Do Some Doctors Sabotage Obese Patients? Continued

These are additional points made by Yoni Freedhoff, M.D., who is very empathetic toward patients traumatized by many of his professional colleagues. For one thing, he believes that pharmaceuticals were invented for a reason, so people could take them if needed, and no unnecessary barriers ought to be set up.

In “10 Ways Docs Sabotage Their Patients’ Weight Loss Journeys” he wrote,

If a patient meets clinical criteria for a medication’s approved indication and a doctor won’t prescribe it because of their personal beliefs, in my opinion that’s grounds for a regulatory complaint.

Dr. Freedhoff is perturbed by what he characterizes as “fearmongering” about the new GLP-1 and related anti-obesity meds. To his way of thinking, the patients who take them just need to be watched over (exactly like when somebody is prescribed a medication against hypertension). He says these meds are “very well tolerated […] when dose titration is slow, monitored, and adjusted appropriately.”

He is also okay with the idea that a patient will probably need to stay with these remedies forever. To put it plainly,

Chronic conditions require ongoing long-term treatment.

Inside dope

One of Dr. Freedhoff’s warnings concerns a matter that more professionals ought to take into consideration. Certain drugs — from atypical antipsychotics to antidepressants to certain antiseizure medications to some blood pressure medications — inevitably cause their users to gain weight.

And the problem here is, apparently, there are doctors who…

[…] will still regularly prescribe them to patients with obesity without first trying patients on available alternatives that don’t lead to weight gain, or without at least monitoring and then considering the prescription of an antiobesity medication to try to mitigate iatrogenic gain.

Ideally, a physician facing an obese patient will be sufficiently informed to refrain from dictating “ridiculous and unrealistic weight loss goals.” Dr. Freedhoff writes,

The goal should be whatever weight a person reaches living the healthiest life that they can honestly enjoy.

This item should go without saying: A patient should be informed of all possible treatment options, and their implications, meaning that doctors should not function as gatekeepers standing between the patient and possible therapeutic interventions. Dr. Freedhoff writes,

Our job as physicians is to fully inform our patients about the risks and benefits of all treatment options and then to support our patients’ decisions as to what option they want to pursue (including none, by the way).

To finish up, Dr. Freedhoff speaks of “the dearth of effective treatments which in turn probably contributed to the overall lack of education for physicians in obesity management despite its extremely high prevalence.” But now that there are effective treatments, it is a good time to get on board with the idea that obesity is just another chronic noncommunicable disease, and people should have a choice in what to do about it.

As for another of Dr. Freedhoff’s desiderata, “patient-centered care free from judgment and blame” — who could be against that?

Your responses and feedback are welcome!

Source: “10 Ways Docs Sabotage Their Patients’ Weight Loss Journeys,” medscape.com, 07/11/23
Image by Karen H./CC BY 2.0 DEED

Do Some Doctors Sabotage Obese Patients?

People may not find themselves in total agreement with everything said by Yoni Freedhoff, M.D., but he tunes in to what turns patients off. In the classic Ten Things format, he provides a list of particulars that any conscientious doctor might well take under consideration.

Check your holding area

A patient waiting room can convey many messages. It might say, “I’ve furnished this room with antiques, so you can understand why my fees have to be so high.” It can say, “I basically disapprove of your oversize body, and that’s why we provide skinny little chairs, and subscribe only to magazines with glamorous thin models on the covers.”

The ambiance may even convey a message like, “When it’s your turn, you will find the scale in the hallway, and if you weigh too much for it, a flashing red “TILT!” sign will be activated, within view of other patients, office personnel, and visiting pharmaceutical reps.” (These are not Dr. Freedhoff’s words of course, but a loose interpretation.)

History in the making

Okay, let’s get serious here. The Canadian MD is very much in favor of taking the patient’s history first (which may initially be done by another staff member, but it is for your doctor’s edification.) The point is, no conscientious medical professional should plunge right in by suggesting that you lose a few pounds.

Why? There might be a history of severe eating disorder, and this might be the first thing a doctor needs to know, because this patient needs a compassionate approach. Then, he says,

In other cases, patients’ social determinants of health would make intentional behavior change efforts in the name of weight management an impossible luxury. And sometimes that same patient may in fact be maintaining a clinically meaningful weight loss from their peak weight already.

There is a definite plea here to avoid conventional advice. Most people know the mantra Eat Less Move More. If it was working for them, they wouldn’t be here. Dr. Freehoff writes,

That’s about as useful as telling someone that making money requires them to buy low and sell high. Or telling someone with depression that they should just cheer up and look at the bright side of things.

And a doctor should eschew the temptation to be a diet chauvinist:

The research is clear: There is no one best dietary approach, and one person’s best diet is another person’s worst. Yet, some clinicians are themselves diet zealots and preach one diet over all others. Of course, many of their patients may well have already tried that approach, while others won’t enjoy it, and so promoting it above all others will fail a great many people.

This subject is worth continuing, and the next post will bring in some other voices, too.

(To be continued…)

Your responses and feedback are welcome!

Source: “10 Ways Docs Sabotage Their Patients’ Weight Loss Journeys,” Medscape.com, 07/11/23
Image by Denisbin/CC BY-ND 2.0 DEED

Obesity As a Science Fiction Plot

The previous post mentioned how some patients will not take their prescribed medications even if the government gives them out for free, but that is not the manufacturers’ problem, as long as somewhere along the line, somebody pays.

Obviously, the profit motive is involved in a big way. If a company can amass fortunes by selling its customers something that will diminish their quality of life and possibly even kill them, why should the manufacturers care, any more than the leaders of an illegal drug cartel care if their heroin kills people? It’s just business.

But some extra-paranoid people suspect that something else comes into play. They relate it to, for instance, Orson Scott Card’s science fiction novel, Xenocide.

The colonizers of a planet introduced a genetic mutation that would cause some of their brilliant population to suffer from OCD. One character spent her day crawling around on the floor, tracing the patterns of woodgrain in the boards. Being so distracted, the natives would not have the time or energy to stand up for themselves politically, try to seize power, or engage in any other troublesome behavior. Because they were so wrapped up in counting and other obsessive-compulsive rituals, the thought of rebellion would not enter their heads.

Paranoia strikes deep

What if there were some gigantic evil plot by ill-intentioned people who wanted humanity to be so preoccupied with trying to shed pounds, they had no time to think about anything else? Or worse yet, what if the evil behind-the-scenes plotters want people to become so fat, they can’t even get out of their homes to vote, politically demonstrate, or do anything else that would disturb the status quo?

Speaking of political ramifications, Dr. Yoni Freedhoff says,

I’ve seen work on the diagnosis of obesity as a chronic disease where conferring a medical diagnosis and using terminology like chronic non-communicable disease actually decreases weight stigma among healthcare providers. That’s a good thing, not a bad thing.

Although he believes that obesity is correctly defined as a disease, he has a problem with the term “epidemic.” Sure, over the past six or seven decades, obesity has increased everywhere. Dr. Freedhoff writes,

There is literally not one country on the planet that hasn’t seen average weights rise in every single age category. From toddlers to people who are seniors, we are seeing weight rise.

This may be a pandemic, but epidemic “is a word that I think perhaps should be relegated to infectious diseases.” With COVID-19, for instance, it is pretty clear that the disease is caused by a particular virus, and that’s an epidemic. But with obesity, the old multi-factorialism comes into play. Many causes contribute.

Your responses and feedback are welcome!

Source: “Obesity (with Dr. Yoni Freedhoff),” TabooScience.show, 12/03/20
Image by Jeff Djevdet/CC BY 2.0 DEED

Views on New Drugs Vary

This page has mentioned Yoni Freedhoff, M.D., a Canadian doctor with some controversial ideas. In a TIME article, he characterized society’s obsession with weight as “hateful,” and deplored the concept that anyone can slim their body if they sincerely want to. Nor does he endorse the idea that the GLP-1 weight loss drugs are a recipe for disaster. In this worldview, what main points seem to need debunking?

First, there is the aspect that many critics regard as a scandalous failure, the necessity of staying on such a med forever, lest the pounds return. The rebuttal begins, “Yes, that’s how treatments for chronic conditions work…”

Second, there are side effects:

But not appreciably more than with other medications used to treat various chronic conditions where the benefits they provide are sufficient to warrant their prescriptions being sustained.

And, people’s bodies seem to gradually acclimate to these drugs, unlike many other substances, so it’s pretty much a matter of just hanging in there. (To which a cynic would say, “Maybe so, but the body also gets used to heroin. That is not necessarily a feature.”)

Also, adult humans presumably have rights. As long as a grownup is willing to pay the bill, she or he can have 67 body-altering plastic surgery procedures and meet no resistance from other people.

So why not a weekly injection? Perhaps Dr. Freedhoff’s most difficult argument to refute addresses the main problem, as seen by many. The new weight-loss meds do not treat the root causes of obesity. Well then,

How many drugs treat root causes? Do asthma drugs treat air quality? Do cholesterol lowering medications regulate trans-fat in our food supply? Do pain relievers prevent injury?

Other publications contain thoughts about other matters. For instance, if a patient presents with high blood pressure, few doctors say, “Go away and try to manage it on your own for six months. Then when you fail, come back and I’ll write you a prescription.” It doesn’t happen that way.

Again, Dr. Freedhoff is less attuned to personal failure and more suspicious of the zeitgeist:

Just as with virtually every other chronic noncommunicable disease with lifestyle levers, intentional behavior change as treatment — which, by definition for chronic diseases, needs to be employed in perpetuity — requires wide-ranging degrees of privilege and is not a reasonable expectation.

…[T]his may be true even if the behavior change required is minimal, the cost is free, and the motivation is large.

What was that about free treatment? Alas, a study showed that among patients who had survived for a year and a half after a myocardial infarction, fewer than half took their pills — even if the cost was zero! And among the folks who were on co-pay plans, fewer than one-third of them took their pills.

How hard is it anyway to swallow a pill? Knowing all this, it would take a real optimist to expect people to reorganize their entire lives and embark on some elaborate exercise program or become vegan chefs. Such dreams indicate what Dr. Freedhoff calls “the folly of believing that knowledge drives behavior change.” Also, it would seem that, in academia, the study of patient non-compliance needs to be pursued more vigorously.

Your responses and feedback are welcome!

Source: “What We Get Wrong About Drugs Like Ozempic,” TIME.com, 06/28/23
Source: “’Patients Fail’ Despite Benefits of Sustained Weight Loss,” Medscape.com, 08/25/23
Image by Jesper Sehested Pluslexia/CC BY 2.0 DEED

Maverick MD on Privilege, Continued

As we learned from the previous post, Dr. Yoni Freedhoff proposes that the idea of holding patients entirely responsible for managing their own weight loss — even with the help of professionals — is unrealistic, to say the least. The privilege he refers to is the amount of free time, energy, money, and enthusiasm that some people have for projects like cooking their own totally clean meals from scratch and enrolling in ambitious exercise regimens.

\Also, not many dangerously obese folks have the means or the time for the intense therapy it would take to get to the bottom of their eating issues. Dr. Freedhoff writes,

There’s a tremendous amount of privilege involved in intentional behavior change in the name of improving health, regardless of what that issue might be. …[W]e all have the same number of hours in the day, but our hours are not all the same.

I would argue that it is a very, very small sliver of the population who truly possesses the privilege to be able to prioritize this as a very important thing in perpetuity. Because this is a chronic condition. If you stop treatment for a chronic condition, the condition comes back.

As a compassionate professional who hears a lot of stories other than his own, Dr. Freedhoff is hyper-aware that many people are already handling as much as they can, and simply do not possess the physical, mental or emotional energy to change their lives in any major or significant way. This is because modern society is just not set up for that to work. He suggests that many aspects of life, even in formerly remote areas of the globe, are rigged to ensure that people continue to eat too much of the wrong stuff, in the wrong ways, at the wrong times, and for the wrong reasons.

Captives and victims of the zeitgeist

Particularly in the USA and other Westernized countries, the spirit/mood/trend of the times is to indulge to our hearts’ content. At the same time, we suffer from enough cognitive dissonance to believe that controlling the damage is entirely up to us. It isn’t. Gigantic corporations with bloated advertising budgets and huge sales staffs are determined to sell us as many worthless and harmful products as they can possibly manage, and we are no match for them.

Especially in America, we love the idea of freedom, even when it is used by greedy corporate interests to turn us into a nation of overweight, unhealthy, fat-shamed people who can’t figure out what’s best for us, and who believe we can do anything we set our minds to, including single-handedly defend ourselves against the corporate juggernaut. If only!

Dr. Freedhoff writes,

It’s true that weight is responsive to lifestyle changes… It’s also true that you can buy low and sell high in the stock market and become a multimillionaire. It’s true that if you just cheered up, you have less depression. So these aren’t useful truths.

Let free enterprise not reign!

As much as we dislike the idea of the government controlling our lives, Dr. Freedhoff believes that something like a tax on sugar-sweetened beverages could help the situation a lot. Despite our deep resentment toward official interference, it’s quite possible that we could all benefit from stricter rules about advertising, especially when children are the targets. Maybe we need a stern government bureau to keep a watchful eye on the claims the food industry makes on their packaging, especially since the industry doesn’t seem to be so good at self-policing.

Perhaps it would be advantageous to keep a closer eye on what children are fed at school. As contrary as this is to the free-enterprise spirit, maybe we could all benefit from restrictions about how many fast-food outlets are built, and in what areas. Speaking of areas, there are still many places, both urban and rural, where people have a really hard time accessing things like fresh vegetables.

We have pretty much managed to get used to the concept of traffic lights and speed limits to save lives. Maybe we could be a bit more accepting of rules in this area, too.

Your responses and feedback are welcome!

Source: “ Obesity (with Dr. Yoni Freedhoff),” TabooScience.show, 12/03/20
Image by Wall Boat/Public Domain

Maverick MD on Privilege

Dr. Yoni Freedhoff, who occupies the roles of Associate Professor of Family Medicine at the University of Ottawa and Medical Director of Ottawa’s Bariatric Medical Institute, has for years been pushing back at what seem to be common assumptions about obesity. Mainly this has to do with personal responsibility, a phrase which often functions as a euphemism for blame.

According to that worldview, whether the issue is treatment with the new weight-loss drugs, or taking part in any other weight-loss regimen, if a person does not sign up for one or the other, their fat body is their own darn fault. His tenets include these:

If any amount of desire, guilt or shame were sufficient to drive sustained change, we’d have been rid of the so-called lifestyle diseases decades ago.

[T]hough everyone possesses the theoretical ability to focus on healthy habits and lives, many people’s realities make lifestyle reform a nearly impossible luxury.

[T]he folks who both read about healthy living and have lives that are appropriately and realistically conducive to change are an incredibly privileged and small subset of the population.

[P]ersonal responsibility-based healthy living efforts require privileges that the vast majority of people don’t possess.

Dr. Freedhoff argues that most people simply do not have the time, the means, or the incentive to do the things they would need to do in order to lose a meaningful amount of body fat. And that’s just ordinary, basically healthy people with families and jobs; who possess “the privilege of life being settled enough to even consider personal responsibility-based healthy lifestyle change.”

Of the people who do not have that privilege, a very large subset are those who live with chronic pain and/or severe fatigue, who “may find purposeful behavior change to be literally too difficult or figuratively too low a priority, given their day-to-day pain and challenges.” To be in that situation without a supportive family and/or a job, is an avalanche of misfortune that few humans have the wherewithal to dig themselves out of.

In Dr. Freedhoff’s view, the society we live in is what needs to change, and in major, consequential ways:

Right now, we’re facing a torrential current of calories, ultra-processed foods and a culture of convenience that considers the use of junk food to reward, pacify and entertain our kids and ourselves at every turn as entirely normal.

We need policies that will help make healthier lifestyles occur by default, or that make purposeful changes easier or more valuable. Whether those changes are sugar-sweetened beverage taxes, front-of-package health claim reforms, banning advertising that targets children, improved school food policies and programs, zoning laws affected where fast food and convenience stores are located and more…

Among other cogent points he makes, one of them is this: The science of weight management is known to involve at least 5,000 genes and 37 hormones whose existence the human body has been fostering and fine-tuning for millions of years, during which time most people on earth have had a hard time getting enough food to sustain life.

We all have ancient genes and we are living in a very non ancient and fairly toxic food environment. When it comes to the availability of calories, they are now everywhere.

Today, almost every aspect of the culture, in almost every corner of the world, tells us to eat eat eat. And, like it or not, there are just some people whose weight will remain stable, or sadly, may increase, even on the most ambitious diet.

Your responses and feedback are welcome!

Source: “Check Your Privilege Before Talking About Obesity and Personal Responsibility,” USNews.com, 09/27/16
Source: “Obesity (with Dr. Yoni Freedhoff),” TabooScience.show, 12/03/20
Image by wp paarz/CC BY-SA 2.0 DEED

New Drugs — Does Lifestyle Intervention Still Count? Part 6

A typical article (from Nature) about versions of the GLP-1 drugs states that people who receive “traditional lifestyle intervention” tend to helplessly regain weight when their program is over. But that discouraging news comes with a mitigating factor:

Regain can be decreased to 10-15% at 1 year with participation in a weight loss maintenance program, offered in person or by phone, which provides continued lifestyle counseling on a monthly or more frequent basis.

Still, after around two and a half years, even that tends to wear off. The author interprets this as revealing that…

These findings reveal the potential benefits of tirzepatide, relative to traditional weight loss maintenance counseling, in not only sustaining weight reduction achieved with intensive lifestyle intervention but in adding to it.

They also say that intensive lifestyle intervention, followed by tirzepatide, has about the same effect as the first year following a sleeve gastrectomy. In addition, these results are said to emphasize the “additional benefits that patients may receive from treatment with tirzepatide after first losing weight with intensive lifestyle intervention, or potentially with their own self-directed diet and activity programs.”

The Nature article also discusses the intensity (defined there as frequency) and scope of lifestyle intervention in conjunction with anti-obesity medications:

Weekly lifestyle visits and daily monitoring of food and energy intake historically have been required to help patients achieve and maintain the 500-750 kcal per day deficit needed to induce clinically meaningful weight loss.

The purveyors of semaglutide and tirzepatide believe that their products help to “physiologically drive this reduction in energy intake,” making a trait such as willpower less essential, which signifies to them that their products are better than conventional lifestyle counseling. Taking the meds to lose some weight is also credited with encouraging exercise — simply because it is easier to move around, which can lead to further weight loss.

They also say,

Trials of the response to antiobesity medications in persons who are unsuccessful with intensive lifestyle intervention are needed, because lack of success with lifestyle interventions has been a common prerequisite for initiation of pharmacotherapy or bariatric surgery.

Still, much of the literature seems to imply that the main component of “intensive lifestyle intervention” is calorie restriction, which would be unfortunate because…

[…] caloric restriction alone does not address the underlying physiology regulating body weight or fat mass, and antiobesity medication has the same overall ultimate effect regardless of whether or not caloric restriction preceded the medication.

It seems to imply that reducing diets are pointless. Maybe various kinds of counseling are pointless too. Except for the one that engages the mind and several personality components; encourages people to figure out what’s going on in their own heads; and offers pathways to that. As Socrates said, “Know thyself,” and this is a good place to mention that BrainWeighve is a tool for doing exactly that.

Your responses and feedback are welcome!

Source: “Tirzepatide after intensive lifestyle intervention in adults with overweight or obesity: the SURMOUNT-3 phase 3 trial,” Nature.com, 10/15/23
Image by Maggie Jones/Public Domain