Crystal Blank had tried all sorts of diets and was well familiar with spending more money on various shakes and supplements than she did on the food she ate. She worked hard at the gym twice a day. She lost 20 pounds more than once. She always gained it back.
In March 2018, she and the family – husband, Jonathan, and their four kids ranging in age from 9 to 16 – took a break from home life in Brighton to spend a few days in Laguna Beach, California. Jonathan snapped a cell-phone photo of Crystal and her two daughters at the beach and posted it on Facebook. “You’re never in pictures with the kids,” he told her.
Despite being down 20 pounds at the time, Blank was mortified. “I didn’t realize how huge I was,” she recalled. She insisted that Jonathan pull the photo and resolved to take a drastic step to get her weight under control.
At UCHealth Family Medicine – Westminster, she sat down with Dr. Julie Paranka, her primary care physician. Blank was in tears. She told Paranka about all the dieting and exercise and how none of it seemed to stick. She wanted to have bariatric surgery, which reduces the size of the stomach and routinely brings sustained weight loss of 100 pounds or more.
Paranka listened, then told her, “Dr. Perreault has a program that might work for you.”
Obesity as diagnosis
Dr. Leigh Perreault is a UCHealth and University of Colorado School of Medicine endocrinologist based at the UCHealth Family Medicine – Westminster clinic. The program was called Pathweigh. It was a pilot study Perreault had designed to see if integrating weight loss into primary care could help patients not only lose weight but also address the various health problems that can accompany obesity.
“The bias in our society and the medical profession is that obesity is something people should be able to control on their own,” Perreault said. “It’s crazy that it’s entrenched in our thinking.”
Perreault felt that the status quo of treating often-serious health problems related to obesity in primary care – type 2 diabetes, sleep apnea, cellulitis, hypertension, osteoarthritis, liver problems, depression, reproductive issues, the list goes on – was failing patients.
With Pathweigh, Perreault said, “We’re doing something that no one has done before, which is prioritizing weight in the clinic, as opposed to everything else.”
She persuaded UCHealth’s Epic electronic health record team to create a Pathweigh tool in Epic that involved adding “obesity” and “weight management” as diagnoses as well as several questions to ask of patients who receive such diagnoses. She then set up a study that would involve herself and Dr. Erik Kramer treating the Pathweigh group in Westminster and two doctors at UCHealth Internal Medicine – Lowry who would serve patients in the control group. On Jan. 1, 2018, the 18-month pilot study launched. It was rolling along when Crystal Blank sat down with Perreault that spring.
Blank brought up bariatric surgery. Perreault told her she wasn’t a candidate – she wasn’t heavy enough for it. Blank started to cry. “But I can help you,” Perreault said. “I want you to be healthy and happy and the best version of you. And this isn’t the best version of you. So let’s get you there.”
A weight management program within primary care
Blank joined the study’s Pathweigh group. Perreault reviewed Blank’s bloodwork and asked questions about her history of weight gain and loss (someone who gains weight after childrearing – as had been the case with Blank – may respond to different treatments than someone who has been obese since childhood, for example) and how her weight affected quality of life. She screened Blank for binge eating, depression, anxiety, and attention deficit disorder. She also asked Blank if she had weight-related health issues, which she didn’t. Then she asked her what her target weight might be.
“I want to get back to when I felt my healthiest,” Blank told her. If I can get to a size 12, that’s where I felt happy.”
She was wearing a size 24 as she spoke. Blank added that, when she got to a 12, she’d splurge on a good photographer for family portraits.
Perreault prescribed Blank two obesity medications – appetite suppressants phentermine and topiramate – and told her that she might think of them as statins: once you’re on them, you stay on them. There were no concrete dietary limitations besides the common-sense suggestions to control portions and avoid junk food, soft drinks, and sugar fixes. Blank was already exercising plenty. Perreault and Blank met to monitor progress every three months at first, and later, every six months,
As Blank’s clothing, as she put it, “started getting bigger,” she put money away to pay a photographer. When her kids hugged her, they said things like “it’s so weird to hug you, mom – we can put your arms around you now!” By the summer of 2019, Blank was back in a size 12. It rained the summer day the photographer came; she smiled right through it. Jonathan was more than welcome to post the winning shots on Facebook.
For lunch at Panera in early January 2019, Blank ordered half a Caesar salad with an apple for a side. She was in a size 9-10 now. She ate about half the salad and saved the apple for an afternoon snack at the Westminster memory care facility where she runs the human resources department. The medicine helps her recognize when she’s full, and she just stops eating, she explained.
“Before, I could eat as much as my husband,” she said.
Blank didn’t actually know how much weight she’d lost – she doesn’t own a scale. Perreault says it was around 100 pounds. While her results have been extraordinary, many in the Pathway group lost 30, 40, 50 pounds or more and kept it off, Perreault says. Among the 109 Pathway patients, the average weight loss was 17.4 pounds – as compared to 5.3 pounds among the control group at the UCHealth Lowry clinic.
The numbers tell only part of the story. The Pathweigh pilot study showed that working on an ongoing basis with a primary care doctor (as well as onsite resources such as behavioral health specialists) and harnessing the power of an electronic medical record can bring sustained weight loss and the mental and physical health benefits that come with it.
“I didn’t feel good about myself. I didn’t want to shop. I didn’t want to do anything,” Blank said. “Now I want to look good, and I feel good, and I want to wear chic clothes.”
She’s also more active – and not just “killing myself trying to lose weight,” as she put it, at the gym.
“I feel like I’m more active in a different way. I’ve always loved hiking and being outdoors. But I didn’t want to get into activewear at all. And I would overheat, and that wasn’t a good thing,” Blank said. “I like being outdoors a lot more, doing stuff with the kids, shooting hoops outdoors with the boys.”
The Pathweigh pilot’s results are awaiting publication in the journal Obesity. UCHealth has already seen enough: it has trademarked PATHWEIGH and is rolling the program out to all 54 of its primary care clinics over the next five years. Perreault hopes that other health systems start using it too. Hundreds of UCHealth Family Medicine – Westminster patients have joined the voluntary program, she says. She and colleagues see about 10% of them for bariatric surgery; about 80% are prescribed medication.
“Not everybody has to have surgery to lose a lot of weight. People need the right medicine, the right coaching, and an ongoing relationship with a person who’s going to be their mentor, coach, and someone who can help them deal with speed bumps along the way – because it’s a journey,” Perreault said.
Over time, Perreault expects trends that emerge in anonymized data from Pathweigh’s past to feed back into the clinic and help doctors see what medicines and approaches seem to work best with different sorts of future patients. For Blank, Perreault seems to have gotten it right already.
“This definitely works,” Blank said. And it’s about more than pounds lost or sizes shrunk: “I think people don’t realize that, if you get your weight under control, a lot of the things that you’re feeling will start to go away. Your body just starts to feel good and everything starts to work right again.”