COMMENTARY

Medicine Is Failing Patients With Obesity

Yoni Freedhoff, MD

Disclosures

May 29, 2020

A recurring COVID-19 medical theme is the additional mortality risk conferred by obesity. Although it's far too soon with this new disease to have any real confidence in how much additional risk obesity poses, a recent preprint reported that the hazard ratio associated with obesity was slightly elevated at 1.35, comparable to that found in patients with chronic cardiac disease, chronic pulmonary disease, chronic kidney disease, cancer, and dementia—but a far cry from that of being older than 50.

Another preprint with a massive cohort looking at COVID-19 hospital death rates found that key factors related to COVID-19 deaths are being old, being male, having uncontrolled diabetes or chronic respiratory disease, being black or Asian, or having a low socioeconomic status. And although obesity was indeed a risk factor too, it carried less risk than those other factors (with the exception of having a body mass index > 40 kg/m2, representing 3% of the population).

Although obesity is only one of the many identified risks for COVID-19 mortality, that hasn't stopped people from penning op-eds about how we could prevent all these deaths if we would just address obesity and our food systems, or stating on social media that if everyone were on a specific diet, we could have prevented the pandemic to begin with, or promoting a course on how to use their diet to flatten the curve.

For just a moment, let's put aside the fact that obesity, while a risk factor, is certainly not the sole driver of COVID-19 morbidity and mortality, and also put aside the fact that there is zero data to support the notion that a particular pattern of eating would help to prevent infection by SARS-CoV-2. What struck me most was that none of these pieces or postings mentioned access to and costs of pharmacotherapy or surgery to help in the management of obesity. It's quite an oversight, because no single diet has ever been shown to durably and reproducibly compete with drugs or surgery to date.

Perhaps this shouldn't be surprising, given the way we approach obesity as a medical community. To illustrate, let me share a conversation I had last year with one of my patients who had been referred to me by her family physician. I had just taken her blood pressure.

"How long have you had high blood pressure?" I asked.

"I didn't know I had high blood pressure," she answered.

"What sort of readings have you been getting with your regular doctor?"

"Oh, he hasn't taken my blood pressure in years. He says he doesn't have a cuff that's big enough."

After the patient left, I did an online search. The cost of an adult large blood pressure cuff was less than the cost of an average single visit to discuss blood pressure. The cost of a thigh-sized cuff (which can also be used on larger arms) was less than the cost of two visits.

What this means is that, given the percentage of people in Canada with obesity, there's a good chance that this physician hasn't been measuring (or accurately measuring, if he sometimes uses a cuff that's too small) the blood pressure of 20% of his adult practice—this in a country where heart disease is a leading cause of death.

Let that sink in for a moment.

Ultimately, a physician has elected not to measure or accurately measure dozens, if not hundreds, of his patients' blood pressures despite being well aware that obesity is associated with an increased risk for hypertension and cardiovascular disease. And why? Because they're fat?

Another patient, this time a post-bariatric surgical patient who was regaining weight, came to see me in consultation to chat about the use of medications to help prevent weight regain. I informed her that multiple studies have demonstrated benefits of the use of glucagon-like peptide 1 (GLP-1) agonists, and suggested a trial to her family doctor. The patient came back to see me a few weeks later. Her family physician told her that he wasn't comfortable prescribing weight loss drugs, and only after her steadfast self-advocacy did she leave his office with a prescription—with a lower dosage than recommended and the admonition that he would only prescribe the drug for 3 months.

What he has effectively told this patient is that in the treatment of obesity, evidence of a drug's safety and efficacy either doesn't matter or isn't important enough to learn about, and that her weight regain isn't something worthy of medical attention despite its medical and psychosocial risks and impact, and the patient's concerns.

More recently, the US Food and Drug Administration requested that the weight loss drug lorcaserin be voluntarily withdrawn because of a small increase in pancreatic, colorectal, and lung cancer in CAMELLIA-TIMI 61 study participants. In response, a prominent obesity physician and researcher stated on social media that its withdrawal "highlights the inevitable issues" with all weight loss drugs in that "weight loss is modest, you have to keep taking it to maintain this benefit, and long-term risks are unknown." Although true, these seem like odd reminders and highlights, given that no drug for any chronic disease is a panacea, that many drugs can cause other problems, that drugs taken for chronic diseases—by definition—need to be taken chronically to maintain their benefits, and that long-term risks for all new drugs are unknown.

There was also the uproar last year when the American Academy of Pediatrics published a policy statement about the use of bariatric surgery in cases of severe adolescent obesity, along with its scientific rationale. Though there were examples of the usual diet zealots reacting with hyperbolic outrage, I was dumbstruck when, the next day, JAMA's deputy editor for clinical reviews and education tweeted, "Bariatric surgery and kids—probably not a good idea," citing a study reporting that kids who have bariatric surgery are likely to develop iron and vitamin B12 deficiencies. These deficiencies are both easily screened for and treated, unlike these patients' severe quantity-of-life-reducing, quality-of-life-destroying obesity that he seems comfortable ignoring.

And just a few months ago, we saw the publication of a supposed systematic review of the long-term treatment of obesity that concluded obesity isn't treatable by way of lifestyle changes—but the review's inclusion criteria only captured studies that didn't continue the intervention through the follow-up period and didn't include medications. But obesity is a chronic disease, and like most other chronic noncommunicable diseases, lifestyle interventions need to be lifelong. And if these efforts prove insufficient, medications should be offered and utilized. Just as we'll never see a systematic review of hypertension treatment studies demonstrating that brief lifestyle counseling and exclusion of medications doesn't lead to lower blood pressure 3 years later, we never should have seen this paper.

What Makes Obesity so Different?

If we're comfortable with the long-term pharmacologic treatment (oftentimes with multiple medications) of hypertension, dyslipidemia, osteoarthritis, and more, why do we often hear that treatments or medications for obesity should be temporary or that we shouldn't bother with them if they "only" provide a 5%-10% weight loss (which has been shown to result in real health benefits)? If we unquestionably value spending our time counseling and working with patients for a whole host of nonremunerable psychosocial and life issues, we shouldn't hear about physicians not exploring, learning about, or counseling around obesity, a leading cause of morbidity and mortality, simply because there is no adequate fee code. Yet, we often do.

If we don't require people to quit smoking before operating on their lung cancer, why do we often require people to lose weight before bariatric surgery? And even though we continue performing coronary artery bypass surgery, which has a perioperative mortality rate at least 10 times higher than that of bariatric surgery—and unlike bariatric surgery, hasn't been shown to markedly extend life or improve its quality—we often hear about physicians who "don't believe" in bariatric surgery.

Medicine is failing patients with obesity. Whether it's bias that directly affects their care (such as not bothering to purchase appropriately sized blood pressure cuffs) or the bias that underlies a fatalistic, blame-based view of obesity treatment and the inability to treat it like any other chronic disease, we need to do better. Obesity is not something our patients choose for themselves, but rather the cumulative impact of thousands of genes, dozens of hormones, an obesogenic food environment, and a broken food culture.

As the authors of a piece highlighting the global rise in weight stated, "We believe it is implausible that each age, sex, and ethnic group, with massive differences in life experience and attitudes, had a simultaneous decline in willpower related to healthy nutrition or exercise." At the very least, we need to stop seeing obesity as a condition for which we blame the patient if the treatment doesn't work.

We need to get over ourselves.

Yoni Freedhoff is an associate professor of family medicine at the University of Ottawa and medical director of the Bariatric Medical Institute, a nonsurgical weight management center. He is one of Canada's most outspoken obesity experts and the author of The Diet Fix: Why Diets Fail and How to Make Yours Work.

Follow Yoni Freedhoff on Twitter: @YoniFreedhoff

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