Obesity Management & Stigma with Dr. Scott Butsch

Podcast Transcript

Scott Steele:  Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.
Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today we're going to talk about a disease process that oftentimes has some stigma associated with it, and that's obesity, as well as obesity management. And we're very pleased to have Scott Butsch, the director of Obesity Medicine in the Bariatric and Metabolic Institute. Scott, welcome to Butts & Guts.

Scott Butsch:  Thank you, Scott. Thanks for having me.

Scott Steele:  So we always like to start out with our guests a little bit about telling us your background. So how did it come that you're here at the Cleveland clinic?

Scott Butsch:  Yeah. I'm originally from Buffalo, New York and did my training there. Then I went to the University of Alabama at Birmingham and did some training there in nutrition. Followed by that, I went up to Boston and I was at Harvard for about 11 years before I was recruited to come here.

Scott Steele:  Well, we're glad to have you here at Cleveland clinic. So let's start very broad, first of all. We've talked a little bit about obesity but not in this section right now. So just for our listeners out there, tell us a little bit about what's obesity and can you describe it as a disease process?

Scott Butsch:  Sure. I mean, obesity is a disease and is defined by a number of organizations and institutes of health in the US. It's a process and it's very tightly regulated. You know, a process in which our bodies control our body weight and our body fat, and so therefore dysfunction of this very regulated system is, in fact, a disease.

Scott Steele:  So we talked and had a previous surgeon on talking about the surgical management of obesity, and today we want to talk a little bit more about the medical management. So can you kind of talk a little bit about your approach or one approach to the medical management of obesity?

Scott Butsch:  Sure. I think it's really important to understand that obesity is a regulated system. So, much like our blood sugar levels that are controlled between a range of 70 and 120, and it's very difficult through willpower alone to be outside those ranges. Our body fat is very tightly regulated as well. So the thing is what happens with people is it's very difficult to lose weight because, in fact, you have your body built to withstand any kind of weight loss or, in fact, weight gain.

So, in fact, when you go to try to help people lose weight, I think it's really important that patients and people understand that there's this very tightly controlled system that prevents weight loss. And therefore when someone is unable to lose weight, it's not their fault necessarily and they shouldn't believe themselves, nor should the medical establishment blame them for not being able to lose weight. And so when we begin to help people lose weight, we really make sure they understand that process.

Scott Steele:  So I have a little bit of insomnia and sometimes if I'll turn on the television, either medical wonder drug that's there or some exercise equipment that promotes that you'll lose half your body weight in the particular time. So what role does exercise and eating and along with genetics play in this process that you're talking about?

Scott Butsch:  You know, we think that the obesity itself is probably 40-70% genetic. So we're hard-wired, maybe even at the beginning of our life, to be predisposed to gaining weight. And obviously we're in an environment today where all these factors, like poor sleep, you mentioned insomnia. So poor sleep we know can lead to weight gain. We're given medications for other medical problems that may cause weight gain and cause us to eat more than we should. We're in a society where we're less physically active.

We have a highly stressed environment. And certainly the food that is processed, ultra-processed, has been shown to cause weight gain. So it's really this huge milieu of factors that's involved in somebody's body weight and why one person may gain weight where the other person may not. And so, diet and exercise are really important, and for some people it's pretty easy. They begin to exercise or they cut back on sort of the stereotypical junk food and all of a sudden they lose weight and everybody pats themselves on the back and says, "Good job. We've lost weight." And this person maybe have a life of a lower weight.

But oftentimes that's not the case. It's probably many different factors that are going on in somebody's life that are contributing to their body weight. So the problem that people end up having, and we as medical providers have, is that we're challenged with trying to figure out how to keep somebody at a lower weight when all these commercials and advertisements sort of speak to the difficulty in losing weight and offer this easy approach. But oftentimes it's not easy because people have a lot of things that are going on in their lives and it's difficult just to manage one's weight when they're trying to manage everything else in their life.

Scott Steele:  So let's focus in a little bit on this overall concept of medical management obesity. As you said, there's multifactorial reasons why people can have weight problems and struggle with it their entire lives. So kind of walk me through your process. Somebody comes into you, they're going to see you as an appointment. And what is that appointment like and then how do you go about a structured plan that not only includes maybe some of the things that grandma would tell you, like you were talking about to eat healthy and exercise and get good sleep and everything, but also touch on where are we at in terms of the anti-obesity medications?

Scott Butsch:  Yeah. So I mean, if someone's telling you to eat less and move more, I mean that's like telling somebody who has a depression just to cheer up. We don't do that. We should not do that. You should not hear that if you are going to a medical provider trying to lose weight. So we're very sensitive about the nature of how we talk to our patients and how we treat our patients with respect and in a nonjudgmental way. That's sort of our first approach.

Obviously, when somebody comes in with a problem with their weight, we want to get a weight history. So oftentimes, what's not done in the medical establishment is people actually understanding what somebody's weight has been over the period of their life, and oftentimes in just a review of someone's history of their weight, we find that there's multiple areas that might have triggered their weight, and that might lead to us thinking about a certain treatment plan.

For example, maybe somebody all of a sudden has gained 40 pounds over the last two years and in a careful review of their history we realize they're on a medication that might have been contributing to that. Therefore, getting rid of the medication is probably the most important treatment in the beginning. That's not to say that there are other things that they can't do to make themselves a healthier individual and decrease their risk, but that's where we start.

When we think about medications, and these aren't just sort of diet pills, you know sort of the old concept of thinking about medications is just let's get something to suppress your appetite and because you have a lower appetite, you eat less food and because you eat less food you lose weight. And that was sort of the mantra of the medical establishment and how we dealt with people trying to help them lose weight.

Just like surgery. We thought surgery worked because someone had a small stomach and ate less food and because they eat less food they lost weight. But we know through science and studies that this isn't the case. It's not that simple. There's many different pathways, as I mentioned before, that are involved in regulating someone's weight. So when we think about using medications, it's in sort of this process of combination therapies, of already helping somebody, let's say with changes in their diet or helping them with stress, and we believe based on maybe their weight being higher than it should and maybe a history of not being able to lose weight, that a medication may sort of alter the brain and alter that regulation of their body weight.

Scott Steele:  So are there medications that are "wonder drugs" or things that kind of come along? Where are we at? I mean, I'm sure for anything else it's a pretty good business market if you're a a pharmaceutical company out there. I mean, are we at that point where there's some effective without going into the actual medication names themselves?

Scott Butsch:  Just as you say, it's important to understand there's a lot of people selling hope out there. And everybody's hopeful and optimistic that individuals can lose weight. These medications are targeted in pathways that are known to regulate body weight. So a lot of the studies that our group in Boston and others did early on is to understand the mechanisms of surgery. And through the mechanisms of surgery there's been targeted medications that have been helpful in helping people lose weight.

Actually, as we begin to have more support from the pharmaceutical industry, but also the national institutes of health and more research has gone into this field, which is heavily stigmatized, we've learned a lot more and there are medications that can cause weight loss, and considering where we are with surgery, close to a surgical effect.

But I think it's really important, Scott, to understand that though the average weight loss of a drug may be, let's say 10 pounds, I mean, I've had people losing over 100 pounds in a year on a medication. And that has nothing to do with changing their diet and nothing to do to changing their exercise pattern. It has everything to do with this drug doing something in their brain. So I think we should realize that there's a spectrum of effect of a medication, we just don't know who's going to respond to what medication.

Scott Steele:  So I'm a patient listening out there. I've struggled with weight my entire life, and there's no question that there's a stigmatism that's associated with obesity. So what are the downsides of having excess weight?

Scott Butsch:  So certainly there's over 220 medical conditions related to obesity. Obesity is defined as having a body mass that's more than normal. We have a measurement called the body mass index, or BMI, and a BMI over 30 is considered classified as having obesity. We don't say someone is obese. We don't describe them by their condition. We say that they have the disease of obesity. So in somebody who has a BMI over 30, they actually have a two-fold, or two times more, risk of developing cardiovascular disease. So it is important to deal with someone's weight. Even though they might not have any medical problems or quality of life might be fantastic, we still have to be true and understand that this person has some risk. So, that's important to understand.

And you were asking about sort of the heavily stigmatized world. I think there's a lot of people out there, and specifically in the medical establishment, that consider obesity as a lifestyle choice, as if someone chose to be overweight and someone chose to be ... and it's just a matter of eating a bag of chips more than the person who's not overweight. And I think that's just a gross simplification that the medical establishment should not have. And so as a person out there who's struggling with weight, you deserve more. You deserve someone who understands and trusts you and speaks to you in a nonjudgmental way. And I think if you don't get that, then I don't think you should stick around and talk about your weight. I think it's as simple as that.

Scott Steele:  So today we're focusing on medical management of obesity and we have another podcast that had discussed the surgical management. So how do you divide these two up?

Scott Butsch:  Yeah, that's a great question because oftentimes people sort of think that there's only two roads, one of changing their diet and exercise and then bariatric surgery, and there's this huge gap in between. And I think that's where people like me and I think primary care physicians can really help individuals, again, in taking a good history, understanding what someone struggled with. Most people who come to a doctor seeking weight loss have already tried about 20 times. So we need to take that into consideration for the medical people out there listening. But for the patients, it's important to obviously have a healthier lifestyle, but we have to understand that that may not change your weight dramatically, though you shouldn't necessarily give up and not try this healthy lifestyle.

But we take a lot of things in in terms of trying to assess somebody and I think that understanding where they are in their pathway of trying to lose weight, where somebody is in terms of their risk, where they are in terms of the severity of their weight or the severity of their obesity, can determine sort of what angle we might choose, what pathway we might choose. I give an analogy sort of like cancer. We have many different forms of obesity, just like many different forms of cancer, but right now we're treating everybody, not understanding there's many different forms of obesity that are out there. So I think it's important to understand that if somebody is not losing weight with diet A or diet B or exercise plan A, that we should move on after three months or so and understand that they're just not responding to that specific therapy and should move on to, let's say, the next diet.

I think we've been caught in this “let's try the latest and greatest fad” because it shows something that people lose weight out there. And then the majority of people, they don't respond to this medical intervention or a diet or an exercise plan. And we sort of get stuck doing this thing for years and years. But we should understand that if we're not responding to something that we should move on.

Scott Steele:  So you go into the bookstore and there's an entire section out there that discusses every different diet, Mediterranean diet, Atkins diet. I mean, there's a million of them. Do diets play a role in this medical management? And specifically, why is it so difficult to lose weight and then why is it so difficult to maintain that weight loss?

Scott Butsch:  Yeah. So I think we clearly know that the food and the way food has been processed has changed something inside us and caused a lot of medical problems that we see today, including obesity. So diets, the term diet has a lot of different takes on it, but a diet or changing your food patterns to eat healthy is certainly the baseline of what we all have to do, regardless of our weight. So there are a lot of diet books out there and we don't know what diet or what milieu of food that somebody should take. Certainly a lower caloric intake and a healthier food intake, more fruits and vegetables, but whether to go low carb or keto, this is all going to depend. And I think if you're really doing it for weight loss, you should take, again, sort of like a three month look if this thing is really effective. "This thing" being this diet. I'm sorry, I forgot about your second question.

Scott Steele:  Just, why is it so difficult to have-

Scott Butsch:  Difficult. Right. What happens with all of us is what we try to lose weight and people lose weight and then all of a sudden they find their weight creeping back up. And a lot of this can be based in sort of this regulation of weight, as I told you before, is that the body doesn't want to be at this reduced body weight state. In fact, all the signals to our brain tell us to eat more. We have more cravings for palatable foods when we're at a reduced state. We see this in The Biggest Loser competition, we see this in studies where people are restricted in their caloric intake, where the body just wants to be at a higher weight. And that gets back to sort of this weight set point or this body weight regulation.

So what we do know is that exercise plays a big role in helping someone maintain weight loss. So the metabolism is slower when people lose weight and therefore your muscle mass is lower. But people should engage in physical activity. And we think about 200 minutes a week would be really helpful to try to maintain that lost weight.

Scott Steele:  So let's talk, wrapping this up here, a little bit about resources for education. So a patient out there goes to their doctor or goes to a weight loss specialist, but are there other avenues for obesity education and to learn a little bit about this and learn about more safe ways to kind of approach this disease?

Scott Butsch:  You know, I think because of the dramatic rise in advertisements around weight loss, whether it's your commercial diets, whether it's a specific doctor in a community who's advertising the latest and greatest therapy, I think you have to stick with sort of academic institutions like the Cleveland Clinic, like other area hospitals, that have this base of knowing what the literature shows and what the best steps are. So I think for the most part, staying in a community or somebody who's educated in obesity. And actually there's a certificate. Physicians and other allied providers can have a certificate in obesity. So looking for someone who might have that background I think would be really helpful for patients.

In terms of resources out there, there's a great video that talks about the regulation of weight called, Time to Act on Obesity. There's a pamphlet that's out there called, Why Weight? There's actually an Obesity Action Coalition, OAC, which is an advocacy made up of patients who have obesity. These are all really good resources. The Obesity Society is a professional society that has a lot of material. The American Society of Bariatric and Metabolic Surgery, ASMBS, is another society that has a lot of education. And Harvard School of Public Health is another one that I like. And I think if you stick with these kind of resources that are based in literature and science and not sort of have an edge of selling a product.

Scott Steele:  Well, that is absolutely fantastic stuff and I appreciate you coming on and shedding some light on this disease process. So we'd like to end up a little bit about you with all of our guests. So Scott, tell me a little bit about what's your favorite food?

Scott Butsch:  You know, I married an Italian, so I actually like pasta, is my favorite food.

Scott Steele:  And your favorite sport?

Scott Butsch:  I play ice hockey and that by far is my favorite sport.

Scott Steele:  The last non-medical book that you've read.

Scott Butsch:  I think the last book I read was, The Firm. I read a long time ago.

Scott Steele:  I read that a long time ago as well. And then, you come from the Boston area, been here at Cleveland. So what do you like about Cleveland?

Scott Butsch:  I love the people. I like the atmosphere. And I like my colleagues.

Scott Steele:  Well, we're really glad that you're here. So for more information about Cleveland Clinic's Bariatric and Metabolic Institute, visit clevelandclinic.org/firststep. That's clevelandclinic.org/firststep. And to make an appointment with a Cleveland Clinic specialist, please call (216) 445-2224. That's (216) 445-2224. Scott, thanks for joining us on Butts & Guts.

Scott Butsch:  Thank you very much for inviting me.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.