Karen Holtmeier, MPH, RD, LN, (pictured) works with a variety of patients in counseling them through their struggles of excessive weight, teaching them to understand their physiology as well as eating strategies for healthier nutrition to effectively bring down their weight.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net

Millions of Americans are gaining dangerous amounts of weight, which can be a precursor to a variety of serious health issues including metabolic syndrome, prediabetes, and in advanced cases, type 2 diabetes. One indicator of the severity of the obesity epidemic in the United States comes from the Centers for Disease Control and Prevention’s (CDC) most recent projections published earlier this year. The CDC now estimates that there are 79 million people who are prediabetic in the U.S., and the numbers are predicted to increase.

As such, weight management centers are beginning to become an increasingly important specialty in the U.S. Weight management centers specialize in helping people lose weight employing methods such as very strict diet plans or bariatric surgery. In the former method, weight centers often use the Very Low Calorie Diet (VLCD), which involves using liquid shakes and other meal replacements as the main means of nutrition initially. Gradually, patients eat solid foods, and eventually transition back to traditional whole foods, once the targeted weight loss has occurred. The VLCD is utilized to lower the caloric intake of people who typically consume excessive calories on a daily basis. These centers also use exercise and counseling as part of the plan to lose weight.

Bariatric surgery is another strategy to help people lose weight, but it is also more recently being considered as an interventional therapy indication for some people with type 2 diabetes. The use of bariatric surgery for people with type 2 diabetes is still a relatively newer treatment, and only indicated for people who fit a certain criteria. Often, patients undergoing bariatric surgery are required to lose weight prior to their procedure and these centers employing VLCDs can help patients lose weight preoperatively.

Some of these centers may employ only the VLCD and not utilize bariatric surgery. Other centers employ surgery as their main means for helping patients to lose weight. In both types of centers, patients need to learn how to eat differently.

Karen Holtmeier understands both the physiology and psychology of her patients who struggle with their weight. The registered dietitian and licensed nutritionist was self-conscious about her weight when she was growing up, so she committed herself to studying nutrition to learn how to eat properly and help others with maintaining a healthy weight.

Early on, Holtmeier learned about VLCDs, and she saw the value of these diets and the importance of teaching patients not only proper nutrition, but understanding the underlying causes of why they were struggling with their weight. Armed with this information, Holtmeier helped co-found the Medical Weight Management Centers in Minnesota.

Today, she is the owner of three of these centers. Holtmeier’s centers take a comprehensive, multi-disciplinary approach to weight loss. They oversee patients who want to lose weight through diets, including those with existing chronic conditions, and help bariatric surgery patients with their preoperative weight loss requirements.

DiabetesCare.net recently spoke with Holtmeier to find out further about how weight management centers approach their care for various patients, including those with prediabetes and diabetes.

DiabetesCare.net: For those who may not be familiar with a weight management center, can you provide an overview about what they are?

Holtmeier: A medically-managed weight loss center incorporates plans for all levels of weight loss and can also help bariatric surgery patients lose weight prior to their procedures. Ideally, these centers have multi-disciplinary medical professionals including a bariatric physician who is not a surgeon, a dietitian, behaviorist, and exercise physiologist, in addition to registered nurses and medical assistants on staff.

We estimate these patients can lose three to five pounds per week depending on the size of the person. A woman would probably average three pounds and a man five pounds. This also depends on how much weight they have to lose as well as their height too.

Weight centers typically have their patients on meal replacement products in the beginning, then gradually supplement normal food back into their diets, and eventually they end up with three meals a day.

In some cases, we have had patients on all liquids for up to a year, and they have lost 150 to200 pounds.

DiabetesCare.net: Can you talk about the primary differences between a weight management center as compared to a primary care practice in terms of helping patients to lose weight?

Holtmeier: In today’s world, the primary care practice treats the related conditions of obesity such as hypertension, high blood sugar, high lipids, and even more chronic or acute disease states. Most primary care physicians are not trained to treat obesity, but more so, do not have the time under insurance regulations. Insurance even prohibits payment for treatment in most cases. A patient can be covered under their insurance for hypertension, elevated lipids, diabetes, but obesity must be listed as the first health problem, and it is not covered by insurance.

DiabetesCare.net: How do most of your patients come to find you?

Holtmeier: Most of our patients are self-referred or came through knowing someone who has been on our program. Many of them are return patients who have lost 50 or more pounds in the past and know that they can do it again on our program.

DiabetesCare.net: Can you talk about your specific care approach in helping people lose weight and attain their goals?

Holtmeier: One of my most important approaches as a dietitian is to review their health and family history. In most cases, the patient has a family and/or personal history of obesity, diabetes, and heart disease including, early myocardial infarction and frequently death. They are “professional dieters,” people who have tried to lose weight many times without success.

They know what they are supposed to do, but they are not able to do it well due to their physiology. You can give them self-esteem right away by explaining to these patients how their physiology drives their behaviors. In order to function or perform at their daily tasks, they need to eat to avoid headaches, lightheadedness, sleepiness, or a lack of energy. The high carbohydrate diets that we have been teaching them for the past 30 years have also contributed to this problem.

During my consultation with them, I review their eating habits and show them how what they are eating contributes to their lack of success. I affirm to them that they are genetically pre-disposed to be good at storing fat, and these patients are almost always insulin resistant.

Using a meal replacement weight loss program provides the right kind of nutrients while controlling calories and helps to re-establish a more normal metabolic cycle for them. They put in a certain amount of food in the right nutrient composition, and their body begins to normalize its insulin production and allows the body to burn its own fat for fuel.

I encourage them to lose as much body fat as possible to reach a reasonable body weight while they are in the weight loss mode. I teach them about controlling their carbohydrate intake in a normal food plan, and I encourage them to use meal replacement products as part of their maintenance plan (post weight loss).

Affirming to these patients that the conventional nutrition information of the past 30 years has not worked well for them is the key to gaining their trust, and supporting their weight loss on meal replacements helps them experience success.

DiabetesCare.net: If someone has prediabetes or diabetes, do you have a special approach in his or her treatment and care?

Holtmeier: Mostly we pay attention to monitoring their medications. If they are on insulin, it must be reduced when their calorie levels are reduced. We have them check blood sugars and report back to our staff physician and continue to reduce insulin as much as possible. Other medications will also be monitored with weight loss. Metformin is usually continued during treatment.

DiabetesCare.net: One of the more exciting treatment facets of diabetes is the inclusion of bariatric surgery as an indication for people with Type 2 diabetes who are not successful in obtaining control via other therapies. How do you counsel these patients in terms of their expectations postoperatively?

Holtmeier: One of my biggest concerns with bariatric surgery is follow-up care. These patients must be taught that they are insulin resistant and that they cannot eat sweet foods and drinks such as soda, malts, or anything else that goes down quickly to restore blood sugar when they can’t eat proteins or other foods that are either contraindicated or don’t agree with them. Their physiology changes postoperatively, and some stomach enzymes are not present for digestion after the surgery.

Postoperatively, bariatric patients can gain their weight back if they are not properly educated and monitored about their food intake. I know surgical treatment seems to aid diabetes immediately, but for most patients that are in the 100 to 200 pound range above their ideal body weight, VLCD/LCD treatment can be as successful as bariatric surgery with fewer complications and far less cost. It is amazing that surgery is covered by insurance, while less invasive, less costly treatment using meal replacements is thought to not be appropriate or successful.

DiabetesCare.net: Patients who have bariatric surgery need to learn to eat differently postoperatively, what are the considerations there in terms of learning to eat?

Holtmeier: While I no longer see post-surgery patients, they need guidelines similar to those that we give our meal replacement patients, except they usually have less capacity for amounts and variety, due to their surgery.

DiabetesCare.net: Losing weight can be compared to quitting smoking, where it may take numerous tries before people can successfully keep excess weight off. How do you counsel these patients to make them understand they can break the chain of their habits and keep the weight off?

Holtmeier: Obesity is a chronic disease, so you always have to work at it. The difficulty as compared to smoking is that you do have to consume food. I counsel my patients to continue to use meal replacements. We use meal replacements as a part of maintenance and we have found this to be significant. It includes a structured plan for how much carbohydrates, proteins, and fats they should be eating.

People also have to learn to narrow their food choices to simple foods that work: a salad, a vegetable, a meat, fruit, milk, and a small amount of starches. We have to change our choices in our world of convenience foods. For example, eating protein in the morning, as opposed to fruit, cereal, and toast. It’s a change from the conventional nutritional wisdom of the past 30 years, which has helped lead us to these prediabetes and diabetes epidemics. When people are properly fed, they are able to carry out the correct behaviors.

To find out more information about medically-managed weight loss centers, you can go to Holtmeier’s website at: http://www.medicalweightcenter.com .

Originally posted by DiabetesCare.net on August 12, 2011.