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Obesity and Lifestyle Medicine by Christina Badaracco, MPH, RD

Updated: Feb 9

I recently had the inspiring opportunity to lead a culinary medicine workshop at a conference for obesity medicine specialists. While this was novel material to be presented at an obesity conference, the content is certainly not new. Culinary medicine represents the intersection of the art of cooking and the science of medicine, and it has a vital role in treating obesity by improving dietary quality outcomes, food security, blood sugar control, hypertension and more. I was thrilled to have this opportunity to inspire healthcare providers who care for overweight patients to integrate further lifestyle interventions focused on healthy food and cooking. As we continue to see both health and cooking skills decline in our country, it is imperative that we integrate nutrition and cooking with medicine and grow the evidence base for using culinary medicine as an essential element of obesity treatment and weight loss maintenance. 


Stanford University Culinary Medicine Class


Why is obesity treatment so important? 


Our country's growing obesity rate is a significant problem for individuals' health and our healthcare system more broadly. Based on 2021 data from the Centers for Disease Control and Prevention, the US adult prevalence of obesity — meaning the condition of having a body mass index (BMI) of at least 30 mg/kg — is 33%. This percentage ranges from 24.7% in Washington, DC, to 40.6% in West Virginia. And our country spends $147 billion annually on obesity-related healthcare. Many factors drive this chronic disease, including genetic predisposition, physical inactivity, excessive caloric intake and high stress. To prevent the problem from growing further, we must consider and implement evidence-based interventions in public and clinical settings. But interventions to treat the condition are also necessary — not only to reduce weight but also to improve the myriad associated health outcomes. 



What are the current options for medical obesity treatment? 


The hype in our country over the latest anti-obesity medications approved by the US Food and Drug Administration (FDA) in the past few years (GLP-1 agonists) may lead some to believe they are magical pills that can solve this major health crisis. Much of their popularity has been driven by evidence of higher effectiveness than earlier anti-obesity medication classes. They have become so popular that there are shortages in the supply that are expected to last into 2024. However, a few factors prevent them from being perfect fixes: 

  • Limited insurance coverage may prevent many eligible patients from accessing these drugs, and they are expensive. Multiple prescription medications have been developed, approved and recognized as safe and effective for long-term use in treating obesity. However, the Centers for Medicare & Medicaid Services has prohibited coverage of these drugs under Medicare Part D or the prescription drug benefit under Medicare based on a decades-old federal statute that excludes them. Many parties are now advocating for coverage based on their ability to improve other health outcomes — but that will surely not happen in the immediate future.

  • Myriad adverse side effects — from nausea and diarrhea to stomach paralysis and bowel obstructions — may make many people think twice before taking them and/or cause them to stop taking them.

  • Perhaps most importantly, these medications are not a permanent solution. If a patient stops taking them, the weight will come right back on if the patient hasn't also implemented healthier lifestyle behaviors.


While anti-obesity treatments have been around for many centuries, the first generation of weight loss drugs was not available and FDA-approved until the mid-1900s. As of 2023, the FDA has approved seven medications to treat adults with a BMI of ≥27 kg/mwith a weight-related condition or for those with a BMI of ≥30 kg/m2 and an inadequate response to lifestyle interventions.


These medications have different mechanisms of action:

  • Previous classes

  • Reduce the amount of fat absorbed in the gut after eating (known as lipase inhibitors)

  • Combine medications that include an antidepressant and an opioid antagonist (which blocks the effects of opioids)

  • Newer classes

  • Stimulate the GLP-1 receptor in the brain to suppress appetite and reduce caloric intake. Known as GLP-1 agonists, they have been shown to be even more effective than earlier medications in causing weight loss — sometimes up to 10–20% — and as effective as more intensive (and expensive) surgical interventions

  • Reduce fat cell formation in the body 

  • Combine medications that include an amphetamine-like drug and an anti-seizure medication that suppresses appetite


What does a comprehensive treatment approach look like?  


Despite the latest hype around medications, the most prominent obesity practice guidelines (from the American College of Cardiology/American Heart Association/The Obesity Society and the American Association of Clinical Endocrinologists/American College of Endocrinology) recommend a comprehensive treatment approach. The guidelines state that lifestyle therapy is the "cornerstone" of treatment for this disease but acknowledge that pharmacotherapy and metabolic and bariatric surgery can produce more significant and sustained weight loss than lifestyle changes alone. 


As with any effective treatment plan, a full assessment and evaluation of the patient provides data about their status, needs and preferences. The Obesity Medicine Association also supports a comprehensive and personalized approach to obesity treatment. This approach is based on four pillars, which should be considered and implemented in conjunction. They include: 

  • Nutrition therapy, which includes education (including through the delivery of culinary medicine) and counseling to create a negative caloric balance while maximizing nutrition density and diversity of dietary intake

  • Physical activity, with a mix of cardio and strength training to increase metabolism and help develop lean muscle mass, which further contributes to fat-burning

  • Behavioral modification through tactics such as cognitive behavioral therapy and goal-setting that address patients' psychological and emotional needs

  • Medical interventions, including both anti-obesity medications and bariatric procedures



How does this affect your healthcare? 


If you or a loved one are considering taking an anti-obesity medication, it's important to talk with your doctor about lifestyle changes — whether or not you decide to proceed with taking a medication. You should

  • Meet with a registered dietitian, whom you can find by asking your physician for a referral, searching on eatright.org, or asking friends or family for a recommendation

  • Learn about and practice healthier cooking skills, such as in a shared medical appointment, at a local community center like a YMCA, or even through a wellness program offered by your employer

  • Engage in physical activity every day

  • Adapt your home environment and surround yourself with a supportive community to help you sustain positive behavior changes throughout your weight loss journey  


Patients and citizens concerned about the access to and affordability of obesity care can also engage in policy advocacy by:

  • Reading more about related policy issues and considering writing to your members of Congress about what you think they should support for the betterment of their constituencies. One example is the recently reintroduced Medical Nutrition Therapy Act, with versions introduced in both the House and the Senate. This bill would expand coverage for medical nutrition therapy, provided by an RDN, for Medicare patients to include additional diagnoses, including obesity. More members of Congress will need to support this bill before it can pass both chambers and be sent to the President for consideration

  • Talking with your insurance company about the benefits you're seeking

  • Having open dialogue with your physician about your preferences and goals of care

  • Engaging in research and sharing information about evidence-based interventions with friends, family and colleagues 


We all benefit when we become more knowledgeable about our health and engaged in bringing about positive change in our healthcare system. 


Resources

  • Resources can be found here.



Christina Badaracco, MPH, RD

Christina is a registered dietitian and author who aims to improve access to healthy and sustainable food and educate Americans about the connections between food and health. She loves to experiment with healthy recipes in the kitchen and share her creations to inspire others to cook.


 Christina completed her dietetic internship at Massachusetts General Hospital and earned her Master of Public Health degree from the University of California, Berkeley. Previously, she graduated with a degree in Ecology and Evolutionary Biology from Princeton University, after conducting her thesis on sustainable agriculture and energy in Kenya. She has done clinical nutrition research at the National Institutes of Health, menu planning and nutrition education at the Oakland Unified School District and communications at the Environmental Protection Agency's Office of Water. She has also enjoyed contributing to children’s gardens, farmers markets and a number of organic farms.


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