Really what I want to do over the next 30 minutes or so is to try and make the case that don't give up on lifestyle just yet. And I think we can more efficiently do this with electronic tools. So that's the case I'll make. Let's see if I do a good job. Here are my disclosures. I don't have any pertinent disclosures for this topic, but I do have some other research in kind of the nutrition support field. But always like to kind of ground our talks in a case. And this is a patient I met, a 44 year old female consultant who was a pharmaceutical rep and referred for assistance with weight loss and medical nutrition therapy. When I spoke to her, you know, her main reason for being there is something is wrong with my metabolism. So just a raise of hands, just post lunch, you know, get everyone stretching. How many have seen a patient like this in the last week? Yeah, it's almost like a daily occurrence, right? And so usually I still like to start by gathering a good weight history. I think it allows us to know what's been going on. And in her case, you know, the reason she's impacted by this is that she says most of her life she never had issues with weight. So in her 20s, her weight stayed pretty stable between 120, 140 pounds. She was a very active runner, had two pregnancies, and again gained weight and brought it right down. It was really in her late 30s when she got a knee injury that she started gaining weight. She was also working long hours at the time, had young kids, right? All that makes an impact. And then this sort of pattern continued into her 40s, and she thinks it got worse when she changed jobs. So now she's more in the consulting end of things, and that requires a lot more travel. And it's starting to catch up, and I think that's what's so alarming is that she started getting diabetes, was started on metformin, depression, and on physical exam really unremarkable, but her BMI has now gone past 30. So when she received a label of obese at her last health exam, that's when she got alarmed and came in to kind of visit me. And on physical exam, main other finding was that it's really central adiposity, so that's where she's storing most of her adipose tissue. And again, she quickly, as we're going through the weight history, she quickly goes into, you know, I've really tried everything under the sun. I feel like I'm a lifetime member of Weight Watchers, Atkins, I've tried paleo, you name it, every diet out there I've tried. And she's looking for other options. So the first thing I usually do is try and gather a dietary history through dietary recall, and this is when she quickly says, I always aim for between 1,200 and 1,500 calories per day. So when she's not traveling, usually she tries to be healthy. Breakfast is oatmeal, snack, rare, but if she does, it's some sort of a fruit. Lunch is a soup or sandwich. Again, she feels that it's well-portioned. Again, no afternoon snacks and dinner is variable, but some form of protein with vegetables, etc., is what she says. Unsweetened iced tea, in terms of the drinks. Activity says, well, I don't have any formal activity, but I'm very active throughout the day. When she's traveling, most of the meals are eaten outside of the home, at restaurants. But she's very quick to say, but I always go with the healthy choices. Activity-wise, I often go to the hotel gym. So again, we just go with a raise of hands, but what would we do next here? She has mild depression. She's on bupropion. Would we refer her to a psychiatrist or psychologist to transition to another therapy for depression? How about going even lower, right? She's not losing weight on 12 to 1500 calories. Who would try to recommend going even lower, 600 to 800 calories? How about initiation of second-line therapy? GLP-1s are working really well, right? Some would consider that. And then intensive lifestyle program. Ongoing kind of monitoring of her dietary intake and activity level. So some. Perfect. I'll try to make the case that this is still a good option for her, even despite what we've gathered in her history. And I'll share some of those, right? To me, I start to look at all the different modalities we have for the treatment of obesity in this kind of risk versus efficacy kind of a graph, right? Lifestyle is still the baseline. And when we look at everything else, if we don't have the foundation, I just don't think you get the results that we want with the others. And I've had that experience with weight loss medications. So if we don't have that lifestyle, patients have come back in three months heavier on the weight loss medication than without it. So, right? So I still kind of want to make the case that this is where we go. And we have state-of-the-art programs here, right? Diabetes Prevention Program, Look Ahead Trial is another one. And I'll kind of share with you some of that data. This one randomized over 5,000 folks, BMI 25 and higher. They had diabetes to either intensive lifestyle therapy, right? Aimed at 7% weight loss. But that intense word is the key. They did weekly sessions for six months to try and get this. This is probably familiar to most of you. The calorie goal was 1,200, 1,800 calories. And they aimed for 175 minutes of moderate intensity physical activity. The control group was what we do in clinic, right? We tell our patients, you need to lose weight. You've just been diagnosed with diabetes. Here's a visit with a dietician. I'll see you in three and four months, right? And this is what happened. So when we look at it at that year mark, you saw 8.6% weight loss in the intense group. It worked, right? Versus 0.7 in the control group. That's what we see in our clinic. But then as time went on, the folks in the intense group lost weight. I mean gained weight, sorry. And then the ones in the control group came down. So by the end, the two were pretty close. And we tended to call this kind of a failure of lifestyle. And I think we've spent a lot of effort on new medications, endoscopic, you know, approaches, bariatric surgery. But if we look at the data, I don't think we give up on lifestyle just yet. And here's the data for the A1C, right? A1C gets better if you lose weight. When you gain it back, it comes back. So just keep that in mind. But if we break this down, right, one of the biggest things is that everyone sort of gained that weight, right? And if we dissect the data out, it's an average. So if we break out the data by who actually lost and gained weight, you can see that there, that almost 22% of patients actually lost more than 10% body weight loss at a year, right? Almost 15% lost more than 15%. And this is intensive lifestyle modification got us this results, right? That's equivalent to some of the endoscopic procedures, like a balloon or the most robust weight we're seeing with the newer GLP-1s, right? So that was just with intense lifestyle. The second part was that this was similar in all patterns, right? Few slides about the more weight folks lost, the better their comorbidities got. I mean, this obviously makes sense. So these were the A1C numbers, fasting glucose, blood pressure, triglycerides, LDL, HDL. You get it, right? But the long-term data is what's so fascinating for me and why I still try to push lifestyle with most of my patients as the foundation. When we looked at the overall picture, they followed these folks for eight years. It was 4.7% weight loss in the lifestyle, in the intense lifestyle group. But it was, again, there were a significant number of patients who had tremendous weight loss over eight years, almost a decade, right? So this is looking at 11% of patients in this study lost more than 15% of their body weight over eight years. That's huge. 26.9% of patients lost more than 10% over eight years, right? So we kind of bundle it together as an average, but the reality is that a lot of patients are going to respond to lifestyle, and we want to encourage that. And then they broke it down based on, you know, those folks who lost less than 5% in that first year, what happened as they moved on, and right, those are the folks we call non-responders or failures, but as they followed them, some of them started to get their act together. And so you had 19% of those folks then go on to lose 5 to 10%, and then almost 15% of those who went on to lose more than 10%, right? So these are folks who didn't lose any weight to begin with. Then they broke down the other categories as well. So this is in terms of those who lost between 5 and 9%, so you could see the same thing. 22% of those went on to lose more than 10% of their body weight. And then what about those with more than 10% weight loss? Same sort of thing. A large majority of those maintained that weight loss. So pretty great results. And the key factors that, you know, contributed to them keeping the weight or losing weight are simple concepts, but it's very hard for us to implement. Those who had more physical activity, right, kept the weight off or went on to lose it. Those who kept up with kind of that calorie reduction. Those who increased their exercise. Those who used meal replacements. And the simple thing, those who weighed themselves, right? So we just keep folks engaged in this, we're gonna get results. And I think, you know, it's inherent to us all that we tend to kind of say, this is not working, let's go on to the next modality. So kind of going back to our case, you know, that's usually where we would start, right? We would start by calculating the amount that she's taking in right now. And based on her height and weight, we use like the Harris-Benedict equation, but you could use any predictive equation. And that would give us a rough calorie target for what she needs for weight maintenance. In her case, she needs about 1,981 calories for weight maintenance. So we would recommend a 500 calorie reduction from that to start with. And if that's not working, you can always go down to 750 reduction, right? And then the macronutrients, for the most part, we try to target kind of a well-balanced diet. But now, you know, there's more and more data emerging about the low-carbohydrate diets, right? There's all these other approaches. Intermittent fasting. So if a patient really wants to engage in those, we have been supportive and have kind of done that as well. But, you know, in her case, recall that she mentioned she's already below that target for most of the time, right? So what could be going on here? And the second part of this is that intense lifestyle modification. How are we going to implement that? And this is the biggest dilemma, I think, in front of all of us, especially over the next 10 years, is how are we going to do this when 42% of Americans have this issue, right? And it's a disease, right? 42% of Americans. It's very costly. But this is the scariest slide to me, is that that pattern is continuing. And as it continues, we're going to reach, by 2030, 48.9% of Americans being obese. And I think in 29 states, that number is going to be well above 1 in 2, right? That's scary. And almost a quarter of the patients are Americans, adult Americans, will have a BMI greater than 35, right? Just imagine that in kind of an average clinic day, right? So these are some of the concepts that I try to discuss with my patients to work on this, because I think when you're dealing with such a large population where we have to do lifestyle modifications, we can't do it one-on-one. This is where electronic tools help us in each step of the journey, and I'll kind of break that down here. So the first concept is to try and give her an answer for why she consumes 1,200 to 1,500 calories but can't lose weight. And the simple answer is, we're awful at remembering what we eat, right? This study showed, and they use doubly labeled water as the comparator group, and they showed that with the dietary recall, we were off by 34%. So women were off by 34% and men by 30% in what they could recall, right? So if she recalls eating 1,200 or 1,500 calories, it could be somewhere between 1,700 and 1,900 or 2,000 in reality, right? And that's common. All of us do this, but when you transition them from this recall in the clinic to the actually keeping track with a food log, like a 24-hour dietary recall, you decrease that error rate by half. And in men, it cut it down to a third, right? You're starting to approach, to me, that single digit mark is where we want to go. So very simple technique, right? And they actually, in this study, asked, you know, why were you missing some of what you had eaten, where it was picked up, in the 24-hour dietary recall? And the two concepts were social desirability and fear of a negative evaluation, right? There's so much stigma that goes against obesity. And so coming in, there's already this sort of, you know, they're going to think it's what I eat, you know, they're going to think negatively of me, and I'm going to think negatively of them. And so, you know, we're going to think negatively of me. And so we've tried our best not to project that kind of an image, that this is more of just data gathering, and we want you to do this kind of safely at home. And this is where the electronic tools are incredible. So I'm not trying to advertise for anyone. Again, I don't have any disclosure, so don't have any stock, right? I missed that boat. But these are some of the ones that we commonly use in our clinic practice. You know, like MyFitnessPal, they've just kept adding more and more features to the point where now you could put in like your raw ingredients, what you're cooking with, and then say, okay, I ate like an eighth of that meal, that kind of a thing. So these are just great, but this is a starting point. And again, sharing with her that, you know, humans are quite inaccurate, so just keep in mind that by doing this, you're going to increase that accuracy, and the key is to try to capture every bit of what you're taking in. And this study was just, I thought this was so awesome, what a brilliant idea. You know, what about that other 17% or 11%, right? What are we missing? And what they did in this study was, they actually had them wear a camera around their neck, and it was like motion-activated camera. I mean, they could obviously turn it off, so they have to go to the bathroom and stuff, right? You don't want to capture that, but the rest of the time, it turned on when there was motion, like this kind of a motion, you know, and so it would capture pictures every 20 seconds. And they also did the 24-hour dietary recall, and then what they found was that they could reduce the error rate down into that single digits. So you could kind of see that here, you know, down into the single digits there by doing this camera, and what they found was, essentially, folks were missing the vast majority of their calories through snacks, right? Makes sense. Walking through the kitchen, there's always something I can grab and eat, and I don't count that in my mind, right? So that's the key concept that this tries to capture, and so this is what I try to impart to my patients, that we're gonna be missing quite a bit of your calories, maybe 10-15 percent coming in through this snacking, kind of picking up food here and there, so it's so important for us to capture that and make sure we do it. The other part, and this I'm more excited about, the technology is starting to emerge, and I'm hoping that some of those same apps can then start to incorporate this, is that more and more technology is starting to add, just take a picture, and it's calculating the calories that are in there. So in this study, they used all the major phones out there. The iPhone has those multiple lenses, so they could use multiple lenses taking a picture at the same time, since there are different angles technically, you could create this 3D image to get a sense of the volume. For the phones that didn't have like those dual lenses, they use this card and had the folks take pictures from different angles to again create that volume, and they got very close to what the dieticians were kind of saying is in that meal. This to me is most exciting, because this tedious work to click and try to, you know, flip through and find what you're eating and then enter it, it gets old real quick, and so if you could just take a picture and have it capture, I mean, that would be incredible. So I'm hoping within the next five years, you know, we'll get there, but the concept is really, really important, right, and this study, just I'm kind of hitting the same points over and over again, but this is what I use to kind of guide my patients, is that self-monitoring is the only way this is going to work, otherwise it's not going to work, and this study, they had a formal program for weight loss, and they provided the patients with a self-monitoring booklet, and they took it, and they saw what percentage of the meals, the activity, the weight tracking was done, and they broke up the patients into quartiles, right, based on how much. So the ones that self-monitored the most, they did it, so 76 to 100 percent of the time, and you can see, they're the ones that really lost the weight, almost 25 to 30 percent weight loss, compared to the ones that came the closest, they self-monitored half to three-fourths of the time, they lost around 5 percent of their weight. The ones who monitored even less, some gained weight, right, so this is another concept that I share, again, to kind of give them encouragement of why it's so important for them to monitor, right, same thing is happening in the realm of activity, and that one's probably the easiest for us, right, but the same concept, we tend to under-report what we eat, and the theme is that we tend to overestimate how much activity we have, right, this is a great study, 236 adolescents and 301 adults, they wore an accelerometer for two weeks, and then also completed a questionnaire, they also looked at the education level to see if it makes a difference, right, the more educated, maybe the more monitoring, and all that stuff they're doing, and then they try to capture moderate and vigorous activity, and this is what they found, right, adolescents were off by like 600 minutes, it's massive, you know, adults 107 minutes, so we all tend to over, you know, estimate how much activity we're in, and education actually was the opposite, the higher the education level, the more we tended to overestimate, right, and smartwatches are kind of keeping us honest nowadays, you know, my Apple watch always is like, you didn't do anything all day, like, can you move, you know, so this is, this is the accuracy is growing, this is an older study, 2019 was when it was published, but they're just getting better and better, but in this case they looked at 40 patients who had cardiovascular disease, and they wanted them to kind of move, and they wanted to analyze the intensity of that activity across three spectrums, and then see how closely the smartwatch was able to capture their overall energy expenditure for the day, and they got really close, this is really incredible for me, you could see how closely the smartwatch was capturing the, the, you know, overall intensity level, but then the energy expenditure, right, I mean, on the, on the low end there, you could see, right, within like 20 calories, I mean, that's good enough, and even on the wide end, somewhere like 80 to 100 calories, that's, that's plenty of accuracy for what we need, so I think that's, these are just great, and the best part of these, these activity devices, is that they actually help the patient to move more, so just by wearing them, they actually help increase activity, so we did this study, we got a hundred thirty-five adults, you know, mean age of 40, and what we did was, we gave them an accelerometer, right, and, and for the blinded group, we literally just used nail polish, and just covered it up, but we said you could keep it, if you take part in the study, and you wear it all the time, the intervention group, they could actually see the number of steps, so very simple intervention, we also gave them some counseling, based on that activity level, and this is what we saw, on average, they walked a half a mile more, 90 calories more, right, they lost a kilo of body fat more, just because they could see, right, they're both wearing the accelerometer, the change in body fat percent, the change in visceral, and their satisfaction was higher, just by being able to track their activity, so very simple, you know, tool, but I think it's just, it's just amazing, and a lot of programs are now combining that, to get better results, with automated messaging, so smartphones that then deliver messages to the patients, to kind of keep encouraging them, right, because when you're looking at 48% of adult Americans needing this, you know, there's not enough endocrinologists, or obesity experts in the world, that can manage this, so we're gonna have to use these electronic tools, so that's what this study did, and their goal was to try to get to 10,000 steps per day, and you can see the phases they did, right, the first phase was blind, so everyone couldn't tell, you know, what they were doing, then they unblinded half, and then kept the other blind to the results of those accelerometers, right, but you can see that when you combine the unblinding with those text messages, almost 81% reached that goal of 10,000 steps, compared to 44% of those who were unblinded, but didn't get the encouraging text messages, so this is, this is a rapidly kind of growing field, and there's more and more companies that are kind of going in this direction, and you can just see the breakdown there in the table of how many more steps they took, versus those who were blinded, etc. Same things happening with coaching, right, I kept saying we need that intense lifestyle modification, but who can do that, right, could you add on a patient every week, you know, it's impossible, so a lot of work is being done on how could we use technology to augment some of this coaching and, and lessen the, the impact, you know, so coaching-wise, this study, about 69 adults, BMI between 25 and 40, they had this program called MOVE, right, the sessions were led by dieticians, psychologists, physicians, they gave them the calorie reduction, the activity level, etc., but then they also had a mobile group that, again, used those same concept, self-regulate energy intake, right, and you receive a coaching message based on how much you're entering, so they did that for the first one to six months, and then month seven through twelve, they attended monthly sessions, and then, in the meantime, did that mobility app, right, to self-monitor, and this is what you see, right, simple concepts, but it's very effective, 4.5 kilograms of weight loss at a year, at six months, versus one kilogram, huge difference, and the same thing, the ones who use the app more, they lost more weight, right, they self-monitored. This is Noom, you know, again, I hate to use, like, trade names, but there's no way to not use them in this case, so it's a big name, they've been at this for a while, and they've got state-of-the-art kind of programs that are all kind of virtual on their app, really effective, and so they looked at almost 35,000 participants who use their app. They had to use it two times or more a month, and for six consecutive months, and you can see the breakdown. Their, their sort of clientele, actually, you know, I think it was like 10% of them were obesity class 2, but 28% were kind of in that obese class 1, and then the big portion were in the overweight category, right, so that was there, but look at the breakdown of the percent weight loss, right, 24% of individuals lost 10% of their body weight, quite effective, I mean, that's gonna get you improvement in diabetes and all of those. 12 to 14 percent had 10 to 15 percent weight loss. Then you're getting into, like, the single digits, but 5%, 1 in 20 out of 35,000 is a huge number to do this in an automated way. Just think of the math, right, so when you multiply this to a hundred million Americans or more, right, this math starts to add up very quickly. If, if you can give 5% of those folks to lose 15 to 20 percent of their body weight, that's huge. So I think these are very, very effective tools. Same concepts, you're getting it, right, the ones who entered their dinner the most lost the more weight. It was the most important factor to success, right, and more frequent input of their body weight, meaning they weighed themselves, again, that also significantly decreased kind of the yo-yo effect that you typically see, because they check, they're gaining weight, they can start to correct their behaviors, right. So kind of to summarize in the last few minutes, back to our case, you know, this is our, our 44 year old female, she's got depression, diabetes, right, comes in, assistance for weight loss, states that it's, it's her metabolism, not her, because of this is her dietary recall, right. So I think most of you already said it, I was hoping to convince you, but you guys are already convinced, probably intensive lifestyle is the way to start, despite the history that she gives us, and this is how we would start. This is a calculator that we use, Harris Benedict, but you can use any sort of predictive equation that you like, you know, this would be our diabetes, our calorie target, 1400 to 1500 calories. Again, I put the macronutrients there, right, to answer her question. I'm already below that, you know, we would share with her the data of dietary recall versus logging on an active basis, and get her started with one of those, right, and I tell all my patients, this is going to be the hardest month of your life. I've done this, it's painful, and I'm hoping, again, this technology changes in the next few years to where you just have to take pictures, but for now, you click, you enter, right, you do the same thing. You get a Fitbit, you get a cheap step counter works just as well, you can get, you know, a smart watch, and then start there. So that's sort of the first month. The hope is that they start to realize what are like the foods that have the highest calorie density, and start to make changes, and we usually combine this, and I'll share that in one second, but for now, if that still is ineffective, the two tools that I've used have been body composition measurements, right, because sometimes they start to make changes, and they're very dejected because the weight is not coming off, but when you look at the body composition, the percent fat is changing, percent lean muscle is changing, right, and that can be more encouraging sometimes for them to continue that journey. The other thing we do is indirect calorimetry, right, the predictive equations are predictive equations for the population, but sometimes patients say that I'm still off, and we will do indirect calorimetry, and every now and then, it will actually show that their calorie needs are even less than what the predictive equation is telling us. And this happens quite a bit when patients have previously gone on drastic diets, right? They've cut down to 600 calories, 800 calories in an attempt to lose weight. They've lost weight, but now their calorie expenditure has changed, right? And now they're gaining weight quite rapidly and their body composition has changed because we would love to lose, you know, all of our fat, keep the muscle. Then when we gain weight, it's all muscle, right? But that's a dream. That doesn't happen, right? When you lose, you lose both muscle and fat unless you're doing resistance training. And when you gain, it's predominantly body fat, right? So, and that can have an impact then on energy expenditure later on. So those are some of the other tools that we sort of work on with our patients. And then it's that intensive cognitive behavior therapy. Again, a lot of the companies are now doing virtual, you know, like I showed some of the data behind some of these. So we often combine those, or we've started a bunch of our programs, thanks to COVID, as virtual programs. And we have no desire to go back to in-person. Those allow us to have eight to ten folks, right? So just think of the math. Instead of having eight to ten, you know, hour or 30-minute long visits with a dietician, you can combine that into a one-hour visit with a dietician and go over the same concepts. And so those are the programs we've created. And then we just have these ongoing on a weekly basis. Patients can join at any time. It's sort of an ongoing thing. And then we're creating a weight maintenance arm to this that they would then shift to, you know, once they're done with the intensive program. And that just meets less frequently. Every other week or once a month. Ongoing. Perfect. So I'll stop there and, you know, open it up for any questions. If you could, are you able to, yeah, because I think it's also being live-streamed. Hi, I'm Adam Stein. I'm an endocrinologist in Northwestern Medicine in Chicago. Great talk. Thank you very much. I know you're focusing a lot on calorie reduction. I was wondering if you felt like the timing of the calories may be important as well. Like, does a larger meal at dinnertime have a greater impact in snacking after dinner? Does that have a greater impact versus snacking at other times of the day? And if so, do any of those apps incorporate that and give suggestions about the timing of meals? Yeah, so there's a lot of work being done in this in the realm of intermittent fasting. So, right, there's a lot of data that's coming out and there's a number of ways to do it. But in the studies, the way it was done most commonly, or the way it is done most commonly, is alternate day fasting. So one day you get to eat whatever you want. The next day you have about 500 calories at lunch. But in reality, in like clinic, it's all like 8 to 16. Meaning they want to eat over 8 hours and then 16. But in the end, when they've done comparators, it's been no difference. It's essentially the overall calories you get in. But the key has been what can you stick to. And so if they want to eat lunch and dinner, you know, I used to be, because I can't do it myself, so I used to be like, you got to eat three meals a day. You have to do this. But now, since I've seen the intermittent fasting data, I'm more like it's okay. It's overall target. And what can you stick to that we go for? And one other quick question. Do you feel like there are any devices that are much less accurate than others that you recommend patients not use? You know, Apple Watch, Fitbit, Garmin, any of those? Yeah, no. We've actually even used like a $20 step counter, right? And we just have them sort of calibrated a bit. Meaning we have a measured space, and then they just sort of walk, and then you count the steps. Because you don't want it to like have, you know, 10,000 steps, and in reality you've walked 5,000. That kind of creates that same situation. So it's more the calibration. And the other other thing we ask is for them to also make sure the step counter doesn't like pick up steps on a bumpy road. So if those two things are met, I'm okay. Because, you know, you have to meet the patient. Not everyone can afford like a $500 Apple Watch. So we're okay with a step counter, because it still encourages them to do more steps. Yeah. Hi, Anaria and Aida from UPenn. Two questions. The first one, when do you think like, okay, you achieve, you do all of these things with the patient? Because most of our patients come, and they already did this, right? They've read online, or they have done 5,000 diets. So when do you think, like, or what percentage of weight you say, okay, I need to start therapy in this patient? Yeah, I beg them to give me like three months. I know, because they're always like, no, I've already done all this. I just beg them, I say, give us three months. Let's have you start logging, capturing. Let's start this program, whether it's virtual in most of our cases. And we'll do that for three months. I will see you back. And at that point, you know, if it's really not moving, then we'll add medications. But often you will get like 3% or more weight loss at that point. And then you can encourage them to kind of keep going. And you can. I didn't mean to say don't add a medication. I think totally valid. But at least you got them the foundation. And then our program at least teaches them all those core concepts of stress management, all of that. So you got them to engage with that program, because they're like, well, he's gonna give me a medication, you know. And so they'll stick to it. So I beg them and they give me three months usually. Perfect, thank you. And the other question was, you know, with health disparities, how do you, have you studied or there's any study about people journaling, maybe in paper, or patients that, you know, cannot afford the watch or the app. And have you studied that? Yeah, no. And all, a lot of the older studies, right, they all use paper monitoring. Works just as well. It's just, can they keep track, you know. And even now, like, everyone literally has a smartphone. I mean, it's just so prevalent. But paper works. And that's where I mentioned, like, the $20 pedometer. You know, there's some that are really, really cheap that don't work as well. You know, you'll drive home and you've walked, like, two miles. So we don't want those. But a little bit of a quality pedometer and paper journaling works just as well. One last one. I know that, you know, depression, anxiety is, like, related with obesity. When you start counting more and give them, like, this task, have you seen patients that get, like, worried, obsessed? I don't know the word to use. Or, like, you discover, like, an eating disorder. And if you had your experience, how do you manage that? That's a brilliant, brilliant question. Those are the ones that we have a discussion on. Honestly, if we're gonna go down this path, because there are patients, and that's some of the weight history that I try to gather, is, do you have a history of bulimia? You know, have you engaged in any kind of vomiting to lose weight? Those kind of behaviors, that's probably not the right way to go for them, right? Then we have to think about more of referring them to our psychologists and kind of doing a psychology-led program and not focusing on as much on this level of monitoring. Yeah, because it will set off. Yeah, that's a great, great point. Hi, Christina Michaels from Houston, Texas. Two questions. One is, I have a lot of patients recently asking me about using CGM for weight loss, and I'm seeing it pop up in, like, lifestyle medicine, like, social media. I'm not sure, I haven't seen any actual data. I wonder if you've seen any. Second question is, how accurate are our calorie counts on packages of food? I've seen evidence that they're not very good. The commercial one, they have to be accurate. So, they use a calorimeter, like, they burn the food and do the measurement that way. But when you're talking restaurants, yeah, that's where, right, because the chef at the corporate level designed the dish to be this, but, you know, the person preparing it is throwing things, and because they've got two minutes to do it, and so that can lead to way more calories. We had this issue at our own facility, because I also am the medical director for food service, and our serving sizes were sometimes double what the meal was intended for, and we really had to work on that, and I got a lot of angry emails, you know, security walks me out usually, but a lot of angry emails about, why are you taking away our portion sizes? And I was like, it was over a thousand calories the way it was being served. Great point. The CGM, like, Continuous Glucose Monitor for Weight Loss? Yeah. I don't know how well it works, or if it, I don't know any evidence that it actually works, but people are asking. Okay. Yeah. What I wanted to ask you about is, how are you seeking reimbursement for the services? I'm from Fort Myers, Florida. They just eliminated our whole dietician department. So, you know, we're endocrinology, but all our type 1, type 2s now are, you know, we're responsible for it. So, I'm just, you know, E78.0 is just not gonna get us enough to keep the lights on, basically. So, we're just, I'm just kind of wondering how you've gotten creative with that, because we're seeing more, we're getting a lot of referrals for obesity without any other developing comorbidities, just to manage the weight loss, because primary care is just kind of sending them over, because they want us to rule out secondary causes, and then we're stuck with the BM, you know, managing the weight. So, I'm just curious to see what you're doing. Yeah, we, so we've done it so that it, we've used the group MNT codes, and it's all dietician-led, and then when you have the eight to ten patients per group, sometimes it can go a little bit more. That's been cost-effective for us, but it's really, you know, I think we're grateful that our institution has not, you know, touched our kind of dietetics program, and so that's how we've been able to do it, because otherwise, if it's eight to ten visits for a dietician individually per week, then you really start to kind of hemorrhage, you know, financially, and so by combining it into a group, that's been really effective, and patients love it, because they get to see that, one, they're not alone, but that others may have had something that really works for them, and so they can be, you know, better teachers, other patients than we can be. Yeah. Yeah. Hi, I'm Amy Aronovitz. I'm from Fort Lauderdale. I'm not sure if this exists, but I think one of the biggest things that you highlighted on, for apps to work, you have to enter data. Are there any of the apps, kind of, that use something like CGM, so that you can look at time and range, or percentage of meals that are done for each meal? Yeah, the printouts are great, so exactly, like, I think even the MyFitnessPal will print out the data that they're entering, but if they're not entering it, yeah, then it's just blank. It's missing, so they will, they can print out the data in a very robust way, and some of the, like, the Fitbit and these things, I mean, the data that they can output from those accelerometers isn't, yeah, to capture, like, how much they're entering, yeah. Yeah, because it'll, it'll kind of show you day by day, or week by week. You can, you can output it in any way. Patients will often bring in these printouts that can tell, and then you can just see which is missing, and then gather it that way. Yeah. Hi, I want to ask what you think about calorie counting for patients who aren't eating traditional American diets, because I find my patients who are coming from other countries, especially, have a really hard time figuring out how many calories are in food. Yeah. And then I also want to ask, for patients with a BMI above, like, 40 or something like that, how much you're really looking to achieve with just lifestyle intervention? I'm sure it'll help with the durability of weight loss when you eventually have surgery or something like that, but just the lifestyle intervention alone? Yeah, no, that's a, that's a great question. So, the data sets are not as robust, right, because a lot of these started with the USDA, kind of the government data dump, and they just started as that being your baseline data, but then, you know, they've added more and more, but you're so right. With those kind of a diet, it's more work. You have to actually add in the ingredients, you know, flour and, and all of that to try and capture that more, and so it's a lot more work. I'm hoping, you know, it's more and more diverse, right, because this is a worldwide problem, and so these companies are starting to branch out, so if they go to other countries, they'll have that local data set that can be used for our patients. For BMIs of 40, I still, I kind of encourage it as more of a foundation, right, because, again, it's more of core concepts that they're gonna use, hopefully, with bariatric surgery or any, any other thing that they do, because with bariatric surgery, even, you know, one in three will regain the weight, so you have to have them self-monitor. You have to have, right, so that's what we're hoping to achieve, and I'm surprised. There's been cases where they've, they've lost so much weight in three to six months that they don't want to pursue surgery anymore, so you're always surprised. I'm not saying that's the norm, but you get one, you know, one a month, that kind of a thing, so I still encourage them and say, try this for three months, and then, at that point, when I see you back, if you're still pursuing surgery, we'll have you meet with our surgeons, so, yeah. Yeah. So I mentioned support, like the reaching out to these patients is a pretty important part of your program. How often do you guys reach out to your patients? Yeah, that's where it's impossible. We were just having this discussion at lunch about our in baskets, right, and how we just can't keep up anymore, so that's where this program has been designed. The intensity has to be a weekly, right, and you can't do that, and so that's where these apps, you know, online programs and our virtual program, they meet once a week, and that creates that accountability so that patients, you know, have to log in, and they have to remember, oh, you know, I have this coming up, and I need to kind of keep logging and things, so once a week is the right intensity to start with, and then you can go to every other week, and then once a month for maintenance. Okay, I think we'll end it there. Thank you.

weight loss

medical nutrition therapy

lifestyle modification

electronic tools

food tracking apps

step counters

smartwatches

self-monitoring