PracticeUpdate Diabetes June 2019

EXPERT OPINION 15

our National Institutes of Health in an inter- vention program in diabetic subjects. And these were not fresh diabetics, they had had fairly long-standing diabetes, and there was a multi-faceted intervention of weight loss and physical activity and diet that was extraordinarily effective. There was weight loss, although there was, of course, the usual rebound. But still, the intervention cohort achieved some weight loss, and that the intervention was much greater than any of us can do in our practices. That was a really focused and successful intervention and it was long term. And there were many benefits that accrued from the people who were in the intervention group. They had better quality of life, they had bet- ter mobility, but when it came time to look at the cardiovascular outcomes, very dis- appointingly, the investigators were unable to show a benefit, so we don’t really have a strong database for intensive intervention in diabetic subjects improving cardiovas- cular outcomes. Now, bariatric surgery is showing even mortality signals, so that’s a rather extreme intervention and one that, I think, is an admission of a societal failure that we have to rely on a bariatric surgery to improve car- diovascular outcomes in our patients with morbid obesity. Dr. Shah: Yeah. So, of those interventions that you talked about in the study, can we establish somethingof ahierarchyas towhichone ismore effective–physical activity, diet, anyof theother

lifestyle. We aren’t going to have it, so here is my stance. I don’t know if you’ve heard of Pascal’s Wager. Dr. Shah: I have. Dr. Libby: Blaise Pascal was a great thinker, a French philosopher, who hundreds of years ago said, “Well, look, if there is a God and I believe inGod, you know, that’s good. If there isn’t a God and I don’t believe in God, well, that’s okay, too. But if I don’t believe in God and there is a God, I could lose big time.” Dr. Shah: I have a problem. Dr. Libby: So, my approach is to make Pas- cal’s Wager about lifestyle intervention for cardiovascular prevention. I don’t think that we’re ever going to have the data, so I’m going to place Pascal’s Wager in favor of its working, thinking that if I behave in a healthy way, that I will improve my cardio- vascular outcomes. And I can assure you that you feel better and it’s easier to do weight control if you exercise. So, I got up pre-dawn this morning and I ran out to the esplanade and did just under a 5-mile run this morning, and I feel terrific. Dr. Shah: That’s wonderful. And you know, if you’re going to make Pascal’s Wager that makes sense to do it on the teenage pop- ulation because it might become a habit for them, so that is wonderful. Thank you so much, Dr. Libby.

lifestyle changes – or is it more a question of seeingwhat the youngperson is doing and then changing their lifestyle for the better? Dr. Libby: I’m very much for sustainability. So, when I’m in a discussion with a patient about lifestyle measures, I try to pick my battles and I try to work with the patient on finding something that is incremental. Not a crash diet, not all of a sudden joining the gym and working out, and then per- haps getting injured or getting discouraged and falling off the exercise or physical activ- ity wagon, or going on a crash diet which just sets you up for yo-yos, which we know is not good for you because instead of replacing the weight with lean body mass, you will do it with fat body mass. So, I strive to find, for each patient something that will work, that would be incremental. I tell a patient you’re not going to go into a beauty contest in July wearing a bikini. I say we’re looking for a 5%, as you say, decrease in body weight, which can accrue enormous metabolic benefits, even if we can’t prove that there’s a clinical ben- efit in terms of cardiovascular outcomes. So, I’ve just written a piece about preven- tive measures in atherosclerosis, where I say for lifestyle, which I believe firmly should be the foundation of cardiovascular prevention, we’re not going to have proof. No one is going to do a long-enough-term, properly controlled, placebo-controlled, blinded study of the kind that we expect with pharmacologic interventions with

Go to www.practiceupdate.com/c/81056 to watch this interview with Dr. Libby.

VOL. 3 • NO. 2 • 2019