Continuing Lifestyle Intervention, Part 5

UCSF (University of California San Francisco) has words for the patient considering weight-loss surgery. Some of those words are, “Not a cure for obesity, but rather a tool…” In addition,

Long-term success depends on your ability to follow guidelines for diet, exercise and lifestyle changes… Now you must commit to a new way of life.

When the Bariatric Surgery Center talks about followup care and the future, it mentions “a support group, dietitian services and continuing education.” These would come under the heading of continuing lifestyle intervention in anybody’s book. Interestingly, part of the lifestyle is to avoid pregnancy — just like with the semaglutide drugs.

In the weight-loss realm, surgical and pharmaceutical patients both receive numerous tips about how and what to eat. The surgical patients are advised to burn calories and build muscle by working out. The users of the hot new drugs are given the same advice, especially since the drugs seem prone to melt away not just fat, but perfectly viable muscle tissue.

More great advice that applies equally to both types, is to maintain and cultivate social relationships, particularly the kind that fosters the goal. Like, join a weight-loss support group. And spend time doing things that are fun and meaningful, which ties in with the importance of positive displacement.

And furthermore

Other comparisons can be made. People who undergo bariatric surgery, or who have diabetes, are not expected to abandon their support systems partway through life. A person isn’t going to someday get their amputated stomach back, or suddenly receive a revelation about how to stay alive without insulin. The program of lifestyle intervention that comes along with the surgery or the shots is a “forever” kind of thing.

Why should people taking GLP-1 drugs be any different, whether they quit after a year, or continue forever? Either way, they need ongoing support and other elements of lifestyle intervention, on a continuing basis. Surgery is not a “set it and forget it” proposition, nor is embarking on a course of elective medication with no time limit in sight. Positive attention must still be paid to every aspect of life — and if we’re doing it right, attention quite often demands intervention.

“Lifestyle” is much more than a glossy magazine cover. There is nothing trivial about it. Life is a serious concept, comprising today and tomorrow and each succeeding day of our existence until it ends. And “style” being the individual choices and cumulative effect of the way we do every little thing, every single day, from now until infinity.

Your responses and feedback are welcome!

Source: “Life After Bariatric Surgery,” UCSFHealth.org, undated
Image by Alachua County/Public Domain

Goodbye to Addiction? Continued

Semaglutide-based pharmaceuticals like Ozempic and Wegovy are thought to achieve results by counteracting genetic mutations. Many people already regard semaglutide as The Answer to obesity, and there is a new wrinkle in the narrative.

Sarah Zhang, staff writer for The Atlantic, reports on evidence that the new drugs might alleviate not only a bad relationship with eating but some other toxic bonds as well. A significant number of people taking Ozempic (for weight loss, not diabetes) say they have lost interest in such compulsive behaviors as drinking, smoking, shopping, and more.

As we have seen, semaglutide and other GLP-1 agonists can quiet “food noise,” which annoys the brain like tinnitus or the thump of a car’s sound system half a mile away. Patients seeking weight loss, who previously would have replaced food with some other dependency, also apparently have those noises extinguished. One way to describe it is that something flipped a switch in their head.

Other strange effects may show up, not all of them positive. Zhang says,

Patients who undergo bariatric surgery sometimes experience “addiction transfer,” where their impulsive behaviors move from food to alcohol or drugs. Bariatric surgery works, in part, by increasing natural levels of GLP-1, but whether the same transfer can happen with GLP-1 drugs still needs to be studied…

But semaglutide could one day be more widely useful, as this class of drug may alter the brain’s fundamental reward circuitry… This drug that so powerfully suppresses the desire to eat could end up suppressing the desire for a whole lot more.

This is not a new concept in the addiction realm. The notion of a universal compulsion turn-off switch has been something of a holy grail. It’s just that nobody has yet found the magic recipe to pharmaceutically extirpate the detrimental behaviors that people feel compelled to engage in.

The long and short of it is, although nothing ever works for everybody, it presently looks as if food cravings are still the most likely kind to be eliminated by these drugs. At the same time, “The long-term impacts of semaglutide, especially on the brain, remain unknown.” Probably the effect on other body parts will be a surprise, too.

Nobody knows how this will turn out, 10 or 20 years down the line. Another whole area of confusion lies in the fact that…

Unlike addiction, compulsion concerns behaviors that aren’t meant to be pleasurable… Still, addictions and compulsions are likely governed by overlapping reward pathways in the brain, and semaglutide might have an effect on both.

The author mentions a woman whose urge to pick at her skin simply melted away, without even an awareness of slowing down. One day, she just realized she wasn’t doing that anymore. Another female patient stopped skin-picking and nail-biting, and experienced quietness of mind, while others affirmed that their minds “no longer raced in obsessive loops.”

Does semaglutide take the joy out of life? According to those who use it to lose weight, no. They still like what they like, just not in the same quantities as before. So it does not extinguish the pleasure-having ability, only makes it more choosy.

Your responses and feedback are welcome!

Source: “Did Scientists Accidentally Invent an Anti-addiction Drug?,” TheAtlantic.com, 05/19/23
Image by Shannon Holman/CC BY 2.0 DEED

The New Drugs and Unforeseen Consequences, Continued

Death and drinking are two more areas that interact with GLP-1 drugs and their cousins. This article by Tyler Durden is very thorough about what happened and when, in the history of tracking a particular problem. The U.S. Food and Drug Administration, which catalogs adverse event reports, recently analyzed a lot of data and found…

[…] 6,253 serious adverse reports, including 163 deaths, tied to Ozempic since 2018. Wegovy has been linked to over 460 serious cases, with 6 fatalities since 2021, while Saxenda is associated with nearly 2,000 serious reports and 49 deaths since 2015. An analysis of around 150 cases linked self-injury and suicidal ideation to these drugs soon after patients started taking them.

Over half the reports make references to suicidal thoughts. According to the analysis, “About 40 percent found relief after quitting the meds or taking a smaller dose.” In other words, of people who were affected in this alarming way, fewer than half were able to feel better after discontinuing the medications.

Damned if you do, damned if you don’t

Of course, failing to treat obesity can also lead to suicide. In 2020, a paper was published about whether childhood obesity leads to an increased mortality risk in young adulthood. A team of researchers based a study on data concerning 41,359 children and teens from the Swedish Childhood Obesity Treatment Register, which is known for the high quality of its information. It has been compiling facts since 1997 and even includes fatalities that take place outside the country’s borders. The findings were:

Both the risk of death due to diseases and the risk of death due to suicide were higher among those who had obesity in childhood… Individuals who had undergone obesity treatment in childhood had an increased risk of death from suicide and self-harm and death from endogenous causes, compared to the comparison group.

Now, what about alcohol?

Tirzepatide can bring along some uncomfortable side effects and, as we have seen, combining it with alcohol can increase the risk of hypoglycemia, and at the same time, mask the warning signs. Some consequences are all too foreseeable. When withdrawal from addictive substances is undertaken, Dr. Pretlow always stresses the importance of avoiding “trigger situations,” or environments that will cause stress, like hanging out in a bar when trying to eject alcohol from one’s life.

Dr. Pretlow once received a letter from a pediatrician — a medical professional! — in her forties who had been an over-eater all her life. When office staff left a plate of brownies in the break room, she resisted until she suddenly consumed the entire dozen. “At that point, she said, she realized that she was just like an alcoholic, an addict in the gutter. It was a stark realization to her, what was going on.”

Point being, it is extremely doubtful whether all the people who take tirzepatide will be able to avoid trigger situations involving alcohol for the rest of their lives. And if they drink, consequences lie in wait for them — some known and some as yet unknown.

Your responses and feedback are welcome!

Source: “Over 200 Cases Of Suicidal Thoughts After Taking Weight Loss Drugs: New Analysis,” ZeroHedge.com, 19/03/23
Source: “Association of childhood obesity with risk of early all-cause and cause-specific mortality,” PLOS.org, 03/18/20
Image by Ed Bierman/CC BY 2.0 DEED

The New Drugs and Unforeseen Consequences

It might be useful to review the things that are known, suspected, or feared, about the new weight-loss drugs. Of course, they are not all the same, or else why even bother to create a different formula? The point is, it really pays to check out the potential side effects of the various possibilities, before making an appointment with a physician. A person might come across some surprising information and decide, without further ado, to give the medication idea a pass.

The stuff works by slowing gastric emptying, to preserve the sensation of fullness. By now, probably everyone has heard about a widely discussed problem:

[S]ide effects of Ozempic, Wegovy and other members of the class have been linked to serious stomach risks, including gastroparesis or stomach paralysis, which can result in severe and long-term gastrointestinal damage.

An AboutLawsuits.com article by Irvin Jackson lists 13 unpleasant consequences of being on semaglutide. Worse, some folks are having miserable side effects even after discontinuing the meds. A discouraging number of lawsuits are currently underway, with potentially thousands more waiting in the wings.

Whether Ozempic was prescribed because of diabetes or for weight loss, if elective surgery is on a person’s schedule, the drug should probably be discontinued at least a week beforehand. In fact, the Mayo Clinic and other prominent medical establishments have come out in favor of quitting semaglutide three whole weeks before surgery. Its job is to empty the stomach slowly, but nobody should be on an operating table with anything in their stomach. Jackson writes,

In late June, the American Society of Anesthesiologists […] warned against using the drugs before elective surgery, due to the risk of vomiting and aspiration during anesthesia.

Skipping it for even that one day could save a life. While the chance of fatality is not huge, neither is it non-existent, and if the temporary cessation of the drug does not seem like enough of a precaution, the surgical team can opt to have the patient intubated for even a minor procedure, which adds not only safety but also discomfort and complication.

As if that weren’t enough, at a semaglutide factory in North Carolina, apparently slipshod quality control has led to government inspectors finding “objectionable organisms” in batches of the drug, and to elevated concerns about microbial contamination on the premises in general.

Your responses and feedback are welcome!

Source: Ozempic Stomach Risks Result in Debate Among Anesthesiologists Over Surgery Guidelines,” AboutLawsuits.com, 09/13/23
Source: Microbial Contaminant Control Problems at Ozempic Manufacturing Facility Has Resulted in FDA Investigator Warning,” AboutLawsuits.com, 09/20/23
Image by Craig Howell/CC BY 2.0 DEED

Induced Gambling Addiction

Published about a decade ago by Princeton University Press, anthropologist Natasha Dow Schüll’s Addiction by Design: Machine Gambling in Las Vegas is the result of 15 years of field research in one of the gaming capitals of the world.

The book, which is said to “change the dialog” on gambling addiction, has either won or come close to winning some important awards, and has been translated into Italian, Japanese, and French. One reviewer praises how it makes academic scholarship accessible to the average reader, while another suggests that it is not so much a book, as a tool.

The author examines the moral, social, and emotional ramifications of a certain genre of electronic games and proposes that just as some people are more prone to addiction than others, “it is also the case that some objects, by virtue of their unique pharmacologic or structural characteristics, are more likely than others to trigger or accelerate an addiction.” The work looks at the many possible types of screen addiction, all of which are combined in gambling machines.

Out with the old

No longer are traditional games the main draw at casinos. What people want are the modernized slot machines that offer what the author calls an “appealing parallel universe” where they can forget about mundane life. The play is solitary, fast, continuous, and utterly compelling — and it is not even about winning. No, at the center of this addiction is what reviewer Emily Martin calls “the imperative some people feel to lose themselves in a machine.”

They long to get into “the machine zone” or simply “the zone,” a trance-like state of consciousness that appears to be the main reward pursued by the adherents to this pastime. There they remain “until all resources are gone;” in other words, until they are stony broke.

On the addiction front, this is radically different from person-to-person games like poker played around a table, because cardsharps need to be hyper-aware of humans. That awareness is at least a skill that can be learned with experience, whereas the machines never offer a leg up. Experience is of no consequence, and the player throws herself or himself blindly, every time, into the abyss of chance.

In with the new

In what Laura Norén of PublicBooks calls “an empirically rigorous examination of users, designers, and objects that deepens practical and philosophical questions about the capacities of players interacting with machines designed to entrance them,” Schüll explores the dark side of both the players’ compulsions and the manufacturers’ goals. In regard to the former, much of the research was carried out at Gamblers Anonymous meetings.

An echo is to be found here of the substance-based food addiction theory versus the behavior-based eating addiction theory. The page speaks of “regulatory debates over whether addiction to slot machines stems from the consumer, the product, or the interplay between the two. ”

In what Noren characterizes as a horror story, the customers are mainly “problem gamblers” whose losses account for between 30% and 60% of the casino’s income. Such individuals tend to have traumatic experiences in their pasts, and to binge until their pockets are empty. She goes on to say, “[T]here is something devilish about the way designers’ intentions and users’ neurology meet up to make video gaming so devastating for some and so profitable for others.”

Even in the 1990s, when Schüll did research, the victims of table games, horse racing, and lotteries were in the minority, and Gamblers Anonymous meetings were mainly populated by machine addicts. By the turn of the century, it was estimated that 85% of the gambling industry’s profits accrued from video gaming. Today, those in the know make a pretty serious claim — that the recidivism rate for gambling is higher than the rate attached to any other addiction.

Your responses and feedback are welcome!

Source: “Natasha Dow Schüll,” NatashaDowSchull.org, undated
Source: “Can objects be evil? A review of ‘Addiction by Design’,” SocialMediaCollective.org, 09/06/12
Image by AisforAmy91/CC BY-ND 2.0 DEED

Continuing Lifestyle Intervention, Part 4

The previous post discussed the run-up to bariatric surgery. because both before and after surgery, lifestyle interventions will be the patient’s new reality. The whole point is to make lifestyle interventions become the lifestyle, and to accomplish that is a lot more difficult than it sounds.

This brings up a quotation from a recent paper with the imposing title, “Effects of Lifestyle and Educational Bridging Programs before Bariatric Surgery on Postoperative Weight Loss: A Systematic Review and Meta-Analysis.” A rather chilling assessment undermines basic assumptions concerning the safety and efficacy of such procedures:

[A]lthough preoperative lifestyle interventions reduce body weight before bariatric surgery more effectively than usual care, this difference disappears 1 year post-surgery… [I]t is currently unclear whether, and if so under what circumstances, participation in a preoperative lifestyle intervention is beneficial.

Of course, the implication here is that if pre-op lifestyle intervention is useless, then maybe post-op lifestyle intervention is futile too, and so is any other kind of attempt to improve the situation. It is very dreary to contemplate. Which leads to another assertion made in this document:

Secondary outcomes and psychological well-being are rarely investigated.

It seems that the way to make a real mark in this field would be to vigorously investigate secondary outcomes and psychological well-being.

After bariatric surgery

The Ochsner Clinic, which offers both the adjustable gastric band (LAGB) and the Roux-en-Y gastric bypass (LRGBY) laparoscopic procedures, describes its method:

During the period of weight loss, we closely observe our patients; we then follow up with them once a year. During these visits, patients commonly have appointments with multiple persons on the bariatric team, including the surgeon, a physician extender, a registered dietician, and/or a mental health care provider, depending on the needs of each patient.

To this institution’s credit, it acknowledges that in the early post-operative stage, due to the “extreme and instant” lifestyle changes, patients tend to be in emotional turmoil. In light of that, once a year doesn’t somehow seem like enough in-touch-keeping. Of course, another section says a patient should report back “at the earliest signs of weight regain” because the sooner, the better.

A thought experiment

This description applies to post-op bariatric patients, but how many of these reactions, or very similar ones, might be let loose by the GLP-1 drugs?

Depression and anxiety medications should be continued for at least the first 6 months. Symptoms of depression should be monitored closely at the first few appointments… If patients were previous stress eaters and become stressed after surgery, they no longer have the ability to eat for stress relief.

Medications for all weight loss patients need to be in crushed, liquid, or chewable forms during the first 6 months for LRGBY and for the patient’s lifetime after LAGB. The use of whole medications may lead to ulceration as they sit in the stomach pouch or pouch enlargement.

Many patients also experience changes in their social scenes, as many American holidays are centered on a big meal. The way patients interact with the significant people in their lives changes dramatically, and their social structure can be irreparably broken.

Your responses and feedback are welcome!

Source: “Effects of Lifestyle and Educational Bridging Programs before Bariatric Surgery on Postoperative Weight Loss: A Systematic Review and Meta-Analysis,” Karger.com, 10/07/22
Source: “Long-term Management of Patients After Weight Loss Surgery,” NIH.gov, Fall 2009
Image by Joel Kramer/CC BY 2.0

Continuing Lifestyle Intervention, Part 3

The broad question under consideration here is whether the GLP-1 drugs in their various manifestations will cure obesity once and for all, and particularly whether they can possibly do so in the absence of continuing lifestyle intervention.

For comparison purposes, and to attempt to predict what the case will be with the new drugs, it is helpful to review the facts surrounding what was, up until recently, considered the last, best hope. Before these revolutionary new medications arrived, bariatric surgery was seen as the ultimate solution. That modality entails much preparation and extensive post-operative followup care.

Most importantly, and perhaps too often overlooked by optimists, this particular type of surgery requires a ton of consistent compliance at every stage — most essentially, the stage known as “the rest of the patient’s life.” This is where lifestyle intervention succeeds or fails.

As we have seen, the fundamentals of lifestyle medicine include appropriate nutrition, frequent physical activity, effective stress management, quality sleep, the maintenance of satisfactory social connections, and steering clear of risky substances (be they food, alcohol, drugs, or whatever.) That last part encompasses not only substances but in the case of non-substance addictions like gambling, requires the active and diligent avoidance of cues that trigger addictive behaviors.

A healthy, well-functioning person who wants to remain that way needs all these “pillars” to hold up the magnificent edifice of their recovery. A person with a problem needs to stay on top of every aspect of those conditions, every hour of every day, into infinity.

Grim odds

The prospect is not an encouraging one. The statistics on weight regain one year after surgery are alarming, and the harm does not stop there. The pounds continue to pile back on. Even under ideal circumstances and optimal conditions, surgery alone is not a fix.

The American Gastroenterological Association (AGA) says, “Patients, on average, return to their baseline weight within 4-5 years.” Numbers like this encouraged the AGA to review its Obesity Guidelines and conclude that good isn’t good enough. The group called current practices “usual care or minimal treatment,” and recommended that a comprehensive maintenance program become the norm.

Childhood Obesity News has talked before about preparation for bariatric surgery. The expectations include such lifestyle changes as weight loss, smoking cessation, restricted diet, counseling, and maybe even exercise. The patient will probably burn off some calories fighting with their insurer.

The overall picture is daunting. Yet even people who go through all that aggro in order to qualify for surgery, can somehow not find it within themselves to get with a program and stick with a program. Apparently, that is the only way to maintain a healthy weight.

Your responses and feedback are welcome!

Source: “Intensive Lifestyle Intervention for Obesity: Principles, Practices, and Results,” ScienceDirect.com, May 2017
Image by Hernán Piñera/CC BY-SA 2.0

Continuing Lifestyle Intervention, Part 2

There are said to be six “pillars” of lifestyle medicine: “plant-based nutrition, physical activity, stress management, avoidance of risky substances, restorative sleep, and social connections.” According to the same source, lifestyle medicine itself (familiarly known as LM)…

[…] is a medical specialty that primarily uses lifestyle changes to treat chronic diseases. It is an evidence-based practice that helps individuals and their families implement and maintain healthy behaviors impacting the quality of life.

Lifestyle medicine is definitely not an afterthought or an inconsequential footnote to treatment. All the six types of intervention are important, and this is certainly true of recovery from obesity, and avoidance of its return.

What does the American Gastroenterological Association (AGA) say? That organization, like so many others, has developed a set of guidelines for weight loss, to encompass a minimum of six months of intensive lifestyle interventions in three areas: reduced-calorie diet, increased physical activity, and behavior therapy.

This boils down to eating in a way that brings in 500 to 750 fewer calories per day than the individual had been accustomed to consuming. Physical activity should be 150 minutes, or better yet, 180 minutes of aerobic activity each week. Here is an interesting detail: “Physical activity alone, however, contributes minimally.”

Acknowledged as key is behavioral therapy, “which provides a set of strategies and techniques to modify diet and physical activity patterns.” Strategy is a thing that most of us might have trouble putting together on our own, but with guidance, we come to understand that self-monitoring is an excellent tactic. As the AGA says, “technological advances provide new ways for patients to self-monitor.”

A vital ingredient

This group’s definition of short-term intensive lifestyle intervention includes “16 individual, on-site counseling sessions with a registered dietitian in the first 6 months.” Psychologists have long noted that personal contact and attention have a strong effect, and this will continue to be true no matter how much assistive technology is added to the arsenal.

The AGA also has an agenda for long-term maintenance, because after six months or even a year of intensive lifestyle intervention, weight regain is widely and regrettably common. According to AGA,

With no further treatment (or with infrequent follow-up meetings) patients typically regain one third of lost weight in the first follow-up year, with continuing weight gain thereafter. Patients, on average, return to their baseline weight within 4-5 years.

By the way, readers of Childhood Obesity News are familiar with two programs that include the means for self-monitoring, and so much more — W8Loss2Go and BrainWeighve.

More on this subject is coming up, but until next time, let us leave readers with this thought: Seriously, a person could look around (including a glance into a mirror) and wonder, “Is there anyone I know who couldn’t use a little bit of lifestyle intervention?

Your responses and feedback are welcome!

Source: “The Impact of the Six Pillars of Lifestyle Medicine on Brain Health,” NIH.gov, 02/03/23
Source: “Intensive Lifestyle Intervention for Obesity: Principles, Practices, and Results,” ScienceDirect.com, May 2017
Image by watchsmart/CC BY 2.0