30 Jun In-depth Perspective – an interview with obesity expert Dr. Ken Fujioka

“Patients don’t understand that when you gain weight, your body will always want to go back.”  Dr. Ken Fujioka

Dr.  Fujioka has dedicated his career to the study and treatment of obesity.  I had the fortunate opportunity to meet Dr. Fujioka while he was speaking in Tyler, Tx.  He was gracious enough to let me interview him over the phone a month later.  Below is a summary of the conversation I had with Dr. Fujioka.

Current Clinical Responsibilities – Director of Nutrition and Metabolic Research, Scripps Clinic San Diego, California and Director of the Center for Weight Management, Scripps Clinic San Diego, California

Born in Los Angles, California to two medical students

Hobbies – He loves surfing in the morning.

Favorite Book – Gone to Texas (A true story of Jose Wales)

2 Habits he contributes to his success

1. Adequate sleep – He gets 8-81/2 hours of sleep a night.
2. Exercises regularly.

He has lived in Hawaii, Colorado, and California.

Initially he trained as a general Internist and practiced as a “Country Doc” in Colorado.

Later he did a fellowship in Nutrition and Metabolism (studying how humans regulate weight.)

Exercise is the best predictor of weight loss maintenance.

Pitfalls that he sees patients frequently make:

– “Patients don’t understand that when you gain weight your body will always want to go back.”

-Several of the hormones that regulate appetite continue to stimulate eating in order to return your weight to its heavier state.

-Gastric Bypass surgery is one of the few things that will return those hormones to a more normal state.

-Because of these hormone changes, most obese patients will need to stay on a diet medication to keep the weight off.

-1 out of 5 obese patients will be able to lose significant weight without medications.

-Lifestyle changes must be permanent.

-Once people lose weight on a weight loss medication, they may need to stay on some type of weight loss medication in order to maintain the weight loss. It is important to think of being overweight as a chronic disease just like high blood pressure or high cholesterol. Unfortunately the human body makes various hormone changes that cause one to go back to the highest weight they have ever weighed.  Even over years of staying at a lower weight the body will try to go back to that highest weight.

Hormones That Control Appetite

1.  These hormones tell you that you are full and to go ahead and burn calories.  Unfortunately, when you gain significant weight these hormone levels never fully return back to the pre-weight gain levels: GLP-1, PYY, GIP, CCK, Leptin, and Amylin (and others that are just now being discovered) .

2.  Ghrelin acts differently.  It makes you want to feed sooner, also known as foraging.

Treatment Considerations

1.  BMI >27-30 Consider medication along with diet and exercise if the patient has comorbidities  such as Diabetes, Prediabetes, Hypertension, Heart Disease, Obstructive Sleep Apnea, Osteoarthritis of the knees or hips and unable to lose weight with diet and exercise alone.

2.  BMI >30 Consider medication along with diet and exercise.

3.  BMI >35 Consider weight loss surgery along with medication, diet and exercise if patient has comorbidities.

4.  BMI >40 Consider weight loss surgery along with medication, diet and exercise.

If somebody remains overweight they risk developing an elevated glucose, hypertension, low HDL and elevated triglycerides.  Life expectancy is significantly decreased.  At least as important, one’s quality of life also becomes impaired often 10-20 years earlier than normal weight individuals.

Lifestyle tips

1. Resistance training is as important as aerobic training.  You need both.
2. Exercise before you eat.
3.  Food choices and diet type are less important than picking a diet that you can follow.  You won’t consistently stick to a diet that you hate.

Weight-loss Medication thoughts

1. Saxenda – His initial medication choice.  Saxenda regulates multiple appetite centers in the brain.  It is the only new weight loss medication to be studied out to 3 years in prediabetics.  It showed improved blood sugar control with two thirds of the patients reverting back to normal blood sugar levels.
2. For binge eating he likes to use Qsymia, Saxenda, or Topiramate.
3. Contrave – Helpful especially in depressed women, and there is evidence that it helps with cravings.  Up to 40% of patients coming in for weight loss have significant cravings.
4. Belviq – Safe in cardiovascular patients. Does not appear to cause heart valve abnormalities. (An older more potent cousin was taken off the market because it caused heart valve abnormalities.)
5. Phentermine – He limits use to only 12 weeks.  He recommends not using doses above 15 mg.

Obesity Surgical Considerations

1. Roux-en-Y gastric bypass – Most helpful in Diabetics and Prediabetics.  It helps maintain glucose control in Diabetics.  Decreases Cardiovascular risk in this group.  Can cause low glucose readings.  You cannot take anti-inflammatory medications once you have this surgery.
2. Gastric Sleeve – Lower risk of complications than the Roux-en-Y procedure.  No dumping syndrome like Roux-en-Y can cause.  O-kay to take anti-inflammatory medications once you have this surgery.

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My take away from the interview –

There is hope!

If you are obese using the word frustrating to describe the weight loss process is an understatement.  As Dr. Fujioka discusses, your hormones will actively attempt to thwart your attempts to be healthy.  If you are struggling, seek the help of a physician that understands recent advances in obesity research.  Along with a healthy diet and exercise program, modern medications and surgical procedures may be needed to help you achieve your goal.

Here’s to the Journey!