Weight gain during the pandemic: An obesity medicine specialist explains [PODCAST]

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“The impact of the pandemic on the lives of Americans will be felt for years, if not generations, to come. This includes its alarming effect on health behaviors that contribute to the already formidable challenge of obesity in this country. Now, more than ever, we must look for creative solutions within the broader health ecosystem that can help individuals adapt their behaviors, in spite of socio-environmental challenges, to prevent, manage, and maybe even reverse chronic disease. The very health of our nation depends on new solutions to our country’s age-old societal, cultural, and behavioral challenges.”

Rami Bailony is an internal medicine physician.

He shares his story and discusses his KevinMD article, “The overlooked factors driving weight gain in the pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Rami Bailony. He is an internal medicine physician, and he wrote the KevinMD article “The overlooked factors driving weight gain in the pandemic.” Rami, welcome to the show.

Rami Bailony: Oh, thank you. Thank you for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Rami Bailony: Yeah, of course. I grew up in San Diego. After that, I went to UCSF for medical school. At UCSF, I worked on a project where I used data to analyze cancer registration data, and that really got me hooked on technology, or on what technology could contribute to medicine. So I went over to Stanford after that to do a fellowship with Medicine X in health care entrepreneurship, and I was working on a project on a diabetes app when I noticed that a lot of the users had a lot of guilt associated with type 2 diabetes. I started exploring that guilt, sat down for lunch with a few of the users, and really figured out that this was getting in the way of them really activating and being engaged with their care.

So I started looking more into guilt and health care, and that led me down a path of why we eat and what drives appetite. I had struggled with weight probably since the age of 16. I had lost 40 to 50 pounds and regained it about five or six times, so this was partly personal. I really started diving into the science of obesity medicine, learning that a lot of our appetite is hormonally and metabolically driven and environmentally cued, and that taking a self-blame approach wasn’t helpful to anybody. So that’s really what drove me behind my passion in obesity medicine.

Kevin Pho: So as an obesity medicine specialist, what would you say are some of the biggest misconceptions about obesity, even among physicians?

Rami Bailony: Yeah, I think the number one misconception is that people who struggle with obesity are not trying to address their disease. A lot of physicians still don’t view obesity as a disease, but rather as a lifestyle choice, and the science is definitely showing otherwise. Seventy percent of the U.S. now struggles with being overweight. In 2020, one of the headlines that was missed was that 40 percent of people in the U.S. have obesity. And to go to the fact that people aren’t trying, we spend $300 billion a year trying to lose weight. So people are trying to lose weight. It’s just that the biology behind weight adaptation, which is sort of a resistance to weight loss, is real. When people do lose weight, their body naturally tries to defend that weight, their appetite changes, and they regain weight. And so it functions like a disease.

I think the biggest misconception we have is that it’s a calories-in, calories-out problem, that it’s very simple to address, and that anybody can easily do it. And I think that attitude often creates more harm than good. I do remember in residency being trained to just tell diabetics to cut the rice and bread. Struggling with prediabetes myself, I knew it wasn’t so easy, but I kept saying it as if it was true, and in retrospect, I was just blaming myself for my inability to cut those foods out of my diet.

So I think the biggest misconception is that this is an easy problem to solve, and it’s clearly not easy when 40 percent of the U.S. population is struggling with it. And really, that’s causing, it’s one of the leading, it’s going to be the leading global health epidemic, I think, in history as we move forward here.

Kevin Pho: Now, you run an obesity medicine clinic. I was wondering if you could briefly share what some of the 2021 approaches are when it comes to obesity treatment today.

Rami Bailony: Yeah, good question. 2021 is going to be an interesting year for obesity. There will actually be a new, or probably two new, drugs getting FDA approval for the treatment of obesity later on, one just around the corner in June, which will be semaglutide, which is Ozempic’s obesity cousin. That drug has actually been shown to produce 16 percent weight loss in some clinical studies with diet and exercise.

So I think the overall approach in 2021 to obesity, from an obesity specialist’s perspective, is, one, to destigmatize obesity, to really get people feeling like this is a disease that needs a long-term approach. There’s no one diet that fits all. There is not one thing that’s going to get you right to that extra weight. It’s going to be a process where you learn about yourself, where you learn what diet works for you. And then if you definitely have a history of losing weight a lot of times and regaining it, probably medications, of which, again, there are four on the market now and two more coming. It’s probably something that we’re going to be seeing a lot more of going into late 2021.

Kevin Pho: All right, let’s talk about the KevinMD article that you wrote. This was back in March. It’s titled “The overlooked factors driving weight gain in the pandemic.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Rami Bailony: The reason I decided to write the article was that we were seeing a lot of folks coming in, in the middle and toward the end of the shelter in place, with weight gain. And again, my bread and my passion around this is really trying to get people to destigmatize their own weight. There are actually great studies that show that people who self-stigmatize their own weight have higher CRP, have higher triglycerides, have higher metabolic health markers, sort of suggesting that on some level, which is unclear, stigma plays a negative role on our health. And I think we can all figure that out.

So we were seeing a lot of people coming in and really blaming themselves for weight regain, and I think what I wanted to do was put that weight regain, which I think we experience as a society, including myself, on a larger, broader scale as to what factors really drive weight. And these factors are a lot of times out of our control. In particular, I think the behavioral health piece and the stress piece are two huge factors.

And then the last factor that the article addresses is the fact that we don’t have a good care model for obesity. Obesity continues to be something that is largely neglected by the health care system, and so the payment fields for it are largely unaddressed. So that was also one thing. A lot of folks have to search for a solution. They have to Google, they have to try to read Yelp reviews and figure out what’s right or wrong. But you don’t do that for diabetes, you don’t do that for heart disease, you don’t do that for CHF, and you don’t do that for autoimmune diseases. You go to your doctor, and your doctor gives you a care path or some possible treatment options. But in obesity, that doesn’t happen, and so people are sort of on their own.

So I wanted to address the broader context of why people may be gaining weight, try to destigmatize the weight gain there, as well as offer some suggestions that society needs to get more serious about tackling obesity from a health care perspective.

Kevin Pho: So let’s go a little bit more granular in terms of those four factors that you talked about. The first is kind of the behavioral health piece. So what do you mean by that?

Rami Bailony: The first factor I addressed was stress and mood. What fascinates me about this is that there are studies that show that people who struggle with weight at baseline tend to gain weight when they are stressed, and people who don’t struggle with weight at baseline tend to actually lose weight, or even stay weight neutral, when they are stressed. So it’s almost like, if you have a biological disability on the weight regulation side, stress negatively impacts you more so than a person who doesn’t have that.

And so I think the fact that this pandemic was such a stressful environment, and that we don’t really have good ways to manage stress, and we are not taught good mechanisms to manage stress, even though it is a huge driving factor, where even if you no longer are on the go, even if you’re working at home, where technically you should have control of your food environment, the stress of what we experienced during the shelter in place, I think, takes over from a weight regulation standpoint, and people can gain weight. And if they blame themselves for that weight gain, the mood and stress just get worse. So it’s almost like a really bad negative cycle, I would say.

Kevin Pho: I did anticipate this factor improving now that things are beginning to trend toward normalcy.

Rami Bailony: Yeah, you know what’s interesting about that? I always tell people, “Hey, with COVID, we had the COVID-19 in terms of weight gain initially.” And I think with stuff opening up, initially, you’re going to see some more weight gain. What people tend to miss is that it’s the habit shifts. During that period, as the body is trying to adjust to a new routine where it really doesn’t know how to regulate weight, the weight set point can get dysregulated.

And there are a lot of hypotheses now that weight gain actually starts with a dysregulation of your weight set point, rather than the reverse, that you have a bad environment, you gain weight, and then your weight set point sets. Now we’re starting to think that you actually have an environmental stressor or a biological stressor, and your brain perceives that, and so it upregulates that weight set point, and you gain weight. So I think any time there is a huge shift in your environment or activities, there’s a chance for weight gain. And so I actually think that we’re going to see additional weight gain with society opening up.

Kevin Pho: One of the other factors that you mentioned was the economics of processed food. I was wondering if you could delve a little bit deeper into that and explain why the economics of processed food during the pandemic is leading to weight gain.

Rami Bailony: Yeah, I mean, I think this is a big overlooked factor, and one that we really need to, it’s obviously not something that doctors would really have to team up with policymakers to address. But processed foods are cheap, right? You can go to Safeway and you can buy, gosh, four pizzas for $5 sometimes, right?

And this pandemic, the one thing about it is that it really impacted people in unfair ways. People who were working more manual jobs, more restaurant-based jobs, more jobs that were impacted by the shelter in place, saw a lot of economic stress, whereas a lot of people who were working more technology-based jobs, or jobs that could be done remotely, actually saw an increase in wealth, right? And so that divergence is super important, because a huge part of society was feeling this economic stress. And when you’re economically stressed and you’re at home, you’re going to lean toward foods that are cheaper when you’re going to the supermarket, and foods that make you feel good, and processed foods are both of those.

And so you really can’t beat processed foods in a time like a pandemic. If you think about it, when astronauts go into outer space, they take a bunch of processed foods, because they’re great for conditions that are harsh. And the pandemic, for a lot of people, was a harsh time. Processed foods give you that dopamine fix, and they are cheap, and so they really work out for times like these.

Kevin Pho: We’re talking to Rami Bailony. He is an internal medicine physician, and he wrote the KevinMD article “The overlooked factors driving weight gain in the pandemic.” Now, you talked about some of these factors that led to weight gain during the pandemic. Let’s talk about some solutions and approaches. What are your best solutions in terms of addressing some of these factors?

Rami Bailony: Yeah, I think on a larger scale, what’s fully needed is more attention to obesity within the health care system. Now, that’s a big-ticket item that I know people can’t take out and do today, but it is important to start addressing obesity seriously, right? We learned with COVID that the mortality rates in people struggling with obesity are a lot higher, significantly higher, with almost 70 percent of the mortality from COVID being associated with people with a BMI of 30 or greater. It’s huge numbers.

Now, I wish I could say that that was a surprise for me, but it wasn’t, because with H1N1, we saw similar results. And there is an argument to be made that COVID was such a devastating pandemic because global obesity rates are so high, and that, independent of global obesity rates, the death rate of COVID would have been much lower. And so I do think obesity is going to be a driving factor for future epidemics and pandemics, and I think we need to start tackling it much more seriously, both on a policy level, and I think that, you know, one of the surprising things for me during COVID is that I did witness the ability of society to come together to address a pandemic. We saw this with HIV, and we saw this with tobacco cessation. What I would say is I want to see this with obesity, and I just feel like it’s not getting the attention it deserves. So that’s the larger, overall piece: really rallying support around that.

In terms of more practical steps, I think the first step we can all take currently is, let’s destigmatize obesity. So when people come into your clinic, even if you have 15 minutes and they’re struggling with obesity, saying something like, “Hey, weight is hard to manage. You’re not in this alone, and it’s not your fault,” is huge. It’s much better than, “Hey, I’d like to see you lose 10 pounds. Let’s cut the carbs. Let’s cut some bread.” I think saying that is a great first line, and then triggering a conversation. Either, as a primary care physician, you can start making yourself aware of treatment approaches to obesity, both pharmacologic and behavioral, or you can refer to obesity specialists who do this on a regular basis.

But I think the first step is really destigmatizing, like, “Hey, we can tackle obesity,” and making yourself aware of the pyramid, the treatment pyramid for obesity. Do-it-yourself is the first step. Most people who come to your clinic have already tried that. The second one would be commercial programs like Weight Watchers, Noom, and Jenny Craig. Most people will have already tried that as well. The third one is medical weight loss, and that’s working with a behavioral expert or a physician. Above that is obesity pharmacology, which, again, there are four drugs now, and there are two more coming out. And above that is bariatric surgery. I would say that the last three columns are underutilized in the U.S. today.

So to give you one example, intensive behavioral therapy for obesity, which Medicare covers and most insurances cover, the utilization in Medicare for people with a BMI over 30 is less than 1 percent, which means that of people struggling with obesity in the Medicare system, only 1 percent are getting counseling on obesity. That’s just a shocking statistic. And there are reasons for that. Those codes pay like $21, so most people are not going to be incentivized to go out and perform them.

But I do think making yourself aware of the treatment options and destigmatizing it. We get a lot of patients who come to us and say, “My doctor says that bariatric surgery is not good,” or, “We really shouldn’t use drugs to lose weight.” And I would just encourage all physicians to educate themselves a little bit, because the science and data are showing the exact opposite. Bariatric surgery is actually the only proven way and the only scientifically backed way to lose weight and keep it off right now. Now, I don’t think that’s going to be the case soon, with these newer medications, but right now, that really is the only way to properly manage obesity. Everything else in clinical studies shows that you lose weight and then regain it.

Now, some of the newer pharmacologic agents, such as GLP-1s, Qsymia, and Contrave, I think the five-year and 10-year data is not there yet to see if those can help sustain weight loss. But I suspect that with combination therapy there, we are going to see an ability for people to lose weight and keep it off without surgery, which is actually the mission statement that we are sort of trying to drive at Enara Health.

But the biggest step is destigmatizing. Those simple words go a long way, because it’s going to activate someone, right? If you tell someone, “Hey, cut the carbs,” they’re going to really take it personally. And if you say, “Hey, the only reason you have knee problems is because you need to lose weight,” or, “Hey, I’m only going to do knee surgery if you lose 50 pounds,” that’s not very activating, because that person has already tried to lose 50 pounds several times, and they perceive their inability to do so as failure, when in fact they should be commended on the effort. The actual approach would be, “Hey, we want to do the knee surgery. We do need to lose some weight first. Let’s see if we can get some help doing so, because losing weight is hard, and there are a lot of factors that we don’t control.”

And so the biggest step that all doctors can do right now, and all providers, nurse practitioners, dietitians, and nurses, is to destigmatize obesity. I think it will go such a long way. And then after that, making yourself aware of the treatment options. And whether you decide to offer that yourself or refer, I think that’s dependent on how busy you are at the practice level.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Rami Bailony: Yeah, I mean, I think the take-home message, I’ve said it, but I do think that I would like to see the urgency we saw in addressing the COVID pandemic toward addressing the obesity epidemic, or really pandemic. Obesity has impacted way more people than COVID has. We don’t perceive it like that, and obesity is going to lead to future pandemics and epidemics that impact us. Future viral illnesses will impact us on a broader, more negative level because of the inflammatory nature of our bodies when we have obesity as an underlying disease.

And so I think the take-home message is, let’s get together, let’s come together, let’s tackle obesity seriously, let’s destigmatize it. And I think if we do that, we can start making serious improvements to health in the U.S.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Rami Bailony: Yeah, no, thank you for having me. This was great.

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