19min chapter

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#314 ‒ Rethinking nutrition science: the evolving landscape of obesity treatment, GLP-1 agonists, protein, and the need for higher research standards | David Allison, Ph.D.

The Peter Attia Drive

CHAPTER

Navigating Obesity Treatment Ethics

This chapter explores the complex ethical considerations in obesity treatment, particularly focusing on GLP-1 agonists and their implications for both health and personal motivations. It contrasts societal views on obesity with the moral judgments attached to weight loss, questioning fairness in treatment accessibility and informed consent. The discussion bridges the gap between medical necessity and personal desire, while also addressing the ethical concerns of performance-enhancing substances in sports.

00:00
Speaker 2
I don't know that I think of that as a moral panic. I think the bigger moral panic is less about the source of the drug, but the use of the drug. You brought up an interesting distinction, which is, let's take an individual who is medically obese and by the way, metabolically unhealthy. So that's the key point I want to get out here. So this is a person whose health is compromised by their weight, both from an orthopedic perspective and metabolically. And then let's take another individual who's overweight, but if you're looking at them objectively, you don't see the metabolic signs of overweight. They're not suffering physical and orthopedic issues associated with it. Both of these people, let's just assume, have a desire to lose weight. One of them to primarily ameliorate the medical conditions and also the aesthetic conditions. Then the latter person just for the aesthetic conversions, right? Okay. We probably look at those people differently. When I say we, I mean society, might make a different moral judgment on those two. That's right. You're
Speaker 1
arguing that's a false dichotomy. It's a legitimate dichotomy to see the situations as distinct situations, but not necessarily distinct recommendations coming from those. Let's refine it to a two by two. We've got people, let's just say four individuals come to you, and we're going to say that you're the objective all-knowing agent. Meaning I determine who goes on the drug? No, you determine their state of being. Got it. Half of the people are objectively at medical, physical risk because of obesity and would be objectively medically helped by losing weight on this drug. Half of the people are not at objectively medical increased risk and would not be predicted to have a major medical benefit. Within each of those groups, half of them think they have a medical problem regardless of whether you objectively determine they do and think they would benefit. And half of them aren't interested in that. They want to do it for cosmetics, income, other opportunities, et cetera, stigma reduction, quality of life. The question is how should those four groups be treated? Now, it seems to me, from an obvious point of view, if we're concerned about expense and the expense is borne by society, not the individual coming, or if there's shortages and we're gonna take it away from someone who's genuinely medically needed, then going to the non-medically needy people is questionable. But if we get over those problems, if the person says, I can afford to pay it for it myself, and the availability is there, and we think there's no big safety problem, or even if there's some safety problem, but we've told them, fully consented, take the libertarian view, it's their choice, it seems to me.
Speaker 2
It's hard to imagine any reasonable person could argue with that position. Well,
Speaker 1
one of the big statements that got in some news was a very reputable entity, major player in mainstream medicine, who has an interest in actually promoting this. A three sort of step statement was made. Step one is, the drugs were intended and designed and studied for this use, meaning treatment of medically needy people. Second, the drugs were approved for that use. Third, therefore they should only be used for that. And the third part is
Speaker 2
a moral judgment, not a factual judgment. The first and the second are true. And what they really tell you is, therefore, the cost-benefit analysis has to be viewed through the lens of that patient population. In other words, when you ask the question about risk and benefit, you to at least acknowledge that the long-term risk, long-term benefit are studied in that population. Correct. And as such, this is what the data are. These are the risks. These are the benefits. Make your judgment. Conversely, if you ask the question, hey, for a person who is subjectively 10 pounds overweight, like me, you could argue I'm 10 pounds overweight. Nobody knows but me basically, but hey, should I be
Speaker 1
taking this drug? So let's take an analogy. Patient comes to you. They're very wealthy. They're in good physical health. They have a they have a car, they have all the material things they need, they have a family. Family loves them, they don't engage in violence. And they'd say, I feel miserable. I'm anxious all the time or I'm depressed all the time. You might try a few things, explore it, but assuming you've explored it, it's real. Maybe you tried some cognitive behavioral therapy, didn't seem to work. You might say, yeah, an anti-anxiety drug or an antidepressant might be for you. FDA approves those things. We take the person's quality of life and their feelings into account. Why is it that the person who says, I feel too fat and I want to be 10 pounds thinner and look good in my bathing suit. Or I want to get this job as the leading actor in that film. Or I want a promotion in my environment and I think I'm more likely to get it if I'm thinner. Or I'm hungry all the time and I don't plan to lose weight, I just want to stop being hungry all the time. Why are that person's feelings or non-medical desires any less valid than the person with depression? Or for that matter, the person with an unusual but not health damaging physical feature, an unusual nose or something who says, I just feel like I'd be judged better.
Speaker 2
I don't think it is. I guess the only thing I would suggest as the backstop to that is when the person who doesn't like their nose goes to the ENT surgeon or the plastic surgeon to have the completely non-essential but emotionally beneficial procedure. If they're seeing a good surgeon, the surgeon can tell them with unambiguous, clarity, what the probability of negative outcomes is. And I think the same is true in the case you described at the outset about the individual with depression or anxiety. A very good physician can explain to them what the risks are. And, by the way, as you know well, very few physicians would give you a medication for anxiety or depression without also prescribing in parallel to it psychotherapy. The data are pretty clear that medication by itself is nowhere near as effective as medication coupled with psychotherapy. So you have two things going for you that make this analogy not apples to apples, which is in the case of depression, we can say much more about the long term side effects. And we're combining it with a behavioral therapy that aims to improve the efficacy. Again, I'm not suggesting that the person who wants to lose 10 pounds doesn't have a legitimate concern. I think my concern is we don't know enough about the long-term risk to tell them for their relatively minor health compromise, is it potentially worth it? Is the trade-off worth it? I think we could probably say that with a higher degree of certainty for the individual with significant obesity because even if we would have kind of a small bracket of understanding the downside potentially of the drug, we really know the downside of having a BMI of 40. Being insulin resistant, having type 2 diabetes, having a BMI of 40 has such a clear downside that the other side of that bed is a pretty easy one to take. So I think that to me, so again, for me it's not a moral question at all when I'm confronted with this question, which I am all the time. Every week I probably, or every two weeks at least interact with a patient who fits the exact description you're talking about, which is, I'd love for this to be easier. And again, I don't think there's anything wrong with wanting something to be easier. But my hope is we get to a point where we could give them the same degree of clarity around risk that the plastic surgeon can give the patient who wants to undergo a rhinoplasty. Right.
Speaker 1
And I agree with you on that. And I think the moral questions come in around how do you conceive of the role of FDA, society, physicians in regulating choices. And by the way, to be clear, that's why I'm not taking one of these drugs. I'd love
Speaker 2
to be 10 pounds lighter. I would love to be 10 pounds lighter. I would love to never be hungry. All of the things that these drugs do, by the way, they improve glycemic control. All of those things are appealing to me. But the truth of it is, for somebody who is quite a risk taker, and I am quite a risk taker. You are. I am. When it comes to my health, I would argue I'm quite a risk taker. But I've watched countless patients take these drugs, and as I've shared with you and others, without exception, the resting heart rate overnight goes up about 10 beats per minute. And I don't know what it is about that fact and the fact that heart rate variability goes down slightly that just has me asking the question, for me personally, is it worth the trade-off? Is there some underlying sympathetic, parasympathetic imbalance that results from this drug that is doing a whole bunch of other good things vis-a my appetite potentially, but you know what, over the arc of my life, is it worth it? And maybe if it were 40 pounds and it was medically a problem, I'd say, oh, I'll take the heart rate bump any day of the week.
Speaker 1
So, informationally, I'm with you 100% and in terms of the morality of the honest communication, I'm with you 100%. Well, by that I mean, informationally, we have a fair bit of data that allowed FDA to make its decisions on the use of these drugs for particular indications in patients who are judged to be quote unquote medically needy of those drugs. And we don't have a lot of data on the person who's thin, but who says, I just want it to be easier, or the person who's thin, but says I'd like to be 10 pounds thinner. And I think any treatment or provision of something to people without a full disclosure of what you know, and an honest disclosure is not right. So I think if I were in your shoes, I'm not a physician, I don't prescribe drugs, but if I were in your shoes and that person came to me, my bare minimum is that I've got to say to them, I want you to be aware that I have no data on this over many decades. We only have a few years. I want you to be aware that it was only tested thoroughly in these populations, which is not your population. And you need to know that there are, as Rumsfeld famous said, the unknown unknowns. Then I think there's an issue of choice. There are lots of things that I think it's acceptable that our society permits, but I don't personally want to do them. Think freedom of speech. I think it's perfectly acceptable and necessary that we allow certain people to come out publicly and make certain statements. But I'm not sure I want to make all those statements. And I can imagine you saying, I think it may be acceptable that somebody provides this drug to this person under these circumstances, but that's not what I want my career or life to be. And I think you should have that choice. So I think these are things we ought to do. And it comes down very much, I think, to this sense of after we have the inputs, we can agree on the facts, or we should be able to agree on the facts. Then what we do with those facts, we can disagree because we have different values. And I think that's where it's how much of a paternalist is one. The FDA is very paternalistic. They're going to decide which drugs are good for whom or how much are you a libertarian, where you say, we'll tell you about the effects to the extent we can of this drug or this treatment, but how good it is, whether you should do it, whether you want to do it, implies values and you make that decision as long as it's a fully informed decision and those are different views of how we should proceed. All right. Let's consider one
Speaker 2
more zinger on this topic. You are now in charge of both WADA and USADA. So world anti-doping and US anti-doping agencies. Thank
Speaker 1
you for defining those for me. You
Speaker 2
have an obvious and clear hard line against drugs that improve performance. An athlete cannot take testosterone or growth hormone or EPO or anything that boosts performance. Now, if you think about it, a lot of sports have their performance improved when the athlete is lighter. Weight management is a big part of many sports. Cyclists, runners, gymnasts, if you think about it, rowers, any sport that is cardiac output versus body weight, those athletes, and I used to be one of them, you are just as focused on weight management as you are cardiac output. Should these drugs be banned by WADA and USADA?
Speaker 1
Are they indeed performance enhancing drugs? Great question. I hadn't thought about that until you asked it. Great question. Because it introduces a whole different set of interests. Prior, we were talking mainly about the individual persons taking the drugs interest and a little bit about the provider's interest, you, a little bit about society, cost, FDA, so on. Here you've introduced a fourth party and that party is the sport. All the spectators, the people who own it, the other participants, the sport has rules. Sport is very different than some other things where there's an arbitrariness to it. Why does the baseball bat have to be this long and not that long? Why does the tennis racket have to be within these dimensions? Well, that
Speaker 2
part's arbitrary, but what's not arbitrary is we want it to be equal. We want everybody to have the same chance. So in other words, we don't spend too much time worrying about the length or weight of the baseball bat. We worry far more that you didn't screw into yours and put cork in there and change the weight of it. That's the thing we care about as fairness. Because that's the
Speaker 1
rule, but the rule, we even change the rules about the intrinsic things. So we change the rules about, in some places, we don't condition on age. In others, we have age brackets. Some boxing, we have weight brackets. Wrestling, we have weight brackets. We don't have height brackets in basketball. Some colleagues and I try to write a whole paper on it, mathematically, what is bias? What do we mean by that? And we use basketball as an analogy and I use myself as the example and say if I try out and I don't do well for the basketball team because I'm short, I don't call that bias because intrinsic to the idea of basketball is these are the rules, we don't have springboards for shorter guys, we could but we don't, we don't have high classes and so that's not biased. In contrast, if you ask me to try out to be a biostatistics professor, and the book is on the top shelf that you want me to lecture from, and there's no step stool, I would argue that's biased because you could have put a step stool there, and it's not intrinsic to biostatistics professor performance to be able to reach tall things. And so we need to look at the sport and say, what do you want it to be? And if somebody says, I want it to be things where part of the sport is being able to maintain your weight. And so I don't want anybody to have a performance enhancing drug, then to me, so be it. I could also alternatively turn around and say, we just want you to be able to get the basket in the hoop or we just want you to be able to row the boat. And if you do it by having more money and hiring a better coach and you do it by taking Ozumpik and you do it by having good genes, all is fair. I don't think there's a right answer there from the sport point of view. But
Speaker 2
given that the sport has already made several decisions, they've already said you can't take a drug that increases the number of red blood cells that you have. That's EPO. You can't take a drug that increases the rate at which your muscles repair themselves after hard training. That would be testosterone. Go on and on and on. You can't take a drug like a diuretic that takes body weight away from you. This is not a philosophical question about drugs. It's a practical question about this class of drugs whose efficacy is, as you said, profound and its safety, at least in the short term, unquestionable. Are we going to basically see at the Olympics this year in France, if they were drug testing for it, what fraction of athletes would be taking GLP-1 agonists of the sports where body weight regulation is a key? I don't expect many shot-boarders to be taking it. No. But I do
Speaker 1
wonder how many boxers and rowers and runners and cyclists will be taking it. Really interesting. We should do that study. Let's work on it. So I don't know the answer. Haven't heard about that before. I think your speculation is apt. I think that as a formalist, I would go and say, well, what is these groups that have said you can't take testosterone and this and this and that? They probably put out some underlying principles. It probably said you cannot take a drug that enhances performance unless you have a medical need. I don't know if they've said that, but if they have, then it could get really tricky because now you say, well, who defines the medical need? What about now is it fair if we take the person who's just below the threshold for needing it who says I don't get to take the drug but the person who's just above the threshold who does you have then also this idea of a fairness of disabilities issue. If I have obesity particularly I've got a strong genetic predisposition to it I can't manage to be not obese without the drug. Do I effectively have a disability? And is this now prejudicial or violation of the Americans with Disabilities Act or something like that? Or different countries have different variants? But is there a fairness issue? And again, I don't know that there's a right answer. I think these would be tough political and moral questions, but it's really particularly tough because you bring in the interest of the sport. And then you're going to get also, it's going to reflect back when you get into the health interests of the individual, just as with many sports, we might say it's in the interest of the team or the coach or the sport itself to have this person at greater risk. But of course it's not in the interest of their situation. And yet we somehow accept that we allow people to play football even though there's concussion risk and we allow people to box and many other things. But are there some limits where we might say, we're not comfortable with your putting yourself at risk for this, we need to protect you as much as the sport.

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