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Home , Body fat percentage, Obesity medicine

THE EPIDEMIC

TACKLING THE

THE LATEST APPROACHES TO A CHRONIC

BY SUZY FRISCH

16 | MINNESOTA | MAY/JUNE 2021 THE OBESITY EPIDEMIC

eremiah Eisenschenk, MD, knows what it’s like to tigmatizing the issue of excess weight. It’s much more complicated than we under- put on a significant amount of weight and feel its stood 30 to 40 years ago when this started emerging.” myriad effects, from blood sugar variability and re- Part of that understanding includes J knowledge that obesity is a chronic dis- flux to eczema, grogginess and exhaustion. He had been a ease, one that is highly complex to manage and treat. must determine what college athlete who was accustomed to fueling his body with factors are causing patients’ obesity, iden- tify the conditions that often accompany seemingly healthy food to power through daily workouts. obesity and weigh numerous options for treating the disease. This complexity is During and , when time and sleep what led Galloway-Gilliam to take on ad- ditional training to become an obesity and were at a premium and refined grains and sugars were abun- integrative medicine specialist so that she can spend time with patients addressing dant, he gained 40 pounds. their issues in a personalized way. “So many other travel along Though he tried exercising his way in Minnesota. More than 30 percent of with obesity. In a primary care model, it can back to optimal health—including run- Minnesotans were obese in 2019, ac- be challenging because you are addressing ning the Twin Cities Marathon—it wasn’t cording to the Minnesota Department all of the other things, like asthma or diabe- until he switched to a low-carbohydrate, of Health, and another 36 percent of the tes or coronary artery disease, and not the weight itself,” Galloway- Gilliam says. “I wanted to work further upstream so that I can focus on this in a way that will be helpful not only for the weight but EPIDEMIChigh-fat that he lost the weight and state’s population is . For Min- for the other disease processes that travel started feeling better. On top of restoring nesota youth ages 10-17, 10.4 percent are along with the weight.” his health and vitality, his new approach obese, below the national average of 15.8 As Galloway-Gilliam pursued her obe- to gave Eisenschenk the tools percent. sity medicine training, she realized how and experience to counsel his obese and As the state’s population steadily gained little she and many other physicians really diabetic patients. weight and many progressed into obesity, understand about obesity and weight reg- A family medicine and obesity medi- it has become clear to physicians that the ulation. It’s not an area that is covered ex- cine specialist at Essentia Health, Eisen- overriding sentiment to eat less and ex- tensively in medical school—and neither schenk sees the toll obesity has taken on ercise more just isn’t working to stem an is nutrition. This can lead to the stigma his patients in the form of , nonal- epidemic. Instead, it requires a multidis- that many people with obesity face, both coholic , metabolic syn- ciplinary, comprehensive and targeted ap- in society and at the doctor’s office, that drome, heart disease, , mood proach that addresses individual’s specific their excess weight is their fault. disorders and more. He seeks to provide situations, says Iesha Galloway-Gilliam, specialist Carolyn them with hope, resources and a roadmap MD, an internist, obesity medicine and in- Bramante, MD, often sees adult and pe- to regaining their health. “I get so much tegrative medicine specialist at Hennepin diatric patients who have experienced joy out of what I do. It is inspiring to see Healthcare in Minneapolis. that stigma. She explains to them that patients reclaiming their health and vital- “There is still quite a bit of mispercep- obesity stems from dysregulation of the ity as they reverse the metabolic dysfunc- tion and misinformation about obesity body’s neurohormonal and digestive sys- tion with intentional lifestyle change,” says and a lack of understanding about the tems. This dysregulation makes obesity Eisenschenk, a hospitalist and chief of the extreme neurohormonal complexity in- stubborn to address solely with lifestyle hospital division at St. Joseph’s Medical volved,” says Galloway-Gilliam, who is changes like diet and . Center in Brainerd. co-director of Hennepin’s Comprehensive “The dysregulation is caused by multiple There are plenty of people for Eisen- Center. “We really levels of influences that are mostly out of an schenk and other physicians to help with want to help our patients, to affirm and individual’s control,” says Bramante, core their weight—in fact, two-thirds of adults confirm their dignity and work on des- faculty member in the University of Min-

MAY/JUNE 2021 | MINNESOTA MEDICINE | 17 THE OBESITY EPIDEMIC

nesota Medical School Center for Pediatric , they give patients confidence that medications can have a big impact on Obesity Medicine and Program for Health they can lose weight, says Daniel Leslie, patients, Eisenschenk says. “I want to use Disparities Research. “We like to think MD, a surgeon and obesity every tool I can. When a patient has the about blame for overeating or not exercis- medicine specialist at M Health Fairview, courage to see me and talk about sensitive ing, but those drives to eat more than we where he is system-wide director of bar- things like their dysfunctional relation- need are caused by things that happened to iatric surgery. Leslie recommends that pa- ship with food, I want to give them all of us in utero or early in life or are influenced tients use the medications both before and the momentum I can to get them running by the microbiome. Then layer on top of after . downhill, to achieve their goals,” he says. that complicated socio-economic factors FDA-approved anti-obesity medications “Appropriate medical are the pil- that make it easier for some people to have are very safe, and they work by disrupting lar of our comprehensive lifestyle-focused healthy food and exercise and other people the dysregulated energy regulatory sys- approach to obesity and diabetes and their don’t. When I bring that up to patients, they tems, Bramante says. This gives patients’ shared link of insulin resistance.” seem to really appreciate it.” behavioral changes to their nutrition and As complicated as obesity is to treat, it’s activity levels a chance to work. Surgery not untreatable. There are many tools avail- Two different combinations of drugs By the time people are considering weight able to physicians to help patients manage have been effective in prompting weight loss surgery, they often have been strug- and often overcome the condition—and it’s loss: phentermine and topiramate gling with their weight for years and have important to use them, says Charles Svend- (Qsymia) and bupropion and naltrexone tried nearly every diet, exercise program sen, MD, a bariatric surgeon and obesity (Contrave). In addition to these options, and medication under the sun. Svendsen medicine specialist at Allina Health, where Bramante uses glucagon-like peptide likes to talk to patients about the three he is director of bariatric surgery. (GLP)1 receptor agonists. GLPS1s are a levers of weight loss: restricting what you “If it was as easy as eat right and exer- newer class of medications that mimic eat, restricting how much you eat and re- cise, there wouldn’t be overweight doctors incretin, a hormone that causes the pan- stricting when you eat. Bariatric surgery— anymore. It’s not news to anyone that it’s creas to produce more insulin after . especially for people with a BMI of 35 and not working because we have 70 per- Currently, it’s prescribed at 1 milligram a higher—will press two of those levers re- cent of the nation overweight,” Svendsen week, and it typically produces a 9 percent lated to the quantity and kinds of food. “I says. “Once your BMI gets over 35, your weight loss. Studies are showing that a think the best analogy for weight loss with chances of losing weight with just diet and higher dose produces 18 percent weight bariatric surgery is that it’s surgically-aided exercise and keeping it off for a couple loss. Bramante expects the FDA to ap- fasting,” Svendsen says. of years is 3 percent. That’s borne out in prove the higher dose soon. “For patients The two main procedures are a vertical multiple studies. With [bariatric] surgery, who respond with good weight loss with a sleeve gastrectomy and a gastric bypass. sustained weight loss at the five-year mark GLP1 receptor agonist, it’s likely that they Gastric sleeves are 68 percent of the bar- is 80 percent.” are deficient in GLP1 receptors compared iatric procedures in the United States; 20 to other people,” she says. percent are gastric bypasses. The remain- Medication It’s also important to make sure patients ing procedures are duodenal switches and Before turning to surgery, many obesity aren’t taking medications that are known gastric bands. Lap bands have drastically medicine specialists prescribe medica- to cause , such as steroids, anti- decreased, Svendsen says, but duodenal tions to spur weight loss. These drugs are psychotic drugs, antihistamines and some switches have increased in popularity effective in shutting off and food forms of birth control. Eliminating these lately. The bulk of patients prefer the cravings in the brain. Used before bariatric medications and then using anti-obesity gastric sleeve because it doesn’t cause malabsorption of nutrients. It also seems “I GET SO MUCH JOY OUT OF WHAT I less drastic to people, he says, even though the procedure involves the same incisions, DO. IT IS INSPIRING TO SEE PATIENTS recovery time and required supplements RECLAIMING THEIR HEALTH AND post-surgery as other surgical methods. VITALITY AS THEY REVERSE THE Another reason to start with a gastric sleeve is that it leaves the digestive pathway METABOLIC DYSFUNCTION WITH intact while removing 70 to 80 percent of INTENTIONAL LIFESTYLE CHANGE.” the stomach volume. This option reduces JEREMIAH EISENSCHENK, MD; HOSPITALIST AND CHIEF OF THE HOSPITAL DIVISION; the long-term risk of complications as ST. JOSEPH’S MEDICAL CENTER IN BRAINERD compared to a gastric bypass, which re- routes the digestive track away from the lower stomach and top of the intestine,

18 | MINNESOTA MEDICINE | MAY/JUNE 2021 THE OBESITY EPIDEMIC

Sleep, nutrition and exercise “THERE IS STILL QUITE A BIT There is a growing body of knowledge OF MISPERCEPTION AND pointing to the importance of sleep in maintaining a healthy weight. It’s vital to MISINFORMATION ABOUT OBESITY get enough quality and quantity of sleep AND A LACK OF UNDERSTANDING because without it, the body increases lev- ABOUT THE EXTREME els of cortisol and ghrelin, two hormones that cause weight gain, Bramante says. NEUROHORMONAL COMPLEXITY Sleep hygiene is one of the first areas she INVOLVED.” addresses with her patients, covering good IESHA GALLOWAY-GILLIAM, MD; CO-DIRECTOR; sleep habits and other issues like sleep HENNEPIN COMPREHENSIVE WEIGHT MANAGEMENT CENTER apnea. “I have a number of patients where the first 5 to 10 percent of weight loss can Leslie says. The sleeve still provides for loss and lining up insurance authoriza- be achieved by improving sleep,” she says. good weight loss, with patients generally tions. Thirty to 40 percent of patients who Eisenschenk makes sleep one of the losing about 60 percent of their excess consult with Leslie about surgery end up four pillars of wellness he addresses with weight in one year. Gastric bypass recipi- going forward, facing a long list of to-do patients, along with nutrition, activity and ents will lose another 10 percent. Svendsen items to accomplish and other people’s behavioral support. When patients with adds that gastric bypasses tend to work sentiments about the procedure. obesity see him, he certainly measures better for people who have bad reflux, “There are all kinds of opinions about BMI and , liver func- significant Type II diabetes or metabolic weight-loss surgery and what it means. tion, A1C, insulin level, waist circumfer- syndrome, and for people around retire- Often patients and families are messaging ence and other assessments. But he also ment age. that weight-loss surgery is an easy way makes a point of asking what they are eat- A benefit of the duodenal switch is out,” Leslie says. “That’s far from the truth, ing. It’s not uncommon to hear about diets that it is effective in controlling diabetes. and it doesn’t recognize that the vast ma- filled with sugar, starch and carbohydrates. Leslie typically reserves this procedure jority of people who try to lose weight will “The most important question doctors are for people who have a BMI of over 50. not be able to over a several-year period not asking their patients is: ‘What are you Often, he will start patients with a sleeve of time.” eating?’” he says. gastrectomy and then later add a duodenal In addition, weight-loss surgery helps “People don’t get overweight or obese switch—with a rearrangement of the in- patients with many other chronic condi- from eating real, nutrient-dense foods,” testines—if someone has not lost enough tions like diabetes, sleep apnea, hyperten- he notes. “Improving one’s dysfunctional weight. sion and joint pain. And in the COVID relationship with food, commonly refined Key to success after a surgery is focus- era, when obesity is the number-one grains and sugars, starts with recognizing ing on the quality of patients’ nutrition. controllable risk factor for hospital admis- the body’s hunger signals, then choosing Svendsen recommends that these patients sion and death, it’s critical to help people to fuel your body with essential proteins, eat a ratio of half protein and a quarter lose weight, Leslie says. That’s one reason fats, vitamins, minerals and water. There each of non-starchy vegetables and low- weight loss surgery resumed in May 2020. is no such thing as an essential carbohy- sugar fruit. “When patients come in, they drate.” have been taught the approach, Using evidence-based guidance, he and a large percentage of people can coaches patients to adopt a low-carbo- starve themselves for six months to a year. But that doesn’t work in the long run,” “[DYSREGULATION OF THE Svendsen says. “That’s where the value of BODY’S NEUROHORMONAL surgery comes in. It gives you control over your diet for the long run, and you don’t AND DIGESTIVE SYSTEMS] IS feel like you’re starving yourself. They are CAUSED BY MULTIPLE LEVELS OF taking in less, but they are also taking in better food.” INFLUENCES THAT ARE MOSTLY Undergoing bariatric surgery is a long OUT OF AN INDIVIDUAL’S process that takes three to 12 months to CONTROL.” arrange, complete with numerous visits CAROLYN BRAMANTE, MD; CORE FACULTY MEMBER; UNIVERSITY OF with a dietician, a psychological evalua- MINNESOTA MEDICAL SCHOOL CENTER FOR PEDIATRIC OBESITY MEDICINE AND PROGRAM FOR HEALTH DISPARITIES RESEARCH tion, education about nutrition and weight

MAY/JUNE 2021 | MINNESOTA MEDICINE | 19 THE OBESITY EPIDEMIC hydrate, high-protein diet, whether it’s a ketogenic or paleo regimen. Comparisons “WE CAN TAILOR YOUR of multiple randomized controlled tri- PHENOTYPE OR OBESITY GROUP als show that restricting carbohydrates is more effective than restricting fats for TO [YOUR] INTERVENTIONS, AND prompting weight loss, improving insulin YOU WILL RESPOND BETTER. resistance and other markers of metabolic FROM USING THIS TESTING, health, such as fatty liver. Low-carbohy- drate diets are cited by the American Dia- PATIENTS ARE LOSING TWO TIMES betes Association as having “the most evi- MORE WEIGHT THAN IF THEY dence for glycemic control.” Once patients JUST GO FOR THE STANDARD get established on the recommended diet, they report that their hunger is controlled, INTERVENTION.” cravings are gone and they have more en- ANDRES ACOSTA, MD, PHD; ASSISTANT PROFESSOR OF MEDICINE; ergy and feel more alert, Eisenschenk says. MAYO CLINIC SCHOOL OF MEDICINE AND SCIENCE “With therapeutic carbohydrate restric- tion, we consistently see decreases in waist ing 5 percent to 7 percent of body weight, Currently, Mayo physicians can put circumference, fat mass, glycemic control, focusing on healthy eating and exercise patients through extensive testing to de- insulin and lipid levels and blood pressure,” and addressing the social determinants of termine the origin of their obesity. Acosta’s Eisenschenk says. “Diabetes and obesity are health that affect weight. The state has 40 Precision Medicine for Obesity Lab, and diseases of nutrition and can be reversed diabetes-prevention initiatives across Min- a spin-off company called Phenomix, are with effective nutritional interventions.” nesota that work with community partners working on diagnostics and treatments Another effective way to help patients on lifestyle-change programs, an effective that will more quickly identify the under- lose weight—or as a complement to a low- way to help people manage their weight lying issues and causes. carb diet—is to adopt intermittent fasting. and prevent diabetes, Ambroz says. Using an “omics” approach that evalu- Svendsen is a big fan, especially a structure ates hormones, DNA, proteins and me- of 16 hours of fasting paired with an eight- Future care tabolites, Acosta and his team can be more hour window for eating healthy food. Inter- Precision medicine is seeping into obesity objective in assessing patients and select- mittent fasting targets obesity by restricting care, with the acknowledgment that the ing treatments. Then they use existing the amount of time that insulin levels are condition has multiple causes. By diagnos- tools for fighting obesity, such as medica- elevated after eating, removing people from ing the origins of individual’s obesity, it tions targeted to specific conditions, a the roller coaster of blood sugar spikes and becomes possible to target treatments to vagal nerve block, bariatric surgery and/or crashes. It’s very difficult to lose weight with these causes. Andres Acosta, MD, PhD, an procedures like endoscopic sleeve gastro- elevated insulin levels. Intermittent fasting assistant professor of medicine at Mayo plasty, intensive diet and exercise regimens also improves metabolism, lowers blood Clinic College of Medicine and Science and behavioral . sugar and reduces inflammation. and a consultant in gastroenterology, The difference is, instead of using a trial- “We’re genetically set up to deal with hepatology and obesity medicine at Mayo and-error method, “we can tailor your phe- fasting. Our body knows what to do,” Clinic, explains that there are four differ- notype or obesity group to these interven- Svendsen says. “It’s safe to do and cheap, ent sub-groups or phenotypes for obesity: tions, and you will respond better,” Acosta and you don’t have to pay for a monthly • Abnormal satiation, or hungry brain— says. “From using this testing, patients are subscription to Weight Watchers or meal signals of fullness either do not travel losing two times more weight than if they plans. It’s more along the lines of intuitive from the stomach to the brain or the just go for the standard intervention.” eating and eating when you’re hungry.” brain does not receive them. For example, when using the pheno- Clinicians have a big role to play in pre- • Abnormal satiety, or hungry gut—the type approach to selecting an anti-obesity venting obesity. Focusing on families and sense of fullness after eating does not last. medication, patients lose 16 percent to 18 using diabetes prevention programs are a • Emotional hunger—high levels of crav- percent of their body weight, compared to 8 good place to start, says Teresa Ambroz, ings, anxiety and depression cause some percent to 9 percent if a medication is cho- RDN, manager of the diabetes and health to eat in response to positive or negative sen without this knowledge, Acosta says. behavior unit in the Minnesota Depart- emotions. Making headway against obesity will ment of Health Center for Health Promo- • Abnormal energy expenditure, or slow require taking a comprehensive approach tion. About one-third of people have pre- burn—the metabolic rate is abnormally that is targeted to patients’ individual diabetes—and many don’t even know it. slow, often coupled with low muscle mass. circumstances and situations. There is a Preventing a shift into diabetes takes los- great deal of variance in what causes and

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