Are Lifestyle Zealots Promoting Weight Bias and Discrimination?
There are no doubt important benefits to be had from following a healthy lifestyle. A healthy diet, plenty of physical activity, restorative sleep, meditation, mindfulness, healthy relationships all contribute to maintaining good health and well-being. And yes, all of the above can and probably should be part of any management regimen for any chronic disease. However, the notion that these measures alone can constitute an effective and feasible treatment approach to obesity is neither supported by long-term randomised controlled studies nor by real-world experience of most individuals living with obesity, who have attempted controlling their weight with such measures. Obviously, there are some anecdotal cases of individuals who have apparently “conquered” their obesity by drastically changing their lifestyle, mostly following rather restrictive dietary regimens (of which there are many) together with a punishing dose of daily exercise – but these rather exceptional cases in fact constitute fine examples of just what it takes to lose and sustain significant weight loss and should readily explain why this approach will simply not appeal to or prove feasible for the vast majority of people living with obesity. Harping on about how lifestyle change is the real answer to obesity is simply promoting “fake news” and clearly implies that anyone who has tried lifestyle measures and failed, has simply not tried hard enough. Such a message can only lead to even greater internalised weight bias and does little more than to reinforce the notion with the rest of us, that people with obesity are simply too lazy, lack motivation or willpower and are perhaps just not smart enough to get it. Thus, every time another health zealot feels called upon to voice their opinion on how they may have personally conquered their obesity or have helped clients conquer theirs, I can only cringe at how my patients living with obesity perceive such messages. Rather than freely acknowledging that trying to manage your obesity with lifestyle measures alone means a lifetime of restrictions and ongoing efforts, healthy living enthusiasts promote notions that do little more than to promote weight bias and ultimately reinforce stigma and discrimination. Perhaps, even more importantly, now that we have effective medical treatments, their messages imply that anyone turning to these treatments is simply taking the “easy way out”, not willing to do the work and should probably be ashamed of themselves for failing to stick to the righteous path of… Read More »
Conflating Effects of Weight Loss With Adverse Effects of Anti-Obesity Medications
The introduction of a new generation of highly effective anti-obesity medications (AOMs) has brought on the “naysayers” with warnings about the “dangers” of using these drugs, especially long-term. In this context, I often see a conflation of issues that are simply the normal and expected consequences of losing weight with the actual known adverse effects attributable to the biological action of these medications. Thus, as we know from people experiencing significant and often rapid weight loss with the use of low-calorie formula diets or bariatric surgery, it is not uncommon to see transient hair loss or gall-bladder stones. Also, the issue of sagging skin and other body parts as a consequence of weight loss is nothing new and has little to do with the biological action of these medications (thus “Ozempic face” could also be called “bariatric surgery face” or simply “weight-loss face”, but that would not be half as catchy). Another issue that has nothing to do with the mode of action of these medications, is that significant weight loss can lead to manifestation of complications due to other underlying conditions and their treatments. For example, the rapid improvement in glycemic control resulting both from weight loss and GLP-1 actions on insulin secretion can lead to hypoglycemia in patients with diabetes who are also on insulin or sulfonylureas. Similarly, the reduction in blood pressure due to weight loss can lead to orthostatic hypotension in individuals on anti-hypertensive medications. These problems should be anticipated and can be avoided by close monitoring of patients and reducing the dose or discontinuing medications that are no longer needed. There has also been much ado about the potential for muscle loss and nutritional deficiencies associated with these medications. However, it is important to remember that any loss of body weight will also result in loss of muscle mass (generally around a third of the total weight loss) and any major reduction in food intake (irrespective of its cause) over time can result in nutritional deficiencies, especially in individuals who start out with sub-optimal nutritional status in the first place. Again, this issue has nothing to do with the biological action of these medications, as these problems can be routinely observed in individuals losing significant amounts of weight on other treatments including dietary restriction or bariatric surgery. Moreover, both issues can generally be managed by close monitoring, optimising dietary intake (especially protein) and increasing physical… Read More »
Can Diabetologists Take On Obesity Care?
For the past 30 years or so, I have given countless talks to diabetologists urging them to pay more attention to obesity management – all to little avail. Interestingly enough, now, that we have new effective medications for obesity, which come with loads of pharma funding for research, education and conferences and as we near the end of significant new pharmacological developments in diabetes care, we are witnessing a sudden surge in interest amongst diabetologists and their professional organisations in taking on obesity as part of their “portfolio”. This is good! Not only is there considerable overlap between patients with type 2 diabetes (T2DM) and those with obesity (indeed, it is hard to find a T2DM patient without obesity), effective treatment of obesity can lead to substantial improvements in glycemic control (and even complete remission of T2DM), and the incretin-based medications for obesity are also of use for managing T2DM. Moreover, given the sheer number of diabetologists out there, together with the rather extensive and well-established infrastructures for diabetes care, expanding their mandate to also managing obesity appears a logical and long-overdue step. However, there are some important caveats. For one, the majority of people with obesity do not have diabetes and will probably never get it. For these individuals, going to a diabetes centre would seem strange, given that glycemic control is the least of their worries. Anyone who has any experience with obesity medicine knows that people presenting at obesity and bariatric centres are rarely there because they are concerned about their HbA1c levels. Their problems are chronic pain, sleep apnea, infertility, polycystic ovary syndrome, fatty liver disease, urinary stress incontinence, osteoarthritis, GERD, migraines, and a host of other issues that have nothing to do with glycemic control. Furthermore, a substantial proportion of patients presenting at bariatric centres have depression, anxiety, ADHD, BED, history of trauma, chronic grief, addictions, internalised weight bias, and plain old emotional eating, all of which need to be properly diagnosed and managed as part of obesity care. Finally, no one can claim to have expertise in obesity medicine, who is also not comfortable with the pre- and post-surgical management of patients undergoing bariatric surgery (so far, despite strong evidence, diabetologists have rarely referred a patient for bariatric surgery never mind getting involved in their post-surgical care). While there is no reason why diabetologists should not be able to learn about and attend to… Read More »
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.
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