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Do We Need Billing Codes For Stopping Insulin?

Starting patients on insulin is not easy. Patients have to be counseled, educated, introduced to self-monitoring, and need to be seen more frequently till they are comfortable and have achieved their treatment goals.  For this, in many countries, there are dedicated billing codes – some of which can be rather attractive. As a case in point, in Germany, billing codes for starting patients with type 2 diabetes on insulin, have resulted in Germany perhaps being the world leader in the use of insulin in patients with T2D.  As we now enter the era of increasingly effective anti-obesity medications, resulting in two-digit weight loss, there will be a growing number of T2D patients, who will eventually need to be taken off their insulin.  This again, is not as simple as it sounds. Many T2D patients are on rather high doses of various types of insulin and will need to be gradually tapered off. During the time of active weight loss, insulin doses will need to be adjusted, both to avoid hypoglycemic episodes but also to ensure that the HbA1c targets are maintained.  This is extra work for doctors (and their staff) and will need to be accounted for.  Thus, it may be reasonable to ask whether it is time to introduce billing codes for stopping insulin, given the large number of patients who are currently on it but will need to come off as they experience significant weight loss.  We have already seen such situations in patients undergoing bariatric surgery, but there, due to the rather rapid improvement in glycemic control, we can often simply hold the insulin following surgery.  With the more gradual weight loss seen with anti-obesity medications, this process will take longer and needs to be closely monitored. In jurisdiction where there are no special billing codes for starting insulin, this may not be an issue. However, in jurisdictions, where such billings provide an incentive to doctors to start patients on insulin, we may need to create new billing codes to incentivise docs to take their patients off insulin as effective anti-obesity medications become more widely available.  DrSharma Berlin, D

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Guest Post: Racism and Health Disparities in Black Americans

Today’s guest post comes from Sean Wharton, my friend and colleague from Toronto, well known to all of us working in obesity medicine. Since the George Floyd incident in the United States, the entire world has taken greater account of instances of racism and discrimination in all walks of life.  Medicine is no different and it is therefore no surprise that much of medicine is steeped in racism.  Many people refer to this as the social determinants of health, but the structure and underlying reasons for those determinants, in many countries, is racism.   In America, the remnant of slavery also lives on in the social determinants that drive the obesity epidemics in African Americans.  African American women have an incidence of obesity of 57%, compared to white women at 40%. This is 42% higher!  This is a staggering difference. What accounts for this?  We now have a greater understanding that most disparities in health, including hypertension, diabetes and obesity, are due to racial and ethnic inequities, many of which are a legacy of their past history.   For obesity in African Americans, we can start by looking at the nutrition during slavery.  A slave’s diet was primarily made up of inexpensive foods that were high in sugar and fat, designed to provide fuel that would be burned off during the day.  As reported historically slave rations could include: 10 quarts rice or peas 1 bushel sweet potatoes 2-3 mullet or mackerel salt fish 1 pint mollasses 2 pounds pork Thus, African Americans became accustomed to this diet and continue to have a palate for such as evidenced by the menu in many Southern African American restaurants and homes.    Today food choices for African American follow a similar pattern as in the times of slavery.  Foods – high starch, fat, sodium, cholesterol, and caloric content, and are inexpensive and often low-quality nature of the ingredients such as salted pork and cornmeal.  This gives us some explanations regarding the disparity in the incidence of obesity between the races, and now we deal with the fact that there is are difference in success of obesity treatment between the races. Again this is likely due to the very same social determinants.   Our own research has documented that women of colour lost less weight at weight management clinic, but when adjusted for the number of visits, the weight loss was the same.   It was clear that… Read More »

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Why Calories Still Matter

Over the past decade or so, alternative explanations for the rise in obesity rates, that de-emphasize the role of caloric intake vs. the role of specific nutrients, have had a field day.   Leading amongst these, no doubt, is the Carbohydrate-Insulin-Model (CIM) of obesity, whereby, carbs stimulate insulin release, which in turn stimulates expansion of adipose tissue, which in turn leads to insulin resistance, resulting in even higher insulin levels, ultimately resulting in a vicious cycle that can only be interrupted by religious adherence to a low-carb diet.  Although this model has had broad populistic appeal, spawning a whole industry of best-sellers, low-carb products, and even treatment programs built around this paradigm, as pointed out in rather comprehensive article by Kevin Hall and a host of notable obesity experts, published in the American Journal of Nutrition, CIM (which has undergone several modifications since its inception), does not quite concur with all of the pre-clinical and clinical evidence.  In this paper, the authors make a rather compelling argument in favor of the Energy-Balance-Model (EBM), which pretty much aligns with virtually everything we know about the science of body weight regulation.  According to the authors, “The EBM proposes that the brain is the primary organ responsible for body weight regulation via integration of external signals from the food environment along with internal signals from peripheral organs to control food intake. Specific brain regions, such as the hypothalamus, basal ganglia, and the brainstem modulate food intake below our conscious awareness via complex endocrine, metabolic, and nervous system signals acting in response to the body’s dynamic energy needs as well as environmental influences…..whereas day-to-day energy intake and energy balance of an individual can be highly variable, neural regulation of energy balance is generally achieved over prolonged time scales.”   The key term in all of this is “positive energy balance”, without which there can be no accumulation of excess weight. Ergo, as calories are  the currency of energy balance, there can be no excess energy balance without excess calories.  As the authors go on to explain, the physiological processes that determine caloric intake are subject to a host of biological and environmental perturbations, explaining both the differences in individual susceptibility as well as the wide variability in shape and size evident even in populations with similar environmental exposure. Furthermore, this model also explains the wide variation in response  to dietary, pharmacological, or even surgical manipulations that… Read More »

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Will the Weight-Loss Results for Tirzepatide Shrink the Field for Future Anti-Obesity Treatments?

At the 2022 European Congress on Obesity, which I attended over the last few days, there was much buzz about the rather spectacular 22% average weight loss achieved with the dual GIP-GLP-1 agonist tirzepatide – a degree of weight loss that is not far from matching the weight-loss outcomes of patients undergoing metabolic surgery. Clearly these results  are shifting the benchmark for what we can expect from future anti-obesity medications.  While we await the full publication of these results and the outcomes of the other trials in the SURMOUNT program, it may be prudent to speculate what these results mean for compounds and treatment options for obesity currently in the pipeline.  At last count, there were over twenty different anti-obesity compounds across a range of modes of action at various stages of clinical development.  Some may well have the capacity to match the degree of weight loss seen with tirzepatide, but matching or even exceeding the 20% mark is likely to be a tall order for most.  Thus, no doubt many anti-obesity medication development programs may now be seriously reconsidering or even abandoning current candidates.   This would be unfortunate!  For one, given the heterogeneity of pharmacodynamics responses, there will always be individuals for whom tirzepatide may either not work or not be well tolerated, leaving ample room for less effective medications that may do the job for these patients.  More importantly, it may well be that, although these compounds may not be effective enough when used alone, they may be ideal candidates for add-on or combination treatments.  An example that comes to mind would be the combination of the long-acting amylin analogue cagrilinitide with the long-acting GLP-1 analogue semaglutide, for which we have early data suggesting that it may well match or even exceed the weight loss seen with tirzepatide.  Given that combination treatment is now the most common approach to treating a host of chronic diseases including hypertension, diabetes, heart or kidney disease, there is no reason why this would not be the case for obesity.   While each component of these combinations may only be moderately effective on their own, they may well have synergistic effects that more than add up (as seen for buproprion plus naltrexone) or allow the use of lower doses, thus improving safety and tolerability (as with the combination of low-dose phentermine and low-dose topiramate).  Thus, rather than abandoning compounds currently in the pipelines just because… Read More »

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Zooming Forward to New Connections

This week I am attending the joint meeting of the European Association for the Study of Obesity (EASO) and the International Federation for the Surgery of Obesity and Metabolic Disorders – European Chapter (IFSO-EC) in Maastricht, held under the timely title ZoomForward2022. Indeed, after two years of virtual meetings on Zoom and other platforms, it is finally time to meet friends and colleagues again in-person.  Given the hiatus, for many young students, postdocs, residents, and other trainees, this may be their first opportunity to meet and connect with their peers in-person.  I therefore thought it would be appropriate to remind everyone of a previous post on how to get the most out of scientific meetings – a guide for early career participants.  The key messages, that I think will be most useful to anyone starting out their careers (and perhaps for some older folks) are summarized in this video on YouTube. Hopefully, these tips, based on my own strategies and tactics, that have helped me throughout my career, will help you get the most out of the next few days (or any other scientific meeting you may attend in the future). See you in Maastricht.DrSharma,Berlin, D

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Deep Dive Into Obesity Phenotypes

Last week, in my capacity as a Strategic Advisor, I had the pleasure of attending the SOPHIA general assembly in Favrholm, just outside of Copenhagen. SOPHIA stands for the Stratification of Obesity Phenotypes to Optimise Future Therapies, and consists of a large research consortium that includes thirty-one international members from academia, industry, and NGOs. With funding support of around € 16 million from the Innovative Medicines Initiative (IMI), a joint undertaking of the European Commission and the European Federation of Pharmaceutical Industries and Associations (EFPIA), T1D Exchange, JDRF, International Diabetes Federation (IDF), and Obesity Action Coalition, the SOPHIA research consortium aims to find better solutions to address obesity and reduce its consequences.  The eight work packages range over a variety of issues ranging from technical challenges like creating a confederation of large harmonised databases to allow sophisticated analyses of phenotypes, trajectories and outcomes, specific projects on the relationship between obesity and diabetes (both type 1 and 2), exploration of surgical outcomes, to important work on better understanding the patient voice and incorporating their views and needs throughout the various projects.  Now in its 3rd year, the progress in all work packages has been remarkable (despite the complications due to COVID) and one of our strategic recommendations has been to perhaps explore opportunities to identify and incorporate additional data sets, particularly in the areas of mental, cardiovascular, and reproductive health. Researchers working in these areas, who may be interested in contributing datasets to this initiative can contact the SOPHIA office via the project website. Overall, this joint effort, guided by the patient voice, is certainly exciting and innovative and I look forward to several of the work packages presenting their findings during the 28th European Congress on Obesity in Maastricht later this week.  @DrSharmaBerlin, D

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