Transcription:
Epidemic of Obesity: Taking a Look at the Science and Solutions

Amanda Wilde (Host): For decades, obesity has been a growing health danger in the United States. We'll examine the obesity epidemic in terms of science and solutions with Dr. Mert Erogul, Medical Bariatrician at Maimonides Medical Center.

This is Maimo Med Talk, a podcast from Maimonides Medical Center. I'm Amanda Wilde. Dr. Erogul, thank you so much for having this possibly uncomfortable, but important conversation.

Dr Mert Erogul: Thank you, Amanda.

Host: We hear about the obesity epidemic and rising rates of overweight and obesity in this country. And as I mentioned, we've been hearing that for many years. What are the statistics right now?

Dr Mert Erogul: Well, yes, at this point, about two-thirds of the country is overweight and 40% of the United States is obese, as measured by the BMI of over 30. And BMI is a rough indication of how round you are. It's your height over the kilogram squared. So in 1980, this number was 15%. And now, we're at 40%. And the projection is that by 2030, we'll be at 50% of the country or half the will be obese. And this is actually a global phenomenon of industrialized countries to some extent. But the United States is definitely leading the way. As you can imagine, there's a huge health impact on the public and, of course, the financial impact paying for the medical care for people who are obese. And there's even a national security angle I've read recently because the military's having a hard time finding recruits who aren't overweight. So, it's this all encompassing problem that has crept up on us and frankly is unprecedented in human history.

Host: So, there are health consequences, there are societal consequences, and it's been going on and growing for decades now. How did we get to this point?

Dr Mert Erogul: Well, the short answer is we don't really know for sure. There are many opinions. There's disagreement among experts. You'd think that people are gaining weight because they're eating more. But it turns out that this is not true, especially after 2000-calorie consumption has been relatively stable and there are actually carefully kept data for this. And activity levels also have been relatively stable. So, we're not necessarily eating more. But what has changed is the food environment in this country, the types of food that are eaten and their quality and these foods are increasingly processed. And the processing affects how our bodies can extract calories from what we eat.

So currently, ultra-processed foods, you may have heard that term, comprise 60% of calories consumed in the United States. And the link to obesity I think has a lot of evidence and momentum. So, the theory is that these hyperpalatable foods that taste better than anything in nature are designed to hijack the reward systems in our brain. And in turn, they change the brain, much like a drug. And there's actually a homology to addiction medicine. But they also change the body and the microbiome, which are the bacteria that live in our gut and make it more likely that we hold onto calories and deposit them as fat.

Host: So, these empty calories are even changing our bodies.

Dr Mert Erogul: Yeah, the thinking now is that calories are not equal. A calorie is not a calorie. The quality of the food that you eat is enormously important. And the theory is that in people who are genetically prone to it, because genetics does sort of play a role here, if you're prone to this, then the consumption of these foods leads to the disease of obesity, and that subsequently leads to overeating and a dysregulated metabolic setpoint, which I'd like to mention at some point as well.

So, I mean, there are other theories and these are not mutually exclusive. Some people have blamed chemicals called obesogens, which pervade our foods and plastics and pesticides and whatever that disrupt endocrine function and metabolism. And this has been shown true to some extent. And then, there's high fructose corn syrup narrative. It's a sweetener that was introduced in the '70s. And by itself, high fructose corn syrup can set into motion certain metabolic survival pathways similar to hibernation, where people eat less but put on more weight. So, all of these are plausible causes, but the ultra-processed food theory really has the greatest momentum right now.

But when I see people, this is on a population level, on an individual level, when I ask people, "Well, what happened?" It's always, "You know what, something very stressful happened," "I had a problem with my child at school," or "I went through a divorce" or "I had prolonged sleep deprivation." Or the pandemic, for example, people gained 19 pounds, that's the joke during COVID-19. So, these factors can also in vulnerable people cause a rise in weight.

Host: Well, you mentioned obesity as a disease, but it also sounds like it's a behavior. So, how do we look at that? Would it be possible to solve the obesity problem just by eating less, exercising and losing weight?

Dr Mert Erogul: Right. There is that narrative of personal responsibility that, "You know what, you can eat less and exercise more." And that's what a lot of people tell themselves. They consider it a personal failure. Unfortunately, even if you go on a massive diet with the greatest willpower in the world and you lose a lot of weight, your body remembers the old heavier weight. And we're figuring out where this is encoded. It's called a metabolic set point. It's like a thermostat. So, your body actually resists weight loss.

So, let me put it a different way, We used to think of weight as the accumulation of calories. If you eat more calories, then you expend through exercise or whatever, you gain weight. But if you expend more calories than you eat, you lose weight. So according to this way of thinking, people just don't have the willpower to decrease their intake or exercise more or whatever, it turns out to be false. The modern understanding of obesity is very different. Now, we see it as a chronic disease of weight dysregulation where the physiologic set point has been changed.

There was a show a few years ago called The Biggest Loser, I don't know if you ever watched this show, where people lost hundreds of pounds in a competition. And one of them at the end was crowned the winner. All of these people regained their weight after the show. Some of them even overshot their original weight. So, they were studied by a researcher named Kevin Halt in the NIH, who found that in these people who lost a lot of weight, their resting metabolism had been slowed across all weights. They'd become functionally hypothyroid, so they're using less energy, slowing everything down to accumulate more weight, their muscles became more efficient and used less energy. The hormones associated with hunger, those profiles changed. They were hungrier, they were ravenous. And so, the body does what it can to get back to the original weight. So yes, you can lose the weight if you have this sort of superhuman willpower. But you're going to live with a constant hunger, constant preoccupation. And for almost everybody, that's too much. So, we actually see that the rates of success are very low without medical intervention.

Host: So, what are the options for treatment for people with obesity? Since it's 40% of our population and growing, I imagine some treatments are out there.

Dr Mert Erogul: So, that's what I do. Let me just say diet, sleep and exercise are obviously the pillars, the three most important things. But once you take into account the set point, you have to use either medications or surgery. That's sort of the common wisdom now that we've arrived at in obesity medicine. And by the way, exercise won't help you lose weight necessarily. And actually, there's a principle of constrained energy expenditures. So, exercise is, I want to say, the most important thing you can do for your health, both aerobic exercise and resistant exercise may be more important even in weight loss, not that you have to choose. But over the long term, they won't lose you weight.

The most long-lasting treatment is bariatric surgery, and this is a safe procedure and most insurance will pay for it. Depending on how much you weigh, there are medical and weight criteria. And let's say you do a gastric sleeve, which is the most popular procedure currently, you'll often achieve about 30% body weight loss. And it's a life-changing procedure for people.

Beyond that, what I do is I prescribe medications and, of course, changes to diet and exercise and sleep, as I mentioned, but you need medications. And fortunately, in the last few years, we have a couple of classes of new medications such as the GLP-1 receptor agonists like Ozempic and Mounjaro. You may have heard about them. They've become a real social phenomenon. They're on TV and TikTok, whatever videos about them. And these drugs work. You take it once a week by injection at home and they curb your appetite. They work very well. So, Ozempic will give you maybe 10-20% total body weight loss. And Mounjaro, which also stimulates another peptide, will give you 15-25%. And there are others in the pipeline that are even more effective. However, they're very expensive. And often, you have to struggle with insurance to get them to pay for it. Even if you have diabetes or something, the insurance companies recognize that if half of the country's obese are overweight, it'll rapidly bankrupt them if they pay for these medications for everybody. So, it's regulated. And the worst thing is if you stop taking the medication, the weight comes back. So, nobody outside of the pharmaceutical executives thinks this is a good solution, you know, to take these very expensive medications for the rest of your life to treat a disease related to overeating. But short of surgery, there's currently no way to reliably treat this disease. And it actually has been very hopeful and helpful for many people. Often if you reduce the weight, people's blood pressure, diabetes and lipid disease goes away. So, there's that.

Host: So, surgery is the gold standard right now. Do you see other advancements or innovations happening or any that you may envision yourself to help us combat the obesity epidemic more effectively moving forward?

Dr Mert Erogul: Yeah, I think the most important thing is to try to change the kind of food that people are eating. And there needs to be a massive social public campaign, and I'm not sure exactly what that would look like. Education, certainly. Maybe banning advertising for junk food to kids. Maybe putting a tax on crappy food that's ultra-processed. You can see how it could be a highly political and contentious issue. And it's also an economic issue. I mean, imagine you're a single parent and you're working two jobs, you're not going to sit down and make a healthy nutritious meal when it's so easy to pop a microwavable whatever in the oven. And I see this quite frequently with my patients who are crunched for time, for sleep, and they're just not sure where to make up for the deficit. So, it's actually a social issue as well.

Host: Yeah, there's just so many demands on all of us. And as you mentioned, this empty calorie food is easy and convenient and available all the time. And then, it's somewhat addictive, so it's hard to resist. Thankfully, there are doctors like you that can sort of help us, as you mentioned, change the set point and use these methods to address obesity.

Dr Mert Erogul: Thank you, Amanda.

Amanda Wilde (Host): Thank you for this important conversation that gave us some context to as well as pointing towards solutions for addressing obesity. That was Dr. Mert Erogul, Director of Metabolic Health and Medical Bariatrician at Maimonides Medical Center. To make an appointment at the Maimonides Bariatric Specialty Clinic, call 718-283-7403. If you found this information helpful, please share it on your social media and thanks for listening to this episode of Maimo Med Talk. I'm Amanda Wilde. Be well.