Cristina Cusin, MD: Finding Solutions for Severe Depression
Episode #26 of the Charged podcast
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PodcastApr | 29 | 2020
Throughout her career, Angela Fitch, MD, has watched obesity treatment transform from an area of medicine rarely discussed to a dynamic, rapidly evolving practice. In what she calls a challenging, yet exciting field, Dr. Fitch wants to transform the way we approach obesity by building patient-focused treatment programs and communities of support to help patients succeed in losing weight and living healthier lives.
In this episode of Charged, Dr. Fitch discusses the importance of re-educating patients and providers to recognize obesity as a chronic disease in order to eradicate the stigma and misinformation surrounding obesity, as well as how developments in personalized medicine and a holistic, multidisciplinary approach are shaping the field of obesity medicine.
Angela Fitch, MD, FACP, FOMA is the associate director of the Massachusetts General Hospital Weight Center. Dr. Fitch has always been interested in how the human body operates, and its relationship with nutrition and disease. After noticing a lack of focus on nutrition and weight loss in the medical profession, Dr. Fitch became interested in helping to develop the field of obesity medicine.
Dr. Fitch completed her bachelor's degree in chemical engineering at Iowa State University, and then went on to work for Proctor & Gamble as a product development engineer before pursuing her passion for medicine. She received her master’s degree from the University of Cincinnati College of Medicine and completed a combined residency in internal medicine and pediatrics. Throughout her career, Dr. Fitch has served as the chair of the clinical management section of The Obesity Society and has received the 2017 Clinician of the Year Award from the Obesity Medicine Association, where she is currently serving as the organization’s vice president.
The obesity epidemic hit a 40-year high in the United States in 2018. According to the Centers for Disease Control, over 40 percent of Americans and nearly 20 percent of children and adults have obesity. And the situation only seems to be getting worse. A recent study from the Harvard T.H. Chan School of Public Health predicts that half of the American population will face obesity by 2030. And half of those will have severe obesity.
Dr. Angela Fitch, Associate Director of the Weight Center at Mass General understands the challenges of treating obesity. It’s a complex, chronic disease. And evidence-based treatments are not always readily available particularly for young people. But it is also an exciting time to be working in obesity medicine. Angela wants to transform the way we approach obesity by building patient-focused treatment programs and communities of support to help patients succeed in losing weight and living healthier lives. So, welcome, Angela.
A: Thank you for having me.
Q: Looking back over your career, what was it that initially sparked your interest in obesity medicine?
A: So, I have always loved healthcare and, and when I was little, I used to want to be a doctor. And then, when I was in high school, I was first, female athletic trainer for the football team, which was a big thing back in the eighties, right? So, I always liked medicine and particularly kind of sports medicine, nutrition, things that focused on that realm. And then, as I went through school, I actually became a chemical engineer instead of going straight to medical school.
And out of that I, again, focused on this love of how the human body operates and how it related to sort of engineering and how the human body is an engineering feat in and of itself. And then I went to work for a while for Proctor & Gamble and I loved doing that work in consumer products research. Then, at the same time I volunteered at the Children’s Hospital. And it was really working at the Children’s Hospital as a volunteer where I recognized, this is really my calling. And this is really what I want to do is to be a doctor.
So, I went back to medical school and then, after that I went on to do internal medicine and pediatric residency, so combining the two, taking care of adults, taking care of kids. But I really wanted to understand more of the disease process that goes along with that. Then, I went out to work in Minnesota for a large health system, I developed a love for working with people on their nutrition and wellness and weight management. So, people would come in to me and they would say, “You know, how do I lose weight?” I’m like, “I don't know. Nobody taught me that in school.”
Because we really didn’t focus on it back then, you know, in medical school or in residency. It was kind of a very minor point to talk about nutrition. And so, because of that I thought, I’ve got to educate myself on this because I really want to help people more than just saying, you know, “I don't know. Go to Weight Watchers,” right? At the time that sort of the biggest thing I could say. So, then as I sort of self-educated myself in nutrition and wellness and I went to the University of Minnesota and I followed people around. I got involved with the Weight Center there and doing pediatric weight management, and helping kids to manage their weight. And out of that, I said, you know, this is really what I want to do for my career. And I switched over from doing primary care to doing full-obesity medicine.
Q: You said, you know, when you were coming up, nutrition wasn’t really something that was talked about or thought about a lot. Do you have a sense of I guess, why that was and has it changed since then?
A: Well, the interesting part is it’s slowly changing, right? But it’s a little bit slow. Because, I mean, to be honest, you know, we didn’t have much of that focus. I mean there was a focus on, you know, carbohydrates, protein, you know, from the standpoint of the biochemistry of how we, what we do with our food and nutrition. And there’s always been a focus on sort of if you’re in the hospital and you need to have IV nutrition, you know, how do that? How do you give somebody IV vitamins and minerals and nutrients that they need to sustain life, right? So, that focus has always been there.
But from a standpoint of, of how the human body, you know, interacts with its food environment and what it does with that food energy, and, and that sort of relationship relates to obesity. Because really what the disease of obesity is, is a storage of excess body fat. And, it’s about the disease of how the human body stores that energy and why it stores that energy. Right? Like it’s storing that energy in an abnormal fashion for certain people.
And, and it’s that interaction between the genes that we have in our body and our environment that’s really producing that mismatch and that sort of tendency towards excess energy storage.
And so that, the focus obesity as a disease and how, that disease has come about has really been only in the past several years that we’ve been working the Obesity Medicine Association that I’m vice president of, as the Obesity Society, the American Society of Metabolic Bariatric Surgeons.
You know, we’re all focused on trying to get that education into medical school and into residencies. We have a residency elective here at Mass General, where the residents come over two weeks and spend time in the Weight Center. And then we also have a fellowship here. Back when I did there was no fellowship in obesity medicine. And so, it was all just everybody self-training themselves, if you will. But now there are fellowships developing across the country. So, because it’s a growing problem, there’s a need there. And we’re really focused on that education.
Q: Can you talk a little bit about this shift to thinking about obesity as a chronic disease and what does that mean and why is it different?
A: Yeah. Obesity was defined as a disease back in 2013 by the American Medical Association. So, there was a push there through some of the work that a colleague of mine did at the American Medical Association to sort of make a statement that obesity is a disease. But even so, I mean, that was back in 2013.
And even so today we don’t have good legislature that sort of supports it as a disease from a treatment standpoint. So, there is a lot bias and stigma around the fact that, you know, we should less and exercise more. And patients bring that even on themselves. I mean I have patients all the time that come into the office and they’re like, well, I should just be able to fix this, right? And people don’t say that about their breast cancer or they don’t say that about their, their heart disease, right?
I mean maybe to a certain extent with things like heart disease, you know, you focus on some—there’s a lifestyle piece of that, too. But at the same time, you know, you don’t come in with blocked arteries and say, you know, “I’m just going to go home and fixed them myself. Right? You know, there’s good, there’s good care that you can have that can fix it today.
And so, as with other chronic diseases, people also think about it as, I just come in and I get some help and I go away and I’m going to be better, right, like a sinus infection. And that isn’t the way it is. It’s a chronic, lifelong thing that you have to focus on.
And that’s why it’s so hard to make a change, right? You’re trying to change Mother Nature. And when you’re trying to change Mother Nature that’s a hard, hard feat.
Q: I know other areas of medicine have gone through similar shifts to thinking about conditions as chronic diseases and disorders rather than a personality flaw. Are there things we can learn from what’s happened in other conditions, things like addition or diabetes, that could be brought into obesity medicine?
A: Yes. So, that’s what we’re doing. Obesity is very much like where we were with depression, you know, 20 years ago or even 30 years ago, now.
But you know, back even when I was training, you know, back in the nineties, depression was sort of a taboo thing or mental illness, is something that people didn’t really talk about, right? It was like my fault that I was depressed or that I wasn’t feeling well. But then, as we recognized, there’s much more chemistry to it, brain chemistry and other things that happen. It’s also genetic. It’s also environmental. There’s a lot of components that go together.
We have to re-educate not only physicians and other providers, but we have to re-educate the patients, right? Again, this isn’t, it’s not about your character; it’s about your chemistry. And that’s really the focus that needs to, that needs to take place, and get that word out.
Q: I’m interested in this reeducation idea. Do you think, if we’re thinking both patients and providers need to go through some of this reeducation process, do you think one comes before the other?
A: We’re trying to work on them both at the same time right now. I think the more that we can, right now I think we’ve, we’ve done a pretty job of working with providers and the care team. You know, the people now recognize that it is a disease. There shouldn’t be blame there. And it’s not people’s fault.
But, but there’s still is certainly a lot of work to be done in that area. But especially in the patient realm, there was a study done actually here, focused here at Mass General looking at—it’s called the ACTION Study. And it looked at people’s perceptions of obesity. And while, you know, while 70% of patients with obesity felt like it was a disease,
But at the same time, 82% of those said that they could fix it by themselves. Right? We’ve gotten a lot ground with it’s, it’s a disease now. But it’s the fact that we want to just fix it ourselves, you know. I have a person doing a great job, you know, working with our dieticians and changing lifestyle and changing physical activity and is doing a fabulous without any need of medication and no need of surgery.
But, but having all those tools together is what, what really is going to help people to get better faster or to manage it long term. And the issue is that we don’t know who needs what, right?
We have this gentleman who’s lost 100 pounds, you know, doing his physical activity and managing his, his lifestyle from a nutrition standpoint, and sleep and all these other factors. He’s doing it in a sort of lifestyle behavioral manner. But, but that’s really a small percentage of people by the numbers that are able to do that.
But people kind of latch onto that saying, you know, “That’s going to be me that can do that, too.” And when it’s not me, then I’m, then there is something wrong with me, right? I’m not good enough, right? And that’s what we have to get away from because while we know some people can do that with their lifestyle changes, and we don’t know why that is—you know, who is the person who genetically is maybe predisposed to be responsive to that treatment, right?
Q: Do you have a sense or an idea of, generally, you said a certain portion of people can do it through diet and exercise and lifestyle? What percentage are sort of in that bucket?
A: It’s an excellent question. And it’s really what we should be focusing on. Only about 2% of people are able to lose greater than 30% of their weight. So, it also depends on how much weight you want to lose.
I had a patient that came in to me the other day. And she says to me, you know, she’s lost 40 pounds. And she says, she’s lost this 26 pounds. She’s doing a great job. And she says, “Well, I always stop here. “I always get to 230 and it stops.”
And I said, “Well, that’s because you’ve lost 10% of your weight.” And we know that 10% is like kind of a magic, you know, a cutoff. Right. There’s not a lot of people that get past 10%.
A: the numbers dwindle. So, if you’re looking at, you know, people that get 5% weight loss, that’s about 40% of people are able to do that with lifestyle interventions. And then 10% weight loss now is 20% of people, able to get 10%.
I said to her, I go, “You’re in the 20%. Like you’re doing a good job.” You know, and she is like, “Oh, I never thought of it that way.”
A: And it gets down, if you get down into, I want to lose 30% my weight, which for a person who’s 300 pounds, is almost 100 pounds, and they want to do that.
And so, helping them understand, what interventions are going to get them there. It’s no different than cancer treatment, right? If you just take out the cancer, maybe you have an 80% of cure. If you take it out, plus you have chemo, plus you have radiation, now you have a 99% chance of cure.
Right? And we know that because, not because people want to have chemo or radiation, nobody want any of that. Nobody wants surgery. Nobody wants cancer in the first place. Nobody wants obesity in the first place. But we have to sort of look at it more in that respect and help educate people on what’s the reality of what they’re trying to do. Because we just think, oh, I can just do this and I can just lose weight.
Q: What do those medical interventions look like? What are the avenues that someone might go down?
A: When we talk about that, we usually have a pyramid that we talk about. At bottom of the pyramid are these sort of lifestyle changes, right, making some lifestyle changes. And the biggest lifestyle change that anybody can make or if people are, you know, trying to educate patients, because it can get sort of overwhelming on the Internet. You know, there is lots of stuff going on as far as, you know, eat this, don’t eat that. And the matter of the fact is that it probably relates to your genes and what you’re eating probably isn’t what, you know, your neighbor can eat. And you can have the same response to that food.
But the, the underlying piece of that is that unprocessed food is the best, right? So, our biggest thing that we’ve come about in the last year or so is a recognition that the best eating is sort of eating that you do of whole foods. Right. When tell patients that sometimes they say, “I have to go to Whole Foods?” I’m like, “No, you don’t to go to Whole Foods. But you have to eat things like berries, things like nuts, things like avocados, you know, things that aren’t made in a factory.
People are misconstrued by the fact that there’s whole grains, right? This is whole grain cereal or whole grain bread. And it isn’t a whole grain any more. It’s great to eat whole grains in the form of quinoa and farro and things like that. But it’s not so great to eat things that are processed you into things made from whole grains.But the basis of the pyramid is these lifestyle changes, sleep, stress, nutrition and activity. Those are the sort of four big ones that we focus on.
And then as we go up a little bit higher on the pyramid, we talk about prescriptive nutritional interventions. So, there may be more prescriptive nutritional interventions. They give us an advantage in some way, shape or form. Different people may respond differently to those prescriptive interventions, i.e., whether you’re eating a low-fat type of diet, whether your eating more of a low-carbohydrate type of lifestyle.
Maybe you’re doing something like meal replacements, you know, so using a bar or a shake so you can stay on track with things. And part of that is behavioral. Part of that is the composition of the products. You know, but the point is that we have these sort of prescriptive interventions that we may decide to deliver.
And the next level is medications. So, we have medications now, just like we have medications for diabetes, that make diabetes better.
So, we have medications that are very effective, that instead of, instead of 40% of people being able to lose, being able to lose five percent of their weight, 60 to 80% of people can lose 5%--
A: --of their weight. And more importantly, some of our new, newer medications that are coming about, 20% of people are in that 20%, 30% category, which is going to be even better, right? So, that we’re getting more people into those higher levels of weight loss that they’re wanting.
And then we have now some endoscopic interventions, which are very exciting. The gastric balloon, you know, putting things into the stomach or doing some endoscopic things that at the gastroenterologists do, that go down and just sort of manipulating things, you know, without and actual surgery.
And then, at the top of the pyramid is surgery, because we know surgery is the most effective tool to get people to that greater than 20 to 30% category. So, 70% of people will get into that category with surgery.
And where I said earlier, only about two percent of people are able to get into the category. And I tell people that all the time. I give them sort of this data, right? That if you need to be in 20 to 30% weight-loss category, you know, you have a 6% chance of doing that with medication, OK? And so, and some people motivated by that. They are like, “I want to be one of the 6%. I’m going to show you.” I’m like, “Good.” You know, maybe that helps them to get there, right?
But, if you’re like, well, you know, maybe that’s not me. Maybe I can’t be one of the 6% because I have three jobs. And I have three kids to care of. And I have a bad back. So, there’s no way I can really do a lot of increased activity except for going to the pool. And it’s hard for me to get to the pool. I mean there are a lot of factors that play a role. And so, for our surgical intervention, it’s just our biggest tool that gets more people into those weight loss categories.
Q: I always wonder, with these surgical interventions, even if you have the surgery, it’s still sort of a lifelong journey.
A: Exactly. Because, as we said earlier, obesity is a chronic disease. And it’s a chronic disease because, again, it’s the, it’s about how our bodies store, stores and uses energy. And there’s a lot more factors than we ever thought about, right?
But why are we not, you know, doing more teaching about it, understanding about it. Because there hasn’t been a lot of focus on it, to be honest. I mean from a research perspective, there’s a lot of focus on, you know, things like cancer. And I’m not saying that’s bad. I mean cancer is very important to treat and cure. And so, obesity, I think, one of the issues is it doesn’t kill you today.
It doesn’t, it’s not something acute, you know, right? It’s 30 years from now that it’s going to be causing more, more issues for you. And that’s where we need to really, change that talk track.
Q: So, is there, are there changes happening to sort of make it more holistic and think about, you know, you have this procedure. And then there might be some other steps along the way?
A: I think we’re really working hard on that. You know, here at Mass General, we had he first, multi-disciplinary weight center in the country, started back in 1999 by Lee Kaplan.
He was very forward thinking back then, that we need to think about it like the cancer center or the transplant center where it’s something you’re going deal with for a long time, right? We’re going to take care of you here at the center in a patient-centered way. And we’re going to get the best care for you at every stage of that. And that’s what we’re doing.
And there’s a lot more weight centers developing across the country now. Before it was primarily, the medical group would have their medical weight-loss programming. And the surgeons would have their, you know, options in their clinic.
And so, the clinics are really starting to come together more and offer a more long-term, comprehensive approach. Because, unlike other surgeries, there is a lot of surgery and you’re done, right? You have your gallbladder taken out because it’s bad and it’s bothering you. And you’re done. You have your appendix taken out. And you come back for a couple of follow-ups and, hopefully, no complications or anything. And you don’t ever have to ever see that surgeon again.
But obesity is a different disease because we know that it goes on for, for the rest of your life. It’s not something you can just make go away.
Q: I know you are fairly new to Mass General, Associate Director of the Weight Center. So, how are you working to change or improve the care that you are providing within the center?
A: It’s really a—I think of it as an ongoing evolution, right? I was fortunate for one, I think to go into engineering. And so, I think a little different about problem solving because I was sort of trained in that. You know, when I was in engineering school, that’s what they do is train you how to problem solve.
So, out of that experience, and then, working in a large, Fortune 500 company like Proctor & Gamble, I got a lot of training in how do you change things, right? I love change, actually. So, I’m one of those weird people who likes to like do something a little different every day. So, I think trying to look at the situation that we have today, because things have changed since 1999, right? And so, we have to evolve the center.
And we’re doing more with telemedicine. We developed in the past couple of years since I’ve been here a robust telemedicine program where we can do follow-up visits. And then, as work forward, there is a huge need across the country for delivering this care in a different way. And I think delivering it virtually is very sustainable because it doesn’t have to be done in person, if you will. definitely examine people when we see them for sort of visit to try to understand what’s going on with their body. But for the most part it’s about, looking weight, looking at how you’re responding to different interventions. And then, you know, making some medical decisions on where to go to from here.
And so, how can we help other people, you know, across the United States and maybe even the world.
Q: Could you talk a little bit more about that pediatric piece and how care for children differs from care of adults in this space?
A: The, one of the big issues, too, with pediatric obesity, is we’ve spent a long time sort of thinking that we can, you know, treat it effectively by mostly lifestyle intervention.
So, the main focus has been on that bottom part of the pyramid, that obesity treatment pyramid. And it’s not wrong, certainly for any reason, especially because, you know, with anything in pediatrics, we don’t have a lot of date on kids and medications. And so, you know, nobody wants take a medication, even if they are adult—and especially when you’re looking at your child and thinking you have to give them some sort of medication. That can be a little bit daunting, you know?
And so, there’s been a focus on that life style piece. And, unfortunately, what we’ve seen is it hasn’t been working. I mean we’ve seen some great results from a preventions standpoint, right? So, the life style piece especially is great for preventing others from developing the disease over time.
But when you have the disease of obesity, right, and you’re, even if you’re ten years old, right. We, we see some of these same abnormalities that we’re seeing in adults with pre-diabetes, with insulin resistance, in kids that are ten. And that’s not their fault. And to just to tell them they have to eat better and make better choices is really not fair when we have some medications that can really do a better job.
A: And so, we’re working on that now, you know, advancing that mission.
Q: How do you work with parents? I imagine there is probably a lot of guilt that happens from the parent perspective.
A: I think we feel like that a lot as a parent. We think, oh, we could have done something different and then something else would have happened. So, we can always think about that. But we have to keep coming back to the reality of what we have today.
You know, same thing with, if your child had lymphoma or leukemia or something, it’s not something you would ever wish upon them or yourself or your own family but we know there is treatment. And so, we know there is treatment that can be safe and effective and make a difference. And so, having that discussion
I spent some time yesterday with a pediatric patient and their, and his family. And his family is very engaged supportive of then environment. And we spent a lot time talking. We spent a lot of time talking about that. We spent a lot of time talking about it’s not your fault. Right?
It’s only natural for us to internalize that. And to focus on it again as a disease and how, you know, these biochemical factors are playing a role in that disease. And then, you know, as I mentioned, you know, working on using more medication interventions I think can help people break out of that cycle of disease.
A: And then they still do the rest of it, as you said. It goes on forever and you still have to work on the environment that we live in is producing 50% of people having obesity by 2030. And so, if you hand me a baby today and you ask me, is this baby going to have obesity, I’m going to say yes, because that’s what the odds are. Right? If I’m a betting woman, that’s what I’m going to bet on, right, because that’s what the odds are.
Because—but we have to choose to interact differently with our environment intentionally if we’re going to make a difference.
Q: I’m interested in this internalization idea. Do you see difference in the way that maybe kids and adults internalize messages about, you know, having obesity or their bodies or the way the interact with the world in relation to that?
A: That’s a great question because there’s been a focus on that. And we’ve seen some where children with obesity, unfortunately, do internalize it a lot. And that’s why I think if you talk about it, you know, if you externalize it, hopefully that can help. We don’t have a lot data on how to fix that. But they do internalize it. And then there is good data to show the more you internalize that, the more you actually struggle with obesity because it becomes more of a brewing problem inside. And you internalize it, then there is more emotional eating that tends to happen.
And then that just makes the problem even worse. So, like the young person I saw the other day isn’t doing a lot of emotional eating. It’s a lot of driven eating by biology, right, and also by some of the just the environment. I mean 60% of environment is processed carbohydrates. If you’re trying to live in a world that’s 60% processed carbohydrates, but you’re also trying to eat whole foods, because that’s what’s good for you, for a multitude of diseases, well, you’re going against the grain, right? You’re a salmon swimming upstream.
And that’s another reason we have psychologists on our team, right, so they can really help patients to work through that and not take I upon themselves and create a problem out of it over their lifetime.
Q: That emotional piece is interesting to me, too. I mean I think a lot of our health has emotional pieces, but the way we present in the world is so important to who we are often and how we think about ourselves. And is it ever challenging to tease sort of the biology from the feelings, so to speak?
A: It’s very hard, right? Every day that’s what, what I do. And, and it’s, it’s a hard thing. And we just have to keep talking about it and keep working, developing, you know, systems that can help with that, right?
And how do we nudge people so they feel better about themselves? I mean I think no matter what you have, even if it is not obesity—maybe you don’t feel good about yourself because of something else, right?
But I think, as we can nudge ourselves into more positive thinking—because here is a good study that came out showing the more positive people are with their thinking, the better off they did. And I think that is one of the reasons why both surgery and adding medication treatment, it sort of—not only because it’s helping you biologically to do better, then you do better. It is like a stone rolling down the hill, right?
It gets faster and faster because it’s like, you know, you’re doing better and better. And that sort of motivates you, internally. And so, trying find ways of enhancing that internal motivation, even it is like a little text, you know, “Hey! Did you know you are a great person today?” Oh, good. I’m a great person. I think some of that can help us, you know, because we see a lot of negativity.
Q: This idea of the positive thinking and the role that it can play—how do you help people to do that?
Q: A lot of us, even if you’re not a person who is facing obesity, you’re still thinking about your health and your body and the things that you put it into. So, how do you help people have a healthy relationship with the world and with themselves?
A: Exactly. And I think that’s where, that’s the magic, you know. That’s the magic bullet, you know, part of it. You know, if we knew that, if we could that sort or more in a global way, we would all do better, right? But right now, I mean really the way we do that is by our one-on-one interventions. So, we’re intervening and that’s what the psychologists do. I mean fundamental basis of that is cognitive behavioral therapy.
So, cognitive behavioral therapy is that self-talk that you do, that’s what I tell people, too, is patients will, you know, I find a lot of time, even when I was in primary care, you know, I’ll say, “Well, you should go see a psychologist.” And there first response is, “Oh, I don’t need.” Or, “I’ve been to a psychologist. They didn’t really help me.” And I said, “Well, did you go in and did you actually like tell them what you wanted? Because you can’t just go into a psychologist and be like ‘I’m sad,’ or ‘Fix me.’ You know, like in other words, they have to kind of understand, you know, what it is you want to work on.”
And the way I see part of psychology is sort of as a trainer. Right? Like you have a coach when you’re Michael Phelps. And, you know, he doesn’t need a coach. He knows how to swim. You know, but he has somebody coaching him because people need somebody to sort of teach them how to do it themselves, right, teach them how to better themselves. And that’s what cognitive behavioral therapy is.
I tell patients all the time, “You know, I do cognitive behavioral therapy on myself all the time. Like I’ll be driving to work and I—early in the morning. I didn’t sleep very well.
And I finished my coffee already because I—my husband likes to make coffee at to save money. So, I finished my cup and I think to myself, oh, I’m going to go through the drive-thru at Starbucks because there it was, right by work. And I think to myself, oh, you know what? I had a bad night or it was a tiring, bad yesterday. I’m going to get a pastry as well, right. So, now I’m getting a pastry and a drink, right? And then I’m thinking to myself, do I really need that pastry? Like is that something really—you know, I’m trying to lose weight. Is that something I really want to do? But you have to think through all of that. That doesn’t happen in—most of the time we make our food decisions in 20 seconds.
You know, so we don’t have a lot of time to be like, you know, doing through the cognitive behavioral process, right. And so, again, and then when we do have those moments where we are like yes, you know, finally as I’m driving through that, it’s my birthday. I’m getting a pastry. Right? And it’s my favorite pastry because that’s the one I really love. So, it’s like something that I’m really going to enjoy. And then, when I eat that, you know, and I do that in a mindful way manner and I’m like, this was really good, you know, I have to like sort of be positive about that.
Because if I’m negative about that and I say, oh, my gosh. I just consumed 800 calories and it’s only 8:00 in the morning, like, you know, what am I going to do the rest of the day? If I’m negative about that, I give up and I just, you know, decide, oh, I already did, I already blew it. Right? I already consumed 800 of my 1500 calories today. I might as well give up, you know? But that then creates a whole, worse situation. If I embrace that say, you know what? But that was really good and I enjoyed that. So, now I’m going to have a salad for chicken for lunch, have a little, smaller dinner because trying to balance it all out.
Q: In so many things, you know, it seems like balance is the key. But it’s easier said than done.
A: That’s what I tell people all the time. I’m like, this is easier said than done. This is, again, like you mentioned earlier, you use the word training and I like to use that word because I think we are sort of constantly have to train ourselves, right? This is a, very much a learned behavior. And we expect things like eating and sleeping to be innate behaviors. I mean they are somewhat innate, obviously.
You know, but at the same time not so much, especially sleeping. You know, is a big factor with obesity as well as other mental health conditions as well as other, and part of that is sociological, you know, meaning we have now, you know, we can binge watch things. And we didn’t use to be—TV used to go off at midnight when I was young. You know, it was like snow. We’d watch that. We’d watch Planet of the Apes until midnight and then all of a sudden there was like [makes snow], you know, nothing.
You know, so, I think the, now that we have all this social media and everything to keep us up, you know, we’re not sleeping. And we’re seeing a lot of, lot of factors related to our lack of sleep.
Q: You’ve been doing this work now for many years, decades. Are there common misconceptions that you find patients often have about obesity or tackling obesity?
A: Yeah. I think the biggest one we mentioned earlier was the point about, that, that, that they can just do it themselves, right? That, that it’s not—you know, there are people, and they are on the cover of People magazine or, they see things like The Biggest Loser, which is a show on TV.
They, they see things like that and think, well, I, you know, I can do that. In reality you don’t have chef at home. You don’t have a trainer for three hours. You’ve got a job. You know, I say, “Well, can you quit your job and, and work out for three hours every day?” You know? So, I mean the biggest thing I hear people say all the time is they come in and they say—I say, “Well, what do you think is your biggest issue as it relates to your weight struggles?”
And they’ll say, “Well, I don’t exercise.” And that’s the most, the biggest thing I get, biggest answer I get. When, in fact, we know scientifically that exercise does not produce a lot of weight loss. Like in other words if you exercise people, you don’t get a lot of weight loss. You get about five pounds. I mean you don’t—again, you get about that, you know, that two percent, you know, weight loss. And it’s not that it’s bad. Exercise is awesome for you for many reasons, right? We all should be being physically and being more physically active. But it doesn’t produce a lot of weight loss, unless you like exercise like Biggest Loser style.
You know, like I mean you have to, you know, do several hours a day for it to make that type of a difference, right? And that is, I think, you know, one of the misconceptions we have to get out of is that it’s really about managing everything that relates to the obesity. And for, for the most part it’s about our genes.
Q: You mentioned The Biggest Loser. And there’s all kinds of TV shows and competitions these days around weight loss and transformation. I guess, do you think, are they a positive force in this world?
A: We as societies in obesity sort of made public statements around the fact that The Biggest Loser is coming, was coming back on TV right now. We felt that that was not the right thing to do, medically, because there was actually a study of The Biggest Loser and published in the New England Journal of Medicine after it was done that showed that patients who participated in that actually lowered their metabolism more than they would have had they not done that intervention.
One of the biggest struggles we have with our weight is that the, the more weight we lose the less calories we burn, right, and the sort of more efficient we become. So, the issue is that with The Biggest Loser as they are, are losing weight and they are dropping their weight, they’re lowering their metabolism
Now, normally what happens is, when you gain that weight back, your metabolism goes back up. It just responds, you know, equally to your, to your weight essentially. But in the Biggest Loser study what they found is that one of the biggest issues is, when they lost that weight and their metabolism went down, when they gained the weight back, their metabolism didn’t go back up to where it was before. So, they actually sort of, you know, injured themselves, if you will, you know, by, by that type of extreme interventions. And so that’s where, as a medical community, we said, “Hey. This really isn’t right to do that to people.”
“I mean at least if you are doing it, you’ve got to educate them that that’s the—have them sign a form. You know, because it’s not really fair.
A: And the biggest thing that that study looked at, too, is the advantage of surgery. Because that’s one of the advantages of the surgery is that it re-engineers who you are. You know, people think of surgery as an easy way out or I’m just having surgery because I’m a failure. I failed everything else. And that’s really not the way we should look at it.
For a lot of people, it is the intervention that they’re going to need to get to that level of weight loss that they either need from a health standpoint or desire and for longer life. Surgery adds seven years to your life. I mean there’s good data on it. It reduces your risk of cancer by 30 to 40%. And so, we have to start thinking about things a little bit more medically, if you will, as we treat the disease.
Q: And I’m wondering, here we are in 2020. You can read all kinds of studies that you know, we’re reaching this epidemic point. And we’re reaching this point where half of Americans are going to be facing these problems. What’s your outlook for the future?
A: Well, I’m very hopeful. I think we’ve made a lot of changes recently, meaning there’s been a lot more work on acceptance of obesity as a disease. And now we have to work on the acceptance of treatment, versus the, I’m going fix it myself sort of mantra. Which, again, isn’t bad. I mean I’m all for people going for and being one of those 2% or one of those 6%.
One of the biggest challenges is educating the legislative system or the, or even our—more importantly our health insurance field.
The health insurance in the country needs to change because right now they still see obesity as people’s fault. And so, health insurers carve out obesity as a separate treatment. Like so a company who wants to treat obesity has to pay extra for their insurance if they want to opt-in for obesity treatment. We don’t opt in for diabetes.
It’s not like a menu. And the company says, well, we’re not going to treat cancer because we can’t afford. You know, we’re not going to treat these other diseases, you know, because it’s just insurance. You know, you just offer insurance at a price point. And you, you give it. You know, employers pay for that insurance. And employers pay for that insurance. And we pay for that insurance, you know, as, as people. So, we have to get to the point were that’s not, that should be the case. It shouldn’t be an opt in, right?
And so, this is happening all over the place. It’s not just, you know, I mean this is a lot of people’s, a lot of the issues that patients have with accessing care is that they don’t have coverage, at least for medical interventions. Surgery has gotten a lot better. They have been working on it a little bit intently for the past ten years or so, on getting coverage, that now surgery is definitely a covered benefit the vast majority of people but not everywhere.
You know, so, again, that work is still ongoing to make sure that patients have coverage for this. And we need that because there’s a huge cost.
Q: Thank you so much, Angela. Before you go, I have my final, five questions.
Q: What’s the best advice you’ve ever gotten?
A: The best advice I’ve ever gotten, I would say, is from my dad, who said, “Life isn’t fair.”
Q: What rituals help you have a successful day?
A: I’m not the best at rituals. And so, I’ve been trying to work on that. And one of them has been, um, my, trying to focus on my physical activity lately and doing exercise more regularly, too. Because I always feel so much better when I do that.
Q: If you weren’t a doctor, what would you be?
A: I like being a doctor. So, that’s kind of a hard one. But I guess I would be an astronaut. I always wanted to be an astronaut. And I think if I could be an astronaut, that would be pretty cool.
Q: What advice would you give your younger self?
A: I would say, don’t take it so personally. I’m one of those people that has been known over time to take things personally and, and then internalize that. And then that just creates too much angst back in the day. I’m better about that now that I’m over 50. But I’ve learned that over time.
Q: What’s the best decision you ever made?
A: I would have to say to decide to have my son. We had trouble with that. And, I could have easily not done that. And we waited for a while before we had kids, to go through all the medical school residency, all that stuff. I didn’t want to complicate things back then. And then had trouble. And I could have just given up but, but I think that’s been a real blessing in life that I’ll never, never regret.
Q: Do you have any guilty pleasures?
A: I would say sweets. I love dessert. I mean I love going out to eat for a really good restaurant and always ordering dessert.
Q: What do you consider your super power to be?
A: I would say my super power is collaboration. I am the ultimate collaborator. And sometimes it’s hard to be that. I mean sometimes I take it, you know, too hard. But I love collaborating with people.
Q: Thank you so much for being here today Angela. It’s been a pleasure.
A: It’s my please, thank you so much Amy.
Charged is a podcast devoted to uncovering the stories of the women at Mass General who break boundaries and provide exceptional care.
Episode #26 of the Charged podcast