Tag Archives: Evidence-based medicine

Diminishing Distress Dials Down Diabetes

First do no harm. Diabetes scare tactics just might kill you.

I recently ran across this article on Diabetes Hub which describes two important studies which correlate distress with poorer outcomes for people coping with diabetes.  The first of these studies involved a randomized trial of 150 women with uncontrolled diabetes.  What the study found is that those women in the study who were able to reduce their level of disease-related distress had significantly improved glycemic control.

Typical sources of disease related distress included fear of getting sicker and feelings of isolation or overwhelm in relation to disease management and treatment.  The EMPOWER study tested various forms of treatment interventions and found that regardless of treatment methodology, those people who were able to lower their distress were more compliant with treatment protocols:

HbA1c dropped much more substantially in those in whom distress was lowered, compared to those with whom distress was unchanged or increased,” Dr. Cummings said. “Medication adherence, self-care behaviors, and diabetes empowerment and self-efficacy were all substantially improved in the group with lower levels of distress at the end of the trial.

The doctors admit that they don’t quite know why lowering distress has such a significant effect on glycemic control among people with diabetes.  However it seems that working to lower distress among people with the disease is an important treatment goal.  According to Dr. Cummings:

We’re surprised at the number of these women caring for children, grandchildren, and other members of their families, often while working, and yet not finding time to care for themselves. It is clearly an important cultural phenomenon that we need to understand better.

The article went on to discuss data gathered from another important study: the national Reasons for Geographic And Racial Differences in Stroke (REGARDS) cohort study.  Dr. Cummings noted that in this study which included 4,000 black and white adults 45 years and older with diabetes and nearly 18,000 adults without diabetes, those subjects with diabetes were more likely to suffer from depression or distress (26.7% vs. 23.2%, P < .001) or both (10.1% vs. 6.2%, P < .001), compared with those without diabetes.  Those people who had diabetes and also symptoms of distress or depression had higher risks for stroke and CV death than people with diabetes without depression or distress.

What all of this seems to make clear to me is the deep need for compassionate, blame-free, stigma-free, evidence-based health care for people coping with diabetes.  The notion of scaring people straight or using dire warnings to fuel completely unrealistic weight loss goals may be more than counterproductive–they might prove especially medically dangerous for this population.  Many forums for people with diabetes are filled with horror stories about how members were stigmatized, told their conditions were their fault and told that if they didn’t get thin, they wouldn’t live to see their children or grandchildren grow up.

But maybe what really needs to grow up is our approach to helping people with diabetes live better, longer and happier lives.  Maybe we need to spend a little less time pointing fingers and a little more time holding hands as we help people make small, incremental, manageable and realistic changes in their lives.  It’s just possible that fear tactics are doing more to harm people with diabetes than to help them.

That’s one of the reasons I’m so excited to be giving a presentation at the upcoming Take Control Of Your Diabetes Conference on September 26 in San Diego, CA  The event focuses on helping people with diabetes take positive, small and sustainable steps to better health.

Advertisements

Doctors Consult on Fat Profits from Medical Weight Loss Programs

Print

New profits from an old formula

A recent article in the New York Times got my blood boiling this morning.  The article cites a few medical professionals (and others) talking about how to fatten profits from offering weight loss products, potions, procedures and magic pills.  In particular Dr. Kaplan (touted as a “leader in the medical weight loss industry) talks about his Long Island Weight Loss Institute and the various products and services he offers people to help them lose weight.

In fact, Kaplan is so well known as an expert in the industry that he has started a consulting business to help other doctors.  Is he helping other doctors figure out what are the best evidence-based options for helping their clients actually lose weight.  Well no.  He’s helping doctors figure out how to increase their bottom line by teaching primary care doctors how to bill insurers for obesity treatments.

This is a very big business, at least in part, due to a provision in the federal health care law requiring insurers to pay for nutrition and obesity screening.  Marketdata Enterprises Research Director John La Rosa has studied the weight loss industry for more than 20 years.  In an interview cited in the Times, La Rosa estimates that medical weight loss programs currently bring in $1 Billion annually–a number he expects to grow 5 percent annually at least through 2019.  La Rosa calls the Federal health care provision a “game changer” and mentioned a seminar he recently sponsored advising entrepreneurs to take advantage of the insurance coverage by opening their own weight loss clinics.

While the profits appear to be new, the procedures being sold don’t seem to be new at all.  In fact many of the procedures, potions, chants, and magic pills offered have not been proven to be effective or have even been discredited as widely ineffective.  Kaplan’s own office offers very low calorie diets, meal replacements, B12 shots and vitamin supplements.  None of these techniques have been demonstrated effective for anything but very short term weight loss which typically begins to reverse very shortly after the treatment period (which can be as short as six weeks).  What’s more, many of these programs offer little medical supervision.  The patients are often actually seen by nurse practitioners or physician’s assistants with little specialized training in the fields of nutrition or bariatric care.  One company, Medi-Weightloss (with over 76 locations throughout the country) advertised for a medical director at its Connecticut facility stating that the hours are “not very demanding” stating that files could be reviewed remotely and “there are no set hours or emergency calls”.

Now don’t get me wrong.  I think most doctors work very hard in a system that is not very hospitable to good medicine.  And I am an entrepreneur.  I believe in the power of invention and good business practices.  But when you are holding seminars to teach guys in white coats the best way to get insurance companies to reimburse the same snake oil they have been trying to sell us for centuries, I get a bit miffed.  I think people are entitled to research-based medicine.  And by research-based, I mean medicine that is proven to be effective, not just turn an ever increasing profit.

In this country, not everyone has access to even basic, decent medical care.  Medicine is very expensive here.  And we are often taught that the reason that medical care is so expensive here is that the fatties are driving  up the costs.  So the idea that doctors are learning to fatten their profits at the expense of their fat patients has got me more than a little upset.  Lets give every BODY access to bias-free, evidence-based, reasonable healthcare.  And let’s put the fat-shaming, profit mongering medical weight loss industry on restriction.  That would seem to be the healthy thing to do for our bodies and for our economy.

Love,

Jeanette DePatie (AKA The Fat Chick)

P.S. Want me to come and speak about evidence-based medicine and wellness to your group?  Go here.  Or just email me at jeanette at thefatchick dot com for more info.

When Docs don’t listen…

I have to thank my colleague Michelle May, M.D., CSP for recently posting links to two articles that I had missed in the past.  Both were very interesting.  But what I found really fascinating was the way they worked together.

The first article she posted was in the BMJ (formerly the British Medical Journal).  It was an editorial article written by Emma Lewis entitled “Why there’s not point in telling me to lose weight”.  In this poignant piece, Emma talks about how no matter what she goes to the doctor for, she’s told she needs to lose weight.  She talks about the fact that her health markers are good and how she exercises regularly and strenuously.  She talks about the fact that doctors often tell her to start exercising, without even asking if she is exercising already.

Emma also talks about how her doctor’s “one-size-fits-all-fatties” approach to wellness makes her feel alienated, unheard, and shamed.  And she talks about how it keeps her away from doctors–how she hasn’t been to see her GP in a while, how she’s not doing routine diagnostic stuff.

This article is in a section of the BMJ called “Practice: What Your Patient is Thinking”.  I applaud BMJ for running this piece.  But I have to fight despair when I read the comments.

The comments are not uniformly bad.  There are a few doctors that get it.  But lordy, lordy, LORD there are quite a few that don’t.  I’ll summarize some of it so you don’t have to waste the sanity points reading the comments yourself.  But most of them go something like this:

1.  The Super Snarker:  Well if the fatties don’t WANT to change, then she’s right–there’s no point telling them to lose weight.

2.  The Concern-Trolling Hand Wringer:  But it would be irresponsible for me as a DOCTOR to not bring it up.  Maybe they don’t know they are fat.  Maybe they don’t think fat is bad.

3.  The Food Policer: Well yeah, she exercises.  But exercise doesn’t make people lose weight.  She just has too much hunger.

4.  The Math Guy:  Well of course she can lose weight.  Energy in vs. energy out!  Look it worked in concentration camps and lands with famine so it’s just math.

5.  The Apocalypser:  Obesity is bad.  Everybody Panic!  Cuz’ FAT!

Like I said, there are some that point out that Emma has a point.  There are some that get the fact that she feels unheard and disrespected and that this is a problem.  But virtually everybody who commented seems to believe that Emma’s main problem with weight loss is a problem of will.  If she wanted to, she could be skinny.

Except the evidence is not in favor of this hypothesis.

We simply don’t know any way of helping any but a very small percentage of people to lose a significant amount of weight and keep it off.  We just don’t.  And for any weight loss intervention we undertake, a very small percentage of people lose some weight and keep it off, the vast majority of the people gain all the weight back and a significant percentage of those people end up bigger than when they started.  And a whole lot of people end up facing serious negative financial, social, medical and psychological side effects from the whole process.

And we simply don’t have enough evidence from the very small percentage of people who lost the weight and kept it off to determine, if even that tiny percentage of people end up healthier because they lost weight.  We know that most people who exercise and eat better experience health benefits regardless of whether or not they lose weight.  But we don’t know if fat people who become skinnier are healthier in the long run.

So all five of the commenter types above are missing a few very important points:

1.  There is no intervention that you can offer Emma that offers her any kind of reasonable chance for significant, long-term weight loss.  In fact, statistically, just about any kind of intervention you offer is statistically more likely to make Emma bigger in the long run than to make her smaller.

2.  Any intervention that you offer Emma is likely to have negative side effects.  These negative side effects include physical, social, financial, emotional, relational, and physical problems.

3.  You can offer no reliable evidence that, should Emma be one of the very few people to achieve long-term, significant weight loss, she will experience health benefits from the weight loss that she would not achieve from far less invasive wellness efforts with far fewer side effects.

Cue the second blog  post shared by Michelle May.

This post called “Let’s Talk About Intentional Weight Loss and Evidence-Based Medicine” is found in the blog entitled Worse for the Fishes by Anna G. Mirer, M.P.H.  In this wonderful post, she talks about all of those wonderful interventions available to the five classes of point-missing commenters above.  She talks about how they don’t work.  She talks about how they cause more problems than they solve.  She talks about how there’s no real evidence that they help anybody.  And she provides lots of links to back this up.

I’m sure that this will all be refuted by another special kind of commenter:

The Research Refuter: Despite the fact that there is massive amounts of evidence supporting what you say–amounting to hundreds of peer-reviewed studies in reputable journals, I don’t like your evidence.  Therefore I will accuse you of cherry-picking your articles.

Again, I have to thank Michelle for bringing these two articles together in my world at the same time.  It so perfectly illustrates how we as a society are perceiving the wrong things as the problem and thus suggesting the wrong solution.

To me the solution is simple:

1.  Everybody benefits from eating well and exercising, along with managing stress, sleeping well, and having strong social relationships.

2.  So medical  professionals just ask if people need any support with eating well, exercising, managing stress, sleeping well and having strong social relationships.

3.  If people say no, then stop.  If people ask for help on any of those specific behaviors, offer help with those behaviors.

The End.

Love,

Jeanette DePatie (AKA The Fat Chick)

P.S. Want me to come and talk to your group about evidence-based medicine and wellness?  Send me an email at jeanette at the fat chick dot com.

P.S.S. You can learn more HERE.