I want you to succeed in losing weight. And I am sorry, but most or all of what you have been told about seniors losing weight and resolving obesity is just plain wrong, and I want to help as many people as I can by giving them the real tools needed to succeed. Have you been made to feel that obesity is a character flaw and that losing the weight is just a matter of complying with the right weight-loss program? In reality there is essentially zero medical evidence to support those assertions. The truth is that there is no proven or published non-surgical weight-loss program that delivers results, and the fact that you have not succeeded in losing the weight is most definitely not your fault.
You may have avoided this topic because people have told you weight-loss surgery is not for everyone who is seriously overweight, but if one looks at the actual published data objectively, weight-loss surgery today is a safe, effective whole-new-lease-on-life kind of opportunity for many, many people. There are risks to surgery, to be sure, but those risks are dramatically overestimated by most people. Even many doctors wrongly advise their patients about the risks of weight-loss surgery, failing to keep current with the times and failing to know that the risks of simply continuing to carry around the extra weight for another year is far, far riskier. Making a good decision means understanding the risks of having surgery, and the risks of not having surgery and making an informed decision.
I am going to spend much of this article discussing a 45-minute procedure with 4 small Band-Aids that is safer than almost all the other operations you or your friends or patients have probably had, and considerably safer than continuing to live with obesity. Not scared of 4 small Band-Aids if it – and the program that goes with it - could add years to your life and meaning to your years? Then read on…
Metabolism and Age
From an early age we're told that weight is harder to take off the older we get. I wish I could say this was a fairytale, or a bit of folk wisdom based on nothing very much, but the fact of the matter is it’s true. As we age, it becomes harder to lose weight. Much harder.
So, what causes this shift from the 20-year-old who can eat a large pizza and lose weight to the 50-year-old who merely walks past the pizza parlor and still gains weight? And worse, why is it so darn impossible to keep weight off even if you do lose it?
There are a variety of contributing factors. In part, most of us simply slow down as we get older. The hyperkinetic energy of youth falls away, and it's a more attractive option to spend an evening watching a movie than out riding dirt bikes or dancing. But it's not just our desire to get out there and do things that slows. Metabolism slows, as well.
Metabolism seems to be a catchphrase, often bandied about without much thought as to what it actually means. One of the most useful definitions is that metabolism is the net calories burned by the body, including both exercise and the normal body activity like breathing and pumping of the heart. A more global definition is the physical and chemical (hormonal) processes of living, or the energy that keeps our bodies going, and is comprised in part of anabolism (the body converting food into living tissue like the building of muscle) and catabolism (the process whereby the body turns food and breaks down tissue into energy and also creates waste products).
As we age, we do this more slowly. Basically, if you're awake and reading this article, you're using energy and burning calories. You utilize a baseline of calories just to get through the day, even if you're not doing anything spectacularly energetic. And as you age, the rate at which you burn calories or use energy (your resting metabolic rate) drops, so that if you had a normal resting rate where you burned 1,200 calories a day, gradually you may utilize only 1,100 calories to energize your normal daily activities. The 100 calories not burned unfortunately get stored in the body mostly as fat. And, if you continue to eat 1,200 calories worth of food every day without increasing your activity levels, you're going to gain more weight, even though you haven't changed anything noticeable in your life.
The average person gains more than two pounds a year after age 40. No, it's not fair. And other factors come into play, causing weight gain with age. Factors like bad knees or hips, or a back injury that limits exercise.
At this point everyone has heard that lean body mass (muscle mass) burns fuel more effectively than body fat. The more muscle you have, the more your body is capable of turning food into energy and using it, rather than storing it in the form of fat. As we age, we lose muscle mass unless we spend a lot of gym time working to keep it. Even then there's a certain amount of muscle mass lost, and the less lean muscle mass we have, the less efficiently we burn fuel and the more easily we gain – and keep – weight. Continuing to train with weights and maintain consumption of the building blocks of muscle (protein) slows down this muscle loss.
Of course, making the commitment to change and eat 100 calories a day less with each decade after age 30 will go some distance toward helping at least maintain weight in most individuals. But what about weight loss? And what about those individuals who are now maintaining unhealthy weights, who are overweight or even obese? Just because you've passed the age of 55 or 60 or even 75, does that mean you're never going to be able to lose weight and are destined to experience the health complications of being overweight or obese (such as diabetes, joint problems and heart disease)?
Regrettably, the peer-reviewed, published literature on diets, and all forms of weight-loss programs that don’t include surgery, shows no evidence of success. Wait, what? You may be saying that your doctor is advising a specific weight-loss strategy with a fancy diet delivered on glossy papers by a Registered Dietitian, so it must work, right? Well, no. Actually, if these diet programs, or any other non-surgical weight-loss program can deliver meaningful results, for God’s sake someone please publish it so the rest of us can take advantage. Sadly, despite decades of a proliferation of diet advice, here is the best that we can show. In the largest and best published meta-analysis of all the U.S. published non-surgical weight-loss programs, 29 total studies were identified that were believed to be of sufficient quality to deserve inclusion. But only 12 of these actually reported data after 4 years.
There a few takeaways here. The first is that even among the best studies, the subset of only 12 studies out of 29 that show favorable results, the average weight lost was 3%. Not enough, obviously.
But worse, what happened to the other 17 studies? Why not tell us what happened after the first year, or two or three? We all already know that temporary weight loss is achievable. I’d venture, based on the not-so-noble history of scientific studies heavily biased toward publishing favorable results over unfavorable results, that the other 17 studies would have showed just what we’ve seen in long term population studies – that nobody kept the weight off with their diet program.
And international efforts are not any better. No one inside, or outside the country it turns out, has a diet/exercise or other multidisciplinary non-surgical program that works.
In this giant meta-analysis, 80 total studies met inclusion criteria, but only 8 of them had results of four years or more. You don’t have to be a genius of publication bias to realize that the few pounds lost is meaningless since the other 72 studies did not even tell us their results. I’m going to go out on a limb here and guess that no one kept the weight off with the other 72 programs either. Even more likely, everybody in the other 72 studies likely gained weight over time, which is what larger population-based studies show is what happens for nearly everyone after age 40.
Why is so hard to keep weight off even when you do pour your heart and soul into a kick-ass diet and exercise program, and even add in counseling, coaching, therapy, pills and hypnosis? Because the body is programmed to regain the weight, genetically, biologically, hormonally programmed with a formidable defense mechanism that works relentlessly to “protect” the body weight it has gotten used to. Once you’ve gained 50 or more pounds, the body establishes this new weight as its new Set Point weight, and the body will work night and day to make sure your body weight climbs right back up there even though you are working almost as hard to lose pounds.
The Physiologic Set Point
How do we know about the Set Point? Well, as you can guess, a lot of studies have been conducted to understand why nobody keeps the weight off despite arduous dieting and weight-loss programs. One of the best was published by the National Institutes of Health researchers who conducted a long-term study of all the contestants from The Biggest Loser television program. Each contestant was studied before and after the intense program of calorie restricted dieting and vigorous exercise with intense coaching and the bright lights of accountability on national TV. The results were stunning.
First of all, these contestants performed heroically on the show, sticking religiously to a tough diet and a really intense exercise regimen every day, and the pounds started falling off. But the human body has other ideas. For starters the resting metabolic rate plummeted right away, in effect turning down the furnace of the body so it burns a lot less calories. Do you think it would be hard to keep the weight off if your body turns down the metabolism dramatically? It is, but that’s just the beginning.
The researchers also drew blood from every contestant and measured some important hormones that help regulate body weight. Ghrelin - considered “the hormone of hunger” because, well, it makes us super hungry and causes weight gain – skyrocketed in all the contestants. Not good if your goal is actually the opposite. But there’s more. Another hormone called Leptin – considered the master regulator of metabolism because it causes satiety and weight loss – plummeted in all the contestants so their body no longer feels a sense of satiety of satisfaction after eating and instead works to acquire and store more calories and weight.
So in the most scientific study of the most intensive supervised weight loss program on the planet, and the one in which its participants have the greatest accountability, do the participants keep the weight off? Nope. Essentially the weight was all regained, sometimes plus some, at the six-year conclusion of the study. Except for one guy who defied the odds. His name was Rudy Pauls, look him up online. What was his secret? How did he overcome this formidable biological mechanism that causes everyone to regain weight and defend the Set Point? You guessed it, he had weight-loss surgery. And he is the success story from that intense weight loss program. His metabolism actually went up after weight-loss surgery, and he has kept the weight off for years. That’s what everyone should know about the Biggest Loser.
So metabolism and biological programming are formidable obstacles to succeeding with weight loss. But does this mean there is no hope? No, it doesn't. There are changes you can make, and a 45-minute procedure that unlocks the metabolism is the key step. Despite the nonsense of unproven diets and programs you have been fed, there is a proven, successful path to weight loss for seniors. You can still succeed in feeling better and living longer. My mission is to show you how.
The Implications of Being Overweight or Obese, and Aging and Why it is Critical to Change Your Story
What would losing a lot of weight mean to you? Feeling better and more energetic, having less pain, taking less medications, living longer? Without losing a lot of weight, the news is grim: Very few overweight or obese individuals live late into life. The effects of being overweight and the health complications brought about by excess weight and obesity are just too hard on a body already dealing with the effects of aging.
Excessive weight gain places more stress on all the organs, causing each functioning system of the body to work harder. Weight gain in excess of what is normal for a specific height and weight means that each of the body's systems (cardiovascular, respiratory, renal filtering system and so on) is more susceptible to injuries and medical problems. And finally, weight gain makes the body less able to defend itself, which means illnesses are harder to detect, tougher to treat and take a higher toll.
A study published in The New England Journal of Medicine, explored the relationship between excessive weight (a Body Mass Index [BMI] of 25 to 30) and risk of death in individuals between 50 and 71, over a 10-year period. The study found that being overweight, in the absence of other factors (such as having been a smoker), significantly increased the risk of death in both men and women aged 50 and older. Their conclusion was that excess body fat is a major harbinger of disease and early death, and that being above normal weight is associated with early death. (“Overweight, Obesity and Mortality in a Large Prospective Cohort of Persons 50-71 Years Old” by Jee, et al. in NEJM, 2004).
The Body Mass Index, or BMI, wasn't necessarily meant to become a guideline for appropriate body weights, but it is such a good predictor of longevity and disease that it has become so. A BMI of more than 35 is considered morbidly obese because that’s when the steepest drop-off in life expectancy begins.
Suppose two men in their mid-50s are exposed to a community-acquired bacterial pneumonia (an infection of the lungs.) The healthy-weight individual has normally functioning lungs, heart and immune system and fights off the infection just fine. If he goes down with the infection, he fights it off with antibiotics and bounces back.
But the other man in his mid-50s is carrying an extra 60 or 70 or 120 pounds on his frame. After developing the fever and cough he starts taking antibiotics, but because he's carrying around all that extra weight he’s already putting a strain on his system. Breathing was already harder for him before he got sick, and now his lungs are actually mechanically fighting more resistance in order to expand each air sac (or alveolus) in the lungs. It's harder for his body to clear out the bacteria and harder for his immune system to fight the disease. In addition, his immune system is weakened, because it's been battling the inflammation associated with arterial plaques and bone and joint inflammation stemming from the extra pounds. When the infection becomes more serious, the cardiovascular system is already more vulnerable as well. When a serious breathing problem occurs, the heart, which has been enlarged and pumping harder with a decreased blood supply over the years, now becomes vulnerable to a major heart attack.
This is an unpleasant tale. What should be a fairly straightforward pneumonia, the kind people acquire and recover from all the time, becomes a life-threatening event for the overweight individual. And the same thing is true for all sorts of other illnesses, even automobile accidents, slip-and-falls, and bug bites.
But don’t get discouraged – get motivated - you can beat those odds by changing that metabolic programming and losing weight!
Even moderately overweight individuals aged 40 and older face a heightened risk of death. A more active lifestyle and cutting back the calories is one step toward better health, but for those individuals who are already significantly overweight, surgical intervention is the key to a long, healthy life.
The most important thing to know is that today it is well-proven that a very safe 45-minute procedure with 4 Band-Aids changes the Set Point once and for all and leads to massive and durable weight loss in seniors. We don’t hear about the potential benefits of minimally invasive weight-loss procedures for people in their 60s and older as often as we do for younger adults, but the benefits are considerable at all ages – mitigating the symptoms of diseases, taking the stress off joints, allowing for more mobility – and today there are minimally invasive procedures available to older patients who previously may not have qualified as surgical candidates.
An important advancement in weight-loss surgery is one of great importance to everyone: the procedures are done laparoscopically. Using a camera (laparoscope) to guide surgical instruments through tiny keyhole incisions, these operations are now minimally invasive. And whether the surgeon uses the high-resolution laparoscopy, or the robotic instruments does not matter, what does matter a lot is that all of these “minimally invasive” techniques mean no big incision and no big pain or big recovery time. No longer do patients need to suffer wide open incisions and long recovery periods.
Laparoscopic operations usually take less than one hour, and recovery doesn't include major time in a hospital, but often only 24 to 48 hours in a surgical facility. These facts are critical for patients who may be suffering from a variety of conditions – from osteoarthritis to diabetes to heart problems. The minimally invasive nature of the procedures allows older patients with potentially serious health problems to undergo weight-loss procedures that can significantly positively affect their health.
Several studies point to the success of weight-loss procedures in older people, who generally lose significant weight after the procedure, enough to feel better, improve health and elevate their quality of life. They also do well after the procedures, often experiencing less pain than their younger counterparts.
Some of my patients have told me the worst part of weight gain and the advance of the years isn't the fear of early departure from the planet; it's really more the fact that the quality of their days is so much less than what it was when they were younger. Think about it: Weight gain isn't just about the size of clothing people wear or how they feel for five minutes after they weigh themselves in the morning. Weight gain affects almost every daily activity in a negative way. As you gain more weight and carry around more pounds, there's greater strain on your spine, bones and joints. Most overweight people I know over the age of 30 or 40 report they're in pain most of the time and that the pain is worse with almost any kind of physical activity. So, right away, fun outings become difficult outings. Playing with the kids or the grandkids, walking the dog, playing golf – it's all difficult or painful. That reduces the quality of life, doesn't it?
Carrying around, say, 50 extra pounds also makes breathing more difficult. So, if you're trying to enjoy hiking or swimming or another outdoor activity, it's harder than it has to be and not as much fun. As a result, my patients often drop the very activities that once brought them pleasure and got them active. Losing the activities just makes it easier for more pounds to pile on.
Losing weight isn't a cosmetic issue; it's a health issue, and most of us feel better when we're slim and healthy and can do the things we want to do. Being able to enjoy activities that bring us pleasure, to move easily and hike, ski, play tennis, take walks or even just move easily, without pain and without effort, are significant to quality of life.
One of my patients used to love to travel overseas but as the pounds piled on, traveling became more difficult. His knees hurt a great deal, so walking to an airline gate or to catch a train was painful, and he was too embarrassed to use a wheelchair or a scooter. As time went on, because he wasn't traveling or walking, he gained more weight. Years later, he had to take an airline flight to a funeral, and he found the experience terribly embarrassing – the flight attendant had to provide him with a seatbelt extender, something he never even knew existed, and the other passengers didn't enjoy sitting next to him.
Another reason people report a lower quality of life with weight gain and aging is the simple fact of needing more medications and dealing with more medical problems and medical procedures. As a doctor, I understand that traipsing down to my office, sitting in the waiting room and then visiting with me are not the top experiences of my patients’ week. I also know they'll leave the office and have to go to pharmacies and fill prescriptions, wait for them to be filled, pay for them and start taking more medications. None of this is any fun, and all of this slowly subtracts from the more enjoyable things these people could be doing with their time. In short, they detract from quality of life.
A bunch of wear-and-tear on the body takes place over years and is dramatically worsened with extra weight. These conditions, like renal failure and heart failure, stem from years and years of carrying extra pounds, which increases problems directly in the arteries and the organs themselves. Amazingly, these conditions improve a great deal after massive weight loss, even though some chronic damage has been done. Think of it like a hip or knee joint that had suffered a lot more grinding because of carrying twice the weight it was designed for. Losing the extra weight does not eliminate the damage that was done over the years, but all of the sudden the knee hurts a whole lot less. For example, overweight people tend to have a much greater amount of fat storage throughout the body. They also have higher circulating fats or lipids in their bloodstreams and are more likely to develop atherosclerosis or plaques that cause thickening and abnormal narrowing of the arteries. This is especially important in the heart, where the coronary arteries become clogged with plaques. Such clogging can lead to heart attacks, some very large and noticeable, others very small and producing incrementally worsening effects on the heart's ability to pump as the years go by. But after weight-loss surgery, the heart can pump much more effectively since there is much less fat and much less resistance for the heart to pump against. And the strain on the kidneys’ filtration system gets a whole lot less after weight-loss surgery, so the kidney laboratory numbers get a lot better.
The effect on diabetes is even more striking. Elevated circulating blood sugars, and the inability of our cells to deal with those sugars lead to diabetes. Insulin is a hormone meant to help the cells process blood sugar, but as we gain weight our cells develop “insulin resistance” and forget how to bring sugar into the cells for fuel. A high percentage of people in this country over the age of 50 already have diabetes and even more have a condition known as pre-diabetes, which can be detected by a blood test. If you are overweight and over 50, odds are high you have at least pre-diabetes. (Hint: get a blood test called the Hemoglobin A1c and be sure today.) This means when your body is given sugar to digest and process, the body is unable to maintain the normal blood sugar level and the circulating blood sugar level rises abnormally high. Raising the circulating blood sugar level produces a variety of problems, promotes diabetes, causes further hunger and weight gain, and can create a host of problems, such as neuropathy, stroke, heart attack, kidney failure and blindness.
But the old thinking about these chronic and “irreversible” diseases has been overturnedwhen people undergo weight-loss surgery. Because in many ways, these chronic diseases, or at least many aspects of them, are reversible when massive weight loss takes places after surgery.
Independent of age, weight gain and obesity are also risk factors for diabetes and high blood pressure, both raising the risk of heart attacks and strokes. So, in many ways, adding weight through your lifetime is like adding fuel to the fire. The risk of high blood pressure and diabetes doubles, triples, quadruples or can go up twentyfold due to the combination of obesity and age.
The short-term risks associated with routine illnesses and accidents combined with the longer-term, cumulative effects associated with chronic conditions add up to unhealthier years and shortened life expectancy.
But weight-loss surgery causes a powerfu
l re-set of metabolism and a dramatic reduction of the strain on the heart, and lungs, and kidneys, and on top of that it puts diabetes into a complete remission in a majority of people. Which is why the American Diabetes Association and the American Heart Association have elevated weight-loss surgery (or “metabolic surgery”) to its top tier of treatment recommendations for people with Type 2 diabetes.