1.       Phentermine. This has been on the market and is still the best. According to some studies, a 5 pound weight loss (vs placebo) can be expected in 1 year. I usually see a minimum of 30 pounds. Phentermine is cheap and safe. It should be used with caution id you have high blood pressure or heart disease. Some studies claim addictive properties, but I have never had any patient become addicted to this—-ever!

2.       Phentermine + Topamax. This is a great combination since it not only suppresses appetite but also curbs carbohydrate craving. Studies show an average of 19 pounds weight loss, but I also see greater than 30 pounds in most of my patients. This is very well tolerated but Topamax can cause memory loss at higher doses and should not be used if you have glaucoma. In addition all women of child bearing ages need to do a monthly pregnancy test since it is devastating to the fetus. The brand, QYSMIA is not better than the generic components and can cost $200/month vs $15 or less/month with the generics.

3.       CONTRAVE is a combination of an antidepressant (Wellbutrin) and a narcotic antagonist (Naltrexone). I have seen mixed results and most of my patients are disappointed. The costs without a coupon is $200/month and obviously cannot be used with narcotics (will eliminate analgesic benefits of opioids). According to studies, one can expect to lose 9 pounds in 1 year.

4.       BELVIQ is similar to antidepressants and therefore should not be combines with them. Studies show an average of 8 pounds lost in the first year. It is hard for me to comment on this because most of my patients don’t like the way it makes them feel. It is also very expensive ($200/month without a coupon)

5.       ORLISTAT has been around for years, first as a prescription and currently over the counter. The average weight loss is claimed to be around 7 pounds. WARNING-fecal leakage is VERY common if you eat any fatty foods. I never recommend this.

6.       SAXENDA is the newest to be approved. It is actually a diabetes medication which delays gastric emptying which makes you feel full. The most common side effect is nausea. No, this will not cause low sugars, even though it is marketed as VICTOZA for diabetics. The recommended dose is almost twice as high as that recommended for diabetes and I think the nausea will really limit its usefulness. I’m also sure insurance will not cover this unless you use VICTOZA off label-but then you’ll probably get labeled as a diabetic. Average weight loss expected is 12 pounds.


To sum things up, I would try phentermine, with or without Topamax and combine this with healthy lifestyle changes. Once weight loss goals have been achieved, I would continue Topamax indefinitely since 97% of  dieters WILL gain ALL of their weight back.

Beware of over the counter supplements: Not only do they not work well but may be dangerous and contain MERIDIA, a terrible weight loss medicine from 20 years ago that was taken off of the market due to heart disease. Yes, some people have found success with HCG but this IS NOT SAFE and should be avoided.




We usually think about obesity in terms of calories and exercise, but not every person who makes lifestyle changes are able to lose weight no matter what they do.

The latest thinking is that obesity is related to inflammation in the body as well as micronutrient deficiencies.

Many researchers are connecting the dots when it comes to MICROBIOME (bacteria in the gut) with inflammation and insulin resistance which can lead to increased bidy fat and weight. There are studies that are looking at the role of both prebiotics and probiotics in weight reduction.(there is also an association of heart disease and depression with abnormal bacteria in the intestines)

Also, deficiencies in Vitamin C, Zinc, Iron, Magnesium, CoQ10 and Calcium have been linked to weight gain.

So, yes, diet and exercise and even sometimes prescription medications can help you lose weight but when that doesn’t help, INFLAMMATION should be considered and treated


Ariel Robarge is a Registered Dietitian who specializes in nutrition for weight loss, disease treatment and prevention.  Ariel received her Bachelor of Science degree in nutrition and dietetics from West Chester University and went on to complete her Dietetic Internship through University of Delaware.  Ariel started her career with the Rothman Institute in Philadelphia where she practiced as a Wellness Dietitian.  At Rothman Institute she worked with a team of doctors to implement nutrition and supplement therapy at multiple doctors’ offices to assist them in utilizing medical nutrition therapy.    Ariel went on to private practice to work with clients and completed her certification in Sports Nutrition.  Ariel provided monthly seminars on various nutrition topics and gave nutrition presentations at local schools in the Philadelphia area.  Ariel has been working as a nutrition consultant in Sarasota, Florida since 2008. Ariel was involved in the launch of Beyond the Scale, a 12 week program covered by the Sarasota Herald-Tribune specializing in nutrition, fitness and mind/body health.

Ariel’s passion is to teach others how to use food as medicine and create a lifelong relationship with food that supports optimal health and well being.  Ariel is constantly researching, refining and applying the cutting edge nutrition techniques to assist her clients in achieving and maintaining their goals.   Ariel believes that we are only beginning to understand the power of food and nutrients on genetic expression, disease treatment/prevention, weight management and health.  Her goal is to reach as many people as possible who are open to the possibility of transforming their personal relationship with food to support optimal health and wellness.



The MAESTRO SYSTEM is a surgically implanted device that will block nerve impulses from the VAGAL nerve. As with many discoveries in the world of medicine this was picked up by accident. Researchers noted that patients who had a surgical vagotomy for the treatment of persistent stomach ulcers seemed to lose weight. Implantation usually takes an hour and is done as an outpatient. The therapy is reversible and can be noninvasively adjusted or turned off when necessary. The most common side effect is nausea. Most patients in the study lost 20%-25% of their weight.

This treatment is recommended only if a patient is severely obese and has failed at least one  medically supervised weight loss over the past 5 years and will be available at select bariatric centers before the end of the year.

Another reason to lose weight

Here is yet another reason to try to lose weight. Researchers have found by monitoring DNA methylation that there is a link between obesity and aging of the liver, including liver cancer. For every additional  10 BMI units, the liver aged by over 3 years.

This may be the reason why many other cancers have been inked to obesity.



Interesting facts about obesity

1. Being overweight was once considered a sign of wealth. It wasn’t until 1997 that the World Health Organization declared it a disease. (So why won’t insurance companies pay for treatment?)

2. 33% of all deaths in the US are associated with obesity.

3. 60% of all diabetics worldwide are caused by obesity

4.Many cancers, including kidney, thyroid and gallbladder   are associated with obesity.

5. The reason for the increased risk of cancer in obesity is due to:

Fat cells that stimulate cell growth

High insulin levels promote the growth of certain tumors

Belly fat causes chronic inflammation in the body, which leads to oxidation and degeneration of cells, thereby increasing cancer risk

6. Among the 4 largest ethnic groups in America, the highest incidence occurs in Latinos, followed by blacks, whites and then Asians.

7. The incidence of obesity is highest in men and women who have lower education and income levels

8.The USA has a higher obesity rate than Great Britain, Saudi Arabia and Mexico

9. Of all the major countries in the world, only The Netherlands was able to lower obesity levels in 2013.

10. Soda and fast foods are a leading cause of obesity and both France and Canada have enacted a direct tax on soda to try to discourage people from buying it.

11. The direct medical cost of obesity in the US is $147 billion a year!




Two(?) new weight loss medications

The FDA was busy last week as they have approved 2 new products for weight loss.

The first is called CONTRAVE and it is a combination of 2 older medications: WELLBUTRIN (anti-depressant) and NALTREXONE (anti-addiction). 40% of patients lost about 5% of their weight. BELVIQ patients lost on average 3.5% and QYSMIA (Phentermine/Topamax) lost almost 9%.

The second drug has also been around for a few years. VICTOZA is an injectable medication used for treating diabetes ( this is NOT insulin). Because it may slow gastric emptying, it can lead to decreased appetite and therefore weight loss. The “new” name of the medicine will be called SAXENDA and will be dosed higher than Victoza. Potential side effects include nausea and pancreatitis. If used in diabetics, SAXENDA may also cause hypoglycemia if used in combination with other diabetes drugs.

I think the best weight loss medication is phentermine and is enhanced when combined with Topamax. I have seen mixed results with Belviq and Wellbutrin/Naltrexone. Adding VICTOZA/SAXENDA to Phentermine and Topamax may be the best combination to achieve your weight loss goals.

Here are 3 important facts to keep in mind:

1.       Just 2% of people who are candidates for drug treatment are using a drug at this time.

2.       Insurers are increasingly paying for the medications, with 60% of privately insured patients now getting some coverage.

3.       There is no generic for BELVIQ or VICTOZA but both QYSMIA and CONTRAVE can both be written as inexpensive generics which should work just as well as the brand names


Low carb diets (Sugar is the enemy – not fat)

Annals of Internal Medicine

According to a new study, a low carb diet may be healthier than a low fat one. After 1 year, the low carb group lost significantly more weight, fat mass and markedly improved lean muscle mass. Total and low-density lipoprotein cholesterol levels and plasma glucose levels did not change significantly in either group, nor did blood pressure levels significantly decrease in either group. However, the low-carbohydrate participants showed significantly greater decreases in C-reactive protein levels, which is an inflammatory maker of cardiovascular risk.

This is not the same as the Atkin’s diet from the 1990’s but rather more in line with a modified Atkin’s type diet. Yes, we all NEED carbohydrates but there are both good and bad types. The brain is also fueled by carbs and not by protein.

To learn more about these kinds of diets, you can Google the topic and also research “glycemic index”.

For further information, we will be happy to discuss this with you or schedule an appointment with our registered dietitian, Nora Clemens. 941-747-2090

I exercise 30 minutes a day an eat healthy but I stopped losing weight!

Some people rely on the government recommendation which suggest 30 minutes of exercise such as walking as a benchmark for daily exercise.  However, this is the minimum needed for maintenance and serves as a good starting point.

Better Exercise.

Amount:  In order to burn fat, we need to exercise longer and harder than the government’s recommendation.  A good workout session includes at least 45 minutes of exercise at a moderate-to-high intensity.

Intensity:  Intensity can be gauged through your heart rate and muscle fatigue.  Your target heart rate during exercise depends on your age and can be estimated from a table.  Muscle fatigue results from repeated movements against resistance (weights and reps).  Try to do 3 sets of 10 to 12 reps of resisted exercise using a moderate weight.   If your heart rate remains in the target range and you can complete 3 sets of 10-12 reps before becoming fatigued, then the intensity is moderate-to-high.  Adjust the weight resistance up or down until the intensity is right.  You should be breaking a sweat and breathing moderately hard.

Target body weight:  Your target body weight can be estimated using a BMI table.  As you approach your target weight it becomes increasingly difficult to lose weight, especially at the belly.  The amount and intensity of your exercise needs to be increased as your weight loss plateaus.  If you are 10-15 pounds overweight and are trying to lose the last few more pounds of belly fat you will need to work out more than 45 minutes at a higher intensity.

Variety:  Walking or even jogging for 30-45 minutes is not going to result in significant weight loss.  This exercise might be good for your lungs and heart but a variety of resisted exercises is needed to accomplish meaningful weight loss.  If you build muscle you not only burn calories during exercise, but also increase your metabolism, allowing you to burn more calories even during rest.  BONUS!  The best way to build muscle – and lose weight – is through a variety of resistance exercises that become progressively more intense over time.  Then rest one day to allow your muscles to recover.

Reward:  Reward yourself after exercise with … weight reduction, not with a double scoop of chocolate ice cream.

Power Plate:  Power Plate Vibration Technology allows a person to experience a full workout at moderate-to-high intensity in fewer minutes and with less impact on the joints.

Pointers:   Consult your physician prior to initiating a weight loss program.  Utilize a personal trainer or physical therapist for coaching and instruction.  Consult with a nutritionist for help with further improving your diet.  Reducing stress at home or at work can lead to more rapid weight loss.

The co$t of obesity

It should not be surprising that obesity continues to rise in the US. Regular readers of my blogs are also aware of the many associated diseases that are related to obesity. The government and insurance companies always say how important it is to lose weight but they have no intentions of paying for it.

Check out these numbers from the Centers for Disease Control and Prevention:

ARTHRITIS——$128,000,000,000/year.  Covered

CARDIOVASCULAR DISEASES——$444,000,000,000/year. Covered

CANCER—–$125,000,000,000/year. Covered

DIABETES—-$245,000,000,000/year. Covered (up 41% from 5 years ago)

OBESITY—–$190,000,000,000/year. NON-COVERED


It seems to me that since obesity can play a role in all of the above illnesses, that insurance companies would want to encourage lifestyle changes and weight loss. If only they would pay for it. We recognized the benefits of aggressive weight loss years ago and became one of the first practices in the country to offer our own gym and registered dietitian for our patients. We also supervise very closely every patient  who is using FDA weight loss medications. (Forget OTC supplement-they are scams not only don’t work but may be dangerous) Unfortunately, most insurance companies will not pay for these services. The mentality of the average patient is that if it is not covered, than they do not want to participate. Or they tell us “I know what to do” Unfortunately knowing what to do and doing it are two different things.

It’s never too late to get proactive with your medical care. And ladies, the price is usually less than a day at the beauty parlor and manicurist/month!

Call our office if you would like to learn more about our programs



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