I need help. In dealing with obesity as a medical problem, that is.
I am pretty solid at arrhythmia management, but as an obesity doctor, not so much. If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient’s BMI. (But since I live in Kentucky, there would surely need to be a correction factor.)
If a student does poorly on an achievement test, is it the student’s or the teacher’s fault? If the obese patient does not lose weight, is it the doctor’s or the patient’s fault?
Today, in the NEJM, I read about Arena pharmaceutical’s attempt at creating the new “wonder pill” for obesity. Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety. Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.
Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight. Thirty pounds is only the prologue for the 300 pound patient.
So, now we may have another pill for fatness. Like we do for tiredness, and the low sex drive of male middle-agedness.
The study conclusion is worded with scientific precision. The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.
Cynicism is knocking at my door, and I am trying to ignore it.
It is clearly true that obesity is one of the developed world’s most important medical problems. Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated. The more sophisticated we become as a society, the fatter we get.
As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease. And these same lifestyle choices work on obesity as well. Call it being on “the program.” Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.
I own only one belt. It is thick leather. At times, as I am human, the white-chocolate-chip brownies in the doctor’s lounge get the best of me. If this behavior persists with any regularity the belt feels tighter. Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium. But if I deny too much the result is grumpiness. The pattern is repetitive.
This simple formula is the problem.
However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue. It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.
If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor. The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain. (And maybe this will be proven so.)
I don’t think we should persecute the obese. Malfeasance is bad for the heart. Nor am I against novel pharmaceuticals or innovative surgery. But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.
As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.
Surely, doctors should emphasize the program more.
JMM
6 replies on “Wonder pill versus good choices…”
Great post! I wonder sometimes though, as a child of obese parents, having been raised with gluttony, does that somehow get ingrained within us, lasting the rest of our lives. Having been obese for a large majority of my life, it sometimes seems like a constant battle to fight my urge to constantly eat the stuff that is so bad for us. I think had I been raised to make healthier choices, it would be easier in my adult life to make healthier choices. I guess my point is, sometimes it is neither the student or the teacher at fault, but the parents at home.
John, I too am flunking as a teacher in the obesity class. I am notoriously blunt with my patients without much success. Interesting article in the WSJ about how the brains of obese patients respond to food. "30 lb is a prologue to a 300 lb patient." is an instant classic.
Bill
Thanks for this post. This is how I felt when Medicare decided to cover bariatric surgery with funds I contribute to, but may never see. I think I should have a voice where my money goes. Who doesn't want to eat the entire pie? I do, but I know that I do not want to weigh 300lbs and I think it's my personal responsibility to manage that. Unfortunately the more we "fix" the more we have to keep fixing. Yikes
A pill might help make eating choices easier to make, but losing weight really is ALMOST as simple as eating less and moving more. I say "almost" because it is a little more complex than that. Along with eating less, we have to be mindful of what kinds of foods we're eating, i.e.; foods not packed with HFCS and other sugars, and starchy foods that turn to sugar once they're digested. In the end, it's a lifestyle change and one that's not easy to maintain in a society that thrives on Big Gulps, burgers, fries and white chocolate chip brownies. I know — I've made that lifestyle change, and it's a matter of constant vigilance. Most of the time I do well. Sometimes, I fall, but I've learned to get back up and keep at it. Nearly 60 pounds lighter now (it's taken more than a year) and still have 20 to go. But it's been worth the fight, Dr. John. Tell your patients the truth. It's the only thing that really works in the end.
-Wren
Not to argue with Sean, but science has shown an inborn propensity to a sweet taste in it's experiments with unborn fetuses. That we all lean toward building up for the famine is a survival characteristic. However, I have come to truly believe that weight is as genetic as height. I have the same build as my father and my grandmother, though I never cook with lard or bacon grease and I eat whole grains rather than white bread and rice. I now eat healthy and don't worry about my weight. I know my EP is going to bang his head on his desk. My weight isn't his failure, and I don't believe it is mine either.
Genetics are indeed a major role player in obesity.
Bike racing has taught me about genetics. There are the skinny climbers and muscular sprinters. They are what they are because of their parents. No amount of training will turn a skinny climber into a sprinter. You can improve on the margins for sure, but your genes cannot be exchanged. Football teams and track teams are yet another illustration of how different we are because of our genes. Runners who race a 100meter dash could not look much different than marathon runners.
It is true that people with "stocky" builds are more susceptible to obesity. And not only do we inherit our parent's shape, we surely inherit our parent's metabolism, and personality as well.
We cannot all look the same, and we shouldn't. But good choices are good choices, whether you are stocky or sticky in figure.
Further, it is clearly true that simply being skinny is not a guarantee for health.
Thanks for reading and writing…
John