Voices Of Medicine

Current Issue

From Sonoma Medicine: Bariatrics

Medical Weight Loss by Jennifer Hubert, DO

Overweight and obesity are complex chronic medical conditions that should be given the same consideration as other chronic diseases. “Overweight” is defined as a body mass index (BMI) of 25-29.9, while “obese” is defined as a BMI of 30 and above. Many comorbid conditions--such as heart disease, type 2 diabetes, hypertension and hyperlipidemia--may be improved or reversed with treatment for obesity and overweight.

Both medical and surgical treatments are available for obesity and overweight. This article focuses on medical treatments, including very low calorie diets (VLCDs) and anorectic medications.

VLCDs

The terms VLCD and PSMF (protein-sparing modified fast) are sometimes used interchangeably, but a VLCD uses liquid meal replacements, whereas a PSMF uses regular food. In the past, VLCDs ranged from 400-800 kcal per day, but now they are commonly set for 800 kcal/day.

Patients with a BMI of 27 and above with comorbid conditions or of 30 and above regardless of comorbid conditions can benefit from a VLCD program. VLCDs can help those who have been unsuccessful on other diets or those that need to lose 30 or more pounds.[1] They can also be used to help the obese lose weight in preparation for surgery, or for patients who cannot or do not want to make food choices.

Patients put on a VLCD should have a complete medical evaluation by a physician trained specifically in the clinical use of VLCDs, such as a bariatrician. VLCD patients need to be closely monitored by the bariatrician or other physician expert. There should be routine lab work and EKG monitoring. A key component of a successful VLCD program is ongoing nutritional and behavioral support and education by trained specialists, such as dieticians and behaviorists.

Women on a VLCD typically lose 3-3.5 pounds per week, and men lose 4-5 pounds per week.[2] The average loss on a VLCD is 2-3 times greater than on a conventional calorie-reducing diet in the same time period.[1] A VLCD can be strenuous on the body and should not be started in patients with a recent myocardial infarction or stroke, or those with pregnancy or a serious illness.

Anorectic Medications

Schedule III and IV anorectic drugs include benzphetamine, diethylpropion, mazindol, phendimetrazine and phentermine. Of these, phentermine is the most widely prescribed. Two Schedule IV anorectics that had been used in combination with phentermine (fenfluramine and dexfenfluramine) were removed from the U.S. market because of heart valve problems. Nonetheless, phentermine was found by the NIH to be useful in weight loss if used for 6-12 months.[3]

Schedule III and IV anorectics have a bad reputation due to their structural similarity to amphetamines and because of inappropriate prescribing. Studies, however, have not shown any tolerance or drug dependence with anorectics. In fact, the Drug Abuse Warning Report of 2006 found that anorectic drugs have one of the lowest drug misuse/abuse rates per 100,000 emergency room visits, even lower than acetaminophen and ibuprofen.[4]

Although most of the published studies of anorectic drugs have run for 12 weeks or less, several studies that have run for longer periods have demonstrated the safety and effectiveness of these medications.[5] With close monitoring and proper starting dose, side effects can be minimized or avoided in most cases.

Non-Approved Treatments

Some weight-loss programs promote the use of human chorionic gonadotropin (HCG), a hormone secreted by the trophoblastic cells of a placenta during pregnancy. However, the use of HCG for weight loss is not approved by the FDA and is not recommended.

In 1954, Dr. Albert Simeons first used HCG for the treatment of obesity in conjunction with a VLCD. He put patients on 500 kcal/day and 125 units of HCG injected 6 days per week for 8 weeks. A few initial studies supported his approach to weight loss, but subsequent studies demonstrated that the HCG part of the diet was ineffective and that the weight loss was solely due to the VLCD portion.[6]

The Future

Several obesity drugs are currently under review by the FDA. In February, for example, the Endocrinologic and Metabolic Drugs Advisory Committee recommended that the FDA approve Qnexa, which combines the appetite suppressant phentermine with topiramate, an anti-seizure medication that may alter hunger hormones, decrease appetite, and adjust glucose and insulin concentrations. The FDA is scheduled to announce its decision on Qnexa in April.

Contrave, another new drug for treating obesity, was rejected by the FDA last year. The FDA stated that a large-scale study of cardiovascular risk from Contrave would be needed before they could consider approval. Guidelines for the study appear to have been clarified, but approval is uncertain.

The FDA has also accepted a re-application for Lorcaserin, an appetite suppressant. The drug may help to eliminate hunger by stimulating parts of the 5-HT2C serotonin receptors located in the hypothalamus, the control center for metabolism and appetite.

Summary

Obesity and overweight are chronic conditions and should be treated as such. Unfortunately, treatments for obesity typically require a change in the patient’s lifestyle and behavior. Without this change, the likelihood that the patient will maintain the weight loss is low.

A multidisciplinary team (bariatrician, primary care physician, dietician, behaviorist) can help patients maintain weight loss. Ongoing support by the patient’s primary care physician is one of the most important factors. A little encouragement and reinforcement can go a long way.

VLCDs and anorectic medications can be effective for weight loss, but they should be prescribed by a trained specialist with a comprehensive program. The use of non-FDA approved medications such as HCG is highly discouraged.

More than a decade has passed since a new weight-loss medication was approved by the FDA and released to the market. Perhaps one of the drugs pending approval could help the two-thirds of Americans suffering from obesity and overweight.


Dr. Hubert, an internist, is medical director of the MedLite Weight Loss & Laser Center in Santa Rosa.

Email: dr.hubert@gmail.com

References: http://www.scma.org/magazine/articles/?articleid=555

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Voices Of Medicine

Previous Issue

Dr. Benjamin Carson, Neurosurgeon, at the National Prayer Breakfast

A Perfect Contrast

By William Sullivan

Contrast can bring clarity. And I do not think that the two warring political ideologies in America have never been personified, juxtaposed, and as clearly defined as the contrast we witnessed at this week's National Prayer Breakfast.

Dr. Benjamin Carson, the famed director of pediatric neurosurgery at Johns Hopkins University, was given the unique opportunity to share his beliefs before a distinguished audience, including President Barack Obama. He did not waste the opportunity, and courageously expressed his beliefs with conviction, contrary though they are to those of the president. 

Much has been made of Dr. Carson's alternative solution to make healthcare more efficient:
Here's my solution: When a person is born, give him a birth certificate, an electronic medical record, and a health savings account to which money can be contributed - pretax -- from the time you're born 'til the time you die. When you die, you pass it on to your family members, so that when you're 85 years old and you got six diseases, you're not trying to spend up everything. You're happy to pass it on and there's nobody talking about death panels.

Number one. And also, for the people who were indigent who don't have any money we can make contributions to their HSA every month because we already have this huge pot of money. Instead of sending it to some huge bureaucracy, let's put it in their HSAs. Now they have some control over their own healthcare.

We must admit -- there is something amazing about this. In two paragraphs, Ben Carson has offered a free market solution to create competition and reduce healthcare costs that is feasible, understandable, and compassionate. (And one that has already been tested -- it is very similar to the system used in Singapore.) Its relative simplicity alone stands in stark contrast to Obama's healthcare solution pitch, the mechanics of which were so confusing that after two years of explaining it, Democrats entreated Americans to not even try to understand it. Just accept it and see what happens, as Nancy Pelosi suggested.

But to focus on the contrast between their healthcare approaches alone is to miss the deeper contrast on display. That is, the contrast between Dr. Ben Carson and Barack Obama, the ideologies that have driven their life's work, and the results of that work.

Years ago, I remember my mother asking if I had ever heard of Dr. Ben Carson. She explained that he was a pioneer in neurological medicine, and that he had an amazing and inspiring story. She had a copy of Dr. Carson's book, Gifted Hands, and began to read passages that she had selected. I was captivated, committed to reading more about him, and later watched the film of the same title starring Cuba Gooding, Jr. Indeed, his story is one of the most amazing and inspiring I'd ever heard, from his unique upbringing to his design of a groundbreaking procedure in 1987 which successfully separated two cranially conjoined twin babies. His life, his work, is nothing short of miraculous.

Dr. Ben Carson was one of two sons born to Sonya Carson, a single mother who had married Ben's father at thirteen years of age. Ben's father was a bigamist, and after learning of his other family, Sonya resolved to raise her two sons alone. Though in poverty, and though she herself had no formal education beyond third grade, she insisted that her sons devote diligent efforts to their education. She required that the boys read books from the public library each week and write lengthy reports for her (which she would review for them to support their effort, despite being unable to read). She worked hard to support them financially, in staunch determination that she would not be a victim, and neither would her children. In short, the Carson family is a testament to personal perseverance and the success that follows. . .

Knowing of his background, it came as no surprise when I reviewed the entire speech at the National Prayer Breakfast that nearly everything Ben Carson said was a perfect contradiction of the values expressed by Barack Obama.

Dr. Carson began his speech, even as he shared the stage with the world's most renowned spokesman for political correctness, by decrying political correctness as a "dangerous" concept. He argued that political correctness acts as a "muzzle," keeping people from "discussing important issues while the fabric of their society is being changed," even as the architect of that "change" sat just a few feet to his right.

He related the admirable tale of his mother's unwillingness to be a victim, as he was in the presence of our president who unequivocally demands that women in such circumstances be viewed and treated as such.

Dr. Carson told the audience about his revelation that poverty is a "temporary" condition, one which people could personally alter. And he said this in the presence of a man whose political ideology is founded upon the notion that poverty is an institutionally applied condition, and that it is the responsibility of society, not the individual, to alter that condition.

Dr. Carson went on to destroy the notion of the progressive income tax, arguing that "God has given us a system" that would work. He argued that because God requires tithing regardless of outcome:
There must be something inherently fair in proportionality. If you make ten billion dollars, you put in one billion. If you make ten dollars, you put in one. Of course you gotta get rid of the loopholes. [Laughter]

But, now some people say, "Well that's not fair, because it doesn't hurt the guy who made ten billion dollars as much as the guy who made ten." Where does it say you have to hurt the guy? He just put a billion dollars in the pot!

Is it possible to say anything more contrary to Barack Obama's insistence on the moral imperative to take disproportionately more from the wealthy to redistribute among the collective?

And this is where the contrast between the two men becomes most apparent. Barack Obama rejects the notion of fairness presented by God, because his devotion to God, if it was ever a driving motivation in his life, has become supplanted by his devotion to the government administration of fairness. That much is abundantly clear. Consider that Dr. Carson carries himself with a pious humility, crediting God and family for giving him the strength of will to succeed. President Obama, whose name would rarely collide with humility in a sentence, insists that the government is responsible for people's success.

The revelation here is not that Barack Obama is a PC thug who intends to transform the fabric of America, or that he makes victims of women rather than empowering them, or that he subscribes to a Marxist's notion of fairness by coercion, or that his healthcare solution is a muddled, hopeless mess sold on Utopian dreams. We already knew all that.

No, the real revelation is that at this year's prayer breakfast, so often only a pious ritual, his exact opposite stood and spoke in sharp contrast to our president. And Dr. Ben Carson owns a legacy as an innovative pioneer of his field and philanthropist whose life and work have personally touched, and even saved, countless others. Barack Obama, on the other hand, despite all his celebrity, owns a legacy that amounts to little more than stirring fear and outrage on the premise that others are not doing enough to help people.

Which ideology has produced the more effective, positive outcome?

William Sullivan blogs at http://politicalpalaverblog.blogspot.com/and can be followed on Twitter. 

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Voices Of Medicine

Past Issue

EHR: Take Care of the Chart, Don’t Worry about the Patient

Who's got time to listen to patients when the government demands 'meaningful' data entry?

The electronic medical record, or EMR, is a computerized system that allows physicians to record patient information electronically instead of using paper records. Test results can be reviewed through the system, and prescriptions can be emailed straight to the pharmacy. You can order medical tests and medications worth thousands of dollars with just a few mouse clicks. 

As stipulated by ObamaCare, Medicare and Medicaid have enthusiastically embraced the concept of a paperless world. Doctors who adopt these programs in a "meaningful" way (more on that later) will be rewarded to the tune of up to $44,000 over five years. For those doctors who say no thanks, reductions in their Medicare payments for service will start in 2015.

At first I thought EMR sounded like a good idea. Then our practice started using one. . .

Tasks that once took seconds to perform on paper now require multistepped points and clicks through a maze of menus. Checking patients into the office is an odyssey involving scanners and the collection of demographic data—their race, their preferred language, and so much more—required by Medicare to prove that we are achieving "meaningful use" of our EMR. What "meaningful use" means no one knows for sure, but our manual on how to achieve it is 150 pages long.

Now the staff scurry about, rictus-like grins plastered to their faces, trying to hide their underlying stress. The patients, each a Job after completing the elaborate new check-in process—and wondering why the government needs to know if they are an Alaska native, among many other things—arrive in my exam room bewildered by their bureaucratic ordeal.

When the clicks don't get me what I want, I naughtily handwrite a prescription. I skip ordering certain tests I might want because it takes too much time—I'll do it next visit. I dreaded the arrival of this season's flu-shot supply—now there were more orders to input!

There was always going to be an adjustment period. As in the aftermath of a tornado, these things take time. I'm sure I'll get faster at using the system, and soon enough the data entry and test-ordering steps will come as second nature.

The end product will be lovely: a meticulously organized digital chart, with gorgeous progress notes. Nuggets of data accessible and ready for the plucking by the numbers crunchers. Medicare says the EMR is going to help me "achieve benchmarks that can lead to improved patient care."

Really? As a colleague remarked, it seems as if this is all about taking care of the chart, as opposed to taking care of the patient. Documentation is important, but the pointing and clicking and cutting and pasting we are so focused on in demonstrating meaningful use of EMR may be getting in the way of meaningful encounters with our patients.

With all the data entry the electronic system requires, my laptop presents a barrier between my patient and me, both physically and metaphorically. It's hard to be both stenographer and empathetic listener at the same time.

Some of the best doctors I've known were famous for the unintelligible scrawl of their hospital chart notes. Yet I doubt that fantastic electronic documentation will translate into fantastic clinical care. The institution of EMR seems to be a case of choosing style over substance, of putting up a few more hoops for doctors to jump through in their quest to simply take care of patients.

So, excuse me if, like a teenager transfixed by her smartphone, my eyes are glued to my screen at your next visit with me. I am truly listening to you. It's just that eye contact has no place in the Land of Meaningful Use.

Dr. Valinoti is an internist in private practice in Bergen County, N.J.

A version of this article appeared October 23, 2012, on page A15 in the U.S. edition of The Wall Street Journal, with the headline: Physician, Steel Thyself for Electronic Records.

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