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Many people are seeking the book, the pill, or the diet that will help them shed excess weight and leave the growing ranks of the obese. But a weight management center led by Pitt’s Madelyn Fernstrom uses a different approach to produce success stories.

The Weight of Change

Bo Schwerin

  John (left) and Madelyn Fernstrom
(Edward C. Gruden photo)

The woman remembers a time when nearly every act of a day was a struggle. When walking a flight of stairs seemed as challenging as a military obstacle course, each step sucking the breath from her lungs and lighting off firecrackers in her knees. When eating with coworkers was a trial of unwanted judgments that she avoided whenever possible. When walking into a doctor’s office waiting room was like entering a kindergarten classroom—all the chairs were too small, as if to say this place is not for you. And then there was the constant back pain, the agonizing thought: I’m going to be like this forever.

Six months later, the woman carries boxes upstairs to her new apartment. She’s winded, but not as much as before. There’s a spring in her step. When she finishes unloading and gets into her car, she buckles the seat belt and loves the fact that it fits far better—the seat belt, the seat itself, the car. She’s not fooling herself; she’s still struggling. But there’s a new feeling—call it comfort—that she notices as acutely as a cool, refreshing splash of water on her face.

That’s because Beverly Popolo weighs 100 pounds less than she did six months ago. That’s because Beverly Popolo made a choice, a choice many people suffering the ill effects of obesity are finding easier to make thanks to the help of a Pitt weight management expert and a world-class treatment center. It was the choice to change.

“I spent most of my life morbidly obese,” says Popolo. “Dieting and exercise weren’t working for me at all. I could lose 20­ to 30 pounds, and then I would start to struggle, and the weight would come back. I was carrying around 200 extra pounds. I didn’t have any significant health problems—yet—but my knees and back would hurt. I found it would be difficult for me to conceive a child and have a family, which was something I always wanted.

“Being that large, you feel a sense of hopelessness.”

Popolo’s is a familiar story to Madelyn Fernstrom. One of the nation’s leading experts on weight management and nutrition, Fernstrom—a Pitt professor of psychiatry, surgery, and epidemiology—has long been tracking a troubling trend that is ballooning into a full-fledged national health crisis: the rise in numbers of the obese and overweight.

“Everybody has lost some balance in knowing the right things to do in terms of diet and exercise,” says Fernstrom.

Statistics from the National Institutes of Health indicate that more than 65 percent of adults in the United States are obese or overweight, a percentage that has increased drastically since the mid-1970s. (“Obese” means an extreme amount of body fat, while “overweight” refers to excess overall body weight—fat, bone, muscle, and water.) One out of every five children is overweight, and studies have indicated that as much as 80 percent of overweight children ages 10–15 become obese by age 25. With the accumulation of fatty pounds comes frightening spikes in an array of serious health concerns; the risk of problems like coronary heart disease, high blood pressure, stroke, type 2 diabetes, arthritis, sleep apnea, and a range of cancers all dramatically increase as a person gets heavier. Not to mention psychological issues such as depression that arise from both poor health and the ostracization many overweight and obese people face in a highly image-conscious society.

All told, health care costs related to obesity and weight problems add up to well more than $100 billion a year.

“Obesity has become a problem in this country over the last 50 years with the abundance of food,” Fernstrom says. Food is everywhere, all the time. Some fast-food restaurants remain open 24 hours a day. Offices feature easily accessible vending machines. Gas stations have become minisupermarkets. The creation and profitability of processed foods have resulted in highly palatable eats containing large amounts of hidden, unhealthy sugars and fats. And portion sizes have exploded. A bagel today, for example, is twice the diameter of a bagel 20 years ago and contains nearly twice the calories. Fernstrom also notes the increasingly sedentary lifestyle of most of the population, influenced by things such as the car culture; technology, like television, video games, and the Internet; demanding work environments; and neighborhood crime concerns, which can prevent kids from playing outdoors.

All of this creates fertile ground for weight management issues, which on the simplest level result from the imbalance of caloric intake versus caloric expenditure. Weight increases when more calories are ingested than are expended through walking, exercise, and other energy output. But simplicity is not a word that applies to weight management. Which is why Fernstrom founded the Weight Management Center, a unique clinical and research umbrella organization that draws on the vast resources of the University and UPMC, its partner medical center, to tackle the complex problems of weight gain from a multitude of angles. Its success in treating obese and overweight patients has won the center and Fernstrom national recognition. Fernstrom, for instance, is the diet and nutrition editor of NBC’s Today show.

When it comes to obesity, Fernstrom says, the human body is a giant black box, a mysterious enigma. Biologically speaking, the various systems of the body, from nervous to digestive to endocrine, are immensely complex, and their various interactions are even more so. Couple this with behavioral factors, and each person with weight management problems becomes a unique puzzle that must be analyzed individually. Treatment requires personalized solutions based on each individual’s own set of circumstances.

“Like everything in human life, weight management involves both biology and behavior,” says Fernstrom, director of the center. “For each person, the parts of this jigsaw puzzle are different. And the strategy for losing 20 pounds is very different from losing 200 pounds.”

The Weight Management Center looks at obesity as a chronic illness very similar to depression, in which both biology and behavior are important factors. Certain cases of depression, for example, arise from chemical imbalances in the brain. More often, depression can result from situations, like constant workplace stress or a death in the family. Behavior—how people handle such situations—can cause or prolong clinical depression. In many cases, both factors play a role. All of this also applies to obesity. Which is why the latest diet fad or weight-loss pill never proves to be the magic bullet “cure” for excess fat. In fact, the center’s rough rule of thumb is that, for any given general treatment, one in five people will probably do well with it.

“Society tends to demand we place simple labels on things, so we try to make obesity an entity, but it’s not,” says John Fernstrom, Madelyn’s husband, who is a Pitt professor of psychiatry and pharmacology and director of research for the Weight Management Center. “It’s a constellation of things. The range of possibilities leading to obesity is enormous. The study of it is made more difficult by the fact that lots of people like to think of obesity as a simple, discrete problem. It’s not.”

On this day, Madelyn Fernstrom checks on patients in a clinic in Magee-Womens Hospital of UPMC, one of the center’s many clinics throughout the hospital system. As she enters the clinic’s waiting room, it’s already apparent that this is not the kind of place Beverly Popolo feared visiting. Expansive sofas and wide, reinforced chairs welcome patients. Inside the clinic are bigger examination tables and wheelchairs and an array of specially sized medical equipment like custom-made blood pressure cuffs, all designed to make sure patients with weight problems don’t feel out of place. “We need to be sure that people are going to be respected and their dignity kept intact,” she says, highlighting another area in which the center makes a special effort.

The Weight Management Center, now in its 10th year, operates with all of these complexities in mind, because, as Madelyn Fernstrom sums up, “When it comes to weight management, one size does not fit all.” The center essentially provides a one-stop shop for people seeking to lose weight, whether 20 pounds, 200 pounds, or more. Because obesity produces a fallout of other health concerns, such as diabetes, hypertension, and arthritis, the center has drawn together doctors from each of the medical specialties—gastroenterology, cardiology, and endocrinology, to name a few—who have a particular interest in heavier patients.

“Obesity pervades so many other illnesses,” says Madelyn. “These doctors understand the overlap of weight and health issues.”

Patients seeking help at the center (about 3,000 each year) enroll in group or, more often, individual programs that seek to assess the causes of each patient’s weight issues and the best ways to approach treating them. Patients schedule regular visits with experts in four general areas: the medical field, exercise, nutrition, and behavior. They begin work on lifestyle issues to start with, because according to Madelyn Fernstrom, lifestyle—eating and exercise habits—underpins all weight management efforts and is key to maintaining a healthy weight. If, as in the case of Beverly Popolo, lifestyle changes alone do not provide an answer, other options like medications and surgery can be considered according to the individual. Bariatric surgery, for example, in which the stomach is either reduced in size or bypassed entirely to limit food intake and absorption, proved to be the key to Popolo getting her weight under control.

In the meantime, the center also provides treatment for various other health issues, like diabetes, that often arise from long-term weight problems. And because obesity is a chronic disorder, the center offers continuing support in the form of its one-of-a-kind Life After Weight Loss program. Often, patients who have lost significant amounts of weight are left with excess skin that can chafe and become infected, or at the very least continue to be a detriment to a person’s self-image. The center helps treat this issue with body contouring surgery that removes the excess skin. It also provides support to those who still face lingering behavioral issues after weight loss.

“We are really one of only a handful of programs in the country that has all the components,” says Fernstrom. “I can’t think of any place where the service line is so integrated. There is not one thing we can’t help a patient with.”

If that reality isn’t remarkable enough, the clinical side of the Weight Management Center is only one part of an endeavor as multifaceted as the disorder it aims to conquer. Behind the scenes, John Fernstrom heads an effort that draws on what the center’s clinics experience with their patients. He uses that to direct research studies aimed at further understanding obesity and improving its treatment.

For the center’s researchers, the interesting questions are numerous. How do hunger and the sensation of fullness work? When does biology trump behavior, and vice versa? How does weight loss affect high blood pressure? Diabetes? How does bariatric surgery affect patients beyond facilitating weight loss? Why do the effects of appetite suppressants plateau, and how can we improve these drugs? How do you get people to tell the truth about what and how much they eat?

The discoveries being made are equal parts fascinating and promising. Center researchers are investigating the role of a brain chemical called neuropeptide-Y that seems to play a significant role in appetite. Targeting the chemical may be the next big step in creating powerful new appetite suppressants. The realization that many patients inaccurately report their eating habits inspired the development of a prototype microcamera/sensor that can be worn around the neck like a pendant or pinned to a shirt. Created by Mingui Sun—Pitt professor of neurological surgery, electrical engineering, and bioengineering—the camera watches and records the food a person eats, using a special program to calculate the person’s caloric intake. It also records body movement to help determine physical activity levels and senses swallowing and breathing changes associated with eating, eliminating any sneaky efforts to scarf down snacks outside of the camera’s visual range.

“In research, people chip away at how to understand behavioral and biological mechanisms,” says John Fernstrom. “Here at Pitt, we can translate some of the biological observations and behavioral strategies directly to the clinical population to see if it actually works. We can have theory moving directly into practice. That is something that is very rare across the country.”

There is still, of course, much to be done. Obesity rates in this country continue to creep upward, which is why the Weight Management Center organizes community outreach programs, distributing information on its services at health fairs, libraries, supermarkets. “A lot of times, people might not seek help, but if they’re passing by and see us right there, they just might,” says Madelyn. The center is also making inroads among the nation’s primary care doctors—most of whom have been trained to treat obesity’s comorbidities but not obesity itself—to catch small weight problems before they become big ones.

“The hope for obesity treatment is earlier intervention,” says Madelyn Fernstrom. “People can change, but the longer it goes on, the worse it gets.”

That’s a sentiment Beverly Popolo understands, but she made the choice to change the person she always was and thought she always would be. Now, it’s Popolo who greets visitors and callers in the Weight Management Center’s offices in Western Psychiatric Institute and Clinic at Pitt’s Thomas Detre Hall. Her personal experience helps her identify with the concerns expressed by current and prospective patients. She knows the weight of change is heavier than anything a scale can measure.

“I always tell them, ‘If it was easy to lose weight, none of us would be overweight,’” Popolo says at the end of her workday, as she prepares to walk to the parking garage instead of taking the shuttle.

Five years have passed since she first began to notice the benefits—easier stair climbs, a looser seat belt—of her decision to change. Now at about 138 pounds, it’s not apparent that Popolo ever battled a weight problem. But it’s something she thinks about as she makes the small but important daily choices that help her maintain her new lifestyle.

“It’s still ultimately up to me to make the choices necessary,” she says.
“I can still gain weight; it’s not foolproof. This is the maintenance period of my life, which is the rest of my life.”

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