Paging Dr La Puma

Archives

Jun28

Should You Take the New Diet Pill in the New Health Care?

Posted in: Drug Food Safety, Obesity and Weight Loss, Wellness and Health

Amid the hub-bub of the week, with the Supreme Court affirmed Affordable Care Act health care law upheld, and with one JAMA study showing that 21 people on 3 different diets for 4 weeks each burn calories differently (no real surprise here: the lowest carb diet had the highest energy burn, the second lowest was second, and the highest carb, well, was bad for metabolic syndrome), other news–that the first prescription medication for obesity in 13 years has been approved–slipped under the radar.

In other words, there is a small high profile study in a reputable medical journal that shows that the kind of calories you eat matters, that calories are not all alike, and that eliminating ultraprocessed carbs gives you a better chance of idealizing your weight.

And also, now, there’s a new FDA-approved drug, Belviq, for obesity. And maybe a second one, called Qnexa, shortly.

Belviq (generic = locarserin) is metabolized by the liver: it acts in the brain to promote satiety by activating the serotonin 2C receptor to increase satiety and taste aversion (so food doesn’t taste good).

About half of obese people who took the drug for a year lost at least 5% of their body weight, compared to 20% of dieters who took a placebo pill.

But people have trouble staying on it: 40% dropped off in a year.

And the drug was turned down in just 2010 because of safety problems (principally psychological and cognitive ones). It can interact with medicines used to treat mood, anxiety, psychotic or thought disorders, including tricyclics, lithium, selective serotonin uptake inhibitors (SSRIs), selective serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), or antipsychotics.

It will be available, reportedly, in early 2013.

Qmexa, on the other hand, is a phentermine (the go-go-go of phen-fen fame) and long-acting topiramate (the anti-seizure drug) combo. Research subjects lost, on average, about 6% of body weight, vs about 2% on control medication, per year.

Phentermine has been on the market for over 40 years; it is a stimulant, and boosts blood pressure and pulse slightly. Topiramate sometimes causes fatigue, slowed thinking, and impaired memory and concentration.

Nevertheless, the FDA wants doctors to have another tool in the tool belt, and with the US Preventive Services Task Force suggesting that all docs should measure BMI, and treat people who measure over 30 kg/m2 (and with Medicare already paying for 22 visits per year for obesity), I think the tide is turning. Doctors are going to become interested in treating obesity again, if they are paid and trained to do so. And have new drugs. And they will.

The real questions: are you really better off taking a pill than getting on the right lifestyle program for you? Do you think that the diet and lifestyle programs that are supposed to come with these new drugs will integrate the nutritional science above? Will our new DIY economy spill over into health care, so you do more of this too, or will you become integrated into the health care system, now that nearly everyone will be covered (say, 5 years from now, and excepting Medicaid patients, whose coverage will likely be quite limited)

Will you be able to say to your doctor…I want your help in losing weight but I don’t want to take drugs? One on one self-monitoring, accountability, individual diet, and tailored fitness programs? Or will you just want the drugs, because they’re new, and your knees hurt, and you’ve tried to stick to diet and exercise, but they’re just not enough? What if you just want the best online programs, rated for weight loss?

I don’t know, but I can’t wait to find out. Meanwhile, you’d be shocked what simply cutting out ultraprocessed carbs and calories will do to your weight. Here’s a first step.
Aug9

Do Statins Raise Diabetes Risk?

Posted in: Aging and Costs of Aging, Diabetes, High Cholesterol, Vitamins and Supplements, Wellness and Health
Probably, in higher doses.

A study of 18000 people without heart disease, called JUPITER, shows that Crestor (rosuvastatin) 20 mg showed that for every 1000 patients on high dose (40mg and up) statins, there are 6 more cases of new diabetes over 2 years.

Crestor also prevented 11 cases of heart attack, stroke, arterial revascularization, hospitalization or death from heart disease, in that 1000 patients.

The newest study includes 32,752 patients without heart disease. Again, 2 cases of diabetes, versus 6 or more cardiac events prevented in a 1000 people over 5 years.

If you actually have heart disease or angina, then the numbers for taking a statin are different.
- 1 in 83 life saved
- 1 in 39 prevented a non-fatal heart attack
- 1 in 125 prevented stroke
- 1 in 167 developed diabetes
Is that worth the trade-off?

I try to find ways for my own patients to get off high doses of statins, especially 80mg doses, because of myopathy and pain.

A cholesterol registry can chronicle how people control cholesterol naturally.

I suggest that any patient 40 and over get screened every 3 years, and make sure they don’t suffer from abnormal lab test syndrome. And I help them make lifestyle changes that help them reduce their need for cholesterol medication.

Statins can be important medications, and their benefits can be greater in diabetics than nondiabetics.

But there’s no sense in tempting fate. Let’s enjoy life, and avoid getting diabetes in the first place. Lower your cholesterol with what you eat.
Mar1

Diabetes Doubles! Food Can Help. Should It Be Reimbursed?

Posted in: Aging and Costs of Aging, Diabetes, Wellness and Health

Americans treated for diabetes doubled to about 19 million (8.5% of the population) in 2007 compared with 9.1 million (4.6% of the population) in 1996, according to the AHRQ, a federal agency.

That doesn’t count the undiagnosed (7 million) and those with prediabetes (79 million).

Health care spending on diabetes more than doubled to $40.8 billion (the ADA says this figure is low: total diabetes costs are $174 billion, they say, in 2007).

But something odd happened: what it was spent on changed.

The amount spent on on prescription medication in 2007 doubled vs 1996: 46.7% compared with 23%. The amount spent on home health actually fell by nearly two-thirds: 9.5% vs 27.1%.

Individuals with diabetes paid double too: $1048 in 2007 versus $495 in 1996.

What do all these numbers mean? They mean diabetes is doubling, fast. They mean that payers are paying for medication–not home care, by a mile. Actually, by billions of dollars.

But I wonder if these same payers know the data about lifestyle program cost and prevention of diabetes.

This slide summarizes the results of the Diabetes Prevention Program. It tested metformin (a good, inexpensive medication) versus diet and lifestyle in reducing diabetes, for a year. Metformin reduced diabetes by 31%.

Lifestyle did better. It reduced diabetes by 58%. Without any complications.

They lost just 7 percent of body weight and exercised only 2.5 hours weekly, on average.

It was an expensive program–about as expensive as medication, not including diabetes costs prevented–but the researchers brought the costs down: United Health is testing a version with the YMCA and pharmacists.

More innovation! That’s the spirit! Should the right food be reimbursed?
Dec21

Treating Overweight Kids…With What?

Posted in: Child Obesity, High Cholesterol, Obesity and Weight Loss

Dr Molly Ferguson is a naturopath in Michigan who is courageous enough to discuss treating childhood obesity.
Video: Treating Childhood Obesity

Putting kids on a diet has long been terrifying to physicians because we are frightened about creating eating disorders (the other way!)

But there is good data to show that the suggestions she makes: “eating the rainbow”, “eating fewer processed foods”, and “avoiding chemical additives” can have beneficial effects on kids’ health: improving immunity, increasing energy level at school, reducing hyperactivity symptoms.

Is there a good diet for overweight kids? If there were just one, all kids would be on it.

Childhood obesity has leveled off in kids ages 2-5, because Moms are super concerned, and have more control over what there is to eat. The next frontier: kids ages 6-11 or 12.

I think teaching kids about food and the basics of how to cook would transform family lives: treat Mom’s diabetes, and Dad’s cholesterol and heart disease, and Sis’ asthma.

Eating and cooking healthfully to lose weight has worked for adults enrolled in Chef Clinic, and in adults who make big lifestyle changes.

Should overweight kids be on a diet? And if so, what would one look like?
Nov3

Stress Reduction and Corporate Wellness

Posted in: Aging and Costs of Aging, Environmental Health, Hypertension, Wellness and Health
I am getting more calls about managing stress among employees. Thoughts impact physiology in about 1/18th second, so it’s worth preparing for them.

What many companies, now asking employees to do with more with less, don’t know is that stress can be measured, reduced and managed. And that their health care costs will go down, and their productivity rates will likely go up.

Chronic stress interferes with memory, concentration, judgments and decisionmaking. It is the most common cause of absenteeism and a prime cause of job turnover. It’s probably the most important benefit of corporate wellness.

And it boosts health costs. A lot. But HeartMath has found $1200 per employee per year in correctional officers’ annual cost savings with simple training programs over time.

Stress is a complex emotional and physiological reaction. It is a natural feeling, one that involves hundreds of biochemical changes which are fatiguing.

Stress can be controlled with practiced actions
- Communicate clearly (does not mean shouting)
- Diminish the drama (helps reduce biochemical impact)
- Practice a positive emotion on purpose: appreciation, care, compassion or gratitude (verbalize or write these, every day)
This looks pretty simple. And it is.

But like eating healthfully, people know what they should do, but don’t usually have the tools or skills to do it. That’s why teaching tools are essential.

For example, rhythmic breathing can be relaxing. But it doesn’t neutralize stress over the long term What does is actively adding a positive feeling like those above.

I’m going to be teaching on-the-job ways to manage stress around the country next year, and I can’t wait. Because effectively managing stress can:
1. Increase resilience – ability to prepare for, and recoup from challenge
2. Improve blood pressure, depression, asthma
3. Reduce fatigue, burnout, hostility, anxiety, distress and anger.
4. Increase brain clarity, focus, attention span, accuracy and learning ability
5. Improve decision‐making, (reduction of decision fatigue)
6. Improve communication skills
7. Improve work/life balance

This means lower health care costs, better presenteeism (defined as the level of performance on the job), less abseenteeism and improved employee satisfaction.

Learning the tools–in even a single hour, and even better, a single day–may be the ticket to less tired, less worried, less annoyed, less anxious employees.