| Family First Feature |

At a Loss

Experts from an innovative Israeli obesity clinic weigh in on the latest weight loss breakthroughs, and how people can shed excess pounds — and keep them off

It should be easy to lose weight. There are a dizzying number of diet plans out there and bookstores full of weight loss guides. The supermarket has a dazzling array of foods that are sugar-free, gluten-free, fat-free, or calorie-free. Nutritional information has become more accessible than ever.

And yet, most people still struggle with their weight — whether it’s a few pounds gained over Yom Tov or a few dress sizes during pregnancy. For some, “the battle of the bulge” is a lifelong struggle with agonizing setbacks: A staggering 90% to 95% of people with obesity who diet and lose weight will gain the pounds back, often with interest.

Since 1975, obesity rates have tripled, with World Health Organization statistics indicating almost one in three people with a BMI over 30 and one out of 25 with a BMI of 40 or over (mortal obesity).

Even more alarming is that obesity is increasing among children. Type 2 diabetes, a direct outcome of obesity and once considered a strictly adult disease, has, since 1990, begun to present in children from age 3. In the US alone, over 5,000 new cases of children with type 2 diabetes are diagnosed annually.

What makes these statistics so grim is the fact that obesity has been linked to serious medical conditions — diabetes, hypertension, cardiovascular diseases, cancer, infertility, as well as sleep apnea and skeletal pain (bad back, aching knees) — so inextricably that obesity is considered a disease unto itself.

A Global Epidemic

The rise in obesity is a relatively new phenomenon, documented in the last 40 years. What’s changed in the course of those decades?

Socioeconomic factors such as urbanization, technology, and transportation have made our lifestyles considerably more sedentary, both in terms of employment and everyday tasks. As the saying goes, “Sitting is the new smoking.”

In addition, high-fat, high-sugar junk food is becoming increasingly pervasive even in the underdeveloped world, where the WHO says populations are exhibiting undernutrition coexisting with obesity.

Professor Amir Tirosh, director of the Center for Diabetes Research and Endocrinology at Sheba Medical Center in Israel, attributes the obesity epidemic primarily to environmental and dietary factors. “In the last 50 years, our world has changed drastically: the air we breathe, the water we drink, and the food we eat, even the bacteria and viruses are different.”

Dr. Ruth Percik, senior specialist at Sheba’s Endocrinology Institute, places most of the blame for the rising obesity on western food culture, which promotes food primarily as a pleasure and only secondarily as a physical need. “We’re constantly bombarded with tempting images and convincing messages to treat ourselves, to enjoy — and practically speaking, it’s available everywhere, all the time,” she says.

“With coffee shops and snack bars lurking on every street corner, we can consume a huge amount of calories for very little money in a short amount of time. We’re accustomed to getting whatever we want, now. In the process, we’ve forgotten what it means to refrain, to delay satisfaction, and to experience hunger.”

When discussing modern nutrition, it’s impossible to ignore the advent of processed foods and the accompanying plastic packaging and preservatives. “We’re exposed to hundreds of chemical additives, categorized by the FDA as GRAS (generally recognized as safe), but whose long-term effects have not been thoroughly examined,” Professor Tirosh explains. “We can assume that most are indeed safe, but we don’t need more than a couple dozen that are not so safe to suffer the consequences.”

In a groundbreaking study conducted together with colleagues from Harvard University, Professor Tirosh observed the effects of propionate, a common preservative found in bread and baked goods. The findings indicated that the chemical can cause elevated glucose levels, impacting insulin sensitivity and metabolism.

While the findings are not yet thoroughly validated in humans to warrant a recommendation to ban propionate, they do point to the need to more closely assess the potential long-term effects of this chemical and perhaps others.

Does that mean that the obesity epidemic will eventually be linked to food additives? According to Professor Tirosh, obesity could never be traced to a single compound. “It’s a combination of the amount of chemicals we’re exposed to, the amount of food and the content of various nutrients in our diet, the level of physical activity we’re engaged in, and multiple genetic factors.

“At the end of the day, weight gain is always a function of the balance between energy intake and expenditure, but it’s never as simple an equation as, ‘Just exercise more and eat less.’

“Human metabolism is so complex, and we’re constantly discovering new aspects of our biology and physiology. The amount we eat and how we engage in food-seeking behavior is controlled by a very complex network of hormones and metabolites. We know that there is an imbalance present in people with obesity and that they respond less to anorexigenic hormones — the ones that tell us to stop eating because we have enough energy. There could also be metabolic dysfunction, not to mention emotional aspects of food intake.”

An Individualized Approach

The urgent need to employ innovative approaches in the treatment of obesity has led to the establishment of specialized, multi-disciplinary clinics in various cities across the globe. One of the pioneers in this endeavor is the Israeli Center for Obesity Management, a division of the Department of Endocrinology at Sheba Hospital.

“The one-size-fits-all approach to obesity often fails because people who suffer from it have different problems,” says Dr. Gabriella Lieberman, senior specialist at Sheba’s Endocrine Institute and director of the Center. “There’s no one obesity, but obesities.”

At the Center, patients undergo a thorough assessment by a team of experts, including an endocrinologist, dietician, psychologist, and sports medicine specialist. After measuring the patient’s metabolic rate as well as body composition, the experts will consult and evaluate all this information to build a tailor-made plan that will suit the individual’s distinctive needs and parameters.

“We try not to aim for a specific weight, but rather, specific lifestyle goals that will lead to weight loss,” Dr. Lieberman says. “For example, I might tell a patient to start by waiting four hours between meals. Let them conquer that, and then we’ll proceed to the meals themselves. When lifestyle changes are made, weight loss will come.

“How much? That depends on different factors including the effort a patient is willing to make, their energy expenditure, etc.”

Professor Tirosh claims that optimally, obesity should be treated in a primary care setting, “but under the current system, where a doctor can devote seven, ten, or at most fifteen minutes to the patient, it’s not feasible to provide a multidisciplinary approach to address this complex disease.”

Rachel Z., 44, from Bnei Brak, succeeded in losing 85 pounds at the Center two years ago — and has since kept it off. She admits that the treatment, which is not covered by her medical insurance, isn’t cheap, but attests, “in my years of attending diet programs, I’m sure I spent 20 times that amount and without receiving any professional guidance.”

Rachel is convinced that the targeted treatment she received, which included psychotherapy as well as a specialized exercise program, together with continued follow-up, are helping her to overcome a weight problem that had become deeply embedded in her persona. “I feel like a new person today. My life has improved in countless ways.”

Measurement of success in terms of weight management is complicated. “In my eyes,” says Dr. Lieberman, “success is when a patient adopts the behavioral changes that will enable him to stick to specific lifestyle modifications and improve his metabolic parameters as well as quality of life. With different people, it takes a different amount of weight loss to reach that point.”

The good news is that it doesn’t take much to achieve a drastic improvement in health. According to Professor Tirosh, “In order to treat metabolic disorder, prevent diabetes, and improve high blood pressure, the goal is to lose 7% of body weight. If a patient can maintain that long-term, I’m very pleased.”

Beyond Eating & Exercise

After receiving their individualized plan, patients come periodically to the clinic to meet with the professionals and track their weight loss. Various tools are available to help the patient achieve maximum, long-term success.

A patient who struggles with emotional eating might benefit from psychotherapy or group therapy. Depending on the circumstances, patients might be candidates for gastrointestinal procedures such as intragastric balloons and duodenal devices, endoscopic sleeve gastroplasty or surgery.

Bariatric surgery is one of the more extreme tools employed at the Obesity Center, primarily for those with morbid obesity. “You have to realize that the things we take for granted, like walking and other simple tasks, are issues for the morbidly obese. Just tying their shoes is a difficult issue,” says Dr. Lieberman.

In addition to precipitating drastic weight loss, bariatric surgery has been shown to help reverse diabetes, eliminate sleep apnea, improve fertility, and ease joint pain and pressure.

“While safer than ever before, clearly, it’s not for everyone,” Dr. Lieberman states. “Candidates must first undergo a thorough psychiatric evaluation. In addition to various physical parameters that we examine, we ensure that the patient isn’t currently suffering from any active eating disorders and that they’re mentally healthy.”

Less invasive than surgery are some relatively new, promising weight loss drugs that have taken the medical community by storm. Saxenda and Belviq work by suppressing appetite and have relatively few side effects, which usually disappear with time. Saxenda is administered by injection as opposed to Belviq, which is taken orally.

When learning about these wonder drugs, the first question patients usually ask is, “How much weight will I lose?” Dr. Lieberman is quick to explain that there is no way she can predict weight loss. “There is an average weight loss, but each individual will experience different results. Some people may lose more than the average; for others, the drug may be less effective.”

Although she’s seen patients make tremendous progress with the help of meds, Dr. Lieberman makes it clear that the drug can never replace lifestyle modification. “I always tell my patients: ‘You must make the change, and the drug can help you make it. On its own, though, the drug is very limited.’ ”

Dr. Lieberman clarifies that weight loss medication will generally need to be prescribed chronically. “No one asks whether their medication for hypertension or high cholesterol needs to be taken chronically. But with obesity, for some reason, people expect that a temporary intervention will have a permanent effect.”

She explains the flaw in this thinking: “According to research, the longer a person diets, the more their metabolism slows down, so that it becomes even more difficult to continue and lose the weight. It’s not like we used to tell our patients that after three, four, or five months, they’ll get used to eating less, their ‘set point’ will change, and they’ll become a lean person. That’s not what happens. The struggle goes on forever, and there’s an option that the drugs will be needed forever.”

On the other hand, Dr. Lieberman is the last person to consign a patient to medication for life. Lifestyle modification is much more potent than any drug, she says. “If you make the change and keep it, you may be able to manage without the drug.”

According to Professor Tirosh, one of the most exciting breakthroughs in obesity research is in the field of genetic screening. Genetic studies have progressed enormously in the last decade with the Human Genome Project, which deciphered human DNA and mapped the genes through which inherited traits (including those that cause disease) can be tracked over generations.

“We’re performing clinical studies here at Sheba and can now screen for mutations to determine if a patient has a genetic propensity to obesity. It’s extremely validating for patients who have been struggling all their lives with obesity to know that they’re not to blame; it’s not because they’re lazy, or because they lack willpower.”

Practically speaking, genetic screening will soon provide endocrinologists with additional tools to determine how to best treat patients with obesity. One example is choosing the best fit in terms of weight loss medication. “Knowing the patient’s genetic mutation will enable us to zoom in on the most effective drug for the individual and get it right the first time.”

Blue Zones

After all is said and done, no matter what procedures or aids are used, it comes down to food intake. Dana Weiner, director of the Department of Nutrition at Sheba hospital, debunks the myths of traditional dieting.

“When people come to me, they expect me to hand them a diet. But I don’t believe in one diet that suits everyone. Even the Mediterranean diet, which I agree is an excellent diet, is not suited to everyone.”

To support her argument, Dana cites research on the Pima Indians, Native Americans originating in southern Arizona, who exhibited spiked rates of obesity, diabetes, and kidney disease once separated from their traditional homeland, diet, and way of life. Similar phenomena have been documented in Israel among Yemenite, and later, Ethiopian populations after they made aliyah and adopted the prevailing westernized diet.

Dana believes that just like all areas in medicine, nutritional science is moving in the direction of a more personalized diet, based on a person’s genetic makeup and where they live. She brings evidence from study of the “Blue Zones,” five areas in the world whose inhabitants exhibited greatest longevity and quality of life, yet each has distinctively different diets. What they all do have in common in terms of regimen is a plant-based diet, strategies to prevent overeating, limited alcohol consumption, and physical activity as a way of life.

“Our problem in the West is that we eat too much, too often, and our food is low-quality nutritionally,” Dana states.

As a rule of thumb, she believes in eating foods that are as unprocessed as possible. “I tell my patients not to buy foods that have more than three ingredients. If there’s something on the label you can’t pronounce, don’t buy it.

“Another rule: eat at home and cook your own food as often as possible. When you cook your own food, you control the ingredients and the quantities.”

Dana believes that people can still eat the foods they enjoy, even they aren’t the epitome of healthy, as long as they exercise portion control. “If a patient tells me that their favorite food is fried schnitzel, I won’t tell them it’s off limits; rather, I’ll say that instead of three large pieces, they should eat one small piece with a salad. The idea is to teach basic nutritional information to empower patients to effect genuine, lasting changes that the person is able to live with for a lifetime.”

In her work with frum patients, Dr. Lieberman quickly learned to identify their distinctive obstacles to weight loss. “The first change patients should make is to their weekend eating habits. Many are capable of adhering to their diet plan throughout the week, but Shabbat is a different story, and whatever they’ve lost all week, they gain back on Shabbat. It may be a mitzvah to eat a piece of challah for hamotzi, but that doesn’t mean the whole challah!”

Simchahs are another challenge. “We’re not going to tell patients not to attend simchahs. We teach them to make choices about what they will eat and how much.”

Dr. Lieberman has heard from patients that their weight gain first began during their years in yeshivah, where the menu was based on carbohydrates and fats with little protein and no vegetables. To this day, cash-strapped institutions resort to satisfying ravenous adolescent appetites with a similar menu — and let’s face it, that’s also what the kids want.

“My dream as a dietician is to establish nationwide programs to educate families, starting from very young children, about healthy lifestyle, proper eating habits, and the importance of eating home-cooked food,” Dana shares.

According to Professor Tirosh, it’s possible to predict already in kindergarten which children will suffer from obesity in the future. It should come as no surprise that negative eating habits, coupled with a genetic tendency, will result in the next generation of people suffering from obesity.

But, hopefully, with the type of work the Center is doing, as well as the intensive research taking place at Sheba aimed at deciphering individual genetic “potholes,” the next generation will have access to better, more personalized strategies that will have a much greater chance for lasting, long-term success.

In a departure from conventional methods, Dr. Percik is researching weight loss solutions to obesity employing neurofeedback — training the brain and harnessing its power to gain greater self-awareness and increase self-control, willpower, and mindfulness.

The notion that obesity could be treated via the brain occurred to her during her stint at the Max Planck Institute for Brain Research in Leipzig, where she learned that the behavior patterns linked to obesity were clearly evident in brain scans.

“Our brains are wired with very organized centers that control the fundamental impulses of hunger-satiety, pain-pleasure,” explains Dr. Percik. “Most people are born with healthy regulation mechanisms. In people with obesity, those systems get hijacked and malfunction.

“Scientists at Max Planck observed that the people who had lost their excess weight and kept it off for a decade, so-called Sustained Weight Losers, all had something in common: a high level of self-discipline, which is clearly discernible in brain imaging,” Dr. Percik explains.

“To illustrate, when obese people were shown an image of their favorite food, all the pleasure centers in their brain lit up, like those of an addict. By contrast, when SWLs were shown their favorite food, only part of their brains was stimulated; the rest was quiet. This indicates an internal restraint mechanism, which translates as their ability to say, ‘No, thank you, not now,’ when offered food outside of their menu plan.”

How does neurofeedback work in practice? The participant, wearing probes that gauge brain activity, is asked to concentrate on thoughts of willpower and self-control while gazing at a computerized image in front of him. The image is “responsive” in accordance with the level of concentration the participant is able to muster.

In her pilot study conducted in 2017, Dr. Percik helped a group of overweight men slim down through targeted exercises that served to reinforce the parts of their brains responsible for self-restraint. Participants were shown an image of a cockpit and had to keep the plane airborne with thoughts of willpower and determination.

“At Max Planck, I learned that the brain is extremely modifiable and can exhibit physiological signs of change even after a single intervention,” Dr. Percik adds, highlighting the potential of the method.

A year and a half after the study, 70 percent of participants have managed to keep the weight off, corroborating Dr. Percik’s hypothesis.

In clinical studies at Max Planck, neurofeedback is measured via fMRI, which is not economically feasible for widespread use. Dr. Percik and her team are currently exploring a device that is compact, portable, and user-friendly. Dr. Percik’s vision is to incorporate neurofeedback treatments in Sheba’s Obesity Center and to establish it, alongside proper nutrition and regular physical activity, as a part of the strategy toward acquiring long-term tools for a healthy lifestyle.

(Originally featured in Family First, Issue 668)

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