The WeightWatchers gamble; employers crackdown on GLP-1s; patients sabotaged by their own physicians; and racism and obesity in our adolescents.

OPINION

• Isabelle Cueto in STAT News reviews The Fit for Healthy Weight Clinic situated on the UCLA medical campus ‘…for children and teens with weight-related health issues.’ This is a place where ‘…the kind of intensive health behavior and lifestyle treatment the American Academy of Pediatrics [AAP] recommended…’ for all children with obesity, and onward to anti-obesity medication and bariatric surgery as necessary.
  • Despite the 2015-2016 data that 20%, or 1 in 5, of US adolescents are obese, the UCLA clinic ‘…runs one half-day per week…’ in comparison to ‘…26 face-to-face hours per year — what the AAP guidelines recommend per patient for behavioral therapy.’
  • The location is ‘…a room with little more than four desktop computers, a whiteboard, and informational pamphlets…’ where pediatrician Cambria Garell works with her psychologist Natacha, licensed clinical social worker Bobby, and registered dietician Yoko, to see kids that have a BMI above the 95th percentile, or a BMI above the 85th percentile, if they have comorbidities.
  • The make-up is similar if not the same to the Health Weight Clinic that I worked with back at UPenn Health System, in 2013, when we started the adolescent bariatric surgery program in conjunction with Children’s Hospital of Philadelphia, better known as CHoP.
  • The detail with which author, Isabelle Cueto, describes the behavioral health program, aligned with past psychological trauma, and socioeconomic challenges is highly worth the time to read this article, and whilst there is certainly value for adolescents to be prescribed medication and/or undergo bariatric surgery, it is futile if we do not work to ‘…fix the systemic issues that make children unwell in the first place.’
  • The article recounts obesity-related co-morbidities across the family too – mother, grandmother, and on, in a more sober approach to real-world care for people, especially our children and adolescents with obesity, in the face of another hyped article on the promise and market opportunity of GLP-1 medications.
• Dr. Hannon at Indiana University, and Dr. Arslanian at the University of Pittsburgh are tasked to review Obesity in Adolescents, leading with a clinical vignette of a ‘…12-year-old boy with excessive weight gain that began when he was approximately 6 years of age [who] presents for evaluation of obesity…’ in the New England Journal of Medicine. The boy had a BMI of almost 42, raised lipid levels, prediabetes and fatty liver disease; his mother has obesity, and his maternal grandmother has type 2 diabetes.
  • The key clinical points from the article cite the need for a long-term care model, expedient evaluation and treatment, intensive face-to-face treatment, the elimination of sugar-sweetened beverages, and use of antiobesity medications or bariatric surgery (or both) along with intensive treatment.
  • The authors review data where ‘…elevated BMIs in both childhood and adulthood were associated with increased relative risks for type 2 diabetes [five-fold], hypertension [almost three-fold], elevated LDL cholesterol levels, [two-fold] and carotid artery atherosclerosis [two-fold] – which is a precursor to stroke. Indeed, structural racism and stigma have fueled an increased prevalence of obesity in adolescents has increased since the 1980s, most markedly in low-income communities and communities of color, and further accelerated during the coronavirus 2019 pandemic.
  • In the realm of treatment, and not just for adolescents, the authors note ‘…insufficient evidence to support antiobesity medication as monotherapy in adolescents without a multidisciplinary treatment strategy…’ given the chronic, multi-year nature of the disease. Surgical therapy is noted to be ‘…associated with weight loss of approximately 26% of the baseline body weight at 5 years…’ with resolution of type 2 diabetes in 86% of adolescents, and for 68% of adolescents with hypertension, though there was weight regain in about 8% of the participants. Importantly, ‘…Lifelong treatment of obesity is needed but is burdensome and cost-prohibitive, with disparities in access.’
• The Washington Post focuses upon Ozempic and other anti-obesity medications, with reference to ‘…how these medications will affect older adults in the long run… [and] …how seniors will pay for these expensive drugs.’ The issue at hand is lack of Medicare to cover weight-loss medications, though the same drug is covered if the beneficiary has type 2 diabetes. Further, the loss of weight comes with loss of muscle mass as well as fat, that is likely to accelerate the natural loss of muscle mass with age, ‘…contributing to falls, weakness, the loss of functioning and the onset of frailty.’
• ‘Ozempic face is not a medical term, and it is not a side effect of taking the medication…’ as per Delaney Nothaft in USA Today. Dr. Judy Korner, endocrinologist and Professor of Medicine at Columbia University, rightly says ‘…the derogatory remarks about what one’s face looks like after weight loss is part of a pattern of abuse against obese patients.’
• ‘Americans go on yo-yo diets, but we also have a yo-yo relationship to dieting…’ such that ‘…the weight-loss industry has bounced between moralizing, shaming, and tepid body positivity, depending on the sentiment of the times…’ from Olga Khazan in The Atlantic. In the 1950s, ‘…dieting organizations ruthlessly shamed people into losing weight…’ and public weigh-ins, through to 2018 when ‘…WeightWatchers dropped weight literally, and rebranded itself as WW, with a new focus on wellness.’ Mindy Grossman, then CEO was known to say ‘Healthy is the new skinny.’ An extreme approach to newer weight loss medications is ‘…whether there’s any point for obese people to frantically diet and exercise with no end in sight.’ A more measured, and appropriate lens is ‘…that this merging of diet apps and injectable pharmaceuticals could be a good thing…’ playing up the multimodal approach to care delivery, over a multi-year period to help patients with obesity, indeed as a chronic disease.
• Dr. Freedhoff, medical director at the Bariatric Medical Institute of the University of Ottawa, asks ‘Are there medical conditions other than obesity where physicians, if even inadvertently, regularly sabotage their patients’ efforts at managing them?’ A top ten list of ‘…ways docs sabotage their patients’ weight loss journeys…’ is a reminder of the bias that exists within the practitioner community. The author reviews pushing useless dietary advice, to refusing medications, fearmongering, setting unrealistic weight loss goals, and not discussing options at all, to land upon a new era, where ‘…we will see obesity treated as we do every other chronic noncommunicable disease with lifestyle levers – with patient-centered care free from judgment and blame, and with a myriad of therapeutic options that physicians objectively, not subjectively, inform and prescribe to their patients.’

DATA

• Drs. Bennett and Puhl at the University of Connecticut note ‘…Adults with type 2 diabetes [T2D] report experiencing stigma across multiple settings, including stigmatizing interactions with their healthcare providers…’ with the intent to ‘…assess attitudes towards individuals with T2D and obesity among physicians who treat T2D.’ Over 200 internal medicine and endocrinology physicians completed ‘…a series of online questionnaires assessing their attitudes towards patients with T2D and obesity.’ The results, referenced by physician attributions of controllability and blame of individuals with T2D and obesity, revealed ‘…1/3 reported being repulsed by patients with T2D and view them as lazy [39%], lacking motivation [44%], and non-compliant with treatment [44%].’ And to top it off, ‘…Physicians endorsed worse levels of bias towards patients with obesity than T2D, but differences were small.’ There is an urgent, obvious, and necessary need for ‘…stigma reduction interventions for physicians addressing both T2D and obesity….’ and further on ‘…the effects of T2D stigma on quality of patient care and health outcomes…’
• Dr. Adolfo Cuevas and colleagues across New York and Massachusetts review the association of self-reported experiences of racial discrimination with adiposity, in a nationally representative sample of children and adolescents. Racial discrimination was quantified in over 6,000 participants from across the US, in association with their weight, height and waist circumference, over a two-year period. The authors note ‘…Exposure to racial discrimination has been recognized as a social determinant of health and a driver of health inequities among children and adolescents…’ and ‘…positively associated with adiposity over time.’

Kind regards, Raj