I recently had the pleasure of speaking at a medical conference devoted to diabetes. Mine was the talk focused on the association between weight gain and diabetes. While there are a great many interesting discoveries occurring all the time in the field of diabetes, it remains the case that the disease itself marches on, increasingly affecting more and more people around the country and around the world.

What strikes me as the most stunning statistic is the one which describes the close relationship between obesity and type 2 diabetes mellitus. The relationship is truly stunning. Even modest weight gain leads to dramatic increases in the development of type 2 diabetes.

We think of a normal body mass index as being 18-25, but really when one goes from a healthy body mass index to a body mass index of 25, the risk of type 2 diabetes more than doubles. Then when the body mass index climbs even higher, hold onto your hats because the risk of diabetes climbs through the roof. What does this mean? How are we to treat this runaway epidemic?

While there are new drugs that come out every year and better insulin management regimens hold promise for steadier regulation of the blood sugar, these treatments do nothing to reverse the growth of the disease around the country among men and women, young and old and people of all races. What is needed is really a prevention solution or a solution aimed at the root cause.

The only real solution at this point in time that reverses and eliminates the disease is weight loss. Weight loss takes a person back down curve and below the threshold at which their body can no longer handle the blood sugar. So while the treatment must involve controlling the blood sugar, and must involve medications, attacking the root cause by losing weight, must become the top priority for most people with type 2 diabetes.

Medically supervised weight loss holds the best promise for producing sustained weight loss in moderately overweight people. Weight loss surgery provides the best results for people with type 2 diabetes with body mass index over 30. There may even be a role for gastric bypass surgery as a type of “metabolic surgery” as the treatment for type 2 diabetes in normal weight individuals.

I saw a patient in the office this week who brought in a list of diet plans and programs that she had read about or heard about. She wanted my opinion on each one. So we went through the list. And I must say that I was very discouraged to see that of the 12 or 13 diet plans that had piqued her interest, only one of them would qualify as having any sort of scientific validity or underpinning whatsoever.

Yet, weight loss fads and popular diets seem to have become more commercially successful and popular in the public consciousness than ever before. It is big business.

Yet why is there such growth in fad diets which offer very little chance of success?

I think the answers come from many corners. From one thing, scientifically based programs usually lack the sort of commercial push behind them that would allow them to be successful in the public market place. It is very difficult to compete with the commercial plans that can hire celebrity spokespeople and buy huge amounts of media time, create magazine and newspaper placements, and, in short, do all of the things that bring their products to our attention. There are many other factors, of course; for example, the media in general is usually very apt to cover “news items” that seem “timely or hot.” They are often interested in fresh angles and novel stories, and medically-supervised weight loss programs don’t always offer that kind of appeal.

But I would argue there is also a lot of blame to laid at the feet of the medical establishment. For many years, physicians and the medical community in general failed to address obesity as a serious disease. Only now that it is the number one cause of shortened life expectancy and the number one preventable cause of disease in the country, are physicians and medical systems really engaging in a serious way in the process. So in a sense, it can be argued that the medical establishment vacated the playing field and left it to commercial enterprises and fad diet profiteers instead of focusing on the challenges of clinical research and finding cures for this serious health problem.

It would be great if a product existed that allowed us all to “burn fat while we sleep.” And it would be great if a diet plan enabled us to effortlessly lose all the pounds we wanted to lose without any sacrifice on our part. And it would be great if some of our favorite fruits contained the secret mystery ingredient of health and fitness. The truth is that you can succeed in losing weight and keeping it off, but it is not easy. You need serious motivation and you need the right tools and the right information. It takes hard work, persistence, dedication and attention to many small and large things that add up over the course of the year to reduce pounds. It won’t happen overnight, but with a sound medically supervised, or scientifically-based weight loss program, you can do it.

With so many people around the world gaining weight, the Metabolic Syndrome has taken on greater importance as a cause of individual heart attacks and strokes, and as a public health problem.

The clinical definition of the metabolic syndrome is as follows:

Metabolic syndrome is diagnosed when a person has three or more of these conditions:
1. Elevated blood pressure. Blood pressure of 130/85 or higher is a component of metabolic syndrome. If only one of your two blood pressure numbers is over the limit, it’s still a risk factor for metabolic syndrome.
2. Elevated triglyceride level in the blood of 150 mg/dL or higher (or you are taking medicine to treat high triglycerides).
3. A lower than normal level of HDL cholesterol, less than 50 mg/dL for women and less than 40 mg/dL for men (or you’re on medicine to treat low HDL).
4. A large waistline. A waist measurement of 35 inches or more for women and 40 inches or more for men.
5. Higher than normal fasting blood sugar (glucose) (or you’re on medicine to treat high blood sugar). Fasting blood sugar of 126 mg/dL or higher is considered diabetes. A fasting blood sugar of 100 mg/dL or higher (prediabetes or diabetes) is a component of metabolic syndrome.
The more of these risk factors, the greater the chances of developing heart disease, diabetes, or stroke. Someone with metabolic syndrome is twice as likely to develop heart disease and five times as likely to develop diabetes as someone without metabolic syndrome.

The treatment for the metabolic syndrome is really based on two concepts: Historically, doctors tried to treat all of these diseases or problems independently. For example, we would treat diabetes with blood sugar lowering pills or insulin shots. We would then treat the high blood pressure with blood pressure lowering medication and lastly, we would prescribe lipid-lowering drugs for the hyperlipidemia. While this still remains a necessary part of the treatment, some of these drugs can have adverse effects also including weight gain. And since weight gain is such a powerful factor in the development of metabolic syndrome, it really makes sense to focus efforts on losing weight.

So the more modern and forward-thinking approach to the metabolic syndrome is to emphasize weight loss as a primary treatment. It is very common to see that people with full-blown metabolic syndrome resolve one, two or three diseases entirely as a result of a successfully medically supervised weight loss program. And while losing weight successfully and keeping it off for the long-term is definitely harder than just taking a pill to treat the high cholesterol level, the results are worth it.

With all of the commercial weight loss programs, centers, diet plans, products and supplements available, is it really the case that a medical weight loss approach might offer some advantages? And what is really meant by “medical weight loss program” anyway?

Well these are great questions as we enter a new era in which physicians and medical centers are beginning to apply their know-how to the problem of weight gain and obesity. In my view it is has been far too long in coming. Physicians and mainstream western medicine have neglected weight problems as though they were social problems or behavioral self control problems and had nothing to do with the mission of medical care to improve life and longevity.

As we all know by now, gaining weight is a health problem and one of the most common and most serious health problems any of us will face. Medical science may have been slow to recognize the seriousness of what has now become an epidemic, but rest assured that many of the best and brightest in an array of disciplines of science and medicine have turned their full attention to this problem, and they are achieving results.

When I describe a medical weight loss program, I am really describing a concept or a program that embraces all of the tools available to successfully battle against those extra pounds. Furthermore, the concept of a medical weight loss center implies an adherence to an evidence-based approach. So in its best sense, it means dedicated people taking the time to develop creative solutions and then test them experimentally to see if they do indeed work for real people. Over time, with enough experiments and enough smart and dedicated people creating new and better solutions, the evidence accumulates that some treatments are in fact superior to others.

It is this devotion to evidence and to proven strategies that brings out the most successful treatments for all kinds of health conditions and diseases. It is true that this approach is imperfect, and open in some cases to manipulation or commercial bias, but it has been the most effective paradigm for developing new and successful treatments across the span of human conditions.

So while some particular commercial programs or individual treatment supplements, formulas, products and theories tend to reflect the commercial goals of the particular products being recommended, medical weight loss centers tend to evolve with the evolving evidence and change strategies as newer and better strategies prove more worthy.

Medical weight loss centers have no restrictions on the types of interventions and treatment options they may recommend or administer, other than those that guide medical practices in general. This certainly makes a very important difference when it comes to prescription medications, a form of treatment that is advancing rapidly in two ways. The first way that the field of weight loss medications is advancing is in the discovery of new medications. With the belated, but now dedicated attention of the pharmaceutical industry, weight loss drug development is now in full swing. Several promising avenues for treatment continue along the pharmaceutical research pipeline. Inevitably within a few years, we will have more options for successful treatment of cravings, hunger and weight gain.

The second way that the field of weight loss medication is improving rapidly is in the area of newer and better clinical trials of existing medications. For example, recent studies have demonstrated the effectiveness of phentermine, a commonly prescribed weight loss medication, in treating adolescents, in treating patients long-term, and for use in induction weight loss programs in combination with very low calorie medically supervised diets. So better clinical research is teaching us better ways to use medications, just one more arm of a comprehensive weight loss approach.

A good medical weight loss center remains curious about the literature and about the newest evidence. A good medical weight loss center maintains an open mindedness to the best treatments that may come from anywhere in the world or from any company or from any discipline. It strives to integrate the best approaches, including behavior modification techniques, communication and education techniques, exercise and fitness training techniques, dietary meal replacement options, prescription medications, supplements and vitamins, hormonal manipulation or other methods.

A quality medical weight loss program remains open to the best ideas that provide its patients with the greatest success. It remains free of commercial bias and is willing to change brands, formulas, medicines or techniques as the science leads in new directions. It is not quick to jump on hot trends or fad programs, but instead expects a certain threshold of evidence and proof and clinical studies before jumping on board. The physicians who operate a medical weight loss clinic should remain actively curious and highly engaged in the medical literature that discusses pharmaceutical, behavioral, social, motivational, psychological and physical methods to achieve health and weight loss.

So does a medical weight loss program offer something unique? I believe it does. I believe that it offers the chance to bring together the very best strategies of all of the competing types of commercial weight loss programs. It can bring together programs centered around meal replacements which have proven successful. It can bring together the motivational social support systems that have been shown to be successful. It can bring together the proven techniques of the branch of psychology that deals with behavior modification that have proven successful in weight loss, smoking cessation and many other behaviors. Elements of life coaching that provide greater depths of motivation and help a person ground their weight loss efforts within the greater context of their life goals.

And added to all of this is the fact that the weight loss program is directed by a physician who can not only apply medical solutions such as prescription medications of weight loss surgical techniques, but can assess the individual for the many related conditions associated with weight gain. Only a physician can determine if for example an individual is currently suffering from a condition such as hypothyroidism which in fact causes weight gain, or can review a person’s medications and see that one or more of them has the unwelcome side effect of causing weight gain, and lastly the physician can be an excellent physician to diagnose the underlying causes and find the treatments for conditions associated with the weight gain like sleep disturbance and snoring disorders, headaches, depressed mood, lowered quality of life as well as the overt medical manifestations like diabetes, high blood pressure and elevated cholesterol.

In short, a well designed, well-executed medical weight loss program combines the best elements of all weight loss disciplines, adding a caring physician to oversee the journey, and providing much needed medical supervision.

Diabetes is among the fastest growing health problems on the planet today. Within the next two decades, over 300 million people worldwide will have Type 2 diabetes. Numerous avenues of investigation have opened for researchers seeking to find a cure. In recent decades, weight loss surgery, or bariatric surgery, has proven highly successful in eradicating Type 2 diabetes among patients whose diabetes stems from being severely overweight.

It is now well demonstrated that approximately 90% of Type 2 diabetics experience resolution of their diabetes after Roux-en-Y gastric bypass surgery, the most commonly performed weight loss procedure in the U.S. A somewhat lower, but still remarkable 65% of patients undergoing LapBand surgery resolve their diabetes.

Both of these procedures are now widely performed in the United States with a minimally invasive, or laparoscopic procedure requiring a minimal hospital stay. Over 200,000 of these procedures are expected to be performed in the U.S. in 2007. Medicare and commercial health insurers increasingly recognize bariatric surgery as an effective treatment of diabetes that saves the plans money in the long run. Four major studies have demonstrated marked increased life expectancy after weiaght loss surgery. In most cases, there is no more need to fund the ongoing treatments of diabetes and its complications after weight loss surgery. So, it is clear that for obese individuals with Type 2 diabetes, there is a strong likelihood that their diabetes can be cured with surgery. But what about surgery for diabetic patients who are not severely overweight?

Recent studies have demonstrated that the surgical techniques applied in weight loss surgery may, in fact, result in resolution of diabetes in non-obese individuals also. A number of centers have begun reporting that even non-obese diabetic patients experience rapid resolution of diabetes after gastric bypass surgery. In many cases, patients are discharged from the hospital in a euglycemic state (normal blood sugar level) and never resume their diabetic medications! This very early and rapid resolution of glucose control is not explained simply by calorie intake or pounds lost. The phenomenon has lead many investigators to think that the surgical technique may fundamentally change the body’s regulation of blood sugar.

Most of the early and dramatic success resolving diabetes has occurred with gastric bypass surgery. A recent study, published in Surgery of Obesity Related Disease, vol 3, 2007, by Cohen et.al., described these researchers’ experience with a surgical procedure called duodenal-jejunal bypass, a fairly simple procedure that causes food intake to bypass the first part of the intestine. Their early findings are that these diabetic patients also resolved their Type 2 diabetes, independent of weight loss.

So, are we entering a new era in which Type 2 diabetes can be cured in a large percentage of cases with a minimally-invasive surgical procedure? Time will tell, but the early studies are leading many to believe that what has been called “bariatric” surgery, or “weight loss” surgery, may prove the most effective treatment yet in the battle against Type 2 diabetes. It may further the call to change thte name of the surgery to “Metabolic surgery”, as it serves to correct metabolic abnormalities and not just obesity.