SUN HEALTH
MEDICAL CLINIC
BODY ROUND INDEX
BRI
CENTRAL OBESITY ALSO KNOWN AS
belly fat, abdominal obesity, truncal obesity, visceral obesity
IF NORMAL WEIGHT
skinny fat, thin outside fat inside (TOFI)
CENTRAL OBESITY DIAGNOSIS
BASED ON HEIGHT
Waist: >50% of Height
or
BASED ON HIPS
Women: >80% of hips
Men: >95% of hips
or
BASED ON WAIST
Women: 35+ inches
Men: 40+ inches​
ABDOMINAL ORGAN FAT CONGESTION
Central Obesity is an important consequence of Dietary Risk and is independent of weight as a risk factor. High fat intake may manifest as steatohepatitis (fatty liver). The liver is a filter for what you eat and is located in the right upper quadrant of the abdomen. The liver is important for glucose metabolism and diabetes prevention.
ADIPOSITY BASED CHRONIC DISEASE
(ABCD)
OVERWEIGHT/OBESITY ASSOCIATED ILLNESS
You are beautiful. We are without judgment and fully supportive.
Do what makes you happy. Start where you are.
OPTIMAL WEIGHT BLUEPRINT
We are ideally 70% water (synchronized with the earth). Ensure your intake is proportionate, consume approximately twice as much water as food, drinking a couple sips/gulps of water will help with digestion, health, performance, weight, and longevity
Wholesome
Minimize processed foods, maximize wholesome foods fruits, vegetable, whole grains, protein, legumes, greens, seesd, nuts
Nutrition and Exercise Log (cognitive therapy)
Research indicates that the most effective strategy for achieving a weight goal is using a simple nutrition and exercise log (see below)
Stimulus Control (behavioral therapy)
Make healthy eating easy and unhealthy eating difficult
Environment trumps willpower. Think about what you would likely do in a library or gym.
Keep water bottle at home, work, transit. Get good groceries. Meal prep. On-the-go healthy snacks.
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Avoid Prolonged/Intermittent Fasting
- no significant difference compared to calorie restriction with consistent mealtimes
Some fasting is good such as when you are sleeping and when you are not hungry. Prolonged fasting breaks down vital tissue including muscle, slows metabolism, and decreases repair. Prolonged starvation mode may paradoxically lead to increased storage of fat for long term energy. This is why it is not uncommon for extremely thin people with anorexia to have cholesterol that is actually high. - Bear vs Horse: Bears hibernate for prolonged periods (bears in Alaska hibernate for up to 4 months) therefore store more fat versus Horses that graze throughout the year during the day and are lean yet strong.
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Adjust Portion Size by 5% and periodically reassess based upon results.
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Avoid Fad Diets​
- Avoid Very Low Carb / Very High Fat (Ketogenic)
not recommended, not good long-term strategies because the preferred fuel is glucose. Ketogenic diets are catabolic so burns fat, yet also burns muscle and consumes more water and energy to convert to glucose. People lose weight, but usually yo-yo up and down with these diets and there a considerable amount of weight lost is from water. We are relatively ketogenic when we are sleeping. Excess fasting can put you into starvation mode so you store more fat when you eat. For this reason, it is not uncommon for anorexics to have high cholesterol. Atherosclerosis risk.​
- Avoid Low Carb / High Fat (Atkins, South Beach, Zone):
not recommended because limits fruits/vegetables, atherosclerosis risk (Dr. Atkins had a heart attack)​
- Avoid Paleolithic: wholesome, less processed, restricts grains/legumes, coconut oil is still highly processed and high in saturated fat, this combined with more meat may pose higher atherosclerosis risk
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Healthier Fad Diets:
+ Low Fat / High Carb (Ornish, Rosemary Conley)
moderate-low evidence of effectiveness​
+ Points Based (Weight Watchers)
moderate-low evidence of effectiveness
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Positive Reinforcement (behavioral therapy)
Set a goal with a reward. Do not give yourself the reward without achieving the goal. You may inform the doctor so we can write this down and check back on the progress, This is super powerful and we have seen phenomenal results with this.
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Exercise
Lose Weight -> increase Aerobic with limited Strength training
Gain weight -> increase Strength training with limited Aerobic
Normal Weight -> 30 minutes 5x per week
Obesity class 1 -> 30-60 minutes 5x per week
Obesity class 2-3 -> 60 minutes 5x per week
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Enjoy your food.
Small bites. Chew carefully (certain foods digest better with saliva than in stomach). Limit talking while drinking, chewing, swallowing.
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Meal Replacement Shake
especially if high Body Mass Index (overweight/obese), also great after exercise
convenient (just add water)
example: Sprouts Vegan Protein (20g protein, 4g carbohydrate, 2.5g fat without saturated fat so lean high quality protein with some carbs and low fat): Pea, Organic Brown Rice, Natural Vanilla, Flax Seed, Stevia, Chia Seed, Sprouted Black Rice, Organic Hemp Seed, Sea Salt, Potassium Chloride, Grape Seed/Skin, Blueberry, Raspberry, Cranberry, Prune, Cherry, Bilberry, Strawberry, Broccoli, Spinach, Tomato, Carrot, Onion, Monk Fruit, Alpha-Galactosidase, Prodigest Enzyme
Calories Count
500kcal per day: decreased intake or increased activity -> lose 1 lb per week
less processed food and more wholesome food promotes even more weight loss
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Timing
When eating, it is best to eat during the day you are active. Eat a substantial breakfast and lunch and if you want to go lighter, do so for dinner and this way you will be more likely to burn excessive calories; soups are excellent example.
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Community Supported Agriculture
Order a CSA bag/box full of groceries are fresh, healthy wholesome, economical, and supports the local farmer
Yasukochi Family Farms (<$30, free delivery)
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​​Bariatric Surgery
- does NOT reduce all-cause mortality in 60-70%
- average life span increase only 2.4 years longer
- considerable risk
- most weight loss is just after surgery with regain over time if lifestyle is not optimized
- surgery is better results than Rx (see below)
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Rx: Glucagon Like Peptide 1 receptor agonist (GLP-1 RA): incretin mimetic
- Evidence-based structural weight management program begins and continues with Medical Nutrition Therapy (review of eating patterns and physical activity). The most important foundational step is to start with a Basic Weight Loss Program. Research indicates a nutrition and exercise diary is the most effective and healthy weight loss strategy compounded with professional medical counseling. You may start this monthly x 3 months at which time if criteria is met (diabetes and/or severe obesity) a GLP1 Rx would be prescribed. This Basic Weight Loss Program will continue for as long as you are on the Rx. The research on GLP1 Rx was done IN CONJUNCTION WITH A BASIC WEIGHT LOSS PROGRAM and is designed to be used not as a substitute, but as an adjunct.
- Mechanism: stimulates pancreas to secrete insulin and hypothalamus to induce satiety (which can also be fulfilled with healthy nutrition and adequate fiber)
- Cost: $870-1400/m and not fully covered by insurance (usually ~$300/m with insurance)
- Risk
- GI intolerance (nausea, vomiting, diarrhea)
- gallstone
- pancreatitis
- gastroparesis (intestinal paralysis)
- bowel obstruction
- sarcopenia (muscle loss)
- retinopathy
- hypoglycemia, dizziness, headache, thyroid cancer, kidney failure, allergic reaction, more
- Long Term uncertain adverse effects (another weight loss Rx fen-phen caused long term harm so removed from market), hypoglycemia and prolonged catabolism can contribute to vital tissue loss, pre-mature aging, and sub-optimal healing
IMPORTANT SAFETY INFORMATION
CONTRAINDICATIONS
•GLP-1 is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2, and in patients with a prior serious hypersensitivity reaction to semaglutide or to any of the excipients in GLP1. Serious hypersensitivity reactions, including anaphylaxis and angioedema have been reported with GLP-1
Warnings and Precautions
RISKS
•Risk of Thyroid C-Cell Tumors: Patients should be further evaluated if serum calcitonin is measured and found to be elevated or thyroid nodules are noted on physical examination or neck imaging
•Acute Pancreatitis: Acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis, has been observed in patients treated with GLP-1 receptor agonists, including GLP-1. Observe patients carefully for signs and symptoms of acute pancreatitis, which may include persistent or severe abdominal pain (sometimes radiating to the back), and which may or may not be accompanied by nausea, or vomiting. If pancreatitis is suspected, discontinue GLP-1 and initiate appropriate management
•Acute Gallbladder Disease: Treatment with GLP-1 is associated with an increased occurrence of cholelithiasis and cholecystitis. In clinical trials in adult patients, cholelithiasis was reported by 1.6% of GLP-1 injection-treated patients and 0.7% of placebo treated patients, and by 2.5% of GLP-1 tablet-treated patients and 1% of placebo treated patients. Cholecystitis was reported by 0.6% of GKP-1 injection-treated adult patients and 0.2% of placebo treated patients. Substantial or rapid weight loss can increase the risk of cholelithiasis; however, the incidence of acute gallbladder disease was greater in GLP-1 patients than in placebo patients, even after accounting for the degree of weight loss. If cholelithiasis is suspected, gallbladder studies and appropriate clinical follow-up are indicated
•Hypoglycemia: GLP1 lowers blood glucose and can cause hypoglycemia. In a trial of GLP-1 injection in adult patients with type 2 diabetes (T2D) and a BMI ≥27 kg/m2, hypoglycemia was reported in more patients treated with GLP-1 versus placebo. In glycemic control clinical trials, the risk of hypoglycemia was increased when semaglutide injection or tablet was used concomitantly with insulin or an insulin secretagogue (e.g., sulfonylurea). Patients with diabetes taking GLP-1 with an insulin or insulin secretagogue may have an increased risk of hypoglycemia, including severe hypoglycemia. The use of GLP-1 in patients with type 1 diabetes or in combination with insulin has not been evaluated. Inform patients of the risk of hypoglycemia and educate them on the signs and symptoms. Monitor blood glucose in patients with diabetes
•Acute Kidney Injury Due to Volume Depletion: There have been postmarketing reports of acute kidney injury, in some cases requiring hemodialysis, in patients treated with semaglutide. The majority of the reported events occurred in patients who experienced gastrointestinal reactions leading to dehydration such as nausea, vomiting, or diarrhea. Monitor renal function in patients reporting adverse reactions to GLP1 that could lead to volume depletion, especially during initiation and escalation of GLP-1
•Severe Gastrointestinal (GI) Adverse Reactions: Use of GLP-1 has been associated with GI adverse reactions, sometimes severe. In adult clinical trials, severe GI adverse reactions were reported more frequently among patients receiving Wegovy® than placebo. Severe GI adverse reactions were reported in 4.1% and 0.9% of GLP-1-injection treated and placebo treated patients, respectively, and in 2% of tablet-treated and 0% of placebo treated patients, respectively. Severe GI adverse reactions have also been reported postmarketing with GLP-1 receptor agonists. GPLP-1 is not recommended in patients with severe gastroparesis
•Hypersensitivity Reactions: Serious hypersensitivity reactions (e.g., anaphylaxis, angioedema) have been reported with GLP-1. If hypersensitivity reactions occur, discontinue use of GLP1, treat promptly per standard of care, and monitor until signs and symptoms resolve. Use caution in a patient with a history of anaphylaxis or angioedema with another GLP-1 receptor agonist
•Diabetic Retinopathy Complications in Patients with T2D: In a trial of adult patients with T2D and BMI ≥27 kg/m2, diabetic retinopathy was reported by 4% of GLP-1 injection-treated patients and 2.7% of placebo patients. In a glycemic control trial evaluating a dose comparable to the 9 mg dose and the 25 mg semaglutide tablet doses in patients with T2D, 1.3% and 1.9% of patients in the 9 mg and 25 mg semaglutide group, respectively, reported moderate-severe non-proliferative diabetic retinopathy events, and 0% and 0.4% reported proliferative retinopathy events, respectively. Rapid improvement in glucose control has been associated with a temporary worsening of diabetic retinopathy. Patients with a history of diabetic retinopathy should be monitored for progression of diabetic retinopathy
•Heart Rate Increase: Mean increases in resting heart rate of 1 to 4 beats per minute (bpm) were observed in Wegovy® injection-treated adult patients compared to placebo in clinical trials. More adults treated with Wegovy® injection compared with placebo had maximum changes from baseline of 10 to 19 bpm (41% vs 34%) and 20 bpm or more (26% vs 16%). Findings were similar in a trial with the Wegovy® tablets. Monitor heart rate at regular intervals and instruct patients to report palpitations or feelings of a racing heartbeat while at rest. If patients experience a sustained increase in resting heart rate, discontinue Wegovy®
•Pulmonary Aspiration During General Anesthesia or Deep Sedation: Wegovy® delays gastric emptying. There have been rare postmarketing reports of pulmonary aspiration in patients receiving GLP-1 receptor agonists undergoing elective surgeries or procedures requiring general anesthesia or deep sedation who had residual gastric contents despite reported adherence to preoperative fasting recommendations. Instruct patients to inform healthcare providers prior to any planned surgeries or procedures if they are taking Wegovy®
•Never Share GLP1 Rx Between Patients, even if the needle is changed. Pen-sharing poses a risk for transmission of blood-borne pathogens
Adverse Reactions
•Most common adverse reactions are: nausea, diarrhea, vomiting, constipation, abdominal pain, dysesthesia, headache, fatigue, dyspepsia, dizziness, abdominal distention, eructation, hypoglycemia in patients with T2D, flatulence, gastroenteritis, gastroesophageal reflux disease, and hair loss
80% weight gain when Rx stopped (with muscle loss while on it so you may be worse off than when you started if you don't continue the Basic Weight Loss Program with health nutrition and exercise)
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THIS CLINIC EMPHASIZES
LIFESTYLE OPTIMIZATION,
WHICH HAS PROVEN BENEFITS
BOTH IN THE SHORT AND LONG TERM
WITHOUT COST OR ADVERSE SIDE EFFECTS.
We are dispensing Rx for weight loss for severe obesity or obesity with certain co-morbid conditions (diabetes type 2, sleep apnea, heart/kidney/liver disease).
Criteria for Bridge program:
BMI >=35
BMI >=30 with heart failure with preserved ejection fraction, hypertension uncontrolled despite 2 Rx, or chronic kidney disesase stage 3a or above
BMI >=27 with pre-diabetes, previous heart attack, previous stroke, symptomatic peripheral arterial disease
To qualify for health insurance approval, the healthcare provider "MUST ALSO CERTIFY THAT YOU'RE GOING TO USE THE DRUG ALONG WITH MODIFYING YOUR LIFESTYLE THROUGH NUTRITION AND EXERCISE". To this end, we ask that you either submit a nutrition and exercise log monthly and/or attend our Habit Huddle on the 1st Wednesdays 4-5PM monthly in order to receive a weight loss Rx monthly. Each month the Habit Huddle will focus upon one habit in the optimal weight blueprint on sunhealth.info/obesity You will also need periodic lab testing. We are here to help you achieve your health goals both with healthy lifestyle and modern medicine in order for you to receive optimal and long lasting results.