Dr. Samantha Harris explains the significant and complex interlink between obesity and diabetes.
I'd like to welcome back dr Samantha Harris. Uh Don't forget she has a really strong background not only on diabetes management but also weight management and leads our weight management program here at Scripps Clinic. So Samantha take it away. Thank you so much Athena. So I'm excited to be talking about sort of the foundation of diabetes and obesity. And I'll be honest this talk was a little bit depressing while I was preparing it and for saturday morning. It's a little bit of a downer. But I hope towards the end there will be some hope and especially with the other talks that are given that will really show that it is possible to lose weight despite my presentation. That's point out some of the difficulties. So here are my disclosures. So here are the objectives for today. We're going to run through diabetes and obesity how they're connected. What the prevalence is are we going to review barriers for caring for caring for patients who have both conditions and talk about meaningful but also realistic goals for these patients. So let's talk about some diabetes and obesity statistics over 34 million people in the US have diabetes. But what's interesting about it is that one in five do not know that they have it. Similarly over a third of the US so 35% of US population almost has prediabetes. But what's even more interesting is that 80% of these patients do not know that they have it. So 84% don't actually know. And even in our lab in Epic. It's only flagged for a glucose that's in diabetes range not for prediabetes range. So it really goes overlooked. Oftentimes in those early stages when I think it's super important to be catching it. Um in the past 20 years, the amount of adults diagnosed diabetes has doubled and this is likely because the population is getting older and also increasing in weight. About 90% of patients with diabetes are overweight or obese. So there is a huge connection between the two. So this is just a graph showing um the increase in total diabetes diagnosis over the years. But what's interesting is it's more so diagnosed diabetes and not so much in undiagnosed diabetes, which is good because at least it shows that we're probably screening better and identifying these patients. So let's talk about obesity. What is obesity? It's basically an abnormal or excessive fat accumulation that may impair health. It's based on a BMI So a BMI greater than or equal to 30 is considered obese. But it's just a screening tool. It doesn't actually say if the obesity is causing health impairments or or if it's not necessarily even accurate based on certain body types. So, here's a breakdown of the BMI ranges and the category. So here's obesity starting around 30 there's a lot of ways that obesity is further identified. So there'll be um classes based on BMI cutoffs usually Class three is BMI 40 or above, which is also called called severe or morbid obesity. But there are other scales out there. So Edmonton obesity staging system is a scale that basically tries not to just use the BME. A number but also grades the stage of obesity by actual impairment. So whether or not there's a presence of physical symptoms, limitations and ambulatory or psychological symptoms. So really try to identify if the weight is impacting the health of the individual. Yeah. Overall about 42% of the U. S. Is obese. And here's a breakdown by gender and also race. And you'll notice it seems like there's an outlier here with non hispanic asian populations being lower in prevalence. But as we know, patients who are of asian background often have more disease that lower BMS. And that's probably related to body distribution genetics. And also um a more central deposit ISA waking in the abdomen. Overall obesity, especially severe obesity is increasing. And what's interesting too. So this is a worldwide problem is it's not just a US problem. And if you look at this table trends and Children, adolescents this is across the world and it's it's probably hard to see the breakdown but you can see overall. So the top two tables. Hopefully you can see my pointer um are showing the increase in obesity over time. So this over here on the right side is 2020 and over here was 1970. So it's increasing in all countries pretty much around the world and on the bottom this is the amount of Children who are severely underweight. So that is decreasing and these pink countries and red are in Africa and the orange ones are in Asia. So you can see where they're even used to be a problem with underweight is now becoming a problem with overweight. So it's not just in really high socioeconomic locations. Um the interconnection between obesity and diabetes is so profound that oftentimes you'll see these maps which is showing the prevalence and they're overlapped. So basically um the darker, especially the darker the green, the higher the prevalence of both diabetes and obesity. And you can see from 2004 to 2016 the map and this is broken down by county is really just getting darker overall in colour. Obesity has not always been recognized as a disease. So it was really up until just a few years ago, it wasn't identified as a disease. It was specifically said that it was not a disease by Medicare and CMS. So the focus would be on the co morbid conditions and not the disease itself. So they would focus on treating diabetes and hypertension and high cholesterol and and really focus on medications and targeting those in research. Um and this led to some difficulty with insurance coverage. So dieticians aren't always covered. That's still a problem. Um, medications for just talking about your weight is not always covered and also, you know, just making sure that you are having visits able to cover for these visits in your billing and medication, weight loss medications are still an issue. And hopefully the speaker later today will address that in 2004 CMS. That's Medicare and Medicaid removed the statement that obesity was not an illness from its coverage Emmanuel. And because of that bariatric surgery within a few years became covered by Medicare patients. So a lot of people don't know this. But actually Medicare covers bariatric surgery, numerous health organizations that we're all pretty familiar with or hopefully our um have issued statements labeling obesity as a disease really trying to promote this knowledge that it's a disease in itself. So they all released statements and in 2000 and 13 finally the am recognized obesity is a complex chronic disease and apparently this one decision led to the most abundant amount of hate mail that the leader of the Emma had ever received because people really didn't think that obesity should be a disease and that it was an individual character flaw in some way. And I'll talk a little bit about that. So here's some of the statements that the organizations have made the FDA the Obesity society, Ace and am if you're familiar with them just stating that they felt that obesity was a disease that warranted treatment and research. So declaring a disease really can help de stigmatize it because if obesity is a disease and not just a character fall like high blood pressure is, then we really kind of take the blame away from patients and the responsibility away from them. And we we focus more on improving access to care treatment and research opportunities. So why is obesity such a big deal? And I'm sure you've seen this before or maybe have not. But this is basically the all mortality all cause mortality curve by being me. And it's a J shaped curve and you'll see it reaches a nadir in the low twenties, around a low to mid twenties, around a normal BMI. And as your weight goes up, so does your mortality. And interestingly, as your weight goes down from this level, so does your mortality. And that probably has a lot to do with more of a correlation than causation. So what is the connection between diabetes and obesity and essentially when people are inactive when they're obese, it leads to this low level chronic systemic inflammation and this inflammation affects multiple cell lines within the body, including the fat cells. The advice sites immune cells, the brain cells and further has other down downstream of facts. So the effect of the adequate site leads to glucose intolerance. So it leads to insulin resistance and type two diabetes, but at the other cell levels it can also increase the risk for cancer. Heart disease or dementia. We know that there is no shortage of medical conditions associated with being overweight or obese um from lung disease sleep apnea to various types of malignancy to infertility and pcos in addition to the classic cardiovascular disease risk factors that we talk about lipids and hypertension. Um there's it's countless, it's really it's it's overwhelming at times, but there are a lot of complications that we don't talk as commonly about. And so I want to take the opportunity to talk about those. So we don't always talk about the effect on dementia or depression and mood, especially in women. There is a very significant decline in their mood with their correlating with their weight, even if they're just overweight, it really kind of impact their mood, their self confidence, um sexual dysfunction. There are personal and social costs and then professional unemployment costs. So what I wanted to talk a little bit about is the fact that there's this huge amount of weight bias and discrimination today's society because I think it starts with health care workers and trying to improve this conversation when I googled images of people who are overweight or obese. These are the types of images that come up on google that were in news articles and it really just portrays people who are obese as being slobs just sitting on the couch eating, not being able to fit into their clothes. So what is weight bias and discrimination essentially, this is uh weight bias is negative attitudes, beliefs, judgment stereotypes discrimination against people because of their weight. And it can be really subliminal and often not fully apparent, but we see it all the time, especially if you watch old movies when, when political correctness was not quite as common. Um, social media relationships with people, even in health care. Like um there's a lot of discrimination even if people don't think that they're biasing against certain patient populations. Um, and it's this belief that individuals with obesity are lazy or unmotivated and lack willpower. And here's another image depicting them. So what I really want to show with this presentation is the truth and that is that obesity is an incredibly complex and chronic disease. It is not very easily treated by just eat less and move more. And I think we're doing a disservice to our patients if that's the only recommendations we give them in a two minute blurb at the end of the visit, which I don't blame people for doing that because usually we don't have enough time to really talk about the complexity that is weight, obesity has many different causes and is progressive by nature. So let's talk about some of the limitations in treating obesity and there are so many of them. I just had to pick a handful of them, but basically there's a lack of resources. So not enough time in a visit. Usually patients are coming to see you just for the weight, fortunately they do come to see me just for that. So I do have that time to dedicate to it. There's a lack of knowledge. Um, a lot of people didn't learn a lot about treating obesity in their education when they were training um er in school and it's kind of hard to find those resources when you don't necessarily practice with them earlier in your training, a lack of support. So just not having a dietician on staff who can talk to patients a lack of comfort and discussing weight. And this is both on patient and providers. It's kind of an awkward topic. It's very emotionally charged that we might feel uncomfortable bringing it up and patients might as well. Plus there's compounding medications, both diabetes and non diabetes and I'll touch on some of these a little bit later too. And then unrealistic weight loss schools and timelines. I have some patients who think that they're going to get back to their high school weight when they're 60 years old and £150 above what they were in high school. Um There's also a lack of utilization of some of the awesome resources that we have available to us and we'll have speakers today talked about medications bariatric surgery, but there's a belief on both patients and providers that using these are a crutch or in some sign of failure on the patient's behalf. So I often your patients make comments to me like I should be able to do this on my own or weight loss surgery is taking the easy way out and it that is so not true and I'm so excited. We have a surgeon talking about that too. It is a tool to help change your behaviors and your eating habits. But it is does not do anything for you. It really is um an intense type of treatment A lot of patients will say I could lose if I want it badly enough. They also think it's a willpower and motivation problem that's internal. And I'll hopefully show you some evidence that explains why that's not necessarily the case or they say I want to lose weight naturally. And some of these patients are my toughest patients. They'll take any over the counter supplement. But as soon as it's a prescription, they need to pick up at the pharmacy. It's like, oh my God, no, I would never take a medication to lose weight. Meanwhile the supplements are not well regulated by the FDA. And in the past they've ended up causing harm and have been withdrawn from the market. So how do we overcome some of these obstacles? So I always suggest and this is something people have seen me speak before. I always say find us respectful, non judgmental way to bring up waiting to visit. So I have two simple sentences and you can choose one. Would it be okay if we discuss your weight today or how do you feel about your weight? And open ended questions just to see how they're feeling about it. Just as a starting point for discussion. Always look for other resources for diet, behavior, medication, surgery, whether the resources that you can give to a patient or resources to educate yourself. There are tons of obesity conferences now. It's like the field is exploding. So there really is no shortage of resources, especially for those in primary care, utilize other resources to be high intensity. If you can't see a patient every two weeks, then find something, send them to weight watchers, um send them to some other support group or a dietician to also meet with them or do group visits or group calls, referrals to weight management clinic alone are associated with better weight loss at a year versus no referrals. So don't be afraid to outsource this if you don't have the time or you don't feel like you have the resources to really help patients achieve their goals. So what are realistic weight loss goals? And when you google images, cartoon images of before and after weight loss. These are the types of things that you will find online and I find these so horrifying. But unfortunately patients do feel that this is what's going to happen to them. So the before pictures will show people who are literally so large there breaking the scale And then after they lose. So wait, he's so muscular, he has the tiniest legs I've ever seen. She has like Barbie waist to hip ratio she has inner thigh clearance. This gentleman on the lower left has a 12 pack, I have no idea what's going on this picture, but she somehow has evolved over time from head down to suddenly head up. And she is also these proportions are just absolutely unrealistic proportions. So how much weight do you actually need to lose to have a meaningful benefit when it comes to your health? And I'm always amazed to see that it's not that much weight. So even at 2 to 3% you'll notice improvement in blood sugars, you get closer to 5% you notice improvements in blood sugars, lipids, blood pressure and continents above that things just keep getting better, including sleep apnea or throw issues. So even arthritis can improve really quickly with small amounts of weight loss and it just gets better. So the sweet spot, the minimal amount for really meaningful noticeable changes that might improve your likelihood of living a longer healthier life is the 5 to 10% range. So we always talk about losing 5 to 10% for those of you who aren't familiar with that, it's 5 to 10% of your total body weight. So if you're £200.05 percent is only £10 I say only, but that is amazing. 5% losing £10 is great and then 10% would be losing £20. So try to set realistic and achievable weight loss goals with patients. The CDC says the good news is no matter what your goal is, even 5 to 10% of your total body weight loss is likely to produce health benefits. I tried to find a realistic image of before and after and I literally could not. So here is my before and after and I kept in the arm of the true after. So this was actually before, during and there was another after. That was so unrealistic that I just cut it off and I left the arm there. So I would remember to tell you guys that this is not actually an image I could find. So isn't it easy to lose weight? Like, can't you just cut calories and exercise more and lose weight and in some in the most general basis of it. Yes, calories in calories out there is some truth to that, but it really is not that simple. There are so many complexities to it. So certain diets might be easier for patients to adhere to, or they might respond to certain plans based on their culture or their preferences. Um, A calorie might not always be a calorie. Like for example, certain food types might have different effects on hunger and satiety, you know, 1000 calories of protein might make someone feel more full than 1000 calories of pure sugar in a day where there's still hungry and they don't feel satiated. There's this carbohydrate insulin model of obesity to that hypothesizes that having high insulin levels, eating a lot of carbs leads to high insulin levels. And this kind of turns off weight loss and there's hormonal reasons why this would happen. So perhaps if more carb intake is happening, then it's going to be really hard to lose weight because the body is always in storage mode and never in weight loss mode. Um zero calorie products like artificial sweeteners. Can they still promote waking? This is such a hot topic. I could spend an hour talking about this alone and the question is, we don't completely know. It probably varies by artificial sweeteners, so blanketing them altogether is probably not super conductive or accurate. Um medications can confound the picture. We'll talk a little bit about diabetes medications, but also beta block or psych medications. There's so many medications that affect weight and then menopause can lead to changes in the body distribution. Also based on metabolic rate. So why is it so hard to lose weight and keep it off? The foundation of the problem is we eat too much and we move too little, but I don't mean this at an individual level, like this person eats too much needs a little. This is a society problem. This is a country, this is a nationwide problem. This is a worldwide problem. Industrialization of food, eating out in restaurants or sedentary at our jobs were not as active. We don't have to walk to work. We don't have to hunt to catch our prey. Like we just don't have to move unless we kind of find the time and force ourselves to move in a lot of ways and also getting healthy food is expensive. It's time consuming. Albert's Dunker was a psychiatrist um For many years, he passed away a few years ago, but he is like one of the most ahead of his time, obesity researchers and experts and um, he did studies years and years ago looking at people and weight loss interventions and after he reviewed his data along with his partner and the preceding 30 years worth of existing data. This was in 1958. So looking at everything from the 1920s, the 1950s, this is what he wrote most. Obese persons will not stay in treatment, most will not lose weight. So those who are in treatment won't lose weight and if those who do lose weight Mosul regain it and this quote is so heavily used and cited and um, it's depressing. But to be honest, this was the truth of the matter then and in a lot of ways now, fortunately we know so much more about obesity and we have all these new tools. The problem is we're not even always using the tools that are available to us. So here is the natural history of weight loss. In the beginning, there's this early rapid weight loss phase and then there's usually a plateau and then a progressive weight regain. And this is a map that meta analysis looking about 30 studies, long term studies on weight loss and how many years after weight loss and what percentage of the weight had been regained. So here it shows one year about 30 to 40% of the weight, 35% of the weight had been regained by five years. About 80%. And to be honest, I think this is optimistic. I usually see after a weight loss endeavor, especially things with like more extreme like liquid diets, keto diets. The weight loss the beginning is really rapid but by a year to two I would say 90% of the weight is regained. So there's variability and it varies by person by eating plan and by study. So again, the natural history of weight loss, people lose weight and this is the blue is without maintenance visits. The red is with maintenance visits. So we can do better if we see these patients more often, probably especially around the point where they reach this level where the body is trying to counteract the weight loss and we can try to prevent the weight regain. Another study just showing with an intervention very low calorie diet, behavior modification or a combination of the two great weight loss initially and then years after treatment by five years out they regained it and even slightly above their baseline weight and we'll talk about why that happens So to providers and to patient it looks like patients lose motivation or willpower like in the first few months they were totally in. But the truth is there are really strong internal forces, physiologic forces increasing their drive to eat more and we'll talk a little bit about that. So what happens after you lose weight? And I'm going to talk about two things. One is your hunger, your appetite and the other is how much energy you expend or your metabolic rate. So after a weight loss attempt, these are in the same patients and white is there Ghrelin levels before they lost weight And in black is after they lost weight and Caroline is like the one of the most potent hormones that the body makes it the hunger hormone. It's turned on all the time. Unless you get the right signals at the right time to turn it off. So please. So they were wired to eat all the time and only until that's turned off. Do we feel satiated? So before weight loss there, Ghrelin levels were okay. This is before breakfast lunch dinner, they're starting to get higher after weight loss. Look at how high their levels are even after they eat lunch, even after they eat dinner there grilling their appetite levels drop to level. That used to be their hunger level. So there never feeling completely full. It's like they're constantly hungry Now, couple that with change in energy expenditure. So with weight loss. So 10% weight loss, 20% weight loss, you'll see that their total energy expenditure per day has decreased by 300-400 calories a day. And over time, that really adds up. So 11 study that was really popularized in the media was the biggest loser study. This was out about five years ago, and they basically looked at people who have been on the TV show, the biggest loser contestants and tried to see what happened years after they were on the show, and you can see that they're resting metabolic rate um was down right after the competition ended. So some were down 200 calories per day in terms of how much they were burning somewhere down 2000, which is insane. Um And even six years out, their metabolic rate was down. And what was disturbing about this is that most of them had regained the weight that they lost. So here now they've regained all this weight, but their metabolism hasn't recovered. So, when people come to you and they say, I eat half of what my whole family eats and I'm the only person started with their weight. I must have a really slow metabolism. They might actually be right in trying to find this history of yo yo dieting can really identify that. But interestingly metabolic adaptation, which is the resting with the residual resting metabolic rate decline after adjusting for changes in body composition and age because you don't need a as high the metabolism at a lower weight as you did as higher weight plus as we age, there's some decline. So you'll see the I mean, it's just insane. six years out. The amount less calories they were burning despite trying to weed out these variables was very significant. And they never really recovered for their full metabolism despite regaining all this weight. And it was so depressing to know this so long term weight loss is incredibly hard. The body will fight everything it can. And it's probably, and I put this caveman picture here because it's probably a good thing in a society where we don't have constant access to food. But in a feast and famine, it was really preserving the body's fat reserves of people didn't starve to death. So for every kilogram or £2.2. So if let's say, you lose 10 kg, about £22. Your metabolism for the one kg, your metabolism will lower by 30 calories per day less. So if you lost £22 you're now burning 300 calories pretty less. But your appetite goes up by 100 calories per kilo loss. So if you lose £20 you are now 1000 calories hungrier than you were before you late, you lost weight, which is crazy. So your body has adapted. And it's gotten smart like I mentioned and the reason I'm saying this is not to be a total Debbie downer on a saturday morning but just so that you know and have compassion for these patients. Weight loss is incredibly hard. So just be mindful of these things add to this picture the effect of the medications by the time patients come see us and they have diabetes and we throw all these medications at them and hopefully we're steering away from some of the older medications. This is just a relative effect of diabetes medications. And wait. Hopefully we're steering away from the insulin to the T. C. D. S. And so funny areas in favor of some of the weight neutral or weight loss promoting medications such as Metformin. The SLT to some GOP wants which we talked about ad nauseam yesterday And really trying to help patients lose weight. So we know that 88 has this awesome algorithm on what medications to start. People on base and heart disease based on cost concerns. Um if they have a compelling need to minimize waking or promote weight loss and they don't have cardiovascular disease. They suggested you if you want to ask guilty too If you remember I said almost 90% of patients with type two diabetes or diabetes are overweight or obese. So the vast majority of people really should be on these agents. The problem is always insurance coverage or feeling comfortable using these medications if they're not things that you trained with and you're using every day. Be mindful of the medications. So, so many medications. Beta blocker steroids, birthstone birth controls, um gabapentin. So we put patients on gabapentin for diabetic neuropathy, sometimes really high doses. This promotes waking antidepressants and just think about what the alternative potentials are out there that can help people lose weight. So in conclusion, in addition to being the most depressing talk you've ever heard, I just wanted to highlight the significant and complex interleague between obesity and diabetes. I wanted to remind everyone, realistic goals are great. Always encourage patients. Just 5-10% is necessary to lead to significant improvements. Um always be mindful of diabetes treatment and the effect on weight so that we're promoting weight loss and focus on the smallest. A compliment sometimes the only accomplishment of patient has when they see me is that they came to see me that day. The rest of the visit is horrifying and I'm just like I am so glad you came. I commend you for coming to see me today because that takes strength and effort. Also use all the available tools to help patients lose weight. So I'm excited. I always, when I give these talks I talk about the five pillars of weight loss and I try to cram in an hour but I am so happy that today we actually have five people talking about each of these topics individually and I am so excited to hear more and see what other people are doing. So you're welcome to contact me. Here's my contact information. I'm also on social media and now I'm going to go through some questions. Oh, there's a good amount of questions. So do I think food addiction is an issue. Um I do think that there are some addictive components to food and um palatable definitely and especially people who have addictive personality. So you'll often see patients who had a drug or alcohol problem or, or tobacco users who then quit and basically replace that addiction with food and that's because food provides us reward. It leads to a neurotransmitter cascade that makes us feel good. Oftentimes temporarily because afterwards we feel really bad about what we ate, but it's like a dopamine rush. So in some ways I do other questions. Overeaters anonymous has had great success for many with no product promotion and cost like weight watchers. So what do you think of a patient is willing? And patients like, you know how much sugar they have to have, what do you think a patient is willing and that patients, you know how much sugar they have to? Um I think Overeaters anonymous is a great support group for those of you who are not familiar with it. It's basically a but for people who tend to overeat and a lot of it is, I mean it's like a 12 step program in some ways, but abstinence from sugar is often promoted and and I think a lot of them tend to try to eat low carb, but like anything accountability and support are helpful in making these really hard changes. So I'm a huge fan of that, and it is low cost. Um but I would say even think those things cost money sometimes, like Weight Watchers, the Byeon promotes people to stick to the plan when it's a free app on your phone, you might be less likely to input the calories, but if you paid some buy in and there's, you know, you have to pay this monthly, you know, you feel like you want to get your money's worth because that's part of human nature, we always want to get our money's worth right? So in some ways some buying and I don't think it, but I think it still needs to be affordable. I really don't like a lot of these other schemes that are promoting products that I don't think are superior to things you get at any local drugstore, but at a really high costs and often times I see people who have done nutrisystem Medifast opti fast, who basically say, I'm like, well what happened one, they had a hard time transitioning to real food, but too, it was too expensive for them to maintain. So then I'm like, well then why would we ever go back to that just because it was successful if it's not sustainable I would try to avoid doing that
