What doctors wish patients knew about maintaining a healthy weight

Losing weight is often hard enough to accomplish and maintaining a healthy weight for the long run can seem like an impossible task for many patients, especially during the COVID-19 pandemic when many packed on pounds in the first year similar to the “freshman 15” in college. Many patients may expect weight loss to happen quickly, but just like weight gain, it does not happen overnight.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines, especially throughout the COVID-19 pandemic.

In this installment, AMA member Fatima Cody Stanford, MD, MPH, MPA, an obesity medicine physician and associate professor of medicine and pediatrics at Harvard Medical School, discusses what patients need to do to successfully obtain and maintain a healthy weight.

To begin, do “an evaluation or an assessment,” said Dr. Stanford. That means asking, “Where am I? What is my starting weight? Have I had significant struggles with my weight throughout the course of my life?”

Additionally, assess to see if there were “certain triggers that may have led to weight gain—maybe medications that you were placed on. Maybe times of trauma or stress that led to an increase in weight,” she said. It’s about taking “a real assessment of where you are.”

“Getting to a certain BMI—or body mass index—range is what most people strive for. The problem with that theory or thought process is that the body mass index is not based out of medicine or out of science, which is surprising to many people,” Dr. Stanford said. “The BMI was derived from the actuarial table's data from the 1930s and 1940s from the Metropolitan Life Insurance Company.

“What they decided at that time was the risk of dying based upon weight status.” she added. That meant “a person was underweight if they had a BMI of less than 18.5. Someone was considered to have a healthy weight … if their BMI was between 18.5 and 24.9.”

“A person was considered to have overweight if their BMI was between 25 and 29.9. And then persons were considered to have obesity if their BMI was greater than or equal to 30,” Dr. Stanford explained. “And then just getting into those three main categories of obesity, a person considered to have mild obesity with the BMI of 30 to 34.9, moderate obesity with the BMI of 35 to 39.9, and then those with severe obesity would be a BMI greater than or equal to 40.”

But “the company at the time was primarily insuring white males and females ... it does not capture the differences in body types and shapes that we often see in racial and ethnic minority communities, which is characterized by different distribution of adipose, or fat tissue, and in certain areas in regions of the body,” she said.

“There’s a lot of different things you can do … at home versus what you can do in a doctor’s office,” said Dr. Stanford who noted that in a doctor’s office, “obviously, we can do a bit more there.”

“The key thing is obviously just weighing yourself,” she said. “But remember, weight—when I weigh myself on a scale—doesn’t tell me how much fat or muscle or water that I have in my body. It does give us a sense of just where we are.”

“My goal is to help you realize that you matter regardless of what the number on the scale shows. My goal is to get you in the best possible health condition, and we will find what that is,” said Dr. Stanford. “For example, if a patient comes in … and we see a significant improvement in their health parameters like their blood pressure or their blood sugar or their fatty liver goes away, sleep apnea goes away, I’m thinking that we’ve had significant success.

“And it wasn’t me getting them to a target number that mattered as much as me getting them to the best health that I could potentially get them to,” she added.

“I'm a huge, huge fan of doing something very basic and very cheap, which is doing a waist circumference measurement,” Dr. Stanford said. “That’s taking a simple tape measure, which should cost you no more than about $6, and measuring at the belly button—or umbilicus if you want to be really fancy—and going around the circumference.”

“Our target waist circumference for women would be 35 inches or less. And for men, it would be 40 inches or less,” she said. “If we can utilize that in conjunction with weight, we can determine one’s risk stratification.”

“When we carry weight in our midsection—what we call central adiposity—it does increase our risk for metabolic diseases like type 2 diabetes and heart disease, so our focus is really in that area,” said Dr. Stanford.

Dr. Stanford often asks her patients “about their diet quality with an emphasis on lean proteins, whole grains, fruits, and vegetables.”

“With diet, I’m not about putting you on this fad diet and the next fad diet and having you pay some exorbitant fees for fake foods,” she said. “My goal is to have you on a nice whole diet with foods that we recognize from nature. That’s really important.”

“For example, I hate skiing. I just do not like doing it. I live in Boston. A lot of people like to ski,” said Dr. Stanford. “If my doctor said, ‘Well, Fatima, you need to ski for exercise,’ I would not be someone who exercises frequently.”

“My goal is helping persons to find the exercise that is their soulmate exercise so that they can do what they enjoy doing because what they enjoy doing is what they'll do chronically,” she said.

“A lot of people are unaware that the brain is the organ that regulates our weight, particularly a portion of the brain called the hypothalamus,” said Dr. Stanford. “And when we are having irregular sleep, poor sleep quality, changes in the timing of our sleep—meaning that we sleep during the day as opposed to during the nighttime—those shifts can cause us to signal down the pathway of the brain that tells us to eat more and store more.”

Several studies have found that “those getting between seven and eight hours most ideally were those who had the healthiest weight status compared to those who were either really long sleepers—those people who sleep for 10 or even 12 hours—or really short sleepers, which might be your four-to-six-hour type people,” she explained, adding that sleep “really is an extremely important issue that we often neglect as it relates to weight and weight regulation.”

“Water is, first of all, something that's already taking up a lot of our bodies,” said Dr. Stanford. “But water in and of itself and hydration, which we're getting from the water, is what can help promote satiety."

“Satiety is feeling full, and a lot of times people misread their hunger cues. They think they're hungry when they’re just thirsty and aren't hydrated well enough,” she said, adding that “water, I would throw in that bucket of things like tea, for example. Of course, not the sweetened tea from the Southeast where I’m from, but just an herbal, green, white or black tea would be great to consider.

“These things are going to give you that fluid onboard so that your body is actually making sure that you’re not thirsty, which can sometimes be mistaken for hunger cues,” Dr. Stanford said.

“If you have parents who have obesity, there is a 50% to 85% likelihood that you yourself will have obesity, even with ideal physical activity, sleep, and diet patterns,” Dr. Stanford said. “We don’t recognize that.”

“I was looking through the genetic test for one of my patients and recognized that their obesity was secondary to a rare genetic form of obesity that we now have a treatment available for,” she said. “But I would’ve never known if I had not done that investigation with the patient that they had a long family history of many persons weighing in excess of 350 and 400 pounds.”

“There are three major times during a woman's life where we see excess weight and accumulation. This is the onset of menses or what we call menarche, when we're an adolescent,” said Dr. Stanford. “If a woman gets pregnant—whether she has a child—that may be weight that she retains.

“And then the one time in women’s lives that we cannot prevent ourselves from getting to, which is menopause, where we see major weight shifts,” she added.

“Let’s get away from feeling like we must look like everyone else. What makes us so unique is that we are unique individuals—we are not like any other human on this earth,” said Dr. Stanford. Yet “why do we conform to standards that ensure that we have to be like the next person or the next person?”

“Take a deep breath. Recognize that your body is different from someone else’s,” she said. “But if you’re struggling with your weight, we have tools that are underutilized for the treatment of diseases like obesity, particularly medications … and surgery, which are only used 1% to 2% of the time in the eligible population.”

“Just because we’ve optimized diet and physical activity does not mean we will always have a healthy weight,” said Dr. Stanford. “And that’s where people struggle because they feel as though they must be doing something wrong.”

“It’s at that point when you’ve optimized diet and physical activity that you need to seek out the care of someone like myself so we can utilize other therapies to help compliment that great work you’re doing in the domain of diet and physical activity.”