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Steve: This is Steve Freed with Diabetes in Control and we are here in San Diego for the American Diabetes Association 77th Scientific sessions. We have some great interviews with some of the top endocrinologists all across the globe. We have a special guest with us, Dr. Ken Fujioka. Maybe we can start off by you telling us a little about yourself and your practice.
Dr. Fujioka: I am in the department of endocrinology at the Scripps Clinic. In the mornings, typically, I do research. In the afternoons, I see patients. Our clinic is a little bit different. Again, it is under department of endocrinology, but our emphasis is actually weight loss in type 2 diabetics. Patients come to us wanting to lose weight, or they are referred to us to get their weight under control to help with their diabetes, and so our emphasis is very different, but I really like our outcomes. We seem to be doing a good service.
Steve: You say your specialty is weight loss, but blood sugars are important, too.
Dr. Fujioka: Correct.
Steve: So, obviously you have to do both.
Dr. Fujioka: Correct.
Steve: Technology has changed dramatically over the years, all the new medications. I am sure that you are familiar, when it comes to weight loss drugs, that’s fairly recent. We used to have them years ago, but we found out they were too dangerous and caused cardiovascular incidences. Basically, we started with nothing after that time-frame after they discontinued them.
Dr. Fujioka: There was one that made it through. That was an oral statin.
Steve: But, now we have a number of drugs that you can use for weight loss. So, just out of curiosity, is there a particular [weight loss] drug….I know you’re always supposed to look at the patient as an individual, different strokes for different people. But is there one of the weight loss drugs that you’ve seen the best success with?
Dr. Fujioka: No. What you’re saying is very appropriate. Every patient is different. It is very important to remember that the way humans regulate their weight is that once they get to the highest weight they have ever been at they are stuck at that weight. But, how they got to that weight, what drives their…maybe too many calories, maybe they can’t burn enough of calories? There’s different ways of looking at it. There are four drugs and each has their own place. One is good for satiety, one is good for cravings, one is particularly good for diabetes and weight, one is just all around great for binge eating. They all vary, and they all have different mechanisms.
Steve: How do you determine the best route to go?
Dr. Fujioka: It is real important that as the healthcare giver you look at the patient and you figure out why is their weight high. It sounds simple, but it is not as easy as calories in and calories out. Cravings is a particular, you can almost say, diagnosis. If somebody thinks about a particular food, and they get a reward from that food. We have a medication for that. Somebody has binge eating, that’s a very classic diagnosis, it’s now in your EMR – you can input binge eating and it will show up. That is somebody who eats two times normal portion feeling out of control. That is very common so there is a drug very specific for that. Some patients just eat simply, a little bit too much. Now they are making some good choices, but their portion size is just too big – there is a medication for that. It really varies, and you really need to take a very good history on the patient. Are they reward eating? Are they binge eating? Are they having trouble with portion sizing, or is it just everything and they are really struggling?
Steve: I noticed that when I looked up the scripts at the clinic, it was mentioned that you see approximately a thousand patients a month. So, I was trying to figure out how many practitioners do they need to see a thousand patients in one month. What kind of staff do they have to take care of the patients, and take care of the patients properly? It’s not a five-minute job when you’re dealing with obesity.
Dr. Fujioka: We actually have bigger time slots, if you can imagine that. Some of the doctors take up to 20 minutes for follow-up and an hour for a consult. That’s a lot of time in this day and age. We have two surgeons, we have 3 MDs, we have 2 NPs, and we have a PA. That’s a big staff. But, in addition, we have multiple registered dietitians that are also educators, we have behaviorialists and psychologists. Again, we will look at what is the cause. Sure some people eat for emotional reasons, that’s a smaller percentage. But it’s there and when you identify it, they see a psychologist. Other folks, its just behavior, they just need to change the behavior when they come home. Instead of getting home and going straight to the refrigerator, maybe they can go home, put the gym shoes on, and go for a 20-minute walk. They may also see a behaviorialistst. Some folks, they come in with a BMI of 45 and they have over 100 lbs to lose, we can throw all the meds and we can throw everything we want, and they fail that – so we need to think of surgery. Again, we look at all the different options.
Steve: What kind of a success rate do you see?
Dr. Fujioka: It’s really dramatically jumped. For surgery, you are talking about 80-85% chance of doing remarkably well. In the old days, with just diet and exercise, it’s about 20%, 1 out of 5 will do great, but 80% will struggle. Now with the meds, we are looking at 65 – 75% of patients who do diet, exercise, on a med, and are doing very well.
Steve: Is there a particular exercise that you like to recommend?
Dr. Fujioka: There is, actually. It’s funny you ask that. It has been studies and you look at different things like swimming, treadmill, stationary bike. First thing is, you want to pick some kind of exercise that has the lowest rate of injuries. It’s hard to imagine this, but if you tell someone to go for a walk and they are overweight, you got a 40% chance they might get injured. It’s very frustrating. We like stationary bike. With that said, we still like walking. Those two are neck in neck. We are looking at the patient and see how they do. Beautiful study by a guy named Tim Church, if you want the maximum weight loss in the diabetic, the best way is actually cardio and resistance training. Doing both – if you do just one or the other, you get weight loss, but not near as much as if you do both.
Steve: I always wondered, even for a person who does not have diabetes, what is the best ratio of aerobic to anaerobic [exercise]? I used to think that aerobic was more important, cardiovascular; if you’re going to die, it’s going to be mostly from a heart attack. But, then the more research that I’ve done, I see that building muscle mass is also very important. And, it increases your metabolism, so you can burn more calories; especially for weight loss. Any thoughts about that?
Dr. Fujioka: I will confine myself to type 2 diabetics. There have been wonderful studies on what is the best exercise, how much cardio, how many weight, which is very complex. As you said, you can preserve your lean tissue if you do resistance training. Generally speaking, diabetics will be on elderly side. The older the patient is, 65 and up, you are looking at a fair amount of resistance training. If you can get a couple of hours in a week, that would be fantastic. Younger folks, maybe they can get by with 20 minutes twice a week. It really varies with the patient but we do not this, and I wish you can gain metabolism, and we have no way of doing that, short of doing crazy things that unfortunately some people do. But, you can preserve your lean tissue, keep your metabolic rate from dropping. So, if I can get a patient to do 20 minutes twice a week, I am happy with that. If I get somebody that enjoys it, and they do two-three hours a week, great! But, they still have to have some cardio in there too. Between the two, now we are talking about 300 minutes a week if you want to lose weight. If you want to maintain weight, it’s lower. But again, you will get benefit from as low as 70 minutes per week.
Steve: With all the advances, and all the technology, and we have wearables now that can track every aspect of your sleep, your waking hours, sometimes it’s just overpowering. It’s just too much information. What do you see as one of the more important recent advances that has helped you to be more successful?
Dr. Fujioka: You bring up an interesting point, about everything from activity monitor to being able to record your food intake. It turns out, we are getting too much data, as you said. There actually is a published study, big time journal, JAMA, showing that when patients follow these things, they can actually gain weight. Unfortunately, the formulas are not correct in these things. They’re looking at, okay you exercise 500 calories per day and you only ate a thousand, so you can actually eat an extra 400 calories tonight. Turns out that’s all wrong. It’s not a correct way of figuring out metabolic rate, figuring out how much you burn. The best thing we know, step counting is still the best. It doesn’t have to be 10,000 steps. It’s somewhere around maybe between 6000-7000 steps. But, if you can just count steps, that’s great, do it! If you record food intake, that great. Now, we know it’s going to be off; a guy named Coby Martin has shown that you will be off by 37%. That’s a huge error rate. But if you’re record your food intake, you will be off, but that is okay. Rather look for trends, look where you are going, and that will then steer you in the right direction. Don’t look at those two together. Just ount your steps, or your minutes of exercise and the other one is look at your trends of food intake, but don’t let them merge, because it will give you wrong information.
Steve: I put together a whole program called Know Your Healthy Steps that Bayer picked up on. It got sent to over a couple hundreds of thousand people along with a free pedometer – that was the important part. I was doing a presentation at a large corporation, two hundred employees. I did half-hour presentations, every 8 hours, three 8-hour shifts. During the first presentation, they were giving out prizes for good work. For their best employee, who did most of the work, they provided him with a parking spot right in front. And I said: why do you want to kill your best employee? But you see that today in the hospitals, Reserved for Doctor, for cardiologist. And I always thought that it would be a really good impression if you put those signs ‘reserved for doctors’ all the way in the back, people would start to wonder why is that. If the cardiologist is going to get few steps two-three times a day, five days per week, over 20 years that’s a lot of steps. I am a firm believer, that as a medical professional, if you talk about physical activity, you better be doing it yourself, because patients will pick up on that if you are not doing it. You have to be really active and passionate the way you talk about it.
Dr. Fujioka: I agree. You need to walk the walk. It’s true. Literally, up to two-thirds of healthcare givers are going to struggle with weight themselves. We need to look at ourselves. I feel lucky, because I have been able to keep my weight down. That’s why I switched from an ER doctor to doing endo and doing weight, because it helped me keep my weight down. But with that said, doctors that are overweight, NPs or PAs that are overweight, shouldn’t feel afraid to talk to a patient about their weight. As it turns out, there are studies showing that, patients will listen to them, regardless of what the weight is. They will listen to you. Because they realize, they want to address it, they want to bring it up; 80% of patients want to bring it up. 20%, sure, they don’t want to deal with it, and that’s okay. And that’s why we say, ask, if they want to deal with it – great, if they don’t – that’s fine.
Steve: What is the most difficult challenge in practicing diabetology, treating the overweight diabetic, especially the geriatric overweight diabetic? Diabetes in every age group is growing, especially that group.
Dr. Fujioka: If you look at the group that is growing largest right now is the geriatrics obese diabetic. That’s a huge number of patients. As these baby boomers are all turning mid-sixties now, this is just ushering in. So, we’ve really have to approach this group. We have great medications for diabetes, to me that’s a new era. I can give a medication for diabetes that causes weight loss. That is fantastic, I got part of the equation. But we still have to deal with activity, food intake, and behavioral changes that need to come with this. The beautiful part is, now we have found out that the geriatric patient does better. This data will be presented at this meeting. For some reasons, as we get older, we are actually better at following diets and losing weight. If we can recognize it and be able to help out the geriatric patient, we will do well. We need to teach this to doctors; this is the hardest part – getting this taught to the physicians.
Steve: Why do you think geriatric patients pay more attention and are more successful than twenty or thirty year olds? It is because we are closer to death, we are concerned about dying and we think about it? Whereas the twenty-year-old does not think about it?
Dr. Fujioka: They’re indestructible. Yeah. There is something to be said for maturity, being older and more mature, we get it. Not everybody gets out of here alive. But the other one is, as patients get older, oftentimex have more time to take care of themselves. So in other words, they are not in the rush, they don’t have to get that closest parking place. They can park further away, and they can walk because they have more time. I actually love patients that have just retired. I can now change their life. I can say, look, retiring from this job, we got a new job. We have to move you in the right direction, so we will put in yoga, exercise, healthy living, and healthy behaviors. The geriatric group is very good about this, and for a lack of a better term, they get it.
Steve: We talked about treating the patient as an individual. That’s been around just recently from the ADA. If you go back 50 years, we had only one oral drug. In 1995, we had two oral drugs. And now, look at what we have. Everything we have is a combination, even a triple combination. That’s not even including the hyperlipidemia. You’re including the weight management in there. The first patient I worked with, I downloaded their monitor, and I out together a beautiful report, made some suggestions, 26 pages with column charts and pie charts. Their readings on Mondays and Thursdays and the weekend. And I remember the physician came in and I said look what I did for Mrs. Rose. He looks at me and says: “are you out of your mind? If you want to give me a report, give me a half of page, summarize it. I don’t have time to look at this stuff.” The reason I bring this up is, patient has hypertension, hyperlipidemia, high blood sugars, and are overweight. You can’t throw it all at once to them. What is your philosophy of how to treat that patient?
Dr. Fujioka: You are getting into what is called polypharmacy. Just giving drugs for this and that. It’s real clear, you get somebody to lose weight, you take care of all that; blood pressure comes down. We also know that if you look at dyslipidemia, the best thing for high triglycerides and low HDL is weight loss, not a statin. We also know that quality of life improves, sleep apnea improves. Hence why we have taken a very different approach at Scripps Clinic, of treating their diabetes but treating their weight at the same time. We treat both – we can actually get rid of medications.
Steve: The sign of a good presenter is that people take away what you say and they put it into practice. What would you like to tell from your experience, what would you like to get out to PCPs as some of the things they should consider and think about doing where you’ve had success?
Dr. Fujioka: If you look at PCPs they are in the best position to deal with both diabetes and obesity. Particularly, early on in diabetes, when weight loss is so critical, you can even put them in remission. One is, just recognize weight. Bring it up, just ask the patient if they would deal with it; 80% are willing to talk about it. It’s not that you have opened up a can of worms: if you are comfortable treating them – go ahead, if not – send them to somebody who is. As we move into this new era of accountable care, we will see more and more weight loss centers within large accountable care groups that deal with [obesity]. You have to look at obesity as a complex, chronic disease. You can’t look at it as a very simple thing. You are going to see centers popping up more and more, and they will be a natural gateway.
Steve: What do you see as the future of treating weight as far as the technology goes. Now there are balloons we can swallow, pills that explode, different forms of bariatric surgery, just so many things out there. What do you see coming down the pike as far as something that can be very effective, even looking into the future?
Dr. Fujioka: Looking into the future, if you are looking at particularly meds, you are looking at the meds that will clearly treat both. They are going to help you burn more calories, help your blood sugar get better, they are going to lower your appetite – they’re going to do all three. The future is really promising, because we now understand the pathway. We didn’t understand the pathway, we used to think humans were cued to eating. They would walk by the bakery, smell the bread, and go in and eat. But no, we are turned on to eat all the time. Now that we now the hormones that come back and tell us to stop eating, and where those hormones go – the sky is the limit. We are going to really be able to help out patients.
Steve: What would you want a PCP to know for a newly diagnosed type 2 diabetic that walks into the office? Most PCPs, I would think, are going to be looking at blood sugars and A1c and treating that, number 1 – hypertension, lipids – that’s part of the scheme of blood sugars. It’s not unusual for a patient to get a prescription for each one of those. I don’t see weight as one of the primary. You see it as a primary because it deals with all the other things; makes common sense. But, I don’t know if PCPs have reached that point. What is your experience?
Dr. Fujioka: I think we are in a turning point right now where I feel very fortunate that myself and other people who have been doing this for while, that have done the research, and have taught how to do obesity medicine, we are being asked to go to these primary care conferences and to teach it. So, I think that the knowledge is just now getting into the hands of primary care doctors. They will be able to treat this and address it. It is as simple as if somebody comes in with the A1c of 6.7% – sure give him metformin. Metformin does help with losing a little bit of weight and it controls your glucose. That is the way we will be looking at things; how can we treat both when that first patient comes in?
Steve: Is there anything at this meeting that is exciting to you, as far as the new information?
Dr. Fujioka: At this meeting? The biggest thing is that obesity has a presence now in diabetes. There is a lot of really excellent talks on obesity in the diabetic. A fair number of them who are top notch are at this meeting. So, it is clear to me that the information is getting out there.
Steve: And that is a change, isn’t it?
Dr. Fujioka: Yes, exactly. You didn’t see this before. You just saw blood sugars, but now we see both.
Steve: I want to thank you for your time. I have to say, I have spoken to a lot of doctors here, you are one of the more motivated ones.
Dr. Fujioka: Thank you.