Louis Aronne, M.D., discusses Overeating & Obesity: Obesity Medicine Today

Louis Aronne, M.D., discusses Overeating & Obesity: Obesity Medicine Today



wow that's tough act to follow right there but thank you very much more can thank you thank you for having me here really appreciate the opportunity to be long I'm going to be talking about obesity medicine under spend most of the time talking about a system that we have developed a massively scale obesity treatments and because I'm only have ten minutes normally and spend ten minutes on that and then I spend 50 minutes on everything else but since i have ten minutes i decided i would spend the 10 minutes on that because i was told this was of interest but before I do I wanted to tell you one thing and that is that as you may have heard obesity is now declared a disease and one of the arguments we always get into is how could you call obesity a disease people are just eating too much they should just stop eating a no lose weight and I know speaking to a sympathetic audience here but I wanted to give you just one example one example of the type of work that's going on now that is convincing the powers-that-be people the AMA people the government evil the FDA that obesity is in fact a disease and I've chosen this paper by Josh Taylor but really Michael Schwartz from the University of Washington the title is obesity is associated with hypothalamic injury in rodents and humans and what this paper says is that the rapid influx of calories damages critical neurons in the hypothalamus these are the neurons that conduct signals from the fat cells stomach and intestine to the cerebral cortex where all the processing curves and what this paper suggests is that when too much food comes in too quickly it overloads the mitochondria of these nerves and the nerves deteriorate more rapidly they start dying more rapidly and other work has shown that the stem-cell mechanism that supports the integrity of hypothalamic Popsy neurons can't keep up and in fact if you look at what happens in this paper as time goes on mice are fed fattening food they have fewer and fewer hypothalamic pom c neurons so what looks like it's happening is that they expand their fat mass to try to amplify signaling through the hypothalamus so if we think about it is damage to your hypothalamus a disease and the answer I'm sure you would agree is yes what's the evidence that that happens in humans and we have just indirect evidence and we can't establish cause and effect but I think that this is an extremely promising an interesting line of research that will revolutionize our field and let me mention one last thing which is so if nerve damage is the cause of obesity that the thing is I would propose that this is the ratcheting phenomena where weight goes up and it won't go down right this is not the addiction this is not anything else this is not eating too much food in the environment I think that what we're going to see is that this is a what causes people to be unable to lose weight so why don't they just lose weight as Ryan did it's because their neurons get overloaded the overloaded neurons can't transmit the signals stem cells which replace the neurons can't keep up and it's been shown if you take normal weight Adams animals who can resist fattening food they have a very robust stem cell mechanism that continually replaces the nerve as they dine or how many died they replaced very efficiently and the problem another problem seems to be besides fewer nerves it's the presence of inflammatory cells glial cells in the hypothalamus and what's been shown in humans is an increase in hypothalamic inflammation with increasing BMI so one of the parts of this paper shows that the higher the BMI the greater the t2-weighted images suggesting inflammation in that area and I think that again I don't present this as the end-all and Beall but I think that this is telling us that the environment is turning into something physical and that our approaches have to be a lot more sophisticated than they happen in the future and that really is one of the key messages the second is that the recognition that obesity causes more than 60 illnesses that too many of the these hormones are come from adipocytes can together cause many of the diseases we spend our time treating in medicine and many other areas I think that this recognition is another thing that is convincing Medicare the FDA very important people that obesity is worth treating so as a result treatment isn't as simple as it looks and I think that professionally let behavioral treatment is going to be the way things go that we are in the midst of the medicalization of obesity management and this is now supported by the US Preventive Services Task Force they agree that based on their traditional review we get a grade B recommendation but that's enough to trigger coverage and it's been shown again and again to be cost effective so despite the fact that you may say well it's not really that effect you only get five to ten percent weight loss the fact is that it's cost effective that reduces the risk of other complications and that's because when you look at the hormones that we're talking about they go down much much more much more rapidly than you would expect that's kind of a good news bad news situation as Ryan's going to find out in the near future because his leptin levels are much lower than they should be for somebody with his BMI and what's going to happen is that low leptin state will begin to trigger a lack of satiety maybe cravings all of the things that we hear about and if it doesn't do that it's going to suppress his skeletal muscle metabolism as my colleagues at Rockefeller are shown in at Columbia shown discover muscle metabolism will be reduced dramatically forty percent with just a ten percent body weight loss so that's why it's so difficult for people to lose and maintain that weight loss not because they don't want to not because they don't have the willpower and in order to do this we need to develop more sophisticated programs to look for problems that can be managed for example one thing I'm big on is the is drug induced waiting we see many patients who come to us we're taking medicines that cause weight gain and everyone's yelling at them to lose weight nobody's changed their medication and I think that now we're going to see a shift in healthcare as a result of accountable care we've heard this already appealing that that will favor prevention and that could in fact hasten the change to obesity management as part of the care model so one of the problems with that is that health care providers don't know how to treat obesity and they have no resources they oversimplify the treatment they told we'll go to Weight Watchers they just don't have a clue and the result has been a failure of the patient and demoralisation of both the patient and health care providers so they don't do anything they don't do anything they completely ignore it and wait until people develop diabetes till they develop hypertension hyperlipidemia because they're comfortable with treating those they have pharmacologic management I've pointed this out that there are more than a hundred more than 100 antihypertensive agents in 10 different categories ten different therapeutic categories so doctors feel very comfortable treating hypertension if a patient has a side effect with one they said oh don't worry we have 99 up there actually more than almost 200 when you look at combinations but when it comes to obesity if one drug doesn't treat everybody people freak out oh my God look at you know it's totally unrealistic to expect any drug to treat everybody if we had 100 drugs in 10 therapeutic categories we would have effective obesity treatment and that is a point that we have to emphasize that that is where this field is going for people with established obesity what prevention I don't want you to think that I don't believe that prevention is important but we've got to be doing this in children because I bet when the day is done we're going to see that very young children is where this process begins and that if we don't start early enough as our good friend dr. Lustig is pointed out that it's that the process the diet is cast the injury is beginning so I believe that there is a need and demand for system to deliver care and support to patients which involves healthcare providers so our solution which we've been working on since 2007 and is an outgrowth of my work on the NIH guidelines of two thousand i edited the guide to obesity treatment which was supposed to go to health care practitioners and when we finish this thing after years of negotiating with the niña everybody else you know we had this book and nobody I said when that one came out nobody's going to use this like am i insane and nobody did and that what we had to do is we had to turn it into something that was useful and immediately available and that is what be em IQ is so it is a structured evidence-based program for live delivery and it is cloud-based the program materials for the provider are right there available to them in front of them and there's a complete supporting interface for the patient so the exact same materials the doctor uses in the office to to manage them is available at home we have all the bells and whistles that that people like the trackers things like that which are the ones that are currently usually we used lose it we're trying to to get my fitness pals attention but they're they're off doing other stuff so this can be delivered by doctors pas and PS and our DS are the ones who are using this most now it's structured if you're a novice if you have no clue what to do but we've made it flexible enough so that registered dietitians who are experts can manipulate the sessions and one thing that we have recently done is made it so that any program can be delivered so for example we're in the process of mounting the mass generals bariatric surgery follow-up program they want to deliver the bariatric surgery follow-up program through our system we are putting that there for them and they will be able to deliver this the way that we deliver our weight loss program another hospital system is asked us to mount their program no problem we are mounting their program so we've taken an agnostic approach like we've seeded it with our material but we can deliver any program pediatric program no problem you just have to deliver you have to put together the materials for the system to deliver and what we now have is education for the patient and we also have in the professionals portal education for the provider so we have continuing medical education credited program that the providers can go through we just finished a handbook of obesity treatment with a few colleagues we're going to have that available and we'll be giving CME credit for that as well so we feel we have the entire package for healthcare providers at any level 22 really finally be able to do what needs to be done and one last thing is that we have detailed sessions that the the patients do so people always ask me like what do you do in the office believe me this covers all the bases and even if the doctor says I don't want to deal with this I want the patient to do it on their own the system will do it on on their own it can be set so that it delivers the sessions week after week the patient can come in be prescribed medicine whatever but the behavioral sessions no one has to deliver them they can deliver themselves we've included an expert assessment this took us a year to build it's an expert assessment that is built on exactly what we do when we evaluate the patient so looking for drug induced weight gain the system actually looks for that and makes recommendations in a consult letter to the health care practitioner it doesn't tell the patient that it doesn't say you know what your antipsychotic is causing you to gain weight stop it immediately no it doesn't do that we'd see that on a popular doctor television show I won't tell you how it but what we do is that what I believe is the responsible thing and make a recommendation and we reference it we reference it so that they can look up the paper if they want to do that and make a suggestion we find sleep apnea I can't tell you how many patients we see who are diagnosed with depression but what they actually have is sleep apnea then they got treated with an antidepressant and then they gained 60 more pounds and this happens every day we see this at least once a week in the new patients we see so the treatment is available it's flexible it's professional and I think that our structured program is effective at a reasonable price point finally okay you're going to say what kind of results did you get this is a pro graham right now we're delivering this for our breast cancer patients the people who are most interested are people at sloan-kettering and people at Cornell who are in the cancer space so they said okay we want a program for our breast cancer patients no problem two weeks we had this program a program up and running for them but this is the result of a program which was delivered at Virginia in Charlottesville Virginia by one of our very good registered dietitians she put 150 patients through the program they're mean BMI was 36 and was 26 weeks she used the twenty six week program she combined live and online sessions which you can easily do they can be in group that can be individual they had gym access and two sessions with a trainer the mean weight loss was 6.5 percent and I have labs from the first 65 patients the rest of it is being put together now triglycerides went down the HDL went up the hba1c was down 0.3% even though they were not diabetic at baseline this is a yep this is these are the results of an actual program the 150 patients that's everybody so in conclusion that's what we have been working on to try to get our our program out there for everybody to deliver I don't have time to tell you any more thank you very much for your attention

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