Your questions about weight management, answered with Dr. Tiffany Shiau

Written by Alicia Estrada, Bold's head trainer

Maintaining a healthy weight plays a vital role in our overall well-being as we age. As Bold’s head trainer, I often hear from members who are looking to lose or gain weight, and many are searching for the “secret” to effective weight management. While there’s no one-size-fits-all solution, the good news is that developing consistent, healthy habits can make a meaningful difference at any age.

I spoke with Dr. Tiffany Shiau, board-certified physician in internal medicine and obesity medicine, to have some of your top questions on weight management answered. As a primary care physician for nearly a decade, she now focuses on practicing as an obesity medicine specialist and is a believer in personalized and empathetic healthcare for all. Let’s dive in!

What is BMI, and why is it important?

BMI is a calculated measure of one’s weight relative to one's height (see CDC’s BMI Calculator). An elevated BMI suggests that a person likely has a higher-than-normal body fat percentage relative to their height.

The four main BMI categories are:

Underweight (Less than 18.5)
Normal/Healthy weight (18.5 to 24.9)
Overweight (25 to 29.9)
Obesity (30 and above)

BMI is a quick, simple, and low-cost screening tool to estimate a person’s risk for chronic weight-associated medical conditions. For example, a BMI in the overweight or obese range suggests that the person may be at a higher risk for medical problems such as high blood pressure, high cholesterol, diabetes, heart disease, etc., relative to another person whose BMI is in the normal range.

It should be noted that BMI is NOT a direct measure of a person’s body fat. For example, BMI cannot distinguish between lean body mass (which includes muscle mass, as well as bone and organ mass) and fat mass, nor can it indicate the location of fat in the body. This is important because we know that the fat surrounding our abdominal organs, commonly referred to as the “visceral fat,” carries a higher health risk compared to body fat in our hips and thighs.

Other limitations of BMI include that it does not account for age, sex, and ethnicity, as well as variations in specific body types. For example, a professional athlete or bodybuilder may have an elevated BMI due to higher-than-average muscle mass, rather than excessive body fat.

What is a healthy weight / BMI for older adults?

While there is no consensus on the optimal BMI for adults aged 65 years or older, some data suggest that a BMI range of 24-31 is associated with better health outcomes in this age group.

But rather than focusing on a specific weight or BMI number, it’s more important to consider a person’s whole health.

This can be done by incorporating other clinical measures of health, including:

Laboratory tests for cardiometabolic health.
DEXA scan (a X-ray study) or other body composition studies to evaluate fat-free mass (which includes muscle mass), fat mass, body fat percentage, and visceral fat.
Body composition studies, or measuring one’s waist circumference and using this value, as well as further calculating the “waist to hip” ratio, can be a helpful clinical surrogate to approximate visceral fat and therefore a person’s cardiometabolic disease risk.
Clinical history and physical examinations that evaluate frailty and high fall risk in patients with a low BMI, considering their overall health. Some of the diagnostic methods include fall screening questionnaires, the Timed Up and Go (TUG) test, and hand grip strength, among others.

Compared to people in the normal or overweight/obesity BMI groups, people with lower or underweight BMI are at higher risk for osteoporosis (low bone density), and the negative health outcomes associated with this, such as falls leading to major bone fractures and increased hospitalization and mortality in this age group.

By understanding a person’s health picture, clinicians are able to individualize care plans and provide BMI recommendations. The goal is to prevent a person from being underweight and therefore clinically frail, but also prevent another person from having too much fat mass, which places them at a higher risk for developing or having uncontrolled cardiometabolic diseases.

What should older adults know about maintaining a healthy weight?

There is no precise “one weight fits all” or “one BMI fits all.”

I recommend that people discuss their weight and BMI with their primary care physician (PCP) during office visits. This helps each person understand their numbers and learn if and how weight can be optimized to enhance their overall health.

Here are some other things to keep in mind:

Focus on a balanced nutritional pattern that increases the intake of whole foods such as vegetables, legumes, whole grains, nuts, seeds, and a variety of sources of protein, rather than a specific “diet.”
Limit ultra-processed foods.
Stay physically active. A combination of different movement modalities is ideal. However, especially important among older adults are strength- and resistance-based exercises that help build and maintain muscle mass. The goal is at least twice a week, but more is encouraged.
Maintain connection. Strong social ties are associated with improved mental health and reduced loneliness. Having a social network can also increase communal accountability and other health-enhancing behaviors.
Optimize sleep and chronic stress management. Poor sleep and/or excessive chronic stress can lead to disruption in the hormones that regulate hunger, appetite, and metabolism, therefore contributing to weight gain.

How can I lose weight?

Healthy eating

Get adequate protein: It takes the body longer to digest protein, which leads to a sustained feeling of fullness, also known as satiety. Having prolonged satiety helps stave off hunger and reduces consumption of less healthy foods. Protein is also essential for building and maintaining muscle mass and bone density. We recommend obtaining protein from a variety of sources, including meats, seafood, dairy, eggs, as well as plant-based options such as nuts, seeds, soy-based foods, legumes (beans, peas, lentils), and whole grains.
Increase fiber intake: Fiber (examples: vegetables, legumes, fruits, whole grains, nuts, and seeds) also increases satiety. Additionally, fiber enhances our digestive health and is beneficial for cholesterol metabolism.
Limit ultra-processed foods. These foods usually contain excessive amounts of added sugars and/or saturated fat—examples include sugary drinks, packaged sweets, and fast foods.
Stay hydrated.
Incorporate healthy fats, also known as unsaturated fats. Some examples include fatty fish such as salmon and sardines, avocados, olive oil, and nuts and seeds.
Consider scheduling a consultation with a registered dietician if this is a cost-feasible option, i.e., a benefit built into some health plans. The personalization and behavioral-changing aspects of this can complement other weight management strategies very well!

Exercise

Rather than strictly framing it as ‘working out,’ it may feel less daunting if we shift our thinking to simply being an effort to increase movement or physical activity. For example, a previously sedentary person with underlying mobility issues can consider starting with seated options. This can include chair yoga or seated strengthening exercises, i.e., repetitions using dumbbells or resistance bands. For someone who has not engaged in intentional cardiovascular activity for a long time, consider starting with 10-15 minute brisk walks 2 to 3 times a week initially, and incrementally increase the intensity and duration as time passes and their conditioning improves.

As you add more movements, celebrate your successes and keep going! Do not feel discouraged if there’s a “lapse” in your exercise habits. Simply acknowledge it happened and pick it back up! If it becomes a recurring pattern, I recommend consulting with the healthcare team to explore how, as a team, you can identify the barriers affecting your consistency and develop solutions to address them.

Aim for a mix of exercise types and work towards the CDC-recommended guidelines:

Physical activity: 150 minutes a week (or 30 minutes a day on most days of the week) moderate-intensity activity, i.e., brisk walks, OR 75 minutes a week vigorous-intensity activity, i.e., jogging/running.
Strength/resistance based: 2 or more times a week of muscle-strengthening activities, ideally to cover all major muscle groups such as legs, hips, back, shoulders, chest, abdomen, and arms.

Weight loss medications

There have been significant advances in the last decade in the efficacy of newer anti-obesity medications. A specific example is the class of drugs referred to as the GLP-1 medications. These work by mimicking a natural hormone made by our body, called GLP-1. An increased level of GLP-1 helps in hunger regulation, increased and sustained satiety, and has favorable effects on insulin resistance and cardiometabolic health. Understandably, these benefits have made GLP-1s a desirable medication class for many people.

However, it is essential to note that GLP-1 medications aren’t a practical fit for everyone, since each medication carries its own profile of potential side effects. For GLP-1s, the side effects are usually manageable and short-lived. But there may be other barriers, including challenges to access, due to limited or a lack of insurance coverage for GLP-1 medications, when prescribed for weight management purposes.

There are non-GLP-1 anti-obesity medications that have been around longer, and can be effective and cost-efficient in the right patient population. Suppose you believe you are a candidate for anti-obesity medications. In that case, I recommend consulting with your primary care physician (PCP) or an obesity medicine specialist regarding your diagnostic and treatment options, as these should be tailored to your specific needs.

Who can I talk to about weight loss?

A primary care physician (PCP) visit is a great starting point to discuss weight management. There are some questions you can consider asking at the visit:

Is my current weight ideal for my overall health? Are there tests to help evaluate my overall health?

Do you recommend any resources or referrals, such as a registered dietitian, guided exercise classes or programs, a therapist for stress or mood management, or literature sources on exercise, nutrition, sleep, or stress, that can help me improve my lifestyle habits and sustain them in the long run?

Am I eligible for an anti-obesity medication?

If I’m eligible for an anti-obesity medication, what are my options?

What is the expected clinical efficacy for the recommended medication(s)?
What are the potential side effects of the recommended medication(s), and how can we prevent or manage these reactions?
What are the monitoring parameters and visit frequencies after I start the medication?

If I’m not eligible for an anti-obesity medication, what’s the next step? Some possible (but not all-encompassing) scenarios include:

You have a healthy weight/BMI, and therefore, no weight loss medication is indicated from a health perspective.
Your BMI may or may not be in the eligible range to start a weight loss medication, but you need more testing to determine if there are additional medical conditions related to excess weight. This helps your care team understand your overall health and can help narrow down therapeutic options. Test results may also increase your chances of having your health plan cover the medication if you have concurrent weight-associated chronic medical conditions.
You have a markedly elevated BMI, and current medication options are unlikely to bring your weight down to a healthy range realistically, or the more effective weight loss medications are cost-prohibitive. In that case, your provider may recommend considering a referral to the bariatric surgery office to discuss insurance-covered surgical options.
If your PCP has time or resource constraints and is unable to provide comprehensive weight loss treatment, but believes that you can benefit from medical weight management, consider asking for a referral to an American Board of Obesity Medicine (ABOM) certified physician in your area, or via reputable virtual health (aka “telehealth”) platforms that employ ABOM-certified physicians.

What are the best exercises to lose weight?

The best exercises are ones that you enjoy and would want to continue doing in the long run.\ Factors to consider when it comes to physical activities to target weight loss and maintenance:

Enjoyment. Keep it fun; this helps with consistency!
Mix of modalities:
- Strength-based exercises to increase muscle mass.
- - Examples: Body weight-based exercises (e.g., lunges, planks, squats, push-ups) or weight-based exercises (e.g., weight machines, dumbbells, kettlebells). Muscle mass burns more calories at rest than fat mass, and therefore is conducive to weight loss.
- Cardiovascular exercises: These are activities that increase our heart rate and improve cardiovascular health, in addition to increasing energy expenditure, which helps with weight loss.
- - Examples include walking, jogging or running, chair cardio, dance, and swimming, among others. If you have joint issues, consider low-impact options like cycling, swimming, and Bold’s low-impact classes.
- Bonus: Consider adding flexibility and mindfulness exercises, such as yoga or Tai Chi, to your routine. While not known for high energy expenditure, these exercises can improve one’s balance, mobility, and mental health, as well as prevent “burnout” from other types of exercises.

I’ve never been able to lose weight before, how do I start?

First of all, it is never too late, and I’m glad we’re talking about it!

I recommend scheduling a dedicated visit to discuss your weight with your primary care physician or an obesity medicine specialist to review your weight and health journey in detail.

In 1998, the National Institutes of Health declared obesity a “complex multifactorial chronic disease.” It is essential to emphasize the complex etiology and chronic nature of obesity, as this requires a personalized, sustainable, and evidence-based approach to achieve the best long-term outcomes.

Having a detailed conversation about your weight journey can uncover the multiple causes contributing to you having excess adiposity (or fat mass). Some topics for discussion include:

Factors that contribute to excess weight:

Genetics: Family health history, including age of onset and pattern of obesity in affected family members, etc.
Biological: Metabolism changes, insulin resistance, medication use, hypothyroidism, etc.
Psychosocial: Chronic stress, depression, anxiety, disordered eating patterns, etc.
Environmental: Limited access to healthy foods, economic instability, cultural norms around food and body types, etc.
Behavioral: Sedentary lifestyle, insufficient/poor sleep, chronic consumption of processed foods, etc.
Previous weight loss strategies: How effective or ineffective were they? Why do you think they did not work or stopped working after a while? Review the physiology involved in weight regulation.

By identifying the risk factors and how they collectively contribute to excess weight, your care team can tailor a treatment plan to help you achieve a healthy weight. The plan should focus on addressing the underlying causes, while also considering a goal weight range that’s rooted in improving overall health, rather than targeting a specific number on the scale.

To maximize your long term health/weight success: once the long term weight-related health goals are established, set a few shorter term tasks to complete within a specified timeline, specify the resources and strategies needed to achieve them, discuss how accomplishing these tasks will help you reach the long term health goals, and lastly, set the next appointment time to revisit these topics.

Remember, Bold has thousands of online classes to help you increase your physical activity levels and support weight management. Stay active, see you in class!