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Clinical Practice Statements for the Management of ObesityPart 3 - Caloric Quality, Quantity and Physical Activity in Obesity Management

Learning Objectives
1. Discuss evidence-based research in the field of obesity and lifestyle medicine as described in the latest version of Obesity Pillars
2. Explain why the Dash Diet and Mediterranean diet patterns are preferred for the management of obesity and pre obesity
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Obesity Medicine Association (OMA) offers clinicians evidence-based obesity management techniques using the four pillars of clinical obesity treatment: Nutrition, Physical Activity, Behavior, and Medication. Learn more

Audio Transcript

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. 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.

Bays: Is that a term?

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—

Bays: It's measurable.

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.

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.

Audio Information

© 2022 Obesity Medicine Association. All Rights Reserved.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

Participation Statement: Upon completion of this activity, learners will receive a Participation Certificate.


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