August 29, 2025 • 35 mins
Proteus was a Greek sea god who could change his form, much like obesity is able to in the body. Doctors Michael Koren, Victoria Helow, and Michael Bernhardt come together in front of a live audience for a discussion on the myriad effects obesity has in and on the body. The doctors move through how excess weight affects the heart, skin, inflammatory systems, and more. They also explain that even when obesity doesn't directly cause a disease is can make other diseases worse. Join these three physician experts to learn why obesity matters
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcement (00:00):
Welcome to the MedEvidence podcast.
This episode is a rebroadcastfrom a live MedEvidence
presentation.
Dr. Michael Koren (00:07):
Okay, well, thank you very much everybody,
and thank you for Dr.
Helow for jumping in.
I was very impressed by thenumber of people who've been
involved in research before.
Thank you again.
Our hearts out to you, becauseyou are the people that make a
difference, you're the peoplethat advance medicine, and Dr
Hilo and I have been doing thisfor quite a while, and Dr.
Helow and I have been doingthis for quite a while, and Dr.
Helow has been amazing to justjump in.
(00:27):
So this originally was going tobe a discussion between me and
one of my colleagues, MicaiahJones, who's a fellow
cardiologist, and unfortunatelyMicaiah called me yesterday and
said that he was not going to beable to make it because he had
to cover the hospital for heartattacks Because the guy that was
supposed to cover the hospitalfor heart attacks had an
out-of-town emergency.
(00:48):
So this is the real world ofmedicine and we are real doctors
.
Just so you know, we do seepatients.
We are real doctors and part ofour goal is to bridge the gap
between scientific research andreal medicine, because we are
real doctors and we do bothscientific research and real
medicine, because we are realdoctors and we do both.
(01:09):
Dr.
Helow, Victoria Helow is apediatrician, adolescent
medicine specialist, works theERs seeing sick kids and
teenagers, and she's also beenan amazing researcher over the
course of the past 20 years now,and so it's always a pleasure
for us to do a program together.
But she's kind of jumping in onsomething that we all deal with
in all of our specialties,which is obesity.
So, although we wanted to focuson the cardiovascular elements
(01:33):
of obesity because Dr.
Jones isn't here and you'rehere, and I think Dr.
Bernhardt, who's adermatologist, will join us
we're going to talk a little bitmore about the protean
manifestations of obesity.
Dr. Victoria Helow (01:45):
All of them
Dr. Michael Koren (01:45):
Yeah.
So thanks for being part ofthis, vicky, sure, sure.
So let's just jump right in.
So, as you know, we do notbelieve in a free lunch here at
WJCT.
We believe you have to work foryour lunch, and so I'm just
(02:06):
curious before I get into thefirst question when you heard
this advertised as the proteanmanifestations, did that make
you more interested in thislecture?
Yes, did it make you lessinterested in the lecture?
Okay, all right.
So we're going to start withprotean.
So have you heard of the wordprotean?
A (02:19):
No.
B (02:22):
I learned it for 10 minutes when I studied for the SATs.
C (02:26):
of course, I've heard of it, but have no idea what it means.
D (02:32):
I have a feeling I'm going to learn the meaning of the word
during this lecture.
Or E (02:38):
isn't it a typo for the word protein?
Okay, so there's really noright answer here, but I was
just curious to see how peoplereacted to this.
It is a word we use in medicineand it's actually a great word,
and let's jump into it a littlebit more in terms of the fact
that obesity is something thathas protean manifestation.
(02:58):
So, Vicky, you can just giveeverybody a little bit of a
sense for all the elements ofobesity and stuff that you deal
with in your practice and whenyou see people in the ER.
Dr. Victoria Helow (03:07):
So protean, as this shows, is, in other
words, all of the possibleconsequences of that condition,
and, as we know, obesity iscomplex and it can have a lot of
consequences.
We were originally going to do,as he said, the cardiovascular
consequences, and we all know,though, it increases your risk
(03:28):
of stroke, increases your riskof heart attack, increases your
risk of kidney disease.
It's obviously a psychologicalcondition as well, especially in
this.
You know society and all of themanifestations of Facebook, etc
.
What you're supposed to be,skinny and active, etc.
It can create all of that and,like I said, the cardiovascular
(03:50):
ones.
And one of the big things thatwe talk about now, as we're
beginning to understand obesity,is obesity increases the risk
of inflammation throughout yourbody, so anything that can be
complicated by inflammationwhich is everything, is
complicated, more complicated inthe obese individual.
And that's crucial.
Dr. Michael Koren (04:11):
Yeah.
So getting to the protean word,there's a picture here and that
guy's clearly not obese.
He has a six-pack going onthere.
He's a pretty impressive guy
Dr. Victoria Helow (04:23):
-Eight-pack!
Dr. Michael Koren (04:23):
Eight-pack.
Yeah, maybe an eight-pack, butthis is actually where the word
protean comes from.
So it's actually of Greekorigin and it comes from Proteus
, who is a Greek sea god who canchange his shape at will.
So obesity is one of thosethings that can change and have
many, many differentmanifestations, and so what it
(04:46):
means in the English language isdisplaying great diversity or
variety.
So when we talk about theprotean manifestations of any
disease, these are diseases thatpresent with great diversity or
variety.
All right, next question whatis the formal definition of
obesity?
A (05:05):
the inability to fit into your wedding dress.
B (05:09):
the ability to rest a beer can on your belly.
C (05:14):
20% or more above the upper limit of healthy body mass index
.
D (05:22):
that uncomfortable pause after someone asks does this
make me look fat?
Or E (05:29):
clothes with horizontal stripes that don't flatter
Dr. Victoria Helow (05:35):
Still don't flatter.
Dr. Michael Koren (05:37):
So what's the answer, Vicky?
Dr. Victoria Helow (05:39):
20% or more above the upper limit of a
healthy BMI.
Dr. Michael Koren (05:43):
So, moving on the growing prevalence of
obesity Among affluent nations,the US has the highest obesity
rate, affecting approximately42% of the population
Dr. Victoria Helow (05:53):
42%!
Dr. Michael Koren (05:54):
I'll tell you what the rest of the world is
catching up.
Yes, so I've had some recenttrips to India.
A lot of obese people in Indianow
Dr. Victoria Helow (06:04):
Again, that's a sign of affluence.
So they encourage that,especially in the females.
So interesting.
Dr. Michael Koren (06:12):
In May I was in Saudi Arabia and Morocco.
More and more obese peoplethere.
In Morocco there were threeMcDonald's restaurants within
walking distance of my hotel.
Dr. Victoria Helow (06:24):
Sad, is that unbelievable Sad?
Dr. Michael Koren (06:26):
Well, again, it depends on what you eat there
.
No one's forcing you to eatthere or what you choose to eat
once you go there, but this is aphenomenon that's affecting the
rest of the world as well.
Obesity-related deaths fromischemic heart disease increased
threefold from 1999 to 2020 inthe United States, but that's
pretty significant, and theWorld Obesity Federation
(06:48):
predicts obesity will affect 1billion people globally in 2030,
one in five women and one inseven men.
Dr. Victoria Helow (06:55):
And again, being a pediatrician, this has
been a huge issue in thepediatric realm.
The ages are getting youngerand younger and younger.
Dr. Michael Koren (07:04):
What percent of the people who you see, say
during a typical emergency roomouting, would you say, are
people who are overweight, andthese are people all 18 or less,
I assume, right.
Dr. Victoria Helow (07:15):
Yes, I would venture to say truly, in
pediatrics it's pushing that 30%.
I see again, depending on whichER I'm working in, I can see
higher than that 30% and some ofthe ERs may be a little bit
lower depending on thedemographics.
Dr. Michael Koren (07:32):
Interesting and that's the obesity paradox
that you're alluding to is thatobesity in the United States is
actually a marker of poverty,and that was not the case 100
years ago.
100 years ago, wealthy peopleoverweight because they indulge
themselves in rich foods, andnow it's the opposite.
Dr. Victoria Helow (07:50):
Because the higher calorie foods are cheaper
.
Dr. Michael Koren (07:53):
So the dual role of adipose tissue in
disease.
So adipose tissue causes healthcomplications in two distinct
ways.
One, it initiates harm throughchronic inflammation and insulin
resistance, and you mentionedthat We've done a lot of
discussions about this conceptof inflammation and elements of
our day-to-day lives thattrigger inflammatory responses,
(08:16):
which have multiple negativeconsequences.
Then it also exacerbates orworsens existing health
conditions, making them harderto manage.
So there's some mention aboutthe COVID booster study that
we're doing here in northeastFlorida.
It's actually a really excitingstudy that's running at three
different locations in northeastFlorida in the Fleming Island
(08:37):
area, on the west side, on thesouth side.
It's funded, as mentioned, byBARDA, which is part of the
Department of Defense,specifically for bioterrorism
preparation.
A lot of concerns about that,but the point that's really
important here is that beingoverweight doesn't make it more
likely that you're going to getCOVID, but it makes it more
(08:59):
likely to get really sick whenyou get COVID
Dr. Victoria Helow (09:01):
Right.
Dr. Michael Koren (09:02):
So that's this concept of exacerbating an
illness.
Okay, adipocytes and obesity.
Adipocytes are actually cellsin your body that are designed
to hold onto fat.
So fat is something we actuallyneed, right, obviously, if too
much of a good thing is not good, but we actually need fat, and
(09:23):
fat is a source of energy forour bodies and it's the way our
bodies store energy.
And if you look at the historyof mankind, we probably needed
our fat stores a lot morethousands of years ago, when we
didn't have as much to eat andwe needed to have a place where,
when we had a big meal, wecould store some of that energy.
Dr. Victoria Helow (09:42):
For the times when we didn't have a meal
and starvation times.
Dr. Michael Koren (09:45):
Exactly, but that's of course with the ready
availability of food these dayshas become something that's now
a liability rather thansomething that gives us an
advantage.
So the adipocytes increase therelease of free fatty acids into
the circulation, which is oneof the chemicals that promotes
inflammation and fibrosis intissues.
Hormones from the adipocytesinterfere with normal
(10:08):
anti-inflammatory and protectiveeffects, and adipocytes
activate immune cells, whichfurther fuels inflammation and
tissue remodeling and also ourability to fight infection.
So when you have immune cellsthat are just promoting
inflammation, they may not be onthe ready for actually fighting
infections as well as theyshould.
Dr. Victoria Helow (10:30):
Yeah, but I just wanted to give a little
explanation of adipocytes ingeneral.
And basically they are kind oflike gas tanks in our body, and
when we fill our car with gasand we don't use that gas,
imagine if it just had a ton ofgas tanks on it.
We would just keep fillingthose and if each one could
(10:50):
expand, it would just sit there.
And that's kind of what happensto us when we take in gasoline
for our body.
And gasoline for our body iscarbohydrates.
And I think it's an importantpoint, because part of what
we're doing with all of this fatphobic zero, zero fat.
A hundred calorie items, it'sjust a hundred calories of
(11:11):
carbohydrate that your body'sgoing to store.
It's worse for you than if youate 100 calories of good fats,
Dr. Michael Koren (11:16):
Right.
very important point.
Dr. Victoria Helow (11:18):
Yeah just yeah, just something to think
about when trying to do somedietary management
Dr. Michael Koren (11:24):
Yeah, so you don't have to eat fat to be fat
or to get fat into theadipocytes.
Your body will make fat out ofany energy source, which is most
commonly carbohydrates.
So I don't know if you want tocomment on all of that.
Dr. Victoria Helow (11:38):
So all of you know obesity we talked about
.
It ends up affecting everything.
So sleep apnea is.
You know, just the simple fatbeing here can end up leading to
sleep apnea.
Obviously, lung diseases areagain.
Lung diseases are primarily aninflammatory problem.
Also, your lungs require arethere so you can increase the
(12:01):
oxygen to your body parts.
Well, if your body is excessweight, you're going to increase
the demands of the lung even ifyou don't have the inflammatory
components.
So it's double and triple theeffects of the negative things.
Stroke we talked about theinflammatory things that you get
in the vessels because of this.
You know these inflammatorymarkers running around.
(12:22):
Same thing with heart disease,liver disease.
We have article, we have awhole book back there put out by
MedEvidence, on fatty liverdisease, which is known as NASH
or MASH.
Non-alcoholic steato hepatitis.
Steato- is fat and thehepatitis you literally -itis on
the end of the word meansinflammation.
(12:43):
So you literally get liverinflammation because of all this
fat sitting in there as it'sbeing stored.
And then, as fat sits there andit causes inflammation, then
causes scarring.
And then, as fat sits there andit causes inflammation, then
causes scarring.
So you literally can getcirrhosis of the liver by being
too fat and never drink a dropof alcohol in your life.
Dr. Michael Koren (13:02):
So the research office.
We cover all these areas.
So show of hands.
You see all these diagnoses onthis chart.
Who in the room has at leastone of those concerns?
So, like virtually everybody.
So that's really the importanttake-home message is that
obesity makes all these thingsworse, and there's a lot of
(13:25):
interest and research aboutdealing with obesity and
hopefully making these thingsbetter, and that's what we do
day to day.
So let's jump in.
It's a little bit about obesitywith cardiovascular disease and
that was going to be ourprimary focus today.
But again, thank you forjumping in and bringing some of
these other really importantpoints into the discussion.
But we know from the cardiologyworld that obesity is a strong
(13:47):
risk factor for other conditionsthat independently contribute
to congestive heart failure.
So one of the major ones thatwe deal with is high blood
pressure, and you probably havea little bit of exposure to high
blood pressure in your patientpopulation.
But I see this all the time andit's so interesting.
When people lose weight, it'svery common that we actually
(14:08):
reduce the number and dose oftheir medications to the point
where we have some people thatactually get off of all their
blood pressure medications whenwe get them down to a normal
body weight.
Dr Bernhardt, they are.
Dr. Michael Bernhardt (14:21):
All right , nice to see you.
Thanks for joining us.
Dr. Michael Koren (14:25):
Dr Bernhardt is an extraordinary
dermatologist who's also goingto talk to us about some of
those manifestations, but we'llgive him a second to catch his
breath.
I know he just got in fromclinic and we do appreciate he's
also been a fabulous clinicalinvestigator that's running
studies on acne vaccine as wespeak Some really cool stuff,
but we'll get into that in asecond.
But anyhow, getting back toobesity, when you're overweight
(14:47):
your blood pressure is higher.
When you lose weight, yourblood pressure comes down.
Blood pressure is the forceagainst which your heart has to
work.
Higher the blood pressure, moreheart work, More heart work,
worse heart performance.
So that's one way to thinkabout it.
Type 2 diabetes it causes anumber of things, including this
(15:11):
concept of diabeticcardiomyopathy.
So you've heard of heartattacks, of course.
Well, that's when the big bloodvessels to the heart get
blocked up.
But when the little bloodvessels get blocked up, it has
all these little, what we callmicro infarcts and although your
heart looks like it's workingokay, it's really not
functioning the way it shouldand sometimes it has a real hard
time with relaxation, whichleads to accumulation of fluid
and breathing problems.
(15:31):
Dyslipidemia.
My favorite topic ischolesterol issues and, of
course, when you're overweight,you're much more likely to have
higher cholesterol, particularlytriglycerides.
Triglycerides are really drivenby this carbohydrate craze that
we have in this country andit's less of an effect, but it
(15:52):
also affects LDL cholesterol.
It doesn't affectlipoprotein(a) very much, which
is your little favorite subjectto talk about
But there are a lot of dietaryelements to cholesterol issue,
but not all of them, and that'swhy you really need to talk to
an expert, because some peoplesay, oh, I'm just going to
change my diet and everything isgoing to turn out right.
(16:12):
Well, you can starve yourselfand you'll still have a high
Lp(a).
Dr. Victoria Helow (16:16):
Yes, and therefore a high LDL.
Dr. Michael Koren (16:19):
Right, but if you starve yourself, chances
are your triglycerides will benormal.
Dr. Michael Bernhardt (16:23):
Deal.
I used to run marathons back inthe day when I was about 30
pounds lighter.
Dr. Michael Koren (16:27):
Well, you just ran one to get here today.
Dr. Michael Bernhardt (16:29):
Well, yeah, because my GPS had me
going around the stadium and soit took me on.
Dr. Michael Koren (16:33):
Yeah, he caught a few plays of the
Jaguars practice.
Yeah.
Dr. Michael Bernhardt (16:37):
But I used to do long-distance running
for about 25, 30 years and Ithought I was bulletproof
because I was doing banking 80,90-mile weeks and nope, the
numbers were still high.
Dr. Michael Koren (16:48):
Yeah, another area that we've worked on as a
research group is sleep apnea,and you're probably familiar
with that.
It's normally when you stopbreathing for a period of time
and everybody does that.
Dr Rothstein, Mitch Rothstein,did a fabulous lecture, really a
master series lecture on thisrecently
Dr. Victoria Helow (17:04):
-t hat you can look up-
Dr. Michael Koren (17:05):
yeah, which is online, check it out.
It's on MedEvidence.
But some degree of sleep apneais kind of normal.
But when that becomes excessive.
it leads to cardiovascularcomplications, most commonly
atrial fibrillation, but alsoworsening of congestive heart
failure and an increase in bloodpressure.
(17:25):
All right, so perfect timingthe skin side of obesity.
So, Mike, several skinconditions are commonly
associated with obesity due tochanges in hormones,
inflammation, increased skinfolds and impaired skin barrier
function.
So the stage is yours, myfriend.
Dr. Michael Bernhardt (17:39):
Thank you , you know.
It's interesting because someof these things are actually
associated with elevated fasting.
Not glucose, but the insulin.
Elevated.
Yes, A lot of these people havehyperinsulinemia and I've
started checking some of my HSpatients, my acanthosis and
agaric cancer patients.
Dr. Michael Koren (17:58):
Yeah, explain that to people, because we're
doing an HS study.
Dr. Michael Bernhardt (18:00):
Okay, yeah, this is kind of
interesting because HShydradenitis we call it HS for
short is one of my areas.
Dr. Michael Koren (18:08):
It's right here on the slide, if you see it
right there.
Dr. Michael Bernhardt (18:10):
Yeah, it's one of my areas of
excessive interest becausebefore I came back to
Jacksonville I was helping onthe dermatology residency clinic
in Tallahassee.
So we were getting a lot of theend-stage referrals and we were
seeing about, well, about fiveto seven really bad hydradenitis
patients per day.
And what happens inhydradenitis?
It's frequently misdiagnosed asquote-unquote boils.
(18:33):
So people will get boilstypically in the areas of fusion
plan on the body the inguinalcrease, the axillary crease, the
inframammary crease and they'llcome and go, remit and resolve,
remit and resolve and typicallystarts early to mid-teens and
as a rule it goes about eight toten years before the person's
(18:54):
properly diagnosed.
The patient will bounce fromurgent care to urgent care to
urgent care and then wind upeither in a primary care office
or a derm office.
That's savvy to what's going onand then they'll get the
electron on hydradenitis.
We know that a lot of thesepeople have elevated fasting
(19:19):
insulin levels,hyperinsulinemia, which is tied
in to the whole Obesity cascadeis one of the driving forces not
just of hydradenitis but alsoacanthosis and agaricans.
We see that patients withpsoriasis usually are 100
kilograms.
So obesity is part and parcel-
Dr. Michael Koren (19:36):
-100 kilograms is 220 pounds.
Dr. Michael Bernhardt (19:39):
Yeah.
So you know, for years wealways thought that this whole
conundrum was kind of a sidebar.
And then some really smartresearchers, particularly a
group up in Howard University,started putting all this
together, and a researcher atPenn, Joel Gelfand, started
putting this whole metabolicsyndrome, as it affiliates to
(20:02):
skin, together and what we foundis that fat cells are called
adipose cells right, and thereare amazing little cells because
they're pluripotent, they cankind of transform into multiple
different cell types and theysecrete all sorts of
inflammatory triggers.
Dr. Victoria Helow (20:20):
We talked about it a little while ago in
the adipose.
When we talked about that.
Dr. Michael Bernhardt (20:23):
Right Adipose cells.
They secrete interleukin-17.
Interleukin-17 is one of thelittle Ferraris, shall we say,
that drives a lot of theseinflammatory cascades.
Dr. Michael Koren (20:34):
And Vicky used the metaphor of cars, so
you guys are on the same pagehere, because it's boom Of
course you're talking Ferrarisand she was talking Teslas, or
Kias Kias.
Dr. Michael Bernhardt (20:46):
I've been watching a lot of Magnum lately
.
I've been hooked on these.
Ferrari things.
But it's a fast driver.
So interleukin-17 getstransformed, the adipose cell
gets worked on by tissuemacrophages, which drives
release of interleukin-17, TNFand those are the inflammatory
mediators that drive HS and alsopsoriasis.
(21:06):
So that there's been studiesthat have been done,
particularly in Europe, wherepeople have lost significant
body mass.
A lot of times they don't needmedication.
Dr. Michael Koren (21:14):
That's great.
I love that, and we'll talkmore about that, because we do
have studies that are looking atthat as we speak.
Dr. Victoria Helow (21:19):
And I can tell you that in the emergency
room we do see a lot of thehydradenitis patients and they
are many times diagnosed asboils and many times people have
actually opened these up to tryto drain them out and given
them volumes of antibiotics andit's not an infectious problem.
Dr. Michael Bernhardt (21:36):
Yeah, so antibiotics are helpful.
Tetracyclines downregulate someinflammatory meters, but really
over the short term they'reBand-Aids and patients really
need to be on more aggressivetherapy.
Dr. Michael Koren (21:55):
So we don't do animal studies here in our
clinics.
We're only about humans.
But there is a lot of things wecan learn from these animal
models, including mice models,which is the most common model
that people use when they lookat things scientifically.
And what's interesting is thateverything we're saying has been
documented in mice, and there'sactually studies where we force
feed different species and thesame bad things happen.
So mice and other animals canactually develop congestive
(22:17):
heart failure based onovereating.
And here we have this.
I don't know if that's a Kitkatbar, what it is that mice are
eating.
Dr. Victoria Helow (22:25):
Chocolate bananas.
Dr. Michael Koren (22:26):
The reason I say kit-kat bar is because this
is how mice can get back at thecats that chase them by eating
the kit-kat bar Anyway Payback,and then, in obesity-prone rats,
a high-fat diet for just 12months leads to metabolic
syndrome and progression of thisheart failure.
H-f-p-e-f stands for heartfailure with preserved ejection
(22:48):
fraction, and that's thatdiabetic cardiomyopathy that we
were just talking about.
We have these little microinfarcts, even though your heart
looks like it's pumpingnormally, it's really not
because the relaxation functionsare impaired.
The American Heart Associationstill debates with people about
should we focus on fats, gramsof fats or just calories?
Dr. Victoria Helow (23:06):
Calories, just healthy foods, real food.
Dr. Michael Koren (23:10):
There you go All right back to audience
questions.
So all of the below aremedically accepted methods to
lose weight, except A (23:17):
calorie restrictive diets.
B (23:22):
bariatric surgery such as a partial gastric bypass.
C (23:28):
medications such as approved classes like
opioid-antidepressant combos,fat blockers and GLP-1s.
D (23:37):
the Ronco binge-eating cleansing diet of popcorn,
colonics and moonshine, orintensive physical activity
program with standard meals.
Dr. Michael Bernhardt (23:48):
I didn't realize.
Moonshine helped you loseweight.
Dr. Michael Koren (23:51):
You haven't been on the Internet lately, no,
so of course the answer is D.
It's not been medicallyaccepted, but do you want to
jump in and just talk aboutthese different ways of losing
weight?
Dr. Victoria Helow (24:03):
Yeah, so you know we have some again
publications back there thattalk about the whole obesity
problem and using calorierestrictive diets.
And you know it meansrestricting your calories.
In certain ways it doesn't meanno calories, it means being
careful with what you eat.
And we had a fabulouspresentation yesterday of a
(24:23):
horrible kidney disease calledpolycystic kidney disease and
then expert from Mayo Clinic wastalking about restricting the
diet by only 10% of yourcalories helped with this
genetic problem that isaggravated by obesity.
So anything that you can do tohelp decrease the fat is going
to help, even like 10%.
(24:44):
Not having seconds decreasingyour portions, the bariatric
surgery what that's doing isbypassing the part of the
intestinal tract that rapidlyabsorbs your sugars so that it
takes a little longer to absorbthose sugars Can in fact help
you with not having so many ofthose bioavailable so quickly.
And of course, we know that themedications have been very
(25:06):
successful.
We've done lots of researchfrom the beginning on these
ozempic et cetera type ofmedications.
We have many active studiesright now looking at these
medications that are proven tobe safe, proven to be effective,
and now we're using them indifferent combinations with
patients with heart failure.
Hey, if we can help them losesome weight, help normalize some
(25:29):
of their insulin issues.
Would it also prove to behelpful for their heart failure?
The obvious answer would be yes.
So we have studies that arelooking at that so that then
people can be prescribed thesebecause of these conditions, not
necessarily just diabetes,which is what the original
intention was.
We need to prove that they infact have an effect on heart
(25:50):
failure and, um, you know, othersituations that are affected by
the obesity issues.
And intensive physical therapyprogram with standard meals,
even a just a physical therapy,a physical activity program in
general, with, again, standardmeals.
And a standard meal is awell-balanced meal Doesn't mean
(26:10):
just cutting out the fats orjust cutting out the
carbohydrates or reducing those.
We need all of those things inour diet but they need to be on
a proper timing, which we knowwhen you eat your meals and how
you eat your meals.
And again, it's in some of ourliterature about eat your
protein first, then yourcarbohydrates, partly that
bariatric surgery it doesn'tgive you that sugar load
(26:31):
immediately absorbed et cetera.
So all of those can beeffective and little bits of
each can help.
Dr. Michael Koren (26:39):
Yeah, so everything but D has been proven
to work in scientific studies,and what's interesting, though,
is that the GLP-1s are gettingall the attention these days,
and they get the attentionbecause they're really effective
.
Yes, and they also have beenshown to actually improve
cardiac parameters and otherparameters, and just a couple of
(27:02):
historical things.
So when I was doing myresidency at Cornell, there was
a guy named Lou Aroni who becamea very famous diet person, and
he actually brought people intothe hospital and confined them.
We were doing this in aconfinement unit in the hospital
, where they can only get 400calories a day-
Dr. Victoria Helow (27:22):
-not enough.
Dr. Michael Koren (27:23):
And that was the first to show yeah, if you
give people only 400 calories aday, they will lose weight.
Unfortunately, when they leavethey tend to not eat only 400
calories a day.
And I remember they had allthese shakes and whatnot to try
to get people to just eat onemeal, and then the shakes that
were low-calorie.
So that works, but you got tostick with it.
Gastric bypasses and thingslike that work, and that was, I
(27:45):
remember when we first came totown.
There was a lot of surgeonsthat actually had abandoned
their general surgery practice,just to do bariatrics because it
was working and then movingdown.
as you mentioned, at the end ofthe day, it's calories in versus
calories out.
Dr. Victoria Helow (27:59):
Gasoline in usage out.
Dr. Michael Koren (28:01):
Right.
So if you're like Mike andrunning 80 miles a week and you
just ate your 1,200 or 1,800calories, you're going to lose
weight.
And then, of course, as Imentioned, we have lots of drugs
, and the really interestingthing about the drugs,
particularly GLP-1s, is welearned about them by accident.
Interesting.
About 20 years ago, the FDA gotconcerned that drugs that were
(28:24):
being developed for diabetescould have adverse effects on
the heart.
So the FDA in its wisdom saidokay, if you get a drug approved
for diabetes, you have to dostudies with cardiologists to
show they're safe for the heart.
(28:45):
So starting around 2006, 2008,our center started doing those
studies just to show that theywere safe, and we actually
worked with Ozempic back thenSmaglutide is the generic name
of it and we were blown away.
So of course we put people onthese drugs that were for
diabetes.
They weren't even for weightloss.
Then they were just to controlthe glucose.
And they're on it and peopleare losing weight and they're
getting excited about that.
Dr. Victoria Helow (29:04):
Their heart's getting better
Dr. Michael Koren (29:05):
And their blood pressure's going down and
their cholesterol's gettingbetter, and then when we start
to look at whether or not theyhave heart attacks, there's a
20% to 30% reduction in heartattacks in the people that are
taking these drugs.
Dr. Michael Bernhardt (29:15):
Whoa.
Dr. Michael Koren (29:17):
And that was all by accident.
So now GLP-1s are actuallyconsidered a standard of care
for congestive heart failure,and it started out as a diabetes
drug that we were worried mightnot be safe for the heart.
So this just shows you howresearch progresses and how we
learn, and we learn because ofpeople like you that get
involved in these programs.
So thank you for that.
Dr. Victoria Helow (29:44):
So the GLP works because basically it's
acting like a normal hormonethat we have in our body that
helps control our sugar levels.
So that's an important point.
We're not trying to dosomething abnormal to the body,
we're just trying to help thebody work in its normal way.
And so they help with theinsulin release because,
although some problems arehyperinsulinemia, we know that
an obesity issue many times isnot an adequate insulin release,
(30:06):
and I explained to you beforethat insulin is what takes that
sugar that's in your bloodstream, those calories that you ate,
and puts them into the cells sothat the cells can be energized
to do whatever their job is,whether it's a muscle or a heart
or lung.
Dr. Michael Koren (30:22):
And this is the key box right here, just to
highlight for the audience howGLP-1 activation affects our
bodies.
So really remarkable.
And to Vicky's point, it's justmimicking what our bodies are
supposed to do, so we have anaudience question here.
The use of GLP-1 drugs such asOzempic and Manjaro has led to
(30:42):
the following in researchprograms Okay A: the side effect
of weight loss.
I talked about these originallydiabetes drugs.
B (30:52):
the side effect of reduced heart disease and blood pressure
.
C (30:55):
the side effect of improved skin conditions.
D (30:59):
the side effect of reduced compulsive behavior in
preliminary studies.
That's really interesting.
Or E (31:06):
all the above protean manifestations?
Yes, sounds like all the aboveto me.
Yeah absolutely all the abovefor sure, so I don't know if you
just want to.
You mentioned actually alreadythat there were studies showing
that when people lose weighttheir skin conditions get better
, and I'll just mention.
I think we covered everythingelse.
But we're finding that thesedrugs actually help people that
(31:28):
have problems with alcohol, thatthe urge for alcohol goes away
when you activate the incretins,the GLP-1 and the GIP systems.
So again, these are mechanismsin our body that are supposed to
be functioning that sometimesneed a little help, and the
GLP-1 agonists, like unzippingand Manjaro, help activate those
systems.
(31:48):
That help us in many ways.
Dr. Victoria Helow (31:50):
Just normalizing all of these complex
interactions.
Dr. Michael Koren (31:54):
And then I'll just jump in and just let
people know that the issue ofcongestive heart failure is a
growing issue and there are 6.7million Americans over the age
of 20 who are now living withheart failure and this number is
anticipated to rise.
So Americans have about a 24%lifetime risk of developing
heart failure, so they'll affectone in four people.
(32:15):
More than 50% of heart failurepatients have heart failure with
a preserved ejection fraction.
And again, there are twoflavors of heart failure One
where the heart muscle is notcontracting like it should and
that typically happens after aheart attack.
Or the flavor where the heartmuscle gets thickened and
becomes dysfunctional because ofthese little microinfarcs and
the effects of diabetes andmetabolic syndrome and it leads
(32:37):
to higher pressures in the heartwhich goes back into the lungs.
That causes edema in the lungsand problems with breathing.
So you're just as likely to endup in the hospital if your
heart muscle function ispreserved versus reduced, which
is an important point.
And, as mentioned, heartfailure is very, very common.
It's the most common hospitaladmission after age 50 and
(33:00):
probably the third most common.
I think childbirth is still themost common and probably the
third most common.
I think childbirth is still themost common, but it's very,
very common in people over 50.
And it's 9.3% of the hospitalvisits in the United States.
So we talked about this, Ithink, pretty well at this point
.
Weight loss is effective in alot of ways, particularly for
people with heart disease Imentioned.
(33:23):
Blood pressure comes down, yourheart's function goes up
because of reduced inflammationand better utilization of
glucose and insulin, and it justlets work for your heart.
So if your heart is a littlebit impaired from a previous
heart attack and you got to move200 pounds around, that's
harder than moving 160 poundsaround, simple as that.
So there are very, verypractical reasons why we
(33:46):
strongly advise weight loss inpeople that have any history of
heart disease, particularlyheart failure.
And this gets into the viciouscycle that you see that when you
have a heart problem, youreduce your activity.
You reduce your activity andI'm just starting from here and
moving along you reduce youractivity and then you're more
likely to get overweight.
You're overweight, the work ofthe heart goes up.
(34:07):
Heart failure worsens as thework of the heart goes up.
Obesity reduces your physicalactivity.
Physical activity is requiredfor weight loss and heart
failure makes exercise difficult, and it goes on and on and on
and on.
So you've got to break thiscycle, and sometimes we need
medications to break this cycle.
(34:31):
And we talked a little bit aboutthis study.
I mentioned this study aboutsemaglutide and cardiovascular
outcomes in obesity withoutdiabetes.
Now, so that was the secondgeneration.
The first generation of thesestudies were with patients with
diabetes, and now we're usingthese drugs in people without
diabetes.
In fact, they're clinicallyindicated in heart failure for
all patients, whether or not youhave diabetes.
And we also highlight thesestudies because all these
(34:52):
studies were performed inNortheast Florida.
So again, shout out toeverybody in the audience that
was part of these studies andthere are many of them.
At this point, there areseveral dozen studies that we've
been involved with throughpatients here in our community.
So you guys make the difference.
Announcement (35:08):
Thanks for joining the MedEvidence podcast.
To learn more, head over toMedEvidence.
com or subscribe to our podcaston your favorite podcast
platform.
Welcome to the MedEvidence podcast.
This episode is a rebroadcastfrom a live MedEvidence
presentation.
Dr. Michael Koren (00:07):
Okay, well, thank you very much everybody,
and thank you for Dr.
Helow for jumping in.
I was very impressed by thenumber of people who've been
involved in research before.
Thank you again.
Our hearts out to you, becauseyou are the people that make a
difference, you're the peoplethat advance medicine, and Dr
Hilo and I have been doing thisfor quite a while, and Dr.
Helow and I have been doingthis for quite a while, and Dr.
Helow has been amazing to justjump in.
(00:27):
So this originally was going tobe a discussion between me and
one of my colleagues, MicaiahJones, who's a fellow
cardiologist, and unfortunatelyMicaiah called me yesterday and
said that he was not going to beable to make it because he had
to cover the hospital for heartattacks Because the guy that was
supposed to cover the hospitalfor heart attacks had an
out-of-town emergency.
(00:48):
So this is the real world ofmedicine and we are real doctors
.
Just so you know, we do seepatients.
We are real doctors and part ofour goal is to bridge the gap
between scientific research andreal medicine, because we are
real doctors and we do bothscientific research and real
medicine, because we are realdoctors and we do both.
(01:09):
Dr.
Helow, Victoria Helow is apediatrician, adolescent
medicine specialist, works theERs seeing sick kids and
teenagers, and she's also beenan amazing researcher over the
course of the past 20 years now,and so it's always a pleasure
for us to do a program together.
But she's kind of jumping in onsomething that we all deal with
in all of our specialties,which is obesity.
So, although we wanted to focuson the cardiovascular elements
(01:33):
of obesity because Dr.
Jones isn't here and you'rehere, and I think Dr.
Bernhardt, who's adermatologist, will join us
we're going to talk a little bitmore about the protean
manifestations of obesity.
Dr. Victoria Helow (01:45):
All of them
Dr. Michael Koren (01:45):
Yeah.
So thanks for being part ofthis, vicky, sure, sure.
So let's just jump right in.
So, as you know, we do notbelieve in a free lunch here at
WJCT.
We believe you have to work foryour lunch, and so I'm just
(02:06):
curious before I get into thefirst question when you heard
this advertised as the proteanmanifestations, did that make
you more interested in thislecture?
Yes, did it make you lessinterested in the lecture?
Okay, all right.
So we're going to start withprotean.
So have you heard of the wordprotean?
A (02:19):
No.
B (02:22):
I learned it for 10 minutes when I studied for the SATs.
C (02:26):
of course, I've heard of it, but have no idea what it means.
D (02:32):
I have a feeling I'm going to learn the meaning of the word
during this lecture.
Or E (02:38):
isn't it a typo for the word protein?
Okay, so there's really noright answer here, but I was
just curious to see how peoplereacted to this.
It is a word we use in medicineand it's actually a great word,
and let's jump into it a littlebit more in terms of the fact
that obesity is something thathas protean manifestation.
(02:58):
So, Vicky, you can just giveeverybody a little bit of a
sense for all the elements ofobesity and stuff that you deal
with in your practice and whenyou see people in the ER.
Dr. Victoria Helow (03:07):
So protean, as this shows, is, in other
words, all of the possibleconsequences of that condition,
and, as we know, obesity iscomplex and it can have a lot of
consequences.
We were originally going to do,as he said, the cardiovascular
consequences, and we all know,though, it increases your risk
(03:28):
of stroke, increases your riskof heart attack, increases your
risk of kidney disease.
It's obviously a psychologicalcondition as well, especially in
this.
You know society and all of themanifestations of Facebook, etc
.
What you're supposed to be,skinny and active, etc.
It can create all of that and,like I said, the cardiovascular
(03:50):
ones.
And one of the big things thatwe talk about now, as we're
beginning to understand obesity,is obesity increases the risk
of inflammation throughout yourbody, so anything that can be
complicated by inflammationwhich is everything, is
complicated, more complicated inthe obese individual.
And that's crucial.
Dr. Michael Koren (04:11):
Yeah.
So getting to the protean word,there's a picture here and that
guy's clearly not obese.
He has a six-pack going onthere.
He's a pretty impressive guy
Dr. Victoria Helow (04:23):
-Eight-pack!
Dr. Michael Koren (04:23):
Eight-pack.
Yeah, maybe an eight-pack, butthis is actually where the word
protean comes from.
So it's actually of Greekorigin and it comes from Proteus
, who is a Greek sea god who canchange his shape at will.
So obesity is one of thosethings that can change and have
many, many differentmanifestations, and so what it
(04:46):
means in the English language isdisplaying great diversity or
variety.
So when we talk about theprotean manifestations of any
disease, these are diseases thatpresent with great diversity or
variety.
All right, next question whatis the formal definition of
obesity?
A (05:05):
the inability to fit into your wedding dress.
B (05:09):
the ability to rest a beer can on your belly.
C (05:14):
20% or more above the upper limit of healthy body mass index
.
D (05:22):
that uncomfortable pause after someone asks does this
make me look fat?
Or E (05:29):
clothes with horizontal stripes that don't flatter
Dr. Victoria Helow (05:35):
Still don't flatter.
Dr. Michael Koren (05:37):
So what's the answer, Vicky?
Dr. Victoria Helow (05:39):
20% or more above the upper limit of a
healthy BMI.
Dr. Michael Koren (05:43):
So, moving on the growing prevalence of
obesity Among affluent nations,the US has the highest obesity
rate, affecting approximately42% of the population
Dr. Victoria Helow (05:53):
42%!
Dr. Michael Koren (05:54):
I'll tell you what the rest of the world is
catching up.
Yes, so I've had some recenttrips to India.
A lot of obese people in Indianow
Dr. Victoria Helow (06:04):
Again, that's a sign of affluence.
So they encourage that,especially in the females.
So interesting.
Dr. Michael Koren (06:12):
In May I was in Saudi Arabia and Morocco.
More and more obese peoplethere.
In Morocco there were threeMcDonald's restaurants within
walking distance of my hotel.
Dr. Victoria Helow (06:24):
Sad, is that unbelievable Sad?
Dr. Michael Koren (06:26):
Well, again, it depends on what you eat there
.
No one's forcing you to eatthere or what you choose to eat
once you go there, but this is aphenomenon that's affecting the
rest of the world as well.
Obesity-related deaths fromischemic heart disease increased
threefold from 1999 to 2020 inthe United States, but that's
pretty significant, and theWorld Obesity Federation
(06:48):
predicts obesity will affect 1billion people globally in 2030,
one in five women and one inseven men.
Dr. Victoria Helow (06:55):
And again, being a pediatrician, this has
been a huge issue in thepediatric realm.
The ages are getting youngerand younger and younger.
Dr. Michael Koren (07:04):
What percent of the people who you see, say
during a typical emergency roomouting, would you say, are
people who are overweight, andthese are people all 18 or less,
I assume, right.
Dr. Victoria Helow (07:15):
Yes, I would venture to say truly, in
pediatrics it's pushing that 30%.
I see again, depending on whichER I'm working in, I can see
higher than that 30% and some ofthe ERs may be a little bit
lower depending on thedemographics.
Dr. Michael Koren (07:32):
Interesting and that's the obesity paradox
that you're alluding to is thatobesity in the United States is
actually a marker of poverty,and that was not the case 100
years ago.
100 years ago, wealthy peopleoverweight because they indulge
themselves in rich foods, andnow it's the opposite.
Dr. Victoria Helow (07:50):
Because the higher calorie foods are cheaper
.
Dr. Michael Koren (07:53):
So the dual role of adipose tissue in
disease.
So adipose tissue causes healthcomplications in two distinct
ways.
One, it initiates harm throughchronic inflammation and insulin
resistance, and you mentionedthat We've done a lot of
discussions about this conceptof inflammation and elements of
our day-to-day lives thattrigger inflammatory responses,
(08:16):
which have multiple negativeconsequences.
Then it also exacerbates orworsens existing health
conditions, making them harderto manage.
So there's some mention aboutthe COVID booster study that
we're doing here in northeastFlorida.
It's actually a really excitingstudy that's running at three
different locations in northeastFlorida in the Fleming Island
(08:37):
area, on the west side, on thesouth side.
It's funded, as mentioned, byBARDA, which is part of the
Department of Defense,specifically for bioterrorism
preparation.
A lot of concerns about that,but the point that's really
important here is that beingoverweight doesn't make it more
likely that you're going to getCOVID, but it makes it more
(08:59):
likely to get really sick whenyou get COVID
Dr. Victoria Helow (09:01):
Right.
Dr. Michael Koren (09:02):
So that's this concept of exacerbating an
illness.
Okay, adipocytes and obesity.
Adipocytes are actually cellsin your body that are designed
to hold onto fat.
So fat is something we actuallyneed, right, obviously, if too
much of a good thing is not good, but we actually need fat, and
(09:23):
fat is a source of energy forour bodies and it's the way our
bodies store energy.
And if you look at the historyof mankind, we probably needed
our fat stores a lot morethousands of years ago, when we
didn't have as much to eat andwe needed to have a place where,
when we had a big meal, wecould store some of that energy.
Dr. Victoria Helow (09:42):
For the times when we didn't have a meal
and starvation times.
Dr. Michael Koren (09:45):
Exactly, but that's of course with the ready
availability of food these dayshas become something that's now
a liability rather thansomething that gives us an
advantage.
So the adipocytes increase therelease of free fatty acids into
the circulation, which is oneof the chemicals that promotes
inflammation and fibrosis intissues.
Hormones from the adipocytesinterfere with normal
(10:08):
anti-inflammatory and protectiveeffects, and adipocytes
activate immune cells, whichfurther fuels inflammation and
tissue remodeling and also ourability to fight infection.
So when you have immune cellsthat are just promoting
inflammation, they may not be onthe ready for actually fighting
infections as well as theyshould.
Dr. Victoria Helow (10:30):
Yeah, but I just wanted to give a little
explanation of adipocytes ingeneral.
And basically they are kind oflike gas tanks in our body, and
when we fill our car with gasand we don't use that gas,
imagine if it just had a ton ofgas tanks on it.
We would just keep fillingthose and if each one could
(10:50):
expand, it would just sit there.
And that's kind of what happensto us when we take in gasoline
for our body.
And gasoline for our body iscarbohydrates.
And I think it's an importantpoint, because part of what
we're doing with all of this fatphobic zero, zero fat.
A hundred calorie items, it'sjust a hundred calories of
(11:11):
carbohydrate that your body'sgoing to store.
It's worse for you than if youate 100 calories of good fats,
Dr. Michael Koren (11:16):
Right.
very important point.
Dr. Victoria Helow (11:18):
Yeah just yeah, just something to think
about when trying to do somedietary management
Dr. Michael Koren (11:24):
Yeah, so you don't have to eat fat to be fat
or to get fat into theadipocytes.
Your body will make fat out ofany energy source, which is most
commonly carbohydrates.
So I don't know if you want tocomment on all of that.
Dr. Victoria Helow (11:38):
So all of you know obesity we talked about
.
It ends up affecting everything.
So sleep apnea is.
You know, just the simple fatbeing here can end up leading to
sleep apnea.
Obviously, lung diseases areagain.
Lung diseases are primarily aninflammatory problem.
Also, your lungs require arethere so you can increase the
(12:01):
oxygen to your body parts.
Well, if your body is excessweight, you're going to increase
the demands of the lung even ifyou don't have the inflammatory
components.
So it's double and triple theeffects of the negative things.
Stroke we talked about theinflammatory things that you get
in the vessels because of this.
You know these inflammatorymarkers running around.
(12:22):
Same thing with heart disease,liver disease.
We have article, we have awhole book back there put out by
MedEvidence, on fatty liverdisease, which is known as NASH
or MASH.
Non-alcoholic steato hepatitis.
Steato- is fat and thehepatitis you literally -itis on
the end of the word meansinflammation.
(12:43):
So you literally get liverinflammation because of all this
fat sitting in there as it'sbeing stored.
And then, as fat sits there andit causes inflammation, then
causes scarring.
And then, as fat sits there andit causes inflammation, then
causes scarring.
So you literally can getcirrhosis of the liver by being
too fat and never drink a dropof alcohol in your life.
Dr. Michael Koren (13:02):
So the research office.
We cover all these areas.
So show of hands.
You see all these diagnoses onthis chart.
Who in the room has at leastone of those concerns?
So, like virtually everybody.
So that's really the importanttake-home message is that
obesity makes all these thingsworse, and there's a lot of
(13:25):
interest and research aboutdealing with obesity and
hopefully making these thingsbetter, and that's what we do
day to day.
So let's jump in.
It's a little bit about obesitywith cardiovascular disease and
that was going to be ourprimary focus today.
But again, thank you forjumping in and bringing some of
these other really importantpoints into the discussion.
But we know from the cardiologyworld that obesity is a strong
(13:47):
risk factor for other conditionsthat independently contribute
to congestive heart failure.
So one of the major ones thatwe deal with is high blood
pressure, and you probably havea little bit of exposure to high
blood pressure in your patientpopulation.
But I see this all the time andit's so interesting.
When people lose weight, it'svery common that we actually
(14:08):
reduce the number and dose oftheir medications to the point
where we have some people thatactually get off of all their
blood pressure medications whenwe get them down to a normal
body weight.
Dr Bernhardt, they are.
Dr. Michael Bernhardt (14:21):
All right , nice to see you.
Thanks for joining us.
Dr. Michael Koren (14:25):
Dr Bernhardt is an extraordinary
dermatologist who's also goingto talk to us about some of
those manifestations, but we'llgive him a second to catch his
breath.
I know he just got in fromclinic and we do appreciate he's
also been a fabulous clinicalinvestigator that's running
studies on acne vaccine as wespeak Some really cool stuff,
but we'll get into that in asecond.
But anyhow, getting back toobesity, when you're overweight
(14:47):
your blood pressure is higher.
When you lose weight, yourblood pressure comes down.
Blood pressure is the forceagainst which your heart has to
work.
Higher the blood pressure, moreheart work, More heart work,
worse heart performance.
So that's one way to thinkabout it.
Type 2 diabetes it causes anumber of things, including this
(15:11):
concept of diabeticcardiomyopathy.
So you've heard of heartattacks, of course.
Well, that's when the big bloodvessels to the heart get
blocked up.
But when the little bloodvessels get blocked up, it has
all these little, what we callmicro infarcts and although your
heart looks like it's workingokay, it's really not
functioning the way it shouldand sometimes it has a real hard
time with relaxation, whichleads to accumulation of fluid
and breathing problems.
(15:31):
Dyslipidemia.
My favorite topic ischolesterol issues and, of
course, when you're overweight,you're much more likely to have
higher cholesterol, particularlytriglycerides.
Triglycerides are really drivenby this carbohydrate craze that
we have in this country andit's less of an effect, but it
(15:52):
also affects LDL cholesterol.
It doesn't affectlipoprotein(a) very much, which
is your little favorite subjectto talk about
But there are a lot of dietaryelements to cholesterol issue,
but not all of them, and that'swhy you really need to talk to
an expert, because some peoplesay, oh, I'm just going to
change my diet and everything isgoing to turn out right.
(16:12):
Well, you can starve yourselfand you'll still have a high
Lp(a).
Dr. Victoria Helow (16:16):
Yes, and therefore a high LDL.
Dr. Michael Koren (16:19):
Right, but if you starve yourself, chances
are your triglycerides will benormal.
Dr. Michael Bernhardt (16:23):
Deal.
I used to run marathons back inthe day when I was about 30
pounds lighter.
Dr. Michael Koren (16:27):
Well, you just ran one to get here today.
Dr. Michael Bernhardt (16:29):
Well, yeah, because my GPS had me
going around the stadium and soit took me on.
Dr. Michael Koren (16:33):
Yeah, he caught a few plays of the
Jaguars practice.
Yeah.
Dr. Michael Bernhardt (16:37):
But I used to do long-distance running
for about 25, 30 years and Ithought I was bulletproof
because I was doing banking 80,90-mile weeks and nope, the
numbers were still high.
Dr. Michael Koren (16:48):
Yeah, another area that we've worked on as a
research group is sleep apnea,and you're probably familiar
with that.
It's normally when you stopbreathing for a period of time
and everybody does that.
Dr Rothstein, Mitch Rothstein,did a fabulous lecture, really a
master series lecture on thisrecently
Dr. Victoria Helow (17:04):
-t hat you can look up-
Dr. Michael Koren (17:05):
yeah, which is online, check it out.
It's on MedEvidence.
But some degree of sleep apneais kind of normal.
But when that becomes excessive.
it leads to cardiovascularcomplications, most commonly
atrial fibrillation, but alsoworsening of congestive heart
failure and an increase in bloodpressure.
(17:25):
All right, so perfect timingthe skin side of obesity.
So, Mike, several skinconditions are commonly
associated with obesity due tochanges in hormones,
inflammation, increased skinfolds and impaired skin barrier
function.
So the stage is yours, myfriend.
Dr. Michael Bernhardt (17:39):
Thank you , you know.
It's interesting because someof these things are actually
associated with elevated fasting.
Not glucose, but the insulin.
Elevated.
Yes, A lot of these people havehyperinsulinemia and I've
started checking some of my HSpatients, my acanthosis and
agaric cancer patients.
Dr. Michael Koren (17:58):
Yeah, explain that to people, because we're
doing an HS study.
Dr. Michael Bernhardt (18:00):
Okay, yeah, this is kind of
interesting because HShydradenitis we call it HS for
short is one of my areas.
Dr. Michael Koren (18:08):
It's right here on the slide, if you see it
right there.
Dr. Michael Bernhardt (18:10):
Yeah, it's one of my areas of
excessive interest becausebefore I came back to
Jacksonville I was helping onthe dermatology residency clinic
in Tallahassee.
So we were getting a lot of theend-stage referrals and we were
seeing about, well, about fiveto seven really bad hydradenitis
patients per day.
And what happens inhydradenitis?
It's frequently misdiagnosed asquote-unquote boils.
(18:33):
So people will get boilstypically in the areas of fusion
plan on the body the inguinalcrease, the axillary crease, the
inframammary crease and they'llcome and go, remit and resolve,
remit and resolve and typicallystarts early to mid-teens and
as a rule it goes about eight toten years before the person's
(18:54):
properly diagnosed.
The patient will bounce fromurgent care to urgent care to
urgent care and then wind upeither in a primary care office
or a derm office.
That's savvy to what's going onand then they'll get the
electron on hydradenitis.
We know that a lot of thesepeople have elevated fasting
(19:19):
insulin levels,hyperinsulinemia, which is tied
in to the whole Obesity cascadeis one of the driving forces not
just of hydradenitis but alsoacanthosis and agaricans.
We see that patients withpsoriasis usually are 100
kilograms.
So obesity is part and parcel-
Dr. Michael Koren (19:36):
-100 kilograms is 220 pounds.
Dr. Michael Bernhardt (19:39):
Yeah.
So you know, for years wealways thought that this whole
conundrum was kind of a sidebar.
And then some really smartresearchers, particularly a
group up in Howard University,started putting all this
together, and a researcher atPenn, Joel Gelfand, started
putting this whole metabolicsyndrome, as it affiliates to
(20:02):
skin, together and what we foundis that fat cells are called
adipose cells right, and thereare amazing little cells because
they're pluripotent, they cankind of transform into multiple
different cell types and theysecrete all sorts of
inflammatory triggers.
Dr. Victoria Helow (20:20):
We talked about it a little while ago in
the adipose.
When we talked about that.
Dr. Michael Bernhardt (20:23):
Right Adipose cells.
They secrete interleukin-17.
Interleukin-17 is one of thelittle Ferraris, shall we say,
that drives a lot of theseinflammatory cascades.
Dr. Michael Koren (20:34):
And Vicky used the metaphor of cars, so
you guys are on the same pagehere, because it's boom Of
course you're talking Ferrarisand she was talking Teslas, or
Kias Kias.
Dr. Michael Bernhardt (20:46):
I've been watching a lot of Magnum lately
.
I've been hooked on these.
Ferrari things.
But it's a fast driver.
So interleukin-17 getstransformed, the adipose cell
gets worked on by tissuemacrophages, which drives
release of interleukin-17, TNFand those are the inflammatory
mediators that drive HS and alsopsoriasis.
(21:06):
So that there's been studiesthat have been done,
particularly in Europe, wherepeople have lost significant
body mass.
A lot of times they don't needmedication.
Dr. Michael Koren (21:14):
That's great.
I love that, and we'll talkmore about that, because we do
have studies that are looking atthat as we speak.
Dr. Victoria Helow (21:19):
And I can tell you that in the emergency
room we do see a lot of thehydradenitis patients and they
are many times diagnosed asboils and many times people have
actually opened these up to tryto drain them out and given
them volumes of antibiotics andit's not an infectious problem.
Dr. Michael Bernhardt (21:36):
Yeah, so antibiotics are helpful.
Tetracyclines downregulate someinflammatory meters, but really
over the short term they'reBand-Aids and patients really
need to be on more aggressivetherapy.
Dr. Michael Koren (21:55):
So we don't do animal studies here in our
clinics.
We're only about humans.
But there is a lot of things wecan learn from these animal
models, including mice models,which is the most common model
that people use when they lookat things scientifically.
And what's interesting is thateverything we're saying has been
documented in mice, and there'sactually studies where we force
feed different species and thesame bad things happen.
So mice and other animals canactually develop congestive
(22:17):
heart failure based onovereating.
And here we have this.
I don't know if that's a Kitkatbar, what it is that mice are
eating.
Dr. Victoria Helow (22:25):
Chocolate bananas.
Dr. Michael Koren (22:26):
The reason I say kit-kat bar is because this
is how mice can get back at thecats that chase them by eating
the kit-kat bar Anyway Payback,and then, in obesity-prone rats,
a high-fat diet for just 12months leads to metabolic
syndrome and progression of thisheart failure.
H-f-p-e-f stands for heartfailure with preserved ejection
(22:48):
fraction, and that's thatdiabetic cardiomyopathy that we
were just talking about.
We have these little microinfarcts, even though your heart
looks like it's pumpingnormally, it's really not
because the relaxation functionsare impaired.
The American Heart Associationstill debates with people about
should we focus on fats, gramsof fats or just calories?
Dr. Victoria Helow (23:06):
Calories, just healthy foods, real food.
Dr. Michael Koren (23:10):
There you go All right back to audience
questions.
So all of the below aremedically accepted methods to
lose weight, except A (23:17):
calorie restrictive diets.
B (23:22):
bariatric surgery such as a partial gastric bypass.
C (23:28):
medications such as approved classes like
opioid-antidepressant combos,fat blockers and GLP-1s.
D (23:37):
the Ronco binge-eating cleansing diet of popcorn,
colonics and moonshine, orintensive physical activity
program with standard meals.
Dr. Michael Bernhardt (23:48):
I didn't realize.
Moonshine helped you loseweight.
Dr. Michael Koren (23:51):
You haven't been on the Internet lately, no,
so of course the answer is D.
It's not been medicallyaccepted, but do you want to
jump in and just talk aboutthese different ways of losing
weight?
Dr. Victoria Helow (24:03):
Yeah, so you know we have some again
publications back there thattalk about the whole obesity
problem and using calorierestrictive diets.
And you know it meansrestricting your calories.
In certain ways it doesn't meanno calories, it means being
careful with what you eat.
And we had a fabulouspresentation yesterday of a
(24:23):
horrible kidney disease calledpolycystic kidney disease and
then expert from Mayo Clinic wastalking about restricting the
diet by only 10% of yourcalories helped with this
genetic problem that isaggravated by obesity.
So anything that you can do tohelp decrease the fat is going
to help, even like 10%.
(24:44):
Not having seconds decreasingyour portions, the bariatric
surgery what that's doing isbypassing the part of the
intestinal tract that rapidlyabsorbs your sugars so that it
takes a little longer to absorbthose sugars Can in fact help
you with not having so many ofthose bioavailable so quickly.
And of course, we know that themedications have been very
(25:06):
successful.
We've done lots of researchfrom the beginning on these
ozempic et cetera type ofmedications.
We have many active studiesright now looking at these
medications that are proven tobe safe, proven to be effective,
and now we're using them indifferent combinations with
patients with heart failure.
Hey, if we can help them losesome weight, help normalize some
(25:29):
of their insulin issues.
Would it also prove to behelpful for their heart failure?
The obvious answer would be yes.
So we have studies that arelooking at that so that then
people can be prescribed thesebecause of these conditions, not
necessarily just diabetes,which is what the original
intention was.
We need to prove that they infact have an effect on heart
(25:50):
failure and, um, you know, othersituations that are affected by
the obesity issues.
And intensive physical therapyprogram with standard meals,
even a just a physical therapy,a physical activity program in
general, with, again, standardmeals.
And a standard meal is awell-balanced meal Doesn't mean
(26:10):
just cutting out the fats orjust cutting out the
carbohydrates or reducing those.
We need all of those things inour diet but they need to be on
a proper timing, which we knowwhen you eat your meals and how
you eat your meals.
And again, it's in some of ourliterature about eat your
protein first, then yourcarbohydrates, partly that
bariatric surgery it doesn'tgive you that sugar load
(26:31):
immediately absorbed et cetera.
So all of those can beeffective and little bits of
each can help.
Dr. Michael Koren (26:39):
Yeah, so everything but D has been proven
to work in scientific studies,and what's interesting, though,
is that the GLP-1s are gettingall the attention these days,
and they get the attentionbecause they're really effective
.
Yes, and they also have beenshown to actually improve
cardiac parameters and otherparameters, and just a couple of
(27:02):
historical things.
So when I was doing myresidency at Cornell, there was
a guy named Lou Aroni who becamea very famous diet person, and
he actually brought people intothe hospital and confined them.
We were doing this in aconfinement unit in the hospital
, where they can only get 400calories a day-
Dr. Victoria Helow (27:22):
-not enough.
Dr. Michael Koren (27:23):
And that was the first to show yeah, if you
give people only 400 calories aday, they will lose weight.
Unfortunately, when they leavethey tend to not eat only 400
calories a day.
And I remember they had allthese shakes and whatnot to try
to get people to just eat onemeal, and then the shakes that
were low-calorie.
So that works, but you got tostick with it.
Gastric bypasses and thingslike that work, and that was, I
(27:45):
remember when we first came totown.
There was a lot of surgeonsthat actually had abandoned
their general surgery practice,just to do bariatrics because it
was working and then movingdown.
as you mentioned, at the end ofthe day, it's calories in versus
calories out.
Dr. Victoria Helow (27:59):
Gasoline in usage out.
Dr. Michael Koren (28:01):
Right.
So if you're like Mike andrunning 80 miles a week and you
just ate your 1,200 or 1,800calories, you're going to lose
weight.
And then, of course, as Imentioned, we have lots of drugs
, and the really interestingthing about the drugs,
particularly GLP-1s, is welearned about them by accident.
Interesting.
About 20 years ago, the FDA gotconcerned that drugs that were
(28:24):
being developed for diabetescould have adverse effects on
the heart.
So the FDA in its wisdom saidokay, if you get a drug approved
for diabetes, you have to dostudies with cardiologists to
show they're safe for the heart.
(28:45):
So starting around 2006, 2008,our center started doing those
studies just to show that theywere safe, and we actually
worked with Ozempic back thenSmaglutide is the generic name
of it and we were blown away.
So of course we put people onthese drugs that were for
diabetes.
They weren't even for weightloss.
Then they were just to controlthe glucose.
And they're on it and peopleare losing weight and they're
getting excited about that.
Dr. Victoria Helow (29:04):
Their heart's getting better
Dr. Michael Koren (29:05):
And their blood pressure's going down and
their cholesterol's gettingbetter, and then when we start
to look at whether or not theyhave heart attacks, there's a
20% to 30% reduction in heartattacks in the people that are
taking these drugs.
Dr. Michael Bernhardt (29:15):
Whoa.
Dr. Michael Koren (29:17):
And that was all by accident.
So now GLP-1s are actuallyconsidered a standard of care
for congestive heart failure,and it started out as a diabetes
drug that we were worried mightnot be safe for the heart.
So this just shows you howresearch progresses and how we
learn, and we learn because ofpeople like you that get
involved in these programs.
So thank you for that.
Dr. Victoria Helow (29:44):
So the GLP works because basically it's
acting like a normal hormonethat we have in our body that
helps control our sugar levels.
So that's an important point.
We're not trying to dosomething abnormal to the body,
we're just trying to help thebody work in its normal way.
And so they help with theinsulin release because,
although some problems arehyperinsulinemia, we know that
an obesity issue many times isnot an adequate insulin release,
(30:06):
and I explained to you beforethat insulin is what takes that
sugar that's in your bloodstream, those calories that you ate,
and puts them into the cells sothat the cells can be energized
to do whatever their job is,whether it's a muscle or a heart
or lung.
Dr. Michael Koren (30:22):
And this is the key box right here, just to
highlight for the audience howGLP-1 activation affects our
bodies.
So really remarkable.
And to Vicky's point, it's justmimicking what our bodies are
supposed to do, so we have anaudience question here.
The use of GLP-1 drugs such asOzempic and Manjaro has led to
(30:42):
the following in researchprograms Okay A: the side effect
of weight loss.
I talked about these originallydiabetes drugs.
B (30:52):
the side effect of reduced heart disease and blood pressure
.
C (30:55):
the side effect of improved skin conditions.
D (30:59):
the side effect of reduced compulsive behavior in
preliminary studies.
That's really interesting.
Or E (31:06):
all the above protean manifestations?
Yes, sounds like all the aboveto me.
Yeah absolutely all the abovefor sure, so I don't know if you
just want to.
You mentioned actually alreadythat there were studies showing
that when people lose weighttheir skin conditions get better
, and I'll just mention.
I think we covered everythingelse.
But we're finding that thesedrugs actually help people that
(31:28):
have problems with alcohol, thatthe urge for alcohol goes away
when you activate the incretins,the GLP-1 and the GIP systems.
So again, these are mechanismsin our body that are supposed to
be functioning that sometimesneed a little help, and the
GLP-1 agonists, like unzippingand Manjaro, help activate those
systems.
(31:48):
That help us in many ways.
Dr. Victoria Helow (31:50):
Just normalizing all of these complex
interactions.
Dr. Michael Koren (31:54):
And then I'll just jump in and just let
people know that the issue ofcongestive heart failure is a
growing issue and there are 6.7million Americans over the age
of 20 who are now living withheart failure and this number is
anticipated to rise.
So Americans have about a 24%lifetime risk of developing
heart failure, so they'll affectone in four people.
(32:15):
More than 50% of heart failurepatients have heart failure with
a preserved ejection fraction.
And again, there are twoflavors of heart failure One
where the heart muscle is notcontracting like it should and
that typically happens after aheart attack.
Or the flavor where the heartmuscle gets thickened and
becomes dysfunctional because ofthese little microinfarcs and
the effects of diabetes andmetabolic syndrome and it leads
(32:37):
to higher pressures in the heartwhich goes back into the lungs.
That causes edema in the lungsand problems with breathing.
So you're just as likely to endup in the hospital if your
heart muscle function ispreserved versus reduced, which
is an important point.
And, as mentioned, heartfailure is very, very common.
It's the most common hospitaladmission after age 50 and
(33:00):
probably the third most common.
I think childbirth is still themost common and probably the
third most common.
I think childbirth is still themost common, but it's very,
very common in people over 50.
And it's 9.3% of the hospitalvisits in the United States.
So we talked about this, Ithink, pretty well at this point
.
Weight loss is effective in alot of ways, particularly for
people with heart disease Imentioned.
(33:23):
Blood pressure comes down, yourheart's function goes up
because of reduced inflammationand better utilization of
glucose and insulin, and it justlets work for your heart.
So if your heart is a littlebit impaired from a previous
heart attack and you got to move200 pounds around, that's
harder than moving 160 poundsaround, simple as that.
So there are very, verypractical reasons why we
(33:46):
strongly advise weight loss inpeople that have any history of
heart disease, particularlyheart failure.
And this gets into the viciouscycle that you see that when you
have a heart problem, youreduce your activity.
You reduce your activity andI'm just starting from here and
moving along you reduce youractivity and then you're more
likely to get overweight.
You're overweight, the work ofthe heart goes up.
(34:07):
Heart failure worsens as thework of the heart goes up.
Obesity reduces your physicalactivity.
Physical activity is requiredfor weight loss and heart
failure makes exercise difficult, and it goes on and on and on
and on.
So you've got to break thiscycle, and sometimes we need
medications to break this cycle.
(34:31):
And we talked a little bit aboutthis study.
I mentioned this study aboutsemaglutide and cardiovascular
outcomes in obesity withoutdiabetes.
Now, so that was the secondgeneration.
The first generation of thesestudies were with patients with
diabetes, and now we're usingthese drugs in people without
diabetes.
In fact, they're clinicallyindicated in heart failure for
all patients, whether or not youhave diabetes.
And we also highlight thesestudies because all these
(34:52):
studies were performed inNortheast Florida.
So again, shout out toeverybody in the audience that
was part of these studies andthere are many of them.
At this point, there areseveral dozen studies that we've
been involved with throughpatients here in our community.
So you guys make the difference.
Announcement (35:08):
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