Speaker 1: 0:04

Welcome to the Healthy Matters podcast with Dr. David Hilden, primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:20

Hey everybody, it's Dr. David Hilden, your host of the Healthy Matters podcast. Welcome to episode 11. Today we are gonna talk about weight management, what it means to be overweight, what is obesity. We're gonna talk about strategies for maintaining a healthy weight, and we're gonna get some tips from an expert in the field today. Joining me is my colleague at Hennepin Healthcare, Dr. Aisha Galloway Gilliam. She is the director of the Comprehensive Weight Management Center here at Hennepin Healthcare in downtown Minneapolis, and has a career and a practice focused on the management of your weight. Dr. Galloway Gilliam, welcome to the episode.

Speaker 3: 0:59

Thank you very much. Happy to be here.

Speaker 2: 1:01

It is great to have you here in a topic that is affects so many people in our world, but we're gonna delve into it a little bit more deeply to see what, what resources are available to people. Could you start us off by sort of giving us a lay of the land on the issue of weight management and obesity? What is the current state in the United States of people who are living with obesity or being overweight?

Speaker 3: 1:24

So, currently about 42% in approaching 45, between 42 and 45% of the United States population is living with obesity by 2030. That's predicted to be more like 50% of the population in the United States will be living with obesity, half the population, half of the population.

Speaker 2: 1:45

Do we know why that is? Why is it going up?

Speaker 3: 1:48

There are hypothesis around that there is not a solidified consensus. My own personal belief after reviewing some of the epidemiological data and other science, is that it really has to do with the way that our environment has changed, in particular our food environment, uh, really rapidly and very radically over the past 50 to 60 years. So more access to food on a more consistent basis, and then also the types of food that we have access to and are eating in addition to beverages that are sugar, latent and heavily sweetened. So

Speaker 2: 2:40

Dr. Galloway, Gillian, what is obesity? Is there a definition of that?

Speaker 3: 2:45

The definition of obesity is based on a metric called body mass index. And the body mass index is a calculation, it's a calculation that really compares height to weight. And the definition is a body mass index of 30 or greater, uh, is considered to be consistent with obesity. Under that definition, there are subcategories, uh, that divide obesity into class one, class two and class three obesity. And then of course, the category of overweight, which is, uh, considered to be a BMI between 25 to 29.9, and a normal BMI is 18.5 to 24.9.

Speaker 2: 3:39

So how is BMI measured?

Speaker 3: 3:41

BMI is an equation. It's an equation that, uh, compares our height to our weight. So you can literally Google it. I mean, the CDC has a link where you are able to input your own specific data. The other way to do it is to look for BMI charts. Again, very much something that you can look on the internet and then you can find your wait, you can find your height, and then you kind of trace it down, uh, to find your bmi. So

Speaker 2: 4:13

We can put a link to one of those BMI calculators in our show notes. I've heard the BMI criticized as, as the only measure in that, what if I've just big bones I have been making, or what if I play for the Minnesota Vikings? Aren't I, uh, they're all obese? Is it an imperfect measure?

Speaker 3: 4:29

It's not a perfect metric for body compartments because that, that really is what's most important about weight, is where and what compartments are affected, because weight is just a number. It doesn't tell us how much of your weight consists of muscle mass, how much of your weight consists of water, and how much of your weight is made up of adipose tissue or fat tissue. So it's, it is an imperfect measure. That said, we know that when we are dealing with a certain severity of obesity, and that's what we would call class two obesity is, is when you have a BMI of 35 or above, uh, there's a pretty solid association with negative health outcomes and consequences. So a adjunct tool is waste circumference, and that's another way to try to assess a person's risk for conditions like high blood pressure and, uh, cardiovascular disease in the long term.

Speaker 2: 5:39

When you bring up waist circumference, that reminds me that people at, at a given weight can have a different body shape. You know, we talk about the pear shape, where you're carrying most of your extra weight in your hips. Mm-hmm.<affirmative> ver, which is versus the apple shape where you're carrying a lot of your weight in your belly. Mm-hmm.<affirmative>, you know, the, the old beer gut that people talk about. Mm-hmm.<affirmative>, does the distribution of your weight make a difference?

Speaker 3: 6:03

Absolutely, yes. Thank you. Yeah. So the, the apple shape is the distribution that is most closely linked to negative health consequences or that increased risk for cardiac disease. The pear shape, however, is the, the weight that we carry around our hips and thighs and our buttocks really hasn't been linked to negative health consequences. In fact, there's some data that's just perhaps that's protective. So it really is the, that weight, uh, around our center, and that's the weight that tends to pack around our organs and ultimately increase our chances for medical conditions in the long run. So,

Speaker 2: 6:49

Aisha, let's talk about the health effects of obesity and overweight. In other words, why should people care?

Speaker 3: 6:56

The health implications are vast. There are definitive associations with increased risk for multiple medical conditions. So this includes heart attack, it includes congestive heart failure, it includes chronic kidney disease, it includes diabetes, it includes high blood pressure, um, even conditions such as infertility, gallstones, gout, skin infections from, uh, chronic swelling and the extremity is arthritis. The list is pretty extensive there.

Speaker 2: 7:37

Like your whole body can be affected. It sounds like

Speaker 3: 7:39

That's exactly right. Even speaking of that sort of, uh, smoldering levels of inflammation can actually be increased in our entire bodies. Is

Speaker 2: 7:51

It preventable? So that's a short question, but it's a larger conversation. It, so for people who are experiencing obesity or being overweight in their life, are there ways that, that we can reduce our risk for that progression? Or is it a genetic thing that you're, that is inevitable?

Speaker 3: 8:09

Uh, it's a good question. It's a complicated answer. Mm-hmm.<affirmative>, uh, that you're right, we won't be able to completely unpack. But here's what I'll say about it. Uh, there's a lot of heterogeneity in obesity, meaning that no two people have the exact same causality for their weight and oftentimes as a genetic predisposition. But there also is a very significant environmental component. Uh, not only that, but when we start to think about genetics, and this is where, uh, things start to get fairly fascinating, um, there's an epigenetic component. And so when we talk about epigenetics, what that means is it's not just about the genes we're born with, but which genes are expressed. So our environments can change the genes that are expressed, which then may increase our risk for conditions, including obesity that we may not have otherwise experienced if those same genes weren't expressed.

Speaker 2: 9:20

Oh. So that's fascinating. So you're saying that you might have a gene that never really amounts to much unless you're in an environment

Speaker 3: 9:28

That turns on the expression for it? Oh,

Speaker 2: 9:31

That is, that is fascinating.

Speaker 3: 9:33

So there's an epigenetic component. There have been some questions around whether even viral infections in the past may change the way that our, uh, genes are expressed in that epigenetic way and increase the risk for developing, uh, obesity later in life, changes that are passed in utero from the, the person carrying the child to the, uh, child later on. And then, of course, like I said, you know, our general environment around food and oftentimes we're conditioned at a very young age, uh, around the types of foods that we're going to be attracted to later on. Our affinity for sweet things often starts in childhood, even when we're looking at baby foods in the way that, uh, those have historically been very sweet and the convenience factor. So we're always on the run picking up, uh, those food items that are, uh, more highly refined and the difference that that has on our biochemistry when we're consuming those more highly refined or ultra processed foods compared to the foods that are more intact or otherwise, uh, known as whole foods. There also is a fair amount of conversation around the way that our environment has changed around physical activity. So are we more sedentary now than we were decades ago? And the answer is probably, but the extent of our increase in sedentary behavior doesn't explain the obesity epidemic in this country. So, so it's, it's multimodal, multifactorial a lot of, of, of reasons for the obesity epidemic. So then when the question is can we prevent it? Well, there's a lot there to, to unpack and perhaps for some people, but probably not for everybody because of some of the pre-condition genetic predispositions that may have been passed along in our current food environment. That makes it harder cuz a lot of this starts to develop, uh, at a younger age. And then by the time it's coming forward, I, in a clinical setting, it then is more of a challenge to, um, manage and then the health conditions and implications of it that may already be in full force.

Speaker 2: 12:02

I do wanna point out that we are talking about obesity and overweight, and there are also medical conditions that lead to being underweight. We're gonna talk about that in a future episode. So listeners, if you are also interested in some of the other issues around, uh, being underweight, stay tuned. We will cover that in a future episode. Today I am talking with Dr. Aisha Galloway Gilliam. She is the medical director of the, uh, comprehensive weight management center here at Hennepin Healthcare in downtown Minneapolis. We've covered a lot of ground already, but when we come back, we're gonna talk about what treatments are available to people who are, uh, looking to manage their weight. We will do that right after a short break. Stay with us. We'll be right back.

Speaker 1: 12:46

You are listening to the Healthy Matters podcast with Dr. David Hilden. Got a question or comment for the doc, email us at Healthy Matters hc m e d.org or give us a call at six one two eight seven three talk. That's 6 1 2 8 7 3 8 2 5 5. And now let's get back to more healthy conversation.

Speaker 2: 13:09

Let's talk about the way people who are living with obesity experience our society or how they, how they're treated. In other words, some of the biases and the mental health issues around it. You'll often hear someone say something like, well, it's your fault. You're just eating too much. You're slothful and lazy. And there's even abundant evidence that people who are living with obesity are overweight, are, are less apt to get jobs and they're less apt to be treated as accomplished and smart and, and none of that's true. Mm. And it's not a character flaw. Yeah. How do you respond to that? Yes. Or, or, or is that, or am am I making that up obviously?

Speaker 3: 13:47

No, this is a great point and it is a conversation that I have on a daily basis with my patients because it's very sad to know that people are being stigmatized for anything. Um, and weight is a part of that, and it very much is again, been conditioned and have the societal views on weight in people who are living with overweight or obesity, having a lack of willpower, this being a cosmetic issue and not a chronic medical condition, which is what it is. And so there is a lot of judgments and a lot of assumptions that patients who are living with overweight or obesity have to navigate on a daily basis when the fact of the matter is someone who's living with obesity may be leading a more healthy lifestyle than me. They may be eating a wonderful diet, they may be very active in exercising, they may be getting great sleep, they may be be managing their stress well and still may be living with obesity because of the complexity of weight regulation and the complexity of, uh, the predisposing factors that contribute to our weight. So it is an unjust assumption to just, uh, accuse someone who is living with obesity of being lazy and not caring about themselves. It's not true.

Speaker 2: 15:16

That's an important message and well said. Uh, what are some effective ways for people to manage their weight?

Speaker 3: 15:23

That's a, a great question. So I think the first part of that is to have a robust support system, and that's where comprehensive weight management programs come into place. Now, if that's not realistic for you and your day-to-day life, I think that really being educated on the physiology or the biology of weight management is a good place to start because you need to have some understanding of the biology of it so that you don't burn out in the process. Mm-hmm. Uh, a lot of people come in really very frustrated because they have been taught that this is a simple thing to manage. If you would only eat less and exercise more, you would lose all of the extra weight you're living with. And that's not the reality of the situation. So I think first it's getting informed on what obesity or overweight is and then what it isn't. And there's a reason we call it weight management and not weight loss.

Speaker 2: 16:32

Before you even move on from that, then Yes. Is it, I take it it's not just diet or it's not just exercise.

Speaker 3: 16:38

Correct. Th there's a, there's a foundation that it really is important to set whenever we're talking about a weight management strategy and there are four cornerstones or four walls to the foundation, what are they? And those are lifestyle therapies. And so it is definitely nutrition, it's how we're eating, it's definitely physical activity or how we're exercising, but it's also how sleeping meaning are we getting enough and is it quality sleep? And if there are other conditions like sleep apnea where you stop breathing in your, in in your sleep at night, are we identifying that and treating it if it's present? And then also, uh, and this is a really important one uh, as well, how are we managing our stress, our chronic, uh, stress?

Speaker 2: 17:23

So let me just say the four years you said are, they are diet, they are physical exercise, but it's also sleep and stress. That's

Speaker 3: 17:30

Correct. Yeah. The way that I think about weight management strategy is we're building a house. And so when we're building a house, the very first thing you wanna do is have a solid foundation, otherwise your house crumbles. Now we have to be realistic about what to expect from those modalities. We could be doing all of those perfectly straight A's, and it still may not and probably won't based on the data, completely normalize your weight. But what it does do is it still allows you to invest in the bank of health long term. So we're still optimizing our chances of living a long healthy life by paying attention to those, uh, those four areas.

Speaker 2: 18:17

So that's the foundation. I love that by the way. I love that you started out with a support system and becoming informed and then these foundational things, diet, exercise, sleep, and stress. What is the role of medication? Yeah. Because that's what people just say. It's almost the first thing people say. Yeah. So I like it that you led with those other things first. Yeah. Yeah. But then what is the role of medication?

Speaker 3: 18:37

Yeah. Very important role for medication as well because again, where this is a chronic condition and so we really have to train ourselves to manage it and see it that way. So just like we have medication options for blood pressure and other conditions, there are medication options for weight management. And so when I think about, well, what's the role for medication? I think about it as another floor of our house. So weight strategy, we're building a house, we got the foundation, maybe we want another floor. And this is all very much individualized. There's a conversation that happens around expectation management and what people want to use for managing their weight. And so medications are a completely valid tool to use. And thankfully now we've got medications that are more effective than

Speaker 2: 19:29

Do they work?

Speaker 3: 19:31

Yes, they did. The newer medications absolutely work now it because

Speaker 2: 19:34

The early ones didn't. Holy cow. We gave medications. They gave you fatty diarrhea, explosive diarrhea. You took them for two weeks and that was that<laugh>.

Speaker 3: 19:42

Yeah. They, and and I think it's important to define or clarify what we mean by work too, because cuz of weight bias, the expectation is if it doesn't cause me to reach a completely normal weight, it's not working. So when we talk about working in the weight management realm, the bar for that is 5% total body weight loss. So the oral medications, most of them are effective for around that. Um, they had to be to even enter the market to

Speaker 2: 20:17

5%.

Speaker 3: 20:18

5%. But it also depends on the person and how they're gonna respond to a a particular medication. But 5% is sort of the bar. And the reason is that we know that with as little as five to 10% total body weight loss, you can achieve really significant health benefits. But the newer class of medications, the injectable class of medications are even more effective than the oral medications. So now we're talking about, you know, up to 15% total body weight loss on average with some of the, uh, injectable medications that are currently approved.

Speaker 2: 20:53

And nothing has achieved that in my career until lately. That's correct. I've never been able to tell a patient, take this medication, you can lose 15% of your body weight. Yeah. And they can do that. Are you seeing that in your practice people losing 15% of their body weight?

Speaker 3: 21:05

Yes. So it's pretty phenomenal.

Speaker 2: 21:07

What is the role of bariatric surgery? Now the word is bariatric B as in boy, B A R i A T R I C O, otherwise known as people talk about gastric bypass surgery. Like do we still do that? Mm-hmm.

Speaker 3: 21:21

<affirmative> We do. And it is still a very, uh, important tool to have, uh, at our disposal medications when we use them for weight management are permanent meaning

Speaker 2: 21:33

You have to take them or the weight comes back, you

Speaker 3: 21:35

Have to take them or yeah, if you stop the weight comes back. A bariatric surgery is still the most effective tool for significant and sustained weight loss on average. Right. So there are some people who are gonna defy averages on either side.

Speaker 2: 21:50

What can people expect with weight loss with surgery? Yeah,

Speaker 3: 21:53

So it depends on the surgery. The amount of total body weight loss with, with surgery on average is somewhere between and 25 to 35%, again, broken up by the type of surgery you have. And this is specifically talking about, um, what's known as the sleeve gastrectomy and gastric bypass. I'm not including the band and those numbers cuz we're, we're

Speaker 2: 22:17

The gastric bandi isn't really doing that.

Speaker 3: 22:19

Yeah, we're, and we're moving away from that. So those are the, that's the kind of average amounts of weight loss that can be seen with with surgery. The other thing with surgery is that we know that there's mortality risk reduction. The medication component is where, where folks think about, oh, I don't wanna take this medication forever. That's not involved with surgery. There are supplements that people will have to take vitamins, but, um, but not having to inject, take that at the medication, um, for their weight. There may be other meds to consider. And then one of the other big things with surgery is for folks who have diabetes, depending upon how long they've had it, if you were diagnosed with diabetes in a short period of time before you had surgery, somewhere between one to four years, you can see diabetes going to remission, uh, after bariatric surgery. And that

Speaker 2: 23:15

Is just a wonderful outcome. So we have all these layers of the house. I wanna, I wanna circle back to some dietary issues. In what you eat, is it all about calories or does it matter what foods you eat?

Speaker 3: 23:27

It definitely matters what you eat. This is a question that is wr with opinions. I am convinced in my my personal and medical opinion that what you eat matters more than the calorie content it contains. Say we're, we're gonna compare a avocado, kind of a medium size avocado, and we're gonna compare that to an average sort of candy bar. Calorie content is actually fairly similar. That said, when we think about what's in the candy bar versus what's in the avocado and what those calories are made of, we know that this avocado is high in calorie mostly cuz it's got great healthy fats in it, mono unsaturated fatty acids, uh, which are healthy fats for the body. Whereas the candy bar a lot of sugar. So when our bodies process those food items, they're gonna elicit a different biochemical response. We also know that calorie restricted diets don't work long term. You may see some weight loss over the short term, but then our bodies actually compensate for that calorie restriction and start to work against us. And so we end up hungrier crankier and still not where we wanna be with our weight goal.

Speaker 2: 24:54

I'm gonna follow up with that. The, the diets. People hear about that. Some people call the fad diets. There's keto, there's Atkins, there's self beach, there's Mediterranean, all all those. Uh, are you saying they don't work?

Speaker 3: 25:05

So it really depends on the dietary approach. So, so something like keto or otherwise known as, you know, uh, kind of a low carbohydrate or carbohydrate restricted diet versus something like, uh, uh, what would be considered an ornish diet, which is mostly plant-based, you know, vegetarian diet, vegan diet. Those approaches are more in line with what I would call macronutrient distribution adjustments. And when I'm talking about macronutrients, I'm talking about carbohydrate, protein and fats. So manipulating macronutrients for health benefits and they can work if you can continue them forever. So that's where it gets tough is that whatever you're choosing, it has to be sustainable. Also, again, because we're talking about genetic predispositions, what works for one person may not work for the next person. Someone might respond beautifully to keto and the next person not at all. So there's this built in trial and error that's involved. But again, the more important part of that is can you sustain that for the rest of your life? Most

Speaker 2: 26:20

Of these you probably can't.

Speaker 3: 26:21

That's correct, yeah. It's sometimes it ends up being very restrictive and people can't have joy in their food and, and it is not always sustainable for those who it is. And they've had a great response to keto or vegetarian, vegan, whatever, uh, type of diet, and they feel it's sustainable for them. And they're also, again, working with their physician and consultation and make sure there aren't deficiencies that are developing or other health conditions that we would be concerned about them, uh, engaging with one of those diets on then great. You know, but, but that's a pretty small percentage of the population. Before

Speaker 2: 26:59

I let you go, what, what tips would you give our listeners?

Speaker 3: 27:03

Yeah, so I think when you are embarking on a weight management journey, remember self-compassion. We haven't talked about that before. Be gentle to yourself along the way, otherwise this is a, a mute point. We're causing more harm, uh, because this is complicated. Two is remember those foundational areas that we talked about. Focus on how we're eating, how we're moving, how we're managing our stress, and how we're sleeping. This is a lot to unpack there as well. Uh, which leads me to my next suggestion would, would be if you are finding yourself struggling to reach out to a trained professional that can help you navigate this really complicated area. And we, we wanna be here to support you and to, to validate what you've experienced and to partner with you on where to go next in your journey with weight management.

Speaker 2: 28:03

Those are great tips for all of us. Thank you Dr. Aisha Galloway Gilia, thank you for sharing your expertise, your wisdom, and your time with us today.

Speaker 3: 28:11

Thank you for having me.

Speaker 2: 28:12

We've been talking about weight management with Dr. Aisha Galloway Gilia here from Hennepin Healthcare. Lots of great information today. I hope you have picked up something that is applicable to your life. I know I have. Please join us for our next episode and in the meantime, be healthy and be well.

Speaker 1: 28:29

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden. To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. If you enjoy the show, please leave us a review and share the show with others. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive producers are Jonathan Camino and Christine Hill. Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.