In your book you noted that “’stressed’ is ‘desserts’ spelled backwards.” For a clinician who is not specialized in this but is seeing obesity, what are you teaching regarding effective interventions? The first thing that we are trying to impart is that the behavior is the result of the biochemistry. Three examples: If you see a kid who drinks and urinates ten gallons of water a day, the kid’s got diabetes insipidus. Now, he could have a psychogenic issue that causes him to drink that water, but there are 200 cases of DI for each of those. Or you see a twenty-five-year-old who falls asleep in his soup, and you think “narcolepsy,” which we now know is a hormonal issue—again, you infer the biochemistry. Schizophrenia was for a century seen as a behavioral disorder, but we now know it to be a defect in dopamine neurotransmission. So three distinct diseases manifesting as behavioral, but every one is biochemical. Sometimes we’re smart enough to know the biochemistry underlying the behavior, sometimes not. We’re just learning the biochemistry of obesity now, but it’s there, and in our clinic we are translating that into treatment, and that’s why our patients are doing well. You wrote about the “holy grail of the antiobesity pill,” but that such medications have been elusive. Any promising changes? There are three new obesity medications on the market since the book came out. Each is designed to hit a different aspect of the energy balance pathways. The results are mixed, to say the least. I think that obesity is so complex that it’s going to be very difficult to find any magic bullet.
You are skeptical about specific diets—paleo, Atkins, Ornish, etc. The real question is, “Who are you and what is the actual problem? What are your insulin dynamics?” Most doctors don’t know how to assess that, and getting things into clinical practice takes twenty-five years from discovery to practice. And we have some outdated guidelines now. The American Diabetes Association says fasting insulin is not useful, but it tells you insulin resistance, which we need to know. And yes, people were recommending the low-fat diet for decades, but some people gain weight on low-fat diets, as it really means a high-carbohydrate diet, which means lots of glucose and thus lots of insulin. In order to see that in patients, you have to look for it, to do an oral glucose tolerance test, with insulin levels; and you have to draw blood early, and do baseline, 15 minutes, 30 minutes, and nobody does glucose tolerance levels that way. But these things are out there, accessible, and potentially remediable and treatable. But I have to say, doctors just don’t get it, and it’s been really hard to teach this.
In your book you run through all the interventions that are needed but say each is “necessary but insufficient.” Right—you need both personal and societal action. The point is the societal interventions are opposed as being “antiAmerican”—a knee-jerk, libertarian, “Don’t tell me what to eat or smoke or drink.” Which is just bull, as we’ve already been told what to eat and drink by the food and drink industries. The basic argument in my TED talk is, “Where were the libertarians over the last forty years when the whole system was being changed under their noses?” They also say, “I don’t want government in my kitchen” and I agree—unless there is a more destructive force there, which is what we have now. And again, as with tobacco, we have a war to fight—you halfseriously refer to a needed “Occupy Nabisco” battle, but it seems a huge struggle against so much money and power. We need to change the lines of engagement. Obamacare puts 32 million sick people on the rolls and says we can pay for that with preventative services, but there are no proven preventative services here—other than getting rid of the sugar. The data are so robust on this now. In our new study we were flabbergasted by it—it’s all right there. It is amazing, and the best thing I’ve been associated with. Regarding the failed San Francisco soda tax . . . We did great. We got 56 percent approval—that was phenomenal, with the beverage industry spending $10 million to defeat that. I don’t consider that a failure. It will be back. The one thing I have learned is you can’t be impatient.
You seem to be fundamentally optimistic. How do you retain your hope and commitment? Well, I have to remain optimistic or I might just give up on life itself. And again, we are starting to see the ground shift. The FDA and USDA and WHO are making new recommendations that are very big. Mexico and Berkeley got a soda tax. Big businesses and insurers are starting to see obesity as a problem for their bottom lines. People are starting to get the picture. And I went into medicine to try to help people, and this seems to me to be the best way I can help the most people all at the same time.
Why do you think that is—the “old docs, new tricks” dynamic? Yeah, we’ve all been told for our entire careers that “a calorie is a calorie,” but in the SUCRE study we’ve got a slam-dunk showing that’s not true. There are still scientists out there who say a calorie is a calorie—but you have to look at who funds them. There are a lot of researchers and doctors paid off by the food industry, just as there were with tobacco. WWW.SFMS.ORG
MAY 2015 SAN FRANCISCO MEDICINE
17