An Open Letter to Dr. Apovian, Who Wants to Prescribe Pills for Obesity

 
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Before you read:

Opinions who I respect greatly noted this article has a rather singular focus (nutrition). I agree, and I omit the role of public health, environment, genetics, socioeconomic status, stress, and many other factors contributing to obesity not because they aren’t important, but because they are beyond the scope of this article. There was an article published hoping to prescribe pills for obesity. I want to offer a counterpoint that there is much work to be done—backed by valid research—before implementing pharmaceutical agents for chronic care. I am Certified in Public Health and care about the whole picture contributing to obesity, but those factors are simply not what I am focusing on here. Thank you for reading. 


Dr. Apovian, 

I don’t know you personally. I know you are a physician and professor, an author, and a lead researcher. I am a second-year medical student. Your record of accomplishments and experience exceed anything I have done by an order of magnitude too large to calculate. I am acutely aware of the dynamic in this hierarchy. 

I am not writing this letter to raise my fists at the power that be or to challenge you on a personal level. I am writing it to offer a public counterpoint to your public commentary. This subject is too important to relegate all opposing views to the comments section below your article; it matters to me there is a public, thorough rebuttal — it matters because I think the paradigm from which you write is harmful to health and traps well-meaning patients in a cycle of sickness. There is a solution, but it isn’t drugs. 

I write to you from a place of concern. Concern for the state of healthcare in this country. This framework for thinking about obesity is frightening and harmful, and it’s a type of medicine I fear perpetuating as I come into physician-hood. I fear perpetuating “sick care,” where we wait for patients to become ill then offer drugs or procedures to manage side effects. I fear a world of medicine where medical opinions are funded by corporations with massive conflicts of interest. I fear a world where “we’ve always done it this way” prevails, even in the face of new evidence and better practices.

These three things are what I want to talk to you about.

Sick Care, Not Healthcare 

From our first day of medical school, we learn drugs. It’s a matching game: Recognize the disease and remember which drugs should go with it.

This practice molds our brain into the way we will think about diseases. We learn to recognize side effects or interpret test results that necessitate the use of pharmacological intervention. Diseases are taught to us in terms of the drugs that will treat them. Any nod towards prevention or behavioral modification is relegated to a parenthetical gesture—a mandated pamphlet or perhaps nutrition advice backed by zero valid scientific data.

We understand drugs. We understand their mechanisms of action and their toxicity profile, we know how to write prescriptions and refills. As metabolic diseases enter global pandemonium, we stick to the pharmaceutical script. We do this because we don’t understand the diseases themselves. If we did, we would understand how to reverse them.

Dr. Jason Fung, in The Diabetes Code, writes: “As our understanding of diabetes increases, we expect that complications should decrease. But they don’t. If the situation is getting worse, then the only logical explanation is that our understanding and treatment of type 2 diabetes is fundamentally flawed.”

It doesn’t seem like you acknowledge this flaw. In your article, you say we treat diseases like hypertension and type 2 diabetes with drugs, so we should do the same for obesity. However, the CDC shows 75 million Americans have hypertension and over 100 million Americans have diabetes or prediabetes. Why would we treat anything the way we are treating these diseases? Their management has been catastrophic. 

Our understanding of the majority of metabolic diseases is fundamentally flawed—we take sick patients and attempt to curb side effects without addressing root causes. We blame willpower, we blame calories, we blame fat, and we blame drugs for not working well enough. Patients are harmed and confused.

Your article hoping to prescribe medications for obesity is placed squarely in The Sick Care Paradigm. I want to do everything I can to avoid that realm.

Funded Medical Opinions

Dr. Apovian, funding bias isn’t a secret — but it is terrifying. Take this analysis for example: Results of “scientific” studies are based almost entirely by who pays the researchers. These studies are circulated and trusted as fact, further confusing the conversation on what “science says” with regards to health, nutrition, and pharmaceuticals. It’s a malicious money-making racket at the expense of patients and consumers, and it’s unethical for physicians to participate in it. 

I was recently at a conference on diabetes management. I watched a physician with a fake tan and an expensive suit stand on stage for 45 minutes, reading from slides that were clearly not his own, singing the praises of new insulin combination formulas made by the pharmaceutical companies that were so predictably listed in his disclosure. They pay him, write his presentation, and use his physician status to advertise for them. It made me feel sick to my stomach.

There is no other realm that normalizes corruption in this way. Dr. Fung uses an example of a hypothetical judge who accepts money from private prisons, and profits when he sentences defendants to those prisons. Even if a judge disclosed that funding, and claimed the funding source did not affect his decisions, the entire scene would be blatantly unethical and would be protested until it ceased.

In medicine, it’s standard. There are physicians and researchers who accept money from pharmaceutical companies then prescribe drugs made by those companies, advertise for them, or publish research favorable to them. It’s untrustworthy. 

I believe if you teach medical students, you should not be allowed to take industry funding. If you write prescriptions, you should not be allowed to take industry funding. If you do research, you definitely should not be allowed to take industry funding. Pharmaceutical companies will inevitably have a relationship with physicians and researchers—but it should be platonic. They should not be in bed together. 

Dr. Apovian, for these reasons, it is difficult to read your article making the case to prescribe pills for obesity. The disclosures you list are manifold. They include huge pharmaceutical companies like Merck & Co, Novo Nordisk, Pfizer Inc, and Takeda. It also includes smaller pharmaceutical companies that specifically tailor drugs to obesity (Orexigen and Genesis), as well as companies that profit from weight loss products (Nutrisystem).

I think the integrity of an article making the case to prescribe obesity medications is called into question when the author is funded by pharmaceutical corporations. This is one example of many, and no one person is the sole perpetrator of this issue, but it’s another piece of the medical industry that is frightening. It harms patients and health, and I don’t want to participate in it. 

Old Paradigm Prevails 

The philosopher David Hume introduced the Is/Ought dilemma: Simply because something is, doesn’t necessitate that it ought. The current paradigm of medicine is the way it is. This does not mean, however, that it ought to be. 

Every day we make a decision to perpetuate or counter it. 

Dr. Sarah Hallberg and her team, Dr. Jason Fung and his team, and other pockets of physician frontrunners are opposing current practices, guidelines, and ways of thinking about metabolic diseases—and they achieve tremendous results. They are reversing type 2 diabetes in the vast majority of their patients. They achieve weight loss and medication cessation in the vast majority of their patients. Managing these diseases using current standards achieves nowhere close to this quality of success.

Nutrition and lifestyle interventions can reverse obesity and type 2 diabetes, but we need the correct intervention. The current guidelines are detrimental to health and essentially ensure failure for patients who hope to regain health by following them. The physicians mentioned above ignore guidelines—which tend to be influenced by funding from food and drug companies—and they achieve successful results.

They use a hormonal model for obesity rather than the dangerously popular energy balance (calorie) model. They implement periods of fasting accompanied by a high fat, low carbohydrate diet which keeps blood sugars low, so the need for insulin and other antihyperglycemic drugs is removed. They encourage whole foods and omit processed ones. Patients are (safely) weaned off medications, lose weight, and learn to implement dietary tools that are sustainable for life. These programs coach patients on movement, sleep, and stress —  a comprehensive hormonal approach that does not necessitates the use of pharmaceuticals. 

It works, but it hasn’t been adopted on a large scale (evidenced by the global pandemic of metabolic disease). We ignore new research and new ways of thinking about diseases, even when current management standards have failed to produce results. We use band-aid tactics to push symptoms under the rug, patting ourselves on the back as the health of a population declines. 

Dr. Apovian, I don’t want to be a part of the old paradigm of medicine. 

Conclusion

I am not anti-pharmaceuticals in a general way. Drugs have given life back to patients with diseases that historically were a death sentence. Scientific advances have been stunning. However, doubling down on pharmaceuticals when they fail to produce positive outcomes in these diseases should be called into question. Strategies that do not work should be abandoned.

Thank you for writing an article to generate this discussion. I hope this letter can be read as sincere, from a second-year medical student who wants to do right by her future patients. I want to practice medicine honestly, objectively, and compassionately; so I must object to the paradigm of medicine that would keep me from doing so.

Thank you for listening, Dr. Apovian. 

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