At the Forefront Live: Conversations on Weight Management

[MUSIC PLAYING] Hello and welcome to the University of Chicago Medicine at the Forefront Live. It is January and many of us are trying desperately to stick with our New Year's resolutions. Of course, one of the top resolutions is to lose weight and be healthy. But losing weight and keeping it off is a real struggle for many and can be disheartening. Today we have two representatives of our weight management team here to answer your questions. So make sure you start typing in your questions in the comments section. We'll try to get to as many as possible today.

We want to remind our viewers that today's program is not designed to take the place of a medical consultation with your physician. So welcome to the program. We'll start off, if you'll introduce yourselves to our viewers and tell us a little bit about your areas of interest.

Thank you so much, Tim, for having us. So I am Silvana Pannain. And I am the faculty here at the University of Chicago. I'm a board certified endocrinologist but also certified in obesity medicine. I've been interested in obesity medicine for at least the last 10 years, or earlier, I would say. And eight years ago, I established Chicago Weight, which is our medical weight management program.

Perfect. Dr. Busby.

All right, thank you so much, Tim. I'm Andrea Busby. I'm a licensed clinical psychologist. I have a specialization in health psychology. I'm on faculty here at University of Chicago Medicine in the departments of psychiatry and endocrinology. And I am the Associate Director of the Chicago Weight program.

Fantastic. Let's just start off talking about Chicago Weight program. I'm very interested. We were discussing a little bit before the program aired-- and I know you guys do a lot of work there-- what exactly is the program and how much does it encompass when you deal with patients?

Thank you so much. So I would like to think of Chicago Weight as much as a comprehensive wellness program. So we have a myself and the nurse practitioner as the medical providers, Dr. Busby as the health psychologist, and we have a dietitian. And I think what's important, we try to look at patients in that 360 degree angle. So you know, we look at the medical conditions that could be associated with excess weight. We look at medical conditions and medications that can favor weight gain.

We ask about sleep. We ask about eating disorders, screen for eating disorders. We offer treatment for eating disorders. And we also look at social stressors, psychological stressors, all those factors that can make it more difficult for patients to lose weight and may have accounted for the weight gain in the past. So really, we want to be as comprehensive as possible. On the other end, we want to really design, very much, and utilize with a plan for our patients.

I would imagine that's the challenge when you are talking about weight loss because there's so many factors, as you mentioned, that impact a person's weight and how they deal with weight and weight loss. And there's just so much that goes into it. What are some of the main reasons that people struggle to lose and maintain that weight loss?

I think this is a very important question. Actually, I often discuss this question and this topic with my patients. So you know, we understand now in the last 10, 20 years that there is what we call a metabolic adaptation to weight loss, which are limiting weight loss, especially when we think about just lifestyle modification. And we are promoting weight regain over time.

So what are those? I mean, there is a couple of things to think about. Number one, it's easy to gain weight, right? We may the orthopedic surgery, and we gain 20 pounds. But then when we try to lose weight, we lose the initial 10 pounds but then the other 10 pounds are more difficult to come off. And so what's happening? Number one, there are studies showing now that when we lose weight, hunger-promoting hormones go up and satiety promoting hormones will go down.

So while we are losing that unhealthy weight, our brain is hearing screaming, I'm hungry. So it's-- on the other end, studies have shown that we will lose weight-- that if we decrease our energy expenditure, specifically that resting metabolic rate. Means the even if by sitting down, we are consuming less calories when we have a lower weight. So now we understand that when our patients are not able to lose a significant amount of weight, clinically significant, or are already gaining weight over time, it's not they're not trying hard anymore.

They're still trying hard. It's not their feeling. But I like to say that that physiology is failing them. So that's why it's important to then call the intervention, or the team, the program, the physician, the psychologist, because there are so many factors that are really leading to that equilibrium and energy balance.

That's just not fair. It seems like the deck is stacked against us almost when we do try to lose weight because of some of the physiological factors. It was interesting. We actually got to-- we talked about getting introduced to one of your patients because we wanted to talk a little bit about some of the success stories. And we spoke with one of your patients just yesterday. And she told us an incredible story.

Her name is Rita and she's been on a weight loss journey that has been very successful. She's lost over 100 pounds. And she has advice for others who are struggling with this situation.

If I could just tell the people not to give up and it's not easy, right? I mean, it's just everyday it's still a struggle because it's a struggle for everyone to stay in shape and to you know, I mean-- but now it puts me on an equal level with everyone else. I mean, it's a struggle for everyone to behave. And it's, you know, you know-- but it puts you on an equal field, you know, or somewhat of an par field because we're still starting from, I think, a little bit behind.

She's a very nice lady and she's had a lot of success, so that's exciting to see that.

I think what's really conveying is when the patients have the right treatment plan, they feel empowered.

Yeah.

So this time is different. I think that's what it's starting to tell us. That's where we're trying to take our patient to.

And a lot of this just is obviously-- deals with psychology. And so we'd love to talk with you a little bit and just get your take on why psychological treatment, why that's such a critical part of this whole process.

Yeah. Well, when I think about losing weight, no matter what your collection of treatment modalities are, intentional behavior change is an inevitable aspect of it. And it's really, really difficult. And what we know is that, even when people are presented with very specific plans, for example, what to eat and what kind of physical activity to engage in, simply knowing what they are supposed to do isn't enough to actually make those things happen.

So a lot of what I'm doing with patients is what I call implementation work. So let's say that you've been given a very specific plan by our dietician or by our medical providers, how are you actually going to make that happen if the things that we're asking you to do are time-consuming, maybe involve some financial expenditure, if they're not particularly fun, if you've got an incredibly busy schedule.

So just really trying to lay the groundwork for success in that way. In addition, for many people, eating is emotional. We don't simply eat just to meet our calorie needs. And so for people with very significant emotional eating or for people who have diagnosable eating disorders, like Dr. Pannain had mentioned before.

Which you diagnose them.

Yeah. I will be addressing those things with patients, yeah.

Yeah. And so it's a long journey as you deal with folks that do need to lose weight. And I think, as you mentioned, it's so important for people to know that they have support. And that's a lot of what happens at Chicago Weight, is that correct?

Almost definitely. People come into our clinic often talking about frequent experiences, even in medical care, of feeling judged, feeling like they've been blamed for their medical condition. And the first thing that we want to do is provide an environment of support and acceptance and nonjudgment so that we can really work together, collaboratively, with patients. Discover both their strengths and weaknesses and try to capitalize on their strengths so that they can be successful with their goals.

Fantastic.

Yeah, the other important message we tell to our patients here is that we are not at this point in what we call precision medicine. So we do not know which diet will work with each patient. We shouldn't know which medication will work with each patient. And even which behavioral approach will work with each patient. So it is also important to understand that weight management is a trial and error type of approach.

And we always tell the patient that if you come out from our clinic with a specific plan, but things didn't work out and you actually were not able to lose weight, come back. Because it's not that you failed. It's that in the treatment plan we designed, it was probably not the plan for your physiology, for you as an individual. So there is many things and many different approaches we can offer to the patients.

It is a lifetime or a long term, really, relationship. A so very important the patient's don't carry that self blame of failure and understand that it is not their responsibility. It is our responsibility as a team to come up with the plan it works for that individual patient.

Yeah, and it's a plan that can evolve over time.

Exactly.

It's very collaborative in nature. We are very interested in patient experiences and perspectives and opinions in terms of how their treatment is going to progress.

So we are getting questions from our viewers. So I want to get some of those. And I want to remind our viewers, please just type them into the comments section. We'll try to get to as many as we possibly can. Our first question from a viewer is, what are your thoughts on low carb? I tried eating a high protein diet but have lost little weight.

OK, that's actually a very important question, and very much in the news. Because I would say that it comes to what's the perfect diet? What's the diet that works best? This question has been probably asked for the last 20 years. There is a time where a high fat diet-- sorry, a low fat diet were much in Vogue.

And then we then we start to say, no, a low carb diet, high fat, low carb diet are better because patients seem to lose more weight. And then, OK, what's the state of art, what we know from what we call evidence-based medicine, from the studies. Number one, now understand-- and maybe there is no significant difference between low carb and low fat. And actually, there was the largest study was published just this year. It's called diet fit study, has to do with fitting the diet with the patient. And they looked not only-- they look at 600 patients. Divided into 300 in a low carb diet and 300 in a low fat diet.

And they were trying to encourage them to follow a healthy diet. So shop at the farmers market, cook your own food, and so on. So the studies showed it was not a difference in weight loss between low carb and low fat. So the question is, possibly, that one specific individual may respond to a low carb diet more better than low fat diet and vise versa. It maybe to do with genes, maybe with to do some metabolic factors.

We don't know. We cannot predict, at this point, which would do best with each diet. But also, what we know in obesity, there is often not only about following a diet. Because if it were just a question of following a diet, like is a question of how much in, how much out, then we will all probably figure out. So that's where the medical-- the comprehensive weight loss program support comes in play, where these other factors, other tools, on top of your other diet, that it comes to play in order to help the patient to move the needle, the set point of the weight.

So will it tell us, there is no one tool or combination of tools. So medical, seeking medical advice, seeking advice of a comprehensive program is probably the next step when we don't-- cannot do by our own.

And Doctor Busby, when you see these patients that come in that are struggling and you're trying to find the different plans, the psychological aspect of this to me seems like it must be just critical because you have to find what they're-- why they're doing this, what their motivation is, that sort of thing. And how challenging is that aspect? Are people willing to open up and work on that part?

Or do they just want to come in and get a quick fix? What do you see when you deal with patients?

Oh gosh, you know, it's really such a variety of things. You know, I certainly have people who come in with sort of a shell-shocked look saying, why am I scheduled to see a psychologist? And then I get other people who come in and say, you know, your part of the treatment is really what I'm most interested in. You know, it certainly is part of my job to help people feel comfortable talking to me. You know, part of my job is asking very in-depth personal questions in the very first meeting with someone.

And I understand how difficult and vulnerable that can be from the patient's side of things. And so that's something that I've had a lot of training in. But certainly there's variability in people's openness and willingness, especially at the beginning, to discuss that with me.

Yeah. We have two questions from viewers and they're basically the same question so I want to make sure we get this one asked and answered. I think it's important. Can diabetic clients do the keto diet?

That's a very important and very much in the news, question in the news. So yes, in a medical setting. So it's very important to add the medical supervision in order to do safely a keto diet. But in that context, we see actually a dramatic response of in terms of sugar levels, in terms of a medication needed to control diabetes with a keto diet.

So it's safe if done in the medical setting where, for example, you have a physician who was able to change the insulin doses or frequency, or the other diabetic medication. So as long as there is medical supervision, yes. Actually, there's dramatic responses published recently. There's a lot of-- in the scientific society-- about the response of diabetics, specifically, to the keto diet.

Interesting. Dr. Busby, this one's for you. Do they incorporate therapy for all patients? That's one of our viewers asking.

Well, every single person who comes into our program is seen by me for their initial visit. And based on that initial visit is when we'll make the decision of, basically, what the next step is. So certainly there are people who come in for their initial visit and we make the decision that that will be the only planned visit with me at that time and then I'll be available as needed later.

There are folks who come in and we determine, based on what's going on with them, that it would be best if they saw me weekly. You know, it really depends on what people's needs are.

Fantastic. Doctor Pannain, how can medication be helpful for people who are struggling with weight loss?

So I think at this point, you know, in world obesity, when they're selling medications are very important. It will help to counteract a little bit that, what we call, metabolic adaptation to weight loss, that biological forces which really make it difficult to most of us to lose weight or maintain weight loss over time. So the medication seems to kind of move, again, a set point lower.

So with medication, combined with lifestyle modification, or combined behavioral therapy, you can achieve a larger weight loss than with lifestyle modifcation alone. And this is what the data show. So pharmacotherapy, it is an important component of our weight lost program, especially because now, in the last 60 years, we have four new medications, which are approved for weight loss. And we know they are safe because we have two, three years of data, safety data, in the studies, in the trials.

And we know they are more effective than the medication we used to have 15 years ago. And that so they've become a very important tool in any weight loss program of excellence. And so-- we are expert in prescribing this medication. We have a lot of experience. But it's very important-- the data showed that those medications alone will not give the same weight loss than combining with the lifestyle modification, the behavioral therapy.

So if possible, our patient should have access to those other tools as well.

Perfect. Now Rita uses a medication to help her with weight loss and she's been very happy with the results so far.

And for me, it was like-- I equated to a light switch. It was like a miracle for me, almost within days of starting the medication, how I react to food totally changed. I wanted to say for the first time in my life, I started eating like a normal person. I could tell what it meant to be full. Before I never knew when I was full.

So I could start separating the behavior component of overeating versus the physical component of it. So now I know what I'm eating because I want to eat, because something tastes good, versus just eating all the time because I am obsessing with food.

That's very interesting. And it showed, obviously, the importance and the success that she's had through your program and with some medical-- some help from medicine. So that's great. Couple more questions for viewers that just came in as we were listening to that little sound bite. What are thoughts on-- your thoughts on intermittent fasting for weight loss?

Again, a lot in the news about intermittent fasting. So the intermittent fasting is that when you fast, at least more than 12 hours, up to 15, 16 hours, there may be what we call a metabolic switch. It means that we switch from using sugar for energy to use fat for energy. So that fat burning more that may actually favor weight loss. Now, studies in rodents, animals, have shown that intermittent fasting may be more successful in terms of weight loss.

Now, human studies-- and we have a just few studies with a limited number of patients-- are not clearly showing a benefit in terms of weight loss. Not necessarily showing what we call a metabolic benefit [INAUDIBLE] diabetes and so on. Again, and the data are limited. But what they're showing that is safe to do intermittent fasting. And it can be as effective as doing the low everyday low calorie diet.

So the idea is-- intermittent fasting can mean two things. Either you do what we do, time restricted feeding. You eat from, let's say, 12:00 to 8:00 but then you fast for 16 hours. Or can be that you eat less than 25% of your caloric need twice a week and you eat a normal diet the other days. That's what-- there are two types, I would say, at least.

So the idea is, for example in our program, the patient actually may have a preference in skipping breakfast and eating in that the eight hours window. It works better for lifestyle or they tried before, it worked. And because the data are not against that, if that's the patient preference, then we do support the patient. And we observe and see if that approach works.

So it is-- they may be promising. We don't have enough human data. But again, it always shows that we don't have the perfect diet, the same way the low carb, better fat. We yet to know if there is a perfect diet. It's very much an individual approach. And that's why that history at the beginning of the first visit, which tends to be a long visit, history will work for the patient in the past and what not work is a very important piece in designing that plan.

And so we really-- it's a collaborative work between the patient and as it's provider, designing the treatment plan. We agree, on it.

Another question from a patient, or a prospective patient. They take Prozac for anxiety, they want to know if they can take medication for weight loss.

Yes. So, we actually have often complex patients with multiple medical problems from diabetes, hypertension, [INAUDIBLE] disease. So we often talk to these patient's psychiatrist with the patient's permission. So there is no contraindications for most of the weight loss medication to be used in concomitance with, for example, antidepressants.

It is very important to monitor the patient response to the medications, closely, in the first few months. Because usually what you see the first few months is what we're going to see over a longer period of time. So we monitor the patient closely. And remember, most of the weight loss medication do act in the brain, suppressing appetite. So it is very bad because they're acting in brain, they could theoretically affect the mood. Sometimes in a positive way, sometimes in a little bit more negatively.

So close monitoring is the key to make this right and really benefit the patient.

Doctor Busby, one of the questions that we received was cravings. How do you deal with cravings? How do you manage cravings? And that's a killer for all of us. I mean, I know I fall in that category where as soon as I get home, I walk through my kitchen and the first thing I do is open my refrigerator.

Right.

It's the dumbest thing I can do. I realize it. But I do it. How do you break those habits?

Yeah. Well, I want to preface this by saying that there is no magic bullet for this.

I wish there was.

Unfortunately. I know, I know. But you know, I would say the typical way that I would approach this with a patient is, you know, I would first provide a little bit of education about what is a craving. You know, how do you distinguish it from true hunger, first of all. You know, talk about how it, in certain ways, cravings are like emotions. They come and they go.

They're typically in response to what's going on in your life. And they come and go naturally without us doing anything about them. You know, want to, of course, normalize the patient's experience that everyone experiences cravings. So they're not unusual or strange or wrong for experiencing that. And then often the next step that I would take is doing what I would call a functional analysis of their cravings, where determining what are the antecedents or the precipitants or triggers of cravings.

And what are the consequences of eating in response to cravings?

For me, it's breathing. I'm joking. And it isn't funny. I shouldn't joke about it. But you know, one of the things that I think-- I don't know if it was you that mentioned it to me. Somebody on your team did. That even the setup of a person's house can impact.

True.

Like I said, I park my car in my garage, the door enters into the kitchen. So there I am.

Yeah.

And it's the first place I see when I go home. And there are days when I try to kind of just rush through and keep going but it's--

Right, so certainly there can be both external and internal triggers. So external, yes, you know, setup of your house, your workplace, your commute. You know, really anything. And then internal triggers, you know, primarily emotions. And so you know, part of what I do is if, you know, if there's a way to decrease the prevalence of the triggers or decrease exposure to the triggers, we can do some work there.

Or-- and then we also talk about the inevitability of being triggered and then that kind of things that you can do to cope with that experience because inevitably the craving will decrease whether you do anything about it or not. So what is it that you can do in that moment, basically, to tolerate it. And what that might be is really individualized. But that's how I would approach it.

I like that. A couple more questions from viewers. This was interesting. Any studies-- have you seen any studies-- on patients who are post treatment for breast cancer? What is the long term effect on metabolism and weight gain or loss for those folks who have lived through breast cancer?

Yeah, so actually what happened is that with new therapies for cancer, we actually see more and more weight gain induced by those treatments. Some of the new agents may induce increased hunger. Or for example, we had to use what we call steroids, that combine that the chemotherapy-- with chemotherapeutic agent may actually induce weight gain.

So actually, in our program we do see patients referred by an oncologist because of past treatment weight gain. We have-- I can think about a few patients, post breast cancer treatment weight gain. So we approach them in a similar way. But what is different is I like to call that what we call drug-induced weight gain. So even if you're not seeing a large weight gain, we know that the weight gain is really was due to a medical treatment.

So we want to aggressively to treat that because the patient-- a lifetime was actually to be a normal weight. It was just a cycle. We call it the [INAUDIBLE] due to medical treatment. So there is no doubt now, weight gain after cancer treatment, which we didn't know-- used to see when we had the old chemotherapy agent and which induce signficant nausea and vomiting. We have more of this.

So I think we need to really be ready to see these patients in our practice. And the problem is that high weight has been associated with 13 types of cancers. So high weight actually may worsen the outcome. It may favor the recurrence of the cancer. So although there is no strong data, it probably is important to help the patient to go back to a normal weight after all that treatment.

Interesting.

So it's probably important for the cancer by itself.

I'm going to try to get to one more question. We're about out of time for the program. But a viewer wants to know if there are studies that show a correlation between the gut microbiome and weight loss, or gain.

Yeah, there's plenty of studies. We're looking at that. There's a lot of interest of the relationship between microbiome and weight gain, or difficulty losing weight. The idea is that maybe the current environment is changing our microbiome. That may explain, for example, why it's difficult to lose weight once we have gained weight. Why our body is sensing the higher weight as being a new normal and is defending that weight.

So the microbiome could be one of the reasons why the sensing of energy in our brain changes in this environment and changes after we gain weight. So a big part, a lot of studies, impossible to summarize one statement. But it's very much a hot topic, which may change in the future the way we treat our patients, or maybe even the type of diet that we give to our patients.

I do to hear from Rita one more time. She's exercising now that she's lost all this and it feels great. The weight loss plan has given her a new outlook and really makes a positive difference in her life.

I've struggled with my weight all of my life. And I've lost weight numerous times, only to gain it back. And right before a doctor-- I saw Doctor Pannain, the same thing was happening. In 2013 I'd lost a little-- right around 100 pounds or so. And around 2014, '15, I don't recall exactly when I started seeing her, I was repeating the same pattern. And wanted to try to stop it from happening again.

So I would lose the weight and then regain it and gain a little bit more. And I always had done it on my own, never sought any help losing weight. I always thought that weight management was mind over matter. And always blamed myself for gaining weight.

Nice to see that she's doing so well. So congratulations. That's exciting. Fun to see patients like that. Thank you for being on the program. You guys were great.

Thank you so much for having us.

That is all the time we have for At the Forefront Live today. We want to thank our experts and Rita for being on the program. And make sure you watch January 22nd as we discuss breast cancer screening and a national study called the wisdom study. We'll take your questions and have our experts on to answer as many as possible.

That's Tuesday, January 22nd. Watch your Facebook page for more information on coming programs. Thanks again for watching At the Forefront Live. We hope you have a great week.