Losing Weight, Gaining a New LifeFor Nancy Erdmann, years of being seriously overweight had taken a toll. Last year, she assessed where she was in life, and it wasn't a pretty picture. She was 55, weighed 280 pounds and had been living with diabetes since 2000.
Nancy had tried to lose weight for years. She hired a personal trainer. She tried Weight Watchers — three different times. However, she achieved only modest weight loss success before the pounds came back.
Finally, she decided enough was enough.
Her primary care physician put her in touch with the Froedtert & The Medical College of Wisconsin Comprehensive Weight Loss Center. A team of experts at the Comprehensive Weight Loss Center works with people like Nancy to provide specific, individualized treatment plans that help them reach a healthy weight.
“Many different specialties of medicine and surgery treat the ramifications of obesity, whether it’s sleep apnea, diabetes, heart disease or another complication, but obesity may be a secondary focus of treatment,” said Irene O’Shaughnessy, MD, a Medical College of Wisconsin endocrinologist who diagnoses and treats issues related to hormones, including metabolism (food burning and waste elimination). “At the Comprehensive Weight Loss Center, we bring together all the resources of an academic medical center to focus on helping people reach their weight loss goals, whether through medically supervised weight loss alone or in combination with weight loss surgery.”
There is no doubt that obesity is difficult to overcome, and statistics reflect this: in Wisconsin alone, at least half of adults in each county are overweight or obese — a rate that has more than doubled since 1990. (Wisconsin Department of Health Services, July 2009) What may be hard to understand is why we are so overweight — not just in Wisconsin, but across the nation.
Physicians and other researchers now know that obesity is a complex, clinical disorder with many contributing factors. For some people, genetics play a role. Others may have thyroid or other endocrine disorders that can make weight loss challenging.
“Fifty percent to 70 percent of a person’s weight is influenced by genetics,” said Bradley Javorsky, MD, Medical College of Wisconsin endocrinologist. “Genes can control a person’s metabolism, strength of appetite and likelihood of being active. The other 30 percent to 40 percent of a person’s weight outlook involves lifestyle factors and environment, such as round-the-clock availability of food in vending machines and fast food restaurants, and technological advances that promote sedentary activities, such as electronic entertainment devices and escalators. Lack of awareness about nutritional factors also contributes to obesity.”
Since being overweight raises a person’s risk for many medical problems, including diabetes, high blood pressure, heart disease, stroke, depression, cholesterol problems, sleep apnea and some types of cancer, specialists in a multi-disciplinary team work together to determine the cause of weight gain and treat it. That team includes endocrinologists, nurse practitioners, registered nurses, dietitians, exercise physiologists, physical and behavioral therapists, psychologists, pharmacists and surgeons who tackle every aspect of health related to obesity.
“To treat obesity successfully,” Dr. O’Shaughnessy said, “we know it’s important to treat the whole person, not just the person’s weight. We look at your complete health picture before forming opinions about a treatment path.” Drs. O’Shaughnessy, Javorsky and other endocrinologists assess risk based on the type and severity of obesity, evaluate secondary causes, evaluate and treat complications such as diabetes, coordinate care among team members, prescribe weight loss medications and when appropriate, prepare the patient for weight loss surgery.
This careful process begins with a thorough evaluation of a patient’s medical history, activity patterns, emotional issues and health screenings. With a complete evaluation in hand, an individualized, medically supervised step-bystep process is formulated to help patients lose the weight — and keep it off. Some people know they want to pursue bariatric surgery, but need to lose weight first (required by some insurance carriers), while others want to explore options other than surgery before deciding. In either case, patients access a range of specialty care under the umbrella of the Comprehensive Weight Loss Center, while an endocrinologist and/or a surgeon continues to monitor all aspects of treatment.
The plan may include nutritional recommendations, education and eating strategies, exercise plans, lifestyle modification, behavioral therapy and/or psychotherapy, and medications, such as appetite suppressants.
Education And Eating StrategiesAn important basic step is managing eating patterns. A registered dietitian completes a nutrition evaluation and formulates a meal plan that will not only encourage weight loss, but also ensure patients receive all of the nutrients they will need to stay healthy during the process of medically supervised weight loss or after surgery. The dietitian also helps patients understand how their eating habits affect their ability to make positive changes toward their goals.
“I started with visits to an endocrinologist and a dietitian to help get my blood sugar under control,” Nancy said. “We worked out a plan where I was limited to 50 carbs per meal and 150 per day.”
Another treatment step includes psychological and behavioral therapy, which are an integral part of the comprehensive approach. Therapists work with patients on managing stress, setting goals, solving problems, controlling stimuli, selfmonitoring and reinforcement. Therapy can help patients cope with underlying thoughts, emotions or behaviors that influence weight gain. Issues may include anxiety, depression, low self-esteem, life changes, such as a job loss or divorce, illness, injuries and past abuse or trauma. Behavioral therapy has been shown to have significant effects on weight loss, especially when combined with diet and exercise.
Medication ManagementConditions such as high blood pressure and diabetes go hand in hand with obesity in what is known as metabolic syndrome. (A person with metabolic syndrome has certain metabolic risk factors, the most dominant of which are excess fat in and around the abdomen and an inability of the body to use insulin efficiently.) If a patient or the primary physician desires, the weight loss team will treat the patient for these conditions and manage medications. As patients lose weight, the need for hypertension drugs or insulin may decrease and adjustments can be made.
Medications For ObesityFor some people, combining weight loss medications with lifestyle and behavioral changes can help with weight loss. However, weight loss medications are not for everyone and their use must be closely monitored.
“There are only two FDA-approved medications for long-term use in obesity management — sibutramine (Meridia®) and orlistat (Xenical®),” Dr. Javorsky said. “We only recommend these medications for patients with an initial body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with other risk factors.”
Because exercise helps people lose weight more efficiently, another important step is guiding patients toward incorporating movement into their lives. After assessing a person’s exercise capabilities, experts map out an achievable daily routine. An exercise physiologist got Nancy walking an hour per day, five to seven days a week. A physical therapist helps patients work within their physical limitations.
While many people find success through carefully monitored nutrition and activity plans, in certain cases, diet and exercise are simply not enough. Therefore, for select individuals, weight loss surgery may provide the only realistic means of overcoming obesity effectively.
Is Bariatric Surgery Appropriate?
After nine months of slow weight loss in spite of efforts at diet and exercise, Nancy decided to take her treatment to a new level. “I had knee problems, and when they didn’t improve, I wanted to get my life back on track faster,” Nancy said. She was evaluated and approved for weight loss surgery.
“With weight loss surgery, you can lose 30 percent to 40 percent of your weight and keep it off for life,” said James R. Wallace, MD, PhD, a Medical College of Wisconsin surgeon and director of the Bariatric Surgery Program at Froedtert & The Medical College of Wisconsin. The program and Dr. Wallace have received the American Society for Metabolic and Bariatric Surgery’s Center of Excellence designation.
The Bariatric Surgery Program has helped hundreds of obese patients lose weight by offering the laparoscopic adjustable band, gastric bypass and other weight loss procedures. After surgery, the treatment plan is long-term and unique to a patient’s needs. It includes access to a bariatric support group and exercise classes specially designed for people struggling with obesity. In fact, the Bariatric Surgery Program is the only one in eastern Wisconsin to provide life-long, postsurgical support to help patients achieve and maintain a healthy weight and lifestyle.
“I had full confidence in Dr. Wallace, because of his experience and the recognition that’s been given to the Bariatric Surgery Program,” Nancy said. “He was not hesitant at all about discussing risks associated with the surgery.”
Even with surgery, modifications in eating, exercise and lifestyle are required for success.
“To effectively lose weight permanently, people have to change the way they eat forever,” said Matthew Goldblatt, MD, FACS, a Medical College of Wisconsin surgeon. “The operations we offer help them do that. The majority of patients who are diabetic will have their diabetes cured or greatly improved. The same thing goes for high blood pressure and sleep apnea. In addition, the risk for infection and even cancer go down with sustained weight loss.”
Three months after surgery, Nancy says she feels like a different person. “I’m off all of my medications and all of my blood work is right where it should be.”
Nancy’s down to 192 pounds and keeps a daily journal of everything she eats to keep her diet on track. She also attends support group meetings, including learning how to deal with a whole new batch of emotions that are part of the weight loss process.
“It’s a big change … and I have to work through that,” Nancy said.
Source: Froedtert Today
Date: May 2010
Online Editor(s): Robin Schultz