I didn’t set out to become an obesity doctor. After graduating from med- ical school, I had just worked with two of my best friends on our first book, The Pact: Three Young Men Make a Promise and Fulfill a Dream, which details our journey from poor, troubled youths in Newark, NewJersey, to becoming doctors (two medical doctors and a dentist). The book debuted on The New York Times bestseller list and stayed there for several weeks. We followed up with two more bestselling books. The three of us were (and still are) traveling the country giving inspirational talks and do- ing some exciting community work though our non-profit organization, The Three Doctors Foundation. I had found my calling in life. Inspiring people from blighted communities, in particular, and communities across the country, in general, especially the youth, became part of my mission. My medical career as an internal medicine specialist was burgeoning, as well. I had a thriving medical practice and a purposeful mission, so I thought my career journey was complete. All the things I wanted professionally in life, I’d accomplished. All the things I was passionate about doing, I was doing. Besides having a wife and children, I couldn’t imagine anything else that could so ignite my passion, much less fit into my schedule.
Then came Sharon.
Sharon was a 45-year-old wife and mother of three when she became my patient around 2007, along with her husband. She was a sweet, soft-spoken woman with a calming presence. She had the gift of making anyone in her presence somehow just feel relaxed.
Back then, she already had at least 100 pounds in excess weight. Her list of medical problems included hypertension and high cholesterol, and I later diagnosed her with sleep apnea. She was really interested in getting healthy and wanted to get off the blood pressure medication she was taking. I told her the best thing she could do was to lose weight. Of course, she knew that, but she was looking to me for guidance. Unfortunately, all I had in my tool box then were four words: eat less, move more. That’s pretty typical. One of the things most doctors don’t do is talk about weight, and when they do, the tools they usually have to offer are the same limited ones I had. A nationwide study of attitudes and behaviors related to obesity revealed some of the barriers people with obesity face in getting appropriate healthcare. The Awareness Care and Treatment in Obesity Management (ACTION) study, from 2017, found that most people with obesity don’t get a medical diagnosis of obesity or a referral for medical care. Just 24 percent of doctors who identified a patient with obesity scheduled a follow-up appointment with the patient to address that issue. The study also found that 82 percent of people with obesity believe their condition is their responsibility alone to handle. The study, which involved 3,000 patients, 600 health care professionals, and 150 employers, is believed to be the first in the United States to examine treatment barriers from the prospective of people living with the disease.
Doctors are generally not trained in medical school to deal with patients’ weight issues, so we don’t talk about what we don’t know. It’s easier, I suppose, just to put the blame and responsibility on the patient. However, the health industry is pushing medical professionals to change somewhat. Now, Medicare and many insurance companies require doctors to note on a patient’s record if the patient has overweight or obesity. The payers are essentially requiring us doctors to acknowledge the connection between obesity and diseases in a more formal way. The presumption is that such acknowledgement will force doctors to have more substantial conversations with their patients about weight.
I definitely needed to talk to Sharon about her weight. Over time, Sharon gained even more weight. Her blood pressure eventually shot up to dangerous levels, and I was worried. By then, she was going through a divorce, had slipped into depression, and was not taking good care of herself. So, instead of taking her off the blood pressure medicine, as she had long hoped, I had to increase it. Sharon promised to get the pounds off, but for a long time, nothing changed.
Her appointment in the summer of 2010 was different, though. She had gained five pounds just in the three weeks since her previous visit. We were reviewing her bloodwork, and not only was her blood pressure out of control, but she had also developed pre-diabetes. I was deeply concerned about her. I knew she was a mother and that her children meant the world to her. So, when we sat down to discuss the results of her tests, I told her I was concerned about her health. She was taking care of everyone else, but if she didn’t get her weight under control, I was worried she might not be around to see them all grow up. I asked about the health of her three kids: “Are your children obese?”
Sharon looked startled and hurt. I hoped she could tell by the tone of my voice that I wasn’t trying to be mean, but it didn’t matter. She burst into tears, and I immediately wished I could take back my words. For the next few minutes, Sharon sobbed uncontrollably, expressing feelings of deep guilt. What I couldn’t have known then was that her son, then about to become an eighth grader, had recently come to her with a heartbreaking concern: He didn’t want to feel like the fattest kid in school and wanted to lose weight. My question had brought the pain home to Sharon: she was the one feeding her children, and so not only was she hurting herself, but she was hurting them. Sharon left my office that day with a quiet determination in her eyes that I had never before seen in her. A few months later, when she returned for her next visit, I was astonished. She had lost a significant amount of weight, and with every visit after that, she just kept getting smaller. Over about two years, she lost 127 pounds, and she did it on her own, mostly by following a low-calorie program that required her to track her food intake and limit her calories. She cut out sweets and other refined carbohydrates. She also began walking faithfully with a friend around a track near her house several times a week.
I told Sharon how proud I was of her and encouraged her every step of the way. It was one of my proudest days as a physician when I took her off all of the blood pressure medications, except for a mild water pill that kept her legs from swelling during the hot and humid summer months. Sharon not only would keep the weight off, but she would go on to run in 5K races and even a half-marathon. She amazed me, but I knew I couldn’t take much credit for her success. She says I inspired her and that she might never have discovered the healthy person she became without that inspiration. But truly, she inspired me.
In seeing her success and how much it affected her health for the better, I was determined to find out more about the science of obesity so I could better help my patients. In the early years of my medical career, I’d never even thought much about how to treat obesity, beyond the cursory “eat less, move more” advice I gave to patients with overweight or obesity. It was all we had been taught in medical school. As an internal medicine specialist for Penn Medicine Princeton Health Systems, I treated lots of patients struggling with weight-related illnesses, such as diabetes, heart disease, and high blood pressure, the so-called triple threat, as we coined it in residency. Somehow, though, I knew the “eat less, move more” mantra just wasn’t quite right. I wanted to be able to do more than just tell my patients to lose weight; I wanted to show them how. The timing was fortuitous, too, because the idea that I should find my niche in medicine had begun percolating in my head. Working in internal medicine was starting to feel a bit like being a “jack of all trades, master of none,” as the old saying goes. I’d also grown tired of prescribing pills and ordering expensive medical procedures to treat health problems that could be relieved by weight loss. Sharon was the rare patient who had managed to change her entire health status with dramatic weight loss. Maybe with my guidance, other patients could do it, too.
It’s Not Your Fault
Curious about what resources were out there, I turned to Google to find an organization for doctors who specialize in treating people who have obesity. The American Society of Bariatric Physicians (now called the Obesity Medicine Association) popped up. I read everything I could find and learned that the organization was having a conference in the near future. Just a couple of months later, in September 2014, I joined the estimated 600 physicians at the conference in Austin, Texas. Many of the doctors there had been practicing internal medicine, like me, and I felt at home among them. They shared the camaraderie of a group with inside knowledge about an epidemic not widely understood in the broader medical community. They talked about obesity as a disease, without assigning any more blame to the one afflicted than a doctor would do to a patient suffering from any other disease. Yes, obesity is a disease, and it has pathways that cause it (termed pathophysiology), and those pathways have very little to do with a person’s willpower (as I will explain in the next chapter). Not only that, but obesity has many factors that contribute to the disease, such as: genetics (including gut hormones and your metabolism, something called metabolic adaptation), your surroundings, medications, your endocrine and immune systems, and behavior. Genetics is involved in every aspect of life, so it’s the biggest factor of all.
OBESITY IS A MULTIFACTORIAL DISEASE
So we have to think about and address all of these factors to effectively treat obesity. Evidence of how important a role genetics play in obesity is show in twin studies. These studies show that identical twins are virtually the same weight (and height) throughout life, while in non-identical twins, weight (and height) varies. This demonstrates how powerful our genes are in regulating our metabolism and the hormones involved in weight control. The good news is, although every individual does it a little differently, we know a lot about how your body (i.e. your genes) does this. And because of this we have a much better handle on fighting obesity.
GENETICS PLAY A MAJOR ROLE IN OBESITY
Non-identical/Fraternal (Dizygotic) Twins
This was all new to me. Like most people, I’d always thought of obesity as a factor of willpower and discipline, which is why I was so shocked when a speaker in one of the sessions casually said something like, “We all know obesity is not the patient’s fault.” Members of the audience nodded in agreement, as if this was common knowledge. I felt like the guy who walks up in the middle of a conversation that everybody else is having. But I quickly became like a new convert at a religious revival that was un- veiling life-altering truth. The speaker talked about how hormones in the gut communicate with the brain to control hunger, make you crave certain types of food, and actually fight against the body’s efforts to lose weight. When it feels threatened by significant weight loss, your body also can lower your metabolism, making it harder for you to lose more weight and easier for you to regain the weight you lost. That’s why the vast majority of people who lose a significant number of pounds gain them back in a short amount of time. I soaked up this new information. I wanted to understand more about how this all works and what the scientific community could do to find solutions, short of bariatric surgery, for the many people who are struggling. I’d found a new passion. I wanted to be part of the solution.
At one point during the conference, a group of us went to dinner. I sat next to Dr. Eric Westman, who was the president of the American Society of Bariatric Physicians at that time, and a group of monks, who had traveled several hours to learn from him. Dr. Westman had written a book about a ketogenic (low-carb) diet. The monks had experienced success with his plan and asked if they could join us for dinner. Yes, of course, he said, and I sat there, listening to their conversation. They thanked him and asked him questions to better understand the science behind the low-carb diet. As I sat there listening to their conversation, I thought to myself that the knowledge in that room could be transformative for people struggling with weight loss.
Carbs: The Real Culprit
Most of the individual doctors I met at the conference were proponents of a low-carb lifestyle. This left an impression on me. These were the professionals who treated patients who had obesity all day every day and, as I saw it, they are far more likely to understand what diets work best and why. What I learned from them upset everything I thought I knew about weight loss. For years, I’d been telling my patients to eat a low-fat diet and exercise more. Too much fat makes you fat—that’s what we’d all been trained to believe, right? Well, as it turns out, eating fat doesn’t make you fat; it can actually help make you thin. Carbohydrates (carbs) are the real culprits; in particular, sugar and refined carbohydrates. I make a point to specifically say sugar and refined carbohydrates because I don’t want to make the same mistake those before me made when they blamed everything on one macronutrient, fat.
Carbs make up about half of the typical American diet— about 312 grams of carbs per day in a 2,500-calorie diet. That is far more than most people burn in a day. During the digestive process, carbs are converted into sugar and burned first—before anything else that you eat—for energy. The carbs that are not burned are converted to fat and stored in fat cells. A low-carb diet pushes the body to burn fat instead of carbs as the primary source of energy. This fat-burning process can put you in a state called ketosis; thus, some low-carb meal plans are called ketogenic diets. This is a simplistic explanation of a more complex process, but the science made sense to me when I first heard it.
Mind you, I don’t want to sound like I’d never heard of a low-carb diet. Low-carb diets aren’t new. The Atkins Diet has been around forever, but I’d never paid much attention to its scientific claims. I’ve never dieted much myself, and I thought Atkins was a fad, like all of the other lose-weight- quick schemes out there, but I would later learn that wasn’t the case. At that 2014 conference, I became mesmerized by science that backed up the health benefits of a low-carb diet.
At the time of the conference, a documentary called Fed Up had been released just months earlier and was generating much buzz among the physicians. One of the speakers suggested we all watch it. Narrated and produced in part by Katie Couric, the groundbreaking film explores the connection between the proliferation of sugar in the nation’s foods and the obesity epidemic, particularly among children. It’s of note that in the 1980s almost no kids had Type 2 diabetes, except for very rare case reports, which is why it was called adult-onset diabetes at the time. But by 2015, a total of 193,000 children and adolescents younger than 20 were diagnosed with diabetes, and about 90 to 95 percent of those cases were obesity-related. Fed Up points out that one in five (nearly 20 percent) of school-aged chil- dren (ages six to nineteen) now have obesity, compared to one in twenty children (5 percent) in the 1970s. The film suggests that the so-called solutions for obesity actually may have helped to make the problem worse. The implication is that the increased sugar, which was added to low-fat foods to improve the taste when the fat was removed, actually made the foods less healthy. And even though fitness club memberships doubled between 1980 and 2000, so did the obesity rate. Between 1977, the start of the low-fat craze, and 2000, the intake of sugar doubled among Americans, as many made the switch to low-fat processed foods. During the same time frame, the obesity rate doubled.
The increase of sugar in American diets has been so alarming that in 2016, the U.S. Food and Drug Administration changed nutrition labels on foods to require a new line for “added sugar” to distinguish between sugar that is in food naturally and sugar added to improve the taste. Researchers from the University of North Carolina found in a detailed study that 60 percent of packaged foods and drinks purchased from American grocery stores—from sauces and soups to fruit juices—have added sugar in some form. The danger is that studies on lab rats have shown that sugar is even more addictive than cocaine. Every child that came of age after 1980 grew up with sugary foods, and sadly, this generation is expected to lead a shorter lifespan than their parents. All the while, we were told fat was the enemy, while sugar and refined carbohydrates were really the culprits. We didn’t know how they were affecting our bodies and continued to consume them even as we tried to lose weight. In the late 1970s during U.S. Senate hearings for the first-ever dietary guidelines for the American people, Senator McGovern, chairman of the committee that created the guidelines, was warned that the science wasn’t there yet to prove whether the change to a low-fat diet would make us healthier. He responded that we didn’t have time to wait for the science; we had to act right away. That turned out to be a deadly mistake.
As I learned more about the obesity epidemic, especially the crisis among our children, I couldn’t help thinking about Sharon and her son (as well as her two daughters), whose own struggle with obesity had brought her to tears in my office that day. If I’d had any doubt before about the next phase of my medical career, it was all gone. I would get board-certified in obesity medicine and become part of the solution.
Practicing What I Preached
In the airport on the way home from the conference, fellow doctors en- couraged me to start studying right away and to take the test when it was offered a few months later. So, I bought the study materials, paid the $1,000 test fee, and dug in, balancing my studies with my daily medical practice. I also decided to practice what I was learning in real time. As I learned something, my patients learned it, too. Some of my patients included nurses and other staff members at the hospital where I worked; a number of them had excess weight and wanted to shed some pounds. I told them the basics, to reduce their daily intake of carbs below 100 grams (with a tar- get of 75 grams). I also explained that if they kept their carbs even lower, below 50 grams, the body would undoubtedly go into ketosis and weight loss would be quick and assured. I had them keep a food log of their carbs. Personally, I wanted to know whether a low-carb diet was sustainable and what kinds of issues my patients might face, so I decided to follow a low-carb eating plan, as well. At six feet tall, I usually weighed in at around 220 pounds, which is considered overweight, according to the Body Mass Index scale used by most doctors (even though I never really thought of myself as overweight, the irony is that that I was just 0.17 pounds from developing obesity). But I wanted to get back down to a comfortable weight, between 190 to 200 pounds. In college, I had been a thin kid, about 180 pounds or so, and had slowly gained forty pounds through medical school, residency, and my early days of practicing medicine. Before starting the low-carb diet, I’d even gotten up to 230 pounds. I’m pretty active, which is generally defined as getting at least 10,000 steps a day. At the time, I played basketball once or twice a week and worked out at least three to four times a week. Over the next eight months to a year, I lost twenty pounds by monitoring my carb intake! Losing those twenty pounds made me feel and look so much better, and the process wasn’t nearly as difficult as I’d imagined. I love to eat, and I found that with a low-carb eating plan, I could still eat enough to feel satisfied and at the same time continue to enjoy many of my favorite foods. I just had to tailor my food choices a bit. As long as I kept my low-carb snacks around and ate enough of the right foods at mealtime, I wasn’t hungry.
The colleagues I was treating also began to lose weight. Their level of activity ranged from person to person; some were very active, while others were barely active at all. But regardless of how active they were, those who stuck to a low-carb meal plan lost weight, while those who faltered did not. Let’s talk about exercise for a moment. Another myth in the weight loss industry is that regular exercise is the key to weight loss. While it is true that exercise helps to burn calories, an hour of intense working out in the gym most likely isn’t even enough to burn off the calories you ate at breakfast. The truth is that 80 percent of weight loss is determined by what you put in your mouth. That’s right—what you eat determines by far whether or not you will lose weight. For example, I had knee surgery in April 2017 and suddenly could no longer play basketball or exercise, as I usually did. I found that super frustrating and worried that I might begin to pick up weight. However, because I stuck to my low-carb diet, just slightly reducing the number of carbs I was consuming, I actually lost an additional ten pounds over the month that I could not move at all.
Now, don’t get me wrong. I don’t want anybody misinterpreting this, telling folks that “Dr. Hunt says you don’t have to exercise!” That is not what I’m saying. Exercise is important for medical reasons, including weight loss, and I highly recommend it to all of my patients. But if weight loss is your primary goal, your primary focus has to be on making good food choices first—foods that are low in carbs and high in proteins and fats—yes, fat! I will talk more in detail about that later. I also will discuss later how to build more physical activity into your daily routines, which actually may be more beneficial than a half-hour or hour-long workout at the gym a few times a week.
Since losing those thirty pounds, I have been able to maintain a low-carb lifestyle and a weight of 190 pounds, a healthy weight for me. I also obtained my certification as a bariatrician (whose title later changed to obesity medicine specialist) at the beginning of 2015. As my co-workers and patients began showing dramatic weight loss results, word quickly spread. New patients began seeking me out for help. Initially, I was not only their medical doctor, but also their therapist, nutritionist, and anything else they needed to be successful—and they were very successful.
The Hunt Theory
During the first year of helping more and more patients to lose weight, I began to notice a peculiar thing: my patients were consuming different amounts of carbs, though all less than 100 grams, and still losing on aver- age one to two pounds a week. I began to think: maybe it wasn’t necessary for everyone to get their carbs down to the standard ketosis range, the theory that Dr. Atkins popularized, to experience consistent weight loss. That’s when I began to develop what I call “the Hunt theory,” the notion that it was possible to develop a personalized plan to help each patient discover his or her “carb number,” the maximum number of carb grams a person can eat in a day and lose at least one to two pounds a week. I developed a plan that helped each of my patients find his or her carb number, and it worked! My plan is not considered a ketogenic diet because some patients don’t have to reduce their carbohydrates to the point of what is considered the ketogenic range to lose weight. Over time, I’ve refined the process, but the premise remains the same: that a “Weight Loss Carb Number” and a different “Weight Maintenance Carb Number” exist for each of us because our bodies burn fat and operate differently. Imagine that—we’re not all the same! People with a more active metabolism can eat more carbs than a person whose metabolism is slower and still lose weight. But both can be successful losing weight and maintaining their weight loss. Once you know your number, weight loss is sure, swift, and above all, healthy.
By the time I went to hospital administrators at Princeton Medical Center to ask for more resources in 2015, they had heard about my successes with treating patients who had overweight and obesity. A few of the top administrators at the hospital had joined my program. Again, timing worked in my favor. Unbeknownst to me, the hospital’s leaders already were considering opening a specialized center for bariatrics, and they had three surgeons on board. But they needed a medical doctor who specialized in obesity to treat patients who did not need or want to go the surgical route. It all came together, and I became the founder and medical director of Princeton Medical Center’s Weight Management Program, located within the Center for Bariatric Surgery and Metabolic Medicine. I established the program’s protocol, based on the four pillars of weight loss:
-Nutrition. We would teach about the benefits of a low-carb diet.
-Behavior Modification. We would use a process called “motivational interviewing,” where a practitioner helps patients to understand on their own why they are eating the way they are eating and help them make the needed adjustments to change.
-Physical Activity. We would encourage them to move their bodies more by exercising and building more movement into their everyday activities.
-Medication and/or Bariatric Surgery. If needed, we would prescribe some of the newer, more effective and safe drugs on the market to assist in controlling hunger and cravings. Also, we would refer a qualified patient to a surgeon to consider one of a number of surgical procedures offered for weight loss. To qualify, a patient would have to have a Body Mass Index (BMI) of 40 and a medical description that used to be called “morbidly obese”; the new, more appropriate term is “Class III Obesity.” A person with a BMI of 35 (now called Class II Obesity) also qualifies if that person has an associated health condition and has failed medically supervised attempts to lose weight.
Penn Medicine Princeton Health dedicated the necessary resources to my Weight Management Program—a nurse practitioner, therapist, nutritionist, personal trainer, and all the equipment I needed. The same year, 2015, I was honored to be named the New Jersey Hospital Association Healthcare Professional of the Year for my work in both internal medicine and obesity medicine. It was a tremendous personal honor, but I was excited that it opened more opportunities for me to talk about obesity.
The need in this country for specialized attention to obesity is indisputable. An estimated 71 percent of all Americans have either overweight or obesity, according to a Centers for Disease Control and Prevention (CDC) study of overweight/obesity trends from 1988 to 2016. The crisis is even more severe among African Americans, where 71 percent of Af- rican American men and 81 percent of African American women has either overweight or obesity, the same study shows. A study by a group of researchers from the Johns Hopkins Bloomberg School of Public Health suggests that if the current trends continue, an astonishing 86 percent of Americans could have overweight or obesity by 2030.
Obesity cuts across all racial and ethnic groups and all income levels. I’ve treated corporate executives, whose struggle is no different than the indigent patients I’ve also treated. According to the Centers for Disease Control and Prevention, more than a third of all U.S. adults suffer from a condition known as metabolic syndrome, meaning they have a combination of at least three medical conditions that increase their probability of developing type 2 diabetes, stroke, and heart disease. Those conditions include high blood pressure, high level of triglycerides, low levels of HDL cholesterol (the so-called good cholesterol), high fasting glucose level, and abdominal fat. CDC data shows that between 1988 and 2012, metabolic syndrome increased across every socio-demographic group and so has type 2 diabetes, and these numbers are expected to grow. These conditions and many others are tied to obesity. But there is so much information—and dare I say, misinformation—out there that people don’t know what to do. The number of weight loss options and programs available is dizzying, and none of them teaches you a thing about the hard-core science behind why people have obesity and why they haven’t been able to keep the weight off. Consider this book as my hand pushing all of that aside. I want you to understand the science in as simple terms as possible, and I want you to have the confidence that you can do this. You can lose weight in a healthy way without being hungry. And you can keep it off!
This book will give you the clarity you need to lose weight and manage it for the rest of your life. Best of all, this program is personalized just for you. Many people have told me that that the books I’ve written with my friends as part of The Three Doctors—The Pact, We Beat the Street and The Bond—made a huge difference in their lives. I truly hope that this book will have the same kind of impact.