Topeka Tubby To the Rescue

 Topeka is 8th Fattest City in USA 

My notes in purple

This news article reported that:

‘Topeka ranked eighth in a listing of America’s most obese cities.”

“According to the poll, which surveyed the 190 U.S. Metropolitan Statistical Areas, 33.3 percent of Topekans were considered obese.”

“The total obesity cost for the Topeka metro area was listed as $109,839,216.”

“If Topeka reached the 15 percent obesity level as recommended by the Centers for Disease Control and Prevention, the city would realize a savings of $60,362,092”.

“The report stated Americans living in the 10 areas with the highest obesity rates pay an estimated $1 billion a year more in health care costs than they would if their community obesity rates were lowered to 15 percent.”

“It is clear that every city in the nation has work to do to reverse an alarming trend with implications for Americans’ collective physical health and financial bottom line,” the report stated. “Achieving real and lasting improvement in Americans’ health may come only with greater awareness, education and initiatives at the community level.”

The above quotes come from a 2012 article by:

Phil Anderson can be reached at (785) 295-1195 or phil.anderson@cjonline.com.

Follow Phil on Twitter @Philreports. Read Phil's blog.

It is 2016.  The American Board of Obesity is now a specialty in medicine.  I took that exam in December and am now a specialist in Obesity Medicine(ABOM).

I live in Topeka.  I hope to help make Topeka an Obesity Center of excellence.

My contribution to Topeka as the first and only board certified specialist of obesity  will be:

1- Aggressive use of 4 new diet medications that are now indicated for the lifelong treatment for the Chronic Disease of Obesity.

2- Recruitment of Bariatric surgeons.  New surgeons will want to come to Topeka as I will help the outcome of their patients maintain their weight loss from surgery long term with diet medication if they start to regain weight.  

3- My personal story of losing 80 pounds, regaining 50 pounds despite 2 hours exercise a day and then losing another 40 pounds with diet medications.  I have maintained weight loss since 2006.

4- Teaching the science of obesity

The challenge of obesity is not weight loss.

The challenge of obesity is maintenance of weight loss

The 4 new diet medications are the treatment of the Chronic Disease of Obesity.

Modern Way to Treat Chronic Disease of Obesity

I am interested in building a multi-disciplined team centered in medicine but closely working with the Bariatric surgeons to get Topeka to the 15% obesity rate.




Surgeon Denis Hami slides from Wash DC OMA meeting



Link to why Bariatric surgery fails

 

10 years of follow up after surgery:
 BANDING (YELLOW)
VERTICAL BANDED GASTROPLASTY (GREEN)
GASTRIC BYPASS (RED)

 WATERFALL EFFECT OF WEIGHT CHANGE AFTER GASTRIC BYPASS SURGERY

On the right notice 5-9% weight gain 6 years after gastric bypass surgery.  

 No Matter how weight loss is achieved physiological changes cause weight regain.

 

I passed the ABOM exam

American Board of Obesity Medicine

 When I found out last year I could be eligible to take the Obesity boards I was very excited. 
There are 4 new diet medications that may be taken for life for the disease of chronic obesity .

I wanted to come out of retirement and help the reduced obese maintain their weight loss with diet medications.  

I signed up for three Obesity courses. 

4/22-26/15 at Columbia College of Physicians and Surgeons. 

9/30-10/4/15 at Washington DC OMA meeting at Omni hotel

11/1-6/15 at LA, CA The Obesity Society Review Course

I also went to National Lipid meeting as Eric Westman spoke
9/18-20/15 at Omni Pittsburgh

There is treatment now for the disease of chronic obesity 

 



 

Excellent article about hunger as the focus of diet

All I want to eat diet by Psychologist helped him lose 50 lbs (link)

My comment in purple:

Excellent article.  I have a similar approach.  I have sad news for the author.  He is only in the 8 month of the reduced obese.  He will learn this inconvenient truth (link).  For the long term treatment of his chronic obesity he will need lifelong diet medicine to maintain weight loss.

“All-I-want diet full of moderately fat comfort food.”

The hunger mood

Hunger isn’t in your stomach or your blood-sugar levels. It’s in your mind – and that’s where we need to shape up

by Michael Graziano

"Whatever else it is, hunger is a motivated state of mind."

"Hunger is a process that’s always present, always running in the background, only occasionally rising into consciousness. It’s more like a mood. When it slowly rises or eases back down, even when it’s beneath consciousness, it alters our decisions. It warps our priorities and our emotional investment in long-term goals."

"The hunger mood is hard to control, precisely because it operates outside of consciousness. This might be why obesity is such an intractable problem."

"Taking all this together, the evidence suggests that a low-carb diet doesn’t make you lose weight because of its effect on your energy utilization.

It makes you lose weight because you eat less.

Or (perhaps more accurately), the ridiculous, super-high death-carb diet stokes up the hunger mechanism and your eating goes out of control."

Below is the "all you can eat" portion of the authors diet

"Third, I could eat as much as I like at each meal.

That last proposition was the hardest.

When you want to lose weight, it’s hard to wrap your mind around the concept of eating more.

I simply had to trust a bizarre psychological twist: if I try to eat less, I’ll end up eating more.

I could give a list of foods – salmon, peanut butter, pork chops, apples, tomatoes, chicken with the skin, tofu, eggs, and on and on – but really the concept is more revealing than the details. The diet had nothing to do with standard health advice.

It had nothing to do with how those particular foods chemically affect my body.

I wasn’t thinking of my arteries or my liver or my insulin.

The approach was designed to speak to my unconscious hunger control mechanism, to encourage it to eat less.

And it worked at a slow drip of about two pounds a week, trailing off finally to a much more comfortable weight. Twenty years of accumulation, 50 extra pounds (I cringe to admit it) went away in a few months.

There is no effort in an all-I-want diet of moderately fat comfort food.

I simply sat back and watched my brainstem do its thing

The beauty of the method was that it required no effort."

My comment:

The only problem I have with this very interesting article is that the diet ends at 8 months.

 
 I suspect the author has not seen the above chart. 
The problem is not losing weight.
The challenge is maintaining weight loss.
I took the obesity boards in Dec. and plan to return to practice medicine in the field of obesity because I believe the four new diet medicines   will help the reduced obese maintain most of their weight loss.  
The author, Michael Graziano, will find that he will slowly gain weight on his diet because his leptin level is low.  
He has his theory, I will look forward to see how he does over 5 years.  
I have data since 2011.  I have not been hungry since 2011 when I started LCHF or Atkins. 

I also did a short term experiment in which I carefully did LCHF with blood nutritional ketosis and one hour exercise a day. I gained four pounds.  

I then decreased exercise to walking 20 minutes a day and went on Qsymia diet pill.

I think after 9 months Mr. Graziano will hit a plateau as I did in this link.

I am on Qsymia, Victoza, and Invokana and I believe I will be on these drugs for the rest of my life just to maintain my weight loss.


 

 

 

Update on the Tubby Theory from 2009

In my book Tubby Theory from Topeka, I coined a term the Tubby Factor to represent the term non-HDL-cholesterol.
I also advised a step approach to using 3 low dose lipid lowering medications
I thought it was easier for patients to remember to ask their Doctors for this number and that it was much more predictive than LDLc.
I preferred LDLp or apoB to non-HDLc but I suspected the guidelines would not accept the particle count as the new standard.
Sure enough the guidelines still use LDLc but there is more acceptance of non-HDLc.

This article, High ApoB in Young Adults Predicts Midlife Atherosclerosis 
states:

"Young adults aged 18 to 30 who had higher-than-average apolipoprotein B (apoB) levels showed an increased risk of developing coronary artery calcification (CAC) by middle age, in an analysis from the Coronary Artery Risk Development in Young Adults (CARDIA) study[1]."

"However, although some clinicians favor measuring apoB as well as traditional lipid biomarkers to help predict CVD risk, and apoB is included in some guidelines, it is not part of current ACC/AHA guidelines, and others are not convinced that studies have demonstrated that apoB adds predictive value. ."

"We take the viewpoint that apoB is a more robust biomarker of CVD risk [than LDL cholesterol and non–HDL cholesterol] based on observational studies and clinical trials such as AFCAPS/TexCaps," he told heartwire . "For all patients with metabolic syndrome and type 2 diabetes, I routinely measure either apoB or LDL particle concentration," he said, adding that "it has been shown that apoB or LDL-particle concentration is more strongly associated with CV risk than LDL cholesterol and non–HDL cholesterol in most studies."

'However, Dr Scott Grundy] told heartwire that although there's no question that apoB is a better predictor of atherosclerosis and heart attack than LDL cholesterol, "it's much more difficult to show that apoB is a better predictor than non–HDL cholesterol."

"Furthermore, non–HDL is easily measured in a clinical lab, whereas apoB requires an extra test (an immunoassay) with added cost. "Should we all start going out and measuring apoB? I think the answer is 'No,' " according to Grundy.

It is also not clear if an apoB target treatment goal would be better than a non–HDL goal, he continued. This may be moot, though, since "the latest [ACC/AHA] guidelines [have eliminated treatment targets and] say that you come up with a certain level of risk and treat [the patient] with a statin and don't ever measure cholesterol again."


"For now, "these data suggest a dose-response association between apoB in young adults and the presence of midlife CAC independent of baseline traditional CVD risk factors," the researchers conclude, adding that "further follow-up is warranted to determine if apoB measurement in young adulthood is a marker of later CHD risk as well."


 Page 147 and page 148 of The Tubby Theory from Topeka which I wrote in 2009 and published in 2010.

Back Cover of my book, The Tubby Theory from Topeka.
I am with my son, now a medical student who helped me write the book. 

 

Curious People will not take a statin but will get a stent or coronary bypass

Curious people will not take diet medicines lifelong but will get a gastric bypass surgery.

Curious nutritionists tell type 2 Diabetics to avoid fats not carbohydrates that raise sugar.



There is an epidemic of heart disease and obesity and diabetes type 2.

As a physician with obesity and diabetes type 2,  I have personally struggled with these 3 diseases.

I lost 80 pounds by the traditional 1500 calorie plus hour day exercise method but then gained back 50 pounds despite exercising more than 2 hours a day.

I began to learn why when I read Gina Koleta's book: Re-Thinking Thin 2008

In my book, The Tubby Theory from Topeka written in 2009, I had not yet read Koleta's book and advised 3 diets with less than 10 per cent saturated fat because that was the teaching of the National Lipid Association.  I did add the caveat on page 128 that weight loss diets don't work.  

I went ahead and listed three diets at 3 different calorie levels:  1850, 1650, 1450 calories. I relied heavily on frozen meals to have accurate calorie and saturated fat counts because I could think of no other way for people to calculate the percentage of their saturated fat.  Imagine my surprise when I learned while studying for the Obesity Boards that Meal Replacements are the most effective way to lose weight. I reviewed Ornish 5 year trial 1998 after AACE guidelines for LDLp and apoB were posted.  I found some interesting items that lead to some interesting questions.

For Very High Risk Patients
                                     apoB                    LDLp
AACE advises        less than 80           less than 1,000

Allan Sniderman     less than 65


Ornish trial      Dropped apoB from 100 to 76

Ornish quoted:
"Twenty-five cardiac events occurred in 28 experimental group patients vs 45 events in 20 control group patients during the 5-year follow-up (risk ratio for any event for the control group, 2.47 [95% confidence interval, 1.48-4.20])"

Patients in the experimental group lost 10.9 kg (23.9 lbs) at 1 year and sustained a weight loss of 5.8 kg (12.8bs) at 5 years, whereas weight in the control group changed little from baseline.

"We found more than twice as many cardiac events per patient in the control group than in the experimental group. These findings are consistent with other clinical trials showing that even small changes in percent diameter stenosis are often accompanied by marked reductions in cardiac events."

Questions?

1- Was the drop in apoB from weight loss, 8% fat diet or a diet that was reduced in carbohydrates as well? The control group did not have weight loss. 

2- There still were 25 cardiac events in the low fat diet group.  Is this just the residual risk to be expected?  Ornish reached the AACE goal for apoB  less than 80 but perhaps he could have avoided the cardiac events if he had reached apoB less than 65 as Sniderman advises.

3- Statins have a pleiotrophic effect which Ornish diet does not provide? 

AACE has LDLc goal of less than 70 for very high risk patients.  On the chart below that correlates with apoB of 54.

 

Treatment for Obesity is here but country doesn't want to pay for it

There is a treatment for the Disease of Chronic Obesity

But:

The 4 diet medicines are very expensive

People don't want to take diet medicine lifelong. 

Family doctors don't know these medications are indicated for life.

It is not understood that the most benefit of these medications is to maintain weight loss. 

Except for Bariatric surgery, there is no profit in Obesity clinics, thus hospitals have not yet developed obesity clinics nation wide as they do not know the above. 

Letter of Lament by a Obesity Specialist looking for a job 

 

Dear Friend,
To my surprise in all my study for the ABOM boards, nutritional ketosis as the reason for Atkins success was never discussed.

I did a short experiment with one hour/day exercise at YMCA weight gym and LCHF in documented blood ketosis.  I gained 4 pounds.
I then went on Qsymia, walked one mile a day 5 days a week and was very sedentary as I studied for obesity boards.

I clearly began eating less ad libitum.  I did eat less.  I lost 5% body weight even after a cruise.  (Nutritional ketosis and exercise did not cause weight loss)

Despite being on Qsymia, Victoza, Invokana, walking a mile a day, eating less ad libitum on LCHF I think I have hit a plateau.
 Perhaps if I stopped all ETOH I would lose again?  I urinate calories in form of glucose and ketones yet no change in weight? (Setback at plateau?)

Obesity is an amazing subject.

The guidelines would suggest increase exercise to one hour a day.  That might help in short term but in long term, I think the physiology catches up on down days.  You can't out run your fork as people who actually work in obesity clinics say.

I am happy to continue my medications just to maintain my weight loss.  I was 280 lbs.
 I achieved and maintain my weight of 216 lbs today ad libitum Atkins, walking my dog one mile 5 days a week and drinking 4 oz ETOH a day. I call it the Bon Vivant diet but mostly it is due to the diet medications. 

All diets are restrictive but LCHF allows ad libitum. It will still fail in most reduced obese as seen in this graph.
That is when one of the new diet medications should be added to prevent weight regain.

I had my annual physical yesterday with my family practice physician.  To my surprise he has been doing obesity work for 3 years.  He did not know there are obesity boards.  He mostly uses phentermine because the other drugs are too expensive.  He also said Contrave did not cause enough weight loss to be worthwhile for his patients.  I tried to tell him about waterfall effect of trials and need to use multiple drugs to individualize therapy.  Too much to talk about in 5 minutes.
 In my search for a job I notice hospitals don't realize they need obesity specialist and bariatric surgeons don't want to share the money even though they need a ABOM specialist to prevent recidivism in their patients with diet medicines. 

I think I have arrived on the scene a little early.  Just as my message about treating early with statins with positive CAC was early in 2009. 2016 MESA analysis of CAC data

In closing, This article about nutrition science shows the need to individualize diet and monitor how healthy that diet is for the individual with LDLp, CAC and CIMT. 

Official guidelines for LDLp and apoB seem a little high to me

My comment in purple. 
In my book The Tubby Theory from Topeka written at the end of 2009,  I advised that non-HDL-C be called the Tubby Factor as it is easier to remember to ask your Doctor, what is my Tubby Factor?
Non-HDL-C is more accurate than the LDL-C.  

More accurate than both of those is the particle number 
 (don't get bogged down with particle size, HDLc or Triglycerides). 
 ApoB and LDLp are the best tests. 
 LDLp Ion method done by Quest lab does not use the numbers in this chart.  
The apoB by Quest is the same range as this chart. 

"Dr Sniderman: The first thing I do is measure apoB to determine whether treatment is necessary or not.

If apoB is elevated, then all things being equal, treatment needs to be seriously considered. Treatment is a collaborative process between the patient and the physician and involves diet, exercise, and lifestyle as well as pharmacologic agents if indicated.

For the majority, my target for LDL-lowering therapy is an apoB < 75 mg/dL.

For those at very high risk, my target is an apoB < 65 mg/dL.

These are the equivalent population levels to the LDL-C and non–HDL-C targets chosen by many recent guideline groups. The apoB targets chosen by many of the guideline groups are much too high. It seems that once 1 group selected values, the others just repeated them."

Above quote from Lipid Round table article 

My 6 CIMTs show atheroma regression with low LDLp 

This chart shows LDLc 70 in same row as Non-HDLc  83 and LDLp 720 and apoB 54. 2008

In high risk patients I try to get(in my book from 2009):
 Tubby Factor (Non-HDLc )less than 80.  INEXPENSIVE
LDLc  les than 70 USUALLY CALCULATED AND INACCURATE IN INSULIN RESISTANCE
apo B less than 60 (immunoassay) PARTICLE COUNT
LDLp less than 750 (done by Liposcience NMR) PARTICLE COUNT-  BEST TEST MY OPINION







The 2014 American Diabetic guidelines are still using the old LDLc. 
Diabetics often have discordance between LDLc and Tubby Factor and Particle number.