methods, not only in the amount of weight loss but also in terms of physical and mental health improvements. Benefits have been shown both for short-term (≤ 12 months) and longer term (≥ 12 months) outcomes when used as part of a medically supervised program. To ensure the most effective options are available to those who need them, the medical community should consider all weight loss options for treating patients with obesity and their comorbid diseases, and include VLCDs among their recommendations as part of a lifestyle change.

12/30/2021

Obesity has been an epidemic in the United States for decades and it now affects 42 percent of the adult population. This is the first time in our history that the national rate exceeds 40 percent. Earlier predictions, including one from a 2010 study by Harvard and the Massachusetts Institute of Technology, anticipated that this level of obesity would not be seen until 2050. However, a 2019 Harvard study now offers a more alarming view and anticipates that nearly 50 percent of the population will have obesity by 2030. This increase has serious consequences for those affected by the disease and the physicians and health care systems that provide treatment.

Weight loss and management are the best options for healthier patient outcomes. A comprehensive weight loss program that includes medical oversight, education, counselling, behavior modification and lifestyle changes offer the most helpful and effective resources to effectively address both the disease of obesity and its symptoms. This approach is imperative because too often only the symptoms are treated, rather than the root cause, contributing to the cyclic nature of treatment while serious health issues such as diabetes and hypertension develop.

Health care systems benefit when weight loss programs are offered in-house. A primary advantage of this is having all patient records centralized and accessible. A surgeon considering a total knee arthroplasty can review a patient’s file to decide if a consultation with the patient’s primary care physician or cardiologist is required without risking unnecessary delay. Pre-surgical weight loss also can lower the risk of surgical complications by reducing cardiovascular risks and problems with anesthesia, and it leads to better wound healing and shorter hospital stays.

There are also financial benefits. Sending patients outside of the system to address health issues bifurcates their care and can result in them leaving the system completely. Further, because obesity is linked with so many comorbidities, an in-house program can quickly grow through referrals across multiple departments whose patients’ health and medical treatment can be significantly impacted by obesity. This includes orthopedics, cardiology, endocrinology and gynecology, among others.

Using medically prescribed meal replacement products as part of a supervised weight loss program offers positive outcomes for patients across specialty areas, as well as those preparing for surgery. Research supports the use of a Very Low Calorie Diet (VLCD) for multiple conditions, and findings show improvements including a reduction in the need for diabetes medication, decrease in hypertension, improved lipid and glucose markers and a better quality of life. The use of a VLCD also has led to greater and more consistent weight loss and management in many groups.

Treating obesity is challenging in today’s health care environment. It demands continued attention to create a common understanding of its impact as a disease with ongoing personal, social and economic implications. In-house weight loss programs using medically-prescribed weight loss supplements is a first step in recognizing and treating obesity as a disease, with benefits to individuals affected by obesity, as well as the medical staff and health care systems that treats them.

12/30/2021

The Underlining Cost of Obesity.
What’s the cost of obesity? A report from the Centers for Disease Control found that more than 48 million surgical and nonsurgical procedures are performed in hospitals and ambulatory surgery centers annually. Another study estimates that Americans undergo an average of nine surgical procedures in a lifetime, including in-patient, out-patient and non-operating room invasive procedures. With surgery comes risk, and for people with obesity that risk can be significant.

Surgery on patients with obesity is more complicated due to their increased adiposity and often results in longer procedures, extended time under anesthesia, more blood loss and lengthier hospital stays. These patients also are more likely to be admitted to an intensive care unit and require a ventilator than non-obese patients. This can lead to higher surgical site infections, increased readmissions, decreased rate of dismissal to home and increased costs for all involved. Although the level of risk varies, it is consistent across various types of surgery including orthopedic, cardiovascular, gastroenterological, plastic surgery and labor and delivery as representative examples.

With literally millions of surgeries occurring each month, the medical challenges faced by patients can quickly become financial burdens for physicians and the health care system. The increased likelihood of surgical and post-surgical complications means that procedures with added difficulty, risk and time requirements will exceed the standard parameters set by Centers for Medicare & Medicaid Services (CMS) and other insurance providers. As such, the predetermined, flat reimbursement rate does not fully cover the costs that are inherent in these more complex surgeries. Similarly, “higher than expected” readmission rates are likewise penalized by the CMS, essentially discriminating against treating patients with obesity or others who are physically or socioeconomically disadvantaged.

One recommendation has been to treat patients with obesity in health care facilities that specialize in the specific illness or disease for which they are being treated. This ensures that medical staff and equipment with most critical to the need being treated are in place. While this might contribute to healthier medical outcomes, these facilities would be treating higher risk conditions, thus incurring greater costs, thereby facing the same issues with CMS and other insurers.

One way to minimize post-surgical risks is pre-surgery weight loss, and physicians should encourage participation in a monitored weight loss program as a criterion for surgery. In-house weight management programs have the added benefit of keeping the patient and their medical history accessible. These programs offer support and counselling to help patients lose weight and attain positive surgical outcomes. A Very Low Calorie Diet (VLCD) or Low Calorie Diet (LCD), such as New Direction Advanced, improves surgical eligibility, minimize medical complications during surgery and reduce post-surgery hospital costs and readmissions. Many hospitals already have established programs which have helped prevent 43,000 cases of obesity over 10 years.

Preventing surgical complications before they arise offers the greatest benefits to the patient, and weight loss is the first step. When this is not possible, the medical community must remain updated on the best practices and resources needed to ensure the health and safety of all patients and minimize risk before, during and after surgery.

12/30/2021

The Academy of Nutrition and Dietetics designates March of every year as National Nutrition Month. Since the Academy recommends meal replacements as “part of a comprehensive weight management program,” this is a good opportunity to review the nutritional benefits of a Very Low Calorie Diet (VLCD) and meal replacements.

Today’s medically prescribed meal replacements are developed based on evidence-based scientific research and use high quality, nutritionally complete ingredients. For example, New Direction meal replacement beverages and bars provide 100% of RDI for protein, vitamins and minerals, exceeding the recommendations established by the National Academy of Sciences National Research, and can be used to support a range of medical issues, including obesity. The additional macro- and micronutrients are specifically selected to allow absorption at different rates to maintain optimal protein levels.

Research provides additional support for meal replacement effectiveness. Studies consistently find significant health benefits including lower cholesterol, blood pressure and blood glucose; cardiovascular improvements; and the reduction or elimination of the need for diabetes medication. And, because they are convenient, portable and require minimal preparation, compliance is often higher. Post-intervention surveys confirm that meal replacement users find this weight loss strategy easier to follow and offer significantly higher scoring for their understanding of and compliance with food amounts — all components to weight loss success.

Yet despite the health benefits associated with meal replacements, there remains a gap in awareness, even among the medical community who treat obesity. A recent study shows that health care professionals with limited knowledge of meal replacement products prescribe them at much lower levels than those who have had formal training in the use of meal replacement products. Similarly, potential users can be poorly informed. A study of meal replacement users found confusion in their understanding about nutrition, balanced meals and eating styles. Among the misperceptions were the belief that meal replacements can compensate for overeating and that exercise was unnecessary when using them.

This lack of education and misunderstanding can have a negative impact on treatment by omitting meal replacements as viable weight loss options for patients who can benefit significantly from their use. This takes on added importance because meal replacements are most effective when they are they are part of a structured program with regular weight and health checks, professional medical advice and recommendations on dietary guidelines. This supports the need not only for baseline training of staff, but also ongoing education to stay abreast of current research and best practices.

Obesity is an epidemic that is being treated more as an afterthought than a disease and this band-aid approach will only continue to contribute to this misguided approach. This is exacerbated by a lack of understanding of the research on meal replacement which acknowledges and recommends them as a relevant option for people with obesity. It is imperative that the medical community be open to effective, scientific alternatives that can offer hope and improved health to patients in dire need.

12/30/2021

Body Mass Index (BMI) is the most commonly used measure to screen for and diagnose obesity, but is it the best tool to do so?

Determined by dividing weight in kilograms by height in meters, squared (kg/m2), a BMI >30 kg/m2 is considered obese. While there is a strong correlation between BMI and body fatness, there are other variables to consider. First, women tend to have more body fat than men, so the same BMI diagnosis likely means different levels of fatness. Similarly, athletes have less fat than non-athletes and some races have more or less body fat than others. This could lead to overestimating (or underestimating) weight-related or other health conditions. Body mass also does not differentiate between fat and lean muscle (or fluids or bones), nor does it account for fat distribution. As such, BMI should always be considered in the context of a clinical assessment.

An alternate — or better yet — complementary measure is body fat percentage. This assessment distinguishes between body fat and lean muscle and identifies different baseline measures for men (>25 percent) and women (>30 percent) to account for varying levels of body fat. However, as with BMI, body fat percentage does not recognize fat distribution, which can be indicative of potential health issues.

To address the fat distribution gap, waist circumference is a useful determinant of visceral adiposity. This screening measure is important because abdominal obesity is strongly associated with insulin resistance, type 2 diabetes and cardiovascular disease. To that end, waist circumference is a much more reliable indicator of health issues as compared to BMI, and it might help explain to patients why those who have a large waist but are not otherwise overweight are still at risk.

Waist-to-hip ratio is another method to predict risk based on fat distribution. This calculation accounts for the difference between apple- and pear-shaped bodies. Both waist circumference and waist-to-hip ratio have different classifications for men and women, and although both measures are considered equally reliable, waist circumference often is favored because it is easier to obtain and interpret.

Regardless of how obesity is measured, weight loss is recommended. Programs, such as one that utilizes meal replacements, offer quick, measurable results in weight, body fat, waist circumference, and waist-to-hip ratio to help reduce the health risks associated with obesity.

The long and short of it is that a single measure is not effective as a diagnostic tool because it rarely gives the full picture. To help patients fully understand, and perhaps accept their obesity, it can be helpful to provide various measures and a clear description of how each is calculated, what it means, and why it is important.

12/30/2021

The greatest advantage a physician has to effectively treat symptoms and their causes is the ability to directly observe and interact with patients. Too often, however, the circumstances preceding and following a consultation may be beyond a physician’s firsthand knowledge or ability to help control. This is because the social, political and economic factors that face patients can have as much — if not more — of an influence on a patient’s well-being than whatever physical health concerns bring them in for an office visit.

These social determinants contribute to health and health care disparities in multiple ways. Upstream determinants, such as policy and governance, determine how downstream determinants — including access to health care, risk behaviors, education and community conditions — affect disadvantaged populations. There are also a number of contributing factors, some of which are uncomfortable to address, that must be overcome before real change can happen. These include discrimination, income and education levels, occupation and availability of health care access.

The current COVID-19 crisis has cast a brutal light on these disparities. Racially and ethnically diverse low-income areas had infection rates nearly eight times higher in early months. These imbalances have led to multiple professional organizations to call for recognition of how social determinants of health contribute to inequities in health care among vulnerable and disadvantaged communities and to demand action at individual, organizational and policy levels.

This is a real problem. In 2000, more than 16 percent of U.S. deaths (n=400,000) were attributed to poor diet and physical inactivity. In roughly that same time period, the rate of obesity increased by nearly 12 percent. The immediacy of mortality from obesity may not compare to the current pandemic, but the outcomes are undeniably similar. Food insecurity, which impacted around 37 million people before the pandemic is anticipated to rise to closer to 54 million people. Combine this number with poor nutrition, and the unfortunate, yet probable result becomes clear: People who are already at high risk become even more vulnerable to obesity and other diseases.

Understanding the social determinants that affect weight allows clearer focus on the development of all types of evidence-based programs to help shift financial support and access to a range of programs that reduce incidents of obesity before they become a costly health issue. This includes education on various weight loss options, including meal replacements. Research increasingly recognizes that a one-size-fit-all approach to diet is ineffective.

Successful weight loss and maintenance only occurs when participants are compliant. So providing options is critical to individual success.

The benefits of healthy communities extend far beyond the physical parameters of any neighborhood. Providing access to health care, food and other needed resources demands commitment from hospitals, health care providers, insurers and governments, as well as those who have or are at risk for obesity. Acknowledging gaps in health care accessibility and addressing the social determinants that contribute to them is the first step and it must be taken now.

12/29/2021

With so many individuals being overweight and obese, there is an ongoing impact on the workplace; lost productivity, absenteeism and limitations due to disabilities create financial burdens on employers and society. In an effort to acknowledge and address weight and health challenges, 80 percent of large employers offer some type of financial incentive to improve health. But how effective are these programs?

Weight loss incentives typically offer some type of financial reward. However, research on their effectiveness is mixed. A study evaluating corporate weight loss programs with more than 9,000 participants found that most participants initially lost weight regardless of incentives — but then gained the weight back. Another study offered participants a variety of incentives for achieving weight loss goals, including an immediate or delayed insurance adjustment or a daily lottery in which those who met their daily weight target could win $10 (18 percent likelihood) or $100 (1 percent likelihood). Almost all intervention participants lost weight but the mean weight loss was not significantly different than that of the control group. There were no significant differences across the intervention groups; however, among intervention participants, roughly 19 percent of the participants achieved the five percent weight loss goal.

On the other hand, incentives to increase physical activity seem to have better outcomes. One study measuring physical activity (increased steps) found that meeting percentile goals that adapt to circumstances or environment resulted in a gradual and, thus, potentially easier to maintain, behavioral change. As such, adaptive goals were much more effective than static goals, such as 10,000 steps per day. This study also found that immediate rewards increased the number of steps each day. A 2019 study suggests that technology has made participation in incentive programs easier and thus more effective. A systematic review of studies that included over 2,000 participants found that physical activity — measured as steps taken — increased by approximately 10-15 percent during the intervention and at the follow-up, thus providing short- and long-term benefits.

These and other findings suggest there are some benefits to incentive programs. For example, more immediate gratification yields better outcomes than the promise of a future reward. Also, incentives for physical activity, specifically increased daily steps, seem to be more effective than for weight loss. Recognizing this could benefit a more holistic behavioral approach to a healthier lifestyle.

Because immediate gratification can be motivating, creating a plan that incorporates an incentive for physical activity with a meal replacement program that leads to quick weight loss can be influential in establishing lasting behavioral change. Goal setting and financial incentives or contracts can be just the thing to start a patient on a health path of change.

12/29/2021

How Can Patients Prepare for Bariatric Surgery?
Bariatric surgery is considered a final option for people with obesity who have potentially life-threatening health issues related to their weight.
With the obesity rate in the United States higher than ever, it is not surprising that the number of people having bariatric surgery also is on the rise. Bariatric surgery, including gastric bypass, sleeve gastrectomy and biliopancreatic diversion with duodenal switch procedures, is considered the final option for people with obesity who have potentially life-threatening health issues related to their weight.

Who are Candidates for Bariatric Surgery?
To be eligible for bariatric surgery, patients traditionally had to be more than 100 pounds overweight or have a Body Mass Index (BMI) greater than 40; or have a BMI greater than 35 with at least one obesity-related comorbidity. Patients also need to demonstrate that they have tried to lose weight but were unsuccessful maintaining a sustained loss.

However, in 2018 the American Society for Metabolic and Bariatric Surgery changed their position statement to recommend that patients with a lower BMI, between 30 and 35, be considered for surgery because of the health benefits they are likely to attain. This includes improvements to or remission of diabetes, hypertension and hyperlipidemia. There is also recent evidence that some patients with fatty livers can experience a significant reduction in liver and heart disease after weight loss surgery.1 Reducing the size of the liver prior to surgery has the added benefit of allowing more room for the surgeon to operate.

Utilizing a Very Low Calorie Diet to Prepare for Bariatric Surgery
As with most surgeries, pre-operative weight loss offers health benefits. Losing five to 10 percent of excess weight prior to surgery led to shorter operating time and hospital stays, and greater weight loss one year after surgery. This is important because the 18-month period following surgery is the “honeymoon period” for weight loss. After that time the body starts adapting, so continued significant weight loss is unlikely. Accordingly, it is important to incorporate lifestyle changes during that window that can become habit and therefore carry over as patients continue their weight loss journey.

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