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 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. 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 the no matter what position you take. Surely we can all agree that there are some dietary patterns that are more healthful than others. It's interesting in this again, this clinical practice statement on nutrition and physical activity, for which you were lead author, you picked out the DASH diet and the Mediterranean diet as the two preferred dietary patterns. Why did you select those two?
Alexander: Well, that's a great question. And when we're thinking about different dietary patterns. I would say you know, taking a step back, the most appropriate nutritional therapy for the management of pre-obesity and obesity first of all, is one that's safe, one that's effective, one that patients can most adhere to and also one that has a very solid, you know, evidence base. And so we do know that the you know Mediterranean diet, while not really a defined diet, but rather a generalized term describing several different meal pattern variants and it has amongst the best consistent and robust scientific data supporting reducing cardiovascular disease risk. And, importantly, it's often a dietary pattern that can be followed over a long period of time, not just in weight loss but also in active weight maintenance, which is really the Holy Grail of treating obesity. It's something that a patient can adhere to over the long term. And so the Mediterranean diet, I think, is very helpful and healthful, but also something with optionality that we can help patients modify their cardiovascular disease risk over long periods of time and keep them healthful, not over just a few months with weight loss and a little bit of active weight maintenance, but over years. And so that was part of, you know, part of our thinking around focus on the Mediterranean diet.
For the DASH diet—which is the Dietary Approach to Stop Hypertension, is what DASH stands for. Also not really a, you know, a diet. Well I would say first of all, not really a diet designed for weight loss, but honestly, more for active weight maintenance, but it can result in weight loss if it if used properly. But it really does improve blood pressure as the name you know, as the name connotes. Blood pressure management and does have a strong evidence base behind it as promoted by the US National Health—National Heart, Lung and Blood institute. It does limit sodium and there does tend to be a lot of sodium in the US diet as well as total fat, especially saturated fat and cholesterol. And I would say this is really important because some of the pathophysiology behind obesity and central obesity is around insulin resistance, and the pathogenesis of obesity related hypertension is that they're increased leptin levels, leptin resistance, the sympathetic nervous system gets fired up then, you know, there's an increase in the renin angiotensin aldosterone system stimulation, and then everything kind of, you know, takes off in this vicious pattern and gets running…with increased sodium retention, increased arterial pressure and so forth. And so when we think about a diet such as the DASH, this is really, really helpful in treating blood pressure issues that can happen in pre-obesity and obesity. And we do know, according to NHANES data, that the prevalence of hypertension in individuals who have a BMI over 30 kg per meter squared is greater than 40%. It's around 42 or 43% of individuals will have hypertension. And we know that nearly 70% of first heart attacks and 77% of first strokes occur in people who have hypertension. And so a focus on healthfulness from this standpoint, as well as a diet like the Mediterranean diet which can be individualized and followed over long periods of time, seemed important to take into consideration.
Bays: Well and it's so much to take into consideration. I mean, I don’t want to presuppose anything, but as you know you and I are working on a roundtable discussion that I hope will be accepted by the Obesity Pillars, and within the context of this roundtable discussion we go into, I think, explicit detail about the ins and outs of the Mediterranean diet cause, that is so important. And at least for me, one of the big take home messages from this round table discussion—again, that we hope to have published soon—it would be that if you just simply implement Mediterranean diet, as healthful as it is, if you're not giving any sort of guidance with regard to caloric restriction, if you're giving no guidance whatsoever with regard to physical activity and such, you may not lose so much weight. Some people might. Some people may not, okay? But if you were to take sort of the best of both worlds and you would say we're going to, we're going to implement these pillars of treatment for obesity, which is the nutrition and physical activity and behavior modification, and maybe even medication, whatever, and you were to layer the Mediterranean diet pattern on top of that, then what the data says—I don't want to say suggests, that's what the data says, so particularly look at meta-analysis and such—is yes, now you do start to see improvement not just in body weight, but in metabolic parameters, like improvements in glucose and blood pressure and lipids and such. So, let me just ask you—and obviously you're an expert in the culinary arts as well as obesity medicine and such—if the Mediterranean dietary pattern has so many potential health advantages, again, particularly with regard to cardiovascular disease risks and such, how do you implement this in concert with measures taken or interventions taken to promote weight loss? Yeah, how do you merge those things together?
Alexander: Well, that's a great question. And just as you have defined, Harold, what's interesting and helpful about the Mediterranean diet is that it does have a lot of optionality. And that optionality is around whole fresh foods and around ancient grains and different types of grains there, as far as the carbohydrate class, mono and polyunsaturated fats. So it's really looking again at these building blocks that we talked about previously, and this this very basic structural framework and then also proteins as well. And so again we have optionality. We can, you know, customize it to the preference you know of our patients and create something there that is that is helpful. And taking this whole fresh foods approach, which is really, if I were to summarize what the Mediterranean diet looks like, that's really what it is. It's about whole fresh foods. When you go into the supermarket and you look around what we often tell patients is, look for something that doesn't have a food label and if it doesn't have a food label, it's a whole fresh food. And that's a great place to start, and we know that when we think about things this way and we implement a Mediterranean diet this way, and then also have a little bit of caloric restriction with that.
And taking a step back, part of whole fresh foods is that we're including the fiber. There is protein in there and these elements—these macronutrients and also the composition of what we're eating that way in a whole fresh food—means that it can be very satiating. And that when you're making that leap from processed food—which tends not to be really that satiating on a calorie-to-calorie basis—that we can implement a lower calorie or a calorie restricted diet for patients that can amount to weight loss when they need it, that weight loss first, and then can allow for active weight maintenance with delicious optionality. And we know that when we do this, either with the Mediterranean diet or with the DASH diet, with the extra sort of clinical involvement from a multidisciplinary approach which looks at decreasing the calorie intake, as well, for these dietary patterns, it turns out that…that there is a greater reduction in total in LDL cholesterol. And we know that when we restrict dietary carbohydrates that are not whole fresh foods, that that results in a greater reduction in serum triglycerides and also an increase in the good cholesterol, or the HDL-C levels.
And so this is, this is very important to our patients because this is what we're really looking for is to improve health, primarily I would say in by reducing cardiovascular disease risk. And reduction in these carbohydrates can also lead to greater reduction in serum glucose and obviously, ergo, hemoglobin A1C levels.
Bays: Look, nobody denies the laws of thermodynamics, that in order for people to achieve clinically meaningful weight loss, I mean it's going to require decreased energy intake, decreased calories in food. It's just really hard to get around that. Okay, but having said that, if you're going to focus not just on the weight of patients but the health of patients, then you’ve got to not just look at the quantity of food that people are eating—you’ve got to look at the quality of the food that people are eating. And I think that's the real take away message that I've taken from the clinical practice statement that you published, as well as the roundtable discussions… We have another round table discussion we've already completed talking about obesity in folks from South Asia. And it's just interesting how many people from South Asia, they're vegetarians, but their heart disease risk [is] you know, really high. Now there's a lot of reasons for that, but one of the reasons is that just because you're a vegetarian, just because you don't eat meat, doesn't mean that your diet is healthful. It doesn't mean that at all, because you can have a pretty unhealthful dietary intake and be a vegetarian, and I think that's the that's the message that I'm hearing from you is that, it's not—yes, we all get it. We all get that reducing energy intake is going to be important, but it but it isn't just about quantity. It's about quality. Am I right about that?
Alexander: Yes, absolutely. One of the you know, sort of one of the discussions we have in my place of work with our dieticians, with our patients, and so forth is that when we have someone who asks is a vegan diet or vegetarian diet…that must be good for me, right? And coming right back to what you said, Harold is really quality that's important, so you could be, you know, an Oreo vegan and that is not going to help.
Alexander: [laughter] It's a term that we use
Alexander: Yeah, you could be a, you know, a Coca-Cola and Oreo vegan and that is, I guarantee you, not going to improve your cardiovascular disease risk, but you can certainly say that you're a vegan as a result of that. And you know, I could, you know, apply that to vegetarianism, as well. I can apply it to a variety of different dietary patterns. We can choose non-quality ingredients and not improve overall health whatsoever. And so the purpose of the clinical practice guidelines was to come up with, you know, to sort of set this framework that is evidence-based, that is qualitative, that is also quantitative, because we are interested in treating pre-obesity and obesity and where there is, you know, patient agreement and patient adherence, as well, so that we can take this multidisciplinary approach where we have our eyes wide open and we're looking at, what does quality look like? How do you define these different areas? And all macronutrients and all calories are not created alike, so you cannot say that having a high protein diet or a, you know, high or low carb diet is the answer unless you look and you say, but what does that mean? Which carb, which protein, which fat are we implementing in these dietary patterns? And when we do that, what happens?
Bays: Well, couldn't agree more. Look, I want to make sure we get this last thing in here before we wrap this up because this has been something that has been bothering me for a long time. With regard to the section on physical activities, one of the most common physical activities for which people are engaged is walking. It sounds very simple, but it's just reality that walking is a primary physical activity for a lot of folks. And I can't tell you, Lydia, for how many years I heard people arguing back and forth: well, does walking really count towards physical activity, or does it only count for physical activity if you meant to use it as physical activity? And whatever and, I just wonder if these clinicians have ever taken care of patients with pre-obesity or obesity, because to be dismissive of the amount of steps that people take per day and say it only counts if they intended to do it, that just seems to be… I don't know it, it's just not the way I think about things, so let me just put it this way. I think people ought to get credit for what they do, whether they intended to do it or not. I mean, that could apply to a lot of aspects of life, I guess. But let me ask you: within the recommendations made by the clinical practice statement and included on the physical activity, yes, it includes the 150, you know, minutes per week of physical activity and more than that if you can, and at least two days a week of resistance training. But it also, for the first time in my knowledge, specifies that a minimum goal…that you can achieve some sort of minimum goal—particularly in patients with pre-obesity or obesity—if you achieve 5000 or more steps per day. What was your sense about that? How do you think that that plays clinically in management of patients with pre-obesity and obesity?
Alexander: Well, I think that, as you had mentioned, the way that we look [at] and define physical activity, I think about it first of all, in this umbrella of five different types of activity. And you know, the most commonly thought of is cardio, the second one is strength, the third one we have balance, then we have flexibility—I'm not going to get into that—and then another very interesting category called NEAT. And so Non-Exercise Activity Thermogenesis. And this is…and I shortened it to non-exercise activity time and so these are all sort of the activities of daily living that we wouldn't count necessarily under the physical activity umbrella as cardio or exercise. And so this is all the, you know, all those movements of daily living, the fidgeting and what you and I have often had some fun and interesting discussions around, the importance of being inefficient. And so when we think about…when we think about that, NEAT is really all those, you know, that inefficiency. If we were, you know, sitting at our desk and being efficient, we probably wouldn't get that many steps in. And so when we were putting together these guidelines, we know that only one in four or five Americans is meeting the guidelines for physical activity and healthfulness around those. And so 5000 steps is really the minimum, is the really the minimum requirement for not being sedentary, and so that is why we chose 5000 steps there, because the majority of Americans right now are not really getting that. As I said, only one in four or five, quite frankly, are meeting the, you know, the movement guidelines around cardio, NEAT, strength altogether there. And walking is one of the easiest forms of activity that we can do. You don't really need any equipment beyond some walking, you know, comfortable walking shoes. It's easily accessible and you can increase its—
Alexander: You bet. You can just, you can measure it on your phone in your pocket, if you happen to have a pedometer. A lot of people have, you know, all these smart devices. They're, you know, on their wrists and so forth that they can do that with, as well. And we know that it's an easy way to sort of make an inroad here to simply alter a little bit of daily activity such as taking the stairs, parking further from your destination, increase being inefficient, putting…you know, pacing while you're talking on the phone, putting away your laundry a few socks at a time. All of these different activities done inefficiently can help get us out of this. Less than 5K sedentary level of activity and it really does improve our health outcomes and so that's why we chose to start there very basically and just kind of address that low hanging fruit that we could make a lot of inroads with.
Bays: And they…and I, hopefully people heard what you said because it's spot on. It matters, it really does improve the health of patients. If they can achieve 5000 or more steps per day, that improves outcomes. Now, is it better if you go above 10 000 steps? Yes. Is it also better if you add that on top of the 150 additional minutes per week? Or…and particularly if you add that to a two times a week of resistance training and such? Yes. Basically the more that you can do, the better off you're going to be in most cases, unless you go to the absolute extreme. But you’ve got to start somewhere and a good place to start would be where people live. Go to a place where people can achieve something and where they can, you know, they can wear their watch or they can put it on their phone or whatever, and when they get that 5000 steps and the watch buzzes or the phone rings or whatever, you know, whatever congratulatory response that they get, that is, I think, the essence of behavior modification or positive feedback. That, yes, maybe it's not as good as over 10 000 steps per day, but for patients with pre-obesity and obesity, my goodness, Lydia. I mean, I think that's a, that's a good start, isn’t it?
Alexander: I think it's a great start. It's an absolutely great start and again, looking at, you know, we’ve got to meet patients where they are. And the most important thing—just as when we talked about nutrition and talked about, you know how can we implement healthful nutrition dietary patterns there—it's you know it's meeting patients where they are. Starting somewhere that is, you know where you're going to have you know, patient adherence and agreement and ability to sort of execute on this in a consistent manner. And so, you know, consistency is key and we know that activities around…around just steps are easy to implement and easy to be more consistent on, and again don't need too much to get started with this. And in fact, that's why when we look at—for instance, Mediterranean culture and myself, you know, being first generation Greek there—we think about what is easy to do and walking is, you know, so taking a healthful walk, which we call volta in Greek culture, after meals to digest has so many health benefits, and implementing that throughout the day, whether it's pre-meal, post-meal, beginning of the day, the end of the day, the different pacing we do—we know that this helps to maintain a healthy body weight. So it's part of active maintenance of weight loss. It helps lower blood pressure. It's got so many health benefits. It helps, of course, decrease the risk of heart disease. It reduces the risk of certain cancers, even. It reduces the risk of dementia, helps promote positive mental health overall, and lowers the risk of type-2 diabetes, improves bone health and strengthening. There's so much that just a little bit of patient pacing and inefficiency to not be sedentary is a great starting point, and then moving up and, you know, up into low activity and then more activity from the standpoint of just walking and pacing I think is super important and helpful and very actionable. And that is really, really important.
Bays: And I like what you said there. I think this is the conversation we had with this roundtable discussion. Basically, any time is a good time for physical activity, right? I mean, as you said, pre-meal, post-meal, whatever. Let's not get so caught up in the timing of it, just do it, right? I think that used to be a slogan for some company or something, right? You know, whenever is you're going to do it, whatever you're going to do, go ahead and just do it. And let's not so much worry about when you might do it.
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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