Why We Need Medications For ObesityMonday, September 30, 2013
Regular readers will know of my support for bariatric surgery. Despite all caveats (discussed in previous posts), it remains the most effective (and perhaps only feasible) option for many struggling with severe obesity.
However, even under the best circumstances, surgery is not a realistic option to deal with an epidemic that affects millions of individuals. Even with 10,000 surgeries a year, it would only take about 100 years to operate on every eligible patient in Canada, who is severely obese today. This is neither feasible nor affordable.
Thus, numbers dictate that overweight and obesity will require treatments that can be taken by millions.
To use an analogy: if there were no pharmacological treatments for hypertension or diabetes and the only treatment was an operation, most people would still be dying of heart disease and other complications that are now perfectly preventable and treatable because we have a large armamentum of anti-hypertensive and anti-diabetic medications.
Yes, people could perhaps do more to prevent getting hypertension and diabetes in the first place – we know that healthy diets and regular exercise go a long way in preventing both conditions – but even if we can adopt prevention measures that miraculously cut the incidence of these conditions in half – we are still left with millions who will have hypertension and diabetes.
If we had no drugs, some of these folks may get some relief by reducing their salt intake or following a strict diet – but we know that in real-life, these interventions are neither realistic nor powerful – without anti-hypertensive and anti-diabetic medications we would certainly not have seen the recent remarkable (over 50%) reduction in cardiovascular diseases – we are seeing far fewer strokes and heart attacks than ever before despite an increasingly overweight and obese populations, an increased prevalence of risk factors (except perhaps smoking) and an aging population.
The only reasonable explanation for this decline is the widespread use of highly effective and “proven” medical treatments for these conditions.
While it is impossible for 10s of millions of people to be operated upon, there is nothing to stop 10s of millions of people taking a tablet or two everyday if it helps lower their blood pressure or control their blood glucose.
These medications were not discovered or tested overnight. It took decades of medical research and innovation to develop the wide range of anti-hypertensive and anti-diabetic medications we have today – medications that are more effective and far safer than the drugs that were around when I graduated from medical school.
Every reader, who has anyone in their family with heart disease or diabetes, has probably benefited from the fact that we have these medications.
Although we have these medications to treat high blood pressure and diabetes, these are only two of the many complications that people with excess weight may experience – for many other health problems related to excess weight we have very limited treatments (e.g. sleep apnea, urinary incontinence, fatty liver disease, osteoarthritis – just to name a few).
Indeed, if excess weight is the main cause of these problems, then treating each of these problems individually, makes far less sense than if we had a treatment that treats obesity itself – the potential benefits of this are evident in patients who undergo surgery or even in those who lose weight by other means (at least till they put the weight back on).
There is indeed no rationale why we should not have drugs to treat obesity.
Yes, weight regulation has a complex physiology – but so does blood pressure or glucose regulation – we understand the physiology and target it to lower blood pressure and control blood sugar.
Yes, weight regulation is complicated by the fact that it is also affected by environmental factors – but so are blood pressure and glucose.
And, weight regulation is further complicated by being tied into the stress and reward system – but so are blood pressure and glucose regulation.
The only difference is that blood-pressure and diabetes medications have been around for almost 100 years and it is widely accepted that these conditions need to be managed and medications are necessary to manage them.
In fact, I am not old enough to remember the days when there were no effective medications for hypertension or diabetes.
So why do we not have medications for obesity?
There are many reasons for this:
1) The inherent belief that obesity is a condition that can be overcome simply with diet and exercise (the science has long established that for most people this is nonsense.)
2) The fact that our understanding of the complex physiology of hunger, appetite, energy homeostasis and other factors is about 100 years behind our understanding of hypertension (renin was discovered in 1898) or glucose (insulin was discovered in 1921) – in contrast NPY was only discovered in 1982, leptin was discovered in 1994, adiponectin was discovered in 1996, vaspin was discovered in 2008, irisin was discovered in 2012 … and we are continuing to discover new molecules involved in fat and energy regulation every week.
3) The statuary regulatory processes for bringing new drugs to market today are several orders of magnitude more restrictive than when many of the widely used anti-hypertensive and anti-hypertensive drugs came to market.
4) While the primitive and harmful medications first launched for hypertension and diabetes in the early part of last century (e.g. mercurial diuretics, ganglion blockers or first generation sulphonylureas) are long forgotten, pharmacological disasters in anti-obesity medications (e.g. Fen-Phen) remain in recent memory.
5) Because of the barriers to bringing new anti-obesity meds to market – pharma companies would rather devote their resources to more promising areas including anti-cancer drugs, HIV drugs, or other better established indications.
6) Reimbursement systems in many countries exclude payments for obesity medications – this significantly reduces the market for these drugs – new drugs are expensive when first launched – without coverage in drug plans, most people will not be able to afford them.
7) Taking medications for obesity is still considered taking the “easy way out” – people expect you to lose and keep off your weight with diet and exercise – anything else simply proves that fat people are lazy.
Take all of this together and it is no wonder that we are still in the early pioneer days of anti-obesity medications.
But, in the end, I see no alternative to finding a pharmacological alternative to surgery – even if this may take another decade or two.
There is certainly no doubt in my mind that obesity is here to stay – the sooner we find anti-obesity drugs that are effective and safe – the better.