Jennifer Arussi a Registered Dietitian and obesity expert in delivering medically based weight loss interventions. Jenny brings with her a wealth of clinical experience from treating thousands of patients at Cedars-Sinai's Center for Weight Loss and The Diabetes Outpatient Treatment and Education Center. She attained a Bachelor's of Science in Dietetics + Food Administration as well as Master's Degree in Human Nutrition. Jennifer is quick to point out that when the American Medical Association defined obesity as a disease a few years ago, “most people that are working with this population said it's about time. It's a disease that needs management. It's a disease that can go into remission.” She discusses the key issues to lose significant weight both naturally and through bariatric surgery with the most important factor being the ability to change your relationship with food.
My name is Jenny Arussi. I am a private practice dietician. I work individually with clients with behavior counseling. I also facilitate groups and do group counseling. I have an undergraduate degree in nutrition as well as a master's degree in human nutrition
In this fast-paced healthcare world, doctors don't have a lot of time with their patients. They may have 15 minutes in a consultation room and they kind of lay the groundwork for the patients. . I like to see the dietician, as a person that they can partner with that will help them to facilitate change. It's very easy for a doctor to say just cut out the sweets. Then the patient comes to me and says, well, doctor so and so told me I have to cut out the sweets; I don't know if I can do that. So my role would be to find out what sweets they like and teaching them about some alternative sweets that they can manage, so it's really trial and error. So I see the dietician as being able to work with them step by step and do the how to's that the doctor really doesn't have time for.
Until a few years ago the American Medical Association really didn't define obesity as a disease, and when they did define obesity as a disease, most people that are working with this population said it's about time. It's a disease that needs management. It's a disease that can go into remission. I think it becomes easier with time for certain patients, just like going to the gym when you start lifting weights. You get stronger over time and that's a very important message to tell patients when I work with them, that even though this may be hard initially, I promise you it's going to get easier with time.
Initially when patients come to see me, in most cases their relationship to food is their best friend. It's their coping mechanism. It's how they manage stress. It's how they deal with their sadness. Most people with obesity or having an unhealthy relationship with food feel the anxiety and they develop the habit where they're just using food to deal with that anxiety or that sadness or that happiness or boredom. So everybody uses food in a different way, and I think there are varying degrees of using food, and that's why Overeaters Anonymous could be a decent free model for patients that maybe can't afford services, like healthcare services, doctor, dietician or a psychologist. I think OA has something important to offer; they can partner with somebody and they can be accountable to that person and it's of no cost.
Eating can be an addiction. You can't say I'm going to be abstinent from food, but you can redefine what potential foods you may be abstinent from. If chocolate is a trigger food for them, I like to find alternative forms of chocolate that they can have in their diet and they can make peace with and feel satisfied. One of them comes to mind is a Vitatop muffin. It's a little portion-controlled muffin; you put it in the microwave; has little chocolate chips and it's heavenly and patients love it.
The causes of obesity are multi-factorial, and I think if you talk to various researchers that specialize in obesity, they're going to have different answers. Kelly Brownell wrote a book called "Food Fight" and he takes a very interesting perspective about the causes of obesity and it being mostly environmental and not genetic. I tend to buy in to what his theory is. Our genes really haven't changed much over the years, even hundreds of thousands of years, but clearly our environment has changed, right? We have more accessibility and availability to food. We can get it 24/7. We can get it cheap. It doesn't matter what neighborhood you live in. You can live in the wealthiest of neighborhoods or the poorest of neighborhoods. Food is accessible and available and usually the higher calorie foods even more so, right?
And then what about physical activity? Physical activity doesn't come naturally, so we have to work at that whereas if we look at our ancestry, we didn't have to. It was estimated that our ancestors were burning something like 3500 calories a day just to travel and retrieve food and now you have to really give a lot of thought and plan for activity to happen.
I think the body mass index is useful. I think there are better indices available, one of which is body fatness.. It's recommended that women have below 28 percent body fat, and for men it's recommended below 20 percent body fat. So body mass index I would consider as a starting place for the nation to kind of figure out where you fall in the spectrum of your obesity or your weight but I think it's better if you can look at it from a deeper perspective.
The majority of people that I work with are coming in with what we call co-morbidity related to their obesity so co-morbidity would be high cholesterol; it would be high triglyceride; it would be diabetes; it would be heart disease. Most people that I'm seeing that are middle age are learning about some co-morbidity: my doctor told me my cholesterol increased; he said if I lost some weight it would go back down. And it is fascinating when I see patients lose weight even in a six-week time frame, their cholesterol levels will drop dramatically. I see blood sugar levels drop dramatically just by changing the method of how people are eating and even making small changes. It doesn't have to be anything drastic. You know, it could be having oatmeal and a hardboiled egg for breakfast. It could be lean protein with a big salad. There's a strong correlation between what you're eating and all of your co-morbidity, whatever you're presenting with, and it's very nice in the medical field when you see patients seeing those results. If all you're looking at is the scale you're going to be unsuccessful. You need to get your blood checked to see how your cholesterol is changing, right? You need to pay attention to how you're feeling physically. There's got to be many different layers and assessment of what's changing as you're losing the weight.
A lot of people have tried to lose weight and they decide that it becomes too hard so they don't believe that they can do it. We call that self-efficacy, especially when you've had so many failed attempts. That comes from patients approaching the weight loss very black and white and saying I need to be on a diet in order to lose the weight and then when my diet finishes I can go back and eat whatever I want, so if they redefined that at the start and say, I need to change my lifestyle; I'm going to start walking; I'm going to start eating breakfast, something with protein in it; I'm going to have an afternoon snack so I try not to overeat at dinner. If they approach it not as black and white, not as rigid, I think it becomes doable. There's no one way for one patient. It needs to be individualized and we need to figure out what's going to work with them.
I consider prescription medication to be an adjunct to the treatment of obesity and it's not for everybody. I see a lot of patients successful with Qsymia and Phentermine. These are FDA-approved medications. Also, Topiramate. I haven't seen many people be successful with over-the-counter medications. In terms of a drug like Qsymia, when patients are taking that and it's working for them, what they say is the urge to eat is dulled; it's diminished; it takes the edge off. So I think that could make a difference.
I don't have any bias against bariatric surgery. I am very willing to have that conversation with patients even early on, especially if they have over a hundred pounds to lose, and they tried every single diet out there and they need to really improve their medical condition as soon as possible. I think they need to learn as much as they can about the procedure and consult with a surgeon, consult with any friends, family, associates that have had the surgery and start to learn more about it.
The hoops that you have to go through have become more cumbersome; for example, certain insurances are requiring a six-month supervised weight-loss program. I think it can be very frustrating for patients, and they feel like, you know what, I've already tried losing weight on my own; that's why I'm having the surgery; why do I have to go through all of these hoops to have the surgery? If you're waiting till the surgery to change your eating behaviors you're going to be in for the biggest surprise of your life. I find that patients that are prepared, that do the work early on, that maybe space their meals, you know, maybe instead of eating two meals a day maybe they're eating four or five meals a day, and that's what you'd need to do post-surgically. Maybe practice eating slowly by putting your fork down between each bite and not just inhaling your food. So simple things like that, implementing those practices prior to surgery, they can consider that as an opportunity to solidify the habits so that when they have the surgery it's all that much easier.
So if patients are participating in a hospital-based program, hopefully that hospital-based program, their pre-surgical program, is strong in education.
So post-surgically, the first few weeks are clear liquids post-surgically where you're sipping on protein drinks. You're taking certain vitamins and minerals every day. You have a vitamin and mineral regimen. You're trying to keep up with your hydration; very common post-surgically patients get dehydrated. After those first few weeks you may move into what we call a full liquid where they're eating maybe a little dairy like yogurt, maybe some sugar free pudding; some soft foods that easily slide down. All of this is intended for your new pouch to heal so you're focusing on high protein and you're preventing dehydration. And then the subsequent week you may have mushy food. Some people do end up buying baby food or they puree some of their food. And then it moves up to chopped food where they're chopping maybe a little bit of chicken up; soft meats are better tolerated. And then slowly but surely, maybe by week six post-operatively, they're eating a regular diet and that regular diet may only be something like six to eight hundred calories a day. It's a very small amount of food, and most patients are sipping on at least two high protein beverages a day, protein shakes, because there's no way they'll be able to eat enough protein, to meet their nutritional goals. So the dietician can play a really important role in helping the patient; problem solve, how they're going to get in their protein, how they're going to get in their hydration.. How they're going to get in their vitamins and minerals. So that first six weeks early post-op phase is really important so they're not getting dehydrated and getting optimal nutrition.
We used to tell patients that the gold standard with weight loss is losing at least 50 percent of their excess weight loss. And we would do the math for them, what that would look like, so if they started out at 300 pounds and their excess weight was a hundred pounds, 50 percent of that would be only 50 pounds. So, yes, you can do 60 percent of your excess weight loss. Yes, you can do 70, 80. I have a few patients that have done a hundred. But really the gold standard in terms of all the surgeons, medical doctors, all of the research articles out there, it's 50 percent of your excess weight loss. And knowing that up front is really important.
If there's one variable that patients could stick to post-surgically and really build upon that would be physical activity. Physical activity is pretty much a guarantee for you to be able to keep your weight off. Yes, it helps accelerate your weight loss, but importantly, the studies show it's a very strong predictor of their ability to keep their weight off.
Early on even if they started walking for 20 minutes, even if they started out with 10 and they did that three or four days a week, that's going to really help them not only maintain their muscle integrity, which is important, but it's also going to help accelerate their weight loss and it's also going to help them cope better because, remember, they're not able to use food anymore to deal with life's stressors, so what else do they have? There is such a thing in the literature called transfer addiction, so where one addiction is eating, it's being replaced by alcohol, or it's being replaced even by physical activity. I say if you can frame physical activity in such a way that it's helping your mindset it's helping you cope better with life's stressors and the icing on the cake, excuse the pun, is that you get to lose weight, so physical activity is a great replacement to using the food.
One of the things that patients struggle with post-surgically is their relationships, whether it's their spouse, significant other or friends; maybe they were dining out a lot with a certain group of individuals; everything changes when that person's relationship with food changes, so instead of going to a Mexican restaurant and having marguerites, chips and salsa, with their friends, they may instead say, hey, do you want to go for a cup of coffee or how about a morning walk, and the friend is, like, uh I want my marguerite chips and salsa. So that could be a challenge
The other thing is if you're in a relationship and you start losing weight I find the other partner may feel threatened that the person's starting to lose weight, getting a lot of attention and what that means. And that is also part of why it may be so hard to keep the weight off, whether it's surgically or non-surgically. I find that some patients, once they feel their weight starting to drop, somehow they sabotage themselves because this idea of drawing attention to them, to themselves, is scary so they eat to avoid that attention. Depending on their family upbringing, there may be an abuse, maybe a sexual abuse early on, and this idea of becoming attractive as a woman and then having men look at me in a different way, that could be very scary, and it could be also in men so there's so many emotional possibilities that could happen post-surgically and so many different dynamics and layers that could go on.
When I have a male as a client, they're very matter of fact. In a way it's a little easier in working with men for me as a dietician because it's kind of clear-cut. It's like I have a goal and I'm going to work toward this goal. With women there's a lot more layers to it. I think they have that story in their head, yes. That's a barrier for them. It is hard for them. I can't tell you how many people come in and say, oh, it's menopause; oh, my metabolism slowed down. So you have to be careful about the stories that you're telling yourself that can be slowing it down about your ability to lose the weight.
When patients feel overwhelmed, when they feel like they have a hundred pounds to lose, oftentimes they get easily discouraged when they may come in and they say, well, I lost 10 pounds but I have 90 more pounds to go, okay, but you've lost 10 pounds. You started something. Let's talk about what you're noticing as you lost these 10 pounds, okay? It's about capturing that and helping them to continue to build momentum so they keep going and they're not bogged down by the idea of how much more weight they have to lose. So they have to break it down, I think, into smaller goals; maybe my goal is I want to at least 40 pounds, and then when I'm at those 40 pounds then I'm going to stop and we'll re-evaluate what I need to do. So it's about looking at smaller, more incremental, doable goals.
There are a lot of studies that show the benefits of accountability when it comes to weight loss. Regardless of diet type, having more frequent visits with the healthcare provider, whether it's in a group setting or it's individually, study after study shows that accountability, going to the appointments, are key indicators in the patient's long-term success. There's a very special dynamic that can occur in a group. People start to care about each other in the group and there's also some sort of healthy competitiveness that goes on. So I think comparing yourself amongst your peers can be motivating if you do it in the right way. I'm always encouraging patients to come to the meetings, and that meeting may involve a weigh-in; that's an additional accountability piece. Some people don't want to weigh-in. Would you ever go a doctor that's managing your blood pressure and say, excuse me, I don't think I want to test my blood pressure today. The doctor is going to look at you like you're crazy; we have to monitor to monitor your blood sugar, or blood pressure, or blood sugar, or whatever it is. Weight is an index so we have to look at your weight and maybe in a nonjudgmental way.
Weight regain is very common post-surgically. People may gain anywhere from I don't know 5, 15 percent of their weight, especially as they've settled in and maybe they're incorporating new foods. When you have other peers to talk to about that and you realize that you're not alone, that can feel a lot of better. It's like, oh, I thought I was the only one; I didn't realize you also put on a little bit of weight post-surgically. I think that's important when you're in the group to get that perspective.
If you're struggling with food it's really important that you redefine your relationship with food and you try to improve that, and you learn healthier coping mechanisms of how to manage all of your emotions.
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