OMA Chief Science Officer, Harold Bays, MD, FOMA, FTOS, FACC, FNLA, FASPC interviews Ethan Lazarus, MD, FOMA, AMA Delegate about the Obesity Medicine Association (OMA) Clinical Practice Statement for which he was first author, titled Cancer and Obesity. The CPS serves as a flexible guide for providers seeking to create or improve an obesity medicine program.
Today's topics include the management and care of patients with obesity following a cancer diagnosis; the need for aggressive treatment of obesity using behavioral, medical and surgical strategies; the benefits of weight loss in cancer patients with obesity; and the devastating impact that clinician bias can have on the long term progression of patients with obesity.
In our article review podcasts, we have carefully selected recent articles included in the latest version of the Obesity Pillars, which is the official Gold Open Access online-only journal of the Obesity Medicine Association and is devoted to the publication of clinical and evidence-based research for physicians, nurse practitioners, physician assistants, and other health care clinicians in the field of obesity that can be found at https://www.journals.elsevier.com/obesity-pillars. We then discuss this new science with obesity experts. To access other resources from the clinical leader in obesity medicine, please visit: www.obesitymedicine.org.
This podcast has been divided into 2 parts, with this being second and the final part.
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Intro: 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 Ethan Lazarus, the current president of the Obesity Medicine Association.
Today, our guests discuss the complex relationship between cancer. Topics include the widespread lack of awareness of obesity as a major driver of both cancer and heart disease. Have the steep decline of nicotine use over the past 30 years can inform us regarding possibilities for obesity Management Today and the true nature of fat as a metabolically hormonally active substance that predisposes the body to different types of cancer. Additionally, our experts discuss the management and care of patients with obesity following a cancer diagnosis as well as the need for aggressive treatment of obesity using behavioral, medical, and surgical strategies. This podcast is presented in two parts. Today we hear the full podcast. Obesity: A Disease podcast is brought to you by the Obesity Medicine Association, a clinical leader in obesity medicine.
Harold Bays, MD: My name is Dr Harold Bayes, medical director and president of the Louisville Metabolic and Atherosclerosis Research Center, located in Louisville, KY. I'm also chief science officer of the Obesity Medicine Association. Welcome to this program today entitled Obesity: A Disease. This is a periodic podcast that's sponsored by the Obesity Medicine Association and today we're going to be talking about a clinical practice statement that was issued by the Obesity Medicine Association and it's entitled Cancer and Obesity. And we're just fortunate to have with us today, Dr Ethan Lazarus, who is the first author on this paper. Dr Lazarus, can you tell the folks who you are and what you do?
Ethan Lazarus, MD: Hi Harold, thank you so much and what a pleasure it is to be on the podcast. My name is Ethan Lazarus and I've been an obesity medicine physician now for nearly 20 years. I run a practice in Greenwood Village, Colorado, where we specialize in a team approach to the chronic treatment of obesity, including physician assistant, registered dietitian nutritionists. And we're skilled at using all the various anti-obesity medications, behavioral strategies and that sort of thing. Also had the pleasure of being a member of the Obesity Medicine Association. For nearly 20 years I've been on their board and currently serve as the President of the OTC Medicine Association. I also represent the Obesity Medicine Association as their delegate in the American Medical Association trying to bring the priority of obesity forward for our whole medical system here in America so again, thanks for the inviting me for the podcast and I look forward to talking about cancer.
Bays: Let's say a patient comes in and they've been diagnosed with cancer and of course one of the first questions that people have is, they're like, how did this happen? How did I get this cancer? I mean the cancers you mentioned. These are not rare cancers, right? These are the most common, basically some of the most common cancers that are out there when you talk about breast cancer or colon cancer, you know, some of these other cancers and such. How often in your practice do you have a sense that patients are either willing to consider or already are considering whether or not their obesity contributed to their cancer? Is that something well known, or is that something that they're surprised to hear?
Lazarus: Well, it's actually a very tricky subject because, you know, at the time of treatment first we got to get them through that acute phase of treatment before we start talking about things like preventing recurrence and whatnot. But you’ve got to be really careful with that patient because you don't want them to feel like the development of cancer was their own fault. That if only I hadn't been so heavy, I would have never gotten the cancer. Because at, you know, at the end of the day, that the body fat mass is just one of many risk factors. There's, you know, environmental exposure and age of first child and breastfeeding status, and you know, exposure to viruses for some of these cancers, genetic predisposition from any of these cancers.
So I think another way that I might approach that question would be that we make a lot of cancer diagnoses during weight loss treatment that had previously been masked or missed. So for example, when a person loses 20 or 30 pounds, it becomes much easier to perform a thyroid exam. And I can tell you during my clinical practice I found five or six thyroid cancers that were there. They were there before the patient started losing weight and we were able to feel them and see them as the patient lost weight. Similarly, we know because of this topic of weight bias that people as they get heavier and heavier are less and less inclined to see their health care provider a lot of times because they've been treated poorly at visits with their health care providers. A lot of patients when they're coming to see me have not had the recommended cancer screening, they haven't had a mammogram, they haven't had their colonoscopy, they haven't had a physical. Sometimes they haven't even had lab in a long time. And so a lot of times engaging in obesity treatment, we can get those patients back into the medical system, get them screened for all the recommended screenings and any additional screenings that might be indicated for that patient based on their unique risk.
So now to get back to your question, how do they feel when they learn that weight is related? Well, I think what I like to tell them is that losing weight and sustaining weight loss might significantly lower their risk of recurrence and might significantly improve their odds at surviving their instance of cancer, especially for the 13 cancers we talked about.
Bays: Well before we move on to the next topic here, you said something that was very curious to me. You said that you found within your practice that many of your patients have not had routine preventive medical screenings that may occur normally in patients who don't have the obesity. I mean, I think I know the reasons for this, but why don't you tell the folks. Why do you think that is? Why do you think it is that studies certainly support that people with the obesity do not get the preventive medical screening that other folks get. Why is that?
Lazarus: Yeah, unfortunately as the person's body mass index gets higher and higher, patients receive a poorer and poorer quality of medical care. Studies have shown that health care providers a lot of times might not use good language with patients. They might blame the patient for their weight. They might just tell the patient that if they could just eat less and move more the obesity would go away. We had a patient this week that, the doctor told the patient that if she just didn't buy the food then she would be less inclined to eat it and this was the treatment for the obesity. In fact, we see that according to one study, 69% of patients with a high body mass index had experienced weight bias in the health care setting. Maybe the doctor didn't have a blood pressure cuff that fit the patient, or they couldn't get an MRI scan because they didn't fit in the scanner, or they were weighed in a public space and derogatory comments were made by the medical assistant. So we have a lot of bias among health care providers that the obesity of the patient's sole fault and it's due to laziness or a lack of willpower, and really not a good acceptance among health care providers that obesity is a medical problem and, while certainly there's a behavioral component to it, that that's not the whole picture. So as we're educating health care providers about cancer, we also want to be educating health care providers about compassionate treatment for patients with all shapes and sizes, so that a patient doesn't feel embarrassed to see their doctor because of their weight and they know that they're going to be welcomed into the doctor's office.
Bays: Well, that's just heartbreaking, so I think I'm going to flip to here, try to. I mean that's just, I mean, it's just so true and it's just so sad. But I want to flip and see if maybe we can go on, maybe look to the positive. Once they're diagnosed as having cancer, the initial approach is to really address the cancer head on and you know get that treatment going and such, but concurrently with that… Look, I think there is pretty good evidence that there's certain types of foods that people can eat if they're engaged in healthful nutrition that can help combat cancer. Things like citrus fruits, things like apples and cherries, and grapes and grapefruits, and these types of things or berries. A lot of, lot of evidence for berries. Every night I eat blueberries and I like blueberries, but I like to think that it's helping me out with disease prevention and specifically cancer prevention. Also cruciferous and green leafy vegetables and such are thought to have anti-carcinogenic you know, properties. And then there are other foods like beans and legumes and nuts and high fiber, and in fact some coffees and such are thought to have ability to prevent or improve the prognosis of cancer. So I think there's definitely things we can do from our nutrition standpoint.
As far as physical activity, people say, well, what about physical activity? Well, look, increasing physical activity can reduce the risk of cancer onset or recurrence. Routine physical exercise can inhibit cancer cell proliferation, can increase cancer cell apoptosis, can have favorably affect that inflammation you talked about, that immune response that you talked about, the metabolism that you talked about. That can…that physical activity can enhance the effectiveness of cancer treatments and equally as important to all of these things is that, look, a lot of times people when they get cancer they become debilitated and such and so routine physical activity can really help out during cancer treatments to help address these complications and potential frailties. So a lot of things we can do, but I think the question that's going to be on the mind of a lot of obesity medicine clinicians out there is: Well, that's great that you've really worked on the nutrition. We agree with that, and you're working on physical activity, and we agree with that. But does weight reduction in patients with the obesity—weight reduction, does weight reduction or fat reduction, does that help patients? So I will ask you, Dr Lazarus, does weight reduction improve the prognosis in patients with specific regard to cancer?
Lazarus: Yeah, so interestingly, this is a question that's been up in the air for a long time and just last month, just in June, there was a large study that got published looking at 30 000 people with a high body mass index, and then they took a look over 10 years at the cancer incidence among just the control group and then a group that lost a lot of weight. So they had a group that lost roughly 50 pounds and kept that off. And interestingly, comparing the group that didn't lose weight and the group that did, the group that lost weight lowered their risk of cancer incidence by 32%, and they also lowered their risk of dying by cancer, dying from cancer by 43%. So that's a humongous risk reduction—lowering the risk of dying from cancer by almost half by getting the body weight under control.
Now the body weight didn't get under control just by eating blueberries or walking on the treadmill. The patients had medical care! Patients lost weight with their doctor, so the group of patients that lost weight and kept it off were a group that had bariatric and metabolic surgery, and they were successful in keeping off an average of 19% of their body weight. And it's reasonable to believe that if we can help patients achieve similar weight loss using medical means or behavioral means or a combination, that they should experience a similar risk reduction for cancer. So we really... I don't think we can accept, you know, just lower the weight a few pounds with a heavier person. We really want to treat obesity aggressively like we treat blood pressure or like we treat diabetes. So you know, if a person has high blood pressure and the blood pressure is 180, we don't just try to lower it five points to 175. We treat them aggressively. We try to get the blood pressure normal so that we're not going to have a heart attack or stroke. And similarly for our patients with obesity, especially at a higher body mass index, say above 35, we need to be treating this aggressively. We need to be using not only behavioral strategies, but medical and surgical strategies. If we're really going to turn this thing around and make a significant reduction in their cancer risk.
Bays: And I mean, I think that's exactly right. I mean, if you look at and again, not just limited to surgery, I don't want to get people the wrong idea that improvement in these hormonal or inflammatory factors is restricted to surgery, because it's not. I mean the fact is weight reduction in patients with the cancer or at risk for cancer—you're going to reduce cancer onset or recurrence with weight reduction. You're going to inhibit cancer cell proliferation. You're going to increase cancer cell apoptosis. You're going to favorably affect inflammation, immune response, body metabolism, and in addition to all of these things, oh, by the way, you're also going to improve their quality of life. You're going to improve their risk for cardiovascular disease and diabetes, wellness, and all sorts of other things. So there really is evidence, evidence-based, and evidence basis for the benefits of weight reduction in patients with obesity with regard to cancer, as well as all these other things that…all these other health issues that adversely affect our patients. So that is just a I think a wonderful overview of the interrelationship between obesity and cancer. Ethan, I would just like for you to just give a, just a, you know summary here at the end. The folks listening to this program maybe weren't aware of this intimate relationship between the obesity and the cancer—from your experience as a clinician, and certainly from your experience as president of the Obesity Medicine Association, what sort of practical advice or guidance could you give to the clinicians out there with specific regard to the obesity and cancer?
Lazarus: Yeah, so patients come in all the time and they're sharing with their health care provider that they have a sister or a mom that had breast cancer, and they're concerned about their risk. And it really opens up the door for the health care provider to talk about the patient's weight in a positive way and to let the patient know that you understand that that's a concern for them and there's something we can work on today to help them lower their cancer risk. But that the patient might not really have insight that their body mass index is really causing them risk for all these other things and that it's treatable and we can do something about it. I find that when we talk to the patient about their obesity as a disease like hypertension or diabetes or cancer, if you'd like, that patients warm up to the idea that it can be treated, it can be treated successfully. So we can really use this to tell people, look you can lower your risk of dying from cancer by 42%, 43% if we treat your weight and treat it seriously. So let's give you all the tools to do the best job with your weight that we can so we can lower your risk and improve your quality of life as much as possible.
Bays: And look, you know, maybe your experience is different than mine, but it's been my experience that you tell somebody that you want to engage in cardiovascular risk prevention, they will listen. They will listen, but if you tell somebody you can reduce their risk of cancer, they're really going to listen. Has that been your experience?
Lazarus: Oh yeah, I think that's absolutely true. A lot of people view heart disease as something that just happens as a result of aging, but there's definitely a fear factor with cancer. And so telling patients strategies where they could lower their cancer risk, I think it's very compelling to help them get motivated and to get to work with you on getting as healthy as they can.
Bays: Well, there you go. I think that's an outstanding summary. So Dr Lazarus, thank you so much. This has been. I think it's been an amazing program about a topic I don't think people talk about enough, and hopefully we've just given people just a glace of the kind of information that's out there. And again, this is all derived from the clinical practice statement put out by the Obesity Medicine Association. Dr Ethan Lazarus is the lead author on the paper and I want to thank you for, I think just an outstanding program and I want to thank you the listeners for attending this podcast sponsored by the Obesity Medicine Association. My name is Dr Harold Bayes and you've been listening to Obesity: A Disease.
Outro: Thank you for listening to this episode of Obesity: A Disease. For more information about Obesity Medicine podcasts and other valuable resources from the clinical leaders in obesity medicine, please visit www.obesitymedicine.org/podcast. If you enjoyed this episode and want to listen regularly, head over to iTunes where you can subscribe, rate, and leave us a much appreciated review. The views expressed in this episode are those of the host and guests, and do not necessarily represent the opinions, beliefs, or policies of the Obesity Medicine Association or its members. Please join us again for our next episode of Obesity: A Disease.
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