Medically Supervised Weight Loss

Patients are often at a loss for the right words to explain to friends and family what it is that they are doing as far as their dietary changes are concerned. Many patients respond that they are eating protein and vegetables (with or without “shakes”) but aren't sure why or how better to explain. I endeavor to break this down with this blog post.

Medical supervision. Most of the patients that come to me have more than twenty pounds to lose. They have developed medical issues related to their weight and wish to lose weight to reduce the health risk and number of medications that they take. It is my job as the Bariatrician (physician who specializes in the care of overweight patients as they address this as a health issue) to ensure that a patient loses weight safely. Some health conditions require closer supervision such as diabetes, kidney disease, heart disease or recent stroke. It is also my job to ensure that medication adjustments are done in a safe and coordinated manner. The addition and subsequent increase in physical activity is another fundamental tenant to my role.

Weight loss. The choice of dietary options requires input of the patient (what has worked in the past, food preferences, lifestyle demands) as well as the Bariatrician. Patient input is based on what has worked and failed in the past regarding diets. Patients are also encouraged to think about their food preferences: can they decrease their carbohydrate intake? Are they vegetarian? What cultural and social influences are influencing their food choices? Finally the demands of a patient's life are taken into account. Many patients have work and home demands that pull their attention away from dieting.

There are two basic options for dietary intervention: protein-sparing modified fast (PSMF) and balanced deficit diet (BDD). The PSMF dramatically reduces the amount of carbohydrates in the diet and generally increases the lean protein intake for a patient. Fat intake is generally kept at a low to moderate level. This change in the composition of the diet pushes the body into ketosis. Ketosis is a natural chemical process that pushes the body to use the calories stored in the fat cells for energy without breaking down lean muscle mass. This alteration in dietary composition can be accomplished by eating all regular food, all meal replacements, or a combination of regular food and meal replacements.

The BDD uses the basic assumption that there are 3500 kcals per pound of fat. The math calculates that if you reduce calorie intake by 500 per day times 7 days in a week a patient should lose 1 pound per week. The extension of this is that reduction of calories by 1000 per day could lead to a 2 pound per week loss. Some people try to accomplish this by increasing their calorie expenditure by 500 (such as with running, swimming, aerobics, etc). Usually a combination of calorie reduction and increased expenditure is used. This type of dieting generally keeps all food groups in the mix and may or may not restrict the carbohydrate intake. This can also be accomplished with use of regular food as well as meal replacements.

Medication. Patients are often familiar with weight loss medications and many have utilized them in the past with good results. Other patients are hesitant out of concern for side effects. The use of medications for the treatment of overweight and obesity is a very personal issue that requires discussion between patient and physician. The American Society of Bariatric Physicians has published very specific guidelines for the use of these medications.

Sources:
Anorectic usage guidelines. Asbp.org.