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Monday, April 28, 2014

Weight loss resistance and choices

Weight is not a behavior, and weight is not a choice. Nobody wakes up and decides what to weigh today. In an age when healthy and unhealthy behaviors are increasingly subject to incentives and disincentives, respectively, this is all too easily forgotten.

Of course, weight is largely the byproduct of behaviors and choices, namely what and how much we eat, and what and how much we do: calories in and calories out. But the simple math of energy balance and the simple premise that our choices are in charge of it are complicated by two considerations.

First is that the choices we make are in turn dependent on the choices we have, and in the case of energy balance, all of modern culture conspires against good choices. In particular, foods designed to be all but addictive and maximize the calories it takes to feel full, designed with the aid of such powerful technologies as functional MRI scanning no less, are a potent sabotage of personal responsibility and good choices.

Second, 2 people may make the very same choices and wind up at very different weights. As a clinician with some 25 years of direct patient care experience, I can say categorically that 2 people can eat the same amount and exercise the same amount, yet 1 gets fat and 1 stays thin. This, of course, is not at all fair. But we have all, I trust, been around that block a time or two. We know life isn’t necessarily fair. Or at best, it’s fairly unfair over time, as bad things happen all too often to thin people, too.

Let’s quickly acknowledge that differential weight outcomes despite comparable diet and activity levels do nothing to repudiate the laws of thermodynamics. The relationship between matter and energy characterized initially by Newton is a basic tenet of physics, and all but unassailable. Certainly, it is stationed well above the pay grade of New-Age iconoclasts who debate the relevance of calories to no valuable end. Yes, calories do count. They are a measure of energy, and anyone wanting to contest the relationship between energy and matter has to go toe to toe with Sir Isaac. He’s never lost yet.

There is no need to revisit laws of physics to explain the paradox of differential weight outcomes. We need only visit the local car dealership. We are well accustomed to the list of attributes highlighted when cars are on sale, and among these is fuel efficiency. Obviously, it varies. That does not alter the properties of the fuel. It does not challenge the reliable meaning of a gallon or liter. It merely indicates that not all engines are created equal.

That is exactly true of the human engine, our metabolism, as well. We vary markedly in fuel efficiency due to various factors. Some are as obvious as our heritage. There are whole populations, such as the Pima Indians of the American Southwest (and originally, Mexico) whose ancestors adapted to survive in a very frugal desert environment, who are remarkably fuel efficient. Such groups, notably including many Native Americans and Pacific Islanders such as the Samoans, gain weight with stunning ease when exposed to modern living, and shed pounds very laboriously.

Underlying such ethnic variation is, of course, genetic variation, so variable response to particular doses of calories in and calories out is partly explained by genes. It is partly explained by body composition as well, which is in turn partly explained by still other genes, as well as experiential factors. A higher mass of muscle increases the calories needed to maintain weight. A lower mass of muscle and higher fat content has the opposite effect.

And then still other factors, some known and some doubtless yet unknown, influence weight outcomes in ways we are just beginning to appreciate. One that is well established is hormonal responses, in particular that of insulin. People who need higher levels of insulin to maintain normal blood sugar are preferentially disposed to deposit calories into body fat and gain weight. Weight gain then tends to worsen insulin resistance, and this very readily becomes a degenerating and very frustrating, spiral.

A more recent and increasingly salient consideration is the status of our microbiome, the bacteria that colonize our bodies, and especially our gastrointestinal tract. We have long known that bacteria outnumber our cells roughly 10 to one, and figure importantly in digestion. We are learning all the time how important they are to other body functions as well, from immune responses to hormonal balance.

One of the new frontiers in medicine is the recognition that significant alterations of the gastrointestinal flora can produce significant alterations in weight. In some cases, it can apparently result in extreme weight-loss resistance.

I have had patients in this category, people who eat very frugally, exercise strenuously and just can’t seem to take off weight. Of course, sometimes people seemingly in this category are telling themselves and their doctor, perhaps inadvertently, little white lies, exaggerating how few calories they consume, or how much they exercise. But among my weight-loss resistant patients are some who have undergone full metabolic testing, verifying the truth of their claims. Some people are almost shockingly fuel efficient, vulnerable to weight gain and resistant to weight loss.

This frustrating problem prompted me to create an online exchange for those affected, so a community could come together and benefit from the ‘hive mind.’ I invite any in this camp to visit the site, and I invite experts in this area to contact me via email to explore the possibility of sharing that expertise. My thanks in advance to those who do so.

There are cases, few and far between thus far, where extreme weight-loss resistance has been linked to disruption of gastrointestinal flora, due to antibiotics or some other trauma. And, in some cases, the still extreme option of fecal transplant, introducing a full suite of normal intestinal bacteria, has proven therapeutic. Lesser instances of the same basic problem may respond well to probiotics, prebiotics or a combination.

In some cases drugs, such as the diabetes drug metformin, may prove useful: metformin enhances insulin sensitivity, and has a potential role in treating insulin resistance in addition to diabetes. In some cases, nutrient supplements may be appropriate. Cinnamon can help stabilize blood sugar and insulin levels. Green coffee bean extract appears thus far to be a safe and effective means to boost metabolism slightly. Garcinia cambogia may help attenuate appetite, among other effects. A product called PGX made from dietary fiber can blunt the glycemic effect of food.

The right response to weight-loss resistance will vary. In some cases, it will be learning to love the skin you’re in, not everyone who wants to lose weight really needs to do so. If you carry extra pounds but are fit and vital and healthy, perhaps you can and should learn to accept rather than fight your “natural” weight, shape and size. Your life may be better if you do.

For those who can’t or won’t accept their weight, or whose health is compromised by it, the options for addressing weight-loss resistance should be explored with a health care professional who knows what they are doing. The approach should be individualized, and given the limits to our current knowledge, will likely involve some trial and error. But it can result in success, so keep the faith.

Weight-loss resistance is real. I’ve seen it, up close and intimately.

Weight, per se, is not a choice. Addressing the variable challenge of weight management with insight, understanding and compassion certainly is. It’s a choice we should all be making.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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