change with training. 2013 moema annual scientific meeting ... · “but what precisely is obesity...

9/24/2013

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2013 MOEMA Annual Scientific Meeting

“Where REALITY MEETS SCIENCE ™ in the

METABOLIC SYNDROME”

September 28, 2013

Presenter: Tom Rifai MD Online CME Course Director, Harvard Medical School:

“Nutrition & The Metabolic Syndrome”

(http://tinyURL.com/PERRSQD)

Medical Director - Metabolic Nutrition & Weight Management

St Joseph Mercy Oakland, Pontiac MI

A Metabolic Doc Can’t Do It

Without a Great Team!

Tom Rifai, MD Medical Director and Lifestyle Coach

Certified Physician Nutrition Specialist & Internist, Lifestyle Group Class Leader

Larissa Shain, RD Chief Dietitian, Lifestyle Group Class Leader

Denise Jones, MA Clinical Program Coordinator

Tova Spring, RN Patient Assessment, Triage, Counseling and Educator

Don Deering, PhD Behavior Modification Coach and CBT specialist

SJMO Physical Therapy As well as Certified Exercise Trainers

Objectives we will try our best to meet

• Understand how to identify insulin resistance/metabolic syndrome & detect it earlier than metabolic syndrome

• Better understanding your patient’s lifestyle contributors (environment/emotional choices) and the need for realistic expectations in terms of our capabilities & goals vs our patients readiness and ability for change

AND MAYBE

• Review macronutrient basics re: protein, carbohydrate, fats

• Understand appropriate role of medical foods and when to refer to comprehensive medical metabolic/behavior mod programs

• Understand the potential use of metformin in pre-diabetes and insulin resistance/weight management

“But What Precisely is Obesity ?”

Most commonly used definition is “BMI ”

Body Mass Index > 30 (wt/in2 x 703)

• But BMI assesses only height & weight, so not optimal

• BMI’s ease for population studies, not accuracy in detecting metabolic risks, made it popular for use in individuals

• DEXA Scan is largely considered the Medical Gold Standard for a potential practical, yet detailed assessment of metabolic risk of body composition. Body fat >20% in men and >30% in women is better definition of “obesity”

• In mine & many other expert clinician’s opinions including the IDF, Abdominal Circumference is the most practical, simple & reproducible technique in a busy practice

Total Body: % Fat

percent

Fat

Lbs.

Lean

Lbs.

Bone

Lbs.

Total Body

Lbs.

ACTUAL DXA RESULTS = 47. 73.8 78.74 4.59 157.14Projected Weight* Age Matched

Low % Fat 31.4 38.14 78.74 4.59 121.48

Projected Weight* Age Matched

Hi % Fat 44.2 66.01 78.74 4.59 149.34

Projected Weight* Young Normal

Low % Fat 24.4 26.9 78.74 4.59 110.23


Hi % Fat 34.8 44.48 78.74 4.59 127.81

Projected Weight* for X% Fat X

X* Total Body

100 78.74 4.598333

(100-X)

Current BMI (kg/m2) is 26.2 Weight at BMI = 18 would be = 107.94

Weight at BMI = 24.9 would be = 149.92* Projected weights are based on assuming that lean and bone tissue are constant over time although lean tissue can indeedchange with training.

Scan measurements by Limbs:Fat (lb) Lean (lb) Bone (lb) Total (lb) Fat (lb) Lean (lb) Bone (lb) Total (lb)

Right

Arm 2.19 3.64 0.22 6.05

Right

Leg 11.49 11.94 0.56 23.99

Left

Arm 2.73 4.53 0.283 7.55

Left

Leg 12.31 12.8 0.804 25.91

Scan measurements by Body Region:

% Fat Fat (lb) Lean (lb) Bone (lb) Total (lb)

Arms 36.2 4.92 8.18 0.503 13.6

Legs 47.7 23.79 24.74 1.364 49.9

Trunk 51.4 42.4 38.47 1.577 82.44

Central fat measure (trunk fat/total fat) = % truncal fat = 57.4

Age matched normal range for % truncal fat (42.8 - 51.2 )

Young Adult (20-29 years) normal range for % truncal fat (36.8 - 45.2 )

Total Body: % Fat

percent

Fat

Lbs.

Lean

Lbs.

Bone

Lbs.

Total Body

Lbs.

ACTUAL DXA RESULTS = 47. 73.8 78.74 4.59 157.14Projected Weight* Age Matched

Low % Fat 31.4 38.14 78.74 4.59 121.48

Projected Weight* Age Matched

Hi % Fat 44.2 66.01 78.74 4.59 149.34


Low % Fat 24.4 26.9 78.74 4.59 110.23


Hi % Fat 34.8 44.48 78.74 4.59 127.81

Projected Weight* for X% Fat X

X* Total Body

100 78.74 4.598333

(100-X)

Current BMI (kg/m2) is 26.2 Weight at BMI = 18 would be = 107.94

Weight at BMI = 24.9 would be = 149.92* Projected weights are based on assuming that lean and bone tissue are constant over time although lean tissue can indeedchange with training.

Scan measurements by Limbs:Fat (lb) Lean (lb) Bone (lb) Total (lb) Fat (lb) Lean (lb) Bone (lb) Total (lb)

Right

Arm 2.19 3.64 0.22 6.05

Right

Leg 11.49 11.94 0.56 23.99

Left

Arm 2.73 4.53 0.283 7.55

Left

Leg 12.31 12.8 0.804 25.91

Scan measurements by Body Region:

% Fat Fat (lb) Lean (lb) Bone (lb) Total (lb)

Arms 36.2 4.92 8.18 0.503 13.6

Legs 47.7 23.79 24.74 1.364 49.9

Trunk 51.4 42.4 38.47 1.577 82.44

Central fat measure (trunk fat/total fat) = % truncal fat = 57.4

Age matched normal range for % truncal fat (42.8 - 51.2 )

Young Adult (20-29 years) normal range for % truncal fat (36.8 - 45.2 )

What is “Insulin Resistance”

PRACTICALLY speaking?

• A physiological state, inducible to some degree or

another in most humans, resulting in higher insulin

requirements to maintain glucose levels and

resulting largely from extensive time periods of

an imbalance between movement (low) & calorie

intake (high)….. DM2 reflects insulin resistance

PLUS beta-cell burnout…

• May begin with epigenetic contributions during

pregnancy (smoking, GDM, macrosomia, premature

or low birth weight) and gut microbes contribution but

these don’t change fact that TLC is a key therapy

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• First, chronologically (after epigenetic factors & gut microbes) you’ll see

too many kids establishing little healthy cooking or healthy

food prep skills while

• Eating minimal fruit & veggies, beans/lentils, lean/low salt proteins

• ..relative to lots of: high calorie (and high salt added)

calorie dense grains, frequently with several forms of sugars added

like HFCS, clarified concentrated juices, honey (regular & sweet

breads/pastries, pizza crusts, bagels, dry cereals, etc) for “carbs”, with

lots of sugary & fatty drinks complimented with high fat dairy, cured

and/or fatty meats, fried potatoes/chips…

• Blended with a lot of sitting/lying around = Cardiometabolic

Syndrome…Let the atheromas and inflammation begin!

URGENT: “Adult” Diseases in Kids – “In U.S….type 2 diabetes accounts for up

to 46% of all new cases of diabetes referred to pediatric centers. The

magnitude of type 2 diabetes is probably underestimated ” CDC

As of 2010, over 30% of the pediatric population in US are now obese or overweight..& likely many of the “normals” suffering poor body

composition



• Abdominal Circumference >37 in a man >32 in a woman

• Plus ANY of the following:

• - triglycerides >200 non fasting

• - sedentary lifestyle

• - personal or FH of any of the metabolic syndrome components

• - Personal history of GDM or eclampsia features


ACADEMICALLY speaking?

• Prior to Metabolic Syndrome you may see < 2 of 5 plus other related metabolic lab findings:

• Non-Hemochromatosis related Hyperferritinemia – Diabetes Care Vol 28; #8 2005

• Hyperuricemia

• Elevated ALT/fatty liver, higher than optimal fasting insulin – e.g., >7)

• Elevated (IMO above 50th percentile) NMR derived “INSULIN RESISTANCE SCORE” (www.TheParticleTest.com)

• Prior to “pre-diabetes” most have “Metabolic Syndrome” (i.e.,> 3 of 5 International Diabetes Federation criteria - see next slide)

Metabolic Syndrome by IDF standards REQUIRES:

Meeting Abdominal Circumference Criteria

>37 inches in Caucasians, Arab and African American men

For Asian (also consider Latinos, American Indians & other high risk groups, including +FH) male threshold drops to

>35”

and

>31.5 in ALL women

Metabolic Syndrome as defined by

International Diabetes Federation

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AND at least 2 of the following 4

• Fasting TG level: > 150 mg/dL or specific treatment for this

• HDL cholesterol: < 40 mg/dL in men, < 50 mg/dL in women

or specific treatment for this (Niacin, Fibrate, some statins)

• Resting BP >130/85 mm Hg, or being treated for BP/HTN

• Fasting plasma glucose > 100 mg/dL on more than one occasion or treatment for this (OGTT is strongly recommended but

is not needed to define presence of the syndrome)

IMO: Imperfect, but consider 2009 ADA defined A1c range 5.7-6.4% as better, overall, diagnostic for pre-DM2

Pulmonary Disorders

• Obstructive sleep apnea • Asthma

Reproductive/Sexual Abnormalities • Abnormal periods • Infertility / PCOS*** • Erectile Dysfunction (CVD)

Gout

Dementia

• Stroke & Depression

More CVD • Heart Attack

• Heart Failure

• Metabolic Syndrome

• Type 2 Diabetes

• High Blood Pressure

• Kidney Failure

Cancers

• Breast, ovarian, uterus

• Colon**

• Prostate

Liver Disorders

• NAFLD*>NASH**>Cirrhosis>Cancer

DVT

*Risks of poor body composition induced insulin resistance* Excess visceral/liver/muscle fat plus below average amount/use of

muscle mass or a combination of BOTH (most common)

Osteoarthritis

*** PCOS = polycystic ovarian syndrome

* NAFLD=Non-Alcohol Fatty Liver Disease **NASH = nonalcoholic steatohepatitis 4083.NIH/NHLBI. September 1998; NIH publication no. 98

“So you “see” insulin

<-- resistance….now what?

Lifestyle change/Behavior modification

is THE gold standard….BUT HARD!

And you know that genetics are certainly a contributor…

…but you KNOW human genes are the virtually the same

now as 10,000 years ago!…

So genetics are a minor issue (especially for diseases

encountered after age of 50) on a population scale,

though EPIGENETIC modifications (e.g., smoking during

pregnancy and macrosomic babies) and GUT MICROBIA

(too many anti-biotics & C-Sections?) are SCARY…yet

still it’s really more about…..

• The most sedentary society in history

– 80-90% of average Americans’ daytime is spent sitting!

– All RISE please (my anti-guilt Rx!)

– Why? Because it’s TOO easy!

Lifestyle Goal: 10,000 steps most days with “3K within 30 min” (get a pedometer)

– Sit < 3 hours per day most days (get a standing desk or a “GET OFF DUFF” alarm

USA 2013: The Perfect Storm for Calorie

Excess Based Diseases

USA 2013: The Perfect Storm for Calorie

Excess Based Diseases

• The most “comfort/junk food toxic” environment in history

– Hyper-palatable “foods” with ADDICTIVE PROPERTIES (high sugar/starch plus salt plus saturated fat = COCAINE EQUIVALENT) that are WAY too convenient

– Irrational “finish your plate” attitude has led to huge portion expectations along with OVER-using food as cultural focus

– EMOTIONAL/STRESS RELATED EATING IS ONE OF THE MOST DIFFICULT FACTORS TO MANAGE (consider CBT or ShrinkYourself.com)

• Excessive Thin, sugar/fat/alcohol based liquid calories: non-satiating (not “sensed” by brain/body)

• Excessive Calorie Dense/Refined Carbs: Grains, most refined & baked/dry grain (flour, rice, corn, oats like: breads/bagels, pies, donuts, cookies, pastries, dry cereals, chips, popcorn, pizza dough, tortillas, wraps, granola bars, muffins), are biggest source of increase in solid food calorie intake since 1980 AND many are mixed with:

• Excessive non-essential fats: Oils, non-skim dairy, cheeses/butter, margarines, feed-lot fed fatty animal meats

Where are the excess - age inducing/free radical

promoting - calories mostly coming from?

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Complementing the “excesses” from

previous slide are:

– SITTING/SEDENTARY TIME INCREASING

– MEAL SKIPPING AND ERRATIC DAYTIME EATING

LEADING TO OVERCOMPENSATION AT NIGHT

– POOR INTAKE OF WHOLE FRUIT n VEGETABLES

– POOR DISTRIBUTION THROUGHOUT THE DAY OF

QUALITY PROTEIN SOURCES (esp in the AM)

All together leading to: muscle/bone loss with fat gain in

liver/viscera and marbled/weaker muscle

PHENOTYPIC INSULIN RESISTANCE

Source: CDC Behavioral Risk Factor Surveillance System.

Obesity Trends* Among U.S. AdultsBRFSS, 2004

(*BMI 30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

Obesity Trends* Among U.S. Adults BRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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HELP PATIENTS RETIRE GUILT:

“WILLPOWER SUCKS” FOR REASONS!

• Human tendency to gain fat is protective against the

frequent lack of calories of most of human history

(“Obesity Paradox” reveals that obese may actually

be made of “tougher stuff” - OPPORTUNITY TO

CAREFULLYEMPOWER THE PATIENT WITH

FACTUAL SCIENCE)

• Tendency towards obesity is a “good thing gone awry”

due to our mismatch of genes to modern environment

Establishing “LIFESTYLE THOUGHT”,

extinguishing “DIET THOUGHT”

Establishing “LIFESTYLE THOUGHT”,

extinguishing “DIET THOUGHT”

• Leningrad World War 2 observation – The food deprivation of the Nazi onslaught seemed to cause more deaths than their bombing…and more body fat victims had at the beginning of siege the lower their risk of death.

• UPSHOT: Wisdom that environmental management beats expecting “willpower” to work as a tool for real lifestyle change! MUST try to make it MINDLESS to eat healthier at home, work, or wherever some control is possible to win the battle against our internal tendencies to overindulge!

The Basics in achieving “Optimal” Nutrition:

Be a Motivational Interviewer

• Accept that even basics can be difficult to

achieve since the US food environment is

currently, overall, VERY poor at supporting healthy

choices and SO MUCH EATING IS EMOTIONAL!

• Consider “Eating The Moment” (Somov), “Shrink

Yourself” (Gould) and best of all, a Cognitive

Behavioral Therapist & Psychiatry if necessary, to

help co-manage their emotional eating triggers &

work on alternative stress management skills.

Stages of Behavior Change

( * = highest yield candidates for intervention)

• Precontemplation (Uninterested - provide requisite info

regarding risks to their health & ask permission to address at

follow up, offer “open door” to come back sooner)

• * Contemplation (Is considering change - explore why they’re

interested in lifestyle change)

• * Preparation (Already preparing to make lifestyle change -

may offer guidance here but also keep re-assessing

motivations for change to “prepare” them for their “journey”)

• * Action (Actively modified, but just started process change of,

lifestyle - not yet habit. NEEDS COACHING,

REINFORCEMENT & monitoring)

• Maintenance - still need long term, though lower intensity,

monitoring for relapse NON JUDGEMENTAL

“Stages of Change” (Pre-Contemplative,

Contemplative, Preparation or ACTION?)

• BE PERSISTENT but PATIENT and MOTIVATIONAL PARTNER/COACH. Inform patient risks of poor lifestyle choices & help reconcile their understanding with facts…. but also ENGAGE them in respectful conversation

• What makes it most difficult for you?

• What motivates them to be healthier?

• What do they actually LIKE or have a history of doing regarding physical activity?

• What/Who sabotages their efforts? Go with THEIR flow, “contract” with them, follow up frequently if needed (note USPSTF rec. on visit frequency for obesity mgt)!



• Simply giving advice alone is not effective

• Clarifying patients strengths & motivations - help

them feel THEY are designing their “journey”

• GUIDE more than ADVISE/DEMAND.

• ASK what THEY feel about what holds them back

and LISTEN CLOSELY before speaking (you’ll

learn AND build TRUST)

• Help them with turning a “slip” into a moment to

S.L.I.P. (see next slide)

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S.L.I.P. - A CRITICAL TOOL FOR THOSE IN

RECEPTIVE STAGE OF CHANGE:

• S top behavior & realize you’re human!

• L ook at the situation realistically

• I nvestigate where the trigger was

• P lan accordingly for a future similar situation

in which the new plan can be put into action

• In TLC: PROGRESS = PERFECTION !

• Do NOT let “perfect” be the enemy of

PROGRESS!



• STEP 1 – TEMPTATION CONTROL: MUST emphasize home environment be a “HEALTHY FOOD ONLY ZONE” as much as reasonably possible

• While indulgences are OK on occasion (and a fact of life), they should generally be left OUTSIDE THE HOME!

• Need proof? Read: Mindless Eating (Professor Brian Wansink PhD)

Stimulus Control for Long Term

Calorie Control

FIRST - REMOVE TEMPTATIONS FROM AS MANY

ENVIRONMENTS AS POSSIBLE while dispelling myth that

“you’ll have to swear off dessert forever!”

Emphasize: “don’t worry, there will be more than enough opportunities

for indulgences in a lifetime without having them constantly around

you, sapping your “daily allotment of ‘willpower’ (i.e., homes/work) by

tempting you constantly day in & day out at home/work”

• Removing calorie dense/hi-salt “comfort foods” from home/work does

NOT at all mean “removing them from your life”

• HABIT ALERT: Success comes with accepting frequently bringing

healthy food with you far more often than before (e.g., work/vacations)

• Will still have to contend with restaurants and outside sources of

“food”, of course – Skipping breadbasket usually,

dressings/cheeses/sauces, using a menu as an “ingredients list”

Lessons from the US National Weight

Control Registry – www.NWCR.ws

• Food/Active Diaries WORK! (written or smart phone)

• Breakfast and Weighing in the AM regularly

• Consider “Dessert with (Hi Protein) Breakfast Diet”

• Accountability and “checking in” regularly (at doc’s

office, Weight Watchers or another structured program)

• At start of a sincere Lifestyle Change, it is NOT

necessary to tell “EVERYONE” you are going on a DIET

• WORTH REPEATING ON EMOTIONAL/STRESS EATING!

Tips for mind re-training for comfort food overeaters:

Book: “Eating the Moment” - Pavel Somov PhD

Website: www.ShrinkYourself.com - Roger Gould MD

“Optimal” Nutrition:

PROTEIN - a Controversial Area!

• …Recent data, including NIH Omni-Heart Trial comparing standard DASH (15% protein, 60% carb, 25% fat) to “High Protein DASH” (shifting protein up to 25% and carbs down to 50%) found far better results in Metabolic Syndrome subjects for lipid control & overall CVD risk factors

• Institutes of Medicine describes a “healthy range” from 15-35% of total daily calories (30% of 1800 cal = 135 grams)

• Overall, protein suppresses appetite hormone ghrelin better/longer than Carbs/Fat take care not to demonize protein in and of itself!

• Higher age = higher protein intake needed to produce muscle mass!



• “Low Protein Diets”, despite common misconception, have NEVER been shown to reduce progression to dialysis, does not mitigate diabetic nephropathy (AJCN, 2008)

• RDA for protein (0.8g per kg, whatever THAT means in the REAL world!) is defined as a MINIMUM intake to meet the requirement of “most” “healthy” adults! But THAT may describe less than 10% of Americans!…Yet protein RDA is commonly promoted as an “optimum” intake. But RDA is frankly inadequate for many and certainly not optimal for most as low protein can = muscle loss contributor. And muscle loss can = increased risk for insulin resistance & total mortality risk!

• Good review on misconceptions re: Protein & the RDA: JAMA June 25, 2008 pgs 2891-2893

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• Protein has caveats, such as it’s Renal Acid Load and that many sources come with “unwanted passengers” (saturated and excess total fat…as in most feed-lot fed animal meat; sodium…like cured meats and 50/90% of raw chicken/pork, respectively; and heme iron as well as high carnitin in red meat) BUT!……

• Adequate protein at most meals, especially breakfast

• Combine “clean, high-protein” sources with low calorie density (or at least unrefined) higher fiber quality sources of lower protein ALKALINE foods (vegetables & fruit). Legumes are great and basically neutral on RAL….whole grains caveats aforementioned



• Protein is critical for maintaining lean tissue mass as we age and is NOT harmful to bone AS LONG AS VEGETABLE AND FRUIT INTAKE is high enough, and grain intake low enough, to address protein’s (and grains’) acidity (hence, an advantage of “Paleo Diet” vs other “low carb” diets is its low salt / high fruits & veggie. Though Paleo is not a practical, nor necessarily ideal, long term diet)

• Protein Intake ideally should be SPREAD throughout the day (e.g., total daily intake for women ~80-100g/day and men ~100-150g) with several 20-35 gram meals/snacks…using medical protein supplements if necessary. Older people need at least 25-30 grams in a “meal” to substantially effect protein synthesis! Not likely going much higher will help though…

BASIC EXAMPLES OF HEALTHY PROTEIN

SOURCES

• Lean, low sodium fish, fowl, egg whites, “Greek” yogurts, pork tenderloin, legumes (e.g., soybeans, edamame, tofu, tempeh, & lentils) which are a good partial “replacement” for some of the average American’s grain intake.

• Must consider high quality, high protein

“Medical Meal Replacements” for appetite control and muscle loss prevention as evidenced by the NIH LookAHEAD ongoing trial of Type 2 Diabetes showing remarkable results considering the subjects’ PCP’s are generally still loading up their patients on weight gain promoting diabetic medications instead of shifting towards more weight loss friendly/neutral options.

Metabolic Medicine with Multidisciplinary

Weight and Lifestyle Management

• State-of-the-art metabolic medical program and its power in

treatment/prevention of diabetes, high blood pressure,

cholesterol problems, fatty liver, obstructive sleep apnea and

other insulin resistance related issues.

• Combining the following 3 proven tools for the first 12-16

weeks (aka – “intensive behavior modification phase”)

• Temporary use of medical formula foods as PART of food

• 12 weekly, intensive group education course (“Lifestyle U”)

• Frequent clinical follow up in the first 3-4 months then

progressively less to complete at least one year


Basic Eating Questions

Since relatively non-controversial eating will include calorie, sodium

and saturated fat control, ask if these risky eating patterns occur:

“Never”(<1x/mo), “Sometimes”(1x/mo-1x/wk) or “Often” (>2x/wk):

• Do you skip breakfast go longer than one hour of awakening?

• Do you ever go more than 3-4 hrs w/o eating?

• Do you drink any of your calories? Do you eat out (sit down or fast food)?

• Do you eat calorie dense sweets (grain based, hard chocolates, ice cream)?

• Do you eat calorie dense starches (breads, cereals, chips, wraps, etc)?

• Do you purposefully add non-essential fats (butter, mayo, dressings, oil)?

• Do you eat cheese (alone, on salad/pizza, in sandwiches)? nuts?

ADDITIONALLY, FOR HEALTHY EATING PATTERN CHOICES ASK:

• Do you eat unfried fish at least twice weekly?

• Do you eat at least 2-3 pieces of whole fruit?

• Do you eat some fresh vegetables daily?

SJMO Metabolic Nutrition

Weight Management Program

• Our program model is based on the most proven medical evidence:

– National Institutes of Health Landmark “Look Ahead” Study

– The Harvard/Joslin Diabetes center “Why WAIT” program

– USPSTF Guidelines on Obesity Mgt (only “intensive” is EBM)

--Initial part of program includes 3 major components-- 1. “Lifestyle University” - a 3 month intensive education package to

prepare for seamless transition to longevity lifestyle:

Weekly lifestyle change/nutrition/behavior modification classes

2 individual RD visits and 3 hour grocery shopping tour

2. Frequent metabolic physician monitoring for safety

• Approximately two times per month for the first three months, then progressively less thereafter … primary care doc kept updated

3. DATA PROVEN Medical Grade Meal Replacements (e.g., shakes) mixed with foods known to help treat disease (vegetables, whole fruits, lean proteins, legumes, small amt of nuts, oils, whole grains) & promote body fat loss & improve health

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Regular Physical Activity starts with NOT SITTING so much!

Even STANDING more and sitting less gives measurable

benefits! (Diabetes Care, 2012) Critical to weight maintenance, better weight loss maintenance potential,

muscle retention and quality of life.

Multiple options

*Physical Therapy – TIP: an underutilized tool! Find a good

PT and “partner” with them on your goals then prescribe PT

for patients as appropriate (which are many!)

Certified Exercise Specialists/Physiologists

Phase III Cardiac Rehab

Initial Evaluation: Attention to building safe,

enjoyable, physical activity

Metformin – a wonder drug?

• Well known first line in DM2 and should stay if on insulin!

• Now used frequently in PCOS, GDM and recently endorsed

by ADA for high risk pre-type 2 diabetics to lower DM2 31%

• Excellent safety profile (likely acceptable up to Cr 1.8)

• Also associated with lower CVD and Cancer (in trials now)

• NEWS FLASH! 10yr follow up to Diabetes Prevention

Program shows TLC cost effective while metformin cost

SAVING! Only 10% of medical tx is actually cost SAVING!

• IMO, B12 should be supplemented (1000mcg PO QD)

• IMO, in pre-diabetics where healthy weight loss is

CRITICAL - best to use metforminER at LUNCH, adjusting

dose up to 1500-2500mg based on GI tolerance

Supplements worth an Honorable Mention

• D3 (IMO - target dose to 25D between ~50ng/dL)

• B12 (IMO - target dose to keep level >500pg/mL with MMA <0.2 umol/L

& Homocysteine <14umol/L; Neurology Sept 27, 2011)

• Omega 3? (caveat: 1000mg fish oil doesn’t = 1000mg w3)

• CoQ10 / Ubiquinone? Maybe statin & CHF patients

• Re others: DO NO HARM! Best is HEALTHY LIFESTYLE! Failures:

Vitamin E, Selenium, Beta-Carotene, Folic Acid for CVD

• Magnesium Citrate/Glycinate? PPI (use ICD-9 995.2)

• Multivitamin? NO EVIDENCE OF BENEFIT FOR GENERAL POP.!

Careful w/ Fe (check ferritin with IR - code 263.0; ferritin levels

>100ng/mL should prompt thought of body iron excess), folate;

Consider QOD? www.naturalmedicinesdatabase.com

Testimonials

REAL RESULTS the GOLD STD: A Physician

Led, Interdisciplinary, Metabolic Program

• One year or more after starting

Metabolic Program, with at least 75% of

all Lifestyle University classes attended,

average weight loss is still over 13%

with mass majority having

substantially improved blood

pressure, cholesterol, blood sugar

and blood tests for inflammation

9/24/2013

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What Might Your Newly Reprogrammed Modern

Hunter-Gatherer Patient Be Doing?

• Eating a healthy breakfast within 1 hr of awakening or meal replacement with about 20-30g of quality protein, moderate amount of unrefined healthy carbs (whole fruit, veg in omelet, small amt of whole grain)

• Eating SEVERAL pieces of whole fruit & vegetables throughout the day and quality sources of “clean, lean” (clean=low sodium; lean=low sat fat) protein with fish happening >2x/wk

• For weight mgt look at “carbs” like this: low starch veggies over starchy veggies/fruit/legumes over cooked whole grains over dry whole grains, over anything refined.

• For weight mgt look at “fats” like this: moderate ALWAYS with unsalted nuts leading the way followed by high fat whole foods (avocado) and touches of “healthy” oils (canola, olive)

• Mindful of Environment and re-engineered home so they can “give their willpower a break!” (Book Rec: Mindless Eating – Brian Wansink PhD)

• Eating out less and more wisely/informed when so doing

• SITTING MUCH LESS and INTEGRATING EXERCISE ALSO

Just in case all else fails,

consider bariatric surgery…..

OR ...

change with training. 2013 moema annual scientific meeting ... · “but what precisely is obesity...

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