Decades before he and Harvey Weinstein triggered the long overdue MeToo movement and crashed from grace before our eyes, Bill Cosby was a fresh, young comedian of enormous talent and great wit. One of his first bits had him playing Noah and conversing with God about how to build the Ark. "Build it 40 cubits wide, 80 cubits high and 200 cubits long" bellowed God. Wanting to comply, Noah/Cosby would respond to every directive with an affirmative, "Riiight", until the very end when he finally asked: "What's a cubit?". In other words, despite nodding his agreement, Noah/Cosby had no idea what God was saying. We have an analogous situation today in healthcare in which perhaps hundreds of thousands of people are being prescribed medications intended to control blood sugar levels in Type II diabetes. The problem is that they are taking it for weight loss, not to reduce their HgA1C. The demand for these medications is so great that a shortage of them was created in short order. While using medications "off label" is not a new phenomenon, the fact that the patients themselves were the principal driver of the demand raises important questions about overweight, eating disorders and the response to them by healthcare.
Let's look at each of these in some detail. Being overweight is one of those issues in our culture that sparks strong emotions. The focus that exists in our society on body image, especially as expressed on television, in movies and in advertising, creates an unrealistic and virtually impossible standard. While there have been attempts over the years to change the narrative around body image, they have been about as effective as designers telling us that a midi-length dress and a miniskirt are indistinguishable. While it may be an enviable, woke position to say that being overweight shouldn't matter, the demand for Ozempic, etc. that is overwhelming pharmaceutical manufacturers, belies it to the point that maintaining it as a mainstream societal belief is tantamount to asserting that the earth is flat. The overwhelming majority of American society either is, or should be, concerned about their weight. The most recent estimate I saw stated that 40% of America is obese. Obese is not just being overweight. Overweight is a body mass index over 25. Obese is a BMI over 30. Overweight is a 5'2" woman weighing 136 or a 5'9" man weighing 169. Obese is a 5'2" woman weighing 164 lbs. or a 5'9" man weighing 203. The average American woman is 5'4" and weighs just over 170 lbs. The average American man is 5'9' and weighs just under 198 lbs. 70+% of Americans are overweight or obese.
Ask any behavioral health provider about eating disorders and they'll talk your ear off about anorexia nervosa or bulimia. They're talking about restricting food intake or binging and purging. Once in a while, someone might mention binging as an eating disorder but it is a distant third behind anorexia and bulimia. Even then, it is the way the patient eats that defines the disorder rather than the result as it is in almost all other diagnosable problems. Some years ago, my wife and I attended a two day conference entitled "Eating Disorders" in Boston sponsored by the Harvard Medical School. For two whole days, speaker after speaker expounded on the topic. Guess what? No one in two days even mentioned overweight or, heaven forbid, obesity. While this conference was going on, I was literally searching around the country for a residential program that would treat obesity for a patient of mine whose weight problem I feared was life threatening. A very large man to begin with, at 6'2" he probably weighed in excess of 325 lbs. I thought I had located a program in Texas but, as I was arranging the admission, the patient collapsed at home, was hospitalized and died. He was in his mid 40's as I recall. There were many residential programs that dealt with restrictive eating disorders but virtually none that dealt with overeating/overweight/obesity. The incidence of the restrictive problems, while significant, is minimal compared to overweight/obesity but behavioral health like medicine in general has its head in the sand or worse as we'll see next.
The healthcare system in America is easily the most expensive in the world and can be the best, as when it performs a miraculous surgery, or the worst when it neglects the true drivers of illness, namely behavior. Ask any PCP off the record and they'll tell you that everything they see all day long is the result of unhealthy behavior. The overwhelming majority of illness is what we term a "secondary" problem. The mechanism is OK. It's the way we are treating it that creates the problems. We start out life with knees that function pretty well. It's when we ask the poor knees to carry an extra fifty ponds for twenty or thirty years that we run into trouble. Maybe there are people with COPD who haven't smoked but very few. In grad school a million years ago, I learned that 90% of Type II diabetes was manageable by diet alone. Guess what, it still is. But not if a daily trip to Dunkin Donuts in the morning is routine. Asthma can be managed but if you're one of the thirty percent of asthmatics that smoke cigarettes, refilling your inhaler regularly probably won't cut it. Nexium is a very effective, but also very expensive, acid controller. When we were considering covering it in the formulary at Blue Cross of Rhode Island, we discovered that the GERD occurred only when the member ate the wrong things. Stay away from certain foods and there is no GERD and no need for Nexium.
Aches, pains and conditions all over the body are the result of our behavior. Healthcare almost systematically ignores behavior. In my years as the Associate Medical Director for Behavioral Health at Blue Cross of Rhode Island, I pushed for primary care practices to colocate with behavioral health providers in order to increase the focus on unhealthy behavior and away from symptom reduction, principally through medication. I wanted the providers to wear jackets with the letters ATF on the back, only, the "F" stood for "food" rather than firearms. Alcohol, tobacco and food account for nearly all of the medical problems presented in primary care 24 hours a day, seven days a week, 52 months a year. These days, we can add opiates and marijuana to the "A". It is reported that 425,000 deaths per year in the United States are related to smoking. These include heart disease, COPD, lung cancer and stroke. The body systems that are negatively affected by alcohol are stomach, intestine, brain, heart, liver, kidneys, pancreas, mouth, throat, etc., etc. And it's a carcinogen. Which brings us to overweight.
Everything orthopedic is made worse by being overweight. Type II diabetes, sleep apnea, heart disease are all linked to being overweight, not to mention obesity. Healthcare should be driving the use of appetite suppressors like Ozempic but it's not. As I mentioned earlier, the driver is the overweight patients. Healthcare would rather treat the lab test than treat the cause. Healthcare would rather treat the symptom than treat the condition. And unfortunately, patients would rather take a pill or tablet than make changes in their behavior. And we haven't even begun to talk about anxiety and depression as contributors and confounders of medical conditions. Next time you see your doctor, try to talk about what's really going on in your life. See how far you get and don't be surprised if at the end he asks: "What's a cubit"?
PS For those of you who access my blogs on my website, drhancur.com, you will notice a new picture. One my good buddy golfing partners, Frank, accused me of using my high school graduation picture on my website. Actually, it was a picture taken around 2010 for a professional organization board I was on. In any event, I got the message and the current picture, a selfie, is the way I look now.