Wednesday, August 1, 2012

Can't I just take a pill for that?

If you are overweight or obese, or work with people who are overweight or obese, then you have probably heard about the new weight loss drugs that have been approved by the FDA, Belviq and Qsymia.  This is big news as it’s the first time in over a decade that weight loss drugs have been approved.  SkepticRD is of the opinion that there are many tools that can be used in treatment of obesity and related illnesses like Type 2 diabetes, particularly if they are used wisely by the physician in a mutually respectful physician/patient relationship, but are several reasons that hearing news like this makes me want to go hide from the internet for a while.

The first reason is that because I accept, based on evidence, that changing your eating habits (and adding in exercise) is the best way to lose weight without having nasty side effects (although some people who have felt crappy after giving up sweets might disagree with me!).  However, I also feel that being virulently anti-medication, something that I see while skulking around on a lot of internet blogs, is getting pretty darn close to anti-science as well.  We have science to keep us from dying, and in some cases, actually live a pretty good life by avoiding complications of some of our health problems (I for one am still happy I never got measles). One example of many that I could give you on how advances in medical science have saved lives is in the treatment of Type 2 diabetes.  This is one particular chronic disease that is greatly affected by lifestyle changes, but sometimes we need other methods to treat it.  Unfortunately, some people, for whatever reason, do not find out they have diabetes or how seriously out of control they are until they wind up in the emergency room with blood glucose levels 600 or higher (normal fasting is 70-100) and generally sick as a dog.  When the ER staff encounters a person like this, are they going to say “You know, you really need to stop the sodas, cut back on your other carbohydrates, eat more vegetables, and start exercising” and then send them home?  No, they are going to give her IV insulin to stabilize her blood sugar, take care of any other problems she  might have (e.g . bladder infections), possibly admit her, and then likely send her home on an insulin regimen.  Hopefully once the person is stable the hospital staff will find some way to get her into decent diabetes education, but they addressed the immediate problem which was that the person was dying.  The parallel here is that when someone weighs 300, 350, 400 or more pounds THIS PERSON IS DYING and we need to provide them will ALL the tools that evidence based medical science has to offer which in some cases might include medication and/or surgical interventions.  To offer anything less is to give poor medical care.

The second reason that SkepticRD sometimes wants to hide from the internet upon hearing this news is that I also see plenty of “the other side” at work on a daily basis.  This “other side” has many levels—there are people who do think that taking a pill will keep them from having to many any changes in their diet (and no, they are not all just lazy, they may really believe this!).  And when the physician won’t prescribe the exact pill that they want, they will either find a physician who will prescribe it or kick up such a fuss that the physician relents.  There are also physicians who lack a decent education in nutrition/lifestyle changes and/or who are so jaded by working with people who refuse to change their lifestyles that they don’t feel that they have any choice but to prescribe a pill.  Some people have been ignoring their doctors pleads to change their lifestyle for years, and when the doc finally sighs and says, “Ok, let’s try this medication” then the person acts shocked, as though they never heard any of the pleas before.   And where I work a lot of people unfortunately do not receive an adequate education on the potential side effects/risks of taking this medication.  And some people don’t even read the package insert either, never mind the “you will need to still change your diet and exercise for this to work” part.

The third reason SkepticRD might be hiding is that all of the people who hold that last legal prejudice—the prejudice against the overweight and obese--come out of the woodwork if they weren’t out already.  There are accusations that the reason people want this drug is only because they are too lazy to change their diet; when in reality they have already tried every diet plan you could think of (some people might have already lost a lot of weight but are worried about the long road ahead).  There are accusations that people who are overweight or obese “have no self control” when in reality they have reached the point where the hormones like leptin that regulate their appetite no longer work correctly.  And also, there are accusations that all people who are overweight are just too stupid to change their lifestyle when in reality they are overwhelmed by the amount of conflicting information that’s out there.  None of these prejudices help the person get the help that they need. 
A fourth, and slightly more personal reason that I get worried about the release of these drugs  is that the drugs that have been used in the past and are currently in use do not have the best track record.  There were the amphetamines in the 1930’s-1960’s or so that caused deaths, there was Fen-phen and Dexfenfluramine (Redux) which were withdrawn because of cardiovascular side effects, there was Sibutramine (Meridia) that was withdrawn also because of fear of cardiovascular issues, and Ephedra which was withdrawn over concerns over increases in blood pressure and death.  Currently you can still get a prescription for Orlistat (Xenical), which you MUST follow a low fat diet unless you want to have uncontrolled oily, smelly diarrhea; and you can also get a prescription for phentramine but be prepared to gain the weight back once you stop taking it.  This article here describes some of the side effects of the newly approved drugs as well as some other concerns that have been raised.  And please, do not get SkepticRD started on the “natural” weight loss supplements either (that’s a whole different blog post there).

So what to do when you or loved one is contemplating taking one of the new diet pills or if your doctor wants to prescribe one for you or a loved one?
1)      If you or your loved one have not made any lifestyle changes, give yourself at least two weeks to 30 days on an evidence-based nutrition plan.    Sometimes just starting is hard, but most of us can put up with something for two weeks and you might even want to stay with it if you are feeling better.
2)       If you have tried everything and are still carrying your extra pounds, don’t beat yourself up for wanting to take a drug, but do realize that it won’t solve all your problems.  If your loved claims that he/she has “tried everything” and wants to take a pill, don’t beat that person up for it either.  And if you have a way of eating that has worked for you, be very, very careful in how you approach that topic, as they might not want to listen to yet another person telling them how to lose weight.  And remember, we as skeptics need to first examine ourselves to see if there are any lingering prejudices against the overweight or obese before we can offer support.
3)      Educate yourself on all the side effects in the most non-biased way possible. Drugs,com is one good website as is rxlist.  Talk to your local pharmacist.  If you are reading about side effects on a website that is trying to push an herbal formula, or where they seem to perpetuate stereotypes about people who might use those drugs (“You don’t need a pill, just put down the doughnut, fatso”) you are very likely getting biased information.
4)      Pick an eating plan that you can actually stick with at least 80% of the time.  Remember, even the new drugs are only effective if you change your eating habits.  And if you are on one just for a short term you don’t want the weight to come back with a few friends along with it.
5)      If you show up at your doctor’s office and the doctor tries to get you to take a medicine or have weight loss surgery without even talking about lifestyle changes, tell that person you are going to try a particular plan (be specific as possible) for the next 14-30 days (of course the doc might be skeptical of you because they’ve heard that before!) and set an appointment date to come back.  If your doc openly scoffs at your plan or is otherwise dismissive, you may want to find another physician.  Sometimes even physicians can fall prey to the fallacy of “one treatment works for everybody” and you need to hold your ground and do your homework before agreeing to the treatment.
6)      If you want to ask your physician for a prescription, do your homework as above first.  Give a list of all the diet plans you have tried before.  Tell the doc about the side effects/risks you are aware of.  Tell the doc about your current or new diet plan.  If the doc gives you a prescription, set up a follow up date to check your progress.  And if you do start to experience any of the side effects, call your physician right away.

Bottom line—the right eating plan for each person makes a huge difference, but sometimes other medical interventions are required.  Educate yourself on the risks of said treatment and work with your physician on what’s best for you.

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