[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 significant 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.
