Hello. My name is Dr. Harold Bays, Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center located in Louisville, Kentucky. Welcome to this program entitled Overcoming the Challenges in Weight Management. What are the new strategies that are out there? I'm a Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center located in Louisville, Kentucky. I've been a Principal Investigator somewhere over 500 clinical trials and I'm also Clinical Associate Professor at University of Louisville School of Medicine and Chief Science Officer of the Obesity Medicine Association and I'm going to try to take that experience and talk about some perspectives about where we are today, where we are going. First slide here talks about what are the myths? A lot of people say well obesity is not really a disease. I mean you say it's a disease but it's really not. But look if you look at any of the criteria used to define any other disease then yes obesity clearly is a disease. It meets every criteria of any reasonable definition of being a disease whether it be relative to diagnosis or contributing to morbidity and mortality or causation treatment and who manages it. The other thing is that it's just very curious that here we are it's 2023 and you would think diagnosing obesity is something that we would have down. Okay you know we have a pretty good bead on how it is to best diagnose obesity but I got to tell you yes body mass index is really good within the context of populations but I can give you numerous examples where the use of body mass index alone in certain patient populations really is not sufficient not within the individual. Instead I think that a much better diagnosis is through body composition and such and that's especially true when you start looking at black populations or when you look at female individuals. The body mass index often does not accurately characterize the degree of adiposity and the body composition in these patient populations. The other thing is I don't know that everybody recognizes the pathogenic potential of adipose tissue. It's not just an inert organ. Instead adipose tissue is very active from an endocrine standpoint and from an immune standpoint and there are these direct adverse effects upon the heart and there are these indirect effects upon the heart such as contribution to major cardiovascular disease risk factors through this sick fat. This sick fat and these indirect effects include things like contributing to the diabetes mellitus, the hypertension, dyslipidemia, all cardiovascular disease risk factors. All right so what's our current understanding of the role of nutrition and the treatment of obesity and cardiovascular health and cancer? Why did I throw cancer in there? Why did I throw cardiovascular health in there? It's because it is remarkable the degree by which the nutritional recommendations we make for treatment of obesity is very similar to the nutritional recommendations we make with regard to prevention of and treatment of cardiovascular disease and cancer and despite what people seem to want you to believe there are universal principles with regard to nutritional intervention. The nutritional intervention needs to be evidence-based. It needs to be healthful with regard to qualitative aspects and quantitative aspects. The patient needs to agree to it. Patient needs to adhere to it. We need to avoid ultra-processed foods. Limit the sodium. Limit the simple carbohydrates. Avoid energy-dense foods and then prioritize healthful whole foods high in fiber and micronutrients. So this doesn't just apply to obesity. It applies to cardiovascular disease and cancer. Another question comes that we hear is do calories matter? Again it's just surprising to people to me that people take something that's many times not that complicated and try to make it complicated. The fact is calories do matter and the caloric density of foods really do matter. So you can have the same grams of foods but the amount of energy within those foods can vary dramatically. I mean here you have an apple 100 gram apple 50 calories and here you have 100 grams of bacon it's 500 calories and I just don't agree with the people that say well there's just no difference between those two with regard to implications respective to obesity cardiovascular disease and cancer. What about physical activity? Again a lot of similarities between the recommendations we make for treatment of obesity to cardiovascular disease and cancer. I think most of us recognize the recommended 150 to 300 minutes or more moderate intensity aerobic activities per week and with at least two times a week with resistance training but the obesity med association has added to that that an alternative with regard to just the the dynamic training would be 5,000 steps per day because for many of our patients with obesity that's the best that they can do. Right now if they can do more than 5,000 steps per day that's great. If they can do over 10,000 steps per day that's great as well but let's start off with something that's doable. Now I know a lot of people say well but the steps shouldn't count unless they're specifically done within the context of physical exercise and I just don't agree with that at all. Folks we're not the step police okay and as one engaged in obesity management if I could get every one of my patients with obesity to walk at least 5,000 steps per day then I don't really care about how they got to 5,000 steps per day or particularly if they got over 10,000 steps per day. I just think that's a meetable and a doable goal for many of our patients. What about resistance training? I think the biggest thing here is yes it needs to be done but also we need to make sure our patients are properly trained. Got to keep it safe. Use proper techniques and these types of things and so a lot of education needs to go into resistance training and how to do it safely but clearly it's an important aspect of not just a cardiovascular disease prevention and obesity prevention and cancer prevention but improvement in overall health. What's the current role of behavior modification? Well look I understand that the etiology of obesity and cancer and cardiovascular disease has to do with the epigenetics, the living environment and all of these things play a role. If you're talking about epigenetics you're talking about DNA methylation and histone modification these types of things but all of these can contribute to obesity but also cardiovascular disease, cancer, diabetes and aging. This goes back to my essential point and when we treat our patients who have the obesity most of the interventions we recommend have hopefully are going to have favorable effects upon not just the obesity but also the risk for cardiovascular disease, risk for cancer, risk for diabetes mellitus and aging. What about mental stress? Well I think we all know this. This is again not complicated. A lot of things can result as due to mental stress. Psychological changes, behavior changes, cognitive changes, sleep changes. A few things are more important than a good night's sleep. Physiological changes, changes in the perception of pain. These things happen with mental stress and we all know this and the other thing we know is that mental stress contributes to obesity and that is true but also contributes to cardiovascular disease, cancer, metabolic disease, inflammatory disease and psychiatric disease. So all of these things are tied together. I mean I don't know if there ever was a time where we could silo all these diseases but it's certainly not true today. We are way beyond this notion that cardiologists, let's take cardiologists for example, can just focus on cardiovascular disease and get the job done. It's just not that way anymore and because I think most cardiologists recognize that as part of the care that they're giving they're addressing the obesity. Branches of cardiovascular disease management also includes cancer and metabolic disease and psychiatric disease and inflammatory disease. So what is the principle when we talk about nutritional intervention? Well what we're focused on is the intake of natural whole foods because that's how your brain was built. So if you eat natural whole foods your brain is more likely to respond with balanced homeostatic effects on the brain and that's healthful. You eat ultra-processed foods where there's been trillions of dollars of investment to trick your brain right to put your brain in a way that it was not meant to be then that can result in unhealthful consequences and that's the challenge that that we often face. So one of the ways we can get around that or address that is to be inefficient. Yes I understand processed foods are efficient but we need to eat whole foods with fiber, water, all these types of things where the caloric absorption is inefficient not efficient. We need to park further away from our buildings to be inefficient not efficient. We need to have altered micro microbiota that cause less efficient gastrointestinal absorption of energy to be inefficient. We need to perform physical exercise in a manner in which our muscles do not become efficient but remain inefficient. We can do that by doing different types of physical activity and we need to get engaged in less efficient non-exercise activity thermogenesis which again is walking, parking space location already mentioned, stairs, on-site shopping, periodic breaks from sedentary work. We also need to get away from this notion that people are born with a predestined set point to obesity is just wrong. There's a lot of things we can do to change our set point. We can change the way that we habitually eat. We can change our physical activity habits. We can change our behavior. We can change our environment. We can address physical and mental health and then yes we also can address satiety hunger hormones with pharmacotherapy and such. I'm not saying these things are easy but I am saying that people are just not predestined to have the obesity. All right, so what are some of the challenges of anti-obesity drug therapy? First, not many people are on them but although I will say this slide was made a year ago I think there are a lot more people on anti-obesity medications now than there were just a year ago but if you look at bariatric procedures less than one percent of the people that are eligible to actually get it. The other thing is look what we're going through with obesity today is exactly where we were 30 years ago when I started work with these wonderful diabetes drugs and hypertension drugs and lipid drugs and early there was skepticism that maybe we shouldn't be using these drugs and they're poorly tolerated and such like treatment of the diabetes mellitus. We had sulfonylureas and pork insulin and such and then we developed much better drugs. We had the metform and we had human insulins. We developed the SGLT2 inhibitors and GLP1 receptor agonists and such. Same thing with hypertension. I had patients that were on clonidine, diazoxide, hydralazine, methyl dopa. People felt terrible and then we developed the calcium channel blockers and the angiotensin converting enzyme inhibitors and the angiotensin 2 receptor blockers and people tolerated them much better and the same thing with cholesterol. We used to treat people with fire and sand you know the niacin with the made people flush like fire and sand the bile acid resins now we have statins and azetamide, PCSK9 inhibitors and benptoic acid so it's just a it's just a very different time now than it was 30 years ago and that's where we're headed with anti-obesity drug treatment. Where we are now we're seeing a parallel to where we were before and the big binary switch that makes the difference between these drugs being not used as much as they should be to being standards of care it's the same with the diabetes drugs and the hypertension drugs lipid drugs it's the cardiovascular disease outcome strengths so as these start to be reported out should they should they demonstrate cardiovascular disease benefits with these new enter newer anti-obesity drug treatments that's when the world changes but in the interim we know that even mild amounts of weight reduction can improve many aspects of people's health and particularly you start getting greater and equal above 16 15 to 16 that's when you really start seeing some major benefits and and I'll just conclude with this one of the unexpected situations that we've encountered as a result of these newer anti-obesity drugs is people losing too much weight they have excessive weight reduction so we we published this article about an algorithmic approach about how you manage the patients who have excessive weight reduction with these highly effective anti-obesity medications and so what I would conclude with is to say this just like diabetes hypertension dyslipidemia obesity is a chronic disease that requires chronic therapy and as cardiologists if you haven't already I think you're soon to find that the advent of these of these newer anti-obesity drug treatments are really going to change the way that we manage our patients not just with the obesity but patients with the obesity who have metabolic diseases that are cardiovascular disease risk factors that have cancer and especially those patients who have the obesity and cardiovascular disease so with that I will conclude and just and just say you know watch out for the future because the future is now and it's a very exciting time.

weight management

obesity

diagnosis

cardiovascular disease

nutrition