By John Mandrola, MD
I need help. In dealing with obesity as a medical problem, that is.
I am pretty solid at arrhythmia management, but as an obesity doctor, not so much. If I was the teacher, and my obese patients were the students, I would surely be fired for poor student test performance. At least, if the core measure was the patient's BMI.
If a student does poorly on an achievement test, is it the student's or the teacher's fault? If the obese patient does not lose weight, is it the doctor's or the patient's fault?
Recently in the NEJM, I read about Arena pharmaceutical's attempt at creating the new "wonder pill" for obesity. Lorcaserin is a novel serotonin re-uptake inhibitor which acts primarily in the brain centers that control hunger and satiety. Theoretically, it provides a patient with the good sense not to eat too often, and as the skinny farmer advises, leave the table before you are stuffed.
Although, Locarserin had no major adverse effects, the weight loss was modest, up to 5-10% of body weight. Thirty pounds is only the prologue for the 300 pound patient.
So, now we may have another pill for fatness. Like we do for tiredness, and the low sex drive of male middle-agedness.
The study conclusion is worded with scientific precision. The researchers say, in conjunction with behavioral modification, the drug was effective in weight loss What people hear, though, and the drug manufacturer are really saying is: take this pill and be thin.
Cynicism is knocking at my door, and I am trying to ignore it.
It is clearly true that obesity is one of the developed world's most important medical problems. Paradoxically, while the fury of modern medicine has lowered death rates from heart disease and cancer, the obesity epidemic continues unabated. The more sophisticated we become as a society, the fatter we get.
As a doctor of the heart, it is crystal clear that lifestyle choices lie at the heart of health. No disease is more preventable by lifestyle choices than heart disease. And these same lifestyle choices work on obesity as well. Call it being on "the program." Not a diet, the program is a simple concept: finding the groove of enough exercise, wise food choices and adequate rest.
I own only one belt. It is thick leather. At times, as I am human, the white-chocolate-chip brownies in the doctor's lounge get the best of me. If this behavior persists with any regularity the belt feels tighter. Thick leather belts do not stretch. The tighter belt says, pedal a little longer and cut smaller pieces of brownie. Doing so restores equilibrium. But if I deny too much the result is grumpiness. The pattern is repetitive.
This simple formula is the problem.
However, the notion that obesity is simply an imbalance of the equation, calories-in, calories-burned, is not in vogue. It seems, by saying to the patient, eat less (really, it is sadly amazing how few calories a sedentary middle-aged human needs) and move more, you are at risk of being perceived as judgmental, incurious and even aloof.
If on the other hand you talk about enhanced receptor sensitivities in hunger centers that may be inhibited by sophisticated chemicals, you are smart, and a sensitive doctor. The obese patient may conclude that poor lifestyle choices are not their fault, rather a chemical imbalance in the brain. (And maybe this will be proven so.)
I don't think we should persecute the obese. Malfeasance is bad for the heart. Nor am I against novel pharmaceuticals or innovative surgery. But taking a pill or having surgery (that someone else pays for) will always be easier than saying no to white-chocolate-chip brownies.
As we advance in medical technology, the simplicity of making a series of good choices should not be overshadowed by the science of receptor inhibition in the brain.
Surely, doctors should emphasize the program more.
John Mandrola is a cardiologist who blogs at Dr John M.
