Dr. Youdim specializes in medical weight loss, medical nutritional therapy and nutritional and metabolic support of bariatric surgery patients. Dr. Youdim received her bachelor’s degree from the University of California, Los Angeles and her medical degree from the University of California, San Diego School of Medicine. She completed her internship and residency at Cedars-Sinai Medical Center as a well as a fellowship specializing in nutrition and bariatric medicine. She is currently Associate Professor of Medicine at UCLA David Geffen School of Medicine and Assistant Professor of Medicine at Cedars-Sinai Medical Center. Dr. Youdim is very open about the problematic issues associated with trendy diet fads of the past, like Phen Phen, but is optimistic about new developments in this area in the near future. She does not shy away from discussing bariatric surgery with her patients and warns that obesity is second only to tobacco for cancer diagnoses today.
My name is Adrienne Youdim. I'm a board certified physician in internal medicine but I'm also certified as a physician-nutrition specialist and an obesity medicine specialist. So my practice is essentially treating common medical conditions through diet, lifestyle and pharmacotherapy to address the excess weight, to address the obesity.
So I did my undergraduate education at UCLA. I went to UC San Diego for medical school; came back to Los Angeles; did my internship, residency, fellowship at Cedars-Sinai, and I practiced there as faculty for about eight years as the director of the Center for Weight Loss at Cedars-Sinai and currently I'm in private practice.
The definition of a disease is a physiology that is aberrant or has gone wrong. Obesity is a difficult disease to treat or to cure. It's challenging because it's not just about the treatment that is offered, whether it's diet, lifestyle, medications or surgery, but it's also about changing a behavior and an environment that is difficult in which to change that behavior. I would consider obesity a chronic disease because it is something that needs to be dealt with on an ongoing basis.
Obesity is a condition that affects every organ system from head to toe. Obesity is associated with common things that we all talk about in this country like heart disease which is the number one killer in both men and women. Diabetes. Risk factors for heart disease other than diabetes, including cholesterol, blood pressure. Obesity affects joints. It affects skin. It puts people at greater risk for cancer. In fact, the most common cancers in the United States, excluding tobacco-related lung disease, are associated with obesity. Breast cancer or prostate cancer, colon cancer, pancreatic cancer, all have associations with obesity.
We know that women who have excess weight are at greater risk for infertility. If they do conceive, they are at higher risk for miscarriages. And they're at greater risk for complications both in themselves during pregnancy and in the child. Not to mention that when an individual is obese before and during pregnancy they pass on that likelihood to their child.
The refreshing news is that even modest amounts of weight loss significantly improve these medical conditions or what we call co-morbidity. So, take for example an individual who weighs 200 pounds, they lose 10 to 20 pounds, which is significant but not tremendous, and as a result get their sugars under better control; blood pressure comes down; sleep apnea improves; they improve their fertility.
Obesity is one of those diseases that you unfortunately wear on your sleeve. So you can't walk around in a crowd and pick out individuals who have diabetes even though, like, diabetes is caused by lifestyle as much as obesity is for example, but obesity is something that you can oftentimes see in an individual. And there's a bias with the excess weight that people carry, and so unfortunately individuals who are overweight and obese do have a lot of psycho-social co-morbidity. They do have more anxiety. They do have more depression. And these things start early. Children in adolescence who are overweight or obese have a significant degree of psychosocial issues, social isolation, and this carries into adulthood.
Bariatric surgery literature shows that there's an interesting or unique dichotomy following weight loss. So as you would expect a lot of people have improvement in their depression following bariatric surgery but there are also a sub-set of patients who develop worsening depression. Perhaps people attribute so much of their problems to the excess weight when, in fact, everybody has problems, right?
It's a challenge to lose weight. It's because obesity is not only a physiology that needs to be changed but it's a behavior that needs to be changed. We live in a world in which we're all about convenience. Fast food or even if it's not fast food it's quick food. We don't take time to eat. We don't take time to prepare, to shop, to create good nutrition for ourselves. Essentially physical activity has been engineered out of our lives. Dishwashers, remote controls, cars, escalators, we don't take time to do extra physical activity or exercise but, even that day-to-day activities that people used to do, we no longer need to do.
Once people develop obesity and have this excess weight, weight loss becomes difficult because the body does not want you to lose weight. So when individuals do lose weight, stomach hormones start to send messages to the brain that the person is hungry. So when people re-gain weight following weight loss, it's not a matter necessarily of lack of willpower, lack of control, but there is actually this physiologic drive to eat more, and that is dictated by hormones in the body.
So for many years there's been a gap in our treatment options for obese patients. On one end of the spectrum, there's diet and lifestyle which we counsel everyone on regardless of whether they use medications or surgery for weight loss. At the other end of the spectrum is weight loss surgery, but there was really not much in between by way of medications. In addition to that, we've had some historical issues with weight loss medication in that there was this Phen Phen fiasco, for example, where people were actually being harmed by weight loss medication.
Fortunately the landscape has changed somewhat in the last several years, and we do have at our disposal more medications to help treat patients with obesity. In general, these medications affect satiety or hunger at the level of the brain. There's several different classes of weight loss medications, and for the most part, they either affect neurotransmitters in the brain that affect hunger cues or they affect gut hormones that are released and signal the brain, again, in regards to hunger.
Invariably all medications have side effects and that's an important issue. Some of the medications are stimulating or stimulatory, so side effects can include agitation, anxiety, insomnia, rises in blood pressure. Usually these side effects are self-limiting meaning that for the most part people feel them at the outset for several days and then they kind of mitigate over time. Common things like thirst and headaches are common side effects of weight loss medication.
The other issue is that there are contradications. So if you have a patient who has known heart disease, which is a known co-morbidity of obesity, you can't give them a stimulatory medication that can make their heart rate go up or their blood pressure to go up. So there are a lot of considerations in how you prescribe these medications, but in an individual who is motivated, who is engaging in a lifestyle change, and who needs a tool, they can be very effective in giving them that extra little bit of help that they need to start to reduce their calorie intake and lose weight. Patients that I can think of on a first-name basis talking to that have lost 50, 60, 80, a hundred pounds of weight over the course of six months, a year, two years, and who are effectively keeping it off. Is it a struggle? Absolutely. Do they gain five pounds, lose it; gain ten pounds, lose it again? Again, they do, but at the end of the day they're successful in achieving not only that five to ten percent weight loss that we talked about but a significant amount of weight that as a result has caused them to get off blood pressure medication, get off diabetes medication or at least reduce it to some degree. I've had patients who have been able to conceive as a result of weight loss.
So the cornerstone of any treatment plan for obesity is lifestyle modification. That includes diet. That includes exercise and behavioral change. And really that is the core, regardless of whether you use medications for weight loss, or you move on to have a weight loss surgery, that core lifestyle change needs to occur. So in my regular practice I spend a lot of time counseling patients on dietary and lifestyle changes, and typically we have goals that are prescribed, just as the medications are prescribed, that we try and achieve on a visit-to-visit basis.
When they are unable to achieve their goal through diet, exercise, lifestyle modification, then we can add medications to help them adhere to those dietary and lifestyle changes.
It used to be that we prescribed medications for short-term use. But there's been a shift now in which the guidelines state that we should use medication lifelong because you're treating a disease that is chronic, and individuals are only going to benefit from that medication while they're on that medication, just like they're only going to benefit from blood pressure medication while they're on that medication.
If they wish to come off or to taper the medication, we try. Sometimes we're successful in maintaining weight without medication and sometimes we're not.
So I like to bring the issue or topic of surgery up early in the game so that everyone is aware that it is an option at some point should it be necessary. When a patient engages in the nonsurgical treatment plan, they may come to a point where it's clear six months down the line, for example, that they're not achieving successful weight loss, or they've achieved successful weight loss and they've had significant re-gain. We know that weight loss surgery is an important treatment option. We know that many people achieve significant health benefits from weight loss surgery.
I find it's refreshing to them to know that this is an option that a medical doctor is discussing with them because there are physicians out there who have opinions about treating obese patients or treating patients with surgery. This is not an opinion. It's a treatment, and as a physician, I think, we are compelled to educate our patients on all the treatment options that are available.
There are definitely those patients who come in who are against surgery and don't even want to address it, in which case we don't address it unless we need to, and then there's others who really have tried and tried nonsurgical weight loss umpteen times throughout their lives and it has become clear to them that they need to do something more.
So a successful treatment plan does include a multidisciplinary team. As the medical doctor, I'm able to counsel my patients but I'm also able to provide prescription medications when and if necessary. In addition to that, I utilize my dietician's help in reinforcing the dietary or lifestyle counseling that I have initiated or provided in the office. There's this significant component of emotional eating, in which it needs to be addressed in order to achieve successful weight loss. In those circumstances, we engage our behavioral specialists to help us with addressing the emotional issues and again supporting the behavioral change that we've prescribed.
And then finally there are the bariatric surgeons that are part of the team in that sub-set of patients who are candidates for bariatric surgery.
So following bariatric surgery or even medical weight loss, there are continued needs. Patients need to continue the lifestyle changes. They need to learn to eat a healthy diet so that despite the weight loss they're getting adequate nutrition. There are vitamin and mineral deficiencies that occur, and so that's where, again, I will play a role in helping treat potential deficiencies. They can have really important consequences. And some of these patients have other psychosocial issues that develop following surgery. This has been a life change for them. And family members may or may not respond well to that change. They personally may or may not respond well to that change. So, again, you have to engage the behavioral specialist to help, so it truly is a multidisciplinary effort that engages all the members of the team, not only in the pre-treatment phase, the active treatment phase, but also the post-treatment phase in order to ensure success in these patients.
So the epidemic of obesity is daunting. A significant proportion of our adult and child population in the United States is overweight or obese. I don't think the message should be one of fear because small changes in lifestyle, small changes in weight, result in significant benefits to individuals' health. And so the message, I think, really needs to be, don't be shy or afraid of tackling this condition because you have everything to gain from even small amounts of weight loss or small changes in your lifestyle.
When we talk about what is the future of obesity, I really don't think you can pin it on any one thing. We have to really to be unique in our prescription of treatment to the patient.
I think bariatric surgery plays a role. I think pharmacotherapy and medications for weight loss are going to play a bigger role because we have had, again, this gap in our treatment options historically that has not addressed pharmacotherapy, and we're addressing that gap by having more medications at our disposal. What's becoming clear is that in order to successfully treat obesity, or affect appetite, you have to affect different inputs and not just one. In fact, the mechanism by which bariatric surgery works is by affecting hormonal change.
We have huge barriers in regards to third-party payers and them approving these medications and paying for the treatment options. In many cases, obesity is actually an exclusion in insurance or health plans and so it's not even an option for these things to be covered. There's a lot of change happening, though. Professional organizations are becoming better about educating Congress and legislators about the need for reimbursement for these treatment options and so I do think it's changing but it is a very slow shift.
We know that obesity taxes the health system at over two hundred billion dollars a year. It's associated with significant collateral damage. Absenteeism from illness and other things in the work force. We will be addressing the tenets of the Affordable Care Act which is prevention, but right now what we're saying doesn't match what we're doing. We say that we're promoting prevention. We say that we want physicians to engage in preventative services but we are not approving the means by which we can prevent diseases from occurring by treating obesity.
It's very important for people out there to recognize that you can achieve so many benefits in health through really small change in diet, exercise and weight. Oftentimes when a patient comes in they have the weight loss goal of 50 pounds, 60 pounds, a hundred pounds. Sometimes that's achievable; sometimes it isn't; but even 10 pounds or 20 pounds will improve the health of that patient. So I think that message really needs to be that when you're ready to tackle this health problem, there are effective treatment options at your disposal, and you can achieve better health through losing weight.
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