Dr. Keith Roach

DEAR DR. ROACH: I am 5 feet, 1 inch tall, weigh 200 pounds, and have found it next to impossible to lose weight, even though I’m active. I swim, walk, or do yoga almost every day. I avoid most processed foods and stick to organic vegetables and pasture-raised eggs and meat.
My doctor put me on metformin; I lost 7 pounds ,but that was it. I do have insulin resistance due to polycystic ovary syndrome (PCOS), and they are concerned about my cardiovascular health.
I’m not sure if metformin helped me. Are there other medications or supplements you might recommend to help with weight loss? — Y.F.
ANSWER: There is reason to be suspect about the benefit of weight loss for many people. What we define as “overweight” (a BMI between 25-30) has a lower risk of overall mortality, compared to a “normal weight” (a BMI between 18.5-24.9). The risk is even less risk compared to people who are “underweight” (a BMI less than 18.5). Losing weight for people who are in the “overweight” category has very little benefit when it comes to improving health.
The concept of a BMI as a measure of health is deeply flawed. While there are attempts to make a new single-number calculator that better expresses risks, I find the combination of waist size and BMI to be helpful. Abdominal fat really does impart greater health risks. A muscular person with a narrow waist can have the same BMI as a nonmuscular person with a large abdomen, but they will have very different risk profiles.
That being said, your calculated BMI is 37.8, in the range called “class 2 obesity.” The term “class 3 obesity” is used when a person has a BMI over 40 or when a person with a BMI between 35-40 has medical complications of obesity, such as sleep apnea or diabetes. Nearly all people at this BMI will have a significantly higher risk of chronic conditions, including heart disease, compared to people who have a BMI less than 30.
As such, treatment to reduce risk should be discussed. This is particularly true in your case, since you are at an increased risk for diabetes due to PCOS.
A healthy diet and regular exercise remain the cornerstone of improving health in people who are overweight or obese. Even if you don’t lose a single pound, eating less-processed food and getting regular exercise greatly improve health, compared to a typical American diet and a sedentary lifestyle. However, there is no good evidence that organic produce has any health benefit compared to conventional produce. I also don’t believe any over-the-counter supplements are safe and effective for sustained weight loss.
The new types of weight-loss drugs like tirzepatide, which is similar to semaglutide, are more effective than other currently available drugs. They also have the proven benefit of decreasing cardiovascular risk. But these are new drugs, and many physicians aren’t comfortable prescribing them yet. However, many primary care doctors like me and all physicians specializing in weight loss are using these drugs when appropriate for people who already have or are at a high risk for an obesity-related illness.
An expert in obesity medicine would be an appropriate consultant for you. I want to end by saying that many medicines we use either directly cause people to gain weight or make it hard for them to lose weight, so a comprehensive review of all medications is essential.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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