In part 2 of this exclusive interview from AACE 2016, Dr. Garvey discusses the available tools — medication, surgery, lifestyle interventions – to combat obesity, and which strategies are most effective.
Steve Freed: You talk about these new tools that are available. They’re fairly new, in the matter of a couple of years. If you go back 30 years, we had diet doctors, they would prescribe all these amphetamines and all these pills, so we had a number of tools back then. Then all of a sudden, the FDA, because of issues and problems with cardiovascular disease, pulled all these medications pretty much off the market, except for maybe one that’s been around for a long time. Now we are seeing three or four new medications that have come into the marketplace. Plus there’s all kinds of exciting things, and I’m sure you are up on some of the research, we’ve got tubes that go down the throat, we’ve got balloons, new medicines coming out. Obesity is such a big thing, everybody wants a piece of the action. From your experience, from right now today and thinking into the future, what do you feel are some the things that have worked well for your patients?
Dr. Garvey: I think, we’re still able to get a 10% weight loss and something in that neighborhood in the majority of patients, using the medications we have available now, using a structured lifestyle intervention. That is sufficient to really benefit patients’ health to a great degree. We’d like to have the medical therapy evolve to a degree of weight loss that you can achieve with certain bariatric surgical procedures, such as the sleeve gastrectomy, or the roux-en-y gastric bypass, where you get about 25-30% weight loss. I think that will happen. I think what’s going to happen though is required combinations of weight loss medications. Just like we do in diabetes. We need diabetes medicines that have different mechanisms of action, working on insulin secretion, insulin sensitivity, restraining a panic glucose output. We use combinations of these medicines to get the best clinical response. The same thing is true in obesity. There’s a lot of mechanisms, a lot of pathways that regulate appetite. The more of these pathways we can hit with the medication to reduce food intake, the more effective we are going to be. That’s where the field is evolving. Right now we know that we have four weight loss medications that have been approved for chronic treatment of obesity since 2012. The fifth one is Orlistat which has been around for a longer period of time. We have no safety data on these combinations of these medicines. The FDA has issued a warning about using these in combinations because of the lack of data. That data will come and I think in more medications are going to be developed by PhRMA and by Biotech. I think obesity right now, is where diabetes was 20 or 30 years ago. I was there 20 or 30 years ago, so we used to think, a common notion was this patient has diabetes. Quit eating so much sugar, lose a little weight and get out of here. Live right and you won’t have diabetes anymore. We know that’s not the case and we have now powerful tools to really control that disease. Obesity, the lay public and even a good number of health care professionals, regard obesity as a lifestyle choice, as opposed to a disease. Ok, go lose some weight, come back after you’ve lost so many pounds. It’s not going to work. We have to treat it like a disease, based on our understanding of the disease pathophysiology.
Steve Freed: So I always ask this question. What is more important in your experience? Education, physical activity, or nutrition, when it comes to obesity. Which one would do you feel plays a larger role if any?
Dr. Garvey: Well, the sine qua non is reduce caloric intake. Without that you’re not going anywhere. So that’s the most important thing. You need to prescribe a reduced-calorie diet and you may need medications to help the patient adhere to that reduced caloric intake. Exercise or increased physical activity is certainly helpful. I think it’s the reduced caloric intake that’s most important. I think where physical activity becomes more important is after you’ve achieved some weight loss, helping to maintain that weight loss over a longer period of time.
Steve Freed: One of the things I’ve found very interesting. I’ve had a chance to interview a Ph.D. Doctor Mattson who works for the NIH, who’s done studies on intermittent fasting. I had the opportunity to talk to him and I said to him who came up with this idea that we have to eat three meals a day? It had to come from someplace. He says you go back to before the industrial revolution where people worked on farms and they worked on factories and they needed three meals a day just to keep their energy up. But now we have McDonald’s every third of a block. Nobody is technically, except for some people, starving. We have all kinds of foods available to us. We may not need three meals a day.
Dr. Garvey: I think you are right. We’ve had increasing rates of obesity in the United States and around the world. Our genes are the same. Our DNA is the same. It’s really a changing environment and the interaction of that environment with our genetic susceptibility that is responsible for increasing rates of obesity. I think you are right. If we became more active, eat two meals a day, walk instead of driving, get our butts up off of the computer screen or the TV, then we are reversing those environmental determinants that interact with the genetic susceptibility genes. Right now I think obesity rates may be leveling off, which is predictable. Once your environment starts to level off, I think obesity rates will. Those individuals who have inherited larger subsets of obesity susceptibility genes, each conferring a relatively small risk of the disease. When you inherit a larger number of these, those are the individuals that are going to be more overweight or obese in any given environment.
Steve Freed: Another question I asked him was: where did we come up with the idea that breakfast is the most important meal of the day? You hear that all the time. He says that came from a couple of studies they did with school kids. They took away breakfast and those kids that had breakfast did better on their scholastics. That study, if you look at it, and when you look at studies, it depends on what you look at in every individual study. You can come up with all kinds of different answers. What they did is that they took kids that have had breakfast for the last twelve years and they took their breakfast away. So obviously they’re not going to do as well because they are used to something and they took it away. “Eating breakfast is the most important meal” may not actually be true.
Dr. Garvey: There’s a whole science evolving what’s called time-restricted feeding. If you separate meals a certain amount, how does that affect metabolism. I know this notion is out here that breakfast is the most important meal of the day. If you look at the research, a lot of these data, they aren’t rigorously performed experiments. We did a randomized clinical trial. People ate the same amount of calories, but they timed their meals differently. Some were randomized to not eating breakfast, some were randomized to eating breakfast and it made absolutely no difference. What I would tell the patients is if you like to eat breakfast, ok, eat breakfast. If that’s part of your routine is just to skip breakfast and wait till lunch, that’s fine too. Over the course of 24 hours though if you have overweight or obesity, your total calories are going to have to go down. We can help you with that. We can put you on a healthy meal plan that you like, reduce calories, structured lifestyle intervention to help you with that. Medications if you need it. We can get you there. It’s the reduced calories that’s going to be critical.
Steve Freed: You mentioned calories a number of times. The word that you only mentioned once was carbohydrates. If we’re talking about, well it doesn’t make a difference, whether it be diabetes or obesity. Where do carbohydrates come in? Obviously reducing your carbs is simple. What is your philosophy of going further and just saying you’ve got to eat fewer carbs?
Dr. Garvey: Well, different people are going to give you different answers to this question of course, which means we probably don’t have sufficient data to address it in a rigorous way. My approach is, it’s not the amount of carbs, and it’s the right carbs. You just want to stay away from simple sugars and work towards more fresh fruits and vegetables, fresh foods with complex carbohydrates. It is true that carbohydrates induce a greater insulin secretory response. You’re more likely to drive lipid synthesis in the liver, triglyceride synthesis, increased VLDL levels. In various randomized trials where they’ve tried different macronutrient compositions of the diet, low carb versus low fat for example. Everybody will lose weight. The low carb, which is a higher fat diet, will tend to lose more initially, but by the time you get a year or two out they kind of come together. I think the initial response to a low carb diet is maybe a little better over the first six months. But over the long term, it doesn’t make much difference. I think a low fat diet, which is higher carb, is fine too, if it provides a macronutrient mix in foods that the patient likes. Stay away from the simple sugars and go more with the complex carbohydrates.
Steve Freed: I don’t want to take much more of your time. If you would like the medical professions to walk away with something from your knowledge, what would a couple of those things be? What would you like to share with them?
Dr. Garvey: Well, as I’ve said, I’ve been a diabetologist my whole career, and the last five years I’ve become an obesity medicine doctor. I just think we have the tools to treat obesity effectively as a disease to improve the health of our patients and we’re not taking advantage of this in American medicine and our patients are the ones that are suffering. It’s true that some of our employers and insurers don’t cover weight loss medications the degree to which we would like, that’s changing slowly over time. We need to advocate on behalf of our patients and drive that process as well. Pay attention to overweight and obesity in patients, just like you would a high blood pressure, a high blood sugar, a high blood cholesterol. It is a disease and it’s causing morbidity and mortality.
Steve Freed: Where’s the best place, now-a-days electronics and the internet play a huge role in knowledge and education, is there any place specifically that you’d recommend that a medical professional would go to to learn more about obesity and the best way to treat it?
Dr. Garvey: I mentioned the AACE comprehensive clinical practice guidelines for the medical care patients with obesity just put online, will be published in July in Endocrine Practice. Read those to start. AACE is developing an obesity resource center online analogous to our diabetes resource center that has very useful information for clinicians. I think there’s a website called “Rethink Obesity.” I think it’s very good. The Obesity Medical Association has a nice website as well.
Steve Freed: The last question is: is there an app out there that could be beneficial? I’ve seen so many of them, I get confused.
Dr. Garvey: There’s apps that help patients track their dietary intake and physical activity. Just the act of self-monitoring is probably from a behavioral standpoint one of the most effective things we can have patients do to enhance the effectiveness of a lifestyle intervention. I like “Lose It” because it’s on my phone.
Steve Freed: What’s it called?
Dr. Garvey: “Lose It”. You can just put in what you eat. It tells you how many calories and it tells you if you go over your calories. It counts them over the course of a day, over a week, over a month. You set your goals, you say how many pounds you want to lose and they tell you how many calories you need to eat over a period of time. You start paying attention to what you eat when you’re recording your diet. I like “Lose It” but there’s a whole vast number of these, of course the Fit Bits. I just discovered my iPhone counts my steps. I used to be just a happy person who would walk around and now I look at how many steps I take every day and getting mad at myself if I’m not over so many thousand.
Steve Freed: Well again I want to thank you for your time. I really appreciate it. I find it very interesting. Coming to these events and talking to the real smart people and learning new things. That’s what makes what we do very interesting, especially for myself. I just bought a stand-up desk and I just put it together two days ago. I’m finding that it’s cool. I don’t mind standing up for half the day. Pacing back and forth while you are working on your computer or whatever. All these little things help. That’s really what it takes is coming up with ideas.
Dr. Garvey: It’s not only voluntary physical activity, it’s reducing sedentary activity, reducing the time during the day that you’re sedentary.
Steve Freed: Again I want to thank you. I really appreciate it.
Dr. Garvey: Thank you very much.