My particular area of expertise is in obesity medicine. And as many of you may have heard, in the last few weeks, the CDC released some recent data on obesity statistics in the United States, which showed that obesity, of course, is on the rise. Not surprisingly, many of us have experienced weight gain over the pandemic. And there are many reasons for that which I have discussed in prior podcasts. But even before the pandemic, obesity was on the rise in the United States, and CDC has been collecting this data since the early 80s.
Is My Weight Normal?: What is BMI and how does it work
Back in the 80s, we had a prevalence rate of about 10% of obesity. And, obesity, I know is a term that we don’t like to hear. It has a negative connotation in the general public, but this is a clinical term, and it just refers to a degree of excess weight as measured by something called the BMI (Body Mass Index). The BMI is a number that is calculated using an individual’s weight and height, and it gives us a number that tells us the degree of excess weight that a person has.
Now the BMI is an imperfect tool because we use one standard number for all races, all genders, all age groups. We know now that there are differences in different ethnicities, for example. The Caucasian populations can tolerate a higher BMI before they start to experience the negative consequences of excess weight whereas Asian populations will start to have consequences or cardiometabolic outcomes like diabetes or high blood pressure at much lower BMI. To use one BMI to qualify all people is flawed, but it is generally a good tool.
You can calculate your BMI by going into a BMI calculator found online. Enter your weight and height and they’ll give you a number. Essentially a BMI of in ther range of 18.5 to 24.9 is considered “normal”. A BMI of 25 to 29.9 is considered overweight and a BMI of 30 or greater is considered obese. That, again, refers to the degree of excess weight that makes us susceptible to obesity-related comorbidities or conditions.
Pandemic Stress: How the pandemic has shifted our pre-pandemic routines and resulted in weight gain
Now, back to the CDC data. They started tracking obesity rates in the United States and back in the early 80s, obesity rates were about 10% on average, in any given state. Pre pandemic, the average was about 30%, meaning the prevalence of individuals who had a BMI of 30 or greater was about 30% in most states. Following the pandemic, the most recent data has shown that 16 states in the United States have prevalence rates of 35% or greater, and a handful of states are approaching 40% or greater.
In addition, there was a survey done in March by the American Psychological Association (the APA), that showed that 42% of Americans reported weight gain at an average of 29 pounds per person. And finally, our children have also been affected by this pandemic, right? Not surprisingly- they have been at home, on Zoom and extracurricular activities were cut out of their lives. They haven’t been exposed to the same stresses and uncertainty that we have as adults but have definitely experienced the negative impact in terms of their weight. The average incidence of obesity has gone up in all age groups, including our younger kids, ages five to seven.
To say that excess weight and weight gain have affected and impacted every age group, every state, and also, of course, every ethnicity and population in our country would be accurate.
Always remember: You are not alone in this weight loss journey
While we judge, blame, and shame ourselves, can we just take a moment and have compassion for ourselves? Because this is something that we have all dealt with. And can we also understand the universality of it? Part of me sharing all this data is to say, “You are not alone.” We have all universally been affected and the reasons for that are multifactorial. Yes, we’ve been at home. Yes, we’ve been closer to our pantries. Yes, there has been emotional eating. There has been more alcohol consumption. There has been more sedentary behavior. All of this contributes to excess weight. But I also want to point out the connection between stress and eating our emotions and soothing with food, because there is physiology that happens there.
Let’s Talk Science: What are hormones and what roles do they play in our hunger
First of all, our hunger is dictated by hormones. Tiny chemicals that are released by our fat cells, our gut, and our pancreas signal hunger to the brain. Those signals are typically regulated by our food intake, right? So you eat food, and there should be a signal telling your brain that you’ve received food, therefore you should no longer be hungry. What we know is that when individuals are stressed, stress literally hijacks our hunger hormones by triggering hormones that tell us or our brains that we’re hungry when we actually have received nutrients and we’re not. (If you want to hear more about the science behind this, check out my podcast episode called The Anatomy of Hunger.)
On top of that, we seek to soothe difficult or negative emotions, and we do so with things that give us pleasure. When we eat highly palatable foods (A.K.A. yummy foods) that are generally high in sugar, fat, even sodium, it triggers a part of our brain (the pleasure centers of our brain) by releasing a neurochemical called dopamine. That dopamine gives us a momentary feeling of pleasure so the natural response is to want to seek out that food again in order to reproduce that feeling of pleasure, which is only temporary.
You can see why these palatable foods will create this habitual response in us. We are stressed or feel negative emotions and seek to be soothed. We know from our past experiences that palatable foods are soothing, and therefore we seek them out again and again and again.
The Easy Answer: Are there still weight loss medication that I can use after the Fen-Phen debacle back then?
I’ve talked about some of the behavioral strategies that help us with weight loss and weight maintenance. Today I want to talk about weight loss medications. Weight loss meds, of course, have gotten a bad rap. Those of you who are old enough to recall the Fen-Phen debacle back in the 80’s know that there was a medication called Fen-Phen that resulted in cardiac outcomes. It resulted in leaky heart valves, and heart failure and so it was removed from the market which left a bad taste in our mouth in terms of our desire for weight loss drugs.
Debunking the Fen-Phen: What are the drugs present in this medication
I want to go over some of the drugs that are still here and FDA approved for weight loss because I think they are an important tool for the right candidate. Fen-Phen was a combination of two drugs, Phentermine and Fenfluramine. It was the Fen (Fenfluramin) that was problematic and has been taken off the market. Phentermine, however, is a drug that has been around since the 50’s, is still around today.
This is a medication that can be used for short-term use and it works by preventing certain neurotransmitters in the brain from being taken up and creating a feeling of satiety or fullness in the brain. It helps trick your brain into feeling full or satiated, so you can get by with eating less. Like all medications, Phentermine has side effects because it is affecting stimulating neurotransmitters. It can cause people to feel a little bit jazzed.
Some people may feel anxious on this medication and so I caution those of us who have anxiety from taking this drug. It can also cause other stimulating side effects like insomnia. Most people will get a dry mouth, and it can also cause constipation. It is of course contraindicated in anyone who is breastfeeding or actively pregnant. Phentermine can be a good agent for people who are young, healthy, don’t have any cardiac issues, aren’t anxious, and are just looking for something to help control their appetite while they get all of their habits under control so that they can maintain those behaviors once off Phentermine.
Let’s Talk About Weightloss Drugs: Qysmia
There’s another drug out there called Qsymia that has Phentermine in it, and when combined with Topiramate can be very effective.
Topiramate is another medication that helps control appetite at the level of the brain. It helps inform the brain of satiety. Basically in this one medication, you get two drugs that help control your appetite. Once again, the side effects can include constipation, dry mouth, insomnia, irritability, and even increased heart rate. I want to point out that this medication, like Phentermine, does not cause heart attacks.
There’s a lot of different ways that people think about these medications, but it has to be prescribed for the right person, in the right way. It can be very effective short or long term in terms to use the second medication, Qsymia, to help control appetite and to help people lose weight.
Let’s Talk About Weightloss Drugs: Contrave
The third drug I want to talk about it has the trade name Contrave. This is a medication that is also a combination drug. It is a combination of an antidepressant called Bupropion and another drug called Naltrexone. Now we’re not using this medication for depression. It just so happens that this anti-depressant also helps control appetite because of the neurotransmitters, or the chemicals in the brain that it affects. Once again, it is tricking your brain to feel fuller faster, or with less food.
Let’s Talk About Weightloss Drugs: Naltrexone
The other drug, Naltrexone is an opioid antagonist. You may know opioids affect part of the brain that is involved in pain but also pleasure. This medication blocks that pleasure center, so that people, in theory, don’t get the same feeling of reward from food. This drug is also a combination medication that helps people with weight loss. It is also FDA approved for long-term use so people can be on it forever, if needed. In my practice, I will really just use it as the patient sees fit and oftentimes that means we use medication for a certain duration, get people initiated again on their healthy routines, get motivated from experiencing some initial weight loss, and then we start weaning off the medication.
This combo drug, Contrave, again, can have side effects. The primary side effects are a short-term increase in blood pressure, that’s minimized or resolved within the first three months, typically. It can also cause nausea and sometimes, as my patients describe it, a “head funk” (headache, feeling of fullness, a non-descriptive sensation).
Let’s Talk About Weightloss Drugs: GLP-1
I wanted to end with a class of medications that’s hit the news a lot in the last few months, which is the GLP-1 or Glucagon-like peptide-1 analogs. GLP is a hormone that we normally release from our intestines or our gut. GLP-1 is released from our guts when we eat food, and it does two things. Number one, it signals the brain that food has been received and therefore it suppresses appetite. Number two, it signals to the pancreas that food has been received, and therefore it stimulates the production of insulin so that the body can manage our blood sugar.
For these reasons, GLP-1 analogs have been approved both for the treatment of Type 2 diabetes, as well as, for the treatment of obesity or excess weight. GLP-1 analogs come in several forms. They can be taken orally, but the more effective ones for weight loss have been the injectables. They are injectable in pen form similar to an EpiPen (Epinephrine pen) used for allergic reactions. The injectable form can be administered either daily or weekly, depending on the type of drug or the brand. GLP-1 analog signal to the brain that mimics a natural gut hormone that signals to the brain that you’re full and signals to the pancreas that you need insulin.
GLP-1 analogs typically can result in GI side effects including nausea, maybe diarrhea, or constipation, depending on the person. They are contraindicated in certain classes of thyroid tumors, so people who have a family history of a certain type of thyroid cancer called MEN or M.E.N. are contraindicated from this drug. The most concerning side effect is pancreatitis, which is an inflammation of the pancreas and can be a serious medical condition, however, it occurs in less than 1% of people using this medication.
This list is not meant to be completely inclusive of all the potential side effects and contraindications. Of course, this is a conversation for informational purposes only to make you feel comfortable about talking about weight loss medications with your own physician or an obesity medicine specialist who specializes in weight-loss drugs. Keep in mind specialists might feel more comfortable with the use of these medications because we use them so frequently. We are very comfortable with who we can and cannot prescribe to, potential side effects, and prescribing practices. This is, of course, not meant to take the place of medical advice. Andto note we must acknowledge that every individual is unique, so that conversation needs to be had on an individual basis with your prescribing doctor.
Truth or Not: Debunking the misinformation and bias around weight loss medications
I want to bring up this topic and talk about weight loss medications because I think there is a lot of misinformation out there. I think there’s a lot of historical bias against weight loss medications, because of some of our past histories with these drugs (Fen-Phen being the main one). I think that these are important tools that should be a part of the discussion for someone who has failed diet and exercise or diet and exercise has failed them and might need some additional help in order to initiate the weight loss process.
We talk about obesity and excess weight often in cosmetic terms. We often only look at the cosmetic consequences, but obesity is in fact considered a disease. It is defined that way by the American Medical Association because there is a physiology behind it. We know that excess weight is not a cosmetic problem because obesity affects every single organ system from head to toe. It can affect the brain in terms of increased risk of stroke, the cardiovascular system, increasing the rate of heart attacks, hypertension, hyperlipidemia, or high cholesterol. It can involve the gastrointestinal system by increasing the incidence of reflux, a fatty liver disease that can go on to result in cirrhosis, or fibrosis of the liver. Excess weight is associated with an increased risk of our most common cancers– breast cancer, prostate cancer, colon cancer. It can, of course, result in joint issues, joint disease, skin conditions and of course can affect the overall quality of life, including increasing the risk of depression. This is an important disease with important medical consequences.
You Are Not Alone In This: Some things to remember
I want to empower you with a few take-home messages. Number one, you are not alone. Excess weight is so common in the United States and across the world, for that matter. It was common before the pandemic and many people have been affected by the pandemic in terms of increased weight, regardless of age group, gender or ethnicity, or background. So…know that you’re not alone. Number two, know that there are physicians out there that specialize in this area of medicine, and that can help you with dietary changes, exercise prescriptions, sleep prescriptions, mindset, and mindfulness, as well as, other tools including weight loss surgery, and medications for weight loss. If you are curious, find a physician that is well versed or specializes in this area so they can give you some real one-on-one guidance. Lastly consult with your provider because the information that is contained within this blog is really for informational purposes only and not to serve as medical advice.
I hope that this has been a helpful primer on weight loss drugs and weight loss medications. If you find this information useful, I encourage you to subscribe to our podcast, Health Bite.