You may have heard about new recommendations that were released to guide doctors on the pharmacological management of obesity. Ordinarily when a new set of medical guidelines is released, very few people notice other than the doctors in the relevant specialty, but this one got some attention because for one thing, obesity affects a lot more people than (for instance) metastatic small-cell lung cancers (that one got a new clinical practice guideline back in August, but you probably didn’t hear about that one). Also, there’s pretty much nothing you can say about obesity that won’t get people fired up. And finally, some of the early coverage made these guidelines sound utterly horrific. Way more horrific than they actually seem to be.
Not, I will note, because the journalists themselves were making up the horrific stuff. An article in Medscape quotes extensively from a telephone press briefing conducted by the lead author of the guidelines. Dr. Caroline Apovian works at the Nutrition and Weight Management Center at Boston Medical Center; she also hawks diet books and pre-made smoothies and has taken money from a long list of pharmaceutical companies that make diet pills (she wrote a whole book promoting Alli, so I think they’re getting their money’s worth). She is really not unbiased here, is what I’m saying. I assume she sincerely believes that being fat is terribly, terribly dangerous for you, but it would also cost her a whole lot of money to seriously question whether staying fat is actually more risky than the stuff that can happen if you go on Belviq.
Anyway. In the press briefing introducing the new guidelines, Dr. Apovian said that the document represented a “blueprint for how to treat obesity with comorbidities.” She said it “shifts the paradigm” by encouraging doctors to treat the obesity first, and only then treat things like high blood sugar, high cholesterol, and high blood pressure if reducing the patient’s weight doesn’t do the trick. Finally (and really most disturbingly), she talked about “which drugs we might suggest and which drugs to taper the patient off of.” The Medscape article expands to say:
[blockquote type=”left, center, right”]For patients already taking insulin, sulfonylureas, thiazolidinediones, beta-blockers, or certain specific selective serotonin-reuptake inhibitors (SSRIs) like paroxetine — all of which can lead to weight gain — the document provides advice on how to taper patients from those medications and switch them to alternative agents that don’t increase weight.[/blockquote]
If you’re overweight and taking SSRIs, just reading those words might make you hyperventilate. Medicating depression requires finding a drug that actually works and doesn’t cause side effects the patient finds intolerable; this often requires trying several, and once you’ve found something that works, doctors will warn you that if you go off it, it might stop working. So taper off that medication that’s working because some shill for the diet industry thinks that being fat is worse than major depression? Wow, nope.
Here is the weird thing, though: the stuff about tapering off isn’t anywhere in the actual guidelines. None of this stuff that the doctor mentioned in that phone interview appears to be anywhere in the actual guidelines and I read them over multiple times and ran a search on words like “taper” and “discontinue” just to make sure I wasn’t missing anything. They also don’t talk about treating diabetes and high blood pressure by getting patients to lose weight; there’s a long section on treating Type II diabetes that’s largely focused on avoiding medications that cause weight gain, or prescribing other medications to counteract that effect.
The main purpose of the document seems to be providing advice on the best way to prescribe diet pills, because a number of new diet pills have been approved in the last year or two. One of the fundamental problems with the idea of treating anything at all with weight loss is that diets don’t work. They don’t work even if you don’t call them “diets.” Even if we grant that being fat is incredibly dangerous to your health (which is a questionable assumption, actually) we are really not very good at making fat people skinny.
If we assume that being fat is really dangerous and people need to do something about it, offering medications is perfectly reasonable; that’s what we do for other conditions that are dangerous yet people can’t change on their own (high blood pressure, high cholesterol, diabetes.) The side effects for Belviq and Qsymia frankly sound like a lot of risk and unpleasantness for a very small amount of weight loss, but almost any drug out there has some horrifying possible side effects and people have the right to decide what their risk tolerance is.
The guidelines also get into the issue of drugs that cause weight gain. There are lots. They have separate advice for each category, including antidepressants and antipsychotics. Here’s what they say about antidepressants:
[blockquote type=”left, center, right”]When antidepressant therapy is indicated, we recommend a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the antidepressant to make an informed decision about drug choice. Other factors that need to be taken into consideration include the expected length of treatment.[/blockquote]
And about antipsychotics:
[blockquote type=”left, center, right”]We recommend using weight-neutral antipsychotic alternatives when clinically indicated, rather than those that cause weight gain, and the use of a shared decision-making process that provides patients with quantitative estimates of the expected weight effect of the alternative treatments to make an informed decision about drug choice.[/blockquote]
If there is one issue that I would really expect the health-at-every-size movement and the weight-loss shills to be able to link arms and sing “Kumbaya” on (or at least agree to pay lip service to), it is this: informed consent is a good thing.
Of course, informed consent doesn’t begin and end with weight gain. If someone needs an antidepressant, there’s a long list to choose from, each of which is more likely to cause some problems, and less likely to cause others. In an ideal world, doctors would ask patients about their symptoms and fears, and suggest whichever antidepressants was the least likely to cause the side effects that most worried them. That does sometimes happen, according to my friends who’ve been through this process, although other doctors have some favorite they prescribe to everyone, or they give everyone whatever’s newest and shiniest, or they always go with an older standby.
In the section on antipsychotic drugs, they mention that Geodon and Abilify cause less weight gain than many of the other antipsychotics (and thus should be preferred). Geodon is available in generic, but Abilify is still new and extremely expensive, which means that a lot of insurers insist that you try other antipsychotic medications first. So, on the “good news” side here: a best-practices document that recommends weight-neutral antipsychotics as the first choice provides ammunition for patients who want their insurer to cover those drugs.
The weirdest recommendations in the document — to my eyes, anyway — were the ones on rheumatoid arthritis treatment, birth control, and antiretroviral treatment for HIV. For rheumatoid arthritis, they said that due to the risk of weight gain, doctors should avoid the use of long-term corticosteroids unless NSAIDs were insufficient. I am not an expert on rheumatoid arthritis treatment, so I asked a friend of mine with RA: are doctors actually handing out corticosteroids willy-nilly instead of having people start with NSAIDs? She said that if I could find out which doctors were casually prescribing corticosteroids right and left, I should please let her know, because that would be awesome.
“When possible, chronic steroid therapy should be avoided” seems to be the basic clinical standard for steroid use already and the “to avoid weight gain” part is largely beside the point, given that steroids cause glaucoma and osteoporosis and mood swings, among other unwanted results. You take them because avoiding osteoporosis down the road is not a compelling reason to be in horrible pain right now.
For contraception, they suggest that in women who are obese, oral contraceptives should be used rather than injectable contraception, due to the risk of weight gain with injectables. But in their “evidence” section they provide no actual evidence to support this recommendation. Also, they seem to be assuming that oral contraception is always estrogen as well as progestin (nope) and they completely ignore the existence of NuvaRing, IUDs, implants, and the Patch.
Finally, they suggest monitoring the weight and waist circumference of patients on antiretroviral therapy, “due to unavoidable weight gain, weight redistribution, and associated cardiovascular risk.” If there is one drug regimen out there where the risk/benefit analysis is straightforward, it’s treatment for HIV. So the monitoring is so that … HIV patients can wring their hands over the loss of their girlish / boyish figure? Being a skinny corpse is not an improvement here.
Fundamentally, people like blogger Ragen Chastain are outraged about these guidelines because they’re worried that they will lead to worse health care for fat people. They’re not wrong to be worried. Doctors are measurably more hostile and less empathetic with fat patients. Even mildly overweight patients are more likely to be misdiagnosed, with doctors attributing their presenting problem to obesity rather than going through the diagnostic process they would with a thin patient. This happens even when the patient is presenting with something like migraine headaches or internal bleeding after being hit by a drunk driver.
Even though the guidelines say that it should be a shared decision whether a patient should use medications that might cause weight gain, it’s easy to foresee this leading to patients being denied medications they need because those medications might cause weight gain.
It’s not surprising or even all that problematic that a bunch of doctors who specialize in obesity view obesity as a problem that calls for significant focus. The problem is how many other doctors buy into this. If you’re seeking treatment for your weight, then presumably you’ll welcome a doctor who’s interested in discussing weight loss medications and other interventions that might help you. If you’re seeking treatment for Type II diabetes, then you probably very much want a doctor who’s well-versed on which diabetes treatments won’t make aspects of the disease worse for you. But if you’re seeking treatment for rheumatoid arthritis, you probably want a doctor who is focused on your pain and your function. Who won’t respond to questions about corticosteroids with, “but they might make you fat!” if those are also the drugs that will give you the best shot at living your life without constant severe pain.
Because guys. Perspective.
There are way, way, way worse things than being fat.