David Rometo, MD, Clinical Director of the UPMC Center for Obesity Medicine

David Rometo, MD,  Clinical Director of the UPMC Center for Obesity Medicine, discusses a shift in mindset when it comes to weight loss, and approaches that can benefit a patient’s overall health.

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– This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.

– Treating obesity as a chronic disease: Can it make a difference in your overall health? Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Dr. David Rometo. He’s the clinical director of the UPMC Center for Obesity Medicine and part of the UPMC Center for Diabetes and Endocrinology. Thank you so much for joining us.

– Thank you for having me.

– So much to talk about with this topic. And, really, I think a lot of times people might think obesity, it’s just a lifestyle issue and due to lifestyle issues. You say it’s much more complex. And, tell me a little bit about that.

– Yeah, we can think of obesity like many other medical conditions, or even just kind of parameters of how someone turns out in life. You’ve got genetics, and you’ve got everything you’re exposed to throughout life. In terms of lifestyle, we know that brothers, and sisters, and siblings can be very different in weight, even twins. But, identical twins end up weighing about exactly the same amount for their height throughout their lives. So, we know it’s very genetic, but we also know that throughout time, obesity has gotten more severe. So, there is an environmental component. Something in the world today in the way we live our lives is causing obesity to be more frequent and to be more severe.

– And, it’s complex because obesity can lead to other serious health problems.

– That’s correct. So, there are weight-related problems like type 2 diabetes, sleep apnea, fatty liver disease, high blood pressure. The list, unfortunately, goes on and on, including increased risks of cancers.

– And, so, then tell me a little bit about DROP and the DROP program, and really what that stands for.

– DROP stands for “Disease Remission in Obesity Programs.” And what these are, are weight-loss programs for patients to enroll in to help them achieve their weight loss and their health goals. And, the programs that we offer are really based on evidence: you know, clinical trials showing a large group of people trying to do this to lose weight lose about this much. And, the disease remission part comes from the fact that we know medical problems can either completely or entirely go away when certain lifestyle changes are made and a certain amount of weight is lost. When I started here as an endocrinologist, I was already interested in obesity and already interested in diabetes, the type of research I did during my fellowship. And, I was treating patients and referring to bariatric surgery, and actually spent some time working in the bariatric surgery clinic at Magee. And, was seeing these fantastic results and realizing that we really hadn’t closed the gap between not doing anything for a patient for their weight, saying, “I don’t know, go do WeightWatchers,” which is a very good program, but it wasn’t the health care system providing it, and, “Oh, you need bariatric surgery. Your BMI is in a range where you need that.” Well, there’s a lot of space in between those two interventions. And, so, I started a program in the endocrine division. We wanted to really have the most effective thing, the thing that was as close to bariatric surgery as possible in its results, both to help people out but also to get attention – to really get people thinking about, “I should see my doctor to lose weight,” and not just for the operation.

– And, so, how long has this program been underway?

– So, we started building these programs about nine years ago, and we keep adding new choices to the program as our staff gets larger and as we kind of grow naturally to have the capacity to serve people and give them more options to reach their goals.

– All of this is based on research. So, you know that this is working. You can say to someone, “Here’s the proof. This is what we know from our studies and clinical trials.”

– That’s right. Academic institutions around the world have been doing obesity research, and weight loss research, and health outcomes research for decades. And, we have trials like “PREDIMED,” which is a Mediterranean diet study across Europe, and then “Look AHEAD,” which was a partial meal replacement diet in patients with type 2 diabetes, and various others. So, these are not commercial programs that have industry-sponsored, advertising claims.

– Right.

– These are things that are presented at national meetings and published in the Lancet and the New England Journal of Medicine.

– Right. Tell me about the staff and the folks that are around the table helping the patient.

– So, we have lifestyle staff. Right now, that consists of registered dieticians. Recently, we had a clinical psychologist, a PhD, who was on our staff, and we’re looking to fill that position now. And, also, exercise physiology, someone who’s going to write prescriptions for what type of exercise needs to be done and doing exercise assessment. So, those are the non-physicians involved in helping people change their behaviors and giving them nutrition guidelines. But, then, we also have the physicians and physician assistants, nurse practitioners as well. So, the medical model is to treat this like a disease and, like other things, you make lifestyle changes, you take medications, even possibly get surgery to achieve your health goals.

– Right. And, so, let’s talk about the different options. And, I guess a first question to start off with or a good question to start off, would be, is anybody eligible for this? Do you have to be at a certain BMI to come in and be able to take part in the program?

– Yeah, great question. So, anyone can come in for an assessment and have the medical evaluation and to talk about options and goal-setting. There are people who have already lost a lot of weight, and they’re gaining it back, and they want that to stop. But, most of the time, it is people who have a BMI over 30 or a BMI over 27 with a medical problem, which are the same criteria for being prescribed a medication to help with weight.

– Right. OK. So, let’s talk about the different options that are available and really the process of you and the team meeting with patients to determine what the best option is.

– So, the foundation for any attempt to lose a significant amount of weight and keep it off is, what are the behaviors that we’re aiming to achieve in terms of the quality of the diet, some type of quantity, portion sizes or calories per day, that type of target? And, then, on the physical activity side, how much time am I going to spend? What type of physical activity am I going to do? Those are the things everyone kind of thinks of when they think about losing weight. But, then, there’s also, how intense is this going to be? What is the rate of weight I’m trying to achieve? So, we have to tailor a intervention to meet those goals. But, we have different intensities of programs, and we have different eating styles that are incorporated. So, one of the low-intensity programs is a Mediterranean diet, and patients are meeting once a month with a dietician for a year. So, it’s not fast, and it’s spread out over time. Andm they’re eating that eating style, which is mostly plant-based, and Mediterranean is getting healthy fats, like from olive oils, and and fish oils, and fish, a reduction in red meat, but an increase in other plant sources. Not just eating salad and starch, but adding in beans, and nuts, and avocados, and hummus, and all other types of high-protein, high-fiber, healthy plant fat foods.

– Right.

– The more intense programs in terms of more frequency of visits and also aiming for a specific kind of weight-loss trajectory in the first six months: We have the partial meal replacement program. So, a meal replacement is having a protein bar or a protein shake by itself and eating real food sometime later. So, it’s not having a shake at the end of a meal, or, you know, having a bar with your sandwich.

– Right. Right.

– And, so, meal replacements are a valuable tool for losing and maintaining weight. And, so, the partial meal replacement program is still a completely sustainable intervention, where you use meal replacements in your planned, “What am I going to eat in a day, usually, and when am I going to eat it?” And, but, those patients are also tracking their calorie intake. They might be using an app to do that, to say, if I want to lose this much weight in six months, I’ve got to stay under this number, or it’s not going to happen.

– Right. So, beyond meal replacements, is medication sort of the next step?

– Right. So, any of those lifestyle interventions is going to cause health improvements and some magnitude of weight loss. The medication part comes in either in someone who’s already done programs like that, and they didn’t like how much weight they lost, or they gained it back, despite continuing to have healthy behaviors. So, the next time that person tries to lose weight, they should just take a medicine during the next weight-loss intervention. But, there are other people who haven’t tried a structured program yet, and they’ll say, “Let me see how much I can lose without medicine.” And, then, when they hit a plateau, then the medicine will be prescribed, allowing them to lose more.

– Sometimes, people might say, “Oh, taking a weight loss drug … that’s ‘cheating,’ or doing this is ‘cheating.'” What do you want to say about, medically –

– Yeah.

– Tell me about: Is it cheating to take a weight-loss drug?

– Yes, yes. It’s cheating to take chemotherapy for your breast cancer. It’s cheating to, you know, take blood pressure medicine for your high blood. It’s cheating to have a cardiothoracic surgeon allow blood flow to get to your left ventricle. Right, it’s nonsense. To say that a, you know, a prescription medication approved by the FDA to treat a disease that is the No. 1 or No. 2 killer in America, the people who say that are holding on to kind of biases and lack of knowledge from the past. And, hopefully, in the next 10 to 15 years, no one working in the health care system will hold those thoughts and say things that convey that idea to patients. Because right now, it’s not just people online who say those things. There’s still significant parts of the health care system itself that haven’t caught up with the science and understand that prescribing an anti-obesity medicine is the same thing as prescribing a statin, or an ACE inhibitor, or a GLP-1 for someone with diabetes.

– Right. And, so, is the total meal replacement, is that just like a protein bar, or all liquid, or what does that look like?

– In our program, there’s bars, shakes, and soups. So, the soups are kind of powdered, mix it with hot water and you get something savory, you know, flavored, salty type thing. But, then, the bars and shakes are, you know, usually some sweetened chocolate, cinnamon –

– Yeah.

– Vanilla type flavor, but they’re fixed portions. So, when you say I have five of these a day, you know exactly how many calories you had. There’s no, “I eyeballed this,” or, a smidgen of that. It’s, you know that was a 900-calorie day.

– Right.

– Beause I had all the meal replacement. And these are diets that no one is supposed to do on their own. They should only be done under medical supervision. And, most of the time, they should only be done if you have to lose a certain amount of weight, and the only way you’re going to get there is to do something unsustainable. And, type 2 diabetes remission, or getting rid of fatty liver disease, or losing enough weight that you don’t need to wear a CPAP for your sleep apnea, or if there’s a weight cutoff for another procedure, like getting your knees replaced or getting listed for transplant. So, there are all these conditions where someone has to lose 15, or 20, or 25% of their weight to become healthy or to get the surgery they need. They’re going to have to do something unsustainable to hit that number. And, so, a total meal replacement and very low-calorie diet program is a way to kind of mimic what happens shortly after bariatric surgery. I’m going to eat so little that the weight comes off fast, but I’m still giving my body what it needs. I’m still getting all the nutrients, the protein, the vitamins, the water. And, in that program, after the unsustainable phase, you have to have the education and support to transition to this healthier, lower-calorie diet that is sustainable. That’s what keeps it from being a yo-yo diet. You don’t just follow something unsustainable and then quit.

– Right.

– And gain it all back. You do something unsustainable and then you say, OK, now what? Now, I’m going to eat this partial meal replacement, or Mediterranean, or otherwise whole food diet. I’m going to continue to track my calories and not go over this number. I’m going to aim for this increased amount of physical activity. Now that I’m carrying 60 fewer pounds, I can do a little bit more exercise than I did before.

– When is it time, and how do you decide, with a patient, if surgery is the best option?

– Yeah. So, in that initial assessment of knowing what they’ve already been through in the past, what their personal goals are, and what doctors would kind of think that their goals should be, surgery could be something we recommend upfront. And, they may have already done nonsurgical interventions with or without medicine, and there may just be a severity of obesity and severity of disease where the plan is to get surgery. We may do something else for six months before that happens, but surgery isn’t always a, “You failed this, and so therefore you need to have surgery.” That’s the wrong way of looking at it. We put bariatric metabolic surgery in the same category as needing a knee replacement or needing a surgery for back pain. You’re going to try other things first, and if your response to those treatments wasn’t the health outcome that we all want, then we intensify to surgery. And there’s no reason to think of surgery for obesity any differently than those.

– And, so, all of these diets that you are talking about, when people leave the program, is there a rate of folks gaining it back? I mean, it sounds like as long as you’re following it, it’s great, but then, you know, once you leave, what does that rate look like, and how do you handle that?

– Depending on the program and how much weight you lost, that’ll factor into how much is regained after. These sustainable programs, we have a maintenance phase afterwards. So, they continue to meet with the dietician virtually monthly for another year after they’re done getting to that lowest weight. So, that’s built in. And weight-loss programs should have a maintenance phase like that. If you do something unsustainable to lose weight, and we can talk about that, that’s our OPTIFAST® program. There is an amount of weight regained that is expected to happen on average. And, being on an anti-obesity medication significantly reduces how much weight you regain in that following year, even if you are continuing to do all the sustainable behaviors.

– And, so, do you have to be referred to the center by a PCP, by your doctor? Can someone self-refer, and what does insurance look like with this?

– Yes, you can be self-referred. So, we have patients who self-refer because of medical reasons or self-refer because they’ve been struggling for weight for a long time and haven’t found something lasting yet. And, from an insurance standpoint, insurance models generally don’t cover longitudinal programs, and a lot of health plans have their own programs that encourage lifestyle changes to reduce disease and reduce costs of care. What we’re doing is we’re pricing the program not to profit from it, but just to cover the staff. So, what we do currently is have a program fee that kind of covers the staff salaries involved for the lifestyle intervention.

– And, so, what would you say you do enjoy most about your job?

– There’s a lot. On the weight management side is, really telling patients that they should feel a lot better about themselves, and what they’ve tried to do, and why it didn’t work, and how much weight they lost compared to how much they wanted to lose, and really explaining from the science that, you know, this person who lost 10% of their weight and they think they’re a failure, and the literature says, “No, you’re the great success.” And, if someone gets, you know, 15% by doing a difficult program plus a medicine, and they say, “But I’m not skinny yet,” telling them that that was never supposed to be the goal. And getting them to understand that, sometimes they feel worse, but a lot of times they’re just so thankful to have someone tell them the truth, which is, you know, weight loss is about, how far away can I get from that high weight I used to be at?

– Right.

– Not about everyone’s supposed to end up with a BMI under 25. That is not real.

– OK. It’s, I had this condition that was this severe. How much of it can I get rid of and keep off?

– Right.

– And where people think I’m going to compare myself to the thin person, that is not what you’re comparing yourself to.

– Right. And, so, as we close, what do you want to say to people about not being afraid to have the conversation about it? Like, sometimes, you know, stigma can be attached to it. “I’m embarrassed, I don’t know if I want to go and have this conversation.” What do you want folks to be thinking about?

– Well, from a patient listening to this is, you take care of yourself, and you don’t worry about what anyone else thinks about what health care path you chose. That is just the advice I’d give about anything. No one else’s opinion means anything about how you take care of yourself. And, everyone is so worried about what other people will think and worried about what someone said to them in the past. It’ll be a long time before people don’t come into my office with significant baggage about how other doctors, or nurses, or family members, or teachers talk to them about weight, and behavior, and what they should or shouldn’t do. We’re two generations from not having to deal with someone’s past getting in the way of the solution to what they’re dealing with now. So, we’re not going to fix that in the short term. But, as a health care system, if we are all united and we continue to educate the people at our nursing schools and medical schools to talk about these things the right way, then we will have a future where there’ll be no difference between talking to someone about taking a medicine for their diabetes and talking to someone to taking a medicine to lose weight for their sleep apnea. That there’ll be no difference in how patients feel about that conversation.

– Well, doctor, some great information, really interesting topic. We thank you so much for coming in and spending time with us today.

– Thank you for having me. This has been wonderful.

– You’re welcome. I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.

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