What does Comprehensive Treatment for Obesity look like?

We have established that obesity is a chronic disease, as discussed in a previous blog.  Let me not beat a dead horse and elaborate on that further.  Because there is no single cause, there is no single best treatment option.  Effective care requires a structured, individualized plan that uses the right combination of therapies at the right time.  This includes a deep dive into what factors are contributing to an individual’s disease, then developing a treatment plan that works best for that individual.  It is also important to remember that the goal is not simply weight loss, but long-term disease management, improving quality of life, prolonging life, and mitigating risk of comorbidities associated with obesity. 

The most successful treatment programs use a multidisciplinary approach that integrates nutrition, lifestyle change, behavioral support, medical therapy, and when appropriate, bariatric surgery.

Step 1: The Deep Dive

This is the most important step, yet is often skipped over by healthcare providers.  Physicians are trained to sniff out disease with a history and physical exam, order appropriate diagnostic studies, and come up with a rational treatment plan.  However, when it comes to obesity, our judgement is clouded by the stigma, the oversimplified assumption that an individual with obesity simply needs to work harder, eat less, and exercise more.  Sound familiar?  

An initial consultation (by an obesity medicine specialist) should include, but not limited to:

·      A thorough discussion of a patient’s medical and mental health history

·      Track weight history and document success and failure of prior weight loss attempts

·      Testing for obesity-related diseases, such as diabetes, hypertension, and sleep apnea

·      A review of medications that could affect weight

·      Clearly define patient goals, expectations, and readiness for change

Step 2: Nutrition, the foundation

A registered dietician is an essential component of the treatment plan.  I often hear from patients that they can get advice online, through books, or “know enough to read a nutrition label”.  The sheer number of fad diets available speaks to their general ineffectiveness as long-term solutions.  A surgeon spends eight years in college and medical school, six years of specialty training, followed by hours of annual continuing medical education in their specialty, and still relies heavily on the specialty of a registered dietician.  Why then do so many people think this component of treatment is optional?  Remember, obesity is a chronic disease.  Sustainable eating patterns that align with cultural preferences and lifestyle realities are paramount or are otherwise doomed to fail.

The ability to read a nutrition label is important but needs to be placed into the context of individual macronutrient goals.  Micronutrient and vitamin supplements are highly discussed and broadly available but not very well understood.  Spending hundreds of dollars on boutique vitamin infusions?  I’ve heard it said that Americans have the most expensive urine on the planet because we eliminate a majority of the unnecessary supplements we consume.  

Step 3: Physical Activity and Lifestyle Change

Big shout out to James Clear here.  His book, Atomic Habits, was a game changer for me.  Lifestyle change implies a change in the way you are living.  This is not accomplished by intermittently performing healthy tasks.  I cannot overstate the importance of this step, but convincing you to read this book will be far more effective than anything else I could say in this section!  Let’s move on.  

Step 4: Behavioral and Psychologic Support

This is similar to step 3 but emphasizes more of the mental rather than physical change.  There are 100 reasons to eat, but being hungry is only one.  Often, we need help defining the “why?”.  Approximately 15% of patients with obesity have binge eating disorder.  Nearly half of patients suffer from some Disordered Eating Behaviors.  Anxiety, depression, and boredom also apply.  Negative emotions are not the only contributors though.  Social events, celebrations, and foods that are “good for the soul” are often not good for the body.  An experienced mental health provider is crucial to guiding behavioral changes.  Overlooking this step is detrimental to long term success in managing a chronic disease. Unfortunately, mental health is a topic that healthcare providers feel uncomfortable addressing and insurance providers do not like to cover.  

Step 5a: Medical Therapy and the Truth About GLP-1 Medications

Medical therapy plays an extremely important role in battling this disease.  Drugs are often viewed in the context of being a less invasive alternative to surgery.  This binary view to treatment is inaccurate and counterproductive.  Let’s use the analogy of cancer treatment to illustrate.  Sometimes chemotherapy is used before surgery, after surgery, instead of surgery, or not at all depending on the clinical need.  The decision is not based solely on which modality has the least side effects.  Similarly, the choice of medical and surgical therapies should be made with the goal of deploying the most effective combination of tools to meet a patient’s specific health goals.  

There is an extensive list of anti-obesity medications available.  Some of the most used medications include:

·      Stimulants.  Phentermine is a stimulant that reduces appetite.  As a stimulant, it can increase blood pressure and have other cardiovascular risks.  There is a tendency to need increasing dosages over time to maintain the same results.  These can be effective, but only FDA approved for short-term usage (12 weeks).  

·      Combination medications.  Phentermine-topiramate combines the stimulant effect of phentermine with topiramate, which makes you feel full and reduces cravings.  Naltrexone-buproprion combines anti-addiction medication with antidepressant to reduce cravings.  

·      Orlistat works in the gut to reduce fat absorption.

·      GLP-1 receptor agonists and GIP/GLP-1 agonists.  These deserve a lengthier discussion, so continue below.

The newer anti-obesity medications such as GLP-1 agonists (Ozempic, Wegovy) and dual GIP/GLP-1 agonists (Mounjaro, Zepbound) have collectively been proven to be much more effective than the other medications on the list.  For simplicity, these medications are all somewhat similar in that they regulate metabolism and gut function on a hormonal level.  These medications are revolutionary in their effectiveness for weight loss and diabetes.  

Reducing appetite is an established and effective mechanism for weight loss.  However, taking in fewer calories without ensuring that macro and micronutrient goals are met can be dangerous.  This is called starvation!  If these medications are taken without appropriate supplementation, protein intake, and lab monitoring, a patient may risk losing predominantly healthy muscle and bone mass.  These medications are also meant to be used continuously.  When therapy stops, whether from lack of access, inability to afford, or intolerance of side effects, patients tend to regain weight. 

While giving credit where it is due (these medications do work), the discussion must include a warning about side effects and the dangers of misuse and inappropriate prescribing.  These medications decrease hunger and increase satiety.  They “slow down the gut”, which means the stomach is slower to empty.  The gallbladder, small intestine, and colon are also slowed.  This explains some of the more common side effects of nausea, vomiting, acid reflux, and constipation.  The risk of pancreatitis, gallbladder complications, and ileus also increases.  Because gastric emptying is slowed, these medications are generally stopped before elective surgery to prevent aspiration of contents that have failed to leave the stomach.  Recent national reporting, including a. 2026 investigation by USA Today, has highlighted a growing number of lawsuits from patients alleging serious complications after using GLP-1 medications.  These medications remain FDA-approved with strong overall safety profiles.  While lawsuits and adverse event reports do not establish cause, this report should serve as a warning to both patients and prescribers that metabolic medications should not be used casually or without appropriate medical oversight.

See the full USA Today article here.

Step 5b: Surgery

Surgery remains the most effective and durable long-term solution for managing morbid obesity.  This should not be considered a last resort.  Despite its effectiveness, there remains a persistent narrative that surgery is invasive, dangerous, extreme, and ineffective.  The data speaks for itself, yet society, media, and an unfortunate number of healthcare professionals ignore scientific data in favor of opinion and anecdotal claims.  

The safety profile of surgery has improved significantly, even over the past decade.  Multiple factors contribute to this, including specialized minimally invasive training, quality oversight by the MBSAQIP, and utilization of a multidisciplinary treatment approach.  The efficacy of surgery has been proven repeatedly in studies.  Success has been measured not only in weight loss, but in reducing risk of cardiovascular death by 40%, reversing liver fibrosis, reducing the risk of developing over a dozen types of cancer, and prolonging life expectancy to name a few.  

Surgery is not perfect and not without risks.  I would like to empower readers who are considering bariatric surgery with the following check list:

·      Will my surgery be performed at an MBSAQIP-verified hospital?  Check here

·      Does my surgeon offer multiple surgical options supported by the ASMBS?  Check here

·      Want to know your specific risks and anticipated weight loss?  Check here

·      Ensure that your program includes resources from BOTH a registered dietician and mental health provider

Step 6: Long-Term Follow up

This is simple.  Obesity is a chronic disease and requires lifelong follow up.  Would you start blood pressure medication and never check your blood pressure again?  Get treated for cancer, then assume it’s gone forever?  Regardless of the pathway you choose, ongoing follow up is necessary if you hope to keep the obesity in remission.  None of the components above are expendable without risking treatment failure.  Unfortunately, many policy makers and insurance providers fail to see the importance of follow up.  Refusing to provide dietician coverage if a patient achieves a BMI less than 30?  Only allowing for a single lifetime procedure for a chronic disease?  Citing the elevated cost of treatment in order to deny coverage, insurance providers ignore the profound economic burden incurred when the disease is left untreated.  Covering the cost of surgery without providing additional resources will only increase complication rates and total cost of care.  

The Bottom Line

A successful obesity treatment algorithm is not about choosing between diet, medication, or surgery. It is about building a personalized, sustainable plan that evolves over time.  

As healthcare providers, we must offer modern approaches to treating chronic disease or be willing to refer our patients to providers who can.

Obesity is a disease! It’s time to treat it like one.

For decades, obesity has been viewed as a personal failure, an oversimplified equation of willpower, diet, and exercise. The prevailing assumption is that individuals with obesity must overeat, move too little, or lack discipline. This narrative is deeply ingrained in our culture, media portrayals, and unfortunately within the healthcare system itself. This perception is not only incomplete, it is counter to scientific evidence and clinically harmful to patients.

More than ten years ago, the American Medical Association (AMA) formally recognized obesity as a disease state. Obesity is not simply a result of taking in excess calories and failing to burn it off with exercise. It involves dysregulation of metabolic pathways, hormonal signaling, genetic predisposition, environmental influences, socioeconomic factors, and countless other variables. One cannot expect to master advanced calculus with only a basic understanding of addition and subtraction.

Despite this formal recognition by the AMA, the disease model of obesity has not been integrated into everyday medical practice. Unfortunately, many patients seeking help for their obesity are met with “eat less and exercise more” by their clinician. While nutrition and physical activity are undeniably important components of health, reducing obesity management to these two variables alone overlooks the underlying pathophysiology. The human body is extraordinary in its ability to maintain homeostasis. Maintaining a body temperature of 98.6F regardless of the environment is a prime example. The reality is that the body actively resists sustained weight loss through hormonal and metabolic adaptations designed to preserve energy stores. These mechanisms evolved for survival in times of scarcity, but work against patients who are trying to lose weight.

During starvation, there is downregulation of insulin and other hormones as the body transitions away from carbohydrates as an energy source. The body slows down many metabolic functions to try and preserve energy. A 100 calorie snack is handled very differently by the body in these conditions compared to normal conditions. This is why most diets and attempts to lose weight often result in weight loss stalls. The body accommodates and the scale doesn’t change despite taking in very few calories. Even worse, muscle mass and “healthy weight” is often what is lost during dieting. Eating less is not always the answer. Not every calorie is treated equally. Exercise during catabolic states without appropriate nutritional intake can actually be harmful. When patients get frustrated by the lack of progress and go back to eating normally, there is typically a rapid regain of weight since the body is still in survival mode. The yo-yo effect is real.

Even within healthcare, gaps in education and training contribute to the disconnect between scientific evidence and medical recommendations. Healthcare providers who have not had focused exposure to obesity medicine may unintentionally perpetuate outdated models of treatment. Advice that is well-intentioned may lack alignment with contemporary evidence-based strategies. Modern management of obesity should include availability of behavioral therapy, dietary education and guidance, pharmacologic interventions targeting appetite and metabolic pathways, and surgery. These treatment modalities are not shortcuts or cosmetic measures. They are all legitimate medical therapies offered by trained professionals and supported by robust clinical data. Offering medication without dietary guidance often leads to unintended side effects and potentially patient harm. Surgical intervention outside of a dedicated multidisciplinary program has higher failure rates and more complications, which in turn propagates the narrative that surgery “is dangerous” or “doesn’t work”.

The persistence of stigma has consequences far beyond hurt feelings or social discomfort. It negatively impacts access to care, insurance coverage, legislative decisions, and patient willingness to seek treatment. The evolution of our understanding of obesity can be compared to shifts in how society came to view depression, PTSD, addiction, and cardiovascular disease. When obesity is viewed as anything other than a medical disease, individuals delay medical attention, internalize blame, and devalue the importance of follow up. A lack of understanding negatively impacts policy decisions and resource allocation, which further limits development of comprehensive care models.

Reframing obesity as a disease does not negate the importance of lifestyle choices. Rather, it places those choices within an accurate biological and clinical context. It acknowledges that sustainable change often requires structured support and evidence-based medical guidance. It shifts the responsibility toward a partnership between patient and healthcare provider. If we as healthcare providers expect the patient to do their part, it is on us to deliver informed, compassionate, and evidence-based care.

The truth about hiatal hernias

So, Your Doctor Says You Have a Hiatal Hernia—Is That Bad?

Let’s break it down.

First Things First: It’s Common

Hiatal hernias are actually pretty common. There are different types, each with varying symptoms, risks, and treatment approaches. In this post, I’ll cover the basics and offer a clear overview—no complicated jargon (for the most part). We’ll save the deep dive for your appointment!

What Is a Hiatal Hernia?

Your diaphragm, a large muscle that helps you breathe, separates your chest (thoracic cavity) from your belly (abdominal cavity). Above the diaphragm: your heart, lungs, and esophagus. Below it: your stomach, liver, intestines, etc.

There’s a natural opening in the diaphragm—called the hiatus—that allows your esophagus to pass through and connect to your stomach. A hiatal hernia happens when part of the stomach pushes up through this opening into the chest.

Why the Hiatus Matters

The area where the esophagus transitions to the stomach is called the gastroesophageal junction—and it’s where your body’s natural reflux "valve" lives. This valve relaxes to let food into the stomach, then contracts to keep stomach contents from coming back up.

But when pressure increases in your abdomen—like from coughing, sneezing, lifting, weight gain, or pregnancy—it can push the stomach upward through the hiatus. That disrupts the valve and often leads to acid reflux or GERD (gastroesophageal reflux disease).

Types of Hiatal Hernia

There are four types of hiatal hernia:

• Type 1: Sliding Hernia
  The most common kind. The gastroesophageal junction moves (or “slides”) above the diaphragm. These typically cause reflux and are managed with medication. Surgery is only needed if symptoms persist despite treatment.

• Type 2: Paraesophageal Hernia
  The junction stays in place, but part of the stomach pushes through the hiatus. Much less common and more likely to cause swallowing issues than reflux.  These should be repaired surgically.

• Type 3: Mixed Hernia
  A combination of types 1 and 2—the junction and part of the stomach move above the diaphragm. These vary in size and severity, but often require surgical repair.

• Type 4: Complex Hernia
  The stomach plus another organ (like the colon or spleen) move into the chest. These also typically require surgical repair.

Why Fix a Hernia?

You might wonder, “What happens if I don’t fix it?” Let’s break this down into two main types of problems that can develop.

1. Reflux-Related Problems

Acid reflux might seem like a nuisance, but it’s more serious than you think. Chronic exposure to stomach acid can cause:

• Inflammation

• Ulcers or bleeding

• Barrett’s esophagus (a risk factor for developing cancer)

• Esophageal cancer

Concerned about long-term medication use? It's a common question. Yes, acid-reducing meds have side effects. But overall, they’re safer than surgery and much safer than letting reflux go unchecked.

2. Mechanical Problems from the Hernia Itself

When the stomach lives in the chest, it crowds out space meant for your heart and lungs. This can lead to:

• Trouble swallowing

• Chest pain or shortness of breath

• Aspiration (food/liquid going into the lungs)

• Pneumonia or chronic lung disease

• Gastric volvulus – a dangerous twisting of the stomach, which can cut off its blood supply and become life-threatening without emergency surgery

Bottom Line

Hiatal hernias are common—and not always a cause for alarm. Here’s what to ask your doctor:

• What type of hernia do I have?

• Are my symptoms under control?

• Do I need a surgical opinion?

If you have a small sliding hernia with manageable symptoms, you probably don’t need surgery. But if it’s larger or your symptoms are worsening, it’s worth seeing a specialist—even if you’ve been told your hernia is “too big to fix” or has come back after prior surgery.

When in doubt, ask and find out.