Hi, I'm Rochelle Corrado. I am a staff internist and obesity medicine doctor at Walter Reed in Bethesda, Maryland. Today I'm going to be talking to you guys about a focus on lifestyle interventions for the treatment of obesity. I have no financial disclosures. Today we're going to focus on these objectives. We're going to define adiposity-based chronic disease or ABCD. We're going to recognize the common cardiometabolic and biomechanical and psychosocial complications of ABCD. We're going to discuss evidence-based approaches to lifestyle interventions that help promote weight loss for your patients. And we're going to review the effectiveness of lifestyle interventions for greater than 10% total body weight loss. So what is ABCD? It is adiposity-based chronic disease and it's really the ace way of redefining obesity. And why? It's because it identifies obesity as a chronic disease that has a complex pathophysiology and it avoids the stigmata that has commonly been associated with the term obesity. So today we're going to focus on ABCD or adiposity-based chronic disease. We're going to use the A schematic for ABCD to help you evaluate your patients. To start, we're going to focus on diagnosis, then move into staging and treatment, and then finalize things out with our goals. First, looking at diagnosis, how do we diagnose our patients with ABCD? To start, we use anthropometric measures. Primarily, we commonly use the VMI. And then we want you to help look for clinical complications of excess adipose tissue in your patients and then the severity of those complications. In order to make our diagnosis of ABCD in our patients, we have to use our anthropometrics to determine who might be at risk. And the most commonly used anthropometric is the BMI, which I'm sure we're commonly familiar with. As you can see here on the chart, BMI is typically classified as then either underweight, normal weight, overweight, class 1, class 2, and class 3 obesity. Individuals of Asian descent tend to have a lower BMI cutoff for excess adipose tissue because they are at risk more so genetically at lower BMIs of excess adipose tissue. You know, BMI is great from a population standpoint at identifying the prevalence of obesity, but it's not the best for the individual person standing in front of you. So typically what I like to use in addition to my BMI is a waist circumference. Typically, waist circumference has been found to be well correlated with metabolic risk. And so in our patients, males of non-Asian descent, the waist circumference of greater than 40 inches or 102 centimeters. And for females, greater than 35 inches or 88 centimeters is classically associated with obesity. And you can see kind of below the cutoffs for Asian males and Asian females. There are other parameters that you could use to help better define the percentage of body fat and even particularly visceral fat. And those include DEXA scans, bioimpedance, air and water displacement, plasmography. But I think commonly in practice, we don't have those on hand. And so I think using your BMI and your waist circumference and additionally looking at those clinical complications from excess adipose tissue are going to be helpful in you making a patient of ABCD in the person in front of you. So how do you measure waist circumference? I typically like to palpate at the top of the iliac crest, and then I place a tape measure around the abdomen at the upper lateral port of the iliac crest. I wait until the tape is snug, but I'm not compressing the skin, and I have the patient breathe normally with minimal respiration to get the best reading. Once you have your anthropometric measures, you also want to be looking for the clinical complications that a patient might have that suggests adiposity-based chronic disease. So looking for those cardiometabolic risk factors like hyperlipidemia, hypertension, pre-diabetes, diabetes, fatty liver disease, PCOS, cerebrovascular disease, et cetera. Then thinking about what potential biomechanical complications do they have. Do they have severe arthritis? Do they have stress incontinence, GERD, sleep apnea, some sort of other disability? And then looking at other things like do they have a mood disorder that is a complication of their weight? Do they have disordered eating behaviors as a complication of their weight? Cancer is a big risk factor for patients who suffer from the disease of excess adipose tissue, particularly those with solid tumors, and then asthma, infertility, and male hypogonadism. So once you've made the diagnosis of ABCD for your patient using your anthropometric measures of typically BMI and waist circumference, plus then evaluating for those clinical complications about excess adipose tissue, you're then going to move on to how do you stage it and then determine how best to treat it. So that's what we're going to focus on next. So using the schematic for ABCD staging, we're going to break it down into stage 1, 2, and 3. So for stage 1, this is the patient that has no clinical complications of their weight. They have maybe metabolically healthy obesity as it's termed, and they have no biomechanical complications or other complications like mood disorders, et cetera, that we just talked about. Really, the focus is going to be on preventing future complications, and the first and foremost line of therapy is going to be lifestyle interventions, which we're going to talk about in a little bit later. Then moving to stage 2, these are your patients who have those mild to moderate complications due to their excess adipose tissue. Those are people who have prehypertension, prediabetes, MAFLD or NAFLD, mild sleep apnea, mild osteoarthritis. Really, the goal is that you want to treat the complications of this excess adipose tissue. Typically, the mainstays of therapy are going to be lifestyle and then really the consideration of anti-obesity medications because people are already starting to suffer from the complications of this excess adipose tissue. Then stage 3 are patients who already have severe complications of their excess adipose tissue. Really, our goal is, again, to treat those complications and to treat the underlying disease of adipose-based chronic disease. That would include lifestyle, which across the board is important for everyone, but then really utilizing anti-obesity medications or AOMs and then really honestly thinking about what surgical interventions might be good for this patient to help them reach their goals and to reduce the complications of the disease of excess adipose tissue. These people in stage 3 really are patients who have type 2 diabetes, coronary artery disease, NASH, hypertension, severe OSA, and severe osteoarthritis. Lastly, thinking about your goal, really you want to prevent or treat the complications of this excess adipose tissue. In order to prevent and primarily treat the complications of excess adipose tissue in our patients, we need to know what our goal weight loss is to show clinical improvement in these weight-related complications and disease processes. As you can see here in this chart, typically weight loss between 5% to 15% shows improvements in a lot of the weight-related complications that we typically see in our clinics. 10% weight loss is typically shown to improve metabolic syndrome. Typically 5% to 15% total body weight loss has been shown to significantly improve type 2 diabetes and even maybe prevent prediabetes and diabetes. 5% to 15% can improve our cholesterol panels and dyslipidemia. We can also show improvements in our blood pressure. About 5% can improve fatty liver disease, but honestly upwards of 10% to 40% is needed to improve NASH to really hit that fibrosis. About 5% to 15% to improve symptoms of PCOS. About 10% to improve sleep apnea. And roughly the same for osteoarthritis and asthma, stress incontinence, SCIRD. And then it's really not entirely clear about how much weight is necessary to help improve mood disorders, but what I have found clinically is that as my patients are losing weight and exercising more and eating healthier and sleeping better, they tend to feel better about themselves and a lot of their mood disorders do tend to improve and potentially even go into remission. So just thinking about 10-kilogram weight loss for a patient, this study shows that it can reduce mortality upwards of 20% to 25%. It can reduce diabetes-related deaths about 30% to 40%. And it can reduce obesity-related cancer deaths from 40% to 50%. It can show improvements in systolic and diastolic blood pressure upwards of 10 to 20 millimeters of mercury. It can reduce antennal symptoms up to 91%. It can significantly improve our lipid profiles and also even reduce potentially our A1C up to 15%. So this is just another schematic to help you kind of determine how best to treat patients with adipose-based chronic disease. Today, we're really going to focus on the lifestyle modifications and particularly those more intensive lifestyle interventions and how they can sometimes get patients upwards of 2 to maybe even 10%. But then also be thinking about how pharmacotherapy, when added, can get patients upwards of 5 to 25%, endoscopic procedures 10 to 20%, and then bariatric surgery upwards of 20 to 40%. Just to note, recently the American Metabolic and Bariatric Surgery Association came out with new guidelines and recommendations for BMI cutoffs for surgery. And actually now they recommend that people who have a BMI of 35 can, can and should, be evaluated for bariatric surgery and people with a BMI of greater than 30 with a significant comorbidity should be a candidate for surgery. Since our goal today is to focus on the lifestyle interventions that you can best counsel your patients on, this is how I like to approach these lifestyle modifications and counseling with my patients. I kind of have them at the middle and I really take an individualized, holistic approach to this. What works for one person might be different that works for someone else. I tend to focus on these four domains, nutrition, physical activity, sleep, and then stress and behavior. As a primary care physician, you can have a tremendous role in helping your patients lose weight and keep it off. And I think some of the important tips that I have learned along the way are that to start, we have to meet our patients where they're at. And I think as you're counseling patients on the lifestyle interventions, telling them to completely avoid fast food when they're eating out 7 to 8 times a week is probably not going to be sustainable nor achievable in the beginning. So maybe instead of trying to say, hey, don't ever go to McDonald's ever again, I say, okay, is there a way that we can reduce your visits to McDonald's by a quarter or even half? And if I can't, is there a way that we can focus on eating something healthier if you do have to make that food choice? And I typically tend to meet them where they're at and go from there and then slowly build on those things over time. I like to collaborate with patients in setting SMART goals. So things that are specific, measurable, achievable, that's really important. And in order to do so, you have to help your patients identify barriers that they might be facing that prevent them from doing the lifestyle modifications that you are going to talk to them about. Studies show time and time again that PCMs who are more helpful and pass less judgment or judgment-free actually have patients who lose more weight than those who are the reverse. I think it's really important to keep in mind that, again, what you think works for one person might not work for another. And so you always have to be modifying your treatment plans. I typically like to follow up with my patients every one to three months to kind of go over, you know, how they're doing and emphasize more lifestyle interventions. Sometimes when I can't do that, I definitely utilize my multidisciplinary team, which could include my nutritionist or dietician, an exercise physiologist, and even a therapist. So I think thinking about what resources do you have and how can you potentially use these resources to help you best care for your patient and provide effective counseling. The first domain that we're going to focus on is nutrition counseling for our patients. A lot of my patients come into clinic asking me, what's the special diet in order to lose weight? And I often tell them that regardless of the macronutrient composition, most studies show that a reduced-calorie diet is the success to weight loss. And I often quote this study that was done by Sachs and his colleagues and published in New England Journal in 2009. It took about 811 individuals, broke them up into four different dietary groups. There was high-carbohydrate, moderate-carbohydrate, and low-carbohydrate groups. There was a moderate to high amount of protein, depending on the group. And then there was a low-fat and high-fat. And as you can see here, when you follow these people over time, and despite group and individual counseling for each of them, the weight loss over time was roughly the same. And so again, I tell people it doesn't matter which diet you do. It's how can you maintain a calorie-reduced diet? Because that, at the end of the day, is the success to weight loss. And many other studies, as you can see here below, have cited the same. A lot of my patients ask me about intermittent fasting because they hear about it on the news and in social media and wonder if that's really the secret sauce to losing weight. So this is a good study that was done and published in New England Journal in 2020. It took about 139 patients, had about 84% completion, and randomized them to two different dietary pattern groups. So the first group followed intermittent fasting pattern of time-restricted eating. They were only eating between 8 and 4 p.m. And then they also had to adhere to a calorie restriction. And then the second group had to adhere to the same amount of calorie restriction, but they could eat throughout the day whenever they would like. They all got individual counseling, and then they followed them over the course of a year. And as you can see here, over the course of a year, there was no statistical difference in the amount of weight loss between the two groups. So I tell my patients, if intermittent fasting works for them because they can easily skip a meal and get rid of 500 kilocalories in their diet, well then great. But if skipping a meal makes you more ravenous and more likely to overeat later in the day and potentially eat something that's more unhealthy because you're so ravenous, then that's probably not the best diet for you. At the end of the day, I end up telling my patients that the best diet is the one that they can adhere to. It's the one that they can remain in a calorie restriction and sustain over the course of time. And this study really shows that nicely. So the graphic on the left is looking at absolute change in weight over the course of a year in comparison to people doing the Atkins, the Zone, Weight Watchers, and Ornish diets. And as you can see, the weight loss over time is not significantly different amongst all the groups. And then if you look at the graphic on the right, they look at percent weight change by dietary adherence. And as you can see, the people who were able to adhere to their diet the most were the ones who were the most successful in their weight loss over time. So again, the key to weight loss from a dietary perspective is how can you remain in a calorie restricted diet and feel satiated, not hungry, and it's something that you can sustain and adhere to over time. A lot of my patients ask me if they should be eating three meals a day or five meals a day, whether or not they should be eating breakfast or not. And so really looking at the data, you know, the frequency of when people eat, whether it's three times a day or five times a day, really doesn't make a whole lot of difference in terms of weight loss. Also looking at whether or not you have to eat breakfast, because I feel like I've definitely told my patients that they must eat breakfast in order to lose weight. There's not overwhelming data to support that. I think if you skip breakfast and then you tend to again overeat later in the day and eat higher energy dense foods that are higher in calories, well then maybe skipping breakfast isn't the best eating pattern for you. There is some data to suggest that if you can make dinner your smallest meal of the day and eat the majority of your kilocalories earlier in the day, that might have some benefit to helping you kind of sustain and meet your weight loss goals. But really consuming breakfast, eating five meals a day versus three meals a day, really no overwhelming data to say that you have to do any of those. Again, what is the best dietary pattern in which you can adhere to and sustain over time while remaining in a calorie deficit? This is a great study by Kevin Hall and his associates at the NIH looking at the types of food that we eat and whether all calories are really the same. He took 20 patients and put them in his inpatient metabolic wards and he exposed them to two different diets for 14 days at a time. He compared ultra-processed diets to unprocessed diets. At the end of 14 days, he found that patients who were eating the ultra-processed diets in the blue line tended to eat 500 more kilocalories per day than the people who were eating the unprocessed diets. Also, they ate faster than the people who were eating the unprocessed diets. Then if you look at their weight change over the course of 14 days, the folks eating ultra-processed diets tended to gain on average one kilogram of weight, whereas those eating the unprocessed diets lost about a kilogram of weight. Really, what does this tell us? There might be something to ultra-processed foods that tend to make us overeat, that maybe tend to not make us feel as full or satiated. Therefore, we continue to consume these kind of energy-dense foods and consume more calories. Maybe why is it that unprocessed diets tend to make us feel full or satiated sooner? You can think about it as that unprocessed diets tend to have more fibrous and whole-grain foods. Those typically take longer to digest, which oftentimes affect increasing satiety and decreasing hunger. Also, it takes more work to break down these fibrous whole grain foods. So we are burning more energy and expending more energy to do so. And then, at the end of the day, everybody's ability to extract energy from foods is different. Some people might, even with the same type of food, get different calories out of different things. But overall, I think this study does support that the quality of our food that we're eating does make a difference. And I typically try to emphasize to my patients that trying to cook as much as they can at home and avoiding ultra-processed foods as much as possible also can be a sustainable way to help achieve their weight loss goals. But I also understand that that's not always financially feasible or time feasible for many people. So I try to work within their constraints and try to address the barriers to help them then maybe pick the healthier option at local fast food places and such. A lot of people ask about very low-calorie diets versus low-calorie diets. So very low-calorie diets are typically dietary patterns to where patients eat less than 800 kilocalories per day, whereas the low-calorie diets are about 1,300 to 1,800 kilocalories per day. So this study was a meta-analysis that looked at various clinical trials that examined very low-calorie diets versus low-calorie diets. And they looked at them in the short-term and then the long-term. So the graphic on the left is looking at studies and the percentage of weight loss in the short-term, which could have been anywhere from six to 18 weeks and an average of 12 weeks on the very low-calorie diet versus the low-calorie diet. And what they found is that in the short-term, on average, the very low-calorie diets lost about 6% more weight than those who were doing the low-calorie diet. But then if you follow them long-term, anywhere from one to five years, they found that that difference really grew smaller and that patients who lost a lot initially with the very low-calorie diet tended to gain it back over time and really catch up then to the people who were doing the low-calorie diet. So at the end of the day, short-term, very low-calorie diets can be an effective way to help people lose weight rapidly, but when you follow them over time and they get back to the low-calorie diet after the initial kind of six to 18 weeks of very low-calorie diet, there's really not a significant difference in the percentage of weight loss. When you look at these very low-calorie diets, again, they significantly have greater short-term losses, but then when you compare them over time, there's really no significant change between the people who did an initial eight to 12 weeks running a very low-calorie diet and then went to just a low-calorie diet. And about 40 to 50% of lost weight was regained after about one to two years. So I think the message here is that very low-calorie diets can be used. I would probably say use them in a very limited circumstance. I see a lot of the bariatric surgeons at my facility use them prior to surgery in order to help jumpstart weight loss and to get people maybe down to a healthier weight prior to surgery. The important thing to keep in mind about these very low-calorie diets is that they require a lot of medical supervision because there's a lot of rapid weight loss. And because of that, there's the potential for a lot of significant health complications. And that could include dizziness, fatigue, gallstones, electrolyte abnormalities, constipation, muscle cramps, and even lean muscle loss. So I think that they have a purpose, but probably not the best bet for everyone. And I think just sticking to a regular caloric restriction of at least 750 to even maybe 500 to 750 kilocalories per day is good enough for most people. So hopefully now I've convinced you that the best diet is the one that your patient can adhere to and live in a calorie restriction while hopefully feeling satiated and without a substantial amount of hunger. So as you're trying to create this individualized plan for patients, I often talk to them about what's worked in the past or what hasn't worked. I often talk to them about what triggers have occurred in the past that have led to their weight gain. I like to focus on things outside of the number on the scale. And I ask them about what are their health and weight goals? What are their food preferences? What are their cultural norms? If I'm recommending them eating certain foods or certain times of the day or certain patterns that don't align and adhere to their cultural norms and beliefs, well then that's not gonna be a positive and meaningful full change for them. I think this is one of the biggest things to talk to our patients about are what are the social economic limitations to trying to adhere to an unprocessed diet? Do they know how to cook? Do they have the resources to store their food? Do they have a place to cook their food? Do they have the financial means to buy fresh fruits and vegetables and lean proteins, which unfortunately sometimes are more expensive than going to the local fast food joint around the corner. And then I also like to ask people, how much effort are you willing to invest now? And then how much effort are you willing to invest in the long term? That'll help you get a good sense on how you can individualize and tailor their eating plans for them. And to kind of summarize some key takeaway points that I often emphasize with my patients is that really at the end of the day, there's no special diet. We're really aiming for a calorie deficit. I shoot for typically 500 to 750 kilocalories per day. I often have them use the NIH Body Weight Planner. They can put in their weight now, their physical activity level, and then where they want their weight to be in about six months, and then it'll help calculate how many calories per day they should be eating, which makes it easier so they don't have to account for this calorie deficit themselves. I talk to them again about how dieting doesn't work. We need to find ways to create healthy, sustainable eating habits. And again, I remind them that it takes them anywhere from 20 to 60 some days to build a new habit. And so they have to stick with us and stay motivated and that it's a marathon and not a sprint. I try to work with them to limit eating out to maybe at least once a week. But again, I try to focus on, again, what are the barriers that might be preventing you from doing that? And maybe for some, that's not sustainable. Maybe going from eating out seven times a week to five times a week is gonna be a win. And again, I really try to help patients focus on the quality of their food because that does matter at the end of the day. Again, going back to Kevin Hall's study at the NIH and the metabolic wards, those ultra-processed foods on the right tend to make people overeat, fill less satiated, and even potentially then increase their weight over time, whereas maybe these unprocessed foods that have more fiber, more whole grain, are leading to us not consuming as much and then also maybe potentially expending more energy to break down these foods. Again, that all needs to be studied further, but I think that's really the crux of what people are starting to believe about these ultra-processed foods. Here are some more practical dietary tips that I talk about with my patients. The first one is probably one of the most important ones is meal prepping. We have so much decision-making fatigue in our lives, and when you come home at the end of the day and you have to figure out what you're gonna make and also think about whether or not you have those ingredients in your refrigerator that can be exhausting. So I recommend to everyone picking one day out of the week to think about what are the meals that they want to make that week, make a list, go to the grocery store, buy everything, and if you have time, even try chopping up things and prep so it'll be easier that night when you make it. I talk to people about packing a lunch and packing healthy snacks so they're prepared to make the right decision even when they're at work and potentially surrounded by a lot of unhealthy foods. I talk to people about meal replacements, whether they're shakes or protein bars. I typically only like patients to do it about one time a day. I will sometimes allow them to do it twice a day, but ideally not every day. I have them focus on looking at the ingredients in the product that they're drinking or eating, whether it's a protein shake or protein bar. I emphasize looking for bars and shakes that have anywhere from 25 to 30 grams of protein and less than five grams of sugar. I think there's a lot of products out there that tend to have lower amounts of protein and higher amounts of sugar and people don't realize it, so really looking at the labels is important. I have people focus on fiber intake and try to get at least 30 grams of fiber per day. It helps us stay full longer. It helps us improve our bowels and prevent constipation and potentially increase our energy expenditure as we're trying to break down these fibrous foods. I always focus on protein, largely because protein has been shown to decrease hunger. I shoot for a goal of at least 1.2 to 1.5 grams per kilogram per day, which I will tell you most patients at first are definitely not meeting their protein goals. So we talk about foods and things that can help them increase their protein. So anything from lean meats and fish to lentils and beans, chia seeds, peanuts, almonds, cottage cheese, plain Greek yogurt, eggs, tofu, all good options and ways to increase protein in their diet. And if they want something other than foods, then trying to get in the protein shake or a protein bar. I really emphasize water intake. I carry around a large jug of water with me everywhere because if I have to fill up a tiny glass of water or an eight ounce or 16 ounce bottle of water, I'm never gonna do it multiple times a day. And so I usually tell my patients, invest in a quality large water bottle that is like 30 to 40 ounces and carry it around with you. Fill it up, drink it, and that will help you maintain a higher water intake. Also, I tell people you can try drinking a glass of water before every meal. And sometimes that tends to make you feel full sooner and reduce how much they will eat. Typically, I tell people that artificial sweeteners are okay. There's been a whole lot of press after the WHO came out and said that artificial sweeteners might be problematic for some people and increase risk of cancer. They kind of put it in the same category as aloe vera. So I think most of us don't think of aloe vera as really an agent that we should have using. I think artificial sweeteners are truly okay unless you're drinking 16, 20, 25 diet sodas a day. If the artificial sweeteners in diet soda prevent you from drinking a regular soda, well then great, drink the diet soda to reduce the amount of calories that you'd be getting from a regular soda. If you can cut out regular soda and just drink water or sparkling water, well then great, don't drink the diet soda. But again, I think if diet soda and artificial sweeteners help you reduce your consumption of something that has more regular sugar and higher calories, well then that's a win. I have people focus on thinking about their plate and trying to make half of it non-starchy vegetables or fruits. I have about a quarter of it be whole grain carbohydrates and then about a quarter of it be their protein source. And again, trying to drink water with every meal is really important. Next, we're gonna talk about some behavioral modification approaches that you can use to work with your patients. One of the first things I talk to patients about in terms of behavioral modifications is building a supportive team. If you have that friend who is always inviting you out for pizza, beer, and wings on the weekends and it's really hard to say no to those things once you're there, well then I think you have to have a heart-to-heart conversation with your friend and say hey, I don't really wanna go eat pizza, beer, and wings anymore. Can we do something else to spend time together? Same with your family, right? If you are trying to decrease the amount of ultra-processed junk food in your house and your family gets frustrated that you're not buying it anymore or they keep buying it and putting it directly in front of the pantry doors when you open it up, well then that's probably not as helpful for you and in your goals. So I think talking to your family, talking to your friends, trying to let them know what you're doing and seeing if they can find ways to support you in that and that might mean if they are gonna buy junk food, putting it high up in the cabinet and far away so it's not directly in your face every single time you open the pantry and then that's tempting you every single time you see it. The next thing I talk to patients about is self-compassion. You have to talk to yourself as if you were talking to your friend. I think a lot of the times we beat up on ourselves and we talk so negatively to ourselves but we're not losing weight and we're not achieving our goals and studies really show that that can be harmful and a detriment to our ability to lose weight. So the key is self-compassion, be kind to yourself, encourage yourself and talk to yourself as if you were a friend. Self-monitoring, so I think in terms of food diarying, I think for some patients this can be helpful, right? If writing down everything that you eat and tracking it in something like, my fitness pal or the Lose It app helps you make better lifestyle decisions or food decisions, well then great. I think for some people though, that tends to make them more pathologic and kind of obsessed over every single thing that they eat and how many calories they eat and I think that can be harmful. So I talk to patients about what is helpful for you and what is not. Maybe just tracking your doing a food diary for a week can be helpful to help people learn the patterns in which they're eating and think about the whys and the what times are they eating? Like what is prompting the eating? How much am I eating? Am I understanding my correct portion sizes? Am I overeating majority of my calories at nighttime after dinner? Now that can help people find some ways to then make other behavioral modifications. In terms of activity, self-monitoring, I think a lot of people like to have Fitbits or the Apple Watches to track their activity and that motivates them to kind of get their steps per day. I think if that is helpful for patients, then by all means do it. And then in terms of weight tracking, I really discourage my patients from tracking their weight every single day. I think it leads to more frustration because there's going to be ups and downs throughout the day depending on what you ate and whether or not you went to the bathroom. I typically recommend checking your weight at least once a week and that would be a good way to see the overall trend of weight loss or weight gain. But I think daily becomes too much as you have the daily fluctuations and then you get frustrated if you don't feel like you're losing weight. In terms of controlling the stimuli that prompt overeating, I think this is huge, particularly around the holiday time period. If there is so much food on the table and everything is in your face, well, then it's going to be really hard not to continue to take seconds or thirds or say, oh, I'm just going to try a little bit of this. Also, potentially when you're cooking dinner, there's a lot of people, including myself, who will overeat and taste things and try things while I'm cooking. And so I think when you're cooking, one of the things that I tell my patients that they can try is putting gum in their mouth so they will chew on that and that will hopefully decrease their amount of snacking or eating while they're cooking. And then I think for holiday periods and really honestly any period in general is take the food off the table, leave the food in the kitchen, put the amount that you want on your plate and then go sit down and leave the food in the kitchen. If you have the food sitting in front of you, it's going to be incredibly hard to avoid wanting to take more and more, especially if it's really good. I think people have to start to anticipate situations that are going to become more tricky and then plan a feasible strategy. So if you are going to a holiday party or a work party and you know there's going to be tons of food and alcohol, thinking about, okay, what are the things that you can do to prevent you from overeating while you're there? And a couple strategies include never showing up to any event hungry because then you're going to be inclined to probably overeat and eat more than you would probably like. Eat something small before you go so you're not hungry so maybe you can avoid all of the things that you don't want to. Take a small little amount, put it on your plate and walk away from the food is key. Chewing gum can be a really good strategy. If alcohol is involved, I think getting a ton of water, putting some lime in it and carrying that around as opposed to always continually drinking multiple alcoholic drinks can be helpful as well. I really help patients set goals that are outside of that number on the scale. I think when you focus on goals of, I want to be stronger, I want to be healthier, I want to reduce my medications, I want to be more functional, I want to run around with my grandkids more, people tend to do better because I think when you're obsessing over that number on the scale as well, I think you're missing the bigger picture in the gains that you might be making in terms of strength and function or energy. So again, setting goals outside of the number on the scale. Creating a contingency strategy for slip-ups and weight gain is really important. It's going to happen and I think we have to tell people, it's okay to maybe not have the best day or maybe not even the best week given whatever you have going on from a life standpoint. It's how do you help yourself? Say, all right, that was last week or that was yesterday, I'm going to do better today. I think again, self-compassion, being kind to yourself, trying to recognize that not every day is going to be perfect and then getting back up and restarting your lifestyle modifications with a positive attitude the next day is going to be really important. Stress reduction is huge. There are so many people now who use food as comfort largely because it makes us feel better when we're sad, when we're stressed out. What are other ways in which we can reduce our stress, whether it's mindfulness, whether it's meditation, whether it's exercise, calling a friend, going for a walk? What are the other things that we can do to manage our stress that don't involve food? And then lastly, I think, utilize your motivational interviewing with patients. Really try to get at the heart of what are the reasons for why they want to lose weight and help them determine what they're willing to do and how they can set their goals and where they're at within this journey. Next, we're gonna talk about sleep and our approach to holistic lifestyle modifications. I think a lot of people don't think about the importance of sleep, particularly when they're trying to achieve their weight loss goals. So we're gonna tell you why it's so important. Sleep is so incredibly important for our patients as they're trying to lose weight. And so I'm gonna tell you why. So first, the graphic on the left is a randomized controlled trial to where they took people who were sleeping about five to six hours per night, and then they randomized half of them to a sleep extension group to where that group got one to one and a half more hours of sleep per night. And then they followed them over time and they looked at the amount of food that they were consuming per day. And the people who were getting more sleep, so that's the people in the green dots, they ate 270 kilocalories less per day than the people who were getting less sleep. And over time, if you kind of look at that reduction in 270 kilocalories per day over the course of three years, that can maybe mean the difference between 12 kilograms of weight loss. So the Nurses' Health Study, the graphic on the right, also kind of supports that sleep is important in patients helping achieve their weight goals. So this is looking at reported weights over time and also in regards to the number of hours that they slept. So the group on the filled in squares, diamonds on the top, was the people sleeping five hours per night. And as you can see, they have the highest weight to start and then the highest increase in slope in weight gain over time. The study shows per this is that the people tended to do the best were getting about seven to eight hours per night. So why do we need sleep to help achieve our weight loss goals? Well, I think a couple of things. One, the less sleep you get, the more hours that you are awake throughout the day to eat. So that's number one. Number two, lack of sleep has been shown to increase ghrelin, which is one of our hunger hormones, and decrease leptin, which is going to affect our hunger and our appetite and our satiety. And I think, you know, really the example I tell my patients is when you're sleep deprived, are you going to be as prepared to make that healthy decision in the morning or in the afternoon with thinking about what you're going to eat? If I'm sleep deprived, there's no way I'm going to eat, you know, my healthy Greek yogurt with fruit and granola. I'm going to say, give me the really greasy sausage, bacon, egg, and cheese sandwich, because that's going to make me feel better in the moment. Even if I know that doesn't align with my dietary goals, when I feel lousy, I really want something to make me feel better. And I think that that's really hard for patients when they're chronically sleep deprived to kind of overcome that system. You know, one thinking that's saying, oh, just eat this. You, it's okay. You feel horrible. This will make you feel better. Don't worry about your diet. You will definitely get back on it tomorrow. But I think, you know, the sleep is really important in that regard. I also tend to screen my patients for sleep apnea. And if their stop bangs are elevated, then referring them for evaluation. And then I also work with my patients who are not getting at least 70 hours of sleep per night and try to figure out why. And I do a lot of CBT to help them get slowly closer to those seven to eight hours of sleep per night, if possible. The next thing we're gonna talk about is physical activity or exercise and this holistic approach to lifestyle modifications for our patients. To start, these numbers are taken from randomized clinical trials and also practice guidelines, looking at the role of physical activity or exercise in weight loss. And starting at the top, you can see that people who are doing less than 150 minutes per week of some sort of aerobic physical activity, really aren't achieving any potential weight loss. And if they are, it's very minimal. People who are getting upwards of 150 to 225 minutes per week, may on average lose about two to three kilograms. If you are getting, you know, more than that 225 minutes per week, upwards of maybe even 400 minutes per week, you know, studies suggest that you might be able to get upwards of five to seven and a half kilograms of weight loss. And then typically most guidelines recommend that people strive for 200 to 300 minutes per week to maintain weight after weight loss. So then breaking it down by exercise type, is there one, you know, type of exercise that's better from a weight loss perspective? So aerobic activity or exercise in clinical trials has been shown to reduce weight about zero to 3%, maybe more if you were doing it in high volume. Resistance training, the weight loss is a little less, maybe you can get more clinically significant weight loss at a higher volume. Doing aerobic and resistance is really no different than aerobic alone. And then calorie restriction plus aerobic exercise has been shown to significantly increase the amount of potential weight loss. So I often tell my patients, as you can see from this is that exercise is not the end all be all to help them lose weight. And I think that exercise is incredibly important, I love exercise, it's great for our minds and our joints, it helps us sleep, it helps us with our stress, it's good for our heart, our blood sugars, you know, our arthritis, but it's not gonna be the end all be all for people in terms of achieving their weight loss goals. And I like to set that standard first because I have a lot of people who tell me they're working out two hours per day and frustrated that they're not losing any weight. And so I like to help them kind of reset their thinking about, you know, why we do exercise and that it is important for so many other reasons outside of the weight loss journey. So why don't people lose much weight with exercise? So this patient, it'll take her about 40 minutes to walk two miles and burn 240 kilocalories. Well, she could just eat one of these candy bars in about one minute and consume the amount of calories that she just burned in 40 minutes. You know, I think sometimes we don't realize that it is much harder to burn calories if you exercise and it is so easy to eat something in the shortest amount of time that will negate all of the benefits of exercise from a calorie standpoint that we just got. What are some other reasons for why we probably don't lose that much weight with exercise? So one, people, when they exercise, sometimes feel more tired and they do less activities of daily living or they do less around their house and they lay around all day. So actually over the course of the 24 hours, they might be burning less calories than they would have otherwise because they're less physically active outside of maybe that 30, 60 minutes that they were doing some strenuous activity. I think a lot of my patients say, okay, well, I worked out so I can eat this. And I think that's where the problem lies. I think a lot of times we overeat the number of calories that we have just burned and it's hard for us to understand that and conceptualize that. Gym machines notoriously overestimate the number of calories that are burned and we significantly underestimate the number of calories that we're eating. And so combine those two together and we are definitely going to be increasing our calorie intake. So I tell people, you know, exercise, again, is so important and I love it, but it's not gonna be your mainstay for weight loss. It is important from a weight management standpoint, but it's not gonna be the end-all be-all for people who are trying to lose weight. And the people who I see who are exercising two hours per day, I ask them, you know, do you like this? If you like this, well, great, keep doing it. If you're doing it and forcing yourself to do it and then later you're ravenous throughout the day and then you tend to overeat and eat whatever you want because you think you can because you worked out, well, then you need to back off in your workouts because that's becoming actually potentially more harmful for you. What are some practical exercise tips that I give to my patients? So one, I really individualize the treatment plan. I think about what are the barriers that you have to increasing your physical activity? Do you not have safe green space? Do you feel like you have limited time? How can we build in more physical activity throughout the day as opposed to setting apart, you know, 60 minutes to work out and then never doing it because you never have that time? How can you, you know, be more active at work? Can you get a standing desk? Can you take a break every hour and go walk up and down the stairs or walk around your office? Can you take your kids outside and go for a walk? Or can you get them involved in your exercise regimen and do things with you and make it fun? I find, you know, addressing these barriers can really be key to helping people, you know, really achieve their goals or increase their physical activity. The next thing, I always talk to people about what do they like to do? I think it's silly if I tell people, well, you have to go run to lose weight because one, that's not true. And two, they're so not motivated to want to do it because they don't like running. So I think the key is you gotta find physical activity that you like. Maybe that's dancing. Maybe that's rollerblading. Maybe that's going on a walk with a friend. But you have to find something that you enjoy because then you're going to want to keep doing it. And that's really key. Again, I set these expectations and I set realistic goals, letting them know that exercise is not the end all be all from a weight loss standpoint. There are wonderful reasons for why I want them to exercise from, again, the sleep, the bone health, the, you know, functionality, the strength, the energy, the improvements in blood sugar, blood pressure, but it's not going to be the end all be all for weight loss. I really talk to people eventually when I'm helping them lose weight about trying to fit in some sort of resistance training, maybe even one or two times per week, focusing on all their major muscle groups to protect their muscle mass during weight loss. I really emphasize this, and maybe I don't do it at the first appointment when I'm just trying to get them, you know, starting on this weight loss journey, but I'm definitely at the follow-up appointment and every appointment from there on out, going to really focus on some sort of resistance training to help them build muscle mass and maintain their muscle mass as they're trying to lose weight. And it can be simple as, you know, do you have resistance bands at home and giving them some exercises they can do or doing gentle weight things at home or if they like to go to the gym, what are the machines, what are the things that you can do to help build your muscle and maintain your muscle? Again, I caution over-exercise. I often feel that people who over-exercise are less physically active for the rest of the day or increase their calorie intake because they're starving, because they worked out so much. So I really try to caution people about that. And again, I think it's okay to delay talking to your patients about all these exercise things if at first they're so incredibly overwhelmed with just trying to do a calorie restriction and these behavioral modifications. You know, again, exercise is not going to be the key to long-term weight loss. It will be the key to weight maintenance. And so I think starting at the second or third appointment and talking about this could be important if your patients are overwhelmed in the beginning. If you're setting exercise goals and prescriptions with patients, I often go by the FIT mnemonic, which is in the top right. So you always talk to them about what's the frequency in which you want to do the exercise. What is the intensity that you want them to have? How long do you want to do it for time-wise? What is the type of physical activities that you want to be doing? And E, and the most important one, do you enjoy it? So just as a reminder, resistance training is just as important as cardio. You have to train yourself to resist chocolate, pastries, fried food, beer, and pizza. And for weight loss, you can't outrun a bad diet, but you should still be active. Hopefully now you feel that you have tools in your toolbox to help you provide effective evidence-based lifestyle counseling to your patients who have ABCD and are trying to lose weight. However, I like to tell my patients that sometimes for many, lifestyle is not going to be effective in the long-term and your body, as you heard in the obesity pathophysiology lecture, may be fighting back against you and making it hard to sustain weight loss over time doing just lifestyle alone. But I let them know that everyone is different and really the lifestyle I like to think of as your pillars. And sometimes you need these additional therapies like pharmacotherapy, endoscopic procedures, and maybe even surgery to help people achieve their goals to become their healthier, happier self. When I talk to my patients a lot about lifestyle modifications, I let them know that sometimes this is not going to be the end-all be-all for everyone in their weight loss journey. For some people, lifestyle modifications are not going to be effective enough to help lose weight and keep it off in a sustainable fashion. And we learned a little bit about why that is in the obesity pathophysiology lecture on how our body, particularly when we have the disease of obesity or adipose-based chronic disease, our body wants to hold onto that weight and wants to push us more towards regaining that weight when we've lost it. And we see this in a lot of clinical trials. And this one is looking at the Lookahead trial, which is a randomized control trial, looking at patients who had type 2 diabetes, and they randomized them to very intensive lifestyle intervention counseling, and then to usual care, diabetes support, and education. So the intensive lifestyle intervention group in the Lookahead trial had very intensive counseling. They were meeting weekly for the first six months, and then they met three times a month for the second six months. And then from year two through four, they had at least one visit per month, and then they had at least one touch base via phone, telephone, or email that month. So lots of intensive counseling that the majority of our patients are probably not doing. And what you can see here is they compared that intensive lifestyle to regular diabetes support and education, which could be giving them a handout in clinic talking about kind of some important tips for dietary modifications to reduce the risk and progression of diabetes, and then potentially their doctor talking to them in their appointment. And as you can see in graphic A, you can see the percentage of weight that was lost in comparison to where they started at one year. And about 68% of people who were even doing that very intensive lifestyle counseling lost about 5%, and then about 37.7% of patients in this intensive lifestyle group lost greater than 10%. And then about 15% of patients lost greater than 15%. And then fast forward to eight years after the start of the trial, even the people who are in the intensive lifestyle group still had a hard time holding and maintaining that weight loss. So about 50% of people now have been able to keep off greater than 5%, and only 26.9% of patients in that intensive lifestyle group were able to keep off 10% weight loss over time, which I think is really important to show again that lifestyle for many, despite even the most intensive of regimen, is going to be challenging for many to maintain weight loss. This graphic was made from data from a meta-analysis of 29 long-term weight loss studies that focused on lifestyle interventions and counseling. And this looked at the average time to weight regain after these interventions. And as you can see, after about two years from these lifestyle intensive therapies, about 50% of lost weight is regained. And at five years, about 80% of lost weight is regained. So this further supports the idea that unfortunately, lifestyle modifications alone are largely not going to be the way for most patients to sustain meaningful weight loss over time. Not to say that lifestyle modifications are not important. I talked to my patients about how the lifestyle are your pillars, and you need to be doing those, but sometimes you need the support of other therapies like pharmacotherapy, endoscopic procedures, surgery. You know, a lot of the older oral medications were studied looking at people who did the meds plus the people who did meds and lifestyle. And in those studies, the majority of the people who did the lifestyle plus the medications did better than the people who were just doing the meds alone. And so I think that, you know, lifestyle is very important as well as you're on your weight loss journey for patients because you could potentially be eating less calories, but it doesn't necessarily, again, mean that you're eating good calories or that you're losing weight in a healthy way. You need to be doing the physical activity to maintain, you know, your muscle mass. You need to be eating the protein to maintain your muscle mass. You need to be eating foods that are high in fiber and high in protein to help support reductions in blood pressure and blood sugar and improvements in fatty liver disease. There are benefits to all the lifestyle modifications. And again, the lifestyle modifications help patients be more successful with the pharmacotherapy that we have. Maybe not necessarily needed as much with our newer medications, but I will say that I have had a lot of patients, even on the newer injectable GLP-1 medications, and the people who tend to have more success in terms of weight loss tend to be the ones who are doing the lifestyle interventions the most effective way possible. So to close, hopefully you guys learned a little bit about how to evaluate patients for adipose-based chronic disease, how to make your diagnosis using your BMI and looking for those clinical complications and grading their severity. Then thinking about staging and treatment and talking about lifestyle interventions with all of your patients. And then also understanding when it's important to consider the use of pharmacotherapy with our anti-obesity meds or even surgery in patients depending on their clinical complications of their adipose-based chronic disease and the severity of it. And then hopefully at the end, you'll realize your goal is to prevent and treat the complications that they have in regards to their adipose-based chronic disease. And hope you found this helpful and have some good tips to take home to your patients.

lifestyle interventions

obesity treatment

ABCD

anthropometric measures

metabolic risk factors

biomechanical complications

evidence-based approaches

weight loss goals

individualizing treatment plans