Wednesday, April 26, 2017

The Cult of Personal Responsibility Only Extends To Obesity #COS17

Yesterday saw the release of the Canadian Obesity Network's Report Card On Access To Obesity Treatment for Adults which grades the availability of obesity treatment options in Canada.

While you're welcome to peek at the report, its bottom line is that despite obesity's growth and prevalence, whether it's behavioural programs (and full disclosure, I run one), medications, or surgery, virtually nothing is covered aside from surgery, and among the report's findings, not a single provincial drug benefit plan covers the cost of pharmacotherapy for obesity, nor do any of the Federal Public Drug Benefit Programs.

And it's important to be clear here too as to what CON is talking about when calling for increased access to obesity treatment options. This isn't about vanity. According to CON, obesity,
"should be diagnosed by a qualified health professional using clinical tests and measures that assess health, not size"
and that it matters because,
"obesity is a leading cause of type 2 diabetes, high blood pressure, heart disease, stroke, arthritis, cancer and other health problems. It also affects peoples’ social and economic well-being due to the pervasive social stigma around it. Weight bias can increase morbidity and mortality, and is associated with significant employment, healthcare and education inequities."
The responses to the report (in the comment sections of various stories) are anything but surprising and can be summed up by the quotes obtained by the National Post from Senator Kelvin Ogilvie in discussing the report with him
"Obesity, to be blunt, is very largely a lifestyle issue", he said.
Translation?

It would seem that according to Senator Ogilvie people with obesity have done this to themselves, and similarly, if they just wanted to badly enough, they could fix things stating,
"So, at some point people have to take some responsibility for their own management, and obesity is one of those areas around which, with some initial medical advice and guidance, people do have the opportunity, largely, to manage it on their own."
Now rather than expound on how the provision of health care should not be blame based, or discuss the fact that only ignorance and weight bias leads a person to cite personal responsibility as obesity's answer while simultaneously discussing the appropriateness of medical attention and treatment for a myriad of other chronic non-communicable diseases (diabetes, heart disease, arthritis, many cancers, mood disorders, and many more) which are all also preventable and/or treatable by way of lifestyle, I want to bring your attention to a new study that just came out in JAMA that explored the use of cholesterol lowering medications in patients who had just suffered a heart attack.

You'd imagine that someone who had just survived a heart attack would be an incredibly motivated patient - one that would likely take on behaviour changes to try to prevent a recurrence. Now this study didn't look at the far more difficult behaviour changes involving dietary overhauls and the adoption of regular exercise that would be required in the management of obesity, this study looked at whether or not post-heart attack patients took their daily recommended cholesterol lowering medication - a behaviour that no one could argue requires much effort.

Cholesterol lowering medications are recommended post-heart attack because people who have had heart attacks are at much higher risks of more heart attacks and these medications have been shown to reduce those risks.

Before getting into this study, I should point out that a prior study had found that less than 30% of Medicare beneficiaries 65 to 74 years of age who were hospitalized for heart attacks filled their prescription for statins within 90 days of discharge. That means that the vast majority of patients who'd had heart attacks didn't even bother to try to take on the behaviour change of filling the prescription for, let alone taking, a medication shown to reduce their risk of having another.

This study wanted to explore the rest - the minority of post-heart attack patients who did fill their prescriptions for cholesterol lowering medications, and it followed nearly 60,000 patients hospitalized for a heart attack who filled their prescription for a high dose of cholesterol lowering medication within 30 days of discharge and then tracked the medication's continued usage.

6 months later 32% had stopped taking it with high adherence. 2 years later and 60% weren't taking it as directed, and 20% had stopped taking it altogether.

Pulling the two studies together (which while not statistically fair is something I'm going to do to make a point anyways) suggests that of those patients on Medicare between the ages of 65 and 74 who had a heart attack, 2 years later only 8% were actually following through on the recommended behaviour change of taking a daily high dose statin.

I bring this up because it demonstrates that behaviour changes, even those that as effortless as taking a daily medications, are challenging to sustain.

Regardless of just how tone deaf it is in the face of decades of global increases in weight, to suggest the useless truism of "eat less move more" as a practical approach to the millions of Canadians whose weights are affecting their health or quality of life, the fact is that sustained changes in behaviour challenge each and every one of us regardless of how beneficial those changes might be.

Change being difficult is part of the human condition, and the provision of health care should not be dependent on a person's success therein. Denying that only when it comes to obesity? Well that's just ignorance, or bias, or both.

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