Guidelines, Quibbles and Quirks — Part 2

The association between the new American Academy of Pediatrics guidelines and Body Mass Index (BMI) has been mentioned. A lot of healthcare providers take issue with the standard of measurement, and this is nothing new. The author here is a psychiatrist and eating disorder specialist Kimberly Dennis, who says there are many more accurate obesity markers, “such as blood pressure, cholesterol levels, blood glucose, mental health, and level of engagement with exercise.”

In the mental health area, she and others see the preoccupation with weight as a species of fat-shaming, and are of course worried that this leads to dangerous territory:

There is robust research showing that a history of dieting is the number-one risk factor for developing an eating disorder, with weight stigma and “the thin ideal” following close behind.

Whether one agrees with that point or not, it is certainly worthwhile for institutions and individual researchers to take the trouble to establish more appropriate measurement standards. Part of what bothers a lot of professionals is the ranking-system nature of using BMI percentages. It’s like a criminal court, where stealing a certain amount is larceny, and anything over that amount is grand theft. This dependence on numerical classification is a trait of bureaucracy, and an essential one in some cases, but perhaps not necessary in assessing medical conditions.

Race

Recently The New York Times hosted an opinion page about the latest developments in the childhood obesity field. Registered dietitian and board-certified eating disorder specialist Cristina Rivera wrote in to say that she and many colleagues reject the new guidelines. The guidelines seem to suggest or imply that losing weight will solve everything, and factors like poverty, an unsafe environment and a lack of access to things like fresh food and healthcare, will no longer be obstacles in children’s lives.

Exactly the reverse is true. Being economically disadvantaged in a chaotic environment is likely to cause unhealthy eating behaviors. Rivera said,

Additionally, as a person of color, I take much offense to these guidelines as they will without a doubt disproportionally affect and further stigmatize Black and brown folks… Rather than using this as an opportunity to state the need for meaningful policy change, the best they can do is encourage practitioners to prescribe weight loss medication to kids? I encourage all health care professionals to take a moment to reflect on the principle of “do no harm.”

Pharmaceuticals

Kate Bauer, an associate professor of nutritional sciences, states that she has seen adults make complicated and significant decisions about entering into a relationship with weight-loss drugs, “with the support of intensively trained health care providers.” Her fear is that children will be carelessly led into such impactful decisions without receiving this level of care. Her stand on the subject is,

General practice pediatricians should not be responsible for providing children pharmacotherapy for higher weight. There are serious medical and emotional implications of starting children on medication to alter their weight. Most pediatricians do not have the proper training to approach this topic with families or to adequately make clinical decisions and monitor.

Your responses and feedback are welcome!

Source: “A Critical Look at New Guidelines for Kids With Higher BMIs,” PsychologyToday.com, 02/11/23
Source: “Childhood Obesity: What to Do?,” NYTimes.com, 02/11/23
Source: “New Childhood Obesity Guidelines May Do More Harm Than Good,” Futurity.org, 02/13/23
Image by Medici con l’Africa Cuamm/CC BY-SA 2.0

Guidelines, Quibbles and Quirks — Part 1

Much has been said about the newest batch of guidelines from the American Association of Pediatrics. Before moving on to what is regarded as the most egregious ruling, the acceptability of bariatric surgery for very young humans, let’s catch up on some of the details, footnotes, and side issues that have been pulled into this conversation.

We have mentioned the burdensome cost of the new generation of weight-loss drugs, whether taken by adults or young people. The traditional choices, appetite suppressants like phentermine and topiramate, are available in generic versions that may cost as little as $30 a month, or a dollar per day. But the newer injectable GLP-1 agonists can run as much as $1,200 per month, or a daily tab of $40.

Insurers don’t want to pay that much, and who can blame them? Not when common sense and years of indoctrination have taught that the problem could be solved by saying no to the Big Mac and yes to running around the track a few times. It has so far proven difficult to convince insurance companies to foot the bill. They ask, quite reasonably, whether there is a medical necessity and whether that urgency could be met in some other way.

A great if unachievable goal

To quell childhood obesity, the AAP would prefer that the first resort be Intensive Health Behavior Lifestyle Treatment, or IHBLT. This means that parents and child(ren) all must be available to travel, sometimes a long way, to attend at least 26 hours of in-person therapy sessions together within three to 12 months. If each session is one hour, that means every other week. And even if weight-loss medication is prescribed for the child, the meetings are meant to continue.

At the Yale New Haven Children’s Hospital, a team headed by the associate director for pediatric obesity Maria Savoye developed the Bright Bodies Program. The AAP greatly admires the program, and this is where the ideal quota of 26 hours per year originated. Family therapy is not simply a finite program completed during a single year; not just a one-and-done proposition. It is recommended to continue indefinitely, which is a fine idea in theory, but how are people supposed to actually comply?

Psychiatrist and eating disorder specialist Kimberly Dennis says,

Because the therapy normally lasts from 3 to 12 months, dropout rates are high. Accessibility is a major problem, especially in socioeconomically disadvantaged communities.

Other views are held by others, like Nancy Ellen Abrams who wrote for the opinion page of The New York Times that overeating can be symptomatic of self-loathing and reminded her fellow grownups, “For children, food is the only numbing drug available.” She wrote,

What children need is a bigger picture that reveals the subtle cruelty of impossible physical expectations. They need a path to self-love, a simple practice of three meals a day and a peer group to discuss how hard — yet possible — it is to find peace with food. The peer group is essential; no one heals from a largely socially caused disease alone.

Your responses and feedback are welcome!

Source: “What you need to know about the new childhood obesity guidelines,” WashingtonPost.com, 01/20/23
Source: “A Critical Look at New Guidelines for Kids With Higher BMIs,” PsychologyToday.com, 02/11/23
Source: “Childhood Obesity: What to Do?, NYTimes.com, 02/11/23
Image by Cajsa Lilliehook/CC BY-SA 2.0

Guidelines Backlash, the Biggies — Drugs, Part 2

“Side effect” is a tricky term. For instance, a drawback of traditional appetite suppressants is that they probably exacerbate high blood pressure, or at the very least, do nothing to lower it. This is a negative side effect. On the other hand, a drug can have a side effect that is considered positive.

Side effects lead to what is called “off-label” use, until the point when the establishment does enough research to deem a drug officially suitable to be prescribed for whatever secondary use it is good for. As we have seen, the class of drugs known as GLP-1 agonists, used mainly to treat diabetes and other endocrine disorders, provide not only insulin sensitivity but appetite control. They imitate a peptide produced in the human gut that helps to regulate glucose in the system, and also contributes to a feeling of fullness. This in turn facilitates weight loss for some people.

Side effects, plural

Now that some drugs of this type have been approved to treat obesity, weight loss is no longer a side effect, but their primary purpose. Unfortunately, they still have other side effects, some of which are merely annoying, and may diminish with continued use as the body acclimates to the drug. Other side effects are more serious and even debilitating. In deciding whether or not to get involved with this type of pharmaceutical, several factors must be considered.

For instance, one of the recently approved drugs of this kind, whose generic name is semaglutide, is said to enable adolescents to reduce their BMI, or body mass index, by about 16%, which is a lot. But under any circumstances, rapid weight loss alone can stir up metabolic issues, hormone imbalance, and a malfunctioning gall bladder. In addition, experts have warned that the newer drugs can cause kidney problems, vision changes, and increased risk for rare forms of thyroid tumors.

As of February 2023, another such drug is on the way, having been set on the approval fast track by the Food and Drug Administration. Tirzepatide is another generic semaglutide whose brand name (if approval is granted) has not yet been chosen. Like its brothers, it works by slowing the passage of food through the digestive track, which allows the patient to feel sufficiently fed on a smaller amount of food.

The previous record of a semaglutide, causing an average weight loss of 16%, has been deemed impressive, but the newest contender beats that. A phase 3 trial chalked up weight loss as high as 20% of the person’s starting body weight, which in some cases translated into the loss of as much as 80 pounds.

There had already been concern over a version of semaglutide often prescribed to diabetes patients under the brand name Ozempic. Then, along came a jacked-up version of this injectable, approved by the FDA for long-term weight loss. When prescribed for that purpose it is branded Wegovy, about which we will have more to say.

Your responses and feedback are welcome!

Source: “The upsides and downsides of blockbuster weight loss drugs,” Web.musc.edu, 02/01/23
Source: “’Ozempic face?’ Dr. Siegel warns of popular diabetes drug’s bizarre side effect,” FoxNews.com, 01/29/23
Image by Jernej Furman/CC BY 2.0

Guidelines Backlash, the Biggies — Drugs, Part 1

Now that the American Academy of Pediatrics has recommended weight-loss meds for teens and maybe even children, what kind of pharmaceuticals are we talking about here? For starters, only six medications have been approved by the Food and Drug Administration specifically for weight loss, and for long-term use in that capacity. Their generic names are semaglutide, liraglutide, orlistat, phentermine-topiramate, bupropion-naltrexone, and setmelanotide. The first two are the ones we hear the most about.

They are GLP-1 agonists, which means they all work by imitating a natural hormone called glucagon-like peptide-1. In other words, GLP-1 works on areas of the brain that regulate appetite and food intake. Semaglutide and liraglutide can control diabetes, but also incidentally are able to reduce obesity, and they can legitimately be prescribed for either case. So far, they are the only two of the GLP-1 agonists that are officially approved to treat obesity in people who do not have diabetes, and even then the green light is brand-specific.

Liraglutide is administered by daily subcutaneous injection. Its ability to bring about weight loss of around 7% over a year has been called “significant.” Semaglutide can be taken by mouth daily, or injected weekly, and is also useful against other endocrine disorders like insulin resistance, metabolic syndrome, and pre-diabetes.

Several other anti-diabetes drugs in this class can also facilitate weight loss, but their use for that purpose is described as “off-label” because it is not really what they are primarily authorized for. They are administered by injection weekly or daily, and one is even a twice-a-day shot.

Dr. M. Regina Castro explains how these drugs “mimic the action of a hormone called glucagon-like peptide 1.” When blood sugar goes up, they stimulate the body into producing insulin to lower the blood sugar level. They curb hunger by slowing down the movement of food from the stomach to the small intestine. Subjectively, many patients feel “full” more quickly, and hold out for longer without becoming hungry again. This type of drug also acts on the brain, and is often very effective in reducing appetite.

The drugs that are FDA-approved were actually tested on humans as young as 12, and are said to be “just as effective and no more dangerous in children than in adults.” Of course, there are caveats. Along with medication, the AAP also recommends eating sensibly and getting a reasonable amount of exercise, because no anti-obesity medication is going to work by itself when the person continues to take direct action against it. It requires a certain amount of cooperation. This aspect raises some serious questions.

The meds work by convincing the body that it no longer feels hunger; that the stomach is full and that there is no rational need to put any more food into it. But what if the person is just engaging in “recreational eating,” or “eatertainment”? What if the pleasure they feel is derived not from a full stomach, but from the sensations of chewing and swallowing, which can theoretically be engaged in for 16 hours per day, regardless of how full the stomach purports to be? To put it bluntly, what if the emptiness is not physical but emotional?

Your responses and feedback are welcome!

Source: “GLP-1 agonists: Diabetes drugs and weight loss,” MayoClinic.org, undated
Source: “An Aggressive New Approach to Childhood Obesity,” NYTimes.com, 01/26/23
Image by ZaldyImg/CC BY 2.0

More Angles on the Guidelines

In yesterday’s post, we mentioned how eating disorder dietician Christine Byrne, as a matter of principle, does not use the terms “overweight” or “obese.” The words were used in her Self.com article only for clarity, because they are employed in the new AAP guidelines.

Today we look at a couple of the ways in which seemingly straightforward thoughts and principles can branch off into disagreements about more particular and specialized ideas. Among other topics, there are fierce debates about whether doctors should mention the advisability of weight loss to juveniles, or even weigh them.

Weight-loss surgery for 13-year-olds has not been advised before, so the author points out that the new recommendations “go against the AAP’s own 2016 guidelines” — which is not, in and of itself, a valid criticism. The concept may be wrong for other reasons, but because it contradicts the group’s previous standard is not one of them. As science marches on, it is quite normal for new discoveries and novel theories to overtake and displace older rules.

The perpetual disagreement continues over whether dieting, “defined as calorie restriction with the goal of weight loss,” is good or bad. Byrne quotes Cheri Levinson Ph.D., clinical director of the Louisville Center for Eating Disorders, who is wary of telling adolescents that they are too heavy, because of the danger of developing an eating disorder. Dietician Elizabeth Davenport agrees, saying,

Dieting is one of the biggest predictors of developing an eating disorder for teenagers, and now doctors will be encouraging kids to diet, even if they don’t use that exact wording.

Doctors are advised to ask young patients whether they skip meals, take diet pills or laxatives, or make themselves throw up. The usefulness of this approach would need to be grounded in a certainty that kids always tell grownups the truth about what they are up to, which is not invariably the case.

Also, it is important for parents and doctors alike to realize that an eating disorder is not “just a phase,” but can be life-altering and even life-threatening. Byrne wrote about the psychological risks of such disorders, as well as the many threats to “heart, bone, brain, digestive, and hormone health.” Speaking of the various bodily systems, but in an opposite direction, there is ongoing resistance against the notion of labeling someone obese if they are not experiencing any actual disease processes.

As for measurements using the Body Mass Index standard,

These curves come from the CDC’s growth charts for individuals ages 2 to 19, and they allow pediatricians to plot each person’s weight, height, and BMI relative to the rest of the population. (Although they’re not based on the current population — they’re based on data collected on American children between 1963 and 1994.)

The standards of normalcy have changed in recent decades, and this detail is a sticking point for many healthcare professionals who are uneasy about the definition of normalcy. Dr. Gewirtz O’Brien is quoted saying:

If I see that someone has always been on the 90th percentile curve, and they’re eating well and moving their body, then I’m happy to see that they’re still on that curve, because it means that they’re developing properly. It’s a red flag when someone rapidly goes down on the growth curve, or when someone rapidly goes up on the growth curve.

Despite this endorsement of allowing leeway, Byrne explains…

[W]ith these new guidelines, pediatricians are being told to recommend weight loss to anyone above the 85th percentile (and weight-loss drugs or surgery to those in higher percentiles) — even if they’ve been there their entire lives.

Your responses and feedback are welcome!

Source: “The New Obesity Guidelines for Kids Are Appalling,” Self.com, 02/02/23
Image by Willy Ochaya/CC BY 2.0

Angles on the Guidelines

Eating disorder dietician Christine Byrne offers this perspective:

I don’t use the terms “overweight” or “obese” in my practice because they pathologize body size and stigmatize people in larger bodies, and because they’re based on body mass index, or BMI, which has racist origins and is a poor measure of health.

She only uses the words when discussing their presence and significance in the collection of treatment guidelines newly issued by the American Academy of Pediatrics.

Byrne points out the noticeable contrast between the new recommendations and those published back in 2016. At that time, the advice was to not put adolescents on weight-loss diets, either with or without pharmaceutical aids. Professionals were urged to emphasize positive body image and healthful everyday habits, and the guidance then did not even mention surgery.

She notes a lot of Americans, including many of her colleagues in the eating disorder field, are outraged by the new guidelines, which cannot help but have “an extremely negative impact on kids’ relationships with food and their bodies.” It is felt that eating disorders will multiply. Of course, not all troubled teens will become anorectic, but some will.

Byrne conceded that in the new guidelines, eating disorder screening is mentioned:

[P]ediatricians are told to ask about “unhealthy practices to lose weight,” inducing meal skipping, using diet pills or laxatives, or inducing vomiting. But eating disorder providers say this is totally inadequate in reducing eating disorder risk, since telling a kid or teenager to lose weight could inherently increase their risk of disordered eating behaviors, body image distress, and, potentially, an eating disorder.

A lot of people deplore the idea that, even when a young person does not appear to experience any health issues, doctors are being told to recommend weight loss. On the other hand, the family doctor is only one voice among many that assail the ears and spirits of vulnerable teens. Thanks to the ubiquitous presence of the internet in everyone’s pockets, it is easy for a young person to take lessons from peers who are experts in the arts of laxative use, voluntary vomiting, and worse.

Many professionals consulted by Byrne agree in their concern that eating disorders are…

[…] known to increase the risk of anxiety, depression, suicidality, substance use disorders, premature death, and serious issues at work, school, and in relationships. They can also have a negative impact on heart, bone, brain, digestive, and hormone health.

Obviously, nobody needs any of this.

Your responses and feedback are welcome!

Source: “The New Obesity Guidelines for Kids Are Appalling,” Self.com, 02/02/23
Image by Tanvir Alam/CC BY 2.0

Guidelines Backlash, the Biggies — Access and Cost, Part 3

Among others heard from on the subject is bioethicist Arthur Caplan who has called obesity one of the biggest moral challenges that contemporary America is up against. He describes both medication and surgery as “Band-Aids” in the sense of being alleged answers that provide the illusion of doing something, but which really do not accomplish much, and in fact, may even worsen the underlying problem.

Brian Castrucci, who heads a nonprofit foundation, has publicly said that more progress needs to be made, instead, with “the policies and environments that can produce better health.” Another concerned professional interviewed by Christopher Curley is pediatric endocrinologist Dr. Sissi Emperatriz Cossio:

If [patients] do not have health insurance, the costs are too high, and if they do, a great deal of paperwork is required to get the procedures approved. As with many maladies that doctors treat, the insurance approval and payment hurdles are among the chief sources of disparity of care quality between wealthier and poorer communities.

As with most issues in the USA, race and ethnicity enter into the controversy. Curley also reported that studies show how obese minority children “vastly underutilize available treatments, from drugs to counseling to surgery, because of these financial and logistical barriers. He quoted the executive report that accompanied the new guidelines:

Targeted policies are needed to purposefully address the structural racism in our society that drives the alarming and persistent disparities in childhood obesity and obesity-related comorbidities.

The AAP guidelines document itself says,

Inequalities in poverty, unemployment, and homeownership attributable to structural racism have been linked to increased obesity rates. Racism experienced in everyday life has also been associated with increased obesity prevalence. Youth with overweight and obesity have been found to be at increased risk… In adults, studies have found positive associations between self-reported discrimination and waist circumference, visceral adiposity, and BMI in both non-Latino and Latino populations.

Fatima Cody Stanford told a journalist…

[…] studies show that Black girls and boys are less likely to get treatment, compared with children of other races, despite having higher rates of the disease. Even those covered by Medicaid are less likely to be treated. “We find biases in who gets referred. If you don’t get the diagnosis, you don’t get the treatment,” she said.

Your responses and feedback are welcome!

Source: “Aggressive treatment guidelines for childhood obesity getting backlash,” WashingtonPost.com, 01/20/23
Source: “Criticism Emerges Over New AAP Guidelines for Childhood Obesity,” Healthline.com, 01/20/23
Source: “Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity,” AAP.org, February 2023
Image by Got Credit/CC BY 2.0

Guidelines Backlash, the Biggies — Access and Cost, Part 2

Becoming too enthusiastic about weight-loss pharmaceuticals or surgery, or even about intensive therapy, could cost a ton of money — which may not be forthcoming from the sources that the most hopeful proponents look to for funding.

Some optimists have suggested that the new recommendations in the AAP guidelines might incentivize insurers, including the government through Medicaid, to willingly open their wallets and pour out payments. Other professionals are not so sanguine in their expectations, like Dr. Katy Miller, who works with teenagers experiencing eating disorders. She says,

We are proposing treatment strategies that are expensive and even in the best circumstances are often unsuccessful. How can we ask someone to diet when we’re not addressing things like poverty, food scarcity and housing instability?

Journalist Sara Monetta met with a mother of three who was enthused about her healthy cooking support group (a YMCA project.) This mom believed in healthy eating and plenty of exercise, and lamented the lack of sports programs and other exercise opportunities for children. She would consider weight-loss drugs or surgery “only if I had tried everything.”

On the question of expenses for any of the options, a Washington Post article said this:

Insurance can be tricky to navigate. Doctors say bariatric surgery for those who are severely obese is usually covered. But only a few states mandate reimbursement for medication and behavioral treatments under Medicaid and private plans vary in their coverage.

Apparently, an anti-obesity bill was introduced to Congress 10 years ago that would have provided coverage under Medicaid, not only for prescription drugs, but also for profound and extensive behavioral therapy. But introduction was as far as the acquaintance went. There was no second date.

More angles

Jason Wachob of MindBodyGreen.com wrote about the relative short-term and long-term costs, predicting that…

[…] pharmaceuticals and surgeries will dwarf the costs of changing school curriculums to reflect our dire need to get our kids and our future generations thriving… what would be required for an overhaul of our education system…

He then went on to suggest some audacious policy changes:

What if we subsidized vegetables, fruits, and nutrient-dense animal products, instead of just corn and soy?

Journalist Ariana Eunjung Cha noted the probability of unequal access to treatment, and added another concern, namely, “worry that earlier medical interventions may create more fat-shaming of vulnerable children.” Meanwhile, other critics have other reasons to object, chiefly because they believe that making this sort of help too easy to get will encourage children to persist in their poor lifestyle choices, i.e. eating too much. Cha wrote,

People on both sides express uneasiness about the potential long-term consequences of putting millions of children on drugs or under the knife, instead of doing more to prevent the condition in the first place.

Your responses and feedback are welcome!

Source: New US childhood obesity guidelines criticised by families,” BBC.com, 01/29/23
Source: “What you need to know about the new childhood obesity guidelines,” WashingtonPost.com, 01/20/23
Source: “The New AAP Childhood Obesity Guidelines Are Setting Kids Up To Fail,” MindBodyGreen.com, 01/17/23
Source: “Aggressive treatment guidelines for childhood obesity getting backlash,” WashingtonPost.com, 01/20/23
Image by Pictures of money/CC BY 2.0