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 »

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: 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 »

How Does Energy Expenditure Change Over Time?

One of the often repeated wisdoms regarding changes in energy expenditure as we age, is that we lose about 10-15 Cal per year. According to this formula, someone going from age 20 to age 50 would lose about 300-450 Cal in energy requirements.  But how accurate is this figure and does it really hold true? This is the topic of perhaps the most comprehensive analysis of human energy expenditure over the lifespan ever to be conducted, by Herman Pontzer and colleagues, published in SCIENCE. The researchers investigated the effects of age, body composition, and sex on total expenditure using a large (n= 6421 subjects; 64% female), diverse (n = 29 countries) database of doubly labeled water measurements for subjects aged 8 days to 95 years. In addition they looked at published measures of basal expenditure in neonates and doubly labeled water–measured total expenditure in pregnant and postpartum women.  After adjusting for body size to isolate potential effects of age, sex, and other factors, they found four distinct phases of human energy expenditure.  The first phase applied to neonates, up to 1 year of age. While during their first month neonates had a size-adjusted energy expenditures similar to that of adults, this increased rapidly in the first year so that between 9 and 15 months of age, adjusted total and basal expenditures were nearly ~50% elevated compared with that of adults. The second phase applied to juveniles, 1 to 20 years of age. While total and basal expenditure continued to increase with age throughout childhood and adolescence along with fat-free mass, size-adjusted expenditures steadily declined at a rate of about 3% per year till about age 20, after which it plateaued at adult levels. In contrast to what one might expect, there was no indication of a pubertal increases in adjusted total or basal expenditure. Although men tended to have a higher energy expenditure, the rate of decline was the same for men and women.  Over the third phase, from 20 to 60 years of age, total and basal expenditure and fat-free mass remained stable from ages 20 to 60 years in both sexes. During pregnancy, adjusted total and basal expenditures remained stable with the elevation in unadjusted expenditures matching those expected from the gain in mothers’ fat-free mass and fat mass. Finally, during the fourth phase, starting at about age 60, total and basal expenditure declined at a rate that exceeded… Read More »

Obesity And Perinatal Care

Last week, I had the pleasure of sitting on the thesis defence committees of two extraordinarily dedicated young trainees, currently completing their medical residencies in obstetrics and gynaecology. Both theses focussed on issues related to obesity within the obstetric community as well as the implications of obesity for the care of women during the gestational period and during delivery (more on these theses in coming posts). For those interested in this topic, I would like to draw your attention to a short review paper by Cecilia Jevitt, Chair of the Midwifery Program at the University of British Columbia, published in the Journal of Perinatal and Neonatal Nursing. Although the paper focusses on the social determinants of health that underly a substantial proportion of the risk for developing obesity (these include socio-economic disparities in employment, education, healthcare access, food quality, and availability), the paper also looks at many of the environment and biological factors that may promote obesity including environmental toxins, epigentics, and the microbiota. As for the impacts of excess body fat on pregnancy, Levitt lists over 30 conditions that can affect the pregnancy, delivery, and the post-partum period, threathening the health of mother and child, which are far more common in women with obesity. This is not to say that many of these problems can not also be encountered in the care of women without obesity, however, excess body weight makes these conditions far more likely and often much more difficult to manage. As Levitt points out, reducing the risk for obesity in the first place would need comprehensive changes at the policy level that not only address issues related to food and activity but also the socio-economic and other social determinants of health that disproportionately affect women of lower socio-economic status. As currently, no such policies are in sight, those charged with the care of women of childbearing age will continue having to watch for and deal with the increased risk for adverse outcomes in women with excess weight – a challenge that is only slowly (as evidenced by the theses mentioned above) coming to the centre of attention of obstetric health professionals. On the positive side, Levitt reminds us that, “Although obesity places women at risk for numerous morbidities, most women with obese BMIs [sic] complete pregnancy and birth without complications.” Improved training of health professionals in the care of women with obesity can no doubt further… Read More »