Introduction: Welcome to Obesity: A Disease, the official Obesity Medicine Association podcast exploring the many facets of the disease of obesity. In this episode, OMA Chief Science Officer, Dr Harold Bayes interviews Dr Lydia Alexander. Alexander specializes in obesity and lifestyle medicine and is the vice president of the OMA. In this series of podcasts, our experts discuss select articles from the latest version of Obesity Pillars, an open access online-only journal published by the OMA committed to providing evidence-based research for health care clinicians in the field of obesity medicine. Today we'll be discussing the recently published OMA clinical practice statements. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.
Harold Bays, MD: Hello. Welcome, my name is Dr Harold Bayes, medical director and president of the Louisville Metabolic and Anthracosis Research Center, located in Louisville, KY. I'm also the chief science officer of the Obesity Medicine Association, and I'm editor in chief of Obesity Pillars, which is the official journal of the Obesity Medicine Association. Today we're fortunate to have with us today a good friend, Dr Lydia Alexander. Lydia, why don't you tell the people who you are and what you do?
Lydia Alexander, MD: Hello Harold, thank you for having me on. My name is Dr Lydia Alexander and my background is that I'm a physician trained in internal medicine with two subspecialties, importantly trained as an obesity medicine specialist and also in a subspecialty called lifestyle medicine. I am the chief medical officer at a med tech startup in the San Francisco Bay area called Enara Health, and I am also the Vice President of the Obesity Medicine Association.
Bays: OK, great. Look, I don't want to spill the beans here right at the beginning, but why don't you tell the folks a little bit about your interest in in food? I mean, that's going to become applicable here very shortly. But you know, what's going on with food in your life?
Alexander: Well, I always…I often say that if I were not a physician I would love to be a chef. And part of my background is that I am trained as what is called a certified culinary medical specialist, which is really a medical chef. And that's exciting to me because of the work that I do as an obesity specialist and how it's very pertinent and applicable to the four pillars of obesity treatment, particularly the nutritional component, and it also informs behavioral modification and really all the work that we do. From a personal standpoint, one of my hobbies is gardening, and I love to, you know, to raise different fruits and vegetables that we use seasonally in our cooking at home with my four children and my husband. And incidentally, we also actually cook fresh food for our dog and she has had better joint health as a result of that. We also have chickens at home, which I raised, as well. So I would say that I'm deep into nutrition, probably from the very you know, after being raised as a young kid here in in the United States and Michigan. My father was very into the same sort of stuff, into gardening and Greek Mediterranean lifestyle, from sort of soup to nuts in terms of whole fresh food.
Bays: Well, and again that leads…that so perfectly leads in to what we're going to talk about. The Obesity Medicine Association has published in Obesity Pillars, its journal, this series of clinical practice statements—and this is going to continue throughout 2022—and one of the very first clinical practice statements that was published, you were first author. And it was the clinical practice statement entitled Nutrition and Physical Activity. I just can't think of any better place to start a conversation within the context of a clinical practice statement that's applicable to clinicians and their patients than what you just talked about: nutrition and physical activity. So let's just get right to it. In this clinical practice statement for which you are the lead author, we did spend some time talking about the basics of biochemistry—understanding carbohydrates, understanding proteins, understanding fats. And maybe for some people they're like, “Oh my gosh, you know I had to learn that in high school and college. You know, why do you, why do we have to talk about that now?” But maybe you agree or disagree. I mean, I think it's important for all clinicians to know this, but why do you feel like it was important to have that information included in a clinical practice state?
Alexander: Well, I feel that… You know, I guess first of all we had to start somewhere and in terms of these clinical practice statements, they're designed to really set the infrastructure, the building blocks from the ground up. I think that's really helpful to ensure that we're all sort of speaking a common language, we're on the same page. And so far as the discussions that we're going to have now and in the future around nutrition and physical activity, and as they pertain to health and the treatment of obesity. And so typically, clinicians, myself included—whether an MD, a DO, an MP, a PA, any of us who are who are clinically practicing in this space—we didn't typically receive a large amount of training in nutrition and physical activity as part of that medical training that we had, and so our thought was to start with the basics and build from there so that we can ensure, again, like a shared common language and definitions to discuss macronutrients and subcategories of macronutrients, as well. So for instance, this becomes important when we're talking about, you know, around substitutions, So and what I mean by that is swapping out, as an example, saturated fats for mono or polyunsaturated fats. What does that exactly mean? Or the isocaloric substitution of ultra-processed carbohydrates for saturated fats. Is that helpful? Or vice versa, there? And so understanding the basics helps the clinician piece together how science informs clinical outcomes and our evidence base. In fact, for you know another example, why does fiber matter when it comes to eating a fruit? What happens, practically speaking, in the body when we digest apple juice as an example compared with the apple itself? So understanding the macronutrients is really the building block for the discussion and for that shared clinical language. And so that is why we felt this was so important. I would also say that additionally just understanding and reading food labels for clinicians and that and how we translate that to patient care is very practical in the application again of nutrition to patient clinical outcomes.
Bays: Well, let's…I don't want you to leave people hanging here. Let's just talk about the issue with regard to refined carbohydrates, ultra-refined carbohydrates, and saturated fats. I mean what is the difference? If you have a person that's say, consuming large amounts of saturated fat and they replace that in an isocaloric basis—in other words, with the same amount of calories—you replace that saturated fat with monounsaturated fats, or you replace it with polyunsaturated fats, or you replace it with ultra-refined carbohydrates, what happens to cardiovascular disease risk?
Alexander: Well, we know that when we replace saturated fats and trans fats with poly- and monounsaturated fats that are cardiovascular disease risk improves and there are lots of studies that that bear this out. We do know, as well, that when you swap out, for instance, you move from fats to carbs or carbs to fats, and you may think, okay, if I want a low-fat diet and I move into carbs, that that must be good for me, right? And that, and you know, that the answer to that really is it depends because carbohydrates as a macronutrient class is a large, you know, very, heterogenous class of macronutrients and it really depends on what we're talking about there. If we're talking about whole fresh foods and an apple or celery or a carrot or something of that nature that is a whole fresh food and yes, a carbohydrate, then that is…that may be a beneficial substitution.
Conversely, if we're talking about ultra-processed food—and what I mean by that would be, say, a cupcake—and we say, well, that's a carbohydrate. So if I'm, you know, substituting a piece of bacon, which is a saturated fat, for a cupcake, and I'm moving from a, you know… I have a low-fat diet there, right? Maybe that cupcake is pretty, it is a is a low-fat cupcake that I'm purchasing from the bakery. That must be good for me, right? And again, what we know about macronutrients and the clinical evidence base is that swapping out saturated fat for an ultra-processed carb, so moving from these two macronutrient classes, does not decrease cardiovascular risk and what really matters is the quality of the macronutrients. So I think the quality is really the important piece here and overall, that is something that we need to spend a little bit of time thinking about as we make different recommendations, dietary recommendations for our ourselves and our patients.
Bays: And I would say the flip side is also true: What if you have a person that's eating a lot of refined carbohydrates and they say I'm going to go on a low carb diet? Yeah, what is the relative difference, at least according to evidence-based medicine, if you were to replace these for the same amount of calories, those refined, ultra-refined carbohydrates. If you were to replace them with monounsaturated fats, polyunsaturated fats, or saturated fats, you know, what happens then?
Alexander: Yeah, so we find something very similar that if you're isocalorically substituting saturated fat or ultra-processed carbohydrates for saturated fats, your cardiovascular disease risk isn't really going to change, and that's what our evidence base shows us. Now, if we think about it and we move from processed, ultra-processed carbohydrates to monounsaturated fats and polyunsaturated fats, such as avocado oil or olive oil as an example of that, versus lard or other, you know, fats, trans fats is another example, then we do see that these more healthful fats do decrease cardiovascular disease risk. So it really matters, again, whether you're moving in the direction of fats to carbs or carbs to fats, that the quality of those macro nutrients really matters a great deal.
Bays: And I think that's such an important message. The other message is—I know people get tripped up on this—but we're talking about isocaloric substitution. And for a lot of the obesity medicine specialists out there, I think we have to acknowledge that these, this data that we're looking at is not looking at situations where you have people on low carb diets and now they're losing substantial amounts of weight, for the people in which that works. Maybe their diabetes goes away and their blood pressure goes down, and lipids get, you know, say their glycerides are decreased and such, and so that's not really what we're talking about, because that hasn't been studied very well. And that if you had a major impact upon obesity and improvement in a lot of metabolic parameters, you know, exactly how does that ultimately end up affecting cardiovascular disease risk? I think most people would say if your risk factor is going down then, your risk goes down, but that's another story. But I think what we can agree upon is what you just said: It's that no matter what position you take, surely we can all agree that there are some dietary patterns that are more healthful than others.
So, Lydia, this has been fabulous. What people should know is this clinical practice statement is in Obesity Pillars, which is the official journal of the Obesity Medicine Association. It is free online, so anybody can just go there. It's not going to cost you anything. And even though we've talked quite a bit about what's in it, I mean people should not get the idea that this, that it only talked about what we talked about. I mean, there's a lot of really great stuff, I think, in this clinical practice statement that's very practical and, as I think you said, actionable. So before we conclude here, do you have any final thoughts that you'd like to give the folks?
Alexander: My final thoughts would just be to, you know, to take a look at the CPS, the clinical practice statement as you mentioned—tons of great information in there, very actionable, very low barrier to entry in terms of what we can take and translate into our clinical practice to make our patients with pre-obesity and obesity healthier, and thinking about the long game. Thinking about not just, you know, weight loss, but the Holy Grail of what we do, which is active weight maintenance and how all of this—nutrition and physical activity, behavioral modification—informs… The entire kind of reason we do what we do is to make our patients healthier, and to do it for the long term. And so I think this is, you know, these clinical practice statements are the building blocks of that, and so I'm super excited to continue the work here because it really informs the excellent care of the patients that we serve.
Bays: Alright, well thank you so much, Lydia. This has been, this has been really extraordinary. I think there's just so much information here and a lot of times people think that a lot of this stuff is controversial. I'm one of those people. I don't think it's as controversial as people make it out to be, as long as we all have one thing in mind, and that's how we best take care of patients based upon the evidence. So, well thank you so much. Again, my name is Dr Harold Bays and you've been listening to Obesity: A Disease.
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