‘Calories in minus calories burned — simple arithmetic.”
For years this was what I told my patients with obesity. I encouraged them to work both sides of the equation; to cut calories while increasing exercise. When they didn’t lose weight or lost and regained, I encouraged them to try again.
The only problem with this sensible plan was that it didn’t work. Each year, I counted on one hand the number of my patients who’d lost a lot of weight and maintained that loss. As the years went by, this fact, plus a few other puzzling observations, made me wonder whether what I’d been calling “simple arithmetic” was actually multi-variable calculus.
I noticed that while many — including patients with obesity themselves — attribute obesity to lack of willpower or discipline, most of my patients who’ve had difficulty losing weight demonstrate plenty of willpower and discipline in other aspects of their lives.
When I asked people why, after many attempts, they finally lost weight, often they couldn’t explain it better than: “Something just clicked.” One patient maintained weight loss by walking, while another gained weight despite running. A man did well for years on a low-carb diet that his wife couldn’t tolerate for more than a week. For some, weight loss surgery was a permanent fix, for others, it was a brief (and expensive and painful) hiatus from lifelong obesity.
Every time patients lost weight, I questioned them closely, hoping to uncover a solution I could pass on to others. Whether or not you consider obesity a disease, as the American Medical Association does now, it’s hard to argue that as a cause of diabetes, heart disease, several types of cancer, liver disease, respiratory ailments, and premature death for millions of Americans, obesity is a medical problem for which we could really use a solution.
But obesity researchers now believe that there is no single solution.
Recently, I met with Dr. W. Scott Butsch, a physician at the MGH Weight Center, to discuss heterogeneity in obesity: the likelihood that the term “obesity,” like “heart disease” and “cancer,” may, in fact comprise several different conditions requiring an array of therapies. We don’t yet understand enough about how to subcategorize obesity types, but research into causes of excess weight — genetic, environmental, psychological, neuro-chemical, even alterations in gut bacteria — suggests there are many, and that one treatment won’t be right for all of them.
Butsch learned the importance of customizing obesity treatment early in his career. As a resident, he had a patient who weighed over 300 pounds. She was motivated to lose weight, but lived in a neighborhood where opportunities to purchase healthy foods and to exercise safely were limited. Constricted by her poverty — and his own lack of nutritional knowledge at the time — Butsch still helped the woman lose a substantial amount of weight by guiding her to make small changes in her choice of groceries at a local gas station convenience store: less sugary cereal, 2 percent instead of whole milk, etc.
After we met, Butsch introduced me to three patients, one his own and two his colleagues’, who have lost large amounts of weight in the past year or so. All three have a genetic predisposition to obesity, have experienced medical complications from obesity, and have struggled with this issue for years. But their paths to healthier weight differ.
Beverly, 52, has dropped 45 pounds by using a smartphone app to track food portions, adding cardio to her weight lifting routine, and switching to vegetarian proteins, like beans. It wasn’t a lack of resources, but insufficient information that hampered her previous efforts. Though she’d been dieting and exercising on and off for 25 years, Beverly hadn’t really known how much she was eating, or that by reducing consumption of animal products and processed food she could lose weight without feeling deprived. She calls the past 18 months “a real eye-opener.”
Tim, 37, also benefited from dietary counseling — but it wasn’t enough. He lost 30 pounds in a “healthy habits” program, but stalled at 300 pounds. Then, his obesity-medicine physician prescribed the weight loss drug phentermine and, as Tim recalls, “it was like a switch was flipped and I started losing weight.” He’s now lost over 100 pounds. Though Tim has reached another plateau, he’s hoping the addition of a second medication will help him break through.
Weight-loss drugs, which worked so well for Tim, didn’t help Jared, 32, at all. After trying medication and countless diets, he had a lap band procedure, and lost but regained weight. This winter, Jared had a second surgery, a gastric bypass, and lost 40 pounds in the first four months. Jared feels confident that this time the weight loss will last — he’s much more vigilant about his diet than he was after the first surgery, and he’s exercising more, too. But there are other reasons Jared thinks the bypass will be more successful.
“The bypass surgery was my second chance,” he said. “I did not feel like the lap band was a success and I may have had it too early in my life. I feel like the progression from the lap band to the bypass helped prepare me physically and emotionally.”
After meeting these three patients, I reflected that the diversity of their responses to obesity treatment shouldn’t be surprising. We don’t, after all, give all patients with cancer the same kind of chemotherapy or offer surgery to everyone with heart disease. Nor do we stop trying to help patients with cancer or heart disease if the first, or even many, treatments fail.
“In the end,” Dr. Butsch told me, “the more we understand about the mechanisms behind weight regulation, the more we understand how difficult it is for many to lose weight. But having a good relationship with your patient and having the determination to keep trying different therapies can lead to weight loss. Without that determination, patients like Beverly and Tim would still be searching for the ‘next best diet’ and Jared may have given up after his first operation.”Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. She can be reached at firstname.lastname@example.org.