The 3Ds of Obesity: Discrimination, Disinformation, & Disinterest
Last week I gave a Keynote presentation to dignitaries and attendees at the 5-Year Anniversary of the Helmholtz Institute for Metabolism, Obesity and Vascular Research (HI-MAG) in Leipzig. Tasked with summarising where we stand in obesity prevention and management for attendees who were not obesity experts, I boiled down the message to three points. We are where we are in addressing obesity both in terms of prevention and management because of the 3Ds: Discrimination, Disinformation, and Disinterest! Not much needs to be said about discrimination, as it is well documented that people living with obesity experience discrimination on a daily basis, be it in educational settings, workplaces, or when moving about in public. In my talk I zeroed in on the discrimination people with obesity face in health care settings: doctors spend less time with them, order fewer tests, prescribe fewer treatments, and generally have little advice to offer beyond “Eat Less Move More”. No wonder, people with obesity turn to doctors as a last resort after all their do-it-yourself approaches have failed. Much of this weight-bias and discrimination is directly fueled by a barrage of disinformation by a multi-billion weight loss industry that has little to offer beyond useless dietary supplements, fad diets, exercise machines, and loads of other stuff that they can happily unload on desperate victims under a barrage of nonsense or half-truths (all those weight-loss secrets your cardiologist does not want you to know!). Unfortunately, governments and policy makers are complicit in this by announcing successive unachievable population goals, that focus largely on food and activity policies, none of which have yet made a dent in the obesity epidemic but do serve as a fine excuse to not provide treatments to those who already have the problem. Finally, it is hard to fathom the amount of disinterest and lack of knowledge that the vast majority of healthcare providers show in the management of obesity. This is particularly true for most of academic medicine, which has bemoaned but otherwise largely ignored the problem. By any metric, be it in the number of academic chairs, PhD theses, research projects, research funding or publications, obesity ranks aeons behind any other major health problem of our time. We are still licensing doctors and other medical personnel that have never managed a single patient for their obesity (not just with obesity). Fortunately, we are now finally seeing some movement in all… Read More »
The Ethics of Aesthetic Use of Anti-Obesity Medications
Given the widespread culture desire for thinness (a term, I first heard used by my dear colleague Lee Kaplan), it should be no surprise to anyone that for many, the primary motivation for seeking a doctor’s prescription (and yes, you do need one!) for an anti-obesity medication (AOM) may well be appearance rather than health. This may seem frivolous and perhaps vain, but what are the real downsides of using AOMs outside their medical indication? For one, there is the risk associated with using any medication. Although the newest generation of incretin-based AOMs are considered safer than anything that has come before, there can be unpleasant (e.g. nausea, vomiting, diarrhoea), and sometimes (albeit much rarer) more serious (e.g. gall-bladder colics, pancreatitis, malnutrition) adverse effects. There are also important contraindications to their use (e.g. pregnancy, history of medullary thyroid cancer). However, once these risks have been discussed and the individual decides that this is a risk they are willing to take, does it really matter whether the person is primarily motivated by aesthetic or health reasons? In fact, I have heard many colleagues tell me that they are happy to harness their patients’ aesthetic motivation to get them to take these meds for health benefits. As important as these discussions are and as much as we need to have serious conversations with individuals who are clearly only interested in losing weight for appearance sake, in practice, there is usually a considerable overlap between the cultural desire for thinness and the need to lose weight for health reasons. Thus, even in people with a BMI as low as 25, around 50% of individuals will have some health issue that is likely to get better with weight loss. For others, who may appear healthy, weight loss may reduce the risk of future diseases that run in their family (e.g. type 2 diabetes, heart disease, osteoarthritis, etc.). As we get to higher BMI levels, the proportion of people with significant obesity related health problems increases to over 85% in those with a BMI over 40. This still leaves some people with a high BMI, who are pretty healthy and for whom the only benefit of weight loss (if desired) would be largely aesthetic, but these are clearly the exceptions. So where do the ethics come into all of this – obviously, we operate under the dictum – primum non nocere – which means that… Read More »
Uk to Spend £40 Million on Obesity Medication Pilot
Yesterday, the UK Government announced a plan to spend £40 million on a two-year pilot to explore ways to make obesity drugs accessible to patients living with obesity outside of hospital settings. As readers may know, anti-obesity medications including semaglutide have already been approved for prescription in hospital-based obesity clinics in the UK (albeit its use is limited to just two years, which makes little sense for a chronic disease like obesity). As noted in the announcement, however, this limitation to use in hospital-based clinics will only reach about 35,000 people living with obesity, a tiny fraction of the over 12 million people with BMIs >30 kg/m2 in the UK. According to the release, “Obesity costs the NHS around £6.5 billion a year and is the second biggest cause of cancer. There were more than 1 million admissions to NHS hospitals in 2019/2020 where obesity was a factor.” The pilot will explore how approved anti-obesity drugs can be made safely available to more people by expanding specialist weight management services outside of hospital settings. This includes looking at how GPs could safely prescribe these drugs and how the NHS can provide support in the community or digitally. The hope is that wider use of these medications can help cut waiting lists by reducing the number of people who suffer from weight-related illnesses, who tend to need more support from the NHS and could end up needing operations linked to their weight – such as gallstone removal or hip and knee replacements. These activities to improve access to anti-obesity medications, of course, also includes negotiating a secure long-term supply of the products at prices that represent value for money taxpayers. Obviously, this is a step in the right direction, as I have previously noted that to have a discernible impact on population health, anti-obesity medications will ultimately have to be made available and properly managed by GPs, not unlike their management of hypertension, diabetes or other common chronic diseases. It will be interesting to see how this pilot develops and if other countries in Europe and elsewhere will follow suit. DrSharmaBerlin, D Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.
How Important Is Predicting Response to Anti-Obesity Medications?
I seldom give a talk on anti-obesity medications (AOMs) where I do not get the question regarding predicting response. Indeed, predicting response appears to be one of those topics that drives much of the enthusiasm around “personalised” medicine (a misnomer, if there ever was one). One must first point out, however, that the desire to predict therapeutic response is by no means unique to obesity. In fact, there is probably no area of medicine, where prediction of response is not something that would be preferred. Unfortunately, with a few rare exceptions, we are far from predicting therapeutic response beyond statistical probabilities. Thus, in most cases, we present a likelihood, i.e. “you have a one in three chance of losing 20% of your weight”. Whether you would see this as a good or poor chance, depends on whether you are of “glass half-empty” or “glass half-full” disposition. Indeed, trying to reliably predict individual responses based on mode of action, pathophysiology or some phenotypical characteristic, has failed miserably (despite all efforts) in most fields of medicine (with cancer perhaps being a notable exception). This has not worked for hypertension, dyslipidemia, diabetes, depression, or most other conditions. Indeed, virtually all guidelines recommend starting with the most “popular” medication (with due consideration of individual indications and contraindications), but then adjusting the dose or adding or switching to another agent based on actual tolerability or response. This “trial and error” or rather “empirical” (which sounds much better) approach to medical management is not uncommon in most fields of medicine. Like it or not, predicting who will tolerate and who will respond to a medication remains largely a guessing game. I see no reason why this should be any different for obesity. The good news is that in medicine we have the luxury of “trying” – something that surgeons don’t have – you cannot try a sleeve gastrectomy – once you have it, there is no going back. It is also good news that with all AOMs, early response remains the best predictor of long-term outcomes – so no one needs to continue on an ineffective medication for all too long. Yes, it does mean some people will have to bear the cost and exposure to a medication that will not work for them, but, in most cases, there is not much harm done. So while, in an ideal world, I would love to be able… Read More »
Are Patients With Type 2 Diabetes Responsible For The Semaglutide Shortage?
Shortages in supply of semaglutide, approved in various countries (including the US, Canada, UK, and the European Union) for the treatment of type 2 diabetes and obesity, have led to calls to restrict its use to patients with type 2 diabetes (T2DM). Indeed, there has been much ado about people using (and misusing) semaglutide “simply” for weight loss, apparently depriving people living with T2DM of this “essential” medication. While it makes no sense to pit one disease against another, one could well argue that it is the people living with T2DM who are in fact depriving the folks living with obesity of this “essential” medication. For one, there are plenty of treatments available for managing T2DM. Although semaglutide may well be a safe and effective medication for T2DM, there are plenty of other GLP-1 analogues around, not to mention the many other classes of medications approved for T2DM. Thus, were semaglutide to disappear from the market, most people living with T2DM would do just fine with the many alternatives that already exist.. This, however, is not the case for obesity! People living with obesity requiring obesity treatment have no alternative that is even remotely as effective as semaglutide, which, for a significant proportion of patients, can result in weight loss comparable only to what can be achieved with bariatric surgery. Thus, while there is no discernable unmet need for people with T2DM, the unmet need for those living with obesity is indisputable. Reserving the limited supplies of semaglutide for them should be a priority. Obviously, most people living with T2DM are also living with obesity (which highlights the absurdity of pitting one disease against the other), but emphasising the need for people with T2DM while ignoring the much greater need for those living with obesity, to me, reeks of weight bias and discrimination. Hopefully, the supply of semaglutide will eventually increase to meet the demand, but perhaps in the meantime those living with T2DM who are not in desperate need of losing weight should help conserve the limited supplies of semaglutide in favour of those living with obesity, who do not have the luxury of switching to an alternative but equally effective treatment. DrSharmaBerlin, D Disclaimer: I have received honoraria as an independent medical, research and/or educational consultant from various companies including Aidhere, Allurion, Boehringer Ingelheim, Currax, Eli-Lilly, Johnson & Johnson, Medscape, MDBriefcase, Novo Nordisk, Oviva and Xenobiosciences.
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