BUILDING THE FUTURE: Seven Exciting Topics in Bariatric Medicine

Sean Bourke, MD

After 14 years in emergency medicine, I headed down an uncharted path. Sick of treating the symptoms of overweight and obesity, I wanted to fight the cause. With a buddy from Stanford Residency, Dr. Conrad Lai, I founded JumpstartMD to combat the biggest health care crises of the 21st century: adiposity and its evil twin adiposopathy, or “sick fat.” Looking back, I had no idea how gratifying this journey would be, and what a positive impact we would have on people’s lives.

I was also surprised to see how misguided the information we’d received in medical school had been on this topic, and how many “luminary” thought leaders would emerge from right here in the San Francisco Bay Area to help lead our field out of the darkness of old thinking and flawed science.

In honor of those luminaries and the marvelous journey that has transpired since we founded JumpstartMD seven years ago, these are the seven topics I find most exciting in bariatric medicine right now:

1. The growing recognition that all calories are not created equal.

Scientific evidence and the collective knowledge of bariatric clinicians on the frontlines of care paint an increasingly clear picture: Individuals vary greatly in their level of carbohydrate tolerance. Carbohydrate intake that exceeds an individual’s tolerance may cause adiposity, adiposopathy, or both. Thus carbohydrates--not fat--may well represent the greatest metabolic and cardiovascular health risk contributing to obesity.

Increased consumption of carbohydrates over the past 40 years, both in relative total and as a percentage of all calories consumed, has been the major macronutrient change, in lockstep with the rise in obesity and diabetes. Treatment informed by this perspective enables bariatric physicians to tailor diets matched to an individual’s level of carbohydrate sensitivity. It also allows patients to wisely embrace behavioral change in line with optimal, individualized dietary guidance.

That path simply won’t be the carbohydrate-heavy, low-fat food “pyramid” we all learned in school. As humans cannot consume more than 30-40% of their calories from protein without untoward consequence, the most carbohydrate-sensitive group (such as those with insulin resistance, type 2 diabetes, or metabolic syndrome) cannot consume a diet that is low in both carbohydrate and fat. For that carbohydrate-intolerant group (and, to varied degrees, the majority of the two-thirds of Americans who are overweight or obese), it is increasingly clear that a well-formulated, low-carbohydrate diet complemented by a good mix of fats is healthier. Additionally, that mix of fats should focus on consumption of heart-healthy monounsaturated fats such as those in avocado, nuts, olive and canola oil; temper fears of cardiovascular risk-neutral saturated fats; ensure adequate intake of omega 3s via fish or good-quality supplements; and minimize intake of industrialized oils (like corn and soy oil).

2. The potential use of two new and potentially influential laboratory assays to assess health risk, monitor efficacy of treatment, and educate and motivate individual patients.

The first assay mentioned, which I am not yet at liberty to discuss, is currently under development and going through academic validation. It promises to accurately predict individual carbohydrate tolerance at the point of care.

The second--lipid fractionation using Ion Mobility testing (the only assay that directly measures low-density lipoprotein particle size)--can more accurately assess metabolic and cardiovascular health risk and pre- and post-weight-loss intervention efficacy of treatment.

Measuring LDL particle size is beneficial because it is carbohydrates, particularly white flours and sugars (again, not fat), that shape LDL particles into the various medium, small and very small sizes that disproportionately drive cardiovascular risk. Further, smaller LDL particles flag an early proclivity to metabolic syndrome even prior to actual rises in insulin. Because carbohydrate restriction and weight loss are the principal treatments for metabolic syndrome patients, lipid fractionation can help tailor diets for insulin-resistant, higher-risk patients. Additionally, measuring lipid fractionation particles pre- and post-weight loss intervention in those patients represents new value in terms of helping patients understand why their macronutrient composition matters, and to further motivate optimal dietary compliance.

3. The recent discovery at the Gladstone Institute that the ketone body Beta-hydroxybutyrate served to potently reduce oxidative stress. (See Shimazu T, et al, “Suppression of oxidative stress by beta-hydroxybutyrate, an endogenous histone deacetylase inhibitor,” Science, Jan. 11, 2013.)

Ketogenic diets have traditionally been maligned by the medical community, largely through a misunderstanding of the differences between the pathologic state of diabetic ketoacidosis (ketone levels 15-25) and the benign state of nutritional ketosis (ketone levels 0.5-5). While further studies are needed, the findings in this study suggest an underlying epigenetic mechanism through which ketogenic diets may serve to prevent oxidative stress and cellular free-radical formation and, thus, might actually slow aging and prevent a variety of diseases, from coronary artery disease to Alzheimer’s and beyond.

4. The Vivus Corporation’s recent FDA approval for an anorectic medication composed partly of phentermine for long-term use.

Let me clarify: I do not believe that Qsymia, the extended-release topiramate-phentermine combination, offers therapeutic benefit proportionate to its cost in comparison with cheaper, older generic anorectics. However, Vivus’s management of the studies needed to assure the FDA that this phentermine extended-release topiramate combination is safe and effective to administer long-term is a positive development.

Bariatrician survey data suggests that the vast majority have been using Schedule III and Schedule IV anorectics off-label safely and effectively long-term for years--but under a chronic and low-level fear of harassment by the Drug Enforcement Administration. Since FDA concerns were not evidence-based, this peeling back of the proverbial onion can only be helpful in further confirmation of their invalidity. The approval of Qsymia for long-term treatment and further studies in progress may therefore pave the way for FDA reevaluation of its regulatory stance around longstanding, safe and effective use of generic anorectics such as phentermine, phendimetrazine and diethylpropion.

Also noteworthy on the medication front: The selective serotonin 2c receptor agonist lorcaserin (Belviq) and a combination bupropion SR and naltrexone SR are both pending FDA approval on the year 2014 horizon.

5. Recognition that, for the vast majority of patients, exercise is a lousy weight-loss tool.

I know this sounds heretical, but the truth will set us all free. While a great wellness tool--think cardiovascular, metabolic, mental and musculoskeletal health--and an important component of weight maintenance, the ill-founded belief that exercise produces weight loss has led too many down a sweaty and demotivating garden path. Living in our “toxic environment” (per Yale Professor Kelly Brownell) rife with ubiquitous and cheap carbohydrate rich foods, you cannot outrun your mouth. Effectively busting that exercise myth is essential.

Why? Because patients need a clear and transparent understanding of what really works to achieve and sustain a healthy weight that’s based on science, not catchy marketing or popular magazine advice. The food industry has a great stake in convincing us that our sedentary lifestyles and lack of exercise, rather than the adulterated food supply they’re selling us, is the cause of the obesity epidemic; but I’ll quote the “consensus statement” from the American Heart Association and the American College of Sports Medicine on this subject: “It is reasonable to assume that persons with relatively high daily energy expenditures would be less likely to gain weight over time, compared with those who have low energy expenditures. So far, data to support this hypothesis are not particularly compelling.”

Exercise as a “not particularly compelling” weight-management tool bears out our experience at JumpstartMD with more than 10,000 patients. This should not discourage exercise or the pursuit of improved fitness, but rather spur patients to focus on nutrition first to lose excess weight, and then integrate exercise to promote health and positive body composition changes and to foster long-term success as a complement to weight-loss maintenance.

6. Everyone eats food: The visions of Alice Waters and Michael Pollan.

Alice Waters, the matriarch of the Bay Area good-food movement, has become queen not of haute cuisine but, to use her own words, “simple foods”--foods sourced locally and grown sustainably. She is also founder of the Edible Schoolyard Project and Chez Panisse Foundation, and she has led many back to the pleasures of their kitchens by way of their gardens. Fellow Berkeley resident Michael Pollan has given us embraceable, actionable, pithy phrases everyone can rally around, such as “Eat foods. Not too much. Mostly plants”; “Don’t eat anything your great-grandmother wouldn’t recognize as food”; “Shop the peripheries of the supermarket and stay out of the middle.” His next book on the importance of cooking is due out shortly.

Along with doctors like Steve Phinney, Ronald Krauss and Robert Lustig, leading food and nutrition thinkers like Pollan, Waters and Gary Taubes are creating a dialogue around the new science that makes one thing clear: Nutrition is the lynchpin on which the solution to the obesity crisis must turn. I am grateful for their leadership, the tangible impact this new thinking has had on the Bay Area food movement and on the health of my patients, and the longer-term impact it will have in the evolution of my field.

7. Building the future.

Yes, everyone eats food; yet our modern food supply barely resembles food any longer. We’re sold “toxic” nutritional time bombs in pretty, easy-to-consume packaging served up fast, cheap and everywhere you look. At a recent lecture, Dr. Robert Lustig noted that 80% of the 600,000 foods listed in our food supply have added sugar. Average American consumption of sugar has increased from 5 pounds per capita per year in the 18th century to 35 pounds in the 19th century to 156 pounds today. Ouch.

The problem is arguably complex, but the solution is simple: real food. It does not lie in the substitution of one toxic product for another, such as liquid “shakes,” chemically preserved “meals,” or pointless point systems that allow Twinkies, tuna and taffy interchangeably. All calories are not created equal.

At JumpstartMD, our practice hinges on this belief. Our clinical outcomes have been proven up to three to four times more effective than traditional offerings, and more than 80% of our maintenance patients remain within one pound of their losses because we help them learn healthy habits tailored to their needs and built upon a foundation of whole, fresh, real-food meal strategies that are meant to last a lifetime.

Moving toward “the” solution to this daunting problem is by necessity a collective process that will employ a comprehensive approach that’s informed by the seven elements outlined in this piece, and those yet to come. It is this collaborative passion and perpetual search for improvement that I find one of the most exciting elements of bariatric medicine today.

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Dr. Bourke, CEO of JumpstartMD, was previously an emergency physician at Marin General Hospital.

Email: sbourke@jumpstartmd.com

[Reprinted by permission of San Francisco Medicine.]