Canadian Obesity Guidelines Double CMAJ’s Impact Factor
There can be little doubt in anyone’s minds that the 2020 release of the Canadian Clinical Practice Guidelines on Adult Obesity, a summary of which was published in CMAJ, represents both a landmark and a watershed in obesity medicine. Within 48 hours of its release, it received over 80 miillion media impressions around the world and the CMAJ summary was the #1 downloaded article on the CMAJ website in 2020. Just how large the impact of these guidelines were, is perhaps best reflected by the recent “thank you” note to the authors from Kirsten Patrick, Editor-in-Chief of the CMAJ, which notes: “I’m writing to thank you for contributing to CMAJ’s doubling its Impact Factor (IF) in this year’s report! CMAJ’s 2021 IF is 16.859. The highly-influential Guideline that you and your colleagues published in CMAJ in 2020 contributed to this big jump. Thanks for choosing CMAJ for your publication. I hope you’ll choose us again.” In fact, according to Google Scholar, the guidelines have already been cited in over 150 articles and downloads of the PDF from the CMAJ website continues at a steady clip of over 2000 a month. This rather spectacular attention to these clinical practice guidelines (generally a rather mundane event that rarely catches the attention of lay media), is testament to the tremendous efforts and forward-thinking approach taken by the over 60 authors, who in 19 chapters layout our current thinking and evidence for addressing obesity as a chronic disease in clinical practice. While I congratulate CMAJ on this spectacular jump in its impact factor, I can only hope that this attention is reflected in the implementation of the over 80 recommendations by payers and health authorities as well as any health practitioners involved in obesity care. As our knowledge continues to advance, I look forward to the continuing updates of these guidelines to ensure that these advances continue to improve the lives of the people living with obesity. @DrSharmaBerlin, D
European Withdrawal of Amfepramone – End of an Era!
On Jun 10, 2020, the European Medicines Agency (EMA) recommended the withdrawal of amfepramone from the European market. This agent, belonging to the group of amphetamine-like stimulants, was authorised in Denmark, Germany, and Romania under the trade names Amfepramone Hormosan, Regenon, and Tenuate for weight reduction. Due to an increased risk of significant side effects including cardiovascular disease, pulmonary arterial hypertension, dependency and psychiatric disorders, as well as harmful effects if used during pregnancy, use of amfepramone was limited to no longer than three months. However, as the EMA review of amfepramone use revealed, “…amfepramone medicines continue to be used outside the current risk minimisation measures included in the product information.” As the EMA could not see any further measures that would be sufficiently effective to minimise the risk of side effects, it concluded that the benefits of amfepramone medicines do not outweigh their risks and recommended that the medicines be removed from the market in the EU. Notably, EMA also stated that other treatment options for obesity are available and that health professionals should inform patients about these options. Thus, it appears that at least in Europe, the era of amphetamine-like sympathomimetic medications for weight loss is finally coming to an end. No doubt, many health care professionals and patients, who may have relied on amfepramone in the past, will state that, despite possible risks, this medication at least was affordable to the many patient desperate for obesity treatment. Indeed, the vast majority of patients seeking anti-obesity medications, who may have swallowed the rather low cost of amfepramone (pun intended), may well baulk at the cost of the newer class of GLP-1 analogues (liraglutide, semaglutide), despite being deemed safer and more effective. This issue will need to be addressed by fair pricing policies and the hope that the daily cost of liragutide will drop considerably once the more effective once-weekly semaglutide enters the market, thus providing an affordable alternative to patients, who have previously relied on amfepramone. Ultimately, I see no alternative than to include reimbursement for safe and effective anti-obesity medications in health plans, thus making these treatments available to more than just the upper 1% who can afford to pay out-of-pocket. @DrSharmaBerlin, D
Guest Post: Reasons For Weight Regain
Today’s Guest Post comes from my friend and colleague David Macklin, MD, Toronto Not long ago I received a message from a colleague looking for help with a patient who was regaining weight. As I thought about my response, it occurred to me that there should be a comprehensive list of why this happens, yet I could not remember coming across one. The following is a more detailed reproduction of the list I sent back to my colleague that day. I’d like to thank Arya for suggesting that I share this list with his readership. An important note regarding this list: Reason number one is the most important and most common reason for weight regain. The other reasons can make the primary reason more complicated. 1.BIOLOGY The primary reason for weight regain is biology. The brain defends against weight loss because of an old biological play book. If our ancestors lost weight, it was not to look good for a wedding or because of bathing suit season. Back then, weight loss was either because of illness or an interrupted food supply. Simply put, defending against weight loss was defending against death. In the last 30 years we have learned how the brain does this. The brain is expert at 1) recognizing fat loss, 2) defending against fat loss, and 3) promoting weight regain. The brain does this by: a) increasing appetite – the motivation for calorie intake b) decreasing metabolic rate Increased appetite seems to be more complicit than slower metabolism in weight regain. Increased appetite, in the form of an increased motivation to eat, leads to increased overall calorie intake, which in turn leads to weight regain. A reminder, the remaining reasons for weight regain operate through the main mechanism, biology. 2. DIETING The next common reason for weight regain relates to dieting. Note that dieting is not an effective method of preventing weight regain. Instead, the three pillars to preventing weight regain are behavioural therapy, medication, and surgery. Simply put, the risk of weight gain is greater the more “diet-like” the weight-loss method. Specifically: a) if the weight-loss effort involved a commitment to a reduced calorie intake that was unsustainable. b) if the weight-loss effort involved a commitment to a level and type of effort that was unsustainable. c) if the weight-loss effort did not accept and involve a conscious commitment to the value of fun, food, drink,… Read More »
What Does Tirzepatide Really Mean For Obesity Medicine?
The last few weeks have been abuzz about the remarkable weight loss seen with the dual GIP/GLP-1 agonist tirzepatide in the SURMOUNT-1 study. While this degree of weight loss surpasses that of the GLP-1 analogue semaglutide by several percentage points, this is not the most important implication of these findings. Rather, the real implication of the SURMOUNT-1 data is, that we will soon see another major global pharmaceutical player, namely Eli Lilly, enter the obesity space. Over the past decade or so, the only major international player in this field has been Novo Nordisk. With the introduction of liraglutide, recently followed by the approval of semaglutide for the obesity indication, Novo Nordisk has not only played a flagship role in developing the field of obesity medicine, it has also had to bear the considerable costs associated with raising obesity awareness, medical education, engaging payers, supporting obesity NGOs, and generally promoting the notion of obesity needing to be managed as a chronic disease. While Novo Nordisk must be commended for their remarkable efforts in promoting a better understanding of obesity as a chronic disease, much more remains to be done in this regard. Thus, having another major company enter the field of obesity medicine should considerably increase the resources that can be put towards professional and public education and supporting the work of the various NGOs working on this issue. For those, who are are perhaps sceptical about industry involvement in physician education or support for NGOs, it is important to remind ourselves of the fact that industry actually provides much of the evidence from large randomised controlled trials on which we base our guidelines and treatment algorithms. Moreover – like it or not – industry also supports substantial academic research, investigator-initiated trials, training of new professionals, and a host of other activities that ultimately benefit our patients. In fact, I cannot think of a single disease area in which most significant therapeutic advances are not largely attributable to industry efforts. We perhaps also need to remind ourselves that the pharmaceutical industry, in contrast to the free-for-all-anything-goes predatory billion-dollar “weight-loss industry”, underlies strict regulatory oversight and is held to ethical codes and standards that provides a transparent and effective framework for their promotional activities. Thus, my expectation is that with the entrance of another major global player like Eli Lilly into the obesity area, we will not only see much-needed competition… Read More »
Guest Post: Why Gynecologists Should Learn About Obesity Medicine
Today’s guest post comes from Emilia Huvinen, MD, PhD, Gynecologist, Helsinki, Finland My first step into the world of obesity research and care began with my PhD studies on gestational diabetes. For a young gynecologist, it was all new in the beginning but soon I found myself immersed in the world of behavioural medicine, adiposity and glucose metabolism. As years went by, and I learned more and more about different aspects of healthy behaviours and the complex biology of weight regulation, I finally got involved in actually treating women with obesity for their obesity. As a gynecologist, it is not difficult to see how obesity can play a crucial role in several periods of a woman’s life; starting from having early puberty and continuing to heavy menstrual bleeding, infertility, pregnancy complications, and stronger menopausal symptoms. Treating obesity can also be beneficial when treating women with polycystic ovaries syndrome (PCOS), infertility and endometrial hyperplasia, a pre-stage of uterine cancer. As obesity is associated with several pregnancy complications, helping our patients better manage their weight preconceptionally can improve pregnancy outcomes and hopefully even influence the health of the next generation. As a gynecologist, being the trusted long-term doctor for women, we have the privilege of being really close to our patients’ lives. We are also very used to discussing intimate and even very delicate issues in our everyday practice. However, it is apparently still a million-dollar-question how to get more gynecologists involved in obesity care. Unfortunately, the general advice currently given to women living with obesity is still to just “eat less and exercise more”. Many of us are still unaware that obesity is a chronic disease, and that people need care and treatment, not guilt and accusations. I suspect that the most common obstacle preventing more gynecologists getting involved in obesity medicine, is simply lack of information. Starting a conversation on obesity feels uncomfortable and delicate, and there’s a general assumption that specific skills are needed that are best left to obesity specialists. Often it is also a question of time, and many feel that it might not be worth the effort. For gynecologists, medications for obesity treatment are also unfamiliar and different from the ones we typically use. My wish is to develop a sustainable and practical protocol for treating and supporting my patients living with obesity. Developing multi-professional networks together with skilled dietitians and psychologists is crucial. I also… Read More »
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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