The image never fails: a slender, happy person holding up that extra-large pair of pants he or she (presumably) used to wear before losing a bunch of weight. What the picture doesn't show is just how hard lasting weight loss can really be. Many people who are obese or overweight need outside help, especially when excess weight affects their health. Medically supervised weight loss is an option for some -- and a specialized diet is just part of the program.
Dr. Ethan Lazarus is the director of Clinical Nutrition Center in Greenwood Village, Colorado. As a family medicine physician and obesity medicine physician, Lazarus brings a dual perspective to treating obesity. The main advantage in centers like his, he says, is that clinicians have training in how to treat weight conditions, which are seen as multifaceted medical issues, not failures of willpower.
In patients' first hourlong visit with Lazarus, he takes a comprehensive medical history. "A lot of that history is focused on their weight, diet and exercise history -- components of their history nobody's ever asked about," he says.
Lazarus assesses patients for medical problems related to their weight, such as sleep apnea, prediabetes, diabetes, anxiety and depression. It's not unusual to find that patients are on several medications that actually make them gain even more weight, he says. He addresses conditions such as low thyroid levels or prediabetes and substitutes problem medications with weight-neutral or weight-loss-promoting drugs.
Each patient gets a customized program, with input from the center's dietitians, physician assistant and psychotherapist as needed. Dietary options include meal replacement with Optifast, which is only used by about 10 to 15 percent of the center's patients, Lazarus says. "The vast majority of our patients are using mostly food you buy at the grocery store," he says. "Optifast is a nice option for people who are really heavy or have done five or six [diets] or are really sick."
Dr. Phillip Snider, medical director of Bon Secours Weight Loss Institute, practices in Norfolk, Virginia. Snider, who was a dietitian and personal trainer before medical school, takes a holistic approach to medically supervised weight loss.
To qualify for the Bon Secours program, a person must have either a body mass index of at least 30 -- in the "obese" range or higher -- or a BMI of at least 27 plus at least one coexisting condition, such as diabetes, high blood pressure or high cholesterol.
"You go through an orientation, find out about it and if you like it, 'it's OK, sign me up,"' Snider says. "You get your blood drawn, then an appointment with me. And we do the medical clearance, a look at your medicines, do an EKG and say, 'Welcome to the program.'"
Unlike commercial diet plans that you follow on your own, super-strict diets require medical monitoring.
Bon Secours uses a New Directions program designed for medical providers. "It's 800 calories a day and under 50 grams of carbohydrates a day," Snider says. "The typical American diet is 450 grams of carbohydrates a day."
Patients have four options: shakes, puddings, bars or soups. "There's a lot of good evidence in the literature that if you take choice away from people, it's a lot easier to adhere to a program," Snider says. "Because it's not like, 'what flavor pizza do I have tonight?' It's, 'Pizza's off the menu.' So it helps them make that decision."
Very low-carb diets can result in a process called ketosis. Ketosis occurs when your body breaks down stored fat, causing ketones to build up in your body. Side effects from ketosis include nausea, headache and fatigue.
"Being on a ketogenic diet makes you lose a lot of water," Snider says. Patients are taken off diuretic medicines and told to drink plenty of water so they don't get dehydrated. Other medications may be adjusted as well, like lowering insulin doses for patients with diabetes.
Depending on their electrocardiogram readings or other medical indications, some patients go on a modified meal replacement program instead of using meal replacements as their sole source of nutrition.
After their initial consult, patients return to the clinic for a weekly group class with the program's dietitian and have their weight, waist size, blood pressure and heart rate checked. Snider sees patients every four to six weeks and re-evaluates their lab work.
So, How Much Weight Loss?
Average weight loss in the Bon Secours program is about 2 to 4 pounds a week, Snider says. "Of course, the women always get frustrated because the men lose more," he says. "The more you have to lose, the quicker you lose in the beginning."
With Clinical Nutrition Center patients, Lazarus says, "We like to see a minimum of 5 percent of weight loss by 90 days. Most people will lose weight for up to six or seven months," he says. While patients would prefer to lose as much as 35 percent of their body weight, he says, about 10 percent is a more reasonable and achievable goal.
Some parts of the weight-loss programs are typically covered by insurance, Snider says, such as physician office visits, the initial EKG and initial and ongoing laboratory tests. "They will not pay for the meal replacements," he says. "We have not even been successful getting people's health care spending accounts to pay for it." But, he adds, what you spend on meal replacements, you likely save on groceries.
Snider says after patients reach their goal weight and gradually transition to eating normal food, they stay on a maintenance program for up to 18 months.
"That's where we really try to get them thinking about, 'What's your relationship to food?'" he says. "'Do you eat when you're not hungry? Do you eat when you're stressed?' The main times people eat when they don't need calories are when they're angry, lonely, sad or bored."
The clinic brings in speakers who teach patients about healthier ways to relieve stress, Snider says. He'll also refer people for counseling within the community and suggest books he's found useful for stress reduction, success strategies and better self-image.
Lazarus says what really works best for long-term weight control is a behavioral program to address unhealthy eating habits. "Most of the time you're making food decisions on the fly with very little thought," he says. "You go to the restaurant and see what looks good. Or you're grabbing something that's in the cafeteria, or skipping meals all day and eating all night."
His program emphasizes stress reduction and specific behaviors such as getting a good's night sleep, eating on a scheduled basis and even what to shop for at the grocery store.
Rather than recommending three workouts a week at the gym, Lazarus says, he suggests making lifestyle adjustments involving sitting less and moving more. Simple fixes like using astanding desk at work or making phone calls on your feet can add up, he says. He may write an exercise prescription for patients or, less frequently, refer them to an exercise physiologist.
Choosing a Program
"Medically supervised" can take on a wide range of meanings, so be careful when you're searching for a weight-loss program. "There are lot of people who might say 'medically supervised,'" Snider says. "They might say 'doctor-recommended program.' But you want to get someone who's a board-certified bariatrician." Lazarus suggests finding weight-loss specialists connected with the Obesity Medicine Association.
When considering a program, Snider says, look at credentials and ask if you can speak to someone who's been through the program. "There are some shysters out there, unfortunately," he says. "A lot of people want to lose weight and are willing to spend money on it. They may have some good temporary success, but I think really where the rubber meets the road is: How do you help your patients protect their weight loss?"