Introduction to obesity care

In this DrTalks, we are going to dive into some of the basics around obesity or weight care. With me, I have a really wonderful guest, Dr. Angela Fitch.

She is a tremendous leader in our world of obesity medicine. She was our most recent Obesity Medicine Association president, and she is the founder and chief medical officer at Known Well, which is a clinic for, people who who want to address their weight and primary care needs.

And it's expanding rapidly. So hopefully you'll be able to hear a little bit about that. Dr. Fitch, thank you so much for joining me. Dr. Francavilla Thank you for having me.

It's always lovely to talk with you. So let's talk about what care for weight or obesity care should look like. In an ideal world, there are so many options out there for people you know, click buttons, people can click to get the medications they need or, you know, quick challenges they can do online.

But what is comprehensive care for weight or obesity really look like? Well, I personally think it's super important, as you mentioned. You know, I've been doing obesity medicine for about 15 years now.

So for quite some time and, and certainly, you know, had spent most of my time in large like academic weight centers delivering comprehensive, you know, obesity care.

And what we mean by that is, you know, looking at you as a whole person, right? And all the things that go along with your obesity, not just, you know, getting a medicine like you mentioned. Right.

But really, you know, focusing on, you know, what are the psychological issues that you're struggling with, what are the nutritional issues or food access issues or just, you know, how busy your day is so that you, you know, can't plan to eat, etc..

You know, what does that look like? What is your physical activity look like? What is your sleep look like? What is your stress look like? And then, you know, how are we going to optimize all of those things, along with the other tools that we have for treatment?

And this is really what we do for all chronic diseases.

Why obesity is treated differently

And I think the key is recognizing that obesity is a chronic disease that's worthy of that type of comprehensive care, just like we might get for cancer treatment or, you know, any other disease that we're looking at heart, you know, heart disease, treatment.

Right. We're not just usually looking at one thing, right? Just get a medicine on the internet with a survey. But we're looking at, you know, how am I going to manage this disease, you know, across my lifetime?

And what does that look like for me? Yeah. Thank you for saying that. I think it's really powerful to recognize that we have, for quite a while now considered obesity to be a disease.

for, for lots of reasons. And it's complicated. There's not one reason why people struggle with their weight or obesity. but we do very much treat it as a chronic condition like diabete or heart disease or asthma or depression.

and it really deserves the same level of care from whoever is providing you that care, whether it's a physician, whether it's telehealth or, in person as any other thing.

And if there's no just one solution, why do you think that it is treated differently? Like why is the access different? Why is it kind of separate it out and not treat it like, say, asthma or heart disease?

Well, and that's because I think that, you know, for, for so long it has been, you know, the, the blame has been placed on the place, on the patient. Right?

That, that this is not, you know, even though, as you mentioned in 2013, the American Medical Association, which I know you were very, you know, are very much involved with and we're so grateful for your advocacy there and your time you spend there that, you know, they said obesity is disease, right?

It's a it's a chronic complex disease, right. Like other diseases. But yet at the same time, it's the only disease that we've pushed over into the sort of the realm of this is just the patient's responsibility to go get care for it.

You know? Right. Like that. This is just, the, you know, go to this mall, go to this mall, go to this book, go to this, you know, place, you know, and and and go do this, go do that.

And we've never really treated it as a comprehensive chronic disease. And there's there's a lot of bias and stigma around that. Right. And and and that's, you know, extremely complicated over centuries.

Right. There's data to show that, Hippocrates is back in 500 BC, which is before Christ, that before Covid, right. But 500 BC, a lot of years ago said, the way we treat obesity is to eat less and exercise more.

And so we have had that sort of paradigm for so long that that's the the answer. And if you as a patient just can't do that, then somehow you're failing, you know, you're failing yourself, you're failing, you're these because you're not good enough.

And trying to do that. And there's just so much of that and so much of that then translated into this diet culture that we're in, this idea that we always need to be on a diet of some sort and, and b in order to achieve that goal.

Right. And we know that I know we're going to get into this in a second, but that unfortunately, just eating less and exercising more in the human body doesn't work very well for, losing weight.

You know, it might work well for preventing weight gain, you know, over time, but it doesn't work as well once we have the disease of obesity, you know, in terms of of putting that into remission or, you know, helping that disease to get better.

Yeah. And this is something that's so eye opening for my patients.

Biology, stigma, and insurance barriers

And I'm sure when you first meet people as well, because they have been told for most of their life that they are doing something wrong, that they need to try harder, that they need to try a different diet, that they need to stick to the diet more, that they need to move more.

And those of us who have been treating obesity for a while and helping people lose weight know that it's it's not that simple and that, you know, most people can do those things to the best of their ability and still not have the dramatic health results that they're looking for.

and I, I agree, there is just so much bias. I see really, you know, successful, intelligent, hardworking people come in and, you know, they may have a really successful business or you know, made it really far in their career in some other way.

And yet they just start crying when they talk about their weight because they have so much internal bias. They themselves up so much that they weren't able to achieve this thing.

and I think one of the gifts I give to people is to like, take that weight off their shoulder and be like, it's not your fault. There's a lot of reasons why you're struggling that have nothing to do with you.

And like, let's figure that out. Exactly. And that's I think, you know, the other big issue that people should know about, especially because this is not well understood in, in our general, you know, country right amongst people is that because, you know, obesity was not considered a disease until 2013, it was carved out of insurance plans as a cosmetic offering.

Right? So the idea that we would offer somebody, you know, through our insurance and, you know, our commercial insurance in the United States, obesity treatment was kind of like having a facelift or having, you know, something else done, right, that that there was this thought process and this was many, many years ago.

Right. When, when it when when it started this way. But that has continued to unfortunately be the issue because it's not a standard benefit on the insurance policy.

So when you go to work for someone, and, and you're going to get your insurance through that employer obesity care not a standard benefit from one place to the other.

And it should be because diseases should be. Right. I mean, absolutely, you don't have to worry about your asthma not being covered when you move to a new job.

Right. and so that I think, is the critical piece that we all need in the United States to stand up and say, we're not going to tolerate that anymore.

Like, this is a disease, and it should just be a standard benefit, you know, on my health insurance plan. And then all those payers should offer it. It doesn't mean that everybody needs that.

Everybody, it has to then we have to give access to very expensive treatments necessarily. We in health care know that not everybody can have the most expensive treatment, just because that's just the way we have to also work on controlling costs, too.

So if there's an opportunity to have your disease treated with a lower cost therapy, that might be something that that is something that you might want to try first right before trying the more expensive treatment.

But at the same time, you know, we have to we have to figure this out in the United States because it's creating a whole sorts of chaos right now. Yeah, yeah.

And I think that is what's so frustrating for people is they're like, well, but this is a disease. And like, look at all the things I'm at risk for and look how I feel.

Why, why is my insurance not helping me out. Why are they not covering this. And it does. It goes back to a lot of that bias and stigma and some really old policies that really, you know, people like you and I are working hard to try to change but take a long time to change.

And so, you know, sometimes I will even encourage my patients to ask, you know, when they're interviewing for jobs, ask, you know, do these is this part of what's covered?

because it may change where they decide to accept an offer. Yeah. And with 70% of our US population potentially, you know, fitting the category where they need their weight treated due to metabolic health issues, right?

Meaning due to other, other diseases, they might be at risk for or developing over time hypertension, diabetes, other prediabetes, etc.. Right? I mean, it's a it's a big problem.

It's not like we're talking about 10% of the population. So we really should treat it at a more, you know, at a more nationwide level and really advocate all of us that it is a standard benefit, you know, on all plans so that we don't have to be and we have to worry about it. If you, Let's talk about what treatment options exist.

So in the summit, we're covering a lot of different things and kind of have experts in, in all sorts of different things, from fasting to, medications to to supplements and exercise and lots of different things.

But I'm hoping you can kind of give an overview, of what people can expect from, from different interventions and sort of how we keep stepping things up if needed.

If someone is not responding to maybe the cheaper, easier, more accessible option for their weight. Exactly. And that's the way we should look at it, like any chronic disease. Right.

Treatment options and expected weight loss

We you know, and and when, when the, the big thing that I think the, the that we, that we don't understand or that most people underappreciated in our country is that, it's really hard to lose weight biologically.

Right. It's not a normal process. Like, that's not the way we were created as humans to lose weight. Otherwise we would have evolved off the Earth like during times of starvation.

We wouldn't, you know, we wouldn't be protected. Right. So the default is to gain weight. So the body fights back when it starts to lose weight. Says, wait a minute, there's something going on here.

I better go back the other direction. Right. And it creates this, this hormonal cascade within our bodies that then drives our weight the other direction.

So we have to have something to, to work, you know, against that, right, against our human metabolism in order to continue to promote that weight loss.

So, or create more weight loss or even sustain it, to be honest. Right? I mean, that's the other thing is to sustain the weight loss. There's also some pretty good data that you need to.

A lot of times stay on medication in order to sustain that. Just like you have to stay on medication to sustain your hypertension treatment, right? Your hypertension gets better when you go on your medication.

Well, you have to continue to stay on that medication if you want your hypertension to continue to stay better because it's a disease, because it's not your fault that you have hypertension, right.

And so again, going back to that, right, we have data to show that only about 5 to 10% of people are able to lose greater than 20% of their weight with a lifestyle intervention.

So and that's just at one year. And the data also suggests that over the next eight years, after that patient has lost that, let's say, 20% of their weight.

And when we talk 20%, let's just level set that right. If you're a person who weighs 250 pounds, which are you about losing 50 pounds, that's 20% of your weight.

That's not an unreasonable ask for someone to come in and say, I'm 250 pounds. I want to weigh 250, 200, right? Like, yeah, I mean, that's not an unreasonable expectation is my point.

Yet it is an unrealistic expectation as far as the way the human body can actually do that. Right. And because it's really hard to lose 20% of your weight.

And when I talk to patients and I say, well, you know, only about 5% of people are able to do that, you know, with a lifestyle program there that they look at people really like because everybody thinks everybody does that with Weight Watchers or Jenny Craig or some other.

You know. We've we've seen the magazine covers our whole life. We've seen the before and after pictures. So we know some people do it. Why can't it be me?

Right. It's five. Percent right. And you're not one of the 5% I'm sorry. Right. If you've tried that, and most people have tried that seven times before, they come to one of us and say, I'd like some help, right?

So it's not like they haven't tried. So they've tried at least seven times. That's what the data shows, you know, to do that. And when they've tried that and it's not been successful and they're not one of the 5% right then they should then employ something else.

Right. Do something else. Right. And that's where we have medication now with our newer medications now, 40 to 60% of people are able to get into that 20% weight loss category.

And with surgery, we've had this data all along with surgery showing that about 80% of people are in that 20% weight category, and that's even, ten years after surgery. So surgery is very well, it's very intensive, meaning you have to have surgery.

it is very robust in terms of the helping patients. Now people will say, well, I know they've I know people they've gained all their weight back. Well, yes, there are 5% of them actually.

The data shows they gain all their weight back. So you're only seeing the 5%, right? You're not seeing the other 95% that haven't gained it all back. And a lot of times people have lost more than 20% with that with an intervention.

And then let's say they lost 40%. So let's say they lost 100 pounds instead of that 50 pounds. But now they've gained half of that back. They still sadly consider themselves a failure, despite the fact that they're still down 20%, which no one really does.

Right without some sort of intervention. Yeah, and I like to be the biggest cheerleader for those patients in my clinic where I'm like, yes, you did regain some weight, but you still have kept off 50 pounds.

Like, that's amazing. That's great. Let's never would. Have done that right. And level fitting that. And we all have to be reminded of that. Right. Because it's, again, that internalized weight bias that we have can be one of the biggest sabotage saboteurs of us.

This is shown by data. I had a discussion with a patient just yesterday about this, you know, and recognizing these is the first step, right? To then sort of saying to yourself, well, I guess I'm not that bad, right?

Like, I'm doing a good job, right? I, I'm not back to where I was before. And even if you are back to where you were before, also knowing too, that that is the normal human bodies behavior, right?

You didn't do anything anything wrong. Right. And and so again, you know, getting a handle on that earlier. Right. And making sure people understand this is not their fault because we I've had so many patients come back to me after surgery.

You know, we're talking ten, maybe even 20 years later. And, and having regained a significant amount of weight and they didn't want to come back because they were shamed.

Right. That and we have to get rid of that. We have to get rid of that shame, get rid of that stigma so we can all just treat the disease for what it's worth.

Right. And and I think if we start comparing it to other medical conditions, we treat like cancer, you would go back and get more treatment if your cancer came back. Right.

You wouldn't, you know, feel like a failure. And and not because your doctor or if your asthma med wasn't working anymore, you would go back and get some help in and change the medication or figure out why, that was going on.

But we do. We have such a culture of telling people like, you just need to work harder. It's your fault if you're struggling with your weight. And I, I hope people are hearing it over and over again at the summit, that there is so much biology that is making our body, hold on to weight.

And really, we're we're mostly programed to be gaining weight. Right? Evolutionarily it makes sense to store fat. but we we don't live in a time of famine.

Most of us have access to food right now. And, our body just hasn't adjusted to the world we live in. Well, there's also other factors. As we mentioned, there's there's, stress, there's sleep, there's, you know, being physically active and being, you know, one of my patients said, well, you know, I, I haven't done as well this month because I, you know, I hit my toe and broke my toe on the side of the bed.

Setting realistic goals and health outcomes

And I have I've been in a boot and I have been able to walk for, you know, like that's what I like to do is work. Well, it's like I mean, these things happen.

That's life. Right? And we, we have to learn how to live life while at the same time improving our health and our health outcomes. You know, as it relates to treating the obesity.

Right. And keep it in perspective, you know, as to why we're doing it, how we're doing it, and how there's care. Like what we're, you know, giving it known.

Well, that's why we created known well was to provide this comprehensive longitudinal care to people across the country because we recognize how hard it is to find that, like you, you offer an amazing clinic like this to at your place.

But it's hard to find those places. And so, you know, being able to offer this in a place where there's no shame, no stigma, you know, that is really, our goal is to be able to offer that, to patients across their lifetime and, and across the country.

And, you know, I think one other thing that's worth talking about is how much weight does someone need to lose to improve their health? Because I have found that the majority of people who, do an initial consultation with me have really, really aggressive goals of how much weight they think they need to lose.

And a lot of times we work on really unpacking. How much weight do you really need to lose in order to to live longer, live better? feel better. So what's your take on that?

How do you guide patients that known well to what a good, healthy weight is? Yeah. So I think it's very important. And there was actually just an article published a couple days ago about this, where the average expectation of someone or their, their goal was to lose around 16% of their body weight and they would be, you know, their sort of ideal rate.

So that wasn't even the idea. The ideal was to be great was 22%. And again, we know that with some of our newer medications are getting closer to that, but still, at 60% of people that are able to reach that 20% weight loss goal with our newer medications.

So it's not everybody. And like I said, even with surgery, it's 80% of people. They get into that 20% weight loss category. So there's still, you know, a decent amount of people that that's going to be a challenge because it is just so challenging to do that. Right.

And the goal should never be to get back to the BMI of 25, because that's what everybody I think comes in. They do the calculation on the computer and they see what the BMI of 25 would be, and that's what they shoot for.

Or maybe a weight that they were in high school. Right. And that's just not what we should set as a goal because it's just very frankly hard to achieve.

It doesn't mean you can't try to get there and you can't continually work on that over years, but the ultimate goal should be aligned with then what you're trying to accomplish, because we have data now to show, for example, that if you are able to achieve, let's say, a 10 to 15% weight loss, that puts your fatty liver disease into remission.

So if you have fatty liver disease and that's your main goal is to get, you know, rid of that fatty liver disease, then that, then you should shoot for that 10 to 15%.

Right. You should also recognize that any weight loss 5% is still good. If you can maintain it for the rest of your life, right. It prevents your risk of diabetes by 50%.

It's like one of our biggest tools we have for the prevention of development of diabetes is that 5% weight loss, even though people don't appreciate that because they they just think that it's only 5%, like I should be able to do better.

And the other thing I'll just end with is that I really, you know, do a lot of counseling for patients who say, well, I'll be happy when I get to this weight, right?

And, you know, my biggest comeback is there's no you should be happy now, like, because, I mean, we should all be happy now. We should not lead weight or our body size or body shape or what our body looks like, be the driver of our happiness.

And I appreciate as a person who has has obesity and has, you know, had my obesity treated for some time, you know, I know what it's like to, you know, to feel, you know, differently about your body and want your body to look differently to just from a sort of, you know, a cultural desire for thinness and just feel better, move better, you know, etc..

But a lot of times that happens with 10% weight loss, you know, feeling better, moving better. So just continually reminding yourself that, you know, not to sort of, put your self-worth, you know, on, on what you look like.

Right? I love that. And I see the same thing. And, I have a slightly different response. As someone who has lived in a thinner body most of my life, which is, you know, just because someone is thin doesn't mean they're happy.

Right? Like, I treat a lot of depression and a lot of anxiety for people who are a size two or a size four. And I promise, like, it doesn't make people happy.

Right? Or like money. I'll say to like, you know, people say all the time, if I had more money, you know, and then of course, there's, you know, probably a lot of people with, you know, more money that certainly aren't happy either have their own issues, you know, that they're dealing with.

Right. So yes, I think that is powerful because, you know, I always ask people what's the reason why they want to lose weight?

Long-term care and Known Well

And so many people will say to feel better about myself like, no, let's, let's work on separating our worth from a number on a scale or a number on a BMI chart, because, you can't control it as much as you think, or possibly at all.

So let's find other ways to feel good about ourselves and reject some of those societal and cultural things about who is a better person or who's a more attractive person based on weight.

Exactly. And that's, you know, we're working on changing that, I think. I mean, in the, in the United States, I mean, there's been quite a bit of work done on that. So hopefully that'll continue.

But at the individual level especially, I think, you know, really, you know, seeking out a, a care provider who's going to be able to be with you longitudinally right.

I think I worry most in our current, days that, there's just a lot of stuff out there that's really fragmented. And we have data to show that if you, lose weight, a significant weight, amount of weight and gain it back, then it's harder to lose the next time.

So it shouldn't be something we should be playing around with either. Right? Meaning. And when I say that, I mean, you know, it shouldn't be something we should just, you know, get some medicine off the internet for six months and, and, and do something with it and then expect that to be to hold on to us for the rest of our life.

Right. I think some people will be able to keep their weight off without medication. Certainly we have those patients with other diseases, but the vast majority of people are going to need, ongoing care, at least in some way, shape or form in order to, really control this disease.

over the course of their lifetime. And if you play roller coaster with it, that's not going to be a good situation. Ultimately. Very true, very true. Dr. Fitch, if people want to connect with you more or find out about Known Well, where can they go?

So our website is, knownwell.co. So, you can find us there, Known Well, you can, you know, Google us now, too. It comes up pretty much at the top. and, we're we're we're seeing patients right now in the northeast, but we've expanded to Texas and we're coming across the country over the next few years. So be on the lookout.

Wonderful. Thank you again for joining us. Thank you for having me. It's been a pleasure.

Angela Fitch, MD, FACP, FOMA, DABOM

The Importance Of Empathetic Obesity Care For Long-Term Health