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TEAM
Meeting with Dr. Xavier Pi-Sunyer
Dr. Xavier Pi-Sunyer, the Chief of the Division of Endocrinology, Diabetes, and Nutrition at St. Luke's - Roosevelt Hospital in New York, is perhaps the foremost authority on obesity in the United States. It would take more than one article to do justice to a career that began over 40 years ago and has included the Presidencies of the American Diabetes Association, the American Society for Clinical Nutrition, and the North American Association for the Study of Obesity, 120 journal articles, academic appointments at Columbia University and Rockefeller University, panel positions at NIH and the FDA, and continuing work in virtually every area of obesity treatment.
It seems that at any given moment he is always involved with the leading developments in obesity research. This year is no different. Dr. Pi-Sunyer was a lead investigator in Sanofi's clinical trials for rimonabant, the latest pharmaceutical drug targeted for obesity. He is on the Obesity Advisory Board for Amylin, which last month began a combination therapy (pramlintide plus leptin) clinical trial.
Dr. Pi-Sunyer is also the co-chair of the executive committee for the Look AHEAD study, a multi-center randomized clinical trial designed to examine the effects of lifestyle intervention on achieving and maintaining weight loss over the long term through decreased caloric intake and exercise. Look AHEAD is focusing on the disease most affected by overweight and obesity, type 2 diabetes, and on the outcome that causes the greatest morbidity and mortality, cardiovascular disease.
We interviewed Dr. Pi-Sunyer in late November at his office at St. Lukes in New York. What struck us as most noteworthy is his optimism about the future for obesity, despite having seen the problem grow to epidemic scale during his professional lifetime. Here are excerpts from our conversation:
Kelly Close: Thank you so much for meeting with us. As part of the research, we went back to read some of your papers and were interested in your views in a paper titled A Clinical View of Obesity, in Science, from 2003. That article really seemed to have crystallized a lot of your views; can you talk about that piece?
Dr. Xavier Pi-Sunyer: As you know, obesity is becoming a big problem in America. And one of the problems from a clinical point of view is that first of all, medical education doesn't prepare the health professionals in this country to deal with that issue. It's always been ignored in the past. So physicians come out of the medical school, and nurses out of nursing school, and psychologists out of whatever school they come from, without adequate grounding in the kind of things they need to help a patient prevent weight gain, or lose weight, if they're overweight.
So, they have a lack of knowledge about nutrition. They're extremely deficient, from a practical point of view, of what they would need to tell patients or help patients with. They have a very rudimentary knowledge about behavior modification and how to go about helping patients change their behavior. And there doesn't seem to be much of a movement as the prevalence of obesity increases and the problems increase in the United States. There hasn't been much of a movement in medical schools to change the curriculum and give more emphasis to these important issues.
So, that's one clinical problem. The second problem has to do with the amount of time physicians have in their offices and the fact that the amount of time they have with patients is being reduced in this country and probably around the world. So, they have less and less time for each patient. The typical patient-physician interaction might be 10 minutes or 12 minutes. There's a lot to talk about. And so, because the patient is not too comfortable with the subject of obesity and the doctor is not either, it just gets shunted aside and is not discussed in a major way by the physician with the patient.
Kelly: Do you think that because practically speaking the therapies to date -- at least, the therapies that are on the market now, Xenical and Meridia have so many different side effect problems in other words, theres no statin for obesity, per se theres no silver bullet?
Dr. Pi-Sunyer: Yes, that was what I was getting to. I think there's a bit of nihilism from the point of view of both the patient and the doctor, saying that there really isn't very much to help me. And certainly the two drugs that are available, even though they have an effect, it's a modest effect. And most people don't get reimbursed for it. So, given the kind of weight trend that we have in America where the whole population is moving to the right, more and more people are overweight. We have about 10% of the population who have a BMI above 35 -- so they're very heavy. If you get such a modest effect, 4 or 5% difference from placebo, it isn't really very much. So people are not willing to spend the money for that kind of drug. So, there isn't a very good pharmaceutical basis for treating . . . If you don't have a pharmaceutical base and you're uncomfortable with a behavior base, then you're going to ignore the problem. I think that's what's happening.
Kelly: If you think about the problems, lack of time, the physician not having time and training, and then not having great drugs and not having good reimbursement for the drugs, how would you assess those problems in terms of the impact?
Dr. Pi-Sunyer: I think the fact that they're not reimbursed has a big impact on the lack of use of pharmaceutical products. In countries where they are reimbursed by government plans, the reason drugs are not used more is because the reimbursement is very heavily controlled. People have to go to specialists. There's a lot of regulation, because the governments don't want to spend the kind of money that it would cost.
The other problem is with the use of pharmaceuticals. This was the attitude of Medicare -- show us they're really effective. And the cost benefit ratio -- for what we're paying, what are we getting out of it, in terms of decreased mortality, decreased morbidity? And there aren't really sustained, long-term trials of how these drugs affect cardiovascular events, type 2 diabetes complications, etcetera.
Kelly: They haven't had time to progress, given the short time trials.