Indication for adding a second diet medication

This slide comes from the Obesity Medicine Certification Review Course for the ABOM exam given in Washington D.C. in December 2015.
The slide belongs to Harold Bays MD and was shown during his Pharmacotherapy lecture.

Best new Diet Books?

Always Hungry by David Ludwig 

Is a great diet book if you want to go on a low carbohydrate high fat diet that is not as restrictive as Atkins.  It allows more low glycemic carbohydrates as you progress in the diet. (nutritional ketosis does not seem to play a role?)  It believes this will reprogram your fat cells.  Of course it doesn't reduce the number of your fat cells. Sadly, Ludwig has no discussion of the other tools in the toolbox:  diet medications and bariatric surgery.

The Change Your Biology Diet
 by Louis J Aronne MD

Is also a great diet book if you want to go on a low carbohydrate high fat diet that is not as restrictive as Atkins. (nutritional ketosis does not seem to play a role?) It also seems Dr Aronne thinks he will out think Leptin with high intensity exercise in the reduced obese.  There is a real difference from Dr. Ludwig in this passage on pages 249-250: 

Dr Aronne also goes into a detailed discussion about the surgical solution for severe obesity in chapter 12.

The Sponge Theory 
I however have a very different approach based on the number of fat cells that never go away even after liposuction.  They eventually come back. 

I learned from both Dr Ludwig and Dr Aronne but I have 
personal experience 
that diet and exercise ultimately fail the reduced obese to maintain weight loss.  
I learned this very early from Gina Kolata's book Re-Thinking Thin and this 1 minute 40 second video.

This idea of the reduced obese regaining weight despite more exercise and strict diet was validated recently in  
NYT article by Gina Kolata- The Biggest Loser

 Thus I must offer my Bon Vivant diet.  
You can't fix the shrunken fat cells with diet or exercise.
It's all about the new drugs.
4 simple points 

How to treat adaptive thermogenesis in the reduced obese. 






 

For the Reduced Obese it is not a sick fat cell, it is a shruken fat cell.

The main challenge in the Obesity Epidemic is to help the people who have lost weight maintain that weight loss.

I learned a major lesson when I watched:
  
HBO Weight Loss Nation 1 min 40 second video

It is clear to me that fat cells become sick, especially in the apple shaped obese.

However, it is also clear to me that insulin resistance is often reversible when there is weight loss.  Thus the fat cell is not sick it is shrunken. 

It has lost it's fat and subsequently the body has a Leptin deficiency. 

Strange, since the body did not have this Leptin deficiency when it was at this lower weight before. 

The younger body did not have all these billions of extra fat cells that will now never go away. 

These are not sick fat cells, on the contrary, these fat cells are very capable of doing their job.  Storing fat to get ready for the next famine. 

In Always Hungry by Dr. David Ludwig he writes: 

ll

I don't believe low glycemic diet will change the nature of a shrunken fat cell that is deficient in Leptin. 
Dr Aronne in The Change Your Biology Diet offers this approach:

Then he suggests that intense exercise may be the key:

Diet and Exercise have failed to helped the majority of the reduced obese because of the billions of fats cells that remain after weight loss. 
These Leptin deficient fat cells cause the body and the brain to regain weight at low calorie diet and high exercise.

I call this:

The Sponge Theory


How to treat adaptive thermogenesis in the reduced obese

Steve Ratner makes good point about result of 16 yrs fighting terrorism

Fascinating discussion over trial that happened 4 years ago

Low carb diet reduces metabolism less than low fat diet link

David Ludwig vs Kevin Hall  6-7-16


Persistent metabolic adaptation 6 years after “The Biggest Loser” competition Kevin Hall May 2016

"Conclusions

Metabolic adaptation persists over time and is likely a proportional, but incomplete, response to contemporaneous efforts to reduce body weight."

 The Biggest Loser NYT article by Gina Kolata 2016

"Danny Cahill

46, speaker, author, land surveyor and musician, Broken Arrow, Okla.

Weight Before show, 430 pounds; at finale, 191 pounds; now, 295 pounds

Metabolic Rate Now burns 800 fewer calories a day than would be expected for a man his size."

“It is frightening and amazing,” said Dr. Hall, an expert on metabolism at the National Institute of Diabetes and Digestive and Kidney Diseases, which is part of the National Institutes of Health. “I am just blown away.”

It has to do with resting metabolism, which determines how many calories a person burns when at rest. When the show began, the contestants, though hugely overweight, had normal metabolisms for their size, meaning they were burning a normal number of calories for people of their weight. When it ended, their metabolisms had slowed radically and their bodies were not burning enough calories to maintain their thinner sizes."

“We eat about 900,000 to a million calories a year, and burn them all except those annoying 3,000 to 5,000 calories that result in an average annual weight gain of about one to two pounds,” he said. “These very small differences between intake and output average out to only about 10 to 20 calories per day — less than one Starburst candy — but the cumulative consequences over time can be devastating.”

“It is not clear whether this small imbalance and the resultant weight gain that most of us experience as we age are the consequences of changes in lifestyle, the environment or just the biology of aging,” Dr. Rosenbaum added.

The effects of small imbalances between calories eaten and calories burned are more pronounced when people deliberately lose weight, Dr. Hall said. Yes, there are signals to regain weight, but he wondered how many extra calories people were driven to eat. He found a way to figure that out.

He analyzed data from a clinical trial in which people took a diabetes drug, canagliflozin, that makes them spill 360 calories a day into their urine, or took a placebo. The drug has no known effect on the brain, and the person does not realize those calories are being spilled. Those taking the drug gradually lost weight. But for every five pounds they lost, they were, without realizing it, eating an additional 200 calories a day.

Those extra calories, Dr. Hall said, were a bigger driver of weight regained than the slowing of the metabolism. And, he added, if people fought the urge to eat those calories, they would be hungry. “Unless they continue to fight it constantly, they will regain the weight,” he said.

All this does not mean that modest weight loss is hopeless, experts say. Individuals respond differently to diet manipulations — low-carbohydrate or low-calorie diets, for example — and to exercise and weight-loss drugs, among other interventions.

But Dr. Ludwig said that simply cutting calories was not the answer. “There are no doubt exceptional individuals who can ignore primal biological signals and maintain weight loss for the long term by restricting calories,” he said, but he added that “for most people, the combination of incessant hunger and slowing metabolism is a recipe for weight regain — explaining why so few individuals can maintain weight loss for more than a few months.”

Dr. Rosenbaum agreed. “The difficulty in keeping weight off reflects biology, not a pathological lack of willpower affecting two-thirds of the U.S.A.,” he said.

Mr. Cahill knows that now. And with his report from Dr. Hall’s group showing just how much his metabolism had slowed, he stopped blaming himself for his weight gain.

“That shame that was on my shoulders went off,” he said.

The above is a great article in NYT by Gina Kolata.  I hope she tells us the rest of the story about the reduction of metabolism in the reduced obese and if low carbohydrate vs. low fat vs. high intensity exercise can prevent it.

 The above is from page 134 of The Tubby Traveler from Topeka when I took issue with Dr. Hall's calculation of 300 calories a day in the energy gap of the reduced obese.  I wrote my book in 2011.
 I used Michael Rosenbaum and Rudolph Liebel's research that people who lose 8-10% of their weight reduced the amount of calories burned during movement by 42%.  Thus instead of needing to walk 3 extra miles a day, my calculation came to an extra 5-6 miles a day.
The people in NWCR walk an hour a day.  3-4 miles a day?  However, if scale goes up they walk more and watch calories more carefully.  At 1500 calorie a day diet I suspect they already are 300 calorie below Dr. Hall's calculated energy gap. 
Subsequently with the Greatest Loser Data my viewpoint has been validated.

NYT Journalist wars

How to treat decreased metabolism of the Biggest Loser

Exercise intensity to muscle failure still does not make shrunken fat cells disappear

NYT article 7-16 Light weight's as good as heavy

Another Gretchen article 

"The other volunteers began the lighter routine. Their weights were set at between 30 and 50 percent of each man’s one-repetition maximum, and he lifted them as many as 25 times, until the muscles were exhausted.

All of the volunteers performed three sets of their various lifts four times per week for 12 weeks."

"Instead, the key to getting stronger for these men, Dr. Phillips and his colleagues decided, was to grow tired.

The volunteers in both groups had to attain almost total muscular fatigue in order to increase their muscles’ size and strength.

That finding suggests, Dr. Phillips says, that there is something about the cellular mechanisms jump-started in muscle tissue by exhaustion that enables you to develop arms like the first lady’s."

Article on losing weight but gaining muscle

"The other 20 volunteers began a diet that mimicked that of the first group, except that theirs swapped the protein and fat ratios, so that 35 percent of their calories came from protein and 15 percent from fat. (50% carbs)

Over all, their protein intake was about three times the recommended dietary allowance for most people."

"CONCLUSIONS:

Our results showed that, during a marked energy deficit, (weight loss diet diet)

consumption of a diet containing 2.4 g protein · kg(-1) · d(-1) was more effective than

consumption of a diet containing 1.2 g protein · kg(-1) · d(-1)

in promoting increases in LBM (Lean body Mass) and losses of fat mass when combined with a high volume of resistance and anaerobic exercise."

 Trial on High Protein High intensity exercise 2016

Link to Gretchen article above.

I did a similar experiment myself while on Atkins and in nutritional ketosis.
I did not lose weight but I gained muscle.

6 weeks of data in nutritional ketosis and weight lifting

Unlike the experiment described by Gretchen I was satiated by the ad libitum Adkins diet.  I also did not do high intensity exercise.   I could tell my muscle tone and definition was much improved.

I thus went on Qsymia.  I stopped the weight lifting and decreased my exercise to walking 1-2 miles a day.  I simply ate less with the diet medication and began losing weight without the pain described in the Gretchen trial.   I quickly lost the muscle tone I gained.  That is mostly water in the muscle to my knowledge?

I quoted Utimate Fitness by Gina Kolata  in my book The Tubby Traveler from Topeka:

Dr. Louis J Aronne in The Change Your Biology Diet book page 224 talks about high intensity exercise program.

I have great respect for Dr. Aronne.  Perhaps this will be the way people can avoid a great reduction in their exercise metabolism by maintaining muscle mass.  I however believe that the billions of shrunken fat cells remain and that the disease of Leptin deficiency (The Sponge Syndrome) will prevent all those muscles to maintain weight loss in the reduced obese in all but the few.

            57 varieties of obesity

Lee Kaplan talk is critiqued in link above.

90% of hypertension is primary.  This means we don't know what causes it.
The remaining approximately 5-10% or less is secondary.  It has a specific cause.  In the office we make the usual blood tests to rule out the obvious secondary causes of high blood pressure and then we usually give a low dose combination ace inhibitor/diuretic to be taken for the patients lifetime.
The same will be true for the reduce obese in the chronic disease of obesity.

How to treat adaptive thermogenesis in the reduced obese

Reduced obese brain responding to low Leptin
 2 minute 53 second video

 This is why diet and exercise maintains weight loss in very few of the reduced obese.
About 10,000 people are self-reported to have maintained weight loss long term in National Weight Control Registry

Dr  David Ludwig in Always Hungry? 2016
on page 204 writes in the chapter Lose Weight Permanently:
"After a few months of optimal eating, improved sleep, stress reduction, and regular physical activities, some people can begin again with a clean slate and tolerate moderate amounts of these foods."
"Others may find that any amount of proceeded carbohydrates triggers carvings or other symptoms, setting the stage for weight regain." (emphasis mine)
I tried to treat my reduced obese state with Atkins diet.  It was a partial success.  I stopped gaining weight.

Dr. Louis J Aronne in The Change Your Biology Diet  2016
on page 137:

 

 I quoted the above article in The Tubby Traveler from Topeka on page 138

 After I wrote these words I watched this video in 2012 from
HBO Weight of the Nation


I tried to treat my reduced obese state with 2.5 hours of exercise a day as per guidelines but I ate ad libitum. (I later learned more exercise only works in context of 1500 calorie/d diet)  I ate low glycemic fruit between meals. I gained 1.5 pounds a month till I gained 50 pounds and switched to Atkins.

On Atkins I continued to eat ad libitum.  I did not gain weight despite decreasing my exercise to walking 20 to 40 minutes a day.

A big change occurred when I changed my medications and added
Invokana, Victoza and Qsymia.  
I did not change my ad libitum Adkins diet or my 20-40 minute walk a day but on diet medications I did eat less.  This program did not feel restrictive to me since I was accustomed to Atkins since 2011 and I drank alcohol.

Thus with respect to my Professors I must say their approach will work for very few people.

The key is to treat the brain with diet medication when the reduced obese are in a state of leptin deficiency.  We must fool their leptin deprived brain that they are not starving.

Diet might do it for some insulin resistant people but I was in nutritional ketosis and thus on very low carbohydrates, exercised every day, was retired with low stress and slept very well.  I clearly fell into the other group Dr. Ludwig talks about.

After losing 80 pounds and exercising 2 hours a day I was reached 200 pounds.  My body thought I was starving.  My sympathetic nervous shut down on me.  I was cold all the time.  70% of resting metabolism is from the brain, kidneys and liver and other organs.  Exercise does not make an impact. At 5'11" I believe I should lose another 10 pounds.  I did not "reach the new lower set point" that Dr. Ludwig talks about on page 204 , first paragraph.
My body would not permit it and almost immediately when I relaxed my intense diet and exercise efforts I gained a quick 10 pounds at a low calorie count and a good amount of daily exercise.  (please read NYT Biggest Loser)


Dr Aronne taught me how to use the diet medications.
Dr Ludwig has written articles that are scientific breakthroughs.

However, I will start my Obesity Clinic on Tues and follow the plan in the video below. 
 Even most Bariatric surgery patients need diet medications to prevent regain. 

2 min 54 second video

Kudos to my sculptor, his exhibit

The  exhibit of 8 of Gomez sculpture portraits is at the Lighthouse Art Center Museum in Tequesta, Florida from June 6 through August 12 2016.

 My bust is in clay at the back.

Repeating the same thing that doesn't work is definition of insanity

By J. Ravitz CNN 
"These figures remain high in spite of the "hundreds of millions of dollars" that have been pumped into research, trials, observational studies, community and hospital programs, and the development of devices and drugs, said an accompanying JAMA editorial."

I quoted Gina Kolata in 2011 on p 144 of The Tubby Traveler from Topeka 

 

Editorial | June 7, 2016

The Unrelenting Challenge of Obesity

Jody W. Zylke, MD¹; Howard Bauchner, MD¹

[+] Author Affiliations

JAMA. 2016;315(21):2277-2278. doi:10.1001/jama.2016.6190

 Paragraph above from the JAMA editorial. 

The solution will be found in basic science that is presently ignored. 
Ochner and Greenway reviews 2016 

 This lesson was taught in the way we treated cancer and HIV in the early days. 

 The Emperor of All Maladies: A Biography of Cancer 
demonstrates how it was not till we learned basic immunological and genetic science (much of it HIV research) that we learned to treat specific cancers. 

Gina Kolata put a spotlight on the new Obesity science in 2008 in Re-Thinking Thin

 After I read Ms. Kolata's book, I realized I was one of the Reduced Obese. 
I wrote a book about dealing with this in this free manuscript The Tubby Traveler from Topeka

I theorized in the Sponge Theory 2011 that billions of shrunken fat cells never go away in the reduced obese.  This causes a very low leptin level which makes your brain believe it is starving.  Subsequently, despite diet and exercise will not maintain weight loss over long term.  It has in a small percentage of people found in  NWCR.

What I have written has been further validated in another article by Gina Kolata  The Biggest Loser

I passed the American Board of Obesity Medicine exam in Dec. 2015. 
I took the exam because I wanted to go back into practice to treat the reduced obese with 4 new obesity medications.

I have been retired from practice since Dec 2009.  I plan to open a Obesity Cholesterol Clinic and want to re-certify with the National Lipid Association.   I attended the Masters Program at the NLA New Orleans meeting in May 2016.  I was disappointed that the obesity portion of the program was not up to date as I describe in this blog editorial:
Obesity update needed in Masters Course at National Lipid Association. 

I have learned the new science of Obesity.  Maintaining weight loss of the reduced obese is not done with diet and exercise, that
 Starvation diet approach
 has failed. 
LOOK AHEAD 10 year long trial

My approach:

Bon Vivant diet

Topeka Tubby Diet in 4 sentences 

My data on Qsymia and Victoza:

I have

 Chronic Disease of Obesity
 and need to be on diet medicine for life











 

Potential of Change Maintained

Mission of Obesity Cholesterol Clinic of Topeka:

"Potential of Change Maintained"

My logo below is a metaphor for it:

The bust is a metaphor for the change of weight loss that can be maintained with the program at the Obesity Cholesterol Clinic of Topeka.
The first bust on the right is the first clay change.  The second bust has small changes you can notice if you look closely.  Clay will not last long just as the reduced obese will usually regain weight.  The third bust is bronze.  It will last 200 years.  This is the mission of the Obesity Cholesterol Clinic of Topeka: To Maintain Weight Loss.  



Kudos to my sculptor, his exhibit