The Nutrition Debate #221: Medscape dropped 2 bombs in my inbox last week

Medscape Medical News dropped 2 bombs in my inbox last week, and my post-bombing analysis of the papers is that they both missed the target. Individually, they’re hardly worth a whole column, so I’ll give them each a third and then share with you a piece of my mind.  I’ll need that time to cool off sufficiently.

“Congratulations! We're Making Strides in Diabetes Care,” by Dr. Anne L.Peters, MD, CDE, a highly respected diabetologist (of the “old school”), is simply a cheerleading piece timed for the ADA convention. She gives three links: recent articles in 1) the Journal of the American Medical Association (JAMA), 2) the Annals of Internal Medicine, and 3) Diabetes (the Journal of the American Diabetes Association) to support her “This is great news. We are doing a better job than ever” quote.

Would her audience, comprised largely of “treating” physicians (like herself,) agree? But then, maybe that’s the point of her getting ginned up to deliver this Pollyannaish piece. It seems to me likely that the treating physicians convened at the Annual ADA Convention are in need of a morale boost.

In spite of the “strides” claimed (which I don’t dispute), I feel there must be among the vast majority of practicing physicians a frustration, a frantic despair, in fact, a feverish frenzy over the failure of the “usual care treatment protocol,” dictated by their medical associations  and their government overseers. Dr. Peter’s problem, and that of the entire medical and public health establishment, is that they simply have the wrong target.

The 2^nd bomb, which appeared just 2 days later, was titled “Diabetes Prevention Programs: A Waste of Money.” This was a Medscape Interview of Richard Kahn, PhD (Professor of Medicine, University of North Carolina, Chapel Hill). A controversial counter message, it focuses, as it should in my opinion, on “lifestyle modification programs geared for weight loss,” since these programs have been shown to “delay or prevent the onset of type 2 diabetes.” The Medscape Editors note that “as many as 82 million Americans are thought to have prediabetes.” “These people” (referring to people who had completed a “usual care” Diabetes Prevention Program) had an enormous amount of attention given by health professionals.” “Those interventions – almost every one – were expensive,” Dr. Kahn asserted.

Dr. Kahn adds: “The first thing you see is that the overwhelming number of studies didn’t even go out to one year,” and “the assumption the authors make” is “that that amount of weight can be lost forever. That has simply never been seen except in bariatric surgery.” “From a medical point of view, it doesn’t look like that initial weight loss does much, if anything. For some clinical effect you have to lose substantially more weight – 20%, 25% of your body…,”and, Dr. Kahn continues, “it would have to stay off for a long time” to be a cost-effective program worthy of “society pay(ing) for the intervention,” given “how difficult it is to keep weight off.”

So, Dr. Kahn’s “after bombing assessment” confirms the ineffectiveness of the “usual care treatment protocol” you are likely to receive in your clinician’s office (“wrong target”) and the reason why so many physicians and patients feel frustrated. Dr. Kahn: Under such “diet and lifestyle” diabetes prevention programs, “the assumption that the weight will be lost and held off for life… is unrealistic. Or maybe it’s realistic, but not in today’s world” (emphasis mine). Dr. Kahn isn’t asked about what he meant by that, but I think I understand: his analysis of the data shows unproven assumptions and tenets; his conclusion: the present modus operendi (a low-fat, “balanced” diet) is simply not cost-effective.

But Dr. Kahn does leave a door open to what I suspect he knows about anecdotally, and I know personally: That long term, permanent weight loss is indeed possible – if we re-program our bomb sights and set our targets on carbs. He says, “Some people decide, ‘I’m going to do it. They’ve invested nothing. That’s great for them, but we’re not arguing about whether people should be encouraged to lose weight. What we’re arguing against is having society pay the bill for this when it hasn’t been effective.” “The individual should pick up the cost,” he says. And I say, choose the target (carbs), and go.

Medscape then asks, “What’s the main takeaway for clinicians, then?” Dr. Kahn’s final remarks, “People who are overweight or obese should be strongly encouraged by their healthcare provider to lose weight and keep it off. If a provider feels that there is a good resource in the community, he or she should refer the person to that resource.” Hello. Anyone listening? Check out how I lost and kept off 33% of my body weight here and here (The Nutrition Debate #213 & #214).