The conversation occurred on the 29th December, 2017, when prof. A. Golay paid a seasonal visit to Vilnius. He kindly invited Ignas to talk at the family apartment in the Old City.
Of course! [Laughs] Let’s start from the beginning. I’m a diabetologist trained in California at Stanford. 90% of the diabetic patients have obesity. I realized that diabetology is not enough after I came back to Geneva.
There is a bad link between obesity and diabetes. In fact, we call it “diabesity.” You get diabetes after 20 years because you have obesity. You have a hard time losing weight, if you have diabetes.
It’s even more complicated because you have accumulated weight. Enzymes make this even more difficult. Later, I realized that 80% of obese patients suffer from depression, anxiety, stress — even more often than stress problems. And more than that, I discovered that 30% of our overweight patients had been raped—a huge psychological effect.
Yeah, three-zero. Thus I started a new way to treat patients 25 years ago. Thus we decided to educate patients.
Today, it’s a European Society of Therapeutic Patient Education — the European Congress on Obesity. We started this at the Geneva School. Why? Because you may be interested to lose weight but most of the time you know but you are not doing. Therefore, we apply approximately 40 different psychological, pedagogical models to the medical approach. If you do not know these models, you are not doing your treatment correctly.
One of them is personality. Let’s start with diabetes. I will feel faint during this interview if I don’t know how many carbohydrates I ate, or I overate, or I didn’t take enough insulin, or I have overeaten this morning.
Therefore, we decided to do some workshops for the patient. The patient is visiting different workshops to learn from my team how to eat. One of the workshops is about fat and how much fat is in these bloody peanuts.
They have no idea. They drink olive oil with glass because they are told, “It’s good for your health.”
Yeah, I know a person who’s on a very strict diet. He had surgery to put the belt on a stomach. And after that, he was taking olive oil with honey all the time. He couldn’t eat anything substantial, so he was taking olive oil, honey, etc.
Let’s skip this carefully. I have a patient who came from Moscow. Very rich. He is an old airplane engineer. He wanted to lose weight. And he ended up eating honey and olive oil all the time and didn't move. I provided him three pieces of advice.
Instead of saying to the patient what to do, I tried to understand what are the significant problems that we can change quickly. He said, “No, I came to see you and you gave me these three pieces of advice. I spent $75,000 to bring my airplane here. And you gave me these three pieces of advice. This is stupid.” I replied, “No, you can do it.”
Not to eat honey all the time, not to drink olive oil all the time, and to do some walking on his property. He has such a big property — he can walk inside. And I say, “See you in three months.” He came three months later with 5 to 10 kilograms less. “It’s fantastic. What did you do?”, I said. He answered, “I cut off all the vodka, I cut this, this and this.”
What is your primary motivation? That’s the key. You will be interested in doing something if you’re motivated, and you have to find out with the patient what the motivation is. Sometimes the motivation is wrong. Sometimes it is powerful. For him, it was easy to understand. He has a new girlfriend, therefore he wants to lose weight. I gave him three pieces of advice, and he lost weight.
Of course, because that’s the biggest motivation.
Sexual life is completely missing most of the time by the physicians. Our primary motivation is to make love. The first point of our approach is to know a little bit better and to understand how the food impacts insulin levels, what drugs and medication do.
Most of the time, the patient takes the prescription, goes to the pharmacy and takes the medication. If you have side effects, you don’t take it. You have to understand how the medication works, how the food and physical activity work.
Typically, we try to understand why we should be treated. I ask the patient, why do you want to lose weight? Why do you want to treat your diabetes? What is the reason? It’s interesting because, most of the time, if they understand better, they will accept some side effects.
Later on, I balance side effects. Alternatively, we discuss the “fantastic effects” too. For example, if you lose 4 or 5 kilograms at the beginning of diabetes, you will have a remission and diabetes disappears. Instead, I say to the patient, “You will lose weight.”
Remission, remission. That’s an entirely different approach. That’s the case.
We publish papers that three-quarters of the patients have no diabetes after six months…
Three quarters, 75%! In the first step, you have to accept the disease, and this is the most tricky because it’s psychological. People do not want to be sick. Eighty percent of diseases are chronic diseases. You have to accept that you will not be able to do this, this and this.
Yeah, for the time being. That’s why we have a different, psychological approach. We have some Psychological Round Table (PRT)—how to live with diabetes, how to live with chronic disease. And this is an additional step.
And the last objective—to understand and accept disease as a friend. You have to learn to live with your illness. The disease helps you to have new priorities. You grow with the disease. It’s a sense of your life.
After I got cancer, I changed my life completely. I sleep more; I eat better. I had less stress at work. I insisted, “I’ve to do something.” Because of cancer, I changed my life. I am better today.
Ten years ago. Cancer of smokers. I never smoked.
No, no, no, no. It was in the bladder.
That’s unique only for smokers. But I said, “Okay, what can I do? I have to change the suffering in my life. I work too much. I want to spend more time with my wife,” I was drinking alcohol very rarely. I said to myself, “I have to do something.” Today, I sleep one more hour. That’s two weeks during the year additionally! I eat correctly. I do sport. And that’s it.
I tried to convince my patients that they should do a significant transformation to change the way. There is a model of personality. You don’t behave the same as other people regarding your emotions.
Yes. It’s important.
We developed a master’s degree for other people in Europe. Students were coming for two to four weeks every two months. To be exact, fourteen different specialties now come from the field of diabetology—physicians, nurses, etc.
It’s not only for physicians.
And they come every two months for one week. They get a certificate after one year and a diploma after two years. They come from everywhere in the world. We have people from who came to .
Diabetes is related to 45 different chronic diseases. We have the same basics to understand how to cope with this disease. Later we published a publication about it. For instance, in our place, we were able to diminish diabetes by 80%. Today we help ninety percent of “blindness patients”, 70% of patients lose weight. We put all this data in the publication. Our team published more than 600 papers that showcase the positive effects of patient education. It’s more powerful than the medication itself. Now, let’s go back to a typical patient.
I am part of the Collaborating Centre of WHO for obesity, diabetes, patient education, but also for an “average patient”. I say, “If you sleep well, eat well, drink not too much, decrease your stress levels, and you stop smoking — those five bad guys are responsible for 80% of all the diseases, World Health Organisation (WHO) written.
I’m giving speeches all the time. I do not speak only to diabetic patients. I’m speaking for the ordinary. The treatment of diabetic patients is the same. You should take care of yourself on a regular basis.
No, no, I don’t put in an order. The patient decides. What are you able to change? We have a paper with five groups of 70 years old patients. They have to decide which ones they can change — diet, physical exercise, quit smoking, drink less alcohol. Stress is not possible in this way.
And after ten years, we have 70 years old patient control groups also—a group that doesn’t do anything and a group that is doing everything. The mortality decreased by 40% of cancer if you stop smoking. Also a similar number if you prevent or diminish your alcohol consumption very drastically.
You decrease the mortality of , mortality if you change your diet. Approximately 40% of mortality is decreased if you do physical exercises. The group who did all four decreased mortality by 75%. They were not sick.
Yeah, they were not sick. In the beginning, there were no research papers of severely ill patients. A healthy lifestyle is never too late.
The stress is the beginning of everything. Because of stress, I have no time to cook or to eat correctly. If I have too much stress, I will smoke and drink. If I have too much stress, I have no time to do sports. That’s why I wrote the book “How to Lose Weight Without Stress.”
The top of the top is the stress and the behavior of our society. I treat patients who have too much stress because they don’t have a job or because they have too much work. After seeing a calendar or the work plan of ministers, I try to diminish the work they have. And on the other side, I treat people who are looking for a job; we do assertiveness tests or some self-esteem exercises with a purpose to find a job. That’s my job as a diabetologist. Can you believe it?
It’s about addiction to food, addiction to cigarettes, addiction to alcohol, and drugs. Carbohydrates or fat use the same reward system in the brain as alcohol and drugs. They cause addiction. You do not treat addiction by saying, “Quit smoking.” In this case, a patient will eat more or drink more.
If you do a surgical operation for losing weight, after a while, after one or two years, the patient starts a different addiction to alcohol or olive oil as a drink — they gain weight.
Fifty percent of the patients who went to the surgical operation gain weight. You have just to stop if you want to quit cigarettes. We call this motivational interviewing and cognitive-behavioral methods: “Why? Why do you smoke? Which situation? What are the stimuli of smoking or drinking?”
I ask patients, “What is the most critical cigarette during the day?” If you quit all of them, and after four or five you try to understand what is the use of this cigarette, what is the use of alcohol or the food. We call this emotional food. I eat chocolate because I had a terrible discussion with my wife or a conversation with my boss. If you just quit without motivation, you have to find a better strategy.
I did a study 20 years ago. We put our patients in the hospital for six weeks. Because if you do publication worldwide, you never know the results of the study irrespective of the diet. Let’s say you have a low carb diet, and when you go to your friends, you eat hamburgers and foods like this.
In the first study we have done in this field, we put the patients; we randomize them by diet: low carb, low fat or balanced diet.
And at that time, physical and calorie activities were the same amount with the same trauma. It was calculated and listed down by how they expend the energy. We measured indirectly using a calorimetry method. The results at that time aren’t different. The most important part is about calories.
Twenty years ago, researchers had involved 7,000 people in 600 studies, in a mega-analysis study. No statistically significant difference between the three control groups was found, except a tendency. The low carb diet helps with up to 8 kilograms per year. The low-fat diet gets rid of absolutely the same — 7.7 kilograms. The balanced diet helps with 6 kilograms. Therefore, a 1 kilogram difference is not significant. The results are approximately the same.
My conclusion has always been the same. You should prescribe something that the patient can do and how he enjoyed the diet. That comes to a personality. Psychiatrist Jung was talking about that.
Jung developed eight different personalities (extroverted or introverted). It’s too complicated for me. Thus we decided to make something more simple. It is beneficial to campaign about the personality of people and how this is related to food.
Businesses use this personality test to hire employees. Once I met a guy from Palo Alto, California. He was doing personality tests for hiring pilots for Swissair. For example, if you put three pilots analyzing all the time, they don’t take off.
If you take the opposite personality, we call promoters; they will not check out. They will take off without any problems. Thus, it’s best to put two different personalities in the same cockpit to be safe. Therefore, I’m hiring my colleagues also using this method. I’ve some controllers, a promoter, analyzer and facilitator.
It’s challenging to put everybody together, but it’s working much better because we don’t make mistakes. I will assign statistics for the analyzer. A promoter will go to the dean. I’m a promoter— thus I go to the dean.
I found a way to convince my dean or director of the hospital, but I’m also a facilitator who organizes parties a little bit. [Laughs] Also, I need a controller to be sure that we are not going on the wrong way. If we have useful research statistics, I can hire more people because we will make a lot of money etc.
Now, I prescribe a diet and drugs depending on the personality. Analyzer interpersonal need is security. Thus, I don’t prescribe anything new. I prescribe something very known and famous. I explain the details well. Analyzers will follow the diet much better. They say, “No,” I reply, “I understand.”
The opposite works for the promoter — I prescribed a new diet and I change all the time, “This is the best medication if we just got it.” The promoter can do, but the compliance or the observance of the analyzer is much better than the promoter going alone. If I do the same discussion with the analyzer, it doesn’t work.
Facilitator will have a strong need for personal dependence. If you have a special diet, a facilitator cannot follow it because he needs to be with his family. He needs to be with friends. In this case, we apply cognitive behavior methods to say “no” and certain other “sorries.”
The idea is simple.
Of course. For example, the controller should go fast. Then, I prescribe a low carb, very restrictive diet, high in proteins. They will lose 10 kilograms in one month. They will be so happy but they are terrible with the rest of the people. They convince everybody to do the diet. If they go outside, they are not the facilitator — they become the controller. They will try to put everybody on a diet. It’s a joke, but this quite often exists.
The promoter will go to extremes — always drink tomato juice instead of having the wine. [Laughs]
I’m a Buddhist. It’s clear for me that we should not eat meat, fish, and animals. But you cannot transmit this to everybody. However, I try not to become too restrictive. That was why I ate shrimps at dinner a couple of days ago when they invited me. I didn’t make any comments. You should not be totally crazy about that. To be vegan, you have to be very aware of how to eat. You need cereals and…
This is very complicated. Because of the loss of muscle, loss of skin, and defect of many other things. For my health, the meat is not suitable. People can eat not too far meat in a small quantity. I have to avoid meat because cholesterol and saturated fats are related to cardiovascular disease.
[Laughs] Yeah, it’s simple for you, but for many people, they have no idea.
They’ve no idea. You can find many opposite comments on that.
You have to eat very well, to achieve this, huh?
20% of the cholesterol is due to the food, and 80% is genetic.
You have to find out if you are in the genetic pathway. For example, I lost my uncle, cousin and father at age 50. Therefore, I decided to take medication 25 years ago.
Today, I have no cholesterol problems because of this understanding. Genetics is very strong.
[Laughs] This is a good question. When I arrived in Switzerland for treating the cholesterol, we put the limit to 6.5. At 6.5 you will have really big problems. We were counting with the government and insurance company how to reimburse this kind of medication to people.
50% of the population reaches a level of 5 in Switzerland. If you put the limit at 4, then 80% of the patients have to be treated.
I cannot go too fast because now, 20 years later, the new limit is 5. And it’s not for the total cholesterol, but we are often talking with the which is the bad one. It’s too complicated.
For me, the total is 5.
After that, you have to discuss it with your patient because even if the patient has family problems they are more vulnerable. If the patient has diabetes, they are more susceptible. If the patient already has a heart attack, they are very vulnerable.
I took pills in primary prevention. I think, for secondary prevention, everybody agrees today that if you already have a heart attack, it’s easier even for the physician.
For primary prevention, I will have a hard time. But for me, I decided to do primary prevention. I was a marathon runner. I was drinking not too much and eating perfectly. However my cholesterol was still higher, around six. I said, “I have to do something.”
Therefore, I did primary prevention for myself, and I gave a lecture a couple of months ago about this. Physicians are reluctant to provide medication forever as primary prevention. I had a hard time convincing them. Suddenly a guy said, “Okay, I’d like to give my own opinion, my own story. I lost four brothers at age 45. I am the only one surviving because I took .”
Yeah, it’s convincing.
[Laughs] This is a significant point today. We made the biggest mistake in our society to have genetically modified food. The body can deal with a thousand different colitis, et cetera. Your body and your brain realize sooner or later that’s a big mistake because it’s only one choice. It’s dangerous.
You will develop antibodies, allergy. Today, my major worry is if anybody is going to develop the fix because we decided to have genetically modified food. I’m an endocrinologist, so I know pretty well these kinds of antibodies against hormones, against thyroids, against pancreas, against diabetes.
I’m worried because it’s a new type of disease. We should go back to biological food. The food should be diverse. I have several patients who had joint pain or . I said, “Okay, let’s try a diet without gluten for three months, six months if you can do it because it’s challenging to follow.”
The pain of joints will be gone. It’s interesting because the patient has a hard time following a diet like this. And they say, “Okay, for the weekend I make an exception. I allow myself to eat good bread or something.” The pain comes back on Monday morning. Then, they need medication.
That’s my explanation. And for me, the gluten-free diet could be beneficial for pain relief. You have sports people, like Djokovic, the tennis player.
He is gluten-free. But after two years he becomes really weak. He was number one in the world, and suddenly something was missing. I cannot explain it in this way. I think he’s not right. “My life and my rules”, we have to eat everything in a small proportion. And if you are vegan, you have to eat everything except the meat. We have to have a balanced diet.
Perhaps, it is essential to think of what you eat. And when people choose to follow any diet, that brings a core to where world views. I didn’t know Djokovic was gluten-free, because I’m not that interested in tennis. But that gives me memories about other cases.
It doesn’t matter which type of diet they’re following. They are aware of what they’re eating. You should not be too much aware also, because they become a little bit rigid. Imagine, if you have to do a gluten-free, vegetarian, and lactose-free diet.
You cannot eat anything anymore.
As long as the patient is interested in doing something, he stays motivated. It’s okay for me.
Yeah. I have to have a good lifestyle because I don’t want to die at age 50. Long-distance running is the perfect sport for cardiovascular.
I started quite early. I was running, doing some sport on the track field and suddenly two guys came to me and said, “We have a cross country competition. And there’s always a prize for the three best, and we are the two best. We need a third one.” I asked, “Do you think I can run cross country?”
Really competitive people trained me. I was in the top 10, and we won almost all the prizes because these two guys were the best.
They pushed me to do 5K, 10K, and half marathon. I came later in my life at age 35 for a marathon. You know that you have to run, sleep, and eat to become a professional marathon runner. You cannot do anything else.
Seriously. Marathon is another story. You have to run twice a day, and I was a medical student. I didn’t want to do these things.
Well, my best time for 10Ks is 33 minutes, and for the half marathon - 1 hour and 12 minutes.
Yeah, but I was too late for the marathon. Forty-two kilometers are too much for me.
Yeah, yeah. And the best one was just below three hours. I didn’t push too much.
To run 42 kilometers like a crazy guy is very mentally and physically demanding. Physical pain is the most difficult for me. You have pain somewhere all the time [Laughs].
It’s changing also.
Well, I’m 62. I try to keep my body in good shape. I bike two or three times a week for one hour at home. During the wintertime, there is no way to go outside at nine o’clock in the evening. Thus, I bike at home watching TV and reading books. It’s difficult to read when you ride a bike. [Laughs]
And I run one or two times a week for 45 minutes to one hour.
No, that’s finished. When I start to compete, I know I can suffer. For me, it’s enjoyable because I’m still able to run. That’s a good point. I walk pretty much with my wife, and she’s jogging sometimes too. I walk most of the time. It is softer.
And enjoyable. Yeah. You walk for one hour, two hours. It’s also good.
We have workshops for patients. I say, “Let’s try to do as much as you can and it will be easy and enjoyable.” People sometimes do not go out of the house. The first step is to go out for 5 minutes, 10 minutes.
Just for a walk. And when you have a patient saying, “I bought a dog; it’s fantastic because then I go three or four times a day out.” After that, you try to put in their mind that the more they do, the better it is. But avoid being stressed.
Later, they start to walk faster and longer. I wrote books on that: three times a week for 45 minutes. You’re walking a bit fast, or doing some specific sport. Or walking 30 minutes five times a week. It’s already a lot, huh, 30 minutes?
Yeah. It’s not easy for many people. Therefore, we have facilities today to measure that. We have a pedometer.
So, I said, “You should reach between 5,000 to 10,000 steps per day.”
And I never use the escalator except if I’m with some groceries or some luggage and things like this. But, usually, I don’t use the elevator.
In principle. That’s a rule.
I enjoyed it too.