Medical schools have trained doctors to understand that learning by case study is an excellent way to turn book smarts into experiential knowledge. Here’s a case that is typical to those I see in practice at my clinic:
A patient comes in for a sore throat and fever. She is very ill, in fact, she is just lying down on the exam table and can barely roll over to talk with me. We find out after testing that she has Strep Throat, and then I send a prescription for Amoxicillin to the pharmacy to take care of her infection. She is relieved to find out what’s wrong (strep throat) and what needs to be done for her treatment (antibiotics). As I’m closing out her encounter in the electronic medical record, she says, “Dr. Brandy, can you please send something for weight loss to the pharmacy? I’m going to be in a wedding next month and my dress doesn’t fit well.” Cue the record scratch – Say what now?
As you can see, even a patient who is extremely sick with a febrile illness wants to talk about weight loss. And painful though it may be, my answer to her question and others like it is ALWAYS NO. I explain that I don’t prescribe weight loss medicine without a full work up and time to dedicate to the problem. If I were to write that prescription, yes, it would make her happy for a short while, but in the long term, dependence on that diet medication may cause her weight to return and then some if she doesn’t have the proper education and weight loss plan (remember what I mentioned in my last blog about parents letting their kids eat tons of Cheetos to keep them happy and that being the same as the doctor letting the patient have what they think they need instead of what they really need)?
So, let’s say my patient goes ahead and takes her medication for strep and starts to feel better. She schedules to see me back in 2 weeks for weight management and she makes it to her appointment. She decided to get her obesity labs done a couple of days before her visit, so we have everything ready to get her started. I have her measurements done and have run the numbers.
Now, let’s talk about her treatment options:
1. Medical Nutrition Therapy
Every patient should be given the option to see a dietitian or nutritionist to learn about eating a healthy balanced diet that is entirely in moderation.
Nutritionists can be expensive depending on the patient’s insurance and a lot of insurance plans won’t cover a dietary consult unless there is a disease resulting directly from obesity (like diabetes for instance). If the patient’s insurance won’t cover a nutrition visit, I encourage patients to pay for one – they only need one and most dietitians can teach them all they need to know in one visit.
If the budget doesn't allow a dietitian visit, I usually give out information on the Plate Method Diet https://www.choosemyplate.gov/ or other non-branded teaching books and websites, like the Calorie King https://www.calorieking.com/us/en/foods/ which has a good introductory section before it breaks the calories/nutrition content down for patients. I really like www.myfitnesspal.com for the excellent nutrition and exercise trackers and the articles on eating a healthy balanced diet (for the most part it’s free although you can spend some money if you want bells and whistles). There is also www.noom.com that does a great job of teaching about balance in one’s life that includes pointers on nutrition, exercise, sleep, and stress reduction (it’s not free, but the price is usually cheaper than a dietitian and the subscription is renewable).
2. Medication
From patients suffering from strep, or the flu, and to those coming in with low back pain, everyone wants a simple pill to make the weight go away.
I wish there was a miracle pill, but THERE ISN’T. I tell patients that medication can help jump start their weight loss, but they will need to put in the work to keep it off by eating a balanced diet and exercising regularly. Once we decide on medicine, the next step is to choose the right one(s).
The Stimulating Stimulants – This medicine group includes Adipex, Phentermine, Diethylpropion and others in its class. I like these medicines for patients who need a “jump start” while they start their weight loss journey. Being a stimulant, they help with weight loss by increasing the metabolic rate to burn off calories, but they are also excellent anorexiants (they keep you from feeling hungry).
Man, I love how these medicines make my patients feel. I hear from them that it helps with increased energy, focus, and they are just not hungry. If only it could last forever! But it doesn’t.
One of the main problems with stimulants is that our brains are so smart that after a while the stimulants don’t work anymore. So, I let patients know that this medicine is a temporary fix to the lifestyle problem we’re addressing and if it’s working, we’ll continue. But if tolerance develops, we will stop that medicine and switch to something else or add a booster medicine to it (like Topamax or Prozac).
Stimulants pack a wallop of side effects including dry mouth, insomnia, constipation, and some can have mood swings or develop a heart issue with long term use. For this reason, I won’t give this class of medicine to anyone with a history of heart disease, heart murmurs, or uncontrolled hypertension. If there is an underlying mood disorder, the mood needs to be treated BEFORE starting with stimulant medication.
Endocrine Active Medicines – Remember when I mentioned in the last article that there are secondary causes for obesity? Well, now it’s time to review the medicines recommended for those secondary problems.
Metformin – I use this medicine for those with prediabetes, diabetes, and hormonal issues like Amenorrhea, Polycystic Ovarian Disease, and Hirsutism. It helps patients feel full and acts as a deterrent to poor food choices (it might cause abdominal upset, cramps, or diarrhea if too much junk food is ingested). Metformin is safe and effective for long term use and can be given to children and adolescents if needed.
Synthroid – patients with abnormal thyroid numbers usually can benefit from Synthroid for weight loss and to help with the other symptoms of thyroid disease. Synthroid is safe and effective for long term use.
Ozempic, and Trulicity – this is a once a week baby shot (the needle is the size of an eyelash) that seems to melt off body fat. It works by increasing the sensation of feeling full and lowers blood sugar. This is a good choice for those with prediabetes, diabetes, polycystic ovarian disease, or high levels of insulin. Ozempic and Trulicity are both safe and effective for long term use.
Saxenda – while similar to Ozempic and Trulicity, it is FDA approved to use for patients who are ONLY treating obesity and none of the other endocrine conditions listed above. Unlike Ozempic and Trulicity, Saxenda is a once daily baby shot and can cost up to $1000 or more if not covered by insurance. Saxenda is safe and effective for long term use.
Victoza – is the exact same medicine as Saxenda and can be given daily for those with prediabetes, diabetes, metabolic syndrome, polycystic ovarian disease, and excess insulin. This medicine can be used in children and adolescents if needed and is safe and effective for long term use.
My, My, My Mood Motivators – If I’m dealing with a patient who clearly shows evidence of stress eating, then we’ve got to treat that stress! Usually I follow the mood with office questionnaires (PHQ9 https://www.med.umich.edu/1info/FHP/practiceguides/depress/phq-9.pdf , GAD7 https://www.mdcalc.com/gad-7-general-anxiety-disorder-7 ) that let me know how my patients are doing regarding depressive and anxiety symptoms.
The medicines that work best for this type of eating are Contrave and Qsymia. Contrave packs a double whammy because it has Wellbutrin (an antidepressant) and Naltrexone (used for alcohol and drug abuse) which together works great for cravings. Qsymia has our friend Phentermine in it paired along with Topamax (a mood stabilizer that has a side effect of anorexia). Please note that Stress Eating is different from Binge Eating.
I liken Stress Eating to Moody Grazing. It happens during specific times when patients are stressed or under pressure. They don’t necessarily consume large amounts of food at one time.
Binge Eating can happen at stressful times, but usually there is no specific trigger. Binge Eaters consume an insane amount of food in a short amount of time. They don’t do this regularly but usually there are at least 1-2 days per week. Why am I highlighting the differences between the two? Because the treatment of these 2 eating disorders is different. Most stress eaters can control their symptoms with one of the medicines listed above, but for Binge Eaters, most of them must be on an antidepressant from the get-go. I usually choose Prozac, Zoloft, or Effexor and then I add a stimulant medicine like Vyvanse to help. This combination seems to produce weight loss that is sustained.
3. Surgery
There is a certain subset of patients that I steer directly to a surgical consult in addition to my own. Those patients are the folks who have had a previous gastric surgery or those whose BMI is greater than 40. That doesn’t mean these patients need surgery, but we need to be mindful that simple lifestyle changes will help, however it may take many years to get them to a normal state and for that reason, surgical intervention may also be necessary.
For those patients with a BMI of 30 or greater, I work hard to get them to commit to medication and exercise for a period of at least 3 months. If we don’t see the progress desired at that time, then I begin to get them mentally prepared for a surgical consult.
I remind patients that while gastric surgery is beneficial, it’s just a tool and the real work happens outside of the clinic with a healthy balanced diet and exercise. Sometimes patients who initially lose weight with gastric surgery will gain it back again over time (usually 5-10 years) and these patients may benefit from medication therapy instead of surgical revision.
4. Exercise
Exercise is a given for any type of dietary and lifestyle plan we make. You can’t get out of exercise (trust me, I tried). And exercise will increase your energy, increase your metabolic rate, and help you maintain a healthy weight. I have my patients make specific exercise goals before they leave their first visit (for example, “I’m going to walk 20 minutes a day”).
I’m not talking about joining a gym. Let me say it again, I’m not talking about joining a gym! If you want to join a gym and feel that is the answer for you, then I’m not stopping you (in fact I’m happy for you). What I’m looking for is ACTIVITY and I don’t care how you do it. It can be chair yoga at home, it can be dancing salsa while meal prepping, it can be short 10-minute walks during your lunch break. I just want you to move. Once you start moving and notice the change in your energy level, it will become a lot easier to keep moving and add even more activities.
“But I can’t exercise because of – knee pain, migraines, back pain, etc.” My answer to that is, “Yes you can!” Can you get up from the couch and go into the kitchen and grab some cookies? Alright then you can make that walk of shame to the pantry into your new workout. Trust me, I'm doing the same thing! Walk back and forth from your chair to the pantry for 5-10 minutes (after all that work, you’ll say, “forget those dadgum cookies!”). Do you have access to a swimming pool? Any activity in the water burns even more calories than the same land-based activities, and since gravity is removed from the equation, your joint pain won’t get worse while you work out in the water.
So now you all have access to my personal treatment algorithm. And I promise you, that as evidence-based medicine changes, so will my treatment plans. Every doctor has a different way to approach obesity and the treatments may vary. In my next article on obesity, I’ll be talking about my personal weight loss journey and what I did to lose 20 pounds! Feel free to comment or ask questions and please subscribe to my blog for the latest updates.