Cardiologists Zoning In on Weight Loss
The American College of Cardiology's annual conference is one of the biggest medical meetings of the year. This March we headed down to New Orleans to attend the conference, which was held in the same convention center that not too long ago acted as a makeshift hospital for Hurricane Katrina victims – strangely appropriate. We were very grateful to have the opportunity to support the city. But why should we – in the diabetes community – care about what goes on in cardiology? Well, one cardiologist neatly summed it up when he told us "diabetes is really the driving force of this meeting." His statement is an apt reminder, we think, that diabetes is one of the leading risk factors for heart disease. We came away from ACC (as the conference is called) with some great learning about a slightly different perspective toward diabetes management.
The Holy Grail of cardiology is weight loss. At this meeting people seemed to be looking for weight loss everywhere – in generic diabetes medications, in new diabetes medications, in traditional appetite suppressants, in new mechanisms, in surgery, in diet, and in exercise. Obesity, if not diabetes, was truly the enemy here – the stubborn, indefatigable enemy. Doctors repeatedly emphasized that a person doesn't need a huge belt size in order to be obese. You know that big, hard belly that some men have despite thin arms and legs? This physique embodies (so to speak) the most harmful type of obesity. Belly fat (or visceral fat, in medical terminology) turns out to be a lot worse than fat in the arms, legs, or butt. It actually sits among your internal organs and releases harmful hormone and protein signals that interfere with your health. Visceral fat has also been linked to chronic inflammation and insulin resistance. This is why "apple-shaped" obesity is more worrisome than "pear-shaped" obesity, though neither type bodes well for cardiovascular health.
So, have they identified the Holy Grail? Unfortunately, no. But doctors are getting closer. In the diet department, the general consensus seemed to be that Mediterranean diets are the most heart healthy. As for drugs, different weight loss agents work differently in different people. This complicates the issue for doctors trying to prescribe a pill for weight loss. For example, anecdotally doctors told us that appetite suppressants (like Abbott's Meridia) don't work well in people who stress-eat or graze, because they're not eating out of hunger. Orlistat (brand name Xenical) suppresses fat absorption, which, depending on the patient, can either mean it's best with a low-fat diet (which minimizes the side effects that come from having undigested fat in the colon) or a high-fat diet (because more fat means less calories being absorbed).
There was some excitement for a new anti-obesity drug called rimonabant, which is already available in Europe (brand name Acomplia) but has not yet been approved in the U.S. The FDA is having an expert panel meeting about rimonabant on June 13 – it's pretty controversial because it's been associated with depression and anxiety in clinical trials. We'll cover the meeting and will let you know what happens! Trial results clearly show that Acomplia does seem to work to reduce cardiovascular risk factors in some people, and may attack visceral fat first, which would be excellent. Interestingly, doctors in the diabetes community seem to find the depression side effect more worrisome than doctors in the cardiology community, based on a few conversations we had (granted, only a few!) – possibly because diabetologists are more likely to think of weight-loss drugs as preventive measures than cardiologists are, and preventive drugs should not cause one disease while preventing another. It may also be that depression is a particularly bad add-on to diabetes – it's certainly more common among diabetes patients – making diabetologists more wary about adding any additional psychiatric burden to their patients.
Cardiologists seem to talk a lot more about diet and exercise than diabetologists do. To us, the phrase "diet and exercise" just seems a little depressing by now since so many of us have the urge, but so few of us can come up with the necessary changes for our lifestyles! The problem with debating the best forms of diet and exercise is that we all already know ways we can improve our health with lifestyle and we just don't do them! ACK! So, here's the key: Sustainability is a huge factor in what the best diet is or what the best form of exercise is. Over 95% of people who lose weight on a diet gain it back.
The most interesting difference between a low-fat and a low-carb diet isn't the weight loss at six months, but how long people can maintain weight loss longer term. In a 2005 article by Dr. Dansinger and colleagues in the Journal of the American Medical Association, there was no difference in weight loss or cardiovascular risk reduction after one year between the Atkins, Ornish, Weight Watchers, and Zone diets. However, there were differences in how many people completed the study. Only about half of the people on Atkins or Ornish diets finished the trial, while 65% of those on Weight Watchers or Zone diets did. The Atkins low-carb diet does tend to do very well at six months – in several studies producing the best weight loss results – but it is not quite as superior at one year, and it also seems especially difficult to stick to. The bottom line from Dr. Lawrence Sperling of the Emory Heart Center: Restrictive dietary approaches are unlikely to be sustained long term, so a really gradual caloric deficit is the way to go, just training yourself to eat less and less. In exercise, the bottom line is similar. Unstructured activity (increasing activity on your own) is just as effective as structured activity (exercising at a fitness center) for weight loss, but is more sustainable after two years.
Our bodies have many mechanisms for accumulating weight, which make it much easier to gain weight than to lose it. This may be due to humans' early evolutionary environment, where food was scarce and it was much harder to gain weight than it is today. Our bodies evolved to readily store fat for future use and to conserve energy in times of famine. Some of the doctors at the ACC thought that the best way to combine weight loss drugs and lifestyle changes was to lose weight by diet and exercise and then to keep it off with the help of medications.
The weight-loss medications that cardiologists focus on are orlistat (Roche's Xenical, soon to be available over-the-counter as GlaxoSmithKline's Alli), sibutramine (Abbott's Meridia), and phentermine (available generically). It seems that doctors, educators, and nurses who focus on diabetes (as opposed to cardiologists) are more open to injected medications, like exenatide (trade name Byetta) or pramlintide (trade name Symlin), which have produced tremendous weight loss in some diabetes patients. In a way, we were surprised that these drugs were so little mentioned at ACC given the emphasis on weight loss. On the other hand, they don't seem to fall in the cardiology community's traditional treatment arsenal of oral drugs. Your diabetes team may be a lot more comfortable with injected medications, so you might want to ask them about trying new drugs to see if you can improve your glycemic control with the addition of a new medication – and lose a few pounds in the process as well. Just don't forget – as a cardiologist might say – that any weight loss drug works best as an adjunct to diet and exercise. As always, we urge you to check with your doctors if you are looking to improve your diabetes – and we stress that now is a great time for that talk, with all the new therapies as new possibilities!
Kelly Close is Editor-in-Chief of diaTribe, an electronic newsletter that helps people learn about new ways to manage diabetes better. diaTribe focuses on new drugs, devices and research. diaTribe is free and available online at www.diatribe.us.
NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.
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James Joyce said that “mistakes are the portals of discovery.” I wonder if insulin levels have been our mistake. Could it be that this hellish week of blood sugars were somehow meant to be? Drastic times call for drastic measures, right? Maybe we were too afraid in the past to take the plunge into drastic measures. Maybe this is oddly what we needed. We had to be truly frightened in order to make bigger, bolder changes. ...