Drugs Don’t Work in Patients who Don’t Take Them
Friday, August 15, 2008
The title of today’s post is allegedly a quote by C. Everett Koop, MD (picture).
I would like to take the liberty of modifying this to the following: “Treatments for chronic diseases only work as long as they are applied” (you can quote me on this 🙂 ).
Why bring this up? Because a) obesity is a chronic disease and b) because, when treatment stops, the weight always comes back.
Simply put, the problem in obesity treatment is not how to lose weight – the only real problem is how to keep the weight off. The answer of course is simple (and by now hopefully known to all regular readers of this blog): do not stop the treatment when the weight has come off!
Easier said than done. But there is nothing unique about this to obesity. In fact, patient adherence to treatment is a problem in all chronic diseases – whether you are dealing with diabetes, hypertension or rheumatoid arthritis – when the treatment stops, the “disease” comes back (this BTW happen to be the definition of a chronic disease!).
Given that this is such a common and ubiquitous problem, it would be a surprise if this issue has not been studied before. A very readable and relevant article on this, is the one by Lars Osterberg and Terrence Blashke, published in the New England Journal of Medicine back in 2005. Although this paper focusses on adherence to medication – the principles also hold true for non-pharmacological treatment.
Of particular interest are the major predictors of poor adherence listed in this paper (each point is referenced in the article):
1. Presence of psychological problems, particularly depression (I would add ADD to this!)
2. Presence of cognitive impairment
3. Asymptomatic disease
4. inadequate follow-up or discharge planning
5. Side effects
6. Patient’s lack of belief in benefits of treatment
7. Patient’s lack of insight into illness
8. Poor provider-patient relationship
9. Presence of barriers to care or treatment
10. Missed appointments
11. Complexity of treatment
12. Cost or co-payment
All of the above also apply to obesity management. Spending some time figuring out which of the above is causing your patient to fall off therapy is key – blaming or threatening your patient is not the answer.
AMS
Edmonton, Alberta
Friday, August 15, 2008
From a patient’s perspective, I find the following to be the most relevant:
1. Presence of psychological problems
As fatness is greatly stigmatized, depression is not a surprising reaction.
3. Asymptomatic disease
For me, I have found that the stigmatization of obesity is a greater problem than extra weight is itself.
5. Side effects
The side effects of treatment are not to be underestimated, especially when the treatment feels to the patient to be worse than the condition itself.
6. Patient’s lack of belief in benefits of treatment
Given the lack of efficacy of many of the treatments, this isn’t surprising from a patient’s perspective, either.
8. Poor provider-patient relationship
A provider who sees only the obesity and not the whole person will exacerbate this issue.
9. Presence of barriers to care or treatment
11. Complexity of treatment
12. Cost or co-payment
These all can make it much harder for a patient to want to, or be able to, continue something for the rest of their lives.
As a person living well with type 2 diabetes (14 years now, diagnosed at age 25) — I’m healthier now than when I was diagnosed. I weigh around 30 pounds less, but that’s a side effect of having found exercise I enjoy and that helps me emotionally as well as physically, and eating in a way that helps me manage diabetes, not solely as a means of maintaining weight loss. My BMI is still high, but at this size, I’m able to manage okay. What hasn’t gone away is the pressure to lose weight, the stigmatization of fatness, and the assumption (undermined by current research) that all obese people must be unhealthy.
I respect your perspective that not all obesity needs to be treated. I think that redefining successful treatment as health maintenance and improvement rather than obesity reduction would go a long way in “improving success.”