Evidence-based Care for Evidence-based Deniers?

[rev ronin]

9 hours ago, SedRate said:

But to address your tangent about the poor long-term success of maintaining weight reduction, shouldn't obese pts still try to treat their obesity? Or are you saying obese people shouldn't treat their obesity because it won't likely stick? 

First, what's the long term survival benefit (or global function improvement, or whatever) for weight loss?  Actually, 0th, on what basis do we assume that higher weighted people have lower life expectancy? Observational.

The basic problem with such issues is that they are all observational and subject to confounders. Weight is easy to manage: just withhold care from patients until they get on the scale--and I wish that was just a tongue-in-cheek aside, but that really happens to people. My wife is in MA school right now, and these proto-MAs are being told that patients must consent to being weighed in order to be roomed and seen. Measuring things like diet and exercise/activity level, or even metabolic markers like A1c, are exponentially harder and costlier. Even BP takes more time to measure well than weight.

The efforts to differentiate between those higher weighted patients with and without metabolic syndrome is severely underfunded compared to the efforts to enforce weight loss on the assumption that it will help improve outcomes.

Not everything can be RCT'ed, but weight loss absolutely could. It would be expensive, of course, and who would pay for it? Not the pharmaceutical companies who are raking in money with phentermine, topiramate, and GLP-1s. The PICO statement has to be set up well: Do patients starting at a higher BMI treated with (one or more current weight loss techniques) have better morbidity and mortality outcomes than patients starting at a higher BMI without treatment?  It's not "heavier" vs. "not heavy" which is where things break down.  Of course someone at a BMI of 25 will be healthier than someone at a BMI of 50.  But does treating the BMI 50 patient and trying to make them look like the BMI 25 patient improve their M&M over their lifetime? And of course almost anyone can lose weight in the short term, but given that the vast majority of lost weight is regained, are the people who lost weight and regained it better off, similar to, or worse than the people who never tried to lose weight at all?

Are we doing harm by recommending dieting without appropriate follow-up? There's some evidence to suggest that weight lost and regained in the short term creates a metabolic yo-yo which leads toward metabolic syndrome and DM II. It's one thing to recommend an intervention that has no discernible downside (You should get 8 hours of sleep with consistent sleep/wake times even on weekend), but when there's a reasonable signal that the intervention may be causing harm, we owe it to our patients to sort out the evidence from assumptions and bias before making recommendations.

[SedRate]

6 hours ago, rev ronin said:

We owe it to our patients to sort out the evidence from assumptions and bias before making recommendations.

I mentioned things like osteoarthritis, which overweightness can contribute to, which you haven't addressed. Just a friendly reminder that the topic at hand is the ethics of withholding care to those who don't legitimately try. I offered obesity and OA as one example of a handful. I'll reiterate: If obese individuals with OA don't legitimately try to lose weight, should they still be offered treatment, such as a TKA? What are your thoughts on the ethics of that? What if obese individuals "can't" lose weight because of things like disorders of their energy homeostasis system (as some current research suggests is a reason obese individuals gain back their weight) or other things like they work too much, they have an injury so they become sedentary, etc. Are they still considered deniers of EBM because they don't lose weight to treat their OA? Interestingly, this actually happens as some obese pts ARE denied TKA if they have a BMI greater than 35 and cannot lose weight. (Whether voluntarily or involuntarily)

Or are these "deniers" in a different category of the one the OP proposed because they can't for voluntary or involuntary reasons? Just some thought provoking ethical questions regarding whether care should be denied to those who don't follow EBM whether voluntarily or involuntarily. 

I'd like to address your other notions about bias and the other things related to care of obese pts and pathophysiology of obesity as it's something I'm very interested in especially given our obesity epidemic and my own anecdotal experience with higher complications seen in obese Ortho trauma pts, but I think that's best done in a separate thread. I'd be happy to contribute should you decide to do that. 

[ohiovolffemtp]

I'm EM not ortho, but I thought that in ortho, patients were considered poor surgical candidates or to have low likelihood of success with TKA if they weighed above a certain amount.  I've seen other patients considered poor or even not surgical candidates for other conditions, e.g. AAA above a certain size.  I think that's a different decision making process than being a "denier".  Another example is that patients who continue to consume alcohol are not allowed on liver transplant lists.

[SedRate]

15 minutes ago, ohiovolffemtp said:

I'm EM not ortho, but I thought that in ortho, patients were considered poor surgical candidates or to have low likelihood of success with TKA if they weighed above a certain amount.  I've seen other patients considered poor or even not surgical candidates for other conditions, e.g. AAA above a certain size.  I think that's a different decision making process than being a "denier".  Another example is that patients who continue to consume alcohol are not allowed on liver transplant lists.

That's mainly because their implant will wear out faster (requiring a revision) and they have higher complications like wound infections, seromas, etc. Also, the surgery can be more technically challenging in obese pts and require larger incisions. (Special mention to hip fx surgery: there is actually special equipment available when operating on morbidly obese pts.) Some pts are still given the option if they lose weight. But some surgeons don't want to take that risk and any risk that might increase risk for revision or periprosthetic infection. After all, the more times you go back in, the higher the risk... 

Edited January 21, 2023 by SedRate