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Pape: Hello this is Joy Pape with Diabetes In Control and we are at the AACE (American Association of Clinical Endocrinologists) 2018 meeting. I have the pleasure of interviewing and talking with my friend and colleague, Scott Kahan. You spoke today, Scott, and the title of your presentation was, “Best Nutrition Practices for Chronic Weight Management.” Well, what a subject! The big question – from healthcare providers, to people who have diabetes, to people who have obesity – is “what should I eat.” So, what would you recommend to healthcare providers to help their patients know what to eat and how to eat?
Kahan: Yes, so in the first part of my talk, the question I tried to answer was, “What’s the best diet?” We actually have quite a bit of data on this. When it comes to the outcome of interest being weight loss, the answer seems to be pretty clear and that is, there is no best diet. Assuming caloric intake is the same, whether people go on a low-carb diet or a very low-carb diet, or a low-fat diet or a very low-fat diet, a Mediterranean diet, vegetarian diet, and on and on, assuming caloric intake is the same, people lose about the same amounts of weight in the short-term, the intermediate-term, and in the long-term. That has been codified in the guidelines, both the AACE guidelines for weight management and also the NIH (National Institute of Health) guidelines for weight management. So, that is part of the answer. Now, I do not think it is the whole answer though. First of all, there’s still more that we are going to learn and so as the science evolves, maybe that answer will change over time. But even now, based on what we do know, I think there are some other really important practical factors.
First, even if people are trying to lose weight, that really isn’t the only outcome of interest. And so, let’s say if a patient has a very high triglyceride level, that will probably, all else being equal, improve more with a lower carb diet than with a lower fat diet. And vice versa, for people who have higher LDL (low-density lipoprotein), that will probably improve more with a lower fat diet than a lower carb diet. So, we can go through a number of different scenarios and outcomes of interest there that may also help the clinician to best give advice to patients.
On top of that, and I think perhaps the most important out of all of this, is personal preference. So, there are lots of dietary patterns which is good because there are lots of different people and different people like different things and have different fits for different types of dietary patterns. And so, I think one of the most valuable things we can do is listen to our patients and allow them to have the autonomy to make the decision for themselves or, at least, in combination with their provider. And that may come down to something like taste; some people just like low-fat dietary patterns because they can eat lots of vegetables and fruits and they can eat more sugary foods and so forth. Other people really like savory foods and protein-type foods and such and they prefer low-carb diets. And again, all else being equal, that’s not a problem but if we follow our patients tastes on those, it may lead to the patient being more successful with that dietary pattern. So that is the first question that I try to answer.
In the second part of my presentation, I went through a framework of some tips that providers who don’t work in this day-in and day-out like you and me can take back to their practice to be able to incorporate just a little bit of nutrition and a little bit of weight management counseling into otherwise busy endocrinology and primary care practices.
Pape: Can you tell me some of those tips?
Kahan: Yes. Actually, I wrote an article in JAMA last year on this. There are a few things. The first thing is, start the conversation ideally before you even meet with the patient. What I mean by that is, especially in a busy primary care practice or endocrinology practice, you can have questionnaires and forms that patients fill out about their dietary patterns, about their likes and dislikes, about their weight history so that even before you see them, you’re going to have information that you can look at so you’re not starting from scratch. So that’s very valuable and then you can use that to build from there. That’s one example.
Another step is to use a structured framework that makes sense to you. Now, the one that I tend to use, because it makes sense to me, is the “5 A’s” framework that was initially developed for smoking cessation counseling. It’s ask, assess, advise, agree, and assist. You can apply that to so many different things but for clinicians who didn’t learn much about that in medical school, like I didn’t either, and who don’t do this day-in and day-out like you and I do, it gives them a basic framework that they can go back to; it’s sort of a cheat-cheat, if you will, to help think through what are the pieces that will make up the encounter as they go about trying to help patients around weight management. I gave a number of further steps like that and I’ll refer you to the article in JAMA that I published late last year with the full list.
Pape: So, something comes up sometimes and people say, “Well if I eat this, won’t it raise my cholesterol?” Let’s say low-carb – you’re looking at triglycerides. Or sometimes people do go on low-fat and their lipids raise. How do you answer that question of how much is really about what they eat and how much is really about what their body makes?
Kahan: I think there are a few parts of this. You just hit the head on the main one. Genetics drives so much of our health outcomes that we have some agency over our health outcomes, of course, but a lot of it is driven by our genetics. So, someone who has a propensity towards very high cholesterol levels, no matter how much they run and no matter how healthy they eat, they may not be able to bring it down to a clinically ideal level. Therefore, they may, for example, need a statin medication or the like and we can think of many permutations of that but genetics are very important.
Now, the other part of that question is a lot of people come in with various beliefs that are positive and negative about what different dietary patterns can do both positively, but also, in terms of risk. I always try to go back to the published data on that. We have very good published data that, the Atkins-type diets to low-carb-type diets, are not going to raise your cholesterol through the roof. Some people will respond badly, but on average, they actually do quite good in terms of lipid control. And same thing with low-fat diets, on the whole, they’re very healthful as well. So, helping people understand the vast research that has been done I think goes a long way in terms of empowering them to work on some steps that they can make in their life.
Pape: This helps us move into the second question or the second b question. But, with what you’re saying, some people make these dietary changes or they don’t and they blame themselves when they don’t see the changes in their labs or on the scale or how their clothes are fitting or waist circumference. How do you respond to that?
Kahan: There is a lot of blame that goes around in the field of weight management. Blame comes from doctors sometimes unfortunately, blame comes from spouses and parents sometimes unfortunately, and often, blame comes from ourselves. It seems like weight management should be easy – just eat less and exercise more. Don’t eat that, eat this. Don’t sit on the couch. But in the real world, we have busy lives and often not enough time in the day to go to the gym or go shopping for all the foods that we would like. And, the healthier foods tend to be much more expensive than the unhealthier foods. When you take all of these different factors together, it makes weight management very challenging for most people and that’s why the vast majority of Americans have troubles with weight. I think it is important that we cut ourselves some slack around all of that. We all need to keep working on it and hopefully patients have the support that can be helpful for them. The derogatory ways that we end up talking to ourselves and blaming ourselves when we don’t accomplish what we want around our weight only serves to make things worse and I don’t think it’s fair to ourselves. So, I think it’s something that is worth having discussions with patients to help them build a more compassionate, productive, self-talk approach to their weight management.
Pape: So, speaking of a self-talk and being compassionate, of the “5 A’s”, you started with “ask.” What does that mean?
Kahan: Yes, so my favorite of the “5 A’s” is that first one and by that, I mean ask permission about talking to a patient about his or her weight. This is a little different than other areas of medicine. If you have a patient that comes into your clinic and they have high blood sugar, you’re not going to ask permission if we can talk about their diabetes and things like that. But when it comes to weight, it’s a very unique and different area of medicine. Weight is a sensitive and personal issue. People who grew up carrying around excess weight probably have been teased throughout their childhood. In our society there is so much weight stigmatization that it hits almost anyone, even people who objectively aren’t heavy. And so, I think one of the most valuable and simple things that we can do as healthcare providers is, before talking about weight, ask the patient’s permission – “Would it be O.K. if we talked about weight today?” Let me expand on that a little bit. If you are a primary care doctor, for example, and you’re seeing a patient and you haven’t talked to them about weight before, you might say something like this: “You know, we have been seeing each other for a few years, and I’ve noticed that your weight has been climbing over the years, and it seems to be leading to your cholesterol going up and such. We know that there are lots and lots of diseases that are associated with weight, and I have some training in this, and I would love to be able to help and support you in addressing your weight and improving your health. Would it be O.K. if we worked together on weight management?” When you approach them in that compassionate way and that patient-centered way, and give them the autonomy to choose whether they are ready and open to talk about it, the vast majority are willing and even eager to have such a supportive partner in their care. And for those who aren’t right now interested, you’re still putting forth yourself as someone who cares about them who is going to treat them compassionately and has a skillset to help them. I bet that they’re going to come back to you, maybe next month or maybe next year, and then you’ll be able to take some steps forward with them.
Pape: Makes me think of your planting the seed if they’re not ready.
Kahan: Yes, I like that.
Pape: So, that really opens up with both of us being so passionate about the topic of preventing and fighting weight bias and stigma. What is that and can you give some tips on that?
Kahan: Yes, so weight is an incredibly stigmatized condition in our society, and throughout most of the world. We all know this from seeing the heavy kid in the schoolyard being teased and shamed, and unfortunately, it’s much more pervasive than just that. It happens in work places, in the healthcare system, and throughout society at large. On top of that, we have a lot of research now showing that not only is weight stigma not nice, but it leads to a range of poor health outcomes. Of course it leads to poor mental health outcomes, things like the propensity towards depression or binge eating or the like, but it also leads to poor physical health outcomes. People who experience weight stigma have a higher likelihood of metabolic syndrome, higher cholesterol, diabetes, and at least one study shows that people who experience weight stigma have a higher likelihood of premature mortality believe it or not. On top of that still, people who experience weight stigma tend to gain more weight and that is a misconception that people really don’t realize. A lot of people sometimes think they’re doing good by stigmatizing towards someone because they think it’s going to motivate them to lose weight but the research shows the exact opposite – it’s going to make things worse. So, it’s an important area to address. Frankly, I think it’s every bit as important as addressing obesity itself, as in the physical aspects of obesity. So that is something that I spend a lot of time speaking on and working with doctors on.
Pape: So, there is an organization that both you and I are involved in and have a lot of respect for and that is the Obesity Action Coalition (OAC). And so, we will tell our members about that. We thank you for joining our board and hopefully through Diabetes In Control, we can get the word more out on what we are talking about today.
Pape: Thank you so much for your work – so many people need it and can be helped.
Kahan: Thanks, Joy.