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: 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 you know, 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 evidence base. And so we do know that the 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: 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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