Changes in How Obesity is Treated

The medical treatment of obesity has fundamentally changed within the last two years.  Some of this is due to ongoing research on the underlying physiologic mechanisms of obesity, which we hope will lead to effective and targeted treatment options.

Additionally, obesity is accepted as a complex life-long condition warranting life-long treatment options.

Some things are fundamental.

Make realistic goals.  Trying to lose 30% of your total body weight is very unlikely to happen without surgical treatment.

Losing  5-7% of your weight over three to six months by diet and exercise is considered great, and reduces blood sugar, blood pressure, snoring, arthritic pain, acid reflux and urinary incontinence.

Using medication and lifestyle change; losing 10-15% is great and over 15% is excellent.

150 minutes of exercise a week is a reasonable goal, and so is reducing how much you eat to result in about a pound a week of weight loss is generally sustainable for longer periods of time.  If you are counting calories, this is going to generally be 1200 calories a day or more.  Certainly, if you are not losing weight on a diet of 1200 calories a day or less you may not be recording them accurately and should reduce portions by half and see if this solves the problem. 

Admittedly, more benefit is to be gained by eating less than by exercising more (a can of soft drink has about 200 calories; running a mile burns off about 100 calories. Ouch.).  So if you have a lot of back or knee pain and exercise is limited, make the most of reducing how much you eat.

In the past few years, a number of prescription medicines have come out that can help you to lose about 5-10 of your total weight.  Furthermore, they are safe to use long-term.  This is quite different from phentermine and others which may not be safe to use for more than a few months.

Contrave, Qsymia, Belviq and Xenical all are found to be safe and effective in long-term weight loss and weight loss maintenance. They each work differently, and can be switched if using one along with diet and exercise is not resulting in at least a 5% weight loss over 3 months.  Also, they have different possible side-effects and safety profiles so by all means, research them thoroughly to make sure that a medication you are interested is safe for you to use.

So far, insurances are willing to cover surgery, but not pills. Go figure.  Look over your formulary carefully as far as not only cost tier but also authorization requirements for coverage.

For the most part, you are probably going to be paying cash straight up on these medicines.  Happily, goodrx is a really useful website (and also a free smartphone app) that allows you to find the best prices close to where you live.

Please feel free to ask about losing weight whether you are interested in using prescription medication or not!

California's Physician-Assisted Suicide Law

As of last Friday's signing by Governor Brown, California becomes the fifth state in which physician assisted suicide is legal, which affects 1 out of every 6 Americans.

Note that this is not euthanasia: doctors will not be giving lethal injections to people.  Rather, this law will allow terminally ill patients to ask for a prescription for medication they could take if they wished to die in a manner of their own choosing.

Similar to other states,

• a patient would have to request such a prescription twice, at least 15 days apart
• the requests have to be verbal and also must include a written request 
• the patient must be a consenting adult
• the patient would have to be agreed on by two different doctors to be terminally ill with six months to live (similar to the criteria for hospice care)
• the doctor cannot administer the medication; the patient must do so.

Oregon was the first state to pass such a law in October 1997.  Looking back over the last eighteen years of Oregon's experience, several things can be seen:

• since 1997, 752 people have died through lethal prescriptions at their request; 72 of these deaths were last year.  This comprised 0.22% of all deaths in Oregon last year (22 out of every 10,000 deaths).
•  1,173 prescriptions were written since 1997 and  752 (64%) were used.  It may be that for many patients, the prescription serves as an assurance that they will not have to suffer a horribly painful death.
• Oregon doctors wrote lethal prescriptions for only one out of every six patients who requested them.  Patients with untreated depression and patients indicating that they felt they were a burden to others were unlikely to be given a prescription.
• 53% of patients who requested lethal prescriptions were college-educated with at least a 4-year degree, and 97% had health insurance.  This argues against the notion that physician-assisted suicide laws are used to cull poor or under-educated patients.
• 85% of patients were already enrolled in hospice services; lethal prescriptions are an addition to hospice, and not so much a replacement for it.

My earlier postings on this matter make my position clear.  I do not feel this law will be abused and it will not be a mechanism for euthanizing elderly or disabled people.  Rather, it will allow dying patients an option to be able to die comfortably in a time and manner of their own choosing if and only if they should wish to do so.  My experience tells me that we do not so much fear dying as we fear dying in miserable pain and alone.

The law for California is likely to take effect some time later in 2016.