Continuing Lifestyle Intervention, Part 1

We have been looking at the idea that the need for lifestyle intervention of some kind might be necessary throughout life. There is nothing wrong with that. Take religion, for instance. No devout believer of any variety would say, “My relationship with God is just a temporary thing, to help me get through a difficult time. But the day will come when I won’t need that connection anymore.”

If something in a person’s life helps to overcome challenges, treat fellow beings with lovingkindness, and become one’s best possible self, why on earth would anyone want to step in and say, “Yeah, but one of these days you’ll have to learn how to make it on your own”?

Take the simplest and most elementary kind of lifestyle practice, and one that is widely recommended: journaling. To take a daily inventory, in the morning or at night or both, and jot down some important realizations and intentions, is a very useful practice. To reference formal religion again, one purpose of morning prayer is to ask the higher power, “Please help me not mess up too badly today.” One purpose of evening prayer is to say, “Thank you for understanding today’s mistakes, and I’ll do better tomorrow.”

The secular version is to stay committed to some kind of structured accountability system. (And yes, a person could do both if that is what works.) Why would any supposed authority feel entitled to announce, “That won’t be needed anymore”? For some third party to step in and decree that there is no further need for either a supreme being or a lifestyle that helps a lot and does no harm — well, it would just be silly. And of course, no responsible medical practitioner would tell a patient with diabetes, “That insulin stuff is fine for now, but eventually you will have to learn to cope without it.”

Back to the question at hand

Practically every inhabitant of the planet has heard about the success of, and demand for, the drugs that have been receiving such rampant publicity — and that will continue to do so in the foreseeable future. It’s a whole new genre of weight loss medications, so what should we expect in terms of their ability to do the job alone? Many enthusiasts are dismayed to find that maybe a prescription cannot carry the whole load, for myriad reasons. For instance, no matter how efficient the medications may be, people are still people.

Take the example of bariatric surgery. Effective as it can be for a great number of dangerously obese people, there are always the few who manage to mess it up. It’s as if they are determined to prove how successfully the stomach can be either stretched or ruptured, whichever comes first. This would be a good time to look into how continuing lifestyle intervention pairs up with surgical intervention.

(To be continued…)

Your responses and feedback are welcome!

Image by Jernej Furman/CC BY 2.0

New Drugs — Does Lifestyle Intervention Still Count? Part 8

Just by the very nature of contemporary life, mental health treatment is not often conducted in person. Apps and devices that monitor physical vital signs have been around for a long time, and now increasingly all kinds of care are administered online or through smartphones. An incredible number of quite respectable podcasts are sponsored by a company that connects potential clients with therapists and facilitates change if the first match is not satisfactory.

Meanwhile, more troubled people come to understand that the day may never come when they will be “fixed.” They may continue to need an impartial listening ear, at least occasionally. Sometimes a person can sail along for years, but then an accident or physical illness may happen, or the death of someone close. When a new relationship begins or an old one ends, a person often needs extra support.

Some people benefit from help for the rest of their lives, and there is nothing wrong with that. We don’t blame people with diabetes for continuing to need insulin, and we don’t blame people who need long-term mental health support. This is especially true of those who aspire to more than just not being sick. For people who want to continue to get better, and then even better than that, there is no limit.

It’s a lifestyle

In an earlier post, we talked about how important it is for a treatment program to embrace every part of life — family, peers, work relationships, and the larger community — as well as a person’s spiritual foundation and ethical standards. Now to any of these factors, add the continuing and ongoing need to manage a substance abuse tendency, whatever that substance may be.

A recent Childhood Obesity News post quoted a man who says, “I spend five hours a day minimum working on staying sober for that day.” Daily attendance at a meeting, for instance, is a definitive lifestyle intervention, and for some people, that’s what it takes.

The quirks of addicts

Author and late-night TV personality Alexander King, who was popular more than half a century ago, had been incarcerated in the federal addiction recovery center in Lexington, Kentucky. While in withdrawal himself, King watched a fellow inmate kneel by his bed as if in prayer, and prepare a hypodermic needle, tie off his arm, and inject a shot of heroin into the vein — all just expertly mimed, of course. The haunting glimpse into another’s sickness made a lasting impression, and King included it later in Mine Enemy Grows Older, one of several best-selling autobiographical volumes.

More recently, for Medium, Eric Allen Been interviewed Judith Grisel about her book, Never Enough, which is pretty much the motto of all addicts everywhere since the beginning of time. Unlike many addicts, however, Grisel has been “clean and sober” for more than three decades, during which time she became a professor of psychology and neuroscience.

When her interviewer suggested that many heroin addicts are addicted not just to the drug, but to the process, “the ritual of being dopesick, scoring, shooting up, etc,” Grisel replied,

Craving is to a point kind of fun. I think the paraphernalia, the bag in your pocket, all those things elicit a sort of anticipatory wide-awake brain state.

Confirming this, comedian Joey Diaz talked on a podcast (reference unavailable) about how the happiest he ever was, was in the car on his way to score (buy cocaine) and then while driving home with it.

Your responses and feedback are welcome!

Source: “A Neuroscientist Explores Addiction, the Brain, and Her Past,” Medium.com, 03/05/10
Image by Robert Miller/CC BY 2.0 DEED

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
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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
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