Replay: “It’s not the diet. It is the diet that’s adhered to that works.”

Are you with us in planning for more healthy eating in the new year? Dr. Newman reminds us that there's nothing more magical than commitment. Read on (or listen) for encouragement to follow through on your plans!

Dedicated to helping other women pursue medical careers, Dr. Newman mentors pre-medical and medical students and young physicians through the American Medical Women’s Association (AMWA), Wellesley College, NYU, and Weill Cornell Medicine. In 2011, she founded the Wellesley Women in Medicine Group, a network of 900 women, including pre-medical and medical students and physicians of all ages, that participates in online conversations on topics such as medical training, career paths, work-life balance, and gender discrimination. Within AMWA, Dr Newman is a member of the Board of Directors, and co-chairs several committees including the Preventive Medicine Task Force, the American Women’s Hospitals Service (AWHS), and the Fellowship Committee. 

Barb: I first talked to today’s guest over a year ago, just before the pandemic began. We talked then about habits and health risks for women regarding alcohol consumption. Yes, little did we know what was coming next. So we’ve shared that podcast a few times over the past year, and we were obviously aware that women were consuming more alcohol because of isolation and stress that they were experiencing, so it remained an important topic over the last number of months. 

But today, I’d like to talk about another topic with our guest, Dr. Connie Newman. She’s been researching excess body weight, the effects, lifestyle changes that can help, and available treatments. Connie is an endocrinologist, physician scientist, and educator at the New York University School of Medicine, and the University of Oxford in the United Kingdom. Welcome back Connie!

Connie: Thank you Barbara. It’s so nice to be here again, and I’m really happy to be able to talk again to your audience. 

Barb: Yeah, thank you. I think this is a topic obviously that many—women in particular—have interest in. Having someone who's been in the field of research and sort of a leading expert in this field will be really enlightening to hear some new news regarding this. I’d like to start out by saying this is a triggering topic for a lot of women, and we recognize that it's a difficult conversation for many. There’s been such a complicated relationship between our culture and how they translate body shape and size, and all the negativity that goes with it. I’ve also seen a presentation that you were involved in that was done for the American Medical Women’s Association, and I’m wondering if you can speak into how the conversations might change to be somewhat more productive around this topic. 

Connie: Okay. So, I’m assuming you are talking about the conversations between doctors and patients. Is that correct?

Barb: Yes, primarily. And I know there are words—triggering words and phrases—that I think we as providers are trying to be sensitive to, but I’d like to hear your opinion on how we can better engage in a conversation with our patients. And how others maybe can speak amongst themselves. Maybe it’s just women-to-women, having conversations. 

Connie: Sure. That is something I want to talk about. When a patient comes into my office, you can see by looking at their body mass index [BMI]—which is usually measured before you see the patient—that the patient has excess weight or has obesity. One of the things that I want to do is to talk to them about that and to see if they would be willing or interested in losing weight. However, it’s difficult to talk to patients about losing weight because sometimes they just don’t want to speak about it. Before I address that topic, I usually talk to my patients about good health and what it means to have a healthy diet, to not drink much alcohol, to not smoke, and then I will mention their weight or their BMI. And ask them if they want to talk about it; if they want to talk about ways to lose weight. Sometimes they say, “No, doctor, I’m just not ready for that.” But at every visit I would approach that again. 

When a patient finally does agree to talk about it, or comes in specifically to lose weight, it’s important to avoid using words that offend them. Some of these words that offend them are “fat” and “fatness,” and even the word “obesity.” These words make patients feel denigrated. As a physician who specializes in obesity medicine, I believe that obesity is a disease. It’s not a matter of will power. Our patients need to understand that: that when a person gains body weight, the body reacts to that weight and tries to then maintain the weight. So once they start to lose weight—let’s say they lost ten pounds—their body’s hormones will change, causing them to get more hungry, so they’ll gain the weight back. So it’s very difficult for a patient to lose weight and to keep that weight off. 

Barb: I was listening to a lecture about weight, and this idea that obesity as a disease was brought up. And that speaker talked about how there are really no other diseases that we would expect our patients to address and journey through without assistance. We don’t expect them to “go home and fix your heart disease. Go home and fix your diabetes.” I’m curious about this idea of obesity as a disease and how that might help change the conversation, or maybe how people come to an acceptance of addressing it more readily. 

Connie: Yeah, thank you. I think that by thinking obesity as a disease, it takes the blame off of the patient. We don’t want our patients to feel ashamed about their body habitus. And it also tells them—the patients and also other doctors—that it is not so easy to lose weight because of the physiological mechanisms in the GI tract and in the brain that work against a person when they lose weight. The mechanisms are that they are hungry and they want to eat more. So I think conceptualizing it as a disease is helpful to patients, and also to doctors. 

Barb: On the other hand, many diseases require patient engagement to help address successful treatment. So I think on the other side is saying, just because it is now considered a disease, and we recognize the complexity of what goes on contributing to obesity doesn’t mean patients can’t contribute to the success of treatment by engaging in a healthy lifestyle, including exercise and diet. I wonder if recognizing it as disease doesn’t take patients off the hook of owning what they can do to better treat it. Or is it more likely to lead to medication use or surgical intervention?

Connie: That’s a good question. I think from our experience, recognizing obesity as a disease actually helps the patient, and there actually are diseases that patients can do things. For example, if you have high blood pressure, you can modify your diet and eat less salt. If you have heart disease, there are special diets that you can follow that are more healthy. So, I think that a patient who knows that the excess weight that he or she has is from a disease will still be able to work on modifying the lifestyle that he or she leads. 

What we don’t do is we don’t tell patients, “Okay, so now you have a BMI of 35. You must cut out a thousand calories a day, and this is what you have to do.” We don’t do that. We talk to our patients. We ask them questions. We use what we call motivational interviewing so we ask questions where we don’t get a yes or no answer. The patient comes to realize what is in the diet that can be changed. And the patient  will then decide—let’s say he drinks two orange juices in the morning—that he won’t drink orange juice in the morning, and that would help. So we try to give the patient autonomy in treating the condition.

Barb: I think I’ve heard that food tracking is one of the best predictors of success. Has that been your experience or observation?

Connie: Yes. A person who can honestly keep a food diary, and also weight is important. It’s important to get on the scale, at least twice a week. That really helps the patient to keep on the low-calorie diet. Speaking about diets, I just want to say there's a new method of dieting which is called restrictive feeding. I’m not sure if you’ve heard about it?

Barb: Tell me more. 

Connie: Okay, so restrictive feeding actually refers to limiting your food intake, let’s say from eight in the morning to six at night. So you can eat during those hours. But after six at night, you cannot eat anything. What happens is that patients will keep their calories down because they don’t eat after six at night, or after seven at night. It seems as though that helps people lose weight that way. They stop snacking after six or after seven. That’s a very popular method.

Barb: Is that another version of intermittent fasting...

Connie: Yes.

Barb: ...defining the hours in which you eat and then avoid eating for whatever hours you define it?

Connie: That’s right. Intermittent fasting could be like eating/fasting every other day, but generally on the fast days, we ask our patients to eat something, like 500 calories of food. And then the other day they can eat whatever they want. But that basically cuts down on the calories that the patient is consuming, and enables weight loss. 

Barb: And I’ve also heard it said that adherence to the diet is key; it’s not the diet itself. So many women are questioning, “Should I do low-fat, Keto, intermittent fasting?” 

Connie: [laughs]

Barb: Can you speak a little bit about that?

Connie: Well, you are absolutely correct. It is not the diet. It is the diet that the patient will adhere to that works. A patient who needs to lose weight, who has obesity, has a calorie-restricted diet which is healthy, and no matter what diet that is, it will only work if the patient will keep to it. So it’s not any particular diet that’s helpful. 

We do know that there are some diets that are healthy for the heart such as the DASH diet, and a Mediterranean diet. And you can use those with restrictive calories to lose weight and also eat foods that are good for your heart. 

Barb: I’m curious if you speak to women about diet—if that’s a term you use—around the idea of dieting or do you speak more in terms of lifestyle modifications that can be sustained for the next 30 years? Because I feel like women are looking for the diet to get them ready for their daughter’s wedding. It’s all about the short term, and it’s hard to get people to engage in the idea of making changes for the long term. I’m wondering if even the terms around dieting are better avoided.

Connie: Well, actually, I definitely agree with you. Diet to people means a short term thing that they will stop. Lifestyle modification is what we emphasize with our patients. But sometimes I revert to saying the word diet when I should not use that term. But people need to learn that this is life-long. 

Now when you do lose weight, and you get to the weight you want, you can modify the calories. You can increase them slowly, just to maintain the weight. You don’t want to keep losing weight forever. But I must say it is difficult to use a lifestyle modification alone to lose weight, and what is really needed is what we call behavioral interventions where patients need to meet with a group or with a counselor—perhaps every month if possible—to help them adhere to their lifestyle changes. And if behavioral modifications and lifestyle changes are not working, or if they worked but there’s a plateau, then as physicians we have to think of other measures perhaps medications which can help keep patients full; help them feel satiated. 

Barb: Can you talk a little bit more about medications and is there anything new around medications or are you anticipating any new medications that might be made available for patients regarding weight loss?

Connie: Okay, sure. I just want to emphasize that with the exception of the medication called Orlistat or Xenical, the other medications work on satiety, on increasing satiety. Orlistat works on blocking fat absorption. And that’s an older medication and actually people have a lot of side effects from that, so we don’t tend to use it that often.

The other medications, I’ll just name some of them: Phentramin, Toperamine, Naltrexone, Buproprion and the one I really like is liraglutide, and that is the generic name. Liraglutide comes in two forms, it comes in a dosage for diabetes and that dose goes up to 1.8 mg and that actually has the trade name of Victoza, but the medication for obesity is liraglutide 3 mg, the dose is higher and has the trade name of Saxenda. And this medication is very helpful in decreasing appetite. It also sometimes has side effects such as nausea, so people don’t eat as much and people can lose multiple pounds of weight. It's really amazing, you can actually use the one for diabetes for weight loss too, but it’s not indicated for that usage, the lower dose. So those and there are more medications being developed, for example, the liraglutide drug is called a glucagon-like peptide 1 agonist, we call them GLP1, and there are others being developed and perhaps others that are longer acting, because liraglutide is taken once daily. There also is something called hydrogel, which is a, let me make sure I have this right, that is not really a medication, it is a pill that you take that fills up, it is more or less a device, it isn’t absorbed. And the particles end up in your stomach and they absorb water and they increase satiety in the stomach. And that helps some people lose weight and that’s relatively new.

Barb: Do people who qualify to be put on medications have to have other health risks associated? Do they have to have hypertension or hypercholesterolemia? Because you do see in my case, women, who really don’t have any other health risk, they are overweight or obese, would like to lose weight. Do you use medication for that purpose or do you really only use it when they have a health risk that you are trying to address by improving weight loss? 

Connie: Thank you, yes, we do use medications if the patient's body mass index is thirty or above. So that patient does not need to have any other problems associated with excess weight, but probably that patient is developing problems and certainly osteoarthritis because it's the weight itself that impacts the weight-bearing joints. But, if a patient has a lower BMI, body mass index, let’s say it's 27, which is in the overweight range, medications can be used, provided they have something else, such as high blood pressure, abnormal lipids, heart disease, some other comorbidity. So you can use medications for people with comorbidities when their BMI is between 27 and 30 and when their BMI is 30 or above, that itself is an indication for medication, in addition to a healthy nutritional plan and exercise.

Barb: It seems that the highest rate of obesity for women occurs roughly between the ages of 40 and 59, that’s really a lot of the demographic of the women I see. For my practice, those women are often experiencing perimenopause, menopause, early postmenopausal times and associate weight gain. Do you have an understanding that the menopausal transition impacts weight?

Connie: Yes. I don’t understand—we don’t understand everything about it, but we think it is because of estrogen. Because estrogen, when it is present, can act in the brain to increase physical activity and energy expenditure. But when you lose estrogen, you lose that. So that is one mechanism why we think that more weight is gained after menopause. The loss of estrogen.

Barb: Yeah, so that’s a conversation I have with women often. I think it would be nice to have a little more science behind it, understanding exactly why that happens. But certainly it is widely experienced, and the majority of women, it appears, do have weight gain associated with menopause. Hopefully we’ll continue to understand more about that. My message for 40-year-olds is, in anticipation of menopause, paying more attention to weight and trying to work toward achieving, maintaining that ideal body weight is probably important. It has been my experience to see women who have yo-yoed over the years to kind of find that higher weight as they transition through menopause versus women who have been able to maintain an ideal body weight, those seem to be somewhat more successful in continuing that in menopause. 

Connie: Yes, I believe those are important observations. I don’t know exactly, but perhaps it’s the habits that the person has who maintains their weight before menopause, and also there could be some genetic factors involved as well. 

Barb: And I think a lot of women experience sleep disruption. Hasn’t there been some suggestion that sleep and weight may have some correlation, sleep quality?

Connie: Yes. That’s something people don’t recognize. The excess weight can cause fat inside your respiratory tract and can impact your breathing and cause what we call sleep apnea, or the patient will stop breathing intermittently during the night and doesn’t feel rested when they wake up in the morning. And if you lose—I didn’t say this before—if a patient, or anyone, loses 5 percent of their body weight, sleep apnea will improve, their joint pain can improve with osteoarthritis, so it doesn’t take a huge amount of weight loss to have improvements in some of the conditions that are associated with obesity. 

Barb: I have a question and follow up. Early on you talked about the hormones that drive appetite, and with weight loss maybe there’s an increased drive, so to speak, back to eat more, and increase your appetite. Is there a point at which that normalizes after some sustained weight maintenance with weight loss?

Connie: You mean doesn’t that happen?

Barb: Yes.

Connie: Well, I’m trying to think. I don’t actually know the data on that. It might. If you maintain the weight for a long period of time, I believe your body does adjust to that weight, but it takes a while for that to happen. And I’m not sure how long that has to happen. But if you just lose quickly, that won’t happen. 

Barb: Right. And that’s probably why the quick successes are not sustained successes. I would imagine that’s a big factor in that. 

Connie: Yes.

Barb: One other question I have is about the GI microbiome and understanding bacterial gut status. Has that shown to be a factor in weight?

Connie: I believe in research studies in animals, that has been shown to be a factor. But we have not yet been able to translate that into ways to treat our patients. But it’s a very important area of research, and very interesting. 

Barb: Yeah, it is intriguing to think that could play a role and if there could be some treatment options around that. 

Connie: One of the things I wanted to mention in terms of nutrition and eating is the portions that patients eat; that not only do they have to eat more healthy foods, but it really helps to know how much of a particular food you can eat. Like how much starch you can eat, or how much protein you need on your plate. Because our patients often have huge portions, and ask for seconds, and that just increases the calories. So there are charts, and the government website showing what we call “My Plate,” which helps patients too. 

Barb: Okay. Yeah, I think that is an important factor because you do hear women talk about, “Well, I eat really healthily.” But even good food—too much high-quality food can result in weight gain.

Connie: Right. 

Barb: And what about exercise? How do you communicate the importance of exercise around weight, weight loss, or is the discussion for you more around nutrition?

Connie: Well, the discussion is around nutrition in order to lose weight on a regular basis. Exercise is important to keep healthy, and patients need to follow the physical activity guidelines, which I believe are 150 minutes of moderate exercise a week. It could be 30 minutes, 5 times a week, and 2 days of some resistance training. So if you increase that, if your energy expenditure is greater than your energy intake, the patient will lose weight. But it’s really difficult to maintain, to continually lose weight by increasing your energy output by exercising more. 

We have a patient in one of our clinics who bikes during the summer months and in the spring, and in that period energy expenditure is high, and the patient’s weight comes down. But when the winter months come along, the patient will gain weight because the patient is no longer exercising like that. It’s a very interesting pattern to see. But it is important to note that weight training—a bit of weight training—helps your muscles, and in building muscles, muscles burn more calories than fat. So it is important to do some weight training. 

Barb: You know when I first started in practice, I saw women—50-year-olds I’ll say, or older—some had done that aging just beautifully and, you know, had maintained an ideal body weight, were able to be active and things worked well. My question for them was “What have you done to achieve this?” and interestingly almost without exception, weight training was part of their routine. It impressed me at the time, “Wow, I think there’s something to this resistance work or weight training.”

Connie: It is! There is, and it’s nice to know that you saw that. Weight training is important, but it doesn’t have to be extensive weight training. It could be twice a week.

Barb: I think the other thing we remind women approaching menopause is one of the consequences of that is a loss of muscle mass—a natural loss of muscle mass—so in an effort to mitigate that, strength training, resistance work is important. And I think when we speak about exercise, it feels like it’s mostly about aerobics, and sometimes resistance training is overlooked in its importance I think. 

Connie: I agree with you. As doctors, I think we have to be more specific about what we say when we talk about exercise. We have to give them a prop—what we call a prescription for exercise; write it down.

Barb: Right. And somewhat recently I’ve seen some data around mortality and weight, and sort of a “V” curve of low body weights aren’t ideal—obviously obesity is not—but our idea of a BMI less than 25 maybe isn’t perfect. Maybe weights above that a bit can result in a really healthy life and actually decrease mortality. Do you have any changes in your view or understanding of healthy weight, and has that changed over time?

Connie: Well, I believe what the data you are seeing, which is increased mortality with low body weights, I think is flawed because it can reflect patients who are quite sick and cachectic, who are dying… you have to take that out of the equation. But for a healthy person, I think having what we call a body weight in the normal range is actually fine. Actually there is some data, and I’m not sure how good it is: that the lower your weight, the longer you live. I don’t know if you’ve read about that. [laughs] But it’s better to keep your weight, your BMI below 25, perhaps 20 to 25. 

Barb: Okay. So we’ll continue to encourage that. 

Connie: It’s absolutely hard to do as you age. And as a woman ages, it’s very difficult.

Barb: Yes. So are there any other important messages to share with the listeners today Connie?

Connie: Sure. I’ll just go over some of them. First of all, I think it’s important for women to feel comfortable about how they look, no matter if they are thin or whether they have excess weight. People should feel good about themselves, women especially. But they should know that with excess weight, there are consequences which they can prevent by losing weight. It’s important to understand that excess weight can lead to diabetes. It can lead to heart disease and poor sleep. It can lead to osteoarthritis and particularly heart disease, high blood pressure and diabetes are consequences associated with excess weight that really could be avoided with weight loss. 

So even though I think women should feel good about their bodies, they should work towards becoming more healthy, which would involve losing some weight. 

Barb: Good. Thanks for reminding us about body image too, and the importance of self-acceptance. 

Connie: Yes. 

Barb: In closing, I like to ask guests where they find fullness at this stage of their lives, and a year ago, you talked about kids and their support and your career. I’m wondering after a very unusual year and unique challenges, are there any other aspects you’d like to add to that or expand on?

Connie: Hmmm. Well I don’t know that I’m expanding on it, but I still think that having children and having friends, people to talk to, or relatives, is very important. And what we’ve done in my family during this period is we have been able to have family-and-friend Zoom calls. So we schedule regular calls with our relatives, with our children, with their friends, so we can see them and feel that we are in touch with them even though we can’t actually be there. So I think that’s pretty important.

Barb: Yeah, and hopefully soon to change.

Connie: Yes, hopefully.

Barb: Hopefully we will have more in-person opportunities. You shared earlier that you were vaccinated, and I am as well and looking forward to the opportunities that’s going to bring as more Americans choose that. 

Connie: I agree. I think that vaccination is critically important, and I just hope that everyone who can be vaccinated will go get vaccinated. Then we will actually be free again!

Barb: Exactly, yes we crave that. Thanks for your time today.

Connie: Oh, thank you very much. It’s been a pleasure.