Wednesday, September 25, 2019

Retrospective #221: Medscape dropped 2 bombs in my inbox last week

Medscape Medical News dropped 2 bombs in my inbox last week. My post-bombing analysis is that they both missed the target. The first was due to a navigational error and the second due to cloud cover. That’s my analysis, anyway.
“Congratulations! We’re Making Strides in Diabetes Care, “by Dr. Anne L. Peters, MD, CDE, a respected, establishment diabetologist, is simply a cheerleading piece timed for the ADA convention. She provided three links to 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, summarizing, “This is great news. We are doing a better job than ever.”
Would that 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. I suppose the treating physicians convened at the Annual ADA Convention are in need of a morale boost. She and her colleagues primarily treat uncontrolled diabetics.
In spite of the “strides” claimed, I feel there must be among the vast majority of practicing physicians a frustration, a frantic despair, in fact, a feverish frenzy over the utter 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 are using the wrong treatment protocol (and many of them know it).
The 2nd bomb, which appeared 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 focused 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. And they failed.
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 that the “usual care treatment protocol” you are likely to receive in your clinician’s office is ineffective and the reason why so many physicians and patients feel frustrated. Dr. Kahn said, under such “diet and lifestyle” diabetes prevention programs, “the assumption that the weight will be lost and held off for life… is unrealistic.” Dr. Kahn isn’t asked about what he meant by that, but I think I understand: his analysis of the data shows unproven tenets and assumptions; his conclusion: the present modus operendi (a low-fat, “balanced” diet protocol) is simply not cost-effective because it doesn’t work long-term.
But Dr. Kahn does leave a door open. I suspect he knows anecdotally (as I know personally), that long term, permanent weight loss is indeed possible – if we re-program our sights and target carbohydrates. 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.” Yeah, he does know. But, alas, the good professor can’t afford to say it. Too bad, really.
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 keep off 40% (150 pounds)of my body weight. See Retrospectives #213 & #214.

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