The Latest on Weight Management

While we all know that being overweight has a negative impact on our health, more and more of us struggle to reach and maintain a healthy weight for our body's frame.  It's not always a simple matter of eating less and being more active.  Often, obesity can be attributed to a hormonal abnormality that leads to storing energy as fat.

Weight management expert Manuel Torres, M.D., physician lead at Baptist Health Primary Care of Kendall Breeze, shares the medical field's latest understanding of the scientific reasons behind weight gain with host, Jonathan Fialkow, M.D.

Their discussion covers the difference between 'weight loss' and becoming leaner, the impact of genetics, the role of the brain in controlling our weight and the latest information on treatment strategies. 

Transcript

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At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit.

Announcer:

Welcome to the Baptist HealthTalk podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Jonathan Fialkow:

Hello, Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventive cardiologist and lipidologist, Deputy Director of the Miami Cardiac and Vascular Institute and Chief Population Health Officer at Baptist Health South Florida.

Dr. Jonathan Fialkow:

After many years of decreasing deaths from cardiovascular disease and other medical conditions, including cancers, we've now started to see a troubling trend of increasing numbers.

Dr. Jonathan Fialkow:

Part of this is attributed to us being a less healthy population. We are certainly older, more sedentary, and by every measure heavier as a population than we've ever been in the past.

Dr. Jonathan Fialkow:

Being overweight and frankly obese has become almost normal in our society. While we tend to pass judgment on those overweight unfairly, as often, it's not a matter of being more active or pushing away the dessert plate, i.e. willpower, but rather hormonal abnormality that leads to energy storage as fat, there is no controversy that obtaining and maintaining a normal weight has health benefits.

Dr. Jonathan Fialkow:

There's a lot to unpack here, but in the interest of delivering some helpful ideas, as well as hopefully provoking our listeners to seek more information about diet, weight management, and our evolution of understanding of this arguable epidemic is Dr. Manuel Torres.

Dr. Jonathan Fialkow:

Dr. Torres is a physician leader at Baptist Health Primary Care, the Kendall Breeze office, who is a Diplomat of the American Board of Obesity Medicine, and who has a part of his practice dedicated to weight management. There's a lot of directions we can take this Manny, and I'll work to keep us focused; but thanks for being our guest.

Dr. Manuel Torres:

Thank you, John. It's a pleasure to be here today.

Dr. Jonathan Fialkow:

So let's talk about some definitions if we could, because we always throw this term around... Obesity or overweight. First, one of the things that always bothers me when we say, "I want to lose weight." If we tell someone to lose weight, because arguably you can cut someone's arm off and they'll lose weight, or I can give you a diuretic and you'll urinate out three pounds of water and you'll lose weight. When we say we want people to lose weight or maintain a healthy weight, what do we really mean by that?

Dr. Manuel Torres:

Well, what we want to do is we want to try to help patients begin to focus on trying to improve their body fat index or body mass index, as we often refer to it. And that number, as you know, as a cardiologist, correlates to cardiovascular risk. And we really want to make sure that that BMI continues to go down or begins to trend down, especially as patients get older, but obviously that tends to trend up.

Dr. Manuel Torres:

So it's not just about the gross number on the scale. It's how that gross number correlates to your body frame and what that means in terms of cardiovascular risk, as you know.

Dr. Jonathan Fialkow:

Great. So for people who may be overweight, which is very common, we'd want them to work to get to a healthy weight. But people who have a healthy weight, we want to help them maintain a healthy weight. And you did mention, there's a tendency, as we get older, to gain weight. So we can talk about that a little bit also.

Dr. Manuel Torres:

Correct. And often, sort of to answer your question in a different way, what is a healthy weight? That's a question that I'm sure you get a lot, "How much should I weigh?" And I always say, it depends upon your body frame, and that's a number that we can calculate.

Dr. Manuel Torres:

Everybody gives me a little bit of a rough time in regards to BMI because they may feel that they weigh what they're supposed to weigh, but the BMI really helps them focus on where am I, according to what my frame allows me to be.

Dr. Manuel Torres:

And that's why you say like, "Yeah, if you cut somebody's leg off, that gross number may go down and their weight may go down, but it's what are you in relationship to your frame? Are you weighing less based upon what your frame allows you to weigh?" And that's what that BMI number means.

Dr. Manuel Torres:

So as you know, a greater than 30 is considered obese, greater than 35 is a stage 2 obesity, and then greater than 40 is considered morbidly obese or category 3 or stage 3 obesity.

Dr. Manuel Torres:

So there's a couple of different classifications in the nomenclature, but generally, most people understand that once you pass that BMI of 30, that already puts you in a category of obesity and the situation really needs to be addressed by your physician.

Dr. Jonathan Fialkow:

So for using the BMI, the body mass index, as an indicator of where your weight should be and where you stand, how does someone get their BMI measured?

Dr. Manuel Torres:

Well, it's pretty easy actually. And nowadays with all of our electronics, you can measure it by plugging your numbers into your phone, right? As far as what do you weigh and how tall you are, and it's a pretty easy calculation to make.

Dr. Manuel Torres:

So most of our common apps that we use, even for calorie counting, or even just general health apps that come already pre-installed in your phone can you give you your BMI. And and obviously of course you can always Google your number.

Dr. Jonathan Fialkow:

So, that last [inaudible 00:04:36]. So I mentioned in my introductory comments that people don't gain weight because they want to. People don't eat more foods that they shouldn't because arguably they want to. There are drivers, cravings and things.

Dr. Manuel Torres:

Correct.

Dr. Jonathan Fialkow:

From your experience, why do people gain weight? Not how do they gain weight, arguably how is if you eat too much. Why?

Dr. Manuel Torres:

Well, there's many different reasons, and part of the specialty of obesity medicine really is to answer that question, particularly because newsflash, not everybody is the same, right? And everybody gains weight actually for different reasons.

Dr. Manuel Torres:

So if we sort of subdivide them into multidisciplinary or multi-faceted reasons as to why somebody gains weight, and then we have genetic causes as to why people gain weight or monogenetic causes; and typically monogenetic causes are very significant obesity-related diseases that are diagnosed in pediatrics and adolescents, where there may be a receptor deficiencies and things like that that really lead to aggressive weight gains or hypothalamic issues. Those are, again, common in pediatric obesity.

Dr. Manuel Torres:

When we talk about routine adults, it typically falls under the umbrella of it's a multifaceted cause. There are multiple things that are contributing to that slow and steady waking, whether it's macro environment issues, like just sort of our population, how we tend to favor the lazy choice in regards to parking spaces and elevators and things like that, which are macro environmental influences and or are there micro environmental influences?

Dr. Manuel Torres:

And I mean by micro environment, I mean micro environment of that patient. Are they surrounded by a family of heavy eaters? Are they surrounded by a family of people that are encouraging poor nutritional decision-making and those kinds of things. So really assessing the macro environment and the micro environment in that particular patient will often lead to decisions on treatment.

Dr. Jonathan Fialkow:

I find it fascinating... You mentioned the genetics and again, the micro, the macro environments, how evolution plays an element. How, if you think about this, man evolved in a very uneven food supply. Most of man's existence was just finding the next meal.

Dr. Manuel Torres:

Right.

Dr. Jonathan Fialkow:

So we're really not evolutionarily geared towards being very active. If I could push a button and do something, evolutionarily that's better than having to use energy because I may not find food to get that. So we're also evolutionarily geared towards storing food, right? If we have extra food, we want to hold on to it. So all those factors.

Dr. Jonathan Fialkow:

So going back to those premise that there are genetic factors, macro environment. It's not because you're not exercising. How often does someone who gains weight come to me and say, "Well, I just have to exercise." No, no, no, it's not. You'll burn calories, but you're still going to store energy eating the wrong foods.

Dr. Jonathan Fialkow:

I do want to get into exactly some of that. What are the kinds of dietary recommendations that might be better than others? And again, there's no one answer for everyone, but before we get to that, going back to the original premise, what are the dangers of obesity? We're not talking about fitting into a Speedo on the beach. [crosstalk 00:07:40] What are the medical components of trying to help people recognize the reasons why we'd want to help them get to a healthier weight?

Dr. Manuel Torres:

Sure. Definitely, there are well documented, over 250 different diseases that are associated with obesity and they really fall along the entire spectrum of medicine.

Dr. Manuel Torres:

So as a primary care physician, obviously we see patients with orthopedic problems. We see patients with cardiovascular problems. We see patients with GI digestive issues, even neurologic issues and of course, the cancerous issues as well.

Dr. Manuel Torres:

Obesity plays a role in pretty much every one of those sub-specialties of medicine, if you will. It makes most of the common diseases that we see a higher likelihood. And then of course, especially if you know the very significant comorbidities that are associated with mortality... Diabetes, hypertension, hyperlipidemia, et cetera.

Dr. Manuel Torres:

So those are just sort of a small taste of how obesity can affect that. And one of the common things that is very important is trying to help patients understand that there should be a shift in the way that physicians approach obesity.

Dr. Manuel Torres:

A lot times we diagnose the chronic condition first and then, "Oh yeah, losing weight will help." And being proactive and trying to address obesity issues before these chronic conditions occur, whether they are again, cardiovascular or GI or neurologic or oncologic or whatever it may be is really probably the smarter approach. And probably the way that hopefully your primary care physician is addressing the issue.

Dr. Jonathan Fialkow:

It's actually well said. First, your original comment. There's really no part of the body that's not affected, whether it's stress on the joints or sleep apnea or your cardiovascular condition or cancer risk and whatnot.

Dr. Jonathan Fialkow:

So it is leading towards this increased less healthy population and of course, costs in healthcare as well. But you mentioned also about how we would address a patient, rather than addressing the weights that they may be gaining or gained, we look at the medical conditions first; what's not appropriate.

Dr. Jonathan Fialkow:

So, everyone who's considered themselves as overweight has tried to diet.

Dr. Manuel Torres:

Of course.

Dr. Jonathan Fialkow:

And why don't diets work? Which is not to say an individual may find a particular way of eating that helps them maintain a healthy weight and arguably avoiding hunger. Why don't diets work? What's the biggest pushback of why diets don't work?

Dr. Manuel Torres:

The biggest perspective is because I think that the majority of patients really try to focus on generalities and generalities of course do apply in the majority of cases; but trying to really fine tune what works for the patient is very important.

Dr. Manuel Torres:

Now, patients tend to do this on their own. Patients tend to do this with guidance that may be misleading. Patients may tend to do this by what their neighbor is doing or what their spouse is doing, or et cetera. And again, not everybody is built the same.

Dr. Manuel Torres:

As we've already talked about, there are very specific ways to approach obesity, where your individual treatment plan for your obesity needs to be evaluated by a physician who has the experience and the knowledge to try to guide you.

Dr. Manuel Torres:

So I think part of the reason why diets work, to try to answer your question is because we try to really approach weight loss with a sort of one-size-fits-all. The current fad of trying to avoid carbohydrates and trying to avoid carbohydrates all together, sure, can have some changes on the scale, but may be difficult in regards to sustainability and longevity, and how does that translate into my daily living?

Dr. Manuel Torres:

Could I really live the rest of my life never, ever, ever having carbohydrates ever, ever again? That's an unrealistic approach for most people. And the big part about dietary challenges is the fact that change is sometimes very difficult.

Dr. Manuel Torres:

That begins to open the door into personalities and why people's personality and approach and motivation really matters because one of the biggest things that we have to do obviously is change and change is sometimes hard to make permanent.

Dr. Manuel Torres:

So if someone decides to go low calorie and low carbohydrate, it's not low calorie and low carbohydrate Monday through Wednesday, and then Thursday, Friday. "Oh, well, it's the weekend." And then, "I'll start again on Monday." It's trying to be consistent.

Dr. Manuel Torres:

I often talk about the three C's: calories, carbohydrates, and the most important one being consistency. The consistency is really what matters.

Dr. Jonathan Fialkow:

No, it does. I think the take home point is no one solution for everyone. People want the magic bullet of I want to be able to, I'll say lose weight, which is a term I hate using. I want to get leaner, but without any sacrifice, or without being hungry.

Dr. Jonathan Fialkow:

Well, you can do it without being hungry. When you go on starvation diets, which is basically anything that will ultimately lower your calories to some degree, hunger kicks in and that's why diets fail.

Dr. Jonathan Fialkow:

But I do think that customized approach what works for me, what's sustainable. It's not something I need to avoid completely for the rest of my life, but to get your body more balanced, get your body healthier, I think those are the goals.

Dr. Manuel Torres:

Right.

Dr. Jonathan Fialkow:

I would even tell people, for example, we've had people who three blood pressure pills, elevated cholesterol, they get off the medications. "Oh, my cholesterol is better." I'm like, "No, now it's normal."

Dr. Manuel Torres:

Right.

Dr. Jonathan Fialkow:

Or, "My blood is better." No, no. Now you're normal. You were abnormal before when you were hypertensive.

Dr. Jonathan Fialkow:

So getting back to now specifically... Quick question, and then I want to get into your particular methodology based on your training and experience. Is it possible for someone to be overweight and hungry?

Dr. Manuel Torres:

Well, yeah, of course. I mean, here's part of the challenge. Part of the challenge is the fact that I think we tend to focus on the wrong organ or we don't necessarily, and this is common. You know, patients don't necessarily understand that you're focused on the wrong organ.

Dr. Manuel Torres:

We're trying to lose body fat, which is what we see in the mirror. But the true organ that is in control of this whole scenario is your brain.

Dr. Manuel Torres:

We spoke a little bit earlier about evolution and sort of how the brain has evolved and the brain will seek to achieve stability and also will seek to achieve storage.

Dr. Manuel Torres:

Most people are genetically predisposed to save energy for that potential crisis. And that's sort of how the foundation of the brain physiology works when it comes to calorie control and adipose storage because the brain doesn't understand that maybe the next meal may not exactly come.

Dr. Manuel Torres:

So, yes, once somebody... We talk a lot about what's called the fat mass set point in the field of obesity medicine. You know, genetically it is believed that there's a predisposition for the brain to be comfortable at a particular set point in regards to BMI and how flexible that set point is in sort of nuances of obesity medicine is pretty interesting.

Dr. Manuel Torres:

But if your fat mass subpoint is set at a high number when it comes to BMI, you're still going to cycle through the phases of hunger, craving, desire, and satisfaction.

Dr. Manuel Torres:

And that also by the way, comes from a hormonal standpoint, which is what your original point was, that this has everything to do with brain control. The brain needs to be satisfied with the consumption of food that's coming in, and the brain needs to be satisfied with how much energy is there available just in case.

Dr. Manuel Torres:

And that back and forth between hormonal play is how our hunger cycle works. And it particularly works in a place called the arcuate nucleus as part of the hypothalamus in the brain and that's important to understand.

Dr. Manuel Torres:

I don't typically get into all of those particular details with the patient, but I try to help the patient understand that what we're trying to help do is to help your brain understand that there needs to be a usage of your reserve tank of energy. And that begins to sort of open the door to the understanding of why a calorie and carbohydrate restriction will begin to do that.

Dr. Manuel Torres:

So, again, I hope that answered your question. I know that was a long answer.

Dr. Jonathan Fialkow:

I'll put that in English.

Dr. Manuel Torres:

Sorry!

Dr. Jonathan Fialkow:

No, no. That's the background for it, but I think what's important is number one, if you're overweight or struggling to lose weight, it's not a personality factor. You're not failing in anything. Your body wants to hold on to this energy. There are drivers that are creating that status, again, of craving and holding onto energy, although there are tools and ways to correct that.

Dr. Jonathan Fialkow:

Ultimately, lean people shouldn't judge overweight people. It's not a personality defect. It's not a flaw. They're not weak minded. They're hormonally... I mean, how many times [inaudible 00:16:23] 300 pounds twins? I mean to the pound. Tell me how it's not genetic and certainly hormonal twins to have almost the same exact weight.

Dr. Manuel Torres:

I'm sorry, I didn't mean to interrupt, but this is all genetically predetermined. And I try to help patients understand. "Sir or ma'am, you're a good weight gainer. Genetically you've been sort of manufactured to be a good weight gainer."

Dr. Manuel Torres:

And then on top of that, if we go back to the discussion in regards to the macro environment, you're living in a macro environment where there's plenty of food availability. So if you match genetics for a good weight gainer with massive amount of surplus of food availability, and then you also match that with other macro environmental situations where you're not really spending a lot of energy to do routine things, then that's going to lead to slow and steady weight gain.

Dr. Manuel Torres:

Actually, we only need to be over by about 11 calories per day to gain about a pound and a half per year as we progress from 25 to 65. And that's pretty amazing. Like you think about where you started at 25, if you're already sitting at a BMI of 32, by the time you hit 65, yeah. You're going to have a problem on your hands.

Dr. Jonathan Fialkow:

So a couple of final points, because obviously we can take any these points and really expand on them. It's fascinating. And again, we're not going to get into different diets and pros and cons. And although I think arguably eating food in the most natural form and avoiding sugar would be a good starting point, as much as you can.

Dr. Jonathan Fialkow:

What's your approach? What do you do uniquely? What tools do you use in your practice as an expert in obesity medicine?

Dr. Manuel Torres:

The good news here is that at Baptist Health, we're really expanding in regards to what is available to the patient. And it's very important that I begin to explain to the patient that we have to implement multiple tools to really help develop a weight loss strategy.

Dr. Manuel Torres:

So looking at again, common calorie intakes, our preferences in macronutrient distribution... How much carbohydrate are you eating? How much protein? How much fat? Doing a little bit of calorie evaluation and having the patient start off with a self-assessment is a very useful tool, and then building on top of that.

Dr. Manuel Torres:

Sort of the next line of that is to evaluate the patient metabolically. Does this patient have a genetic disorder? Is this patient genetically predetermined to gain weight? What are the factors there? And then implementing a pharmaceutical strategy. And sometimes pharmaceuticals can come in very handy, especially if the patient already has additional comorbidities.

Dr. Manuel Torres:

So for example, a lot of diabetic medications, as you're aware of, are now really favoring weight loss as opposed to before, where we were using diabetic medications that were really favoring weight gain.

Dr. Manuel Torres:

So maybe even medication adjustment. Psychotropic medications if the patient has a behavioral health issue and is on psychotropic medications that are really prone to weight gain, can we talk to the psychiatrist? Can we try to adjust those medications so on and so forth to promote weight loss?

Dr. Manuel Torres:

And then advancing that and sort of seeing how the patient goes and really trying to assure that there is adequate follow-up and good accountability for the patient and talking about additional, more significant strategies that definitely have a greater effect on weight loss, like for example, bariatric surgery.

Dr. Manuel Torres:

I work very closely with our bariatric surgeons and we definitely implement a surgical approach when it's indicated. Some patients, unfortunately, come in and they're sort of at the situation where I help them understand that bariatric surgery may be part of the strategy.

Dr. Manuel Torres:

It may not be the strategy that we implement today, but it's definitely a tool in our toolbox that we can definitely use when the time is right, when they're ready, and when they're ready to understand the fact that even after surgery with such significant weight loss, there's still going to be a need for diet, exercise, maybe even pharmaceutical therapy, et cetera, et cetera, et cetera.

Dr. Jonathan Fialkow:

I really appreciate that. It's a customized approach. You look for secondary factors, which might be missed... Hormonal, thyroid, things like that. You get into, obviously, the patient's psychosocial components to help them as well assess on what might be driving the difficulty in getting down to a leaner weight.

Dr. Jonathan Fialkow:

But then you use whatever other tools are available. There might be medical therapies which are beneficial as you said. Even bariatric surgery, which has had good outcomes in the right patient, but you're not starting with, "Okay. Surgery. Next? Surgery. Next?"

Dr. Manuel Torres:

Correct. Correct. And again, it's very important that patients understand that there's not a silver bullet. Yes, surgery is the most effective tool. And thank God we've been able to implement surgery safely and decrease a lot of the complications that come with the surgery. We have excellent surgeons on staff that are very well trained and very well qualified, which is fantastic. So we can really control the environment and have them have excellent outcomes. But that's just a tool. That's just a tool in the shed.

Dr. Manuel Torres:

And again, after the surgery, there's going to be significant follow-up. There's going to be significant treatment. There's going to be significant nutritional changes. You know, their life does change just as your life does need to change when you're simply starting a diet.

Dr. Manuel Torres:

Going from eating whatever you want to eating absolutely no carbohydrates is a change. So again, understanding the behavioral component to this and understanding the fact that acceptance of change and really transitioning a patient through change is really actually one of the more gratifying parts of treating patients for obesity.

Dr. Jonathan Fialkow:

This is great information. I think a couple of take-home points. It's kind of like getting older in our society kind of promotes circumstances that would enable people to gain weight and how we recognize that and then change to get healthier. And as we said, not for the Speedo, but for the medical benefits and the health benefits.

Dr. Manuel Torres:

Speedos for you, buddy. Not for me.

Dr. Jonathan Fialkow:

One day. One day. I'm getting there.

Dr. Jonathan Fialkow:

Great stuff, Manny. Again, hopefully we'll have you back for maybe some more conversations.

Dr. Manuel Torres:

I'd love to do that. Excellent.

Dr. Jonathan Fialkow:

And to our listeners. Again, as usual, if you have any thoughts regarding this or other podcasts or any requests for topics for the future, please email us at BaptistHealthTalk@baptisthealth.net. That's BaptistHealthTalk@baptisthealth.net. Please go to your podcast app and give us five star rating and otherwise stay safe and mask up.

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