Obesity

Public perception of disease is everything. “Diabetics” are now referred to as “people living with diabetes,” and an “obese person” is now an “individual living with obesity.”

But what is the definition of obesity? Does it refer to a disease or a risk factor? And is the term so tainted in negativity, blame, and bias that the only solution is to scrap it and completely rename it? Society (and medicine) have changed significantly since the Latin word obesitas was adopted back in the 1600s.

Despite so much hinging on the word “obesity,” it’s remarkable that the label persists while the concepts underpinning it have evolved significantly. So perhaps it is more about finding the least-worst option rather than pursuing the impossibility of a solution that suits all?

This is precisely the challenge faced by a Lancet Diabetes & Endocrinology Commission on the Definition and Diagnosis of Clinical Obesity, which is due to publish its initial findings this coming fall. The global task force has 60 leaders in the clinical management of obesity, including representatives with lived experiences of obesity. Leading the project is Francesco Rubino, MD, chair of metabolic and bariatric surgery at King’s College London.

“Renaming ‘obesity’ is very important,” states Dr. Rubino. “The word is so stigmatized, with so much misunderstanding and misperception, some might say the only solution is to change the name.”

One possibility for a new name, introduced by the American Association of Clinical Endocrinologists (now –Endocrinology) and the American College of Endocrinology back in 2016, was based on framing the disease on the central characteristic of adiposity and was termed ABCD, for adiposity-based chronic disease.

Dr. Rubino welcomes “ABCD” but has some reservations. “It is good from a physiological point of view, but the problem is it speaks to scientists and medical professionals. I don’t know how much it would appeal to the general public. ‘ABCD’ still falls short of telling us what the illness is.”

He adds that the Lancet Commission’s approach is rather to call it “clinical obesity.” “ ‘Obesity’ itself doesn’t necessarily convey the message that you have a disease or an illness,” he observes. “It is similar to the difference in meaning between depression and clinical depression, which communicate two different things.”

But underpinning any renaming is greater clarification of the definition and diagnosis of obesity. In 1997, the World Health Organization recognized obesity as a chronic disease; in 2013, the American Medical Association did likewise, adding that it warranted medical attention; while it took until 2021 for the European Commission to define obesity as a “chronic relapsing disease, which in turn acts as a gateway to a range of other non-communicable diseases.”

Yet, 25 years after the initial recognition of obesity as a disease, the concept is still riddled with negativity, whether openly or unconsciously. Such stigma denigrates overweight people and those with obesity as “lazy, sloppy, unintelligent, and unattractive.”

Dr. Rubino explains that first, it’s important to establish and define the essential components and characteristics of the disease of obesity. This is key to improving access to clinical care, reducing personal blame, and nurturing a more supportive research environment to help inform both clinical and policy decision-making.

“This is the question that is at the core of our commission. We have a problem with the current definition of obesity, and the way we measure it does not allow us to accurately define a state of illness with obesity,” he explains.
 

Labels shape public perceptions of disease; ‘obesity’ epitomizes this

Another expert championing the need for a name that better reflects the definition – whatever that turns out to be – is Margaret Steele, PhD, School of Public Health, University College Cork (Ireland), who, according to her university webpage, has a special interest in “ ‘fatness’ as a cultural, social and political phenomenon.”

She believes that labels, including “obesity,” have a pivotal role in shaping public perceptions. In our digital, information-rich age, the boundaries of medicine and society overlap, with public perception shaping decisions of a medical nature as never before. But with this comes controversy and division – obesity management being a case in point.

Specifically, the word “obesity” is too widely associated with negative connotations, she says, and therefore she welcomes the dialogue around redefining and renaming it. Despite wide general support for a name and definition that reflects adiposity, due to its central physiologic role in the complications of obesity, Dr. Steele believes that the “effects on adipose tissue are downstream of brain issues and the food environment,” and she wants to see more attention brought to this.

Referring to most Westernized societies, she describes how people who grew up in times of food scarcity, before processed foods became widely available, have a different taste profile from those who grew up afterwards. “Growing up in 1940s and ‘50s Ireland, people recall how they remember getting an orange as a treat at Christmas, because the idea that you could have food all year-round – any fruit and veg that you want, when you want it – just wasn’t there.”

By comparison, societal changes leading to more financial and time pressure in later decades meant that fast, high-fat, high-sugar, and processed foods became more desirable, she points out. “Most young children now recognize the company name, and even the specific fast-food brand [they like], before they know their alphabet.”

The current environment has cultivated “a very different physical reaction to foods, maybe a different kind of emotional response,” she believes, highlighting the tightly woven relationship between obesity, society, mental health, and food options.

Dr. Steele wants to stimulate a conversation about the term used to describe individuals, conventionally described as ‘”obese” or using the word “obesity.” “We’re thinking in terms of maybe chronic appetite, chronic food intake, or dietary intake dysregulation.”

Changing medical terminology when it has become useless or harmful is not new, she argues, with co-author, Francis Finucane, MD, consultant endocrinologist at Galway University Hospitals, Ireland, in a recent paper on the subject.

“In the 20th century, the terms ‘feeble-minded’ and ‘moron’ had become used in a pejorative way in the wider culture and were dropped from medical usage,” Dr. Steele points out. She adds that changing the term “obesity” can facilitate pursuit of the strategic goals of clinical medicine “without causing needless controversy with those who, given their own goals and contexts, understand body mass index or body weight in a radically different way.”
 

Obesity: Disease, risk factor, or both?

Dr. Rubino stresses that prior to any renaming, there is a need to establish and define the essential components and characteristics of the disease of obesity. “This question is at the core of our Commission, and it is not an easy conversation to have.” He further explains that the struggle with the current definition of obesity, and the way it is conceived, is largely centered on it still being considered a risk factor for something else.

Disease is characterized by three things, says Dr. Rubino. These comprise the phenomenon of having a pathogenic cause, leading to pathophysiologic alterations (of the organs), causing clinical manifestations.

He adds that obesity is currently described by what it can cause – for example, type 2 diabetes, cancer, or hypertension. “Each of these things have their own clinical manifestations but obesity doesn’t. [As a disease], we don’t have a definition of the clinical manifestations of obesity other than excess adiposity.”

“If we use BMI, this does not predict excess adiposity, nor does it determine a disease here and now. There is no disease without an illness, which is the clinical manifestation, and the perception by the patient of it being an illness,” explains Dr. Rubino, pointing out that the Lancet Commission is filling this gap in knowledge by asking, “If obesity is an illness, then what does it look like?”

He adds that waist circumference probably provides a better measure than BMI in directly indicating the abnormal distribution of adiposity, known to be associated with poor cardiometabolic outcomes, “but it doesn’t tell you if you have an illness here and now – only that someone is at risk of developing cardiovascular disease in the future. Most people with some excess fat around the waist are perfectly functional and don’t feel ill.”

He also explains that confusion persists around whether obesity – or excess adiposity – is a risk factor for or a symptom of another disease. “The picture is blurred, and we do not know how to discriminate between these. We only have one name, and it applies to all those things, and we have one criterion – BMI – to diagnose it!”

Dr. Rubino adds, “So, what defines it? Is it diabetes? No, because that is another disease. You don’t define a disease by another. It has to stand on its own.”

Recently, the American Medical Association advised that BMI now be used in conjunction with other valid measures of risk such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors.

Aayush Visaria, MD, an internal medicine resident at Rutgers University, New Brunswick, New Jersey, agrees that a new name might help change public perception of obesity for the better. A study he presented at the 2023 Endocrine Society Meeting found that BMI “vastly underestimates” obesity.

He agrees with Dr. Rubino that the challenge lies in the lack of precise understanding of the mechanisms driving obesity: “It’s multifactorial, so not just appetite or food intake. Putting this into one phrase is difficult.”

However, if a new term can incorporate the many facets of the disease, “overall, it’ll reduce stigma because we’ll start to think about obesity as a disease process, not a personal thing with blame attached,” says Dr. Visaria.

But simultaneously, he expresses caution around possible negative connotations associated with the classification of obesity as a disease. Dr. Steele also reflects on this risk, highlighting that medicalizing body size can be counterproductive in feeding into weight stigma and fatphobia.

“Medicalizing obesity can be discouraging rather than empowering, but by specifying more clearly that we’re talking about a specific set of interrelated metabolic conditions, it would make it much clearer, and that ... this isn’t about making people skinny, it isn’t about an aesthetic thing,” Dr. Steele observes.
 

The word ‘obesity’ hinders disease explanations

Dr. Steele explains that her goal is to overcome the ambiguity around the word “obesity” that hinders explanations of the disease of obesity to the wider public.

“Much confusion and controversy might be avoided if we were to clarify that when doctors say that obesity is a disease, they do not mean that being ‘fat’ is a disease.”

Nevertheless, adipose tissue is an active endocrine organ, producing hormones that function less well in people with obesity, she notes. “This new knowledge has led to better treatments, including drugs like semaglutide and tirzepatide. These drugs, like bariatric surgery, typically lead to significant weight loss and to improvements in overall metabolic health.”

Dr. Rubino also expresses concerns around medicalization, as determined by definition and diagnosis and the availability of drug treatment that could potentially lead to overtreatment. “Currently, when everyone with a BMI of greater than 30 gets access to every obesity treatment out there, we see drugs are running out of stock. We should prioritize that treatment.”

Ultimately, the diagnosis of obesity as a disease needs an anthropometric biomarker that provides, on an individual level, the confidence that a person has a disease today, or at least close to a 100% likelihood of developing this disease and illness, asserts Dr. Rubino.

“If we use BMI, or even waist circumference, these might diagnose the disease; but if the person lives to 90 years, what’s the point of labeling somebody as having an illness?” he points out.

“As doctors, we have to be cautious. We say this is a disease, but you must think about the implications for the person on the receiving end of that diagnosis of a chronic disease that is substantially incurable. When we say it, we need to be certain.”

Dr. Steele and Dr. Visaria have disclosed no relevant financial relationships. Dr. Rubino disclosed that he has received research grants from Novo Nordisk, Medtronic, and Johnson & Johnson. He has undertaken paid consultancy work for GI Dynamics and received honoraria for lectures from Medtronic, Novo Nordisk, and Johnson & Johnson. He is a member of the data safety monitoring board for GT Metabolic Solutions and has provided scientific advice to Keyron, Metadeq, GHP Scientific, and ViBo Health for no remuneration.

A version of this article first appeared on Medscape.com.

Public perception of disease is everything. “Diabetics” are now referred to as “people living with diabetes,” and an “obese person” is now an “individual living with obesity.”

But what is the definition of obesity? Does it refer to a disease or a risk factor? And is the term so tainted in negativity, blame, and bias that the only solution is to scrap it and completely rename it? Society (and medicine) have changed significantly since the Latin word obesitas was adopted back in the 1600s.

Despite so much hinging on the word “obesity,” it’s remarkable that the label persists while the concepts underpinning it have evolved significantly. So perhaps it is more about finding the least-worst option rather than pursuing the impossibility of a solution that suits all?

This is precisely the challenge faced by a Lancet Diabetes & Endocrinology Commission on the Definition and Diagnosis of Clinical Obesity, which is due to publish its initial findings this coming fall. The global task force has 60 leaders in the clinical management of obesity, including representatives with lived experiences of obesity. Leading the project is Francesco Rubino, MD, chair of metabolic and bariatric surgery at King’s College London.

“Renaming ‘obesity’ is very important,” states Dr. Rubino. “The word is so stigmatized, with so much misunderstanding and misperception, some might say the only solution is to change the name.”

One possibility for a new name, introduced by the American Association of Clinical Endocrinologists (now –Endocrinology) and the American College of Endocrinology back in 2016, was based on framing the disease on the central characteristic of adiposity and was termed ABCD, for adiposity-based chronic disease.

Dr. Rubino welcomes “ABCD” but has some reservations. “It is good from a physiological point of view, but the problem is it speaks to scientists and medical professionals. I don’t know how much it would appeal to the general public. ‘ABCD’ still falls short of telling us what the illness is.”

He adds that the Lancet Commission’s approach is rather to call it “clinical obesity.” “ ‘Obesity’ itself doesn’t necessarily convey the message that you have a disease or an illness,” he observes. “It is similar to the difference in meaning between depression and clinical depression, which communicate two different things.”

But underpinning any renaming is greater clarification of the definition and diagnosis of obesity. In 1997, the World Health Organization recognized obesity as a chronic disease; in 2013, the American Medical Association did likewise, adding that it warranted medical attention; while it took until 2021 for the European Commission to define obesity as a “chronic relapsing disease, which in turn acts as a gateway to a range of other non-communicable diseases.”

Yet, 25 years after the initial recognition of obesity as a disease, the concept is still riddled with negativity, whether openly or unconsciously. Such stigma denigrates overweight people and those with obesity as “lazy, sloppy, unintelligent, and unattractive.”

Dr. Rubino explains that first, it’s important to establish and define the essential components and characteristics of the disease of obesity. This is key to improving access to clinical care, reducing personal blame, and nurturing a more supportive research environment to help inform both clinical and policy decision-making.

“This is the question that is at the core of our commission. We have a problem with the current definition of obesity, and the way we measure it does not allow us to accurately define a state of illness with obesity,” he explains.
 

Labels shape public perceptions of disease; ‘obesity’ epitomizes this

Another expert championing the need for a name that better reflects the definition – whatever that turns out to be – is Margaret Steele, PhD, School of Public Health, University College Cork (Ireland), who, according to her university webpage, has a special interest in “ ‘fatness’ as a cultural, social and political phenomenon.”

She believes that labels, including “obesity,” have a pivotal role in shaping public perceptions. In our digital, information-rich age, the boundaries of medicine and society overlap, with public perception shaping decisions of a medical nature as never before. But with this comes controversy and division – obesity management being a case in point.

Specifically, the word “obesity” is too widely associated with negative connotations, she says, and therefore she welcomes the dialogue around redefining and renaming it. Despite wide general support for a name and definition that reflects adiposity, due to its central physiologic role in the complications of obesity, Dr. Steele believes that the “effects on adipose tissue are downstream of brain issues and the food environment,” and she wants to see more attention brought to this.

Referring to most Westernized societies, she describes how people who grew up in times of food scarcity, before processed foods became widely available, have a different taste profile from those who grew up afterwards. “Growing up in 1940s and ‘50s Ireland, people recall how they remember getting an orange as a treat at Christmas, because the idea that you could have food all year-round – any fruit and veg that you want, when you want it – just wasn’t there.”

By comparison, societal changes leading to more financial and time pressure in later decades meant that fast, high-fat, high-sugar, and processed foods became more desirable, she points out. “Most young children now recognize the company name, and even the specific fast-food brand [they like], before they know their alphabet.”

The current environment has cultivated “a very different physical reaction to foods, maybe a different kind of emotional response,” she believes, highlighting the tightly woven relationship between obesity, society, mental health, and food options.

Dr. Steele wants to stimulate a conversation about the term used to describe individuals, conventionally described as ‘”obese” or using the word “obesity.” “We’re thinking in terms of maybe chronic appetite, chronic food intake, or dietary intake dysregulation.”

Changing medical terminology when it has become useless or harmful is not new, she argues, with co-author, Francis Finucane, MD, consultant endocrinologist at Galway University Hospitals, Ireland, in a recent paper on the subject.

“In the 20th century, the terms ‘feeble-minded’ and ‘moron’ had become used in a pejorative way in the wider culture and were dropped from medical usage,” Dr. Steele points out. She adds that changing the term “obesity” can facilitate pursuit of the strategic goals of clinical medicine “without causing needless controversy with those who, given their own goals and contexts, understand body mass index or body weight in a radically different way.”
 

Obesity: Disease, risk factor, or both?

Dr. Rubino stresses that prior to any renaming, there is a need to establish and define the essential components and characteristics of the disease of obesity. “This question is at the core of our Commission, and it is not an easy conversation to have.” He further explains that the struggle with the current definition of obesity, and the way it is conceived, is largely centered on it still being considered a risk factor for something else.

Disease is characterized by three things, says Dr. Rubino. These comprise the phenomenon of having a pathogenic cause, leading to pathophysiologic alterations (of the organs), causing clinical manifestations.

He adds that obesity is currently described by what it can cause – for example, type 2 diabetes, cancer, or hypertension. “Each of these things have their own clinical manifestations but obesity doesn’t. [As a disease], we don’t have a definition of the clinical manifestations of obesity other than excess adiposity.”

“If we use BMI, this does not predict excess adiposity, nor does it determine a disease here and now. There is no disease without an illness, which is the clinical manifestation, and the perception by the patient of it being an illness,” explains Dr. Rubino, pointing out that the Lancet Commission is filling this gap in knowledge by asking, “If obesity is an illness, then what does it look like?”

He adds that waist circumference probably provides a better measure than BMI in directly indicating the abnormal distribution of adiposity, known to be associated with poor cardiometabolic outcomes, “but it doesn’t tell you if you have an illness here and now – only that someone is at risk of developing cardiovascular disease in the future. Most people with some excess fat around the waist are perfectly functional and don’t feel ill.”

He also explains that confusion persists around whether obesity – or excess adiposity – is a risk factor for or a symptom of another disease. “The picture is blurred, and we do not know how to discriminate between these. We only have one name, and it applies to all those things, and we have one criterion – BMI – to diagnose it!”

Dr. Rubino adds, “So, what defines it? Is it diabetes? No, because that is another disease. You don’t define a disease by another. It has to stand on its own.”

Recently, the American Medical Association advised that BMI now be used in conjunction with other valid measures of risk such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors.

Aayush Visaria, MD, an internal medicine resident at Rutgers University, New Brunswick, New Jersey, agrees that a new name might help change public perception of obesity for the better. A study he presented at the 2023 Endocrine Society Meeting found that BMI “vastly underestimates” obesity.

He agrees with Dr. Rubino that the challenge lies in the lack of precise understanding of the mechanisms driving obesity: “It’s multifactorial, so not just appetite or food intake. Putting this into one phrase is difficult.”

However, if a new term can incorporate the many facets of the disease, “overall, it’ll reduce stigma because we’ll start to think about obesity as a disease process, not a personal thing with blame attached,” says Dr. Visaria.

But simultaneously, he expresses caution around possible negative connotations associated with the classification of obesity as a disease. Dr. Steele also reflects on this risk, highlighting that medicalizing body size can be counterproductive in feeding into weight stigma and fatphobia.

“Medicalizing obesity can be discouraging rather than empowering, but by specifying more clearly that we’re talking about a specific set of interrelated metabolic conditions, it would make it much clearer, and that ... this isn’t about making people skinny, it isn’t about an aesthetic thing,” Dr. Steele observes.
 

The word ‘obesity’ hinders disease explanations

Dr. Steele explains that her goal is to overcome the ambiguity around the word “obesity” that hinders explanations of the disease of obesity to the wider public.

“Much confusion and controversy might be avoided if we were to clarify that when doctors say that obesity is a disease, they do not mean that being ‘fat’ is a disease.”

Nevertheless, adipose tissue is an active endocrine organ, producing hormones that function less well in people with obesity, she notes. “This new knowledge has led to better treatments, including drugs like semaglutide and tirzepatide. These drugs, like bariatric surgery, typically lead to significant weight loss and to improvements in overall metabolic health.”

Dr. Rubino also expresses concerns around medicalization, as determined by definition and diagnosis and the availability of drug treatment that could potentially lead to overtreatment. “Currently, when everyone with a BMI of greater than 30 gets access to every obesity treatment out there, we see drugs are running out of stock. We should prioritize that treatment.”

Ultimately, the diagnosis of obesity as a disease needs an anthropometric biomarker that provides, on an individual level, the confidence that a person has a disease today, or at least close to a 100% likelihood of developing this disease and illness, asserts Dr. Rubino.

“If we use BMI, or even waist circumference, these might diagnose the disease; but if the person lives to 90 years, what’s the point of labeling somebody as having an illness?” he points out.

“As doctors, we have to be cautious. We say this is a disease, but you must think about the implications for the person on the receiving end of that diagnosis of a chronic disease that is substantially incurable. When we say it, we need to be certain.”

Dr. Steele and Dr. Visaria have disclosed no relevant financial relationships. Dr. Rubino disclosed that he has received research grants from Novo Nordisk, Medtronic, and Johnson & Johnson. He has undertaken paid consultancy work for GI Dynamics and received honoraria for lectures from Medtronic, Novo Nordisk, and Johnson & Johnson. He is a member of the data safety monitoring board for GT Metabolic Solutions and has provided scientific advice to Keyron, Metadeq, GHP Scientific, and ViBo Health for no remuneration.

A version of this article first appeared on Medscape.com.

Public perception of disease is everything. “Diabetics” are now referred to as “people living with diabetes,” and an “obese person” is now an “individual living with obesity.”

But what is the definition of obesity? Does it refer to a disease or a risk factor? And is the term so tainted in negativity, blame, and bias that the only solution is to scrap it and completely rename it? Society (and medicine) have changed significantly since the Latin word obesitas was adopted back in the 1600s.

Despite so much hinging on the word “obesity,” it’s remarkable that the label persists while the concepts underpinning it have evolved significantly. So perhaps it is more about finding the least-worst option rather than pursuing the impossibility of a solution that suits all?

This is precisely the challenge faced by a Lancet Diabetes & Endocrinology Commission on the Definition and Diagnosis of Clinical Obesity, which is due to publish its initial findings this coming fall. The global task force has 60 leaders in the clinical management of obesity, including representatives with lived experiences of obesity. Leading the project is Francesco Rubino, MD, chair of metabolic and bariatric surgery at King’s College London.

“Renaming ‘obesity’ is very important,” states Dr. Rubino. “The word is so stigmatized, with so much misunderstanding and misperception, some might say the only solution is to change the name.”

One possibility for a new name, introduced by the American Association of Clinical Endocrinologists (now –Endocrinology) and the American College of Endocrinology back in 2016, was based on framing the disease on the central characteristic of adiposity and was termed ABCD, for adiposity-based chronic disease.

Dr. Rubino welcomes “ABCD” but has some reservations. “It is good from a physiological point of view, but the problem is it speaks to scientists and medical professionals. I don’t know how much it would appeal to the general public. ‘ABCD’ still falls short of telling us what the illness is.”

He adds that the Lancet Commission’s approach is rather to call it “clinical obesity.” “ ‘Obesity’ itself doesn’t necessarily convey the message that you have a disease or an illness,” he observes. “It is similar to the difference in meaning between depression and clinical depression, which communicate two different things.”

But underpinning any renaming is greater clarification of the definition and diagnosis of obesity. In 1997, the World Health Organization recognized obesity as a chronic disease; in 2013, the American Medical Association did likewise, adding that it warranted medical attention; while it took until 2021 for the European Commission to define obesity as a “chronic relapsing disease, which in turn acts as a gateway to a range of other non-communicable diseases.”

Yet, 25 years after the initial recognition of obesity as a disease, the concept is still riddled with negativity, whether openly or unconsciously. Such stigma denigrates overweight people and those with obesity as “lazy, sloppy, unintelligent, and unattractive.”

Dr. Rubino explains that first, it’s important to establish and define the essential components and characteristics of the disease of obesity. This is key to improving access to clinical care, reducing personal blame, and nurturing a more supportive research environment to help inform both clinical and policy decision-making.

“This is the question that is at the core of our commission. We have a problem with the current definition of obesity, and the way we measure it does not allow us to accurately define a state of illness with obesity,” he explains.
 

Labels shape public perceptions of disease; ‘obesity’ epitomizes this

Another expert championing the need for a name that better reflects the definition – whatever that turns out to be – is Margaret Steele, PhD, School of Public Health, University College Cork (Ireland), who, according to her university webpage, has a special interest in “ ‘fatness’ as a cultural, social and political phenomenon.”

She believes that labels, including “obesity,” have a pivotal role in shaping public perceptions. In our digital, information-rich age, the boundaries of medicine and society overlap, with public perception shaping decisions of a medical nature as never before. But with this comes controversy and division – obesity management being a case in point.

Specifically, the word “obesity” is too widely associated with negative connotations, she says, and therefore she welcomes the dialogue around redefining and renaming it. Despite wide general support for a name and definition that reflects adiposity, due to its central physiologic role in the complications of obesity, Dr. Steele believes that the “effects on adipose tissue are downstream of brain issues and the food environment,” and she wants to see more attention brought to this.

Referring to most Westernized societies, she describes how people who grew up in times of food scarcity, before processed foods became widely available, have a different taste profile from those who grew up afterwards. “Growing up in 1940s and ‘50s Ireland, people recall how they remember getting an orange as a treat at Christmas, because the idea that you could have food all year-round – any fruit and veg that you want, when you want it – just wasn’t there.”

By comparison, societal changes leading to more financial and time pressure in later decades meant that fast, high-fat, high-sugar, and processed foods became more desirable, she points out. “Most young children now recognize the company name, and even the specific fast-food brand [they like], before they know their alphabet.”

The current environment has cultivated “a very different physical reaction to foods, maybe a different kind of emotional response,” she believes, highlighting the tightly woven relationship between obesity, society, mental health, and food options.

Dr. Steele wants to stimulate a conversation about the term used to describe individuals, conventionally described as ‘”obese” or using the word “obesity.” “We’re thinking in terms of maybe chronic appetite, chronic food intake, or dietary intake dysregulation.”

Changing medical terminology when it has become useless or harmful is not new, she argues, with co-author, Francis Finucane, MD, consultant endocrinologist at Galway University Hospitals, Ireland, in a recent paper on the subject.

“In the 20th century, the terms ‘feeble-minded’ and ‘moron’ had become used in a pejorative way in the wider culture and were dropped from medical usage,” Dr. Steele points out. She adds that changing the term “obesity” can facilitate pursuit of the strategic goals of clinical medicine “without causing needless controversy with those who, given their own goals and contexts, understand body mass index or body weight in a radically different way.”
 

Obesity: Disease, risk factor, or both?

Dr. Rubino stresses that prior to any renaming, there is a need to establish and define the essential components and characteristics of the disease of obesity. “This question is at the core of our Commission, and it is not an easy conversation to have.” He further explains that the struggle with the current definition of obesity, and the way it is conceived, is largely centered on it still being considered a risk factor for something else.

Disease is characterized by three things, says Dr. Rubino. These comprise the phenomenon of having a pathogenic cause, leading to pathophysiologic alterations (of the organs), causing clinical manifestations.

He adds that obesity is currently described by what it can cause – for example, type 2 diabetes, cancer, or hypertension. “Each of these things have their own clinical manifestations but obesity doesn’t. [As a disease], we don’t have a definition of the clinical manifestations of obesity other than excess adiposity.”

“If we use BMI, this does not predict excess adiposity, nor does it determine a disease here and now. There is no disease without an illness, which is the clinical manifestation, and the perception by the patient of it being an illness,” explains Dr. Rubino, pointing out that the Lancet Commission is filling this gap in knowledge by asking, “If obesity is an illness, then what does it look like?”

He adds that waist circumference probably provides a better measure than BMI in directly indicating the abnormal distribution of adiposity, known to be associated with poor cardiometabolic outcomes, “but it doesn’t tell you if you have an illness here and now – only that someone is at risk of developing cardiovascular disease in the future. Most people with some excess fat around the waist are perfectly functional and don’t feel ill.”

He also explains that confusion persists around whether obesity – or excess adiposity – is a risk factor for or a symptom of another disease. “The picture is blurred, and we do not know how to discriminate between these. We only have one name, and it applies to all those things, and we have one criterion – BMI – to diagnose it!”

Dr. Rubino adds, “So, what defines it? Is it diabetes? No, because that is another disease. You don’t define a disease by another. It has to stand on its own.”

Recently, the American Medical Association advised that BMI now be used in conjunction with other valid measures of risk such as, but not limited to, measurements of visceral fat, body adiposity index, body composition, relative fat mass, waist circumference, and genetic/metabolic factors.

Aayush Visaria, MD, an internal medicine resident at Rutgers University, New Brunswick, New Jersey, agrees that a new name might help change public perception of obesity for the better. A study he presented at the 2023 Endocrine Society Meeting found that BMI “vastly underestimates” obesity.

He agrees with Dr. Rubino that the challenge lies in the lack of precise understanding of the mechanisms driving obesity: “It’s multifactorial, so not just appetite or food intake. Putting this into one phrase is difficult.”

However, if a new term can incorporate the many facets of the disease, “overall, it’ll reduce stigma because we’ll start to think about obesity as a disease process, not a personal thing with blame attached,” says Dr. Visaria.

But simultaneously, he expresses caution around possible negative connotations associated with the classification of obesity as a disease. Dr. Steele also reflects on this risk, highlighting that medicalizing body size can be counterproductive in feeding into weight stigma and fatphobia.

“Medicalizing obesity can be discouraging rather than empowering, but by specifying more clearly that we’re talking about a specific set of interrelated metabolic conditions, it would make it much clearer, and that ... this isn’t about making people skinny, it isn’t about an aesthetic thing,” Dr. Steele observes.
 

The word ‘obesity’ hinders disease explanations

Dr. Steele explains that her goal is to overcome the ambiguity around the word “obesity” that hinders explanations of the disease of obesity to the wider public.

“Much confusion and controversy might be avoided if we were to clarify that when doctors say that obesity is a disease, they do not mean that being ‘fat’ is a disease.”

Nevertheless, adipose tissue is an active endocrine organ, producing hormones that function less well in people with obesity, she notes. “This new knowledge has led to better treatments, including drugs like semaglutide and tirzepatide. These drugs, like bariatric surgery, typically lead to significant weight loss and to improvements in overall metabolic health.”

Dr. Rubino also expresses concerns around medicalization, as determined by definition and diagnosis and the availability of drug treatment that could potentially lead to overtreatment. “Currently, when everyone with a BMI of greater than 30 gets access to every obesity treatment out there, we see drugs are running out of stock. We should prioritize that treatment.”

Ultimately, the diagnosis of obesity as a disease needs an anthropometric biomarker that provides, on an individual level, the confidence that a person has a disease today, or at least close to a 100% likelihood of developing this disease and illness, asserts Dr. Rubino.

“If we use BMI, or even waist circumference, these might diagnose the disease; but if the person lives to 90 years, what’s the point of labeling somebody as having an illness?” he points out.

“As doctors, we have to be cautious. We say this is a disease, but you must think about the implications for the person on the receiving end of that diagnosis of a chronic disease that is substantially incurable. When we say it, we need to be certain.”

Dr. Steele and Dr. Visaria have disclosed no relevant financial relationships. Dr. Rubino disclosed that he has received research grants from Novo Nordisk, Medtronic, and Johnson & Johnson. He has undertaken paid consultancy work for GI Dynamics and received honoraria for lectures from Medtronic, Novo Nordisk, and Johnson & Johnson. He is a member of the data safety monitoring board for GT Metabolic Solutions and has provided scientific advice to Keyron, Metadeq, GHP Scientific, and ViBo Health for no remuneration.

A version of this article first appeared on Medscape.com.

The annual probability of a person with overweight or obesity losing at least 5% of their body weight is about 1 in 10, while weight loss to a healthy category is even less common, new research finds.

On the brighter side, those with higher body mass index (BMI) had greater odds of losing at least 5% of body weight than those with lower BMI, and women were more likely to do so than men. The chances of achieving a healthy weight category – defined as BMI of 18.5-24.9 kg/m² – was less likely than losing 5% in all groups, however.

Even a modest 5% weight loss at any BMI has been associated with improved health measures, including lower systolic and diastolic blood pressure, lower fasting glucose level, lower hemoglobin A1c level, and higher HDL cholesterol level, write Lyudmyla Kompaniyets, PhD, of the National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and colleagues.

The data from more than 18 million U.S. adults from a nationwide ambulatory electronic medical record database, called IQVIA, suggest that “clinicians and public health efforts can focus on messaging and referrals to interventions that support individuals with excess weight in achieving and sustaining meaningful weight loss, i.e., ≥ 5% for adults at any level of excess weight,” the authors say.

The study population was health care–seeking but not necessarily for weight loss, and their intent to lose weight was unknown. “Several studies suggest that persons who are trying to lose weight may experience greater reductions in weight,” the researchers point out in their article, which was published in JAMA Network Open.

At the initial visit, 72.5% of the participants were categorized as having either overweight (BMI, 25.0-29.9kg/m²) or obesity (BMI, ≥ 30.0 kg/m²). The median age of the patients was 54 years. A little over half (56.7%) were women, 72.3% were White, and 7.7% were Black.

During a maximum follow-up period of 14 years, the proportion with 5% or greater weight loss was 33.4% of those with initial overweight and 41.8% with initial obesity. The proportion achieving healthy weight (BMI, 18.5-24.9 kg/m²) was just 23.2% and 2.0%, respectively.

For the combined overweight/obesity groups, the adjusted annual probability of 5% or greater weight loss was 1 in 10, increasing with BMI category from 1 in 12 for those with initial overweight to 1 in 6 for those with initial BMI of 45 kg/m² or higher. The annual probability was slightly lower among Black than White women (1 in 9 vs. 1 in 8, respectively).

In contrast, the adjusted annual probability of reducing BMI to the healthy category ranged from 1 in 19 with initial overweight to 1 in 1,667 with initial BMI of 45 kg/m² or higher. This probability was higher among women than men and was highest among White women.

“These findings could, in part, be explained by barriers in availability of and access to obesity management options, including lifestyle interventions and pharmacotherapy. There is a continual need for policies and strategies that ensure community access to nutrition and physical activity opportunities,” Dr. Kompaniyets and colleague write.

Moreover, they say, “understanding patterns of weight loss could help support populations, including Hispanic or Latino and non-Hispanic Black individuals, who are disproportionately affected by obesity due to factors such as structural racism and race and ethnicity-based social and economic disadvantages.”

The authors have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

The annual probability of a person with overweight or obesity losing at least 5% of their body weight is about 1 in 10, while weight loss to a healthy category is even less common, new research finds.

On the brighter side, those with higher body mass index (BMI) had greater odds of losing at least 5% of body weight than those with lower BMI, and women were more likely to do so than men. The chances of achieving a healthy weight category – defined as BMI of 18.5-24.9 kg/m² – was less likely than losing 5% in all groups, however.

Even a modest 5% weight loss at any BMI has been associated with improved health measures, including lower systolic and diastolic blood pressure, lower fasting glucose level, lower hemoglobin A1c level, and higher HDL cholesterol level, write Lyudmyla Kompaniyets, PhD, of the National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and colleagues.

The data from more than 18 million U.S. adults from a nationwide ambulatory electronic medical record database, called IQVIA, suggest that “clinicians and public health efforts can focus on messaging and referrals to interventions that support individuals with excess weight in achieving and sustaining meaningful weight loss, i.e., ≥ 5% for adults at any level of excess weight,” the authors say.

The study population was health care–seeking but not necessarily for weight loss, and their intent to lose weight was unknown. “Several studies suggest that persons who are trying to lose weight may experience greater reductions in weight,” the researchers point out in their article, which was published in JAMA Network Open.

At the initial visit, 72.5% of the participants were categorized as having either overweight (BMI, 25.0-29.9kg/m²) or obesity (BMI, ≥ 30.0 kg/m²). The median age of the patients was 54 years. A little over half (56.7%) were women, 72.3% were White, and 7.7% were Black.

During a maximum follow-up period of 14 years, the proportion with 5% or greater weight loss was 33.4% of those with initial overweight and 41.8% with initial obesity. The proportion achieving healthy weight (BMI, 18.5-24.9 kg/m²) was just 23.2% and 2.0%, respectively.

For the combined overweight/obesity groups, the adjusted annual probability of 5% or greater weight loss was 1 in 10, increasing with BMI category from 1 in 12 for those with initial overweight to 1 in 6 for those with initial BMI of 45 kg/m² or higher. The annual probability was slightly lower among Black than White women (1 in 9 vs. 1 in 8, respectively).

In contrast, the adjusted annual probability of reducing BMI to the healthy category ranged from 1 in 19 with initial overweight to 1 in 1,667 with initial BMI of 45 kg/m² or higher. This probability was higher among women than men and was highest among White women.

“These findings could, in part, be explained by barriers in availability of and access to obesity management options, including lifestyle interventions and pharmacotherapy. There is a continual need for policies and strategies that ensure community access to nutrition and physical activity opportunities,” Dr. Kompaniyets and colleague write.

Moreover, they say, “understanding patterns of weight loss could help support populations, including Hispanic or Latino and non-Hispanic Black individuals, who are disproportionately affected by obesity due to factors such as structural racism and race and ethnicity-based social and economic disadvantages.”

The authors have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

The annual probability of a person with overweight or obesity losing at least 5% of their body weight is about 1 in 10, while weight loss to a healthy category is even less common, new research finds.

On the brighter side, those with higher body mass index (BMI) had greater odds of losing at least 5% of body weight than those with lower BMI, and women were more likely to do so than men. The chances of achieving a healthy weight category – defined as BMI of 18.5-24.9 kg/m² – was less likely than losing 5% in all groups, however.

Even a modest 5% weight loss at any BMI has been associated with improved health measures, including lower systolic and diastolic blood pressure, lower fasting glucose level, lower hemoglobin A1c level, and higher HDL cholesterol level, write Lyudmyla Kompaniyets, PhD, of the National Center for Chronic Disease Prevention and Health Promotion, Atlanta, and colleagues.

The data from more than 18 million U.S. adults from a nationwide ambulatory electronic medical record database, called IQVIA, suggest that “clinicians and public health efforts can focus on messaging and referrals to interventions that support individuals with excess weight in achieving and sustaining meaningful weight loss, i.e., ≥ 5% for adults at any level of excess weight,” the authors say.

The study population was health care–seeking but not necessarily for weight loss, and their intent to lose weight was unknown. “Several studies suggest that persons who are trying to lose weight may experience greater reductions in weight,” the researchers point out in their article, which was published in JAMA Network Open.

At the initial visit, 72.5% of the participants were categorized as having either overweight (BMI, 25.0-29.9kg/m²) or obesity (BMI, ≥ 30.0 kg/m²). The median age of the patients was 54 years. A little over half (56.7%) were women, 72.3% were White, and 7.7% were Black.

During a maximum follow-up period of 14 years, the proportion with 5% or greater weight loss was 33.4% of those with initial overweight and 41.8% with initial obesity. The proportion achieving healthy weight (BMI, 18.5-24.9 kg/m²) was just 23.2% and 2.0%, respectively.

For the combined overweight/obesity groups, the adjusted annual probability of 5% or greater weight loss was 1 in 10, increasing with BMI category from 1 in 12 for those with initial overweight to 1 in 6 for those with initial BMI of 45 kg/m² or higher. The annual probability was slightly lower among Black than White women (1 in 9 vs. 1 in 8, respectively).

In contrast, the adjusted annual probability of reducing BMI to the healthy category ranged from 1 in 19 with initial overweight to 1 in 1,667 with initial BMI of 45 kg/m² or higher. This probability was higher among women than men and was highest among White women.

“These findings could, in part, be explained by barriers in availability of and access to obesity management options, including lifestyle interventions and pharmacotherapy. There is a continual need for policies and strategies that ensure community access to nutrition and physical activity opportunities,” Dr. Kompaniyets and colleague write.

Moreover, they say, “understanding patterns of weight loss could help support populations, including Hispanic or Latino and non-Hispanic Black individuals, who are disproportionately affected by obesity due to factors such as structural racism and race and ethnicity-based social and economic disadvantages.”

The authors have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

Obesity, in and of itself, and independent of other cardiovascular risk factors, may cause changes to the heart that can lead to sudden cardiac death, a new case-control study suggests.

Researchers who analyzed hearts taken at autopsy from people who had died from sudden cardiac death found that a number of the hearts obtained from obese decedents were heavier than those from normal-weight decedents and that the hazard ratio of unexplained cardiomegaly in this cohort was 5.3, compared with normal-weight individuals.

“Even when we ruled out any conditions that could potentially cause enlargement of the heart, including hypertension, heart valve problems, diabetes, and other cardiovascular risk factors, the association with obesity cardiomyopathy, or OCM, and sudden cardiac death remained,” lead author Joseph Westaby, PhD, from the Cardiac Risk in the Young (CRY) Cardiovascular Pathology Laboratories at St George’s University of London, said in an interview.

The study was published online in JACC: Advances.

Intrigued by this finding, Dr. Westaby and associates sought to characterize the clinical and pathological features of OCM associated with sudden cardiac death by comparing this population to two control groups: sudden cardiac death patients who were either obese or of normal weight, and had morphologically normal hearts.

Their group is uniquely positioned to do such research, Dr. Westaby explained.

“Here at St George’s University of London, we have a specialized cardiovascular pathology service. ... All hearts obtained at autopsy from individuals who have died from sudden cardiac death, or who were suspected to have had a cardiovascular cause of death, anywhere in the U.K., are referred to the CRY Centre for further analysis,” he said.

Patients were divided into two groups according to body mass index: an obesity group (BMI > 30 kg/m²) and a normal-weight group (BMI, 18.5-24.9).

An increased heart weight above 550 g in men and 450 g in women in the absence of coronary artery disease, hypertension, diabetes, or valvular disease was classified as unexplained cardiomegaly, and individuals with obesity and cardiomegaly were defined as obesity cardiomyopathy.

Age- and sex-matched controls with obesity (n = 106) were selected based on a BMI greater than 30, with a morphologically normal heart weighing less than 550 g in men and than 450 g in women. 

Age- and sex-matched normal weight controls (n = 106) were selected based on a BMI of 18.5-24.9 and a morphologically normal heart weighing less than 550 g in men and less than 450 g in women. 

The researchers identified 53 OCM cases from a cohort of more than 4,500 sudden cardiac death cases that had BMI measurements. In normal-weight patients, there were 14 cases of unexplained cardiomegaly.

The mean age at death of individuals with OCM was 42 years (range, 30-54 years). Most of the deaths occurred in men (n = 34; 64%), who also died younger than women (40 ± 13 years vs. 45 ± 10 years; P = .036).

The average heart weight in OCM patients was 598 ± 93 g. Risk of sudden cardiac death increased when BMI reached 35.

Compared with matched controls, there were increases in right and left ventricular wall thickness (all P < .05) in OCM cases. Right ventricular epicardial fat was increased in OCM cases, compared with normal-weight controls only.

Left ventricular fibrosis was identified in seven (13%) OCM cases.
 

Role of genetics to be explored

“This study highlights the need for further investigation into these individuals because, at the moment, we can’t be sure that the only contributing factor to this is the obesity,” said Dr. Westaby.

In the works are plans to see if there may be an underlying genetic predisposition in obese individuals that may have contributed to the development of an enlarged heart. The group also plans to study the families of the deceased individuals to determine if they are at risk of developing cardiomegaly, he said.

“This paper makes an important contribution to the literature that raises many important questions for future research,” Timothy P. Fitzgibbons, MD, PhD, from the University of Massachusetts, Worcester, wrote in an accompanying editorial.

Being able to access so many autopsy samples gives the current study considerable heft, Dr. Fitzgibbons said in an interview.

“A lot has been made of the obesity paradox and the perhaps benign nature of obesity but this paper suggests the opposite, that it is a very serious problem and can, in fact, in and of itself, cause heart abnormalities that could cause sudden death,” he noted.

The fact that only 13% of OCM cases had fibrosis on histology suggests that fibrosis was not the main cause of sudden cardiac death, he said.

“Often we will do MRIs to look for areas of fibrosis within the heart because those areas make patients prone to re-entry arrhythmias, in particular, ventricular tachycardia. But the authors suggest that the enlarged myocytes may themselves be predisposing to arrhythmias, rather than fibrosis,” Dr. Fitzgibbons said.

The study was supported by Cardiac Risk in the Young. Dr. Westaby and Dr. Fitzgibbons have reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

Obesity, in and of itself, and independent of other cardiovascular risk factors, may cause changes to the heart that can lead to sudden cardiac death, a new case-control study suggests.

Researchers who analyzed hearts taken at autopsy from people who had died from sudden cardiac death found that a number of the hearts obtained from obese decedents were heavier than those from normal-weight decedents and that the hazard ratio of unexplained cardiomegaly in this cohort was 5.3, compared with normal-weight individuals.

“Even when we ruled out any conditions that could potentially cause enlargement of the heart, including hypertension, heart valve problems, diabetes, and other cardiovascular risk factors, the association with obesity cardiomyopathy, or OCM, and sudden cardiac death remained,” lead author Joseph Westaby, PhD, from the Cardiac Risk in the Young (CRY) Cardiovascular Pathology Laboratories at St George’s University of London, said in an interview.

The study was published online in JACC: Advances.

Intrigued by this finding, Dr. Westaby and associates sought to characterize the clinical and pathological features of OCM associated with sudden cardiac death by comparing this population to two control groups: sudden cardiac death patients who were either obese or of normal weight, and had morphologically normal hearts.

Their group is uniquely positioned to do such research, Dr. Westaby explained.

“Here at St George’s University of London, we have a specialized cardiovascular pathology service. ... All hearts obtained at autopsy from individuals who have died from sudden cardiac death, or who were suspected to have had a cardiovascular cause of death, anywhere in the U.K., are referred to the CRY Centre for further analysis,” he said.

Patients were divided into two groups according to body mass index: an obesity group (BMI > 30 kg/m²) and a normal-weight group (BMI, 18.5-24.9).

An increased heart weight above 550 g in men and 450 g in women in the absence of coronary artery disease, hypertension, diabetes, or valvular disease was classified as unexplained cardiomegaly, and individuals with obesity and cardiomegaly were defined as obesity cardiomyopathy.

Age- and sex-matched controls with obesity (n = 106) were selected based on a BMI greater than 30, with a morphologically normal heart weighing less than 550 g in men and than 450 g in women. 

Age- and sex-matched normal weight controls (n = 106) were selected based on a BMI of 18.5-24.9 and a morphologically normal heart weighing less than 550 g in men and less than 450 g in women. 

The researchers identified 53 OCM cases from a cohort of more than 4,500 sudden cardiac death cases that had BMI measurements. In normal-weight patients, there were 14 cases of unexplained cardiomegaly.

The mean age at death of individuals with OCM was 42 years (range, 30-54 years). Most of the deaths occurred in men (n = 34; 64%), who also died younger than women (40 ± 13 years vs. 45 ± 10 years; P = .036).

The average heart weight in OCM patients was 598 ± 93 g. Risk of sudden cardiac death increased when BMI reached 35.

Compared with matched controls, there were increases in right and left ventricular wall thickness (all P < .05) in OCM cases. Right ventricular epicardial fat was increased in OCM cases, compared with normal-weight controls only.

Left ventricular fibrosis was identified in seven (13%) OCM cases.
 

Role of genetics to be explored

“This study highlights the need for further investigation into these individuals because, at the moment, we can’t be sure that the only contributing factor to this is the obesity,” said Dr. Westaby.

In the works are plans to see if there may be an underlying genetic predisposition in obese individuals that may have contributed to the development of an enlarged heart. The group also plans to study the families of the deceased individuals to determine if they are at risk of developing cardiomegaly, he said.

“This paper makes an important contribution to the literature that raises many important questions for future research,” Timothy P. Fitzgibbons, MD, PhD, from the University of Massachusetts, Worcester, wrote in an accompanying editorial.

Being able to access so many autopsy samples gives the current study considerable heft, Dr. Fitzgibbons said in an interview.

“A lot has been made of the obesity paradox and the perhaps benign nature of obesity but this paper suggests the opposite, that it is a very serious problem and can, in fact, in and of itself, cause heart abnormalities that could cause sudden death,” he noted.

The fact that only 13% of OCM cases had fibrosis on histology suggests that fibrosis was not the main cause of sudden cardiac death, he said.

“Often we will do MRIs to look for areas of fibrosis within the heart because those areas make patients prone to re-entry arrhythmias, in particular, ventricular tachycardia. But the authors suggest that the enlarged myocytes may themselves be predisposing to arrhythmias, rather than fibrosis,” Dr. Fitzgibbons said.

The study was supported by Cardiac Risk in the Young. Dr. Westaby and Dr. Fitzgibbons have reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

Obesity, in and of itself, and independent of other cardiovascular risk factors, may cause changes to the heart that can lead to sudden cardiac death, a new case-control study suggests.

Researchers who analyzed hearts taken at autopsy from people who had died from sudden cardiac death found that a number of the hearts obtained from obese decedents were heavier than those from normal-weight decedents and that the hazard ratio of unexplained cardiomegaly in this cohort was 5.3, compared with normal-weight individuals.

“Even when we ruled out any conditions that could potentially cause enlargement of the heart, including hypertension, heart valve problems, diabetes, and other cardiovascular risk factors, the association with obesity cardiomyopathy, or OCM, and sudden cardiac death remained,” lead author Joseph Westaby, PhD, from the Cardiac Risk in the Young (CRY) Cardiovascular Pathology Laboratories at St George’s University of London, said in an interview.

The study was published online in JACC: Advances.

Intrigued by this finding, Dr. Westaby and associates sought to characterize the clinical and pathological features of OCM associated with sudden cardiac death by comparing this population to two control groups: sudden cardiac death patients who were either obese or of normal weight, and had morphologically normal hearts.

Their group is uniquely positioned to do such research, Dr. Westaby explained.

“Here at St George’s University of London, we have a specialized cardiovascular pathology service. ... All hearts obtained at autopsy from individuals who have died from sudden cardiac death, or who were suspected to have had a cardiovascular cause of death, anywhere in the U.K., are referred to the CRY Centre for further analysis,” he said.

Patients were divided into two groups according to body mass index: an obesity group (BMI > 30 kg/m²) and a normal-weight group (BMI, 18.5-24.9).

An increased heart weight above 550 g in men and 450 g in women in the absence of coronary artery disease, hypertension, diabetes, or valvular disease was classified as unexplained cardiomegaly, and individuals with obesity and cardiomegaly were defined as obesity cardiomyopathy.

Age- and sex-matched controls with obesity (n = 106) were selected based on a BMI greater than 30, with a morphologically normal heart weighing less than 550 g in men and than 450 g in women. 

Age- and sex-matched normal weight controls (n = 106) were selected based on a BMI of 18.5-24.9 and a morphologically normal heart weighing less than 550 g in men and less than 450 g in women. 

The researchers identified 53 OCM cases from a cohort of more than 4,500 sudden cardiac death cases that had BMI measurements. In normal-weight patients, there were 14 cases of unexplained cardiomegaly.

The mean age at death of individuals with OCM was 42 years (range, 30-54 years). Most of the deaths occurred in men (n = 34; 64%), who also died younger than women (40 ± 13 years vs. 45 ± 10 years; P = .036).

The average heart weight in OCM patients was 598 ± 93 g. Risk of sudden cardiac death increased when BMI reached 35.

Compared with matched controls, there were increases in right and left ventricular wall thickness (all P < .05) in OCM cases. Right ventricular epicardial fat was increased in OCM cases, compared with normal-weight controls only.

Left ventricular fibrosis was identified in seven (13%) OCM cases.
 

Role of genetics to be explored

“This study highlights the need for further investigation into these individuals because, at the moment, we can’t be sure that the only contributing factor to this is the obesity,” said Dr. Westaby.

In the works are plans to see if there may be an underlying genetic predisposition in obese individuals that may have contributed to the development of an enlarged heart. The group also plans to study the families of the deceased individuals to determine if they are at risk of developing cardiomegaly, he said.

“This paper makes an important contribution to the literature that raises many important questions for future research,” Timothy P. Fitzgibbons, MD, PhD, from the University of Massachusetts, Worcester, wrote in an accompanying editorial.

Being able to access so many autopsy samples gives the current study considerable heft, Dr. Fitzgibbons said in an interview.

“A lot has been made of the obesity paradox and the perhaps benign nature of obesity but this paper suggests the opposite, that it is a very serious problem and can, in fact, in and of itself, cause heart abnormalities that could cause sudden death,” he noted.

The fact that only 13% of OCM cases had fibrosis on histology suggests that fibrosis was not the main cause of sudden cardiac death, he said.

“Often we will do MRIs to look for areas of fibrosis within the heart because those areas make patients prone to re-entry arrhythmias, in particular, ventricular tachycardia. But the authors suggest that the enlarged myocytes may themselves be predisposing to arrhythmias, rather than fibrosis,” Dr. Fitzgibbons said.

The study was supported by Cardiac Risk in the Young. Dr. Westaby and Dr. Fitzgibbons have reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

Consuming a higher percentage of calories from added sugars is linked with a higher prevalence of kidney stones, new research suggests.

Though added sugars have been linked with multiple poor health outcomes, their link with kidney stones has been unclear.

Added sugars are sugars or caloric sweeteners added to foods or drinks during processing or preparation to add flavor or shelf life. They do not include natural sugars such as lactose in milk and fructose in fruits.

Researchers, led by Shan Yin, a urologist at Affiliated Hospital of North Sichuan Medical College, in Nanchong, China, compared the added-sugar intake by quartiles in the U.S. National Health and Nutrition Examination Survey 2007-2018.

A total of 28,303 adults were included in this study, with an average age of 48. Women who consumed less than 600 or more than 3,500 kcal or men who consumed less than 800 or more than 4,200 kcal were excluded.

Researchers adjusted for factors including age, race, education, income, physical activity, and marital, employment, and smoking status.

Compared with the first quartile of percentage added-sugar calorie intake, the population in the fourth quartile, with the highest added sugar intake, had a higher prevalence of kidney stones (odds ratio, 1.39; 95% confidence interval, 1.17-1.65).

Compared with the group with fewer than 5% of calories from added sugar, the group that consumed at least 25% of calories from added sugar had nearly twice the prevalence of kidney stones (OR, 1.88; 95% CI, 1.52-2.32).

Findings were published online in Frontiers in Nutrition.

“By identifying this association, policymakers and health professionals can emphasize the need for public health initiatives to reduce added sugar consumption and promote healthy dietary habits,” the authors write.
 

Added sugar in the U.S. diet

Sugar-sweetened beverages such as soft drinks and energy and sports drinks account for 34.4% of added sugars in the American diet. Previous studies have shown the relationship between consuming sugar-sweetened beverages and a higher risk of obesity, diabetes, and cardiovascular disease, diseases that often co-occur with kidney stones.

Researchers note that even though most added sugars in the United States come from sugar-sweetened beverages, it’s unclear whether the association between added sugars and kidney stones is caused by the beverages or other sources. For instance, fructose intake has been found to be independently associated with kidney stones.

How much is too much?

The recommended upper limit on added sugar is controversial and varies widely by health organization. The American Heart Association says daily average intake from added sugars should be no more than 150 kcal for adult males (about 9 teaspoons) and no more than 100 kcal for women (about 6 teaspoons). The Institute of Medicine allows up to 25% of calories to be consumed from added sugars. The 2020 Dietary Guidelines for Americans and World Health Organization set 10% of calories as the recommended upper limit.

Further investigating what causes kidney stones is critical as kidney stones are common worldwide, affecting about 1 in 10 people in the United States alone, and occurrence is increasing. Kidney stones have a high recurrence rate – about half of people who get them have a second episode within 10 years, the authors note.

The researchers acknowledge that because participants self-reported food intake, there is the potential for recall bias. Additionally, because of the cross-sectional design, the researchers were not able to determine whether sugar intake or kidney stone occurrence came first.

This work was supported by the Doctoral Fund Project of North Sichuan Medical College. The authors declare no relevant financial relationships.

Consuming a higher percentage of calories from added sugars is linked with a higher prevalence of kidney stones, new research suggests.

Though added sugars have been linked with multiple poor health outcomes, their link with kidney stones has been unclear.

Added sugars are sugars or caloric sweeteners added to foods or drinks during processing or preparation to add flavor or shelf life. They do not include natural sugars such as lactose in milk and fructose in fruits.

Researchers, led by Shan Yin, a urologist at Affiliated Hospital of North Sichuan Medical College, in Nanchong, China, compared the added-sugar intake by quartiles in the U.S. National Health and Nutrition Examination Survey 2007-2018.

A total of 28,303 adults were included in this study, with an average age of 48. Women who consumed less than 600 or more than 3,500 kcal or men who consumed less than 800 or more than 4,200 kcal were excluded.

Researchers adjusted for factors including age, race, education, income, physical activity, and marital, employment, and smoking status.

Compared with the first quartile of percentage added-sugar calorie intake, the population in the fourth quartile, with the highest added sugar intake, had a higher prevalence of kidney stones (odds ratio, 1.39; 95% confidence interval, 1.17-1.65).

Compared with the group with fewer than 5% of calories from added sugar, the group that consumed at least 25% of calories from added sugar had nearly twice the prevalence of kidney stones (OR, 1.88; 95% CI, 1.52-2.32).

Findings were published online in Frontiers in Nutrition.

“By identifying this association, policymakers and health professionals can emphasize the need for public health initiatives to reduce added sugar consumption and promote healthy dietary habits,” the authors write.
 

Added sugar in the U.S. diet

Sugar-sweetened beverages such as soft drinks and energy and sports drinks account for 34.4% of added sugars in the American diet. Previous studies have shown the relationship between consuming sugar-sweetened beverages and a higher risk of obesity, diabetes, and cardiovascular disease, diseases that often co-occur with kidney stones.

Researchers note that even though most added sugars in the United States come from sugar-sweetened beverages, it’s unclear whether the association between added sugars and kidney stones is caused by the beverages or other sources. For instance, fructose intake has been found to be independently associated with kidney stones.

How much is too much?

The recommended upper limit on added sugar is controversial and varies widely by health organization. The American Heart Association says daily average intake from added sugars should be no more than 150 kcal for adult males (about 9 teaspoons) and no more than 100 kcal for women (about 6 teaspoons). The Institute of Medicine allows up to 25% of calories to be consumed from added sugars. The 2020 Dietary Guidelines for Americans and World Health Organization set 10% of calories as the recommended upper limit.

Further investigating what causes kidney stones is critical as kidney stones are common worldwide, affecting about 1 in 10 people in the United States alone, and occurrence is increasing. Kidney stones have a high recurrence rate – about half of people who get them have a second episode within 10 years, the authors note.

The researchers acknowledge that because participants self-reported food intake, there is the potential for recall bias. Additionally, because of the cross-sectional design, the researchers were not able to determine whether sugar intake or kidney stone occurrence came first.

This work was supported by the Doctoral Fund Project of North Sichuan Medical College. The authors declare no relevant financial relationships.

Consuming a higher percentage of calories from added sugars is linked with a higher prevalence of kidney stones, new research suggests.

Though added sugars have been linked with multiple poor health outcomes, their link with kidney stones has been unclear.

Added sugars are sugars or caloric sweeteners added to foods or drinks during processing or preparation to add flavor or shelf life. They do not include natural sugars such as lactose in milk and fructose in fruits.

Researchers, led by Shan Yin, a urologist at Affiliated Hospital of North Sichuan Medical College, in Nanchong, China, compared the added-sugar intake by quartiles in the U.S. National Health and Nutrition Examination Survey 2007-2018.

A total of 28,303 adults were included in this study, with an average age of 48. Women who consumed less than 600 or more than 3,500 kcal or men who consumed less than 800 or more than 4,200 kcal were excluded.

Researchers adjusted for factors including age, race, education, income, physical activity, and marital, employment, and smoking status.

Compared with the first quartile of percentage added-sugar calorie intake, the population in the fourth quartile, with the highest added sugar intake, had a higher prevalence of kidney stones (odds ratio, 1.39; 95% confidence interval, 1.17-1.65).

Compared with the group with fewer than 5% of calories from added sugar, the group that consumed at least 25% of calories from added sugar had nearly twice the prevalence of kidney stones (OR, 1.88; 95% CI, 1.52-2.32).

Findings were published online in Frontiers in Nutrition.

“By identifying this association, policymakers and health professionals can emphasize the need for public health initiatives to reduce added sugar consumption and promote healthy dietary habits,” the authors write.
 

Added sugar in the U.S. diet

Sugar-sweetened beverages such as soft drinks and energy and sports drinks account for 34.4% of added sugars in the American diet. Previous studies have shown the relationship between consuming sugar-sweetened beverages and a higher risk of obesity, diabetes, and cardiovascular disease, diseases that often co-occur with kidney stones.

Researchers note that even though most added sugars in the United States come from sugar-sweetened beverages, it’s unclear whether the association between added sugars and kidney stones is caused by the beverages or other sources. For instance, fructose intake has been found to be independently associated with kidney stones.

How much is too much?

The recommended upper limit on added sugar is controversial and varies widely by health organization. The American Heart Association says daily average intake from added sugars should be no more than 150 kcal for adult males (about 9 teaspoons) and no more than 100 kcal for women (about 6 teaspoons). The Institute of Medicine allows up to 25% of calories to be consumed from added sugars. The 2020 Dietary Guidelines for Americans and World Health Organization set 10% of calories as the recommended upper limit.

Further investigating what causes kidney stones is critical as kidney stones are common worldwide, affecting about 1 in 10 people in the United States alone, and occurrence is increasing. Kidney stones have a high recurrence rate – about half of people who get them have a second episode within 10 years, the authors note.

The researchers acknowledge that because participants self-reported food intake, there is the potential for recall bias. Additionally, because of the cross-sectional design, the researchers were not able to determine whether sugar intake or kidney stone occurrence came first.

This work was supported by the Doctoral Fund Project of North Sichuan Medical College. The authors declare no relevant financial relationships.

TOPLINE:

A high parathyroid hormone (PTH) level was significantly associated with nonalcoholic fatty liver disease (NAFLD) and nonsignificantly associated with nonalcoholic steatohepatitis (NASH) in a meta-analysis.

METHODOLOGY:

• The researchers conducted a systematic review and meta-analysis of 12 case-control studies of patients with NAFLD/NASH and a comparison group without NAFLD/NASH.
• All studies had data on mean PTH levels in cases and controls.
• Pooled weighted mean difference (WMD) was calculated by combining WMDs of each study using a random-effects model.

TAKEAWAY:

• A meta-analysis of 10 studies with 1,051 patients with NAFLD and 1,510 controls revealed a significant association between high PTH level and NAFLD, with a pooled WMD of 5.479.
• A meta-analysis of four studies with 99 patients with NASH and 143 controls revealed a trend toward an association of high PTH level and NASH, with a pooled WMD of 11.995; statistical significance was not achieved owing to inadequate power.
• Both meta-analyses had high statistical heterogeneity (I² of 82.4% for NAFLD and 81.0% for NASH).

IN PRACTICE:

“These findings may have clinical implications as they may suggest that high PTH level could be another biochemical marker of presence of NAFLD and possibly NASH,” the researchers wrote.

SOURCE:

This study was led by Aunchalee Jaroenlapnopparat, MD, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Mass. It was published online in Diabetes & Metabolic Syndrome: Research & Reviews. The study had no funding.

LIMITATIONS:

This systematic review and meta-analysis included observational studies, which might not show a causal relationship owing to potential confounding effects. Both meta-analyses demonstrated high statistical heterogeneity, probably because of differences in study design, population, and quality among the included studies. The number of studies and participants in the NASH-related analysis were limited, which may have compromised the statistical power of the analysis.

DISCLOSURES:

The authors have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

A high parathyroid hormone (PTH) level was significantly associated with nonalcoholic fatty liver disease (NAFLD) and nonsignificantly associated with nonalcoholic steatohepatitis (NASH) in a meta-analysis.

METHODOLOGY:

• The researchers conducted a systematic review and meta-analysis of 12 case-control studies of patients with NAFLD/NASH and a comparison group without NAFLD/NASH.
• All studies had data on mean PTH levels in cases and controls.
• Pooled weighted mean difference (WMD) was calculated by combining WMDs of each study using a random-effects model.

TAKEAWAY:

• A meta-analysis of 10 studies with 1,051 patients with NAFLD and 1,510 controls revealed a significant association between high PTH level and NAFLD, with a pooled WMD of 5.479.
• A meta-analysis of four studies with 99 patients with NASH and 143 controls revealed a trend toward an association of high PTH level and NASH, with a pooled WMD of 11.995; statistical significance was not achieved owing to inadequate power.
• Both meta-analyses had high statistical heterogeneity (I² of 82.4% for NAFLD and 81.0% for NASH).

IN PRACTICE:

“These findings may have clinical implications as they may suggest that high PTH level could be another biochemical marker of presence of NAFLD and possibly NASH,” the researchers wrote.

SOURCE:

This study was led by Aunchalee Jaroenlapnopparat, MD, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Mass. It was published online in Diabetes & Metabolic Syndrome: Research & Reviews. The study had no funding.

LIMITATIONS:

This systematic review and meta-analysis included observational studies, which might not show a causal relationship owing to potential confounding effects. Both meta-analyses demonstrated high statistical heterogeneity, probably because of differences in study design, population, and quality among the included studies. The number of studies and participants in the NASH-related analysis were limited, which may have compromised the statistical power of the analysis.

DISCLOSURES:

The authors have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

TOPLINE:

A high parathyroid hormone (PTH) level was significantly associated with nonalcoholic fatty liver disease (NAFLD) and nonsignificantly associated with nonalcoholic steatohepatitis (NASH) in a meta-analysis.

METHODOLOGY:

• The researchers conducted a systematic review and meta-analysis of 12 case-control studies of patients with NAFLD/NASH and a comparison group without NAFLD/NASH.
• All studies had data on mean PTH levels in cases and controls.
• Pooled weighted mean difference (WMD) was calculated by combining WMDs of each study using a random-effects model.

TAKEAWAY:

• A meta-analysis of 10 studies with 1,051 patients with NAFLD and 1,510 controls revealed a significant association between high PTH level and NAFLD, with a pooled WMD of 5.479.
• A meta-analysis of four studies with 99 patients with NASH and 143 controls revealed a trend toward an association of high PTH level and NASH, with a pooled WMD of 11.995; statistical significance was not achieved owing to inadequate power.
• Both meta-analyses had high statistical heterogeneity (I² of 82.4% for NAFLD and 81.0% for NASH).

IN PRACTICE:

“These findings may have clinical implications as they may suggest that high PTH level could be another biochemical marker of presence of NAFLD and possibly NASH,” the researchers wrote.

SOURCE:

This study was led by Aunchalee Jaroenlapnopparat, MD, Mount Auburn Hospital/Beth Israel Lahey Health, Cambridge, Mass. It was published online in Diabetes & Metabolic Syndrome: Research & Reviews. The study had no funding.

LIMITATIONS:

This systematic review and meta-analysis included observational studies, which might not show a causal relationship owing to potential confounding effects. Both meta-analyses demonstrated high statistical heterogeneity, probably because of differences in study design, population, and quality among the included studies. The number of studies and participants in the NASH-related analysis were limited, which may have compromised the statistical power of the analysis.

DISCLOSURES:

The authors have no relevant conflicts of interest.

A version of this article first appeared on Medscape.com.

Ashley Raibick is familiar with the weight loss yo-yo. She’s bounced through the big names: Weight Watchers, Jenny Craig, and so on. She drops 10 pounds and then slides off the plan only to see her weight pop back up.

But a day at her local med spa – where she gets facials, Botox, and fillers – changed all that for the 28-year-old hairstylist who just wanted to lose 18 pounds.

During one of her visits, she noticed that the spa’s owner was thinner. When Ms. Raibick asked her how she did it, the owner explained that she was on semaglutide and talked Ms. Raibick through the process. Ms. Raibick was convinced. That same day, she got a prescription from a doctor at the spa and got her first shot.

“Are people going to think I’m crazy for doing this?” she recalls thinking.

At 5 foot 4, her starting weight before the drug was 158, which would put her in the overweight, but not obese, category based on body mass index (BMI). And she really just wanted to get down to 140 and stop there.

Ozempic is part of an ever-growing group of GLP-1 receptor agonists that contain a peptide called semaglutide as its main ingredient. Although first meant to treat type 2 diabetes, the reputation of Ozempic and its siblings picked up when already-thin celebrities were suspected of using the injectable drugs to become even slimmer.

The FDA approved Ozempic’s cousin, Wegovy, for “weight management” in patients with obesity a few years ago, whereas Ozempic is currently approved only for diabetes treatment. Curious patients who don’t fit the criteria can – and do – get off-label prescriptions if they can afford to pay out of pocket, often to the tune of more than $1,400 a month. But is Ozempic worth it, especially if one has a relatively minor amount of weight to lose?

For many – mainly those who have been on the drug for a couple of months and have lost weight as a result – taking Ozempic has not only helped them shed stubborn weight, but has also freed them from the constant internal chatter around eating, commonly called “food noise.” But experts do not all agree that semaglutide is the right path for those who aren’t technically obese – especially in the long term.

After her first 9 weeks on semaglutide, Ms. Raibick had already lost 18 pounds. That’s when she decided to post about it on TikTok, and her videos on GLP-1s were viewed hundreds of thousands of times.

For the time being, there is no data on how many semaglutide takers are using the drug for diabetes and/or obesity, and how many are using it off-label for weight loss alone. But the company that makes Ozempic, Novo Nordisk, has reported sharp increases in sales and projects more profits down the road.

Ms. Raibick knows of others like her, who sought out the drug for more minor weight loss but aren’t as candid about their journeys. Some feel a stigma about having to resort to a weight-loss drug intended to treat obesity, rather than achieving their goals with diet and lifestyle change alone.

Another reason for the secrecy is the guilt some who take Ozempic feel about using their financial privilege to get a drug that had serious shortages, which made it harder for some patients who need the drug for diabetes or obesity treatment to get their doses.

That’s what Diana Thiara, MD, the medical director of the University of California, San Francisco’s weight management program, has been seeing on the ground.

“It’s one of the most depressing things I’ve experienced as a physician,” she said. In her practice, she has seen patients who have finally been able to access GLP-1s and have started to lose weight, only for them to regain the weight in the time it takes to find another prescription under their insurance coverage.

“It’s just horrible, there are patients spending all day calling dozens of pharmacies. I’ve never had a situation like this in my career,” said Dr. Thiara.

Ann, 48, a mom who works from home full-time, has been taking Ozempic since the end of January. (Ann is not her real name; she asked that we use a pseudonym in order to feel comfortable speaking publicly about her use of Ozempic). Like Ms. Raibick, she has been paying out of pocket for her shots. At first, she was going to have to pay $1,400 a month, but she found a pharmacy in Canada that offers the medication for $350. It’s sourced globally, she said, so sometimes her Ozempic boxes will be in Czech or another foreign language.

Unlike a lot of women, Ann never had any qualms with her weight or the way her body looked. She was never big on exercise, but it wasn’t until the pandemic that she started to gain weight. She noticed the changes in her body once places started opening back up, and her clothes didn’t fit anymore.

She tried moving more and eating healthier. She tried former Real Housewives of Beverly Hills cast member Teddi Mellencamp’s controversial weight-loss program, infamous for its incredibly restrictive dietary plan and excessive cardio recommendations. Nothing worked until another mom at her daughter’s school mentioned that she was on Ozempic.

Ann also started to get hot flashes and missed periods. The doctor who prescribed her Ozempic confirmed that she was perimenopausal and that, for women in this stage of life, losing weight can be harder than ever.

Ann, who is 5 foot 7, started out at 176 pounds (considered overweight) and now weighs in at 151, which is considered a normal weight by BMI measurements. She’s still on Ozempic but continues to struggle with the shame around the idea she’s potentially taking the drug away from someone else who might desperately need it. And she doesn’t know how long she’ll have to stay on Ozempic to maintain her weight loss.

Ann has reason for concern. A 2022 study found that most people regain the weight they lost within a year of stopping Ozempic.

Once Ms. Raibick hit her initial goal weight, she felt that she could keep going and lose a little more. It wasn’t until she got into the 120-pound range that she decided it was time to wean off the dose of semaglutide she had been taking.

“I got to the point where my mom was like, ‘All right, you’re a little too thin.’ But I’m just so happy where I’m at. I’m not mentally stressed out about fitting into clothes or getting into a bathing suit,” said Ms. Raibick, who has now lost around 30 pounds in total since she started the shots.

At one point, she stopped taking the drug altogether, and all of the hunger cravings and food noise semaglutide had suppressed came back to the surface. She didn’t gain any weight that month, she said, but the internal chatter around food was enough to make her start back on a lower dose, geared toward weight maintenance.

There’s also the issue of side effects. Ms. Raibick says she never had the overwhelming nausea and digestive problems that so many on the drug – including Ann – have reported. But Dr. Thiara said that even beyond these more common side effects, there are a number of other concerns – like the long-lasting effects on thyroid and reproductive health, especially for women – that we still don’t know enough about. And just recently, CNN reported that some Ozempic users have developed stomach paralysis due to the drug’s ability to slow down the passage of food through the digestive tract.

For Ms. Raibick, the out-of-pocket cost for the drug is around $600 a month. It’s an expense she’s willing to keep paying for, even just for the peace of mind the drug provides. She doesn’t have any plans to stop her semaglutide shots soon.

“There is nothing stopping me from – a year from now, when I’ve put a little weight back on – looking back at photos from this time and thinking I was way too skinny.”

Dan Azagury, MD, a bariatric surgeon and associate professor of surgery at Stanford (Calif.) University, tries GLP-1s for patients with obesity before considering bariatric surgery. For his patient population, it’s possible that drugs like Ozempic will be part of their lifelong treatment plans.

“We’re not doing it for the cosmetic part of it, we’re doing it for health,” he said. “What I tell my patients is, if you’re planning to start on this medication, you should be OK with the idea of staying on it forever.”

For doctors like Dr. Thiara who specialize in weight management, using Ozempic long-term for patients in a healthy weight range is the wrong approach.

“It’s not about the way people look, it’s about health. If you’re a normal weight or even in an overweight category, but not showing signs of risk of having elevated cardiometabolic disease ... You don’t need to be taking medications for weight loss,” she said. “This idea of using medications for aesthetic reasons is really more related to societal ills around how we value fitness above anything else. That’s not the goal, and it’s not safe.”

A version of this article first appeared on WebMD.com.

Ashley Raibick is familiar with the weight loss yo-yo. She’s bounced through the big names: Weight Watchers, Jenny Craig, and so on. She drops 10 pounds and then slides off the plan only to see her weight pop back up.

But a day at her local med spa – where she gets facials, Botox, and fillers – changed all that for the 28-year-old hairstylist who just wanted to lose 18 pounds.

During one of her visits, she noticed that the spa’s owner was thinner. When Ms. Raibick asked her how she did it, the owner explained that she was on semaglutide and talked Ms. Raibick through the process. Ms. Raibick was convinced. That same day, she got a prescription from a doctor at the spa and got her first shot.

“Are people going to think I’m crazy for doing this?” she recalls thinking.

At 5 foot 4, her starting weight before the drug was 158, which would put her in the overweight, but not obese, category based on body mass index (BMI). And she really just wanted to get down to 140 and stop there.

Ozempic is part of an ever-growing group of GLP-1 receptor agonists that contain a peptide called semaglutide as its main ingredient. Although first meant to treat type 2 diabetes, the reputation of Ozempic and its siblings picked up when already-thin celebrities were suspected of using the injectable drugs to become even slimmer.

The FDA approved Ozempic’s cousin, Wegovy, for “weight management” in patients with obesity a few years ago, whereas Ozempic is currently approved only for diabetes treatment. Curious patients who don’t fit the criteria can – and do – get off-label prescriptions if they can afford to pay out of pocket, often to the tune of more than $1,400 a month. But is Ozempic worth it, especially if one has a relatively minor amount of weight to lose?

For many – mainly those who have been on the drug for a couple of months and have lost weight as a result – taking Ozempic has not only helped them shed stubborn weight, but has also freed them from the constant internal chatter around eating, commonly called “food noise.” But experts do not all agree that semaglutide is the right path for those who aren’t technically obese – especially in the long term.

After her first 9 weeks on semaglutide, Ms. Raibick had already lost 18 pounds. That’s when she decided to post about it on TikTok, and her videos on GLP-1s were viewed hundreds of thousands of times.

For the time being, there is no data on how many semaglutide takers are using the drug for diabetes and/or obesity, and how many are using it off-label for weight loss alone. But the company that makes Ozempic, Novo Nordisk, has reported sharp increases in sales and projects more profits down the road.

Ms. Raibick knows of others like her, who sought out the drug for more minor weight loss but aren’t as candid about their journeys. Some feel a stigma about having to resort to a weight-loss drug intended to treat obesity, rather than achieving their goals with diet and lifestyle change alone.

Another reason for the secrecy is the guilt some who take Ozempic feel about using their financial privilege to get a drug that had serious shortages, which made it harder for some patients who need the drug for diabetes or obesity treatment to get their doses.

That’s what Diana Thiara, MD, the medical director of the University of California, San Francisco’s weight management program, has been seeing on the ground.

“It’s one of the most depressing things I’ve experienced as a physician,” she said. In her practice, she has seen patients who have finally been able to access GLP-1s and have started to lose weight, only for them to regain the weight in the time it takes to find another prescription under their insurance coverage.

“It’s just horrible, there are patients spending all day calling dozens of pharmacies. I’ve never had a situation like this in my career,” said Dr. Thiara.

Ann, 48, a mom who works from home full-time, has been taking Ozempic since the end of January. (Ann is not her real name; she asked that we use a pseudonym in order to feel comfortable speaking publicly about her use of Ozempic). Like Ms. Raibick, she has been paying out of pocket for her shots. At first, she was going to have to pay $1,400 a month, but she found a pharmacy in Canada that offers the medication for $350. It’s sourced globally, she said, so sometimes her Ozempic boxes will be in Czech or another foreign language.

Unlike a lot of women, Ann never had any qualms with her weight or the way her body looked. She was never big on exercise, but it wasn’t until the pandemic that she started to gain weight. She noticed the changes in her body once places started opening back up, and her clothes didn’t fit anymore.

She tried moving more and eating healthier. She tried former Real Housewives of Beverly Hills cast member Teddi Mellencamp’s controversial weight-loss program, infamous for its incredibly restrictive dietary plan and excessive cardio recommendations. Nothing worked until another mom at her daughter’s school mentioned that she was on Ozempic.

Ann also started to get hot flashes and missed periods. The doctor who prescribed her Ozempic confirmed that she was perimenopausal and that, for women in this stage of life, losing weight can be harder than ever.

Ann, who is 5 foot 7, started out at 176 pounds (considered overweight) and now weighs in at 151, which is considered a normal weight by BMI measurements. She’s still on Ozempic but continues to struggle with the shame around the idea she’s potentially taking the drug away from someone else who might desperately need it. And she doesn’t know how long she’ll have to stay on Ozempic to maintain her weight loss.

Ann has reason for concern. A 2022 study found that most people regain the weight they lost within a year of stopping Ozempic.

Once Ms. Raibick hit her initial goal weight, she felt that she could keep going and lose a little more. It wasn’t until she got into the 120-pound range that she decided it was time to wean off the dose of semaglutide she had been taking.

“I got to the point where my mom was like, ‘All right, you’re a little too thin.’ But I’m just so happy where I’m at. I’m not mentally stressed out about fitting into clothes or getting into a bathing suit,” said Ms. Raibick, who has now lost around 30 pounds in total since she started the shots.

At one point, she stopped taking the drug altogether, and all of the hunger cravings and food noise semaglutide had suppressed came back to the surface. She didn’t gain any weight that month, she said, but the internal chatter around food was enough to make her start back on a lower dose, geared toward weight maintenance.

There’s also the issue of side effects. Ms. Raibick says she never had the overwhelming nausea and digestive problems that so many on the drug – including Ann – have reported. But Dr. Thiara said that even beyond these more common side effects, there are a number of other concerns – like the long-lasting effects on thyroid and reproductive health, especially for women – that we still don’t know enough about. And just recently, CNN reported that some Ozempic users have developed stomach paralysis due to the drug’s ability to slow down the passage of food through the digestive tract.

For Ms. Raibick, the out-of-pocket cost for the drug is around $600 a month. It’s an expense she’s willing to keep paying for, even just for the peace of mind the drug provides. She doesn’t have any plans to stop her semaglutide shots soon.

“There is nothing stopping me from – a year from now, when I’ve put a little weight back on – looking back at photos from this time and thinking I was way too skinny.”

Dan Azagury, MD, a bariatric surgeon and associate professor of surgery at Stanford (Calif.) University, tries GLP-1s for patients with obesity before considering bariatric surgery. For his patient population, it’s possible that drugs like Ozempic will be part of their lifelong treatment plans.

“We’re not doing it for the cosmetic part of it, we’re doing it for health,” he said. “What I tell my patients is, if you’re planning to start on this medication, you should be OK with the idea of staying on it forever.”

For doctors like Dr. Thiara who specialize in weight management, using Ozempic long-term for patients in a healthy weight range is the wrong approach.

“It’s not about the way people look, it’s about health. If you’re a normal weight or even in an overweight category, but not showing signs of risk of having elevated cardiometabolic disease ... You don’t need to be taking medications for weight loss,” she said. “This idea of using medications for aesthetic reasons is really more related to societal ills around how we value fitness above anything else. That’s not the goal, and it’s not safe.”

A version of this article first appeared on WebMD.com.

Ashley Raibick is familiar with the weight loss yo-yo. She’s bounced through the big names: Weight Watchers, Jenny Craig, and so on. She drops 10 pounds and then slides off the plan only to see her weight pop back up.

But a day at her local med spa – where she gets facials, Botox, and fillers – changed all that for the 28-year-old hairstylist who just wanted to lose 18 pounds.

During one of her visits, she noticed that the spa’s owner was thinner. When Ms. Raibick asked her how she did it, the owner explained that she was on semaglutide and talked Ms. Raibick through the process. Ms. Raibick was convinced. That same day, she got a prescription from a doctor at the spa and got her first shot.

“Are people going to think I’m crazy for doing this?” she recalls thinking.

At 5 foot 4, her starting weight before the drug was 158, which would put her in the overweight, but not obese, category based on body mass index (BMI). And she really just wanted to get down to 140 and stop there.

Ozempic is part of an ever-growing group of GLP-1 receptor agonists that contain a peptide called semaglutide as its main ingredient. Although first meant to treat type 2 diabetes, the reputation of Ozempic and its siblings picked up when already-thin celebrities were suspected of using the injectable drugs to become even slimmer.

The FDA approved Ozempic’s cousin, Wegovy, for “weight management” in patients with obesity a few years ago, whereas Ozempic is currently approved only for diabetes treatment. Curious patients who don’t fit the criteria can – and do – get off-label prescriptions if they can afford to pay out of pocket, often to the tune of more than $1,400 a month. But is Ozempic worth it, especially if one has a relatively minor amount of weight to lose?

For many – mainly those who have been on the drug for a couple of months and have lost weight as a result – taking Ozempic has not only helped them shed stubborn weight, but has also freed them from the constant internal chatter around eating, commonly called “food noise.” But experts do not all agree that semaglutide is the right path for those who aren’t technically obese – especially in the long term.

After her first 9 weeks on semaglutide, Ms. Raibick had already lost 18 pounds. That’s when she decided to post about it on TikTok, and her videos on GLP-1s were viewed hundreds of thousands of times.

For the time being, there is no data on how many semaglutide takers are using the drug for diabetes and/or obesity, and how many are using it off-label for weight loss alone. But the company that makes Ozempic, Novo Nordisk, has reported sharp increases in sales and projects more profits down the road.

Ms. Raibick knows of others like her, who sought out the drug for more minor weight loss but aren’t as candid about their journeys. Some feel a stigma about having to resort to a weight-loss drug intended to treat obesity, rather than achieving their goals with diet and lifestyle change alone.

Another reason for the secrecy is the guilt some who take Ozempic feel about using their financial privilege to get a drug that had serious shortages, which made it harder for some patients who need the drug for diabetes or obesity treatment to get their doses.

That’s what Diana Thiara, MD, the medical director of the University of California, San Francisco’s weight management program, has been seeing on the ground.

“It’s one of the most depressing things I’ve experienced as a physician,” she said. In her practice, she has seen patients who have finally been able to access GLP-1s and have started to lose weight, only for them to regain the weight in the time it takes to find another prescription under their insurance coverage.

“It’s just horrible, there are patients spending all day calling dozens of pharmacies. I’ve never had a situation like this in my career,” said Dr. Thiara.

Ann, 48, a mom who works from home full-time, has been taking Ozempic since the end of January. (Ann is not her real name; she asked that we use a pseudonym in order to feel comfortable speaking publicly about her use of Ozempic). Like Ms. Raibick, she has been paying out of pocket for her shots. At first, she was going to have to pay $1,400 a month, but she found a pharmacy in Canada that offers the medication for $350. It’s sourced globally, she said, so sometimes her Ozempic boxes will be in Czech or another foreign language.

Unlike a lot of women, Ann never had any qualms with her weight or the way her body looked. She was never big on exercise, but it wasn’t until the pandemic that she started to gain weight. She noticed the changes in her body once places started opening back up, and her clothes didn’t fit anymore.

She tried moving more and eating healthier. She tried former Real Housewives of Beverly Hills cast member Teddi Mellencamp’s controversial weight-loss program, infamous for its incredibly restrictive dietary plan and excessive cardio recommendations. Nothing worked until another mom at her daughter’s school mentioned that she was on Ozempic.

Ann also started to get hot flashes and missed periods. The doctor who prescribed her Ozempic confirmed that she was perimenopausal and that, for women in this stage of life, losing weight can be harder than ever.

Ann, who is 5 foot 7, started out at 176 pounds (considered overweight) and now weighs in at 151, which is considered a normal weight by BMI measurements. She’s still on Ozempic but continues to struggle with the shame around the idea she’s potentially taking the drug away from someone else who might desperately need it. And she doesn’t know how long she’ll have to stay on Ozempic to maintain her weight loss.

Ann has reason for concern. A 2022 study found that most people regain the weight they lost within a year of stopping Ozempic.

Once Ms. Raibick hit her initial goal weight, she felt that she could keep going and lose a little more. It wasn’t until she got into the 120-pound range that she decided it was time to wean off the dose of semaglutide she had been taking.

“I got to the point where my mom was like, ‘All right, you’re a little too thin.’ But I’m just so happy where I’m at. I’m not mentally stressed out about fitting into clothes or getting into a bathing suit,” said Ms. Raibick, who has now lost around 30 pounds in total since she started the shots.

At one point, she stopped taking the drug altogether, and all of the hunger cravings and food noise semaglutide had suppressed came back to the surface. She didn’t gain any weight that month, she said, but the internal chatter around food was enough to make her start back on a lower dose, geared toward weight maintenance.

There’s also the issue of side effects. Ms. Raibick says she never had the overwhelming nausea and digestive problems that so many on the drug – including Ann – have reported. But Dr. Thiara said that even beyond these more common side effects, there are a number of other concerns – like the long-lasting effects on thyroid and reproductive health, especially for women – that we still don’t know enough about. And just recently, CNN reported that some Ozempic users have developed stomach paralysis due to the drug’s ability to slow down the passage of food through the digestive tract.

For Ms. Raibick, the out-of-pocket cost for the drug is around $600 a month. It’s an expense she’s willing to keep paying for, even just for the peace of mind the drug provides. She doesn’t have any plans to stop her semaglutide shots soon.

“There is nothing stopping me from – a year from now, when I’ve put a little weight back on – looking back at photos from this time and thinking I was way too skinny.”

Dan Azagury, MD, a bariatric surgeon and associate professor of surgery at Stanford (Calif.) University, tries GLP-1s for patients with obesity before considering bariatric surgery. For his patient population, it’s possible that drugs like Ozempic will be part of their lifelong treatment plans.

“We’re not doing it for the cosmetic part of it, we’re doing it for health,” he said. “What I tell my patients is, if you’re planning to start on this medication, you should be OK with the idea of staying on it forever.”

For doctors like Dr. Thiara who specialize in weight management, using Ozempic long-term for patients in a healthy weight range is the wrong approach.

“It’s not about the way people look, it’s about health. If you’re a normal weight or even in an overweight category, but not showing signs of risk of having elevated cardiometabolic disease ... You don’t need to be taking medications for weight loss,” she said. “This idea of using medications for aesthetic reasons is really more related to societal ills around how we value fitness above anything else. That’s not the goal, and it’s not safe.”

A version of this article first appeared on WebMD.com.

“The patient is ready,” the medical assistant informs you while handing you the chart. The chart reads: “Chief complaint: Weight gain/Discuss weight loss options.” You note the normal vital signs other than an increased BMI to 34 from 4 months ago. You knock on the exam room door with your plan half-formulated.
 

“Come in,” the patient says, almost too softly for you to hear. Shock overtakes you as you enter the room and see something you never imagined. The patient is holding their disconnected head in their lap as they say, “Nice to see you, Doc. I want to do something about my weight.”

You’re baffled at how they are speaking with a disconnected head. Of course, this outlandish patient scenario isn’t real. Or is it?

Patients with mental health concerns don’t literally present with their head disconnected from their bodies. Too often, mental health is treated as separate from physical health, especially regarding weight management and obesity. However, studies have shown an association between mental health and obesity. In this pivotal time of pharmacologic innovation in obesity care, we must also ensure that we effectively address the mental health of our patients with obesity.

In this article, I’ll share six ways that clinicians can improve mental health care for patients with obesity.
 

Screening

Mental health conditions can look different for everyone. It can be hard to diagnose a mental health condition without validated screening. For example, depression is one of the most common mental health disorders. The U.S. Preventive Services Task Force recommends depression screening in all adults.

The Patient Health Questionnaire-2 (PHQ-2) is one screening tool that can alert doctors and clinicians to potential depression. Patients with obesity have higher rates of depression and other mental health conditions. It’s even more critical to screen for depression and other mental health disorders when prescribing these new medications, given recent reports of suicidal ideation with certain antiobesity medications.
 

Stigma

Mental health–related stigma can trigger shame and prevent patients from seeking psychological help. Furthermore, compounded stigma in patients with larger bodies (weight bias) and from marginalized communities such as the Black community (racial discrimination) add more barriers to seeking mental health care. When patients seek care for mental health conditions, they may feel more comfortable seeing a primary care physician or other clinician than a mental health professional. Therefore, all physicians and clinicians are integral in normalizing mental health care. Instead of treating mental health as separate from physical health, discussing the bidirectional relationship between mental health conditions and physiologic diseases can help patients understand that having a mental health condition isn’t a choice and facilitate openness to multiple treatment options to improve their quality of life.

Support

Addressing mental health effectively often requires multiple layers of patient support. Support can come from loved ones or community groups. But for severe stress and other mental health conditions, treatment with psychotherapy or psychiatric medications is essential. Unfortunately, even if a patient is willing to see a mental health professional, availability or access may be a challenge. Therefore, other clinicians may have to step in and serve as a bridge to mental health care. It’s also essential to ensure that patients are aware of crisis support lines and online resources for mental health care.

Stress

Having a high level of stress can be harmful physically and can also worsen mental health conditions. Additionally, it can contribute to a higher risk for obesity and can trigger emotional eating. Chronic stress has become so common in society that patients often underestimate how much stress they are under. Assessments like the Holmes-Rahe Stress Inventory can help patients identify and quantify potential stressors. While some stressors are uncontrollable, such as social determinants of health (SDOH), addressing controllable stressors and improving coping mechanisms is possible. For instance, mindfulness and breathwork are easy to follow and relatively accessible for most patients.

Social determinants of health

For a treatment plan to be maximally impactful, we must incorporate SDOH in clinical care. SDOH includes financial instability, safe neighborhoods, and more, and can significantly influence an ideal treatment plan. Furthermore, a high SDOH burden can negatively affect mental health and obesity rates. It’s helpful to incorporate patients’ SDOH burden into treatment planning. Learn how to take action on SDOH.

Empowerment

Patients who address their mental health have taken a courageous step toward health and healing. As mentioned, they may experience gaps in care while awaiting connection to the next steps of their journey, such as starting care with a mental health professional or waiting for a medication to take effect. All clinicians can empower patients about their weight by informing them that:

Food may affect their mood. Studies show that certain foods and eating patterns are associated with high levels of depression and anxiety. Limiting processed foods and increasing fruits, vegetables, and foods high in vitamin D, C, and other nutrients is helpful. Everyone is different, so encourage patients to pay attention to how food uniquely affects their mood by keeping a food/feeling log for 1-3 days.

Move more. Increased physical activity can improve mental health.

Get outdoors. Time in nature is associated with better mental health. Spending as little as 10 minutes outside can be beneficial. It’s important to be aware that SDOH factors such as unsafe environments or limited outdoor access may make this difficult for some patients.

Positive stress-relieving activities. Each person has their own way of reducing stress. It is helpful to remind patients of unhealthy stress relievers such as overeating, drinking alcohol, and smoking, and encourage them to replace those with positive stress relievers.

Spiritual well-being. Spirituality is often overlooked in health care. But studies have shown that incorporating a person’s spirituality may have positive health benefits.

It’s time to stop disconnecting mental health from physical health. Each clinician plays a vital role in treating the whole person. Just as you wouldn’t let a patient with a disconnected head leave the office without addressing it, let’s not leave mental health out when addressing our patients’ weight concerns.

Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness,” (Baltimore: Purposely Created Publishing Group, 2019) was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022.

Dr. Gonsahn-Bollie is CEO and Lead Physician, Embrace You Weight and Wellness, Telehealth & Virtual Counseling. She has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

“The patient is ready,” the medical assistant informs you while handing you the chart. The chart reads: “Chief complaint: Weight gain/Discuss weight loss options.” You note the normal vital signs other than an increased BMI to 34 from 4 months ago. You knock on the exam room door with your plan half-formulated.
 

“Come in,” the patient says, almost too softly for you to hear. Shock overtakes you as you enter the room and see something you never imagined. The patient is holding their disconnected head in their lap as they say, “Nice to see you, Doc. I want to do something about my weight.”

You’re baffled at how they are speaking with a disconnected head. Of course, this outlandish patient scenario isn’t real. Or is it?

Patients with mental health concerns don’t literally present with their head disconnected from their bodies. Too often, mental health is treated as separate from physical health, especially regarding weight management and obesity. However, studies have shown an association between mental health and obesity. In this pivotal time of pharmacologic innovation in obesity care, we must also ensure that we effectively address the mental health of our patients with obesity.

In this article, I’ll share six ways that clinicians can improve mental health care for patients with obesity.
 

Screening

Mental health conditions can look different for everyone. It can be hard to diagnose a mental health condition without validated screening. For example, depression is one of the most common mental health disorders. The U.S. Preventive Services Task Force recommends depression screening in all adults.

The Patient Health Questionnaire-2 (PHQ-2) is one screening tool that can alert doctors and clinicians to potential depression. Patients with obesity have higher rates of depression and other mental health conditions. It’s even more critical to screen for depression and other mental health disorders when prescribing these new medications, given recent reports of suicidal ideation with certain antiobesity medications.
 

Stigma

Mental health–related stigma can trigger shame and prevent patients from seeking psychological help. Furthermore, compounded stigma in patients with larger bodies (weight bias) and from marginalized communities such as the Black community (racial discrimination) add more barriers to seeking mental health care. When patients seek care for mental health conditions, they may feel more comfortable seeing a primary care physician or other clinician than a mental health professional. Therefore, all physicians and clinicians are integral in normalizing mental health care. Instead of treating mental health as separate from physical health, discussing the bidirectional relationship between mental health conditions and physiologic diseases can help patients understand that having a mental health condition isn’t a choice and facilitate openness to multiple treatment options to improve their quality of life.

Support

Addressing mental health effectively often requires multiple layers of patient support. Support can come from loved ones or community groups. But for severe stress and other mental health conditions, treatment with psychotherapy or psychiatric medications is essential. Unfortunately, even if a patient is willing to see a mental health professional, availability or access may be a challenge. Therefore, other clinicians may have to step in and serve as a bridge to mental health care. It’s also essential to ensure that patients are aware of crisis support lines and online resources for mental health care.

Stress

Having a high level of stress can be harmful physically and can also worsen mental health conditions. Additionally, it can contribute to a higher risk for obesity and can trigger emotional eating. Chronic stress has become so common in society that patients often underestimate how much stress they are under. Assessments like the Holmes-Rahe Stress Inventory can help patients identify and quantify potential stressors. While some stressors are uncontrollable, such as social determinants of health (SDOH), addressing controllable stressors and improving coping mechanisms is possible. For instance, mindfulness and breathwork are easy to follow and relatively accessible for most patients.

Social determinants of health

For a treatment plan to be maximally impactful, we must incorporate SDOH in clinical care. SDOH includes financial instability, safe neighborhoods, and more, and can significantly influence an ideal treatment plan. Furthermore, a high SDOH burden can negatively affect mental health and obesity rates. It’s helpful to incorporate patients’ SDOH burden into treatment planning. Learn how to take action on SDOH.

Empowerment

Patients who address their mental health have taken a courageous step toward health and healing. As mentioned, they may experience gaps in care while awaiting connection to the next steps of their journey, such as starting care with a mental health professional or waiting for a medication to take effect. All clinicians can empower patients about their weight by informing them that:

Food may affect their mood. Studies show that certain foods and eating patterns are associated with high levels of depression and anxiety. Limiting processed foods and increasing fruits, vegetables, and foods high in vitamin D, C, and other nutrients is helpful. Everyone is different, so encourage patients to pay attention to how food uniquely affects their mood by keeping a food/feeling log for 1-3 days.

Move more. Increased physical activity can improve mental health.

Get outdoors. Time in nature is associated with better mental health. Spending as little as 10 minutes outside can be beneficial. It’s important to be aware that SDOH factors such as unsafe environments or limited outdoor access may make this difficult for some patients.

Positive stress-relieving activities. Each person has their own way of reducing stress. It is helpful to remind patients of unhealthy stress relievers such as overeating, drinking alcohol, and smoking, and encourage them to replace those with positive stress relievers.

Spiritual well-being. Spirituality is often overlooked in health care. But studies have shown that incorporating a person’s spirituality may have positive health benefits.

It’s time to stop disconnecting mental health from physical health. Each clinician plays a vital role in treating the whole person. Just as you wouldn’t let a patient with a disconnected head leave the office without addressing it, let’s not leave mental health out when addressing our patients’ weight concerns.

Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness,” (Baltimore: Purposely Created Publishing Group, 2019) was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022.

Dr. Gonsahn-Bollie is CEO and Lead Physician, Embrace You Weight and Wellness, Telehealth & Virtual Counseling. She has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

“The patient is ready,” the medical assistant informs you while handing you the chart. The chart reads: “Chief complaint: Weight gain/Discuss weight loss options.” You note the normal vital signs other than an increased BMI to 34 from 4 months ago. You knock on the exam room door with your plan half-formulated.
 

“Come in,” the patient says, almost too softly for you to hear. Shock overtakes you as you enter the room and see something you never imagined. The patient is holding their disconnected head in their lap as they say, “Nice to see you, Doc. I want to do something about my weight.”

You’re baffled at how they are speaking with a disconnected head. Of course, this outlandish patient scenario isn’t real. Or is it?

Patients with mental health concerns don’t literally present with their head disconnected from their bodies. Too often, mental health is treated as separate from physical health, especially regarding weight management and obesity. However, studies have shown an association between mental health and obesity. In this pivotal time of pharmacologic innovation in obesity care, we must also ensure that we effectively address the mental health of our patients with obesity.

In this article, I’ll share six ways that clinicians can improve mental health care for patients with obesity.
 

Screening

Mental health conditions can look different for everyone. It can be hard to diagnose a mental health condition without validated screening. For example, depression is one of the most common mental health disorders. The U.S. Preventive Services Task Force recommends depression screening in all adults.

The Patient Health Questionnaire-2 (PHQ-2) is one screening tool that can alert doctors and clinicians to potential depression. Patients with obesity have higher rates of depression and other mental health conditions. It’s even more critical to screen for depression and other mental health disorders when prescribing these new medications, given recent reports of suicidal ideation with certain antiobesity medications.
 

Stigma

Mental health–related stigma can trigger shame and prevent patients from seeking psychological help. Furthermore, compounded stigma in patients with larger bodies (weight bias) and from marginalized communities such as the Black community (racial discrimination) add more barriers to seeking mental health care. When patients seek care for mental health conditions, they may feel more comfortable seeing a primary care physician or other clinician than a mental health professional. Therefore, all physicians and clinicians are integral in normalizing mental health care. Instead of treating mental health as separate from physical health, discussing the bidirectional relationship between mental health conditions and physiologic diseases can help patients understand that having a mental health condition isn’t a choice and facilitate openness to multiple treatment options to improve their quality of life.

Support

Addressing mental health effectively often requires multiple layers of patient support. Support can come from loved ones or community groups. But for severe stress and other mental health conditions, treatment with psychotherapy or psychiatric medications is essential. Unfortunately, even if a patient is willing to see a mental health professional, availability or access may be a challenge. Therefore, other clinicians may have to step in and serve as a bridge to mental health care. It’s also essential to ensure that patients are aware of crisis support lines and online resources for mental health care.

Stress

Having a high level of stress can be harmful physically and can also worsen mental health conditions. Additionally, it can contribute to a higher risk for obesity and can trigger emotional eating. Chronic stress has become so common in society that patients often underestimate how much stress they are under. Assessments like the Holmes-Rahe Stress Inventory can help patients identify and quantify potential stressors. While some stressors are uncontrollable, such as social determinants of health (SDOH), addressing controllable stressors and improving coping mechanisms is possible. For instance, mindfulness and breathwork are easy to follow and relatively accessible for most patients.

Social determinants of health

For a treatment plan to be maximally impactful, we must incorporate SDOH in clinical care. SDOH includes financial instability, safe neighborhoods, and more, and can significantly influence an ideal treatment plan. Furthermore, a high SDOH burden can negatively affect mental health and obesity rates. It’s helpful to incorporate patients’ SDOH burden into treatment planning. Learn how to take action on SDOH.

Empowerment

Patients who address their mental health have taken a courageous step toward health and healing. As mentioned, they may experience gaps in care while awaiting connection to the next steps of their journey, such as starting care with a mental health professional or waiting for a medication to take effect. All clinicians can empower patients about their weight by informing them that:

Food may affect their mood. Studies show that certain foods and eating patterns are associated with high levels of depression and anxiety. Limiting processed foods and increasing fruits, vegetables, and foods high in vitamin D, C, and other nutrients is helpful. Everyone is different, so encourage patients to pay attention to how food uniquely affects their mood by keeping a food/feeling log for 1-3 days.

Move more. Increased physical activity can improve mental health.

Get outdoors. Time in nature is associated with better mental health. Spending as little as 10 minutes outside can be beneficial. It’s important to be aware that SDOH factors such as unsafe environments or limited outdoor access may make this difficult for some patients.

Positive stress-relieving activities. Each person has their own way of reducing stress. It is helpful to remind patients of unhealthy stress relievers such as overeating, drinking alcohol, and smoking, and encourage them to replace those with positive stress relievers.

Spiritual well-being. Spirituality is often overlooked in health care. But studies have shown that incorporating a person’s spirituality may have positive health benefits.

It’s time to stop disconnecting mental health from physical health. Each clinician plays a vital role in treating the whole person. Just as you wouldn’t let a patient with a disconnected head leave the office without addressing it, let’s not leave mental health out when addressing our patients’ weight concerns.

Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness,” (Baltimore: Purposely Created Publishing Group, 2019) was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022.

Dr. Gonsahn-Bollie is CEO and Lead Physician, Embrace You Weight and Wellness, Telehealth & Virtual Counseling. She has disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Nonalcohol substance use disorder (SUD) was 2.5 times more common in people who had gastric bypass surgery, compared with a control group who received usual obesity care, a new prospective study has found.

The findings suggest that the risk for nonalcohol SUD should be carefully explained to patients getting a gastric bypass and that the risk should be considered in care before and after the surgery, said the study authors and editorialists.

Though alcohol use disorder is a well-known side effect for some bariatric procedures, little is known about the link between the procedures and other substance abuse, wrote the study authors, led by Per-Arne Svensson, PhD, with the department of molecular and clinical medicine, Institute of Medicine, at the University of Gothenburg (Sweden).

The study was published online in Obesity.

The researchers analyzed data from the SOS study. It was originally designed to compare bariatric surgery with usual obesity care, with overall mortality as the primary outcome. The protocol also called for reporting negative effects of included treatments.

The study was conducted throughout Sweden at 25 public surgical departments and 480 primary health centers. Participants were between ages 37 and 60 years and had a body mass index of at least 34 kg/m² for men and 38 for women.

After people with previous nonalcoholic SUD were excluded, the study population included 1,990 patients who had undergone bariatric surgery between September 1987 and January 2001, as well as 2,030 matched controls who received usual obesity care. The three types of bariatric surgery were gastric bypass (264 patients), vertical banded gastroplasty (1,353), and gastric banding (373), as chosen by the surgeons.

The follow-up was nearly 24 years.
 

Link found only with gastric bypass

The researchers identified participants who had nonalcoholic SUDs using the ICD from the Swedish National Patient Register covering hospital treatment (hospital stays or hospital-based outpatient care) but not primary care.

Only gastric bypass was associated with an increased incidence of nonalcoholic SUD (adjusted hazard ratio, 2.54; 95% confidence interval, 1.14-5.65), compared with controls during the follow-up period.

Among those who had gastric bypass surgery, three developed opioid-related disorders; three had sedative-, hypnotic-, or anxiolytic-related disorders; and three had other psychoactive substance–related disorders, the study authors wrote.

The researchers found no statistical difference in the incidence of nonalcoholic SUD when the groups who had undergone different surgical procedures were compared with each other.

“It is important to acknowledge that the number of affected patients was relatively low, in the single digits,” Jihad Kudsi, MD, a bariatric surgeon and chairman of surgery at Duly Health and Care, Oak Brook, Ill., said in a press release.

The findings “highlight the critical role of bariatric behavioral health clinicians in the comprehensive evaluation and care of patients both before and after weight loss surgery,” added Dr. Kudsi, who was not associated with the research.
 

Bariatric surgery candidates should be warned, monitored

The data indicate that patients who are candidates for bariatric surgery should be “carefully warned” about risks for nonalcoholic SUD and be monitored after the procedure, wrote James E. Mitchell, MD, a psychiatrist with the department of psychiatry and behavioral science, University of North Dakota, Fargo, and Devika Umashanker, MD, with Obesity Medicine, Hartford (Conn.) Health Care, in an accompanying editorial.

They acknowledged, however, that monitoring can be difficult given the typical low rate of follow-up of these patients.

Though the reasons for the rise in nonalcoholic SUD are not clear, Dr. Mitchell and Dr. Umashanker said biologic and psychosocial issues may be contributors to the increase.

The persistence of medical comorbidities and a lack of noted improvement in quality of life or physical mobility after the surgery has been addressed in a paper on suicide risk after bariatric surgery, the study authors also noted.

Dr. Svensson said in an interview that a mechanism for alcohol abuse after gastric bypass surgery is more evident, as measured by “increased blood alcohol levels after the surgery for a given amount of alcohol.” However, for other addictive substances, the mechanism is not obvious and needs further study.

The editorialists reminded clinicians that measuring phosphatidylethanol can be very useful in identifying and quantifying recent alcohol intake, suggesting that all clinicians, not just those in bariatric surgery clinics, should be aware of the connection between the procedures and subsequent alcohol abuse and monitor those patients carefully.

Both the study authors and the editorialists pointed out that the SOS cohort was recruited when vertical banded gastroplasty and banding were commonly used, and both methods are now rarely, if ever, used. Gastric sleeve procedures are now the most common approach, and those patients were not included in the study.

“However, gastric bypass surgery patients were included, albeit in a minority of the sample,” Dr. Mitchell and Dr. Umashanker wrote. In addition, the sample size of patients with SUD was too small to determine the drugs that were being abused.

Dr. Svensson said in an interview the main limitation is that SUD events were identified in the Swedish National Patient Register, which misses nonhospitalized patients.

“This register is very complete for hospitals, but it does not include SUD events detected in the primary health care setting,” he said. “Hence, the absolute number of events is probably a clear underestimation. However, it is unlikely that this limitation would affect the study groups (control group vs. groups with different surgical procedures) in different ways and hence the conclusions from this study are most likely valid.”

The study authors and the editorialists reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Nonalcohol substance use disorder (SUD) was 2.5 times more common in people who had gastric bypass surgery, compared with a control group who received usual obesity care, a new prospective study has found.

The findings suggest that the risk for nonalcohol SUD should be carefully explained to patients getting a gastric bypass and that the risk should be considered in care before and after the surgery, said the study authors and editorialists.

Though alcohol use disorder is a well-known side effect for some bariatric procedures, little is known about the link between the procedures and other substance abuse, wrote the study authors, led by Per-Arne Svensson, PhD, with the department of molecular and clinical medicine, Institute of Medicine, at the University of Gothenburg (Sweden).

The study was published online in Obesity.

The researchers analyzed data from the SOS study. It was originally designed to compare bariatric surgery with usual obesity care, with overall mortality as the primary outcome. The protocol also called for reporting negative effects of included treatments.

The study was conducted throughout Sweden at 25 public surgical departments and 480 primary health centers. Participants were between ages 37 and 60 years and had a body mass index of at least 34 kg/m² for men and 38 for women.

After people with previous nonalcoholic SUD were excluded, the study population included 1,990 patients who had undergone bariatric surgery between September 1987 and January 2001, as well as 2,030 matched controls who received usual obesity care. The three types of bariatric surgery were gastric bypass (264 patients), vertical banded gastroplasty (1,353), and gastric banding (373), as chosen by the surgeons.

The follow-up was nearly 24 years.
 

Link found only with gastric bypass

The researchers identified participants who had nonalcoholic SUDs using the ICD from the Swedish National Patient Register covering hospital treatment (hospital stays or hospital-based outpatient care) but not primary care.

Only gastric bypass was associated with an increased incidence of nonalcoholic SUD (adjusted hazard ratio, 2.54; 95% confidence interval, 1.14-5.65), compared with controls during the follow-up period.

Among those who had gastric bypass surgery, three developed opioid-related disorders; three had sedative-, hypnotic-, or anxiolytic-related disorders; and three had other psychoactive substance–related disorders, the study authors wrote.

The researchers found no statistical difference in the incidence of nonalcoholic SUD when the groups who had undergone different surgical procedures were compared with each other.

“It is important to acknowledge that the number of affected patients was relatively low, in the single digits,” Jihad Kudsi, MD, a bariatric surgeon and chairman of surgery at Duly Health and Care, Oak Brook, Ill., said in a press release.

The findings “highlight the critical role of bariatric behavioral health clinicians in the comprehensive evaluation and care of patients both before and after weight loss surgery,” added Dr. Kudsi, who was not associated with the research.
 

Bariatric surgery candidates should be warned, monitored

The data indicate that patients who are candidates for bariatric surgery should be “carefully warned” about risks for nonalcoholic SUD and be monitored after the procedure, wrote James E. Mitchell, MD, a psychiatrist with the department of psychiatry and behavioral science, University of North Dakota, Fargo, and Devika Umashanker, MD, with Obesity Medicine, Hartford (Conn.) Health Care, in an accompanying editorial.

They acknowledged, however, that monitoring can be difficult given the typical low rate of follow-up of these patients.

Though the reasons for the rise in nonalcoholic SUD are not clear, Dr. Mitchell and Dr. Umashanker said biologic and psychosocial issues may be contributors to the increase.

The persistence of medical comorbidities and a lack of noted improvement in quality of life or physical mobility after the surgery has been addressed in a paper on suicide risk after bariatric surgery, the study authors also noted.

Dr. Svensson said in an interview that a mechanism for alcohol abuse after gastric bypass surgery is more evident, as measured by “increased blood alcohol levels after the surgery for a given amount of alcohol.” However, for other addictive substances, the mechanism is not obvious and needs further study.

The editorialists reminded clinicians that measuring phosphatidylethanol can be very useful in identifying and quantifying recent alcohol intake, suggesting that all clinicians, not just those in bariatric surgery clinics, should be aware of the connection between the procedures and subsequent alcohol abuse and monitor those patients carefully.

Both the study authors and the editorialists pointed out that the SOS cohort was recruited when vertical banded gastroplasty and banding were commonly used, and both methods are now rarely, if ever, used. Gastric sleeve procedures are now the most common approach, and those patients were not included in the study.

“However, gastric bypass surgery patients were included, albeit in a minority of the sample,” Dr. Mitchell and Dr. Umashanker wrote. In addition, the sample size of patients with SUD was too small to determine the drugs that were being abused.

Dr. Svensson said in an interview the main limitation is that SUD events were identified in the Swedish National Patient Register, which misses nonhospitalized patients.

“This register is very complete for hospitals, but it does not include SUD events detected in the primary health care setting,” he said. “Hence, the absolute number of events is probably a clear underestimation. However, it is unlikely that this limitation would affect the study groups (control group vs. groups with different surgical procedures) in different ways and hence the conclusions from this study are most likely valid.”

The study authors and the editorialists reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Nonalcohol substance use disorder (SUD) was 2.5 times more common in people who had gastric bypass surgery, compared with a control group who received usual obesity care, a new prospective study has found.

The findings suggest that the risk for nonalcohol SUD should be carefully explained to patients getting a gastric bypass and that the risk should be considered in care before and after the surgery, said the study authors and editorialists.

Though alcohol use disorder is a well-known side effect for some bariatric procedures, little is known about the link between the procedures and other substance abuse, wrote the study authors, led by Per-Arne Svensson, PhD, with the department of molecular and clinical medicine, Institute of Medicine, at the University of Gothenburg (Sweden).

The study was published online in Obesity.

The researchers analyzed data from the SOS study. It was originally designed to compare bariatric surgery with usual obesity care, with overall mortality as the primary outcome. The protocol also called for reporting negative effects of included treatments.

The study was conducted throughout Sweden at 25 public surgical departments and 480 primary health centers. Participants were between ages 37 and 60 years and had a body mass index of at least 34 kg/m² for men and 38 for women.

After people with previous nonalcoholic SUD were excluded, the study population included 1,990 patients who had undergone bariatric surgery between September 1987 and January 2001, as well as 2,030 matched controls who received usual obesity care. The three types of bariatric surgery were gastric bypass (264 patients), vertical banded gastroplasty (1,353), and gastric banding (373), as chosen by the surgeons.

The follow-up was nearly 24 years.
 

Link found only with gastric bypass

The researchers identified participants who had nonalcoholic SUDs using the ICD from the Swedish National Patient Register covering hospital treatment (hospital stays or hospital-based outpatient care) but not primary care.

Only gastric bypass was associated with an increased incidence of nonalcoholic SUD (adjusted hazard ratio, 2.54; 95% confidence interval, 1.14-5.65), compared with controls during the follow-up period.

Among those who had gastric bypass surgery, three developed opioid-related disorders; three had sedative-, hypnotic-, or anxiolytic-related disorders; and three had other psychoactive substance–related disorders, the study authors wrote.

The researchers found no statistical difference in the incidence of nonalcoholic SUD when the groups who had undergone different surgical procedures were compared with each other.

“It is important to acknowledge that the number of affected patients was relatively low, in the single digits,” Jihad Kudsi, MD, a bariatric surgeon and chairman of surgery at Duly Health and Care, Oak Brook, Ill., said in a press release.

The findings “highlight the critical role of bariatric behavioral health clinicians in the comprehensive evaluation and care of patients both before and after weight loss surgery,” added Dr. Kudsi, who was not associated with the research.
 

Bariatric surgery candidates should be warned, monitored

The data indicate that patients who are candidates for bariatric surgery should be “carefully warned” about risks for nonalcoholic SUD and be monitored after the procedure, wrote James E. Mitchell, MD, a psychiatrist with the department of psychiatry and behavioral science, University of North Dakota, Fargo, and Devika Umashanker, MD, with Obesity Medicine, Hartford (Conn.) Health Care, in an accompanying editorial.

They acknowledged, however, that monitoring can be difficult given the typical low rate of follow-up of these patients.

Though the reasons for the rise in nonalcoholic SUD are not clear, Dr. Mitchell and Dr. Umashanker said biologic and psychosocial issues may be contributors to the increase.

The persistence of medical comorbidities and a lack of noted improvement in quality of life or physical mobility after the surgery has been addressed in a paper on suicide risk after bariatric surgery, the study authors also noted.

Dr. Svensson said in an interview that a mechanism for alcohol abuse after gastric bypass surgery is more evident, as measured by “increased blood alcohol levels after the surgery for a given amount of alcohol.” However, for other addictive substances, the mechanism is not obvious and needs further study.

The editorialists reminded clinicians that measuring phosphatidylethanol can be very useful in identifying and quantifying recent alcohol intake, suggesting that all clinicians, not just those in bariatric surgery clinics, should be aware of the connection between the procedures and subsequent alcohol abuse and monitor those patients carefully.

Both the study authors and the editorialists pointed out that the SOS cohort was recruited when vertical banded gastroplasty and banding were commonly used, and both methods are now rarely, if ever, used. Gastric sleeve procedures are now the most common approach, and those patients were not included in the study.

“However, gastric bypass surgery patients were included, albeit in a minority of the sample,” Dr. Mitchell and Dr. Umashanker wrote. In addition, the sample size of patients with SUD was too small to determine the drugs that were being abused.

Dr. Svensson said in an interview the main limitation is that SUD events were identified in the Swedish National Patient Register, which misses nonhospitalized patients.

“This register is very complete for hospitals, but it does not include SUD events detected in the primary health care setting,” he said. “Hence, the absolute number of events is probably a clear underestimation. However, it is unlikely that this limitation would affect the study groups (control group vs. groups with different surgical procedures) in different ways and hence the conclusions from this study are most likely valid.”

The study authors and the editorialists reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

SAN DIEGO – Bariatric surgery produced sustained, long-term glucose control and weight loss for at least 7 years, and for up to 12 years, in some U.S. patients with type 2 diabetes and a baseline body mass index (BMI) of at least 27 kg/m², according to new study results.

The findings are from ARMMS-T2D, a prospective, controlled trial with the largest cohort and longest follow-up of bariatric surgery reported to date. The results reinforce the potential role of surgery “as an option to improve diabetes-related outcomes, including people with a BMI of less than 35 kg/m²,” said Anita P. Courcoulas, MD, at the recent annual scientific sessions of the American Diabetes Association.

People who underwent bariatric surgery (gastric band, sleeve gastrectomy, or Roux-en-Y gastric bypass) had an average 1.6–percentage point drop in hemoglobin A1c from baseline 7 years after surgery and an average 1.4–percentage point reduction from baseline after 12 years. Average decreases from baseline were 0.2 and 0.3 percentage points at these time points, respectively, among controls who underwent lifestyle and medical interventions only. Between-group differences were significant at both the 7-year (primary endpoint) and 12-year time points in the intention-to-treat analysis, reported Dr. Courcoulas, a professor of surgery at the University of Pittsburgh.

Average weight loss from baseline to 7 and 12 years was 19.9% and 19.3%, respectively, in the surgery group and 8.3% and 10.8%, respectively, among controls, which was significantly different between groups at both time points (a secondary endpoint).

Dr. Courcoulas highlighted that the 10.8% average weight loss after 12 years among controls included crossovers, with 25% of patients progressing from their initial intervention of lifestyle and medical management to undergoing bariatric surgery during follow-up. Among the controls who never underwent surgery (per-protocol analysis), the 12-year average weight loss from baseline was 7.3%.
 

High-dose incretin-hormone therapy missing

A major limitation of ARMMS-T2D (Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes) is that it prospectively followed a combined cohort from four independently run controlled U.S. trials that all began more than a decade ago, before the contemporary era of medical weight loss management that’s been revolutionized by incretin-hormone receptor agonists such as semaglutide (Ozempic/Wegovy, Novo Nordisk) and tirzepatide (Mounjaro, Lilly).

New randomized, controlled trials “are needed” that compare metabolic bariatric surgery with medical and lifestyle management that includes “high-dose incretin-hormone therapy,” commented Robert H. Eckel, MD, designated discussant for ARMMS-T2D at the session.

The results also showed notable rates of two adverse events associated with bariatric surgery: a 14% incidence of bone fractures, compared with a rate of 5% among controls, and a 12% incidence of anemia after surgery, compared with a rate of 3% among controls.

The control group also had a significantly higher 3% incidence of new need for hemodialysis, compared with no incident dialysis cases among the surgery patients.

“The fracture difference [after bariatric surgery] needs more careful follow-up,” commented Dr. Eckel, an endocrinologist and emeritus professor at the University of Colorado at Denver, Aurora.

ARMMS-T2D included data from 262 people with overweight or obesity and type 2 diabetes randomized in any of four U.S. studies that compared the outcomes of 166 patients who underwent bariatric surgery with 96 patients who served as controls and had lifestyle and medical interventions for weight loss and glycemic control. Seven-year follow-up included 82 (85%) of the initial 96 control patients and 136 (82%) of the initial 166 surgery patients. After 12 years, 31 of the controls (32%) and 83 surgery patients (50%) remained for the A1c analysis.
 

A quartet of studies joined together

The ARMMS-T2D prospective analysis resulted from an early partnership by the organizers of the four independent randomized studies that compared bariatric surgery with lifestyle and medical intervention in people with type 2 diabetes and overweight or obesity: STAMPEDE, which included 150 people at the Cleveland Clinic starting in 2007; SLIMM-T2D, which included 88 people at Brigham and Women’s Hospital and the Joslin Diabetes Center in Boston starting in 2010; TRIABETES, which included 69 people at the University of Pittsburgh starting in 2009; and CROSSROADS, which included 43 people at the University of Washington, Seattle, starting in 2011.

Further secondary findings from the ARMMS-T2D analyses showed that 38% of the surgery patients and 17% of controls had an A1c < 6.5% after 7 years.

At 7 years, type 2 diabetes remission, defined as those with an A1c < 6.5% who were not taking any antidiabetes medications, was reached in 18% of surgery patients and 6% of controls. At 12 years, 13% of the surgery patients and none of the controls met this metric, Dr. Courcoulas said.

The duration of diabetes a person had before undergoing bariatric surgery “may be an important factor” as to whether patients undergo remission, suggested Dr. Eckel. He noted that longer duration type 2 diabetes usually results in increased glucose intolerance and makes remission less likely

Roux-en-Y gastric bypass appeared to have the best rates of patients achieving both lower A1c levels and more weight loss, followed by sleeve gastrectomy and gastric banding, which had the worst performance. But Dr. Courcoulas cautioned that the study was underpowered to reliably compare individual surgical procedures.

In terms of those with an A1c < 7.0%, surgery patients maintained a steady prevalence rate of about 55% during the first 5 years of follow-up, roughly twice the rate of controls, at 28% during all years of follow-up starting at year 5.

About 37% of enrolled patients had a BMI < 35 kg/m², and the A1c-lowering benefit and weight loss in this subgroup were consistent with the overall findings, which supports consideration of bariatric surgery for people with type 2 diabetes and a BMI < 35 kg/m², Dr. Courcoulas said.

She also highlighted that bariatric surgery was linked with significant reductions in triglyceride levels and increased high-density lipoprotein cholesterol levels, compared with controls. However, 22% of surgery patients experienced abdominal pain, compared with 10% of controls, and 7% experienced dysphagia, compared with no cases among the controls.

ARMMS-T2D received no commercial funding. Dr. Courcoulas had no disclosures. Dr. Eckel has been a consultant to numerous companies but said he had no relevant disclosures.

A version of this article first appeared on Medscape.com.

SAN DIEGO – Bariatric surgery produced sustained, long-term glucose control and weight loss for at least 7 years, and for up to 12 years, in some U.S. patients with type 2 diabetes and a baseline body mass index (BMI) of at least 27 kg/m², according to new study results.

The findings are from ARMMS-T2D, a prospective, controlled trial with the largest cohort and longest follow-up of bariatric surgery reported to date. The results reinforce the potential role of surgery “as an option to improve diabetes-related outcomes, including people with a BMI of less than 35 kg/m²,” said Anita P. Courcoulas, MD, at the recent annual scientific sessions of the American Diabetes Association.

People who underwent bariatric surgery (gastric band, sleeve gastrectomy, or Roux-en-Y gastric bypass) had an average 1.6–percentage point drop in hemoglobin A1c from baseline 7 years after surgery and an average 1.4–percentage point reduction from baseline after 12 years. Average decreases from baseline were 0.2 and 0.3 percentage points at these time points, respectively, among controls who underwent lifestyle and medical interventions only. Between-group differences were significant at both the 7-year (primary endpoint) and 12-year time points in the intention-to-treat analysis, reported Dr. Courcoulas, a professor of surgery at the University of Pittsburgh.

Average weight loss from baseline to 7 and 12 years was 19.9% and 19.3%, respectively, in the surgery group and 8.3% and 10.8%, respectively, among controls, which was significantly different between groups at both time points (a secondary endpoint).

Dr. Courcoulas highlighted that the 10.8% average weight loss after 12 years among controls included crossovers, with 25% of patients progressing from their initial intervention of lifestyle and medical management to undergoing bariatric surgery during follow-up. Among the controls who never underwent surgery (per-protocol analysis), the 12-year average weight loss from baseline was 7.3%.
 

High-dose incretin-hormone therapy missing

A major limitation of ARMMS-T2D (Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes) is that it prospectively followed a combined cohort from four independently run controlled U.S. trials that all began more than a decade ago, before the contemporary era of medical weight loss management that’s been revolutionized by incretin-hormone receptor agonists such as semaglutide (Ozempic/Wegovy, Novo Nordisk) and tirzepatide (Mounjaro, Lilly).

New randomized, controlled trials “are needed” that compare metabolic bariatric surgery with medical and lifestyle management that includes “high-dose incretin-hormone therapy,” commented Robert H. Eckel, MD, designated discussant for ARMMS-T2D at the session.

The results also showed notable rates of two adverse events associated with bariatric surgery: a 14% incidence of bone fractures, compared with a rate of 5% among controls, and a 12% incidence of anemia after surgery, compared with a rate of 3% among controls.

The control group also had a significantly higher 3% incidence of new need for hemodialysis, compared with no incident dialysis cases among the surgery patients.

“The fracture difference [after bariatric surgery] needs more careful follow-up,” commented Dr. Eckel, an endocrinologist and emeritus professor at the University of Colorado at Denver, Aurora.

ARMMS-T2D included data from 262 people with overweight or obesity and type 2 diabetes randomized in any of four U.S. studies that compared the outcomes of 166 patients who underwent bariatric surgery with 96 patients who served as controls and had lifestyle and medical interventions for weight loss and glycemic control. Seven-year follow-up included 82 (85%) of the initial 96 control patients and 136 (82%) of the initial 166 surgery patients. After 12 years, 31 of the controls (32%) and 83 surgery patients (50%) remained for the A1c analysis.
 

A quartet of studies joined together

The ARMMS-T2D prospective analysis resulted from an early partnership by the organizers of the four independent randomized studies that compared bariatric surgery with lifestyle and medical intervention in people with type 2 diabetes and overweight or obesity: STAMPEDE, which included 150 people at the Cleveland Clinic starting in 2007; SLIMM-T2D, which included 88 people at Brigham and Women’s Hospital and the Joslin Diabetes Center in Boston starting in 2010; TRIABETES, which included 69 people at the University of Pittsburgh starting in 2009; and CROSSROADS, which included 43 people at the University of Washington, Seattle, starting in 2011.

Further secondary findings from the ARMMS-T2D analyses showed that 38% of the surgery patients and 17% of controls had an A1c < 6.5% after 7 years.

At 7 years, type 2 diabetes remission, defined as those with an A1c < 6.5% who were not taking any antidiabetes medications, was reached in 18% of surgery patients and 6% of controls. At 12 years, 13% of the surgery patients and none of the controls met this metric, Dr. Courcoulas said.

The duration of diabetes a person had before undergoing bariatric surgery “may be an important factor” as to whether patients undergo remission, suggested Dr. Eckel. He noted that longer duration type 2 diabetes usually results in increased glucose intolerance and makes remission less likely

Roux-en-Y gastric bypass appeared to have the best rates of patients achieving both lower A1c levels and more weight loss, followed by sleeve gastrectomy and gastric banding, which had the worst performance. But Dr. Courcoulas cautioned that the study was underpowered to reliably compare individual surgical procedures.

In terms of those with an A1c < 7.0%, surgery patients maintained a steady prevalence rate of about 55% during the first 5 years of follow-up, roughly twice the rate of controls, at 28% during all years of follow-up starting at year 5.

About 37% of enrolled patients had a BMI < 35 kg/m², and the A1c-lowering benefit and weight loss in this subgroup were consistent with the overall findings, which supports consideration of bariatric surgery for people with type 2 diabetes and a BMI < 35 kg/m², Dr. Courcoulas said.

She also highlighted that bariatric surgery was linked with significant reductions in triglyceride levels and increased high-density lipoprotein cholesterol levels, compared with controls. However, 22% of surgery patients experienced abdominal pain, compared with 10% of controls, and 7% experienced dysphagia, compared with no cases among the controls.

ARMMS-T2D received no commercial funding. Dr. Courcoulas had no disclosures. Dr. Eckel has been a consultant to numerous companies but said he had no relevant disclosures.

A version of this article first appeared on Medscape.com.

SAN DIEGO – Bariatric surgery produced sustained, long-term glucose control and weight loss for at least 7 years, and for up to 12 years, in some U.S. patients with type 2 diabetes and a baseline body mass index (BMI) of at least 27 kg/m², according to new study results.

The findings are from ARMMS-T2D, a prospective, controlled trial with the largest cohort and longest follow-up of bariatric surgery reported to date. The results reinforce the potential role of surgery “as an option to improve diabetes-related outcomes, including people with a BMI of less than 35 kg/m²,” said Anita P. Courcoulas, MD, at the recent annual scientific sessions of the American Diabetes Association.

People who underwent bariatric surgery (gastric band, sleeve gastrectomy, or Roux-en-Y gastric bypass) had an average 1.6–percentage point drop in hemoglobin A1c from baseline 7 years after surgery and an average 1.4–percentage point reduction from baseline after 12 years. Average decreases from baseline were 0.2 and 0.3 percentage points at these time points, respectively, among controls who underwent lifestyle and medical interventions only. Between-group differences were significant at both the 7-year (primary endpoint) and 12-year time points in the intention-to-treat analysis, reported Dr. Courcoulas, a professor of surgery at the University of Pittsburgh.

Average weight loss from baseline to 7 and 12 years was 19.9% and 19.3%, respectively, in the surgery group and 8.3% and 10.8%, respectively, among controls, which was significantly different between groups at both time points (a secondary endpoint).

Dr. Courcoulas highlighted that the 10.8% average weight loss after 12 years among controls included crossovers, with 25% of patients progressing from their initial intervention of lifestyle and medical management to undergoing bariatric surgery during follow-up. Among the controls who never underwent surgery (per-protocol analysis), the 12-year average weight loss from baseline was 7.3%.
 

High-dose incretin-hormone therapy missing

A major limitation of ARMMS-T2D (Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes) is that it prospectively followed a combined cohort from four independently run controlled U.S. trials that all began more than a decade ago, before the contemporary era of medical weight loss management that’s been revolutionized by incretin-hormone receptor agonists such as semaglutide (Ozempic/Wegovy, Novo Nordisk) and tirzepatide (Mounjaro, Lilly).

New randomized, controlled trials “are needed” that compare metabolic bariatric surgery with medical and lifestyle management that includes “high-dose incretin-hormone therapy,” commented Robert H. Eckel, MD, designated discussant for ARMMS-T2D at the session.

The results also showed notable rates of two adverse events associated with bariatric surgery: a 14% incidence of bone fractures, compared with a rate of 5% among controls, and a 12% incidence of anemia after surgery, compared with a rate of 3% among controls.

The control group also had a significantly higher 3% incidence of new need for hemodialysis, compared with no incident dialysis cases among the surgery patients.

“The fracture difference [after bariatric surgery] needs more careful follow-up,” commented Dr. Eckel, an endocrinologist and emeritus professor at the University of Colorado at Denver, Aurora.

ARMMS-T2D included data from 262 people with overweight or obesity and type 2 diabetes randomized in any of four U.S. studies that compared the outcomes of 166 patients who underwent bariatric surgery with 96 patients who served as controls and had lifestyle and medical interventions for weight loss and glycemic control. Seven-year follow-up included 82 (85%) of the initial 96 control patients and 136 (82%) of the initial 166 surgery patients. After 12 years, 31 of the controls (32%) and 83 surgery patients (50%) remained for the A1c analysis.
 

A quartet of studies joined together

The ARMMS-T2D prospective analysis resulted from an early partnership by the organizers of the four independent randomized studies that compared bariatric surgery with lifestyle and medical intervention in people with type 2 diabetes and overweight or obesity: STAMPEDE, which included 150 people at the Cleveland Clinic starting in 2007; SLIMM-T2D, which included 88 people at Brigham and Women’s Hospital and the Joslin Diabetes Center in Boston starting in 2010; TRIABETES, which included 69 people at the University of Pittsburgh starting in 2009; and CROSSROADS, which included 43 people at the University of Washington, Seattle, starting in 2011.

Further secondary findings from the ARMMS-T2D analyses showed that 38% of the surgery patients and 17% of controls had an A1c < 6.5% after 7 years.

At 7 years, type 2 diabetes remission, defined as those with an A1c < 6.5% who were not taking any antidiabetes medications, was reached in 18% of surgery patients and 6% of controls. At 12 years, 13% of the surgery patients and none of the controls met this metric, Dr. Courcoulas said.

The duration of diabetes a person had before undergoing bariatric surgery “may be an important factor” as to whether patients undergo remission, suggested Dr. Eckel. He noted that longer duration type 2 diabetes usually results in increased glucose intolerance and makes remission less likely

Roux-en-Y gastric bypass appeared to have the best rates of patients achieving both lower A1c levels and more weight loss, followed by sleeve gastrectomy and gastric banding, which had the worst performance. But Dr. Courcoulas cautioned that the study was underpowered to reliably compare individual surgical procedures.

In terms of those with an A1c < 7.0%, surgery patients maintained a steady prevalence rate of about 55% during the first 5 years of follow-up, roughly twice the rate of controls, at 28% during all years of follow-up starting at year 5.

About 37% of enrolled patients had a BMI < 35 kg/m², and the A1c-lowering benefit and weight loss in this subgroup were consistent with the overall findings, which supports consideration of bariatric surgery for people with type 2 diabetes and a BMI < 35 kg/m², Dr. Courcoulas said.

She also highlighted that bariatric surgery was linked with significant reductions in triglyceride levels and increased high-density lipoprotein cholesterol levels, compared with controls. However, 22% of surgery patients experienced abdominal pain, compared with 10% of controls, and 7% experienced dysphagia, compared with no cases among the controls.

ARMMS-T2D received no commercial funding. Dr. Courcoulas had no disclosures. Dr. Eckel has been a consultant to numerous companies but said he had no relevant disclosures.

A version of this article first appeared on Medscape.com.

Continuous glucose monitors (CGMs) may help curb the severity of hypoglycemia after weight loss operations and even other gastrointestinal procedures, according to recent findings from a small study published in Diabetes, Obesity, and Metabolism.

Hypoglycemia is a chronic and persistent complication common in patients following bariatric surgery, affecting as many as 30% of people who undergo a sleeve gastrectomy or Roux-en-Y gastric bypass.

The symptoms of hypoglycemia, including lightheadedness, heart palpitations, difficulty concentrating, and confusion, can mimic anxiety disorders, arrhythmia, and dumping syndrome.

If a postoperative patient experiences these symptoms within a few hours following a meal or exercising, “primary care doctors should consider the possibility that hypoglycemia may be a contributor,” said Mary-Elizabeth Patti, MD, director of the Hypoglycemia Clinic at the Joslin Diabetes Center in Boston and senior author of the new study. 

“In fact, hypoglycemia is a possible diagnosis even among those who underwent [operations other than bariatric, including] fundoplication or other upper gastrointestinal or esophageal surgeries,” she said. 

To understand how CGM could benefit patients, Dr. Patti and colleagues recruited 22 participants who had undergone bariatric surgery more than 8 years prior and had postbariatric hypoglycemia. Their mean age was 51 years, 90% were women, 82% were diagnosed with level 3 hypoglycemia, and none had type 1 or 2 diabetes. 

All participants experienced neuronal dysfunction with symptoms like fatigue, concentration difficulties, and confusion. More than 90% had received medical nutrition therapy for postbariatric hypoglycemia in the past.

CGM data were collected in the 22 individuals in two sequential phases: masked (no access to sensor glucose or alarms) and unmasked (access to sensor glucose and alarms for low or rapidly declining sensor glucose). Twelve participants wore a CGM (Dexcom G4 device) for a total of 28 days, whereas 10 wore a CGM (the Dexcom G6 device) for a total of 20 days.

The team observed that the percentage of time when the participants’ blood glucose was below 70 mg/dL – the definition of hypoglycemia – was significantly lower during the unmasked phase. 

Though CGM devices are not sensitive enough to serve as a diagnostic tool for hypoglycemia, “the alarms on CGM devices can provide some much-needed awareness,” Dr. Patti said. “After a detailed diagnosis, CGM devices can be a helpful tool to assess dietary patterns and make modifications that could reduce the severity of postbariatric hypoglycemia.”

If a patient frequently experiences hypoglycemia, they may not sense when their glucose levels drop, also known as hypoglycemia unawareness, according to Dr. Patti. Studies have found that postbariatric hypoglycemia remains underdiagnosed because most patients are asymptomatic. 

“The use of CGM devices may improve safety in postbariatric hypoglycemia, particularly for patients with hypoglycemia unawareness,” the researchers conclude.
 

Next steps 

Patients are more vulnerable to hypoglycemia after a sleeve gastrectomy or gastric bypass surgery because these procedures involve removing the pylorus. This valve plays a crucial role in only allowing small portions of food to enter the intestine and prevents sudden spikes in blood glucose.

Without the pylorus, large amounts of food directly enter the intestine and soon result in large amounts of glucose getting absorbed, according to Sriram Machineni, MD, an associate professor of medicine at Albert Einstein College of Medicine, New York, who was not affiliated with the study.

“The pancreas then goes into overdrive and produces a lot of insulin, which continues reducing sugar levels,” Dr. Machineni said. “That is what causes hypoglycemia.”

Dr. Patti and associates are next working on research using CGM-derived data to investigate how different types of meals, physical activities, and other factors could influence glucose metabolism patterns in patients with hypoglycemia.

The study was funded by Dexcom, a manufacturer of continuous glucose monitoring systems. Dr. Patti reported receiving grant funding from the Diabetes Research Center.

A version of this article appeared on Medscape.com.

Continuous glucose monitors (CGMs) may help curb the severity of hypoglycemia after weight loss operations and even other gastrointestinal procedures, according to recent findings from a small study published in Diabetes, Obesity, and Metabolism.

Hypoglycemia is a chronic and persistent complication common in patients following bariatric surgery, affecting as many as 30% of people who undergo a sleeve gastrectomy or Roux-en-Y gastric bypass.

The symptoms of hypoglycemia, including lightheadedness, heart palpitations, difficulty concentrating, and confusion, can mimic anxiety disorders, arrhythmia, and dumping syndrome.

If a postoperative patient experiences these symptoms within a few hours following a meal or exercising, “primary care doctors should consider the possibility that hypoglycemia may be a contributor,” said Mary-Elizabeth Patti, MD, director of the Hypoglycemia Clinic at the Joslin Diabetes Center in Boston and senior author of the new study. 

“In fact, hypoglycemia is a possible diagnosis even among those who underwent [operations other than bariatric, including] fundoplication or other upper gastrointestinal or esophageal surgeries,” she said. 

To understand how CGM could benefit patients, Dr. Patti and colleagues recruited 22 participants who had undergone bariatric surgery more than 8 years prior and had postbariatric hypoglycemia. Their mean age was 51 years, 90% were women, 82% were diagnosed with level 3 hypoglycemia, and none had type 1 or 2 diabetes. 

All participants experienced neuronal dysfunction with symptoms like fatigue, concentration difficulties, and confusion. More than 90% had received medical nutrition therapy for postbariatric hypoglycemia in the past.

CGM data were collected in the 22 individuals in two sequential phases: masked (no access to sensor glucose or alarms) and unmasked (access to sensor glucose and alarms for low or rapidly declining sensor glucose). Twelve participants wore a CGM (Dexcom G4 device) for a total of 28 days, whereas 10 wore a CGM (the Dexcom G6 device) for a total of 20 days.

The team observed that the percentage of time when the participants’ blood glucose was below 70 mg/dL – the definition of hypoglycemia – was significantly lower during the unmasked phase. 

Though CGM devices are not sensitive enough to serve as a diagnostic tool for hypoglycemia, “the alarms on CGM devices can provide some much-needed awareness,” Dr. Patti said. “After a detailed diagnosis, CGM devices can be a helpful tool to assess dietary patterns and make modifications that could reduce the severity of postbariatric hypoglycemia.”

If a patient frequently experiences hypoglycemia, they may not sense when their glucose levels drop, also known as hypoglycemia unawareness, according to Dr. Patti. Studies have found that postbariatric hypoglycemia remains underdiagnosed because most patients are asymptomatic. 

“The use of CGM devices may improve safety in postbariatric hypoglycemia, particularly for patients with hypoglycemia unawareness,” the researchers conclude.
 

Next steps 

Patients are more vulnerable to hypoglycemia after a sleeve gastrectomy or gastric bypass surgery because these procedures involve removing the pylorus. This valve plays a crucial role in only allowing small portions of food to enter the intestine and prevents sudden spikes in blood glucose.

Without the pylorus, large amounts of food directly enter the intestine and soon result in large amounts of glucose getting absorbed, according to Sriram Machineni, MD, an associate professor of medicine at Albert Einstein College of Medicine, New York, who was not affiliated with the study.

“The pancreas then goes into overdrive and produces a lot of insulin, which continues reducing sugar levels,” Dr. Machineni said. “That is what causes hypoglycemia.”

Dr. Patti and associates are next working on research using CGM-derived data to investigate how different types of meals, physical activities, and other factors could influence glucose metabolism patterns in patients with hypoglycemia.

The study was funded by Dexcom, a manufacturer of continuous glucose monitoring systems. Dr. Patti reported receiving grant funding from the Diabetes Research Center.

A version of this article appeared on Medscape.com.

Continuous glucose monitors (CGMs) may help curb the severity of hypoglycemia after weight loss operations and even other gastrointestinal procedures, according to recent findings from a small study published in Diabetes, Obesity, and Metabolism.

Hypoglycemia is a chronic and persistent complication common in patients following bariatric surgery, affecting as many as 30% of people who undergo a sleeve gastrectomy or Roux-en-Y gastric bypass.

The symptoms of hypoglycemia, including lightheadedness, heart palpitations, difficulty concentrating, and confusion, can mimic anxiety disorders, arrhythmia, and dumping syndrome.

If a postoperative patient experiences these symptoms within a few hours following a meal or exercising, “primary care doctors should consider the possibility that hypoglycemia may be a contributor,” said Mary-Elizabeth Patti, MD, director of the Hypoglycemia Clinic at the Joslin Diabetes Center in Boston and senior author of the new study. 

“In fact, hypoglycemia is a possible diagnosis even among those who underwent [operations other than bariatric, including] fundoplication or other upper gastrointestinal or esophageal surgeries,” she said. 

To understand how CGM could benefit patients, Dr. Patti and colleagues recruited 22 participants who had undergone bariatric surgery more than 8 years prior and had postbariatric hypoglycemia. Their mean age was 51 years, 90% were women, 82% were diagnosed with level 3 hypoglycemia, and none had type 1 or 2 diabetes. 

All participants experienced neuronal dysfunction with symptoms like fatigue, concentration difficulties, and confusion. More than 90% had received medical nutrition therapy for postbariatric hypoglycemia in the past.

CGM data were collected in the 22 individuals in two sequential phases: masked (no access to sensor glucose or alarms) and unmasked (access to sensor glucose and alarms for low or rapidly declining sensor glucose). Twelve participants wore a CGM (Dexcom G4 device) for a total of 28 days, whereas 10 wore a CGM (the Dexcom G6 device) for a total of 20 days.

The team observed that the percentage of time when the participants’ blood glucose was below 70 mg/dL – the definition of hypoglycemia – was significantly lower during the unmasked phase. 

Though CGM devices are not sensitive enough to serve as a diagnostic tool for hypoglycemia, “the alarms on CGM devices can provide some much-needed awareness,” Dr. Patti said. “After a detailed diagnosis, CGM devices can be a helpful tool to assess dietary patterns and make modifications that could reduce the severity of postbariatric hypoglycemia.”

If a patient frequently experiences hypoglycemia, they may not sense when their glucose levels drop, also known as hypoglycemia unawareness, according to Dr. Patti. Studies have found that postbariatric hypoglycemia remains underdiagnosed because most patients are asymptomatic. 

“The use of CGM devices may improve safety in postbariatric hypoglycemia, particularly for patients with hypoglycemia unawareness,” the researchers conclude.
 

Next steps 

Patients are more vulnerable to hypoglycemia after a sleeve gastrectomy or gastric bypass surgery because these procedures involve removing the pylorus. This valve plays a crucial role in only allowing small portions of food to enter the intestine and prevents sudden spikes in blood glucose.

Without the pylorus, large amounts of food directly enter the intestine and soon result in large amounts of glucose getting absorbed, according to Sriram Machineni, MD, an associate professor of medicine at Albert Einstein College of Medicine, New York, who was not affiliated with the study.

“The pancreas then goes into overdrive and produces a lot of insulin, which continues reducing sugar levels,” Dr. Machineni said. “That is what causes hypoglycemia.”

Dr. Patti and associates are next working on research using CGM-derived data to investigate how different types of meals, physical activities, and other factors could influence glucose metabolism patterns in patients with hypoglycemia.

The study was funded by Dexcom, a manufacturer of continuous glucose monitoring systems. Dr. Patti reported receiving grant funding from the Diabetes Research Center.

A version of this article appeared on Medscape.com.