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Steve Freed: Maybe start off by telling us a little bit about yourself because you have an interesting background.
Dr. Mechanick: I’m a clinical endocrinologist in private practice in New York City and an attending and clinical professor at Mount Sinai, at the Icon School of Medicine at Mount Sinai to be more specific. I’m also director of metabolic support. Here at AACE, I’m a past president of AACE and I will be the president elect of the American College of Endocrinology or ACE. I’ve also been a past president of the American Board of Physician Nutrition Specialists, a member of the president’s council on fitness, sports, and nutrition science board in Washington. I just completed a term as editor-in-chief of the President’s Council’s Elevate Health. I was also just appointed as Chair of the Board of Visitors of the College of Computer, Mathematics and Natural Sciences at the University of Maryland.
Steve Freed: So when do you have time to practice being a doctor?
Dr. Mechanick: All the time. I do it all the time.
Steve Freed: That’s great. So what are the reasons why you are here?
Dr. Mechanick: I’m here obviously as an officer, this is one of my very pleasurable duties each year, but even before I was an officer and before I was a board member, it was a very important meeting as a clinical endocrinologist to attend. So these are our national meetings, this is where really the best research and translational studies, the best workshops, the best interactions can be found for those of us that who do practice clinical endocrinology.
Steve Freed: What are some of the presentation that you will be doing here?
Dr. Mechanick: Yesterday, I participated in a symposium that was moderated and chaired by Dr. Chris Garren on cardiovascular disease and endocrinologists practicing metabolism. So there were various lectures on hypertension, lipids, and diabetes. My lecture was on the role of nutrition and lifestyle, really within a preventive care framework, or paradigm, and cardiovascular disease.
Steve Freed: That’s interesting, that’s a lot to talk about. I’m sure you did all of that in 4 hours?
Dr. Mechanick: It was a 4-hour talk in about 40 minutes. I spoke very slowly.
Steve Freed:You mentioned two important things: metabolism and nutrition. They play a major role when it comes to type 2 diabetes, but obviously type 1, but more so type 2. So what are some of the things you do? How much time do you have with the patient?
Dr. Mechanick: So this actually brings up a good point, because what you’re alluding to is the fact that rarely do physicians engage in a constructive and even comprehensive discussion of nutrition and lifestyle in the very constrained amount of time for a routine patient encounter. That’s really the nature of the question. The answer is that first because of a lack of formal training in nutrition and lifestyle medicine, we’re ill-prepared. The point though, and the point of the talk is that with better education and training, particularly in a formal nature, we can do it. It absolutely can be done. If you go around the world, there are a lot of endocrinologists who have far less time per patient encounter than what we have here in the States. But the fact is that within a 15-minute encounter you can at least begin the discussion. What are the components of an effective discussion about lifestyle medicine and nutrition? In order to go into that, if I may, let me just break it down into some of the parts. So first, lifestyle medicine is not only nutrition but really healthy eating patterns. It also includes physical activity, but not just rigorous exercise, aerobic exercise, but strength training, maybe even some relaxation techniques and stretching and other forms of physical activity incidental physical activity. It can be done during ordinary daily activities. Lifestyle medicine also includes proper sleep hygiene, which extends beyond just the requisite 7 hours of sleep duration, but the quality of sleep, the way in which you go to sleep. The way in which you sleep uninterrupted, you go through all the normal cycles and the next day you are refreshed, you’re not sleepy, you don’t take very long naps and have sleep inertia the next day, but to have healthy amounts of sleep, we’re all aware of the emerging research connecting proper sleep with our metabolism, with cortisol and with glucose intolerance. There really are a lot of important integrative physiologic connections among sleep and insulin, diabetes, obesity, stress, etc. Another component of lifestyle medicine is behavioral medicine and stress reduction. It also includes tobacco cessation, alcohol moderation and the avoidance of any kind of substance abuse. So these are all things that although we’ve heard of them, we really have not been exposed to formal training, so that’s what we used as a framework for the talk, but then we focused more on the nutrition. In order to go into the nutrition we discussed patient-centered care, motivational interviewing, where you’re really having a conversation with the patient. If the patient needs to lose weight, which those effects get amplified in terms of having salutary effects on lipids and blood pressure and insulin resistance and well-being. Small amounts of weight loss can have huge effects and larger amounts of weight loss can almost eradicate a lot of the pathology that we see and traumatically reduce the amount of pharmacotherapy that we require. But how do you engage that conversation. It’s not about lecturing. It’s not about sitting up on high and talking down to a patient, but rather involving the patient, letting the answer come from the patient. Hearing what the patient is able to do, what they’re not able to do. A lot of times the solution, the patient will offer rather than the doctor instructing the patient to do this or that. So we moved from that into some basic dietetics and then into what I would consider to be a modern approach to nutrition, where we would define nutrition, not simply about the food we eat but the interaction of these eating patterns, these healthy eating patterns or unhealthy eating patterns with our own metabolism. We actually even discussed doing all of this on a molecular scale, so called molecular nutrition where we have networks of molecules in the foods we eat in aggregate, interacting in a complex fashion, but a fashion that we can understand with the networks of molecules in our metabolon. With that, we were able to draw some conclusions and conclude this very brief 40-minute talk with 4 hours’ worth of information.
Steve Freed:What you just said, if I was a patient, and you told me, this is the things that we’re going to discuss, the things that I would have to know, I would run out of that room so fast because most people if you throw too much at them, they are going to walk away with nothing. How do you do it in your practice? Do you do it over a year? You certainly can’t do it within 10-15 minutes. How do you get all that information so it’s effective for that patient?
Dr. Mechanick: So these are all the very obvious and important questions. How do you translate something that most people haven’t been formally trained on? Something that a lot of people and when I say people, I mean health care professionals, particularly physicians and clinical endocrinologists, are really struggling to find their footing with this. The answer is quite simple, you speak to patients like people. Use common language, not terribly sophisticated or technical. So it starts off with “what do you eat?”, “what did you have for breakfast yesterday?” And you compile an understanding of what their eating pattern actually is now. Then you slowly morph it. You slowly adjust it into an evidence-based healthy eating pattern that you as the expert know. So you establish were you are at point A. You know where you want to be at point B. But just like you said, you don’t have to get there all at one time. You can take your time with it. It can be a recurring theme over a sequence of visits. It doesn’t all have to be accomplished in one visit. Isn’t that really what we do in diabetes care anyway? We can’t accomplish all aspects of comprehensive diabetes care in one visit, or initial visit. You prioritize what you want to do, it really takes some time to change the culture of health for that patient with diabetes so that they can be healthier. It extends far beyond simply having target glycemic control.
Steve Freed:Being an endocrinologist, I presume you don’t get a lot of patients with prediabetes. I would imagine that a lot of your patient base comes from other medical professionals that threw up their hands and say this is too much for me, you need an expert. Do you get to see any patients with prediabetes?
Dr. Mechanick: The answer is yes. In Manhattan, in New York City, we get quite a bit of patients who are being referred over with prediabetes. You may say the next question is well, then how are they screened? How is the aggressive case finding done? There is an awareness and that awareness really is a result from terrific education that you see from conferences like at AACE, where AACE was really in the forefront of establishing insulin resistance syndrome and prediabetes as a necessary part within a preventive care paradigm, focusing on primary prevention. It’s part of our diabetes algorithm, it’s part of our diabetes guidelines. How do patients come to me? They’re screened with A1Cs. There may have been an A1C that’s somewhere between 5.7 and 6.4 inclusive. They’re sent over to the endocrinologists because there is an awareness, a confidence that really the expert, the person who’s going to be able to manage this situation the best is going to be a clinical endocrinologist. So yes, we do see them a lot more now. Those patients with prediabetes.
Steve Freed:I always feel that when they reach the stage of prediabetes you can do so much more with so much less to really have an impact on that person. It’s a matter of changing lifestyle. That is probably one of the hardest things that you can get a patient to do and that is to change the lifestyle. How do you accomplish that?
Dr. Mechanick: So first of all, you are absolutely correct about how important lifestyle is in this particular setting. As opposed to just, right out of the gate, going to a medication like Metformin. In all the algorithms, lifestyle is the initial step and it’s the step that’s concurrent with any add-ons within the algorithm, whether it’s pharmacotherapy, or in the case of severe obesity, bariatric surgery, you still have lifestyle as an important part. How do I do it? Again, I have a conversation. I establish what the eating patterns are and I work to formulate a healthy eating pattern. We talk about physical activity, what the capabilities are, what the cardiac status is, what the attitudes are towards physical activity. I ask questions about sleep, how well do you sleep? Here’s a little tip, a lot of patients will say, I don’t sleep well because I worry, I’m under so much stress. I have problems with my child, or problems with my marriage, or problems with finances or workplace. One of the tips is to schedule worry time. A little technique, a little tool. Just to schedule worry time. Other aspects of sleep hygiene that are evidenced-based that work. Other aspects of stress reduction, techniques for stress reduction. These are the conversations. But as I said before, they don’t all have to be done at one sitting, but they must be done as part of a therapeutic priority.
Steve Freed:One of the major changes that I’ve seen here and I’m sure that we’ll see at ADA and that’s basically more information about obesity, because now we have more tools to treat obesity. I noticed that recently they’ve just come out with new guidelines for treating obesity and bariatric surgery. So far what I’ve read about bariatric surgery is that a lot of the patients lose the weight initially but eventually gain that weight back. They just went through a major surgical operation to get to the same result. What are your thoughts and where does it fit in in this whole paradigm?
Dr. Mechanick: You bring up several points. I’ll start with the last because I remember it the best. Most patients who have bariatric surgery are not going to regain the weight all the way back to baseline. However you’re correct that some patients will regain too much weight and it’s a problem and it highlights the need for what I said before, which is not only concurrent lifestyle change but we need more education, more research, more knowledge, more experience, about implementing lifestyle change. As far as bariatric surgery as well having a therapeutic effect, you may have seen the recent report in Diabetes Care from the Diabetes Care Summit from Francesca Rubino. AACE was fortunate enough to be part of that. I was a representative at that that diabetes surgery summit. AACE endorsed the findings. Although whether I’m not sure whether these findings are going to be static, I expect they’re going to be changing these recommendations over time. I think they’re very important findings and they illustrate the effects in these patients who really are at the extreme of the spectrum, where lifestyle and pharmacotherapy are not having a sufficient effect on halting or abrogating these very detrimental effects with diabetes in the natural history of diabetes that you really find yourself in a place where you need to call in bariatric surgery. Let’s move on to the obesity guidelines by AACE. I was privileged to work with Tim Garvey, who was the chair and with the other members of the writing group and the reviewers and this was a project that we were really able to complete within a year. It’s a very large, long comprehensive guidelines. Hundreds of pages for 1000 references, all evidenced-based, in strict adherence with our AACE protocol for guidelines with guidelines. Very transparent in terms of the methods. Here’s how it differs and here’s how it impacts the obesity space. First of all, it’s comprehensive, it’s not just talking about drugs. It’s not just focusing on weight loss, though weight loss obviously is very important. It’s not just focusing on BMI as the target. It really is emphasizing complications. Weight loss or weight related complications. Weight gain or weight loss. Weight related complications. It’s those complications which are the biological relevance of the anthropometric changes and we talk about different anthropometric changes, whether it’s BMI or waist circumference in different ethnicities. How in an individual, they are translated to affect different organs and cause organ dysfunction. We focus on the lifestyle changes. We focus on a broad array of pharmacotherapy that must be available. This is really a call to action for our American health care system that we need to have all of these various weight loss drugs available so that individual physicians can individualize for their individual patients. That’s what’s necessary, not just have one type of treatment for every type of patient who has obesity or preobesity, which is being overweight. So, these guidelines are really moving the needle forward and advancing the care. One other thing that’s in these guidelines as you thumb through them and you go to the appendix, is we offer an AACE care model, a chronic care model for obesity, really serving to anchor and provide context for these guidelines so the recommendations truly are actionable and they have relevance for today. The components of that care model are first, that you have an activated patient. The patient wants to lose weight. The patient understands the benefits. The health benefits, reducing the risk for complications, or reducing the progression of complications that may already exist, with a comprehensive program for obesity. Second, preparedness of the clinical practice. The physician needs to be well-informed. The physician needs to have access to these guidelines. The physician needs to have the proper equipment in their office, proper training. Sensitivity to obesity as a disease. Third, community engagement, the schools, houses of worship, the workplace, community meeting places, that the whole system is involved in a sensitivity and a desire and a diligence to combat obesity. Lastly, a health care system that can receive these components of a chronic care model and make them work. We need better reimbursement strategies for drugs for bariatric surgery. We need training for lifestyle, we need reimbursement for lifestyle change, reimbursement for nutritionists, and reimbursement for those who can teach physical fitness, reimbursement for sleep studies, reimbursement for behavioral medicine. These things, not only did they not exist before, but in the current health care economic climate, they are few and far between and there is really a schism between what we need and what we have.
Steve Freed:If you go to the government and say we need to get reimbursed for this and for this and for this, it’s just not going to happen that way. Even though, I think all the studies have shown that preventative health, paying for it up front, is going to save money on the back end, but it’s very difficult to show people that, you need to get this to get this result. It’s going to take time. What are your thoughts on that?
Dr. Mechanick: So, that’s our challenge. There are those that believe that for these chronic complex diseases, like obesity and diabetes that it’s hopeless. That we have no ability to change legislation, to change behavioral economics, to change the way Washington works, and although it’s hard, we know that’s not true. We know that the nature of our government is designed for change even though it may be difficult, even though it may take some time. I don’t think the question should be framed that it’s hopeless. I think the question should be framed, how we as health care professionals adapt to this latency between what we need now and what we can realistically expect at some point in the future? I don’t think I can offer you really an answer right now but this is a high priority for American Association of Clinical Endocrinologists, this is a high priority for many of the major medical centers and health care systems around the country, a high priority for other professional medical organizations. The answer is going to be collaboration. We need to have everybody pull their resources together. We need to have consensus, we need to have as close to a single voice as possible and with that critical mass, I am confident that we will be able to affect some change.
Steve Freed:One of my favorite questions to ask somebody from AACE organization is, I’ve always learned that according to the ADA, recommended A1C, and I know it’s all individualized, but in general the recommended A1C for the American Diabetes Association is 7 and below. You know as well as I do that AACE says 6.5 or below. I know where these come from, they come from clinical studies showing directly when the first problems with diabetes appear. When I tell people that, I say why can’t these two organizations get together and come up with one number? Because some doctors will treat according to ADA and some doctors will treat according to AACE. Why is there this difference and why can’t we come up with one single number?
Dr. Mechanick: So first of all, it’s not so concretely different anymore. You’re absolutely right that at the beginning AACE firmly had this target of 6.5 which was probably more evidenced based than 7.0. But again it depends on which evidence base you are looking at and how you prioritize your methodologies. That isn’t the case now. In 2011, with Dr. Handelsman chairing the writing committee for the guidelines, we actually extended the upper limit as high as 8.0 that was repeated in our most recent guidelines. The reason is precisely for what the commentary was, for in some patients it was too risky and obviously based on a chord in some other studies, too risky to keep layering on more and more medication. So our guidelines do allow that latitude, depending on the individualization, personalization of comprehensive diabetes care. Just to summarize, the answer’s in two parts. First we do explicitly provide a range that in the ideal world, yes, 6.5, but we do allow a higher upper limit. Second, to bear in mind that the nature of AACE guidelines, compared to other guidelines, is the comprehensive focus, that although glycemic control is very important it is not the only important target. A1C is not the only important target. That if you inject that algorithm for just glycemic control, in a basin of all of the problems that someone with diabetes has or could have in a preventive care paradigm, then you understand what AACE guidelines are about. You understand that yes it’s about glycemic control, but it’s also about lifestyle, nutrition, physical activity, hypertension treatment and prevention, dyslipidemia treatment and prevention, vascular biology and all of the other hosts of complications.
Steve Freed:So, my last question in an interesting one. I imagine different endocrinologists have different ideas about it and how they treat patients. There’s been a great paradigm shift in the treatment of diabetes. Just going back a couple of years, it was always focused on blood sugars, on A1C, that’s all you had to worry about besides hypertension and hyperlipidemia, those were included also. But the real focus was preventing the complications from diabetes and dropping the A1C that was important. In fact, even today I think physicians get paid according to how low the A1C is, if you can normalize it. About 3 years ago, they came out with a couple of drugs that actually prevent dying from heart disease. Now, since most patients, at least 70% of diabetes patients, are going to die from heart disease, strokes, and heart attacks. Now we have a drug that actually can prevent it in a certain way. So now we have to realize, do we treat the blood sugars as importantly, do we give a patient these new drugs, the SGLT-2 drugs that have benefits of not only lowering blood sugar but preventing death? Now we have two ways to treat patients. What are your thoughts on that?
Dr. Mechanick: It comes back to the point I was making before, what’s more important, treating a number or treating the person. Although the mainstay of diabetes care has and will still continue to be, treating that number, treating to target, using the A1C, really it has to be within the context of the biological marker of the clinical marker, of the clinical relevance, which is decreasing the risk for what patients with diabetes are really at risk for, which is cardiovascular disease, cerebrovascular disease, peripheral vascular disease. I think the fact that there’s only a small number of medications that have as yet to have been shown to do that, that doesn’t mean that others won’t enjoy that same benefit, once the proper studies are conducted. Whether an algorithm should favor some of those drugs that have already shown an effect in preventing cardiovascular disease over drugs that have not yet show that effect, we’ve included that in our discussions, when we formulate our diabetes algorithm, that’s one of the reasons why our algorithm is going to be refreshed and revised and vetted every single year to incorporate some of this new information. So it’s important, but it still needs to be thought about. There still needs to be deliberation, it’s not black and white, just because one particular medicine is showing a benefit in terms of cardiovascular risk, that that medicine should be used for everybody. It still needs to be incorporated in a lot of clinical judgment for individualization of care. This is an argument for the thinking clinical endocrinologist, as opposed to a robotic, computer-assisted decision tree for diabetes.
Steve Freed: Well, you just destroyed my idea of putting statin in our drinking waters. I want to thank you for your time, I know you are busy. Enjoy the rest of your time here and thank you very much.