Our second talk is going to be by Dr. Carolina Povian, who recently was recruited to the Brigham and Women's Hospital, where she is the director of the Obesity Treatment Center there. She's a professor of medicine at Harvard Medical School and is also like Dr. Kushner and a past president of the Obesity Society. She's gonna talk to us today on lifestyle therapy for obesity, advantages, limitations, and contributions to a comprehensive strategy. Dr. Povian, Carolina, thank you for coming. Okay, I'm so happy to be here today talking about lifestyle therapy for obesity in terms of diet and exercise. All right, these are my disclosures. All right, so most of what I'm gonna talk about today has, we developed guidelines for the management of overweight and obesity in adults way back in 2013. At that time, we reviewed, you know, five years worth of, it took us five years to review a lot of very well-done studies specifically on diet, exercise, lifestyle, and we also made recommendations here on surgery. So I'm gonna be talking about what those guidelines state in the next few minutes. So the guidelines recommend based on the literature that primary care providers and other healthcare providers do use the BMI to identify risk, waist circumference, and we found evidence that as little as a three to 5% sustained weight loss reduces risk factors and risk of diabetes for those with overweight and obesity, prescribe a set number of calories per day, and there's no ideal diet despite what you hear on media. All right, so the recommendations from these guidelines is 1,200 to 1,500 calories a day for women, and that is based on the premise that a typical daily intake for a woman is about 2,000 calories a day, and if you reduce by that much, 500, remember that number, 500 calories a day, you're gonna lose about a pound of weight per week. Same is true only higher levels for men, 1,500 to 1,800 calories a day for men because they tend to have more higher weights and therefore need more calories to sustain their weight. All right, and then there is no ideal diet, so prescribing one of the evidence-based diets that restricts certain food types, such as high carb, low fiber, and high fat foods to create that energy deficit is all you need to do, easier said than done. All right, so there's now new evidence that suggests that it is really our ultra-processed food environment that may have been one of the major culprits in, of course, causing this epidemic of obesity and also creating a situation where it's very difficult to stay on one of these diets if you don't pick the right types of foods, all right? So this may facilitate overeating, and we have a study that I'm gonna talk about that illustrates that beautifully. Here's the study. Kevin Hall at the NIH took 20 adults and gave them, and this was unbelievable, gave them in order either a ultra-processed diet or an unprocessed diet to eat AdLib for 14 days each, and he watched them eat. This was inpatient, and they could eat whatever they wanted for three meals and snacks. What was amazing was the ultra-processed diet. Now, what's ultra-processed? It's these are foods that have been processed with added chemicals and machinations processing the macronutrients so that they have a lot more fat and calories and sugar per volume of the food. Ultra-processed versus unprocessed, they were matched for calories, sugar, fat, fiber, and macronutrients unbelievably, and so they were prescribed in random order, and when the study was done, it was found that when given ultra-processed diet, same amount of calories, that patients ate 500 calories more per day than eating the unprocessed diet. Now, you can start to figure out why would that be? Is it just that you can't get those calories in with a diet that is very, very high in fiber, high volume, nutrient-poor like an unprocessed, not calorie-poor like an unprocessed diet? We need to figure that out, but it stipulates that somehow your body does not recognize the satiety until you've eaten 500 calories more of the ultra-processed diet. This is very key because when we give patients diets that are high in carbs and low in fat, we have to make sure that what kinds of carbs we're giving those patients, because if it's ultra-processed, we really may be setting up a situation where patients cannot keep the weight loss. All right, so having said that, setting realistic goals for your patients, very important with lifestyle. Five to 10% weight loss at six months is considered significant. And this is a symposium all about endoscopic therapies for obesity. So certainly lifestyle is a part of this. It's going to help your patients with the weight loss and also maintaining that weight loss post-endoscopic procedure. All right, let's talk about a few successful lifestyle interventions. All right, so here we have, I have listed for you, very high-intensity lifestyle interventions. Dr. Kushner talked about some of these methods of getting high intensity. High intensity means frequent phone calls, frequent technological interfaces, plus diet and exercise interventions. Look Ahead, DPP, and other studies have shown that you can really get many, many patients to lose greater than 5%, so that's the total bar, and greater than 10% of their weight at a year with intensive lifestyle interventions. But with pharmacotherapy, which Dr. Kaplan's going to talk about next, you can see that you can also do this with maybe less than intense lifestyle interventions. So basically the combination of these therapies can maximize weight loss. All right, so these are studies that looked at intensive lifestyle without pharmacotherapy. The Qing study and the Diabetes Study finished Diabetes Prevention and U.S. Diabetes Prevention Program, DPP. They all took patients who were at risk of type 2 diabetes and obesity, so they had obesity, they had impaired glucose tolerance, and found that with as little as a 5% to 10% weight loss, the average was 7%, that the risk reduction in development of type 2 diabetes was 42, 58, 58%. This was with a sustained weight loss of 5% to 10%. So in the efficacy of 5% to 10% weight loss, this is what you can get with the best intensive lifestyle interventions alone can, was shown to prevent diabetes, increase life expectancy, blood pressure, lipid profile, decrease cancer risk, and more of the anatomic conditions related to obesity, back pain, reflux, arthralgias, and also sleep apnea. And this was all done in a series of studies over the past 20 years or so. Okay, and so again, with the DPP program, you see the diabetes risk reduction, which is dramatic. And, you know, even though the intensive part of DPP and studies like Lookahead ended at a year, you can still get residual benefit several years down the line. And that's what looked at the longer term follow-up studies for Lookahead showed that this is efficacious even though patients start regaining weight because remember that lifestyle needs to be lifelong for patients to maintain a body weight. Okay, so what is the intensive lifestyle change that we're talking about? Beyond instruction, there was a lot of labor intensive work done to help patients maintain and a lot of coaching done to help patients with this. And now as Dr. Kushner mentioned, we are trying to simulate this kind of one-on-one with our technological internet-based therapies. Case managers met with participants for 16 sessions in the first 24 weeks and then every other month individually. So they received instruction, diet, exercise, behavioral modification with goal setting, self-monitoring, problem solving. They did lower, what was the diet? They got a balanced macronutrient content diet with 12 to 1500 calories for women, 15 to 18 for men and lowering fat to less than 25% of intake. They weren't really given specific calorie goals until they failed at the weight loss and then more intensive calorie goals were given. All right, and studies like Lookahead showed that if patients did extremely well at year one, now this Lookahead was followed out to 10 years. Year one, if you got the patients who got more than 10% weight loss at year one compared to those with greater than 5% weight loss, they had a better chance of maintaining that weight loss at year eight. So that's what this bar graph, these two bar graphs show that they looked at the people who did greater than 10% initial weight loss at year one and showed that more of those people were able to keep that weight off at year eight. This is dramatic. So this suggests that if you have patients, you're giving them a lifestyle diet and exercise and they do really well, great. That may be all they need. If they don't, this is where you want to add other interventions, pharmacotherapy and endoscopic procedure, right? That's what this shows us here. But there's a certain cadre of patients who are gonna do well. Do we know who they are up front? We do not, but we have learned a few things from not randomized controlled trials, but registries, which I'll talk about. All right, so the Dacheng study was mainly an exercise study in Asians a while back now and also showed that if you did well, initially you were able to keep a lot of the weight loss from year one out to up to 20 years. This is the beauty of capturing those patients who can do well with a lifestyle intervention. All right, here's the weight loss registry. Now, while this was not a randomized controlled trial, the National Weight Loss Control Registry is a registry of now 10,000 participants and they were all captured by phone call around the country. They had to maintain at least a 50 pound weight loss for at least five years with lifestyle alone, diet and exercise. The average now is maintaining a 66 pound weight loss for five years. By questionnaire, we found that they eat about 1800 calories a day with 27% fat. They perform a lot of exercise, 2700 calories per week. What else do they do? They're vigilant. They weigh themselves daily at 40%, at least about half of them daily, at least a fifth of them weekly. They don't watch a lot of TV. They limit their diet variety. Most eat breakfast. They only go out and eat fast food, ultra processed food max once a week. They're vigilant. Not everybody can be vigilant. We only have 10,000 of these people. Yes, there are more than that, but this is what we've captured. It taught us that there's a certain type of patient who can do this. Others will need more help. All right, so 10 years, they found at questionnaire level 10 years out that if they reduced what they do, they start to regain weight. So if they don't weigh themselves daily or weekly, they start to regain weight. If they don't do the exercise that they usually do, if their exercise decreased by 500 calories a week, they regain nine kilograms, all right? So this tells you what you need to do with lifestyle alone to keep the weight off. You have to be vigilant. Not again, not everybody has that kind of a cognitive vigilance, all right? So there you go. National Weight Loss Registry, those that maintain weight, you gotta continue that exercise. If you decrease activity, you see greater regain. Decreases in dietary restraint, that's very important. Less weight regain. What do we do in terms of our patients? Long-term weight loss, regular support. Frequent patient follow-up is key. The CMS allows for four visits a week covered by CMS. One visit a month, month two to six and seven to 12. If there is a weight loss, one visit a month. So we see our patients every month at least to maintain lifestyle change. Okay, remember initial weight loss predicts ultimate success. If you don't see an initial great weight loss, this is a key that you need. Adjunctive therapy, medications and endoscopic procedures. Adherence, not the diet predicts success. It doesn't matter what kind of diet you put your patient on as long as they can stay on that diet. All right, a bit about exercise. We already talked about it. The more exercise you do, the more the weight is maintained. And this was a study in 2012, looking at two years follow-up. Those who did more exercise were able to maintain more weight loss even though others did as well. But the greater the exercise, the more the weight loss maintenance. All right, so I just want to summarize. I talked about the 2013 obesity guidelines recommending a set number of calories a day, no ideal diet, five to 10% weight loss is the goal for lifestyle alone. The initial weight loss predicts ultimate success. Lifestyle interventions with a strong behavioral component can be successful. So the more intense the lifestyle, the better, as we're gonna see in the next, in the sessions that come after mine, the better the total weight loss is going to be. Thank you so much for your attention.

obesity

lifestyle therapy

BMI

sustained weight loss

calorie intake