The Medical Science of Obesity

OMA Spring Presidential Address

Good morning.

I am Craig Primack. I’m the president of the Obesity Medicine Association. Today, I’m going to talk to you about the medical science of obesity.

Me and Tennis

I want to start by telling you a story about myself. I grew up north of Chicago, went to a small school in a small town, and I played tennis on our high school tennis team. My friend, John, and I became a number one doubles team. Well, fast forward a few years, and I went to medical school. I moved to Arizona, got married, had kids, and started looking for an activity to do. So I started playing tennis again. First, taking some private lessons and then playing with a doubles group. I think I did it for about a year. I think I got pretty good. Well, at least pretty good for a guy who works, has a baby, and was doing this in his extra free time.

I could hit with topspin. I had a nice yet one-handed backhand. Again, yeah, I thought I was pretty good. So I recall after this year of lessons, I made plans to play one of my friends where at the time didn’t play much tennis. First, we hit for just maybe 20 or 30 minutes. And I was happy with my skills. When we actually started to play a set or two that’s when things changed. If he hit the ball to me, I’m really good at returning it back. But then he started mixing it up. That’s what you do when you’re actually playing. He hit a long one. He hit a short one, he hit a little left, he hit a little right. So on the short one, I’m late getting to the ball and I either hit it right in the net or hit it right back to him at the net.

The Medical Specialist

And he just put it away. He kept mixing it up long, short, long, short, and me, when it’s short, I’m late on the ball. Remember, me who was originally really cocky, does not win either said that we played. Sometime not long after that, I was at the eye doctor for a routine exam and he had me put on a pair of 3D glasses and there were four circles and I had to tell him which circle was closest to me. It’s a test that measures depth perception. Well, I didn’t do so well. The doctor told me that my depth perception was definitely not normal and there was not a lot that they could do about it.

My Depth Perception

Then things started to click, started to make sense. Without cues from around the periphery. For example, like I could see in the daylight, I noticed that at night, when pulling up to an intersection with my car, I was stopping too soon before the red light. When the ball was hit short, I couldn’t see it right away. That was it. It’s not that I’m officially bad at tennis. Not that I’m bad at hitting the ball. I don’t believe its that I’m not trying really hard or that I’m not mobile. It’s that I just don’t see the ball like other people see the ball. If you hit it short, I’m late on the ball. Not because I’m really bad. But unless you change your stroke significantly so that I can see that you’ve changed it, then they don’t see the ball is short and I’m late running up to it.

I Don’t See the Ball like other People See the Ball

I don’t see the ball like other people see the ball. Pretty sure I want to be a good tennis player. Practice is really, really hard. I had a lot of willpower. But at this point, once my weakness is figured out it’s easily taken advantage of. Fast forward, in 2004, I started practicing some weight loss as part of my primary care practice. In 2006, with my business partner, I started my own clinic and gave up primary care. Fast forward again to 2011. Now practicing weight loss full-time for about five years, I was actually at an OMA meeting when I heard about an article that explained to me why people with weight problems have weight problems. You think to yourself, “I know why people with weight problems have weight problems.” Well, you believe people who are overweight just eat too much. And maybe generally just don’t exercise enough.

Eat Less and Move More

This is what we call eat less and move more, ELMM. Do you think it’s just eat less and move more? Is it just that out of every three out of four people who struggle with their weight have not been told to eat less and move more? Do you think it’s that they can’t? Or do you think it’s that they won’t? So let’s go back to the article. The article was published in the New England Journal of medicine. One of our most prestigious journals in the US. We call it the Sumithran article. The article showed for the first time that people in this study and there’s about 50 of them who were overweight, were able to lose weight over about 10 weeks. And then they were followed for a year. Let me back up. You know that hunger and fullness are controlled by hormones. These chemicals in the blood allow one part of our body to speak to another part of our body. The stomach, the intestines, the fat, the pancreas, and the gallbladder can tell the brain that I’m either hungry or full.

Leptin and Ghrelin

The two most common well studied of these are leptin and ghrelin. We want leptin to be high it’s coming from the fat stores themselves. We want ghrelin to be low, which come from which comes from the stomach. Well, these hormones that control appetite were found to be changed in this study. Let me say this again. The hormones that control the appetite when we lose weight were changed.

These changes are what we call counterregulatory in people who are overweight. They work to increase hunger and decreased fullness. The leptin tells us that we’re full goes down and the ghrelin that tells us that we’re hungry goes up and they stay that way. Therefore, over time, pushing us, encouraging us because now we’re less full and more hungry than we used to be. Pushing us to gain the weight or regain the weight that we have lost. It’s like there’s this little guy sitting on your shoulder and he’s yelling, right at your brain.

As you lose weight he begins to whisper, “Eat.” And the more weight you lose, the louder he gets, “Eat.” So when you see food, “Eat.” When you should be full, you eat. And when you used to be able to stop and pass up dessert, or that next piece of pizza, or the full order fries, you now eat it. You don’t have hunger and fullness like other people. The key to treating obesity, this disease of being overweight is to block those abnormal signals before they’re getting to the brain. It’s like putting earmuffs on. The guy is still shouting, but you just don’t hear it.

Blocking the Appetite Signals

I think there are five ways to install these ear muffs. The strongest one that we are always dedicated to is using medications to block those signals or getting you off medicines that are causing increased hunger. It may be some type of dietary change with fewer calories, of course, often with higher protein and less carbohydrate. Maybe gentle exercise.

Lastly,  restorative sleep of at least seven hours. And most likely at least 64 ounces of water. Yes. So I’m a physician who treats people for obesity and overweight. This specialty that we’re all part of is called obesity medicine. This whole medical specialty dedicated to treating the over 100 million people that have overweight and obesity and at least another, I’ll call it medical diagnoses like pressure, diabetes, or high cholesterol.

As of last spring, 2020, there were over 4,100 physicians who are diplomats of the American Board of Obesity Medicine as well as many other nurse practitioners and physician assistants or PA’s who have dedicated their career to the clinical treatment and medical treatment of obesity. If there’s a specialist or many of us, the ones here who are watching this video right now, why don’t more people seek the medical help they need for their weight? It’s because they think that they have normal fullness. It’s all they’ve ever known.

The Toolbox for Weight Loss

I do treat people who don’t use medicines for their weight loss. Also, I have patients who don’t use diets for their weight loss. Even some other people, patients who use all five of the tools in my toolbox. For many of these patients, they are now at a weight that they never thought was possible again. Some say that their best weight in the past 20 years. Some say that their best weight since they were in high school. One of my current patients just told me, “I cannot believe that I did not ask for help sooner.”

I’m going to get on my soapbox for a minute. Treating obesity is my job, but it’s also a passion. Treating weight successfully is probably easier than you think it is, but it’s not easy. It’s definitely harder than doing nothing. It is harder to say no to foods. It’s hard to say no to foods when those around us apparently can eat them.

When we’re using food when we’re happy when we’re sad when we’re bored, lonely, or tired. I’m going to start to wrap up my talk by leaving you with a message. It’s a message I’ve been preaching for several years now. It’s a simple sentence. Here goes, treat or refer. Most of you, at least statistically see a medical provider at least once a year. Statistically, also three out of four of you are overweight or have obesity. When was the last time your medical provider brought up a weight loss strategy that was beyond eat less and move more, or just watch what you eat, as if we weren’t already doing that?

Treat Weight or Refer to Someone Who Does

If your provider has the tools or you as a provider have the tools or have some training in obesity medicine, please use it. But if you don’t have the tools to help your patients with weight or the person that your friend, family member, or other patients are seeing, you should refer them to someone who does. Someone understands that your hunger is not normal and has the tools to help you treat it. The failure to treat or refer you to a comprehensive medical weight loss specialist is medical malpractice.

Just like if your blood pressure was 200/100 and you weren’t sent to the emergency room. Just like if you had cardiac chest pain and you immediately did not go to the emergency room or be referred to a cardiologist. Treat or refer. Treat or refer. I’m going to end my talk by reminding you that I don’t see the ball correctly when I play tennis. My depth perception is abnormal. And right now there is not a treatment for that. People who are overweight don’t feel hunger and fullness correctly either. There are tools luckily to help them when treated by trained professionals.

Treat or Refer this Disease

When the world adopts a treat or refer strategy, when we as a society begin to treat weight medically as a disease, when this happens, we will begin to ace obesity.

Thank you.