HJNO Sep/Oct 2023

CHANGING THE CARE: OBESITY 14 SEP / OCT 2023 I  HEALTHCARE JOURNAL OF NEW ORLEANS   nancing mechanisms that reward the surgeons and the hospitals that perform these surgeries. Bariatric surgery is the ultimate form of “com- pliance” where we physically force, with their consent, the gastrointestinal tract to — at least temporarily — consume fewer calories with a subsequent result of weight loss. I say tempo- rarily, because in my experience many of these patients eventually regain all or a large portion of the weight they lose over time as the ca- pacitance of their stomach stretches and allows greater amounts of food consumption. In my own experience, which is admittedly purely anecdotal, many of these patients later regret having had the surgery. Fur- thermore, the problem with surgery or any fad diet is that it doesn’t fundamen- tally address the root causes of disordered eating patterns. It doesn’t change any underlying maladaptive coping mecha- nisms such as emotional eating. It doesn’t address if they suffer from binge eating disorder or nighttime eating disorder or why they suffer from it in the first place. It also doesn’t address the fact that many people with obesity suffer from impaired self-efficacy or adverse childhood trauma and have not yet embarked on a mental health improvement journey that provides them insight into their current patterns of unhealthy behaviors. Critics would point out that patients do see a psycholo- gist or counselor a few times scattered throughout the bariatric surgery process, but I would argue that those sessions are not diving deeply into the root causes of maladaptive coping behaviors. None of it takes the form of rapidly cycling iterations of continuous learning and improvement where the desired end result is weight loss occurring because of willful changes in hu- man behavior rather than forced surgical compliance of their gastrointestinal tract. Medications like semaglutide (otherwise known as Ozempic) or tirzepatide (Mounjaro) are exciting new advances in the treatment of obesity that reflect our understanding of its pathogenesis and do offer some promise, but, again, we fall prey to distorted mechanisms of conventional financing. The makers of these drugs clearly have a profit motive that aligns with keeping patients on these drugs for as long as possible. While it is good these medica- tions help overcome the cultural stigma of not regarding obesity as a disease, we also need to work toward prescribing medications only when benefits clearly exceed potential harms. And that may very well be the case, especially in situations where hormonal and physiologi- cal alterations play a dominant role in difficulty achieving weight loss, like postmenopausal women for example. However, we do not yet understand the long-term effects of these drugs. And while they have been transforma- tive in the management of diabetes, the broad assertion that all persons with obesity should take semaglutide for the rest of their life can- not be endorsed by evidence to date. Instead, when I do use these medications — or other combinations such as phentermine/topiramate or bupropion/naltrexone — it is typically as a “bridge” to help a patient on their journey across metaphorical rough waters, even as we are providing the “swimming lessons” that will hopefully help them change behaviors and em- brace lifestyle modifications that obviate the need for the bridge in the first place. These “swimming lessons” are provided by therapists, health coaches, and dietitians that are not ad- equately remunerated through fee-for-service. Even though I am an internist, and my primary weapon against many diseases is medication, one of my favorite things to do is take medications away when people no longer need them, especially insulin. While insulin is essential and life saving for patients who suffer from insulin defi- ciency (i.e., Type 1 diabetes), its role in the management of diabetes characterized by insulin resistance is ancillary at best. Sometimes it is needed in Type 2 diabet- ics with poorly controlled blood sugar. But through the design of an effective clinical microsystem that utilizes build-measure- learn and improve feedback loops to gen- erate continuously improving outcomes, getting them off insulin becomes possible once they’ve lost enough weight. It is the type of care model that looks at achieving a 97% rate of adequate glycemic control as simply a small step in the right direc- tion. Completion of the journey involves achieving a minimum 10% reduction in body mass index, while striving for > 15 to 20% reductions in weight if specified as a goal by the patient. This latter part is imperative because none of it is possible without the patient specifying their goals and the care team discovering what mat- ters most to them. Each patient’s goals need to be identified prospectively as part of the care delivery process. We need to be especially attentive to any patients with eating disorders where a discussion of weight, or even the act of weighing, can be triggering for them. When these patients are identified, it is essential to acknowledge their issue as em- pathetically as possible and then get them help through available mental health resources that are embedded within the clinical microsystem. “A prevailing construct is that people have freedom of choice, thereby deciding howmuch time to devote to exercise or not, what they choose to eat and how much of it to consume, and whether to follow the advice of a well-meaning physician or dietitian. Please tell that to the young woman who works three jobs to provide food, shelter, and clothing for her children.”