Harold Bays: Welcome! My name is Dr. Harold Bays, Medical Director and President of the Louisville Metabolic and Atherosclerosis Research Center located in Louisville, Kentucky. I'm also Chief Science Officer for the Obesity Medicine Association. Today we're going to be discussing an article with Doctor Craig Primack. Craig, tell the folks who you are and what you do.
Craig Primack: Hi, Harold. I am a physician in Arizona and I've been a full-time obesity medicine practitioner or physician for the last 13 years. As of tonight I am the President of the Obesity Medicine Association.
HB: What an opportunity it is to talk to the President of the Obesity Medicine Association. The article that we're going to talk about, [1:30] that is part of the Obesity Algorithm, was published in Gene Experimentation in 2018. The name of the article is “The Effects of Physical Exercise on Fatty Liver Disease.” I think the genesis of this article is that the increase of prevalence of obesity has made non-alcoholic fatty liver disease the most common form of chronic liver disease. One of the things [2:00] this article goes into is there are a lot of potential benefits of physical exercise and physical activity on fatty liver disease. It does so through a variance of mechanisms and such. So I will just read the conclusion here—the conclusion is that physical exercise is a proven therapeutic strategy to improve fatty liver disease. So Dr. Primack, for [2:30] clinicians listening to this podcast, who may have a patient who they suspect or know has fatty liver disease, what does this article tell them?
CP: That I think we should consider non-medicinal, not just weight loss by itself, as a treatment protocol, and that exercise is a known way to treat fatty liver disease.
HB: Currently we're doing a lot of clinical trials looking at investigational agents to treat fatty liver. But there's no specific drug that's indicated [3:00] to treat fatty liver disease. So you are an obesity medicine specialist. You see patients with fatty liver disease all the time. Do you have a general brief approach before we get into the nuances of this article?
CP: It is surprising in the last couple years that we're seeing so much fatty liver disease. And as patients' BMIs get over 35, over 40 we're seeing much more of it. So we've taken an overall approach towards [3:30] “Let's lose weight,” because until I read this article, that was really the keystone for me.
HB: Right, because it's got to be a multifactorial approach, don't you agree? Nutrition, physical activity…
CP: Yes, overall obesity medicine usually involves four pieces of (1) some kind of dietary manipulation, (2) exercise, (3) behavior modification, and (4) medicines and we were really just using that approach and we didn't emphasize exercise as one of these pieces.
HB: One of the things [4:00] when you start talking about physical activity or even nutrition, you're wanting to reduce that insulin resistance. You want to reduce the delivery of free fatty acids and glucose to various organs of the body. You want to increase fatty acid oxidation. You want to improve mitochondrial function. And it is quite remarkable that when you do a lot of these things with appropriate nutrition and physical activity, you can really can see a difference in crude measures [4:30] like liver enzymes and such. Would you agree with that?
HB: So again, let's say that you have a patient, they come in, they have got that mild elevation in liver enzymes, and you suspect they may have fatty liver. What do you do?
CP: For most people that come to me, we presume they have fatty liver when their enzymes are up. We then start overall weight loss. Now, I'm putting another emphasis on the exercise component of that as treatment, specifically, [5:00] for the fatty liver disease. Because we didn't have a lot of other things to offer them up until now
HB: And when you say physical exercise, I mean when you have a patient with obesity, do you have some sort of general prescription, for example? What is your general approach when you're advising patients on increasing their physical activity or physical exercise?
CP: That's a great question. What we believe is taking them from where they are and bringing them forward. [5:30] So I think people fall into three overall major categories: you have someone who doesn't do any regular exercise, you have someone who goes to the gym two or three days a week and maybe get on the treadmill for 30 minutes which is a great amount of exercise. But I also have people with obesity who are marathon runners. And just because you're a marathon runner surely does not preclude you from having obesity. And I think someone who is not exercising at all, we try to just do some very basic exercise.
HB: Because something's better than nothing, right?
CP: Something is definitely better than nothing. [6:00] But to recommend the guideline of 150 minutes a week and so forth to someone who isn't currently exercising at all … There was a study that looked at when you gave those exercise guidelines, it actually was less motivating to them because you're like “I'm already doing nothing.” “I'm doing nothing, and now you're asking me to do so much exercise that is just beyond my current capabilities.”
HB: I would make the analogy to pharmacotherapy. The majority of benefit for say [6:30] lipid drugs or diabetes drugs or anti-hypertension drugs is at that first dose. I think what clinical trials have supported is the greatest benefit you're going to get from physical activity is exactly what you just said, going from nothing to something, just moderate and such. This generally applies to fatty liver and glucose management, blood pressure, and lipids and such. But do you have any kind of specific things? [7:00] You have that patient that's really not doing much of anything—what have you found to be effective interventions or recommendations to make, that get people to do something?
CP: So I first asked them if they're not doing anything, “If you were to begin doing something, what would it be? Let's find the low-lying fruit and all of a sudden you're going to hear, “Well I would go to the gym, I would start walking in the morning, maybe I'll just take my dog out a couple times a week,” and I think those are all great suggestions. I'm a planner. If you're going to walk in the morning, the night before let's put our shoes together, let's get our clothes done [7:30]. When you wake up in the morning, you know, like me, I put my contacts in, I take the exercise clothes that are already laying on the floor, and just get out the door.
HB: People always ask me, you know, “What's the best kind of exercise? Is it the walking, the swimming, the running, going to the gym? What's the best form of exercising?” My response is uniformly very similar to yours, which is the best exercise for you to do is, whatever you will do, right?
CP: The one you like. [8:00] If you like it you'll do it, and if you do it you're going to get benefit from it.
HB: Okay so let's say that you have patients engaged in moderate physical activity. What do you tell those folks?
CP: So if they're doing cardiovascular as their moderate activity, we may try to add some weight-lifting in at that point, some strength training, up to around two days a week in the beginning. And then fine-tuning if they're doing all low-level cardiovascular activity, maybe put some high-intensity exercise in there also.
HB: Right, and [8:30] that takes quite a bit of education, doesn't it? Resistance training, people think you just go lift weights, and it is really not that way at all. There's so much that goes into resistance training, not just from the efficacy standpoint but boy, safety is so important when you talk about resistance training, wouldn't you agree with that?
CP: Absolutely, and a nice thing in Arizona, at least, we have many gyms now that baseline are only $10 a month. And so if you add a little on to that you can see a trainer occasionally also. [9:00] Many of them are throwing in a couple of sessions with their trainers and I say just to learn how to use the equipment that's in the gym.
HB: That is that is so spot-on, learning how to use the equipment. I mean it's one thing to say, “I'm doing resistance training and my muscles are sore,” but if you're doing resistance training and your joints are sore, you got to work on your technique. We're not here to hurt people, we're here to try to help people.
CP: So that's I think that's another thing is someone joins a gym and they start with the trainer [9:30] 3 plus days a week, which may be too much in the beginning. The trainer, some of them, believe ”The more I push someone in the beginning the more benefit they'll get, and so forth and it'll be inspiring.” I think it's just the exact opposite. If you do so much exercise in the beginning that you can't lift your arms the next day, that you feel bad about getting out of bed, the likelihood of you going the next day to the gym is pretty low.
HB: I got to tell you, some people are like “You know if you wake up the next morning after resistance training and you can still walk then you didn't do it right.” [10:00] But that's for people that are engaged in.,,
CP: That goes back to the “no pain no gain.” So I say mild discomfort is what you want, not pain.
HB: Not incapacitating pain that prevents you from moving forward. Overall what I'm hearing from you is that when you recommend physical activity or physical exercise for folks that have the fatty liver, or even the diabetes, hypertension, dyslipidemia, [10:30] it sounds like you take a balanced approach of both dynamic or aerobic as well as resistance training. Is that what I'm hearing from you?
CP: Absolutely. If you overall are going to run or walk a mile, you're going to burn about a hundred calories, if we're looking directly at weight loss. If you put substantial muscle on over time, then even at baseline you might burn more calories. If you then do cardio on top of that extra muscle, you can just burn a few more calories each day.
HB: [11:00] But at least when we circle back to the article we're reviewing here, several clinical trials have shown that both aerobic and resistance exercise reduce hepatic fat content.
CP: Absolutely. What I think this is going back and saying is what we've been saying since the beginning, which is it almost doesn't matter what exercise you're doing to help decrease the fat in your liver and such, it's just that you're doing something safe and effective you hopefully enjoy.
HB: [[11:30] Okay, very good. Well thank you, Craig. Thank you for attending and speaking at today's podcast. And I want to thank you for listening, you the listener for listening to today's podcast. This has been the Obesity Medicine Association podcast Article Review.
Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
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