eHealth summit 2019 in Africa

Healthcare Conference in Africa

Interestingly, the response to this post from the dietitian community was both humbling and indeed an honour. Not only did the post receive an unusually large number of lengthy and passionate comments (both here and on social media), but I also received a most thoughtful letter signed by well over 200 dietitians, suggesting I reconsider or at least clarify my post.

This overwhelming response to my post was humbling, because, I do not believe that there is anything I could possibly have written that would have elicited an even remotely similar prompt and passionate response from my own medical colleagues – clearly dietitians care strongly about what they do. Apparently, they also appear to pay attention to what I have to say – which is an honour indeed!

That said, I agree very much that some clarification is in order.

For one, as stated above, the title of the post was indeed entirely rhetorical – if I did, for even a second, have any doubts as to the important role that dietitians have in obesity management, I would probably not have bothered writing the post at all.

Secondly, I would have thought that both my opening and closing paragraphs would have made it entirely evident just how much respect I have for the professional expertise that dietitians have with regard to their discipline and their essential role in obesity management. I truly believe that it would be entirely fair to say that dietitians’ knowledge of biochemistry, disease processes, counseling techniques, client-centred care, and clinical passion are second to none (and I happily include my own colleagues in the comparator).

Furthermore, nowhere did I state or imply that my comments apply to ALL (or even the majority of) dietitians – in fact, I thought I had made it clear that the issues I raised applied to a small minority (perhaps no more than a handful?) of dietitians. (I did not single out anyone by name, as I do not believe in, nor intended, any ad hominem attacks).

In my post, I touched on a few different but related issues:

1) The unequivocal endorsement of obesity as a chronic disease.

2) Potential gaps in specific obesity training.

3) Reluctance (of at least some practitioners) to consider weight loss as a realistic (and often necessary) therapeutic option.

digital healthcare conference

Apart from the fact (as I have done in countless previous posts) that I have called out members of my own (or for that matter, any) medical profession on the exact same issues, I am also fully aware that within any health profession there is a wide range of expertise, experience, and opinion on virtually any issue.

But, I do believe that each of the above-mentioned issues is of importance (not just for dietitians), and I will happily clarify my stance and thinking on each of them in subsequent posts.

As to why, if my comments apply to all health professions, I decided to single out dietitians for this particular post, the reasons are simple:

1) This specific post happened to be prompted by actual conversations over the past few months with several dietitians from across Canada, who all (independently!) raised similar concerns about what they thought was perhaps amiss amongst some (younger?) members within their profession when it comes to obesity management (again, no names!).

2) Ten years of blogging have taught me that to initiate a lively discussion with any post, it needs to be opinionated, one-sided, strongly worded, and provocative – anything less, is a waste of time (sadly, balance is boring!). If nothing else, my post certainly achieved that.

3) I truly do consider the role that dietitians have to play in obesity management of the utmost importance. Dietitians are in fact “THE” profession, that other health professionals most often look to when it comes to obesity management. With that comes immense responsibility, which I know dietitians take very seriously.

Digital Health Conference

I promise that I will attempt to do my utmost to clarify and expand on the specific issues raised in my previous post in subsequent posts.

Hopefully these “clarifications” will be taken in the respectful and constructive spirit in which they are offered – I am fully aware that nothing in medicine is black and white; we all happily operate in shades of grey (as I always emphasize to my patients).  I’m also very aware that today’s certainties may well turn out to be yesterday’s follies – as our understanding of disease processes and treatments evolve, so do our clinical approaches (as they should).

I spent the first 10 years of my professional life studying and treating hypertension. As a bit of a history buff, I dug out old books on hypertension and went back to reading papers on blood pressure that were written in the 20s and 30s. I also had numerous mentors, who were around well before the advent of modern diagnostics or pharmacotherapy. In retrospect, I believe that there is much we can learn from the history of hypertension.

In the early part of last century, as we learnt more about the physiology of blood pressure regulation, numerous forms of “secondary” hypertension were identified (e.g. renal artery stenosis, Conn’s Syndrome, pheochromocytoma, etc.). Although these were rare conditions, they taught us much about pathophysiology – but (to this day), most case of elevated blood pressure are still considered “essential”, meaning that they do not appear to have a defined cause (genetics and environment both play a big role but the details remain rather murky).

Digital Healthcare summit

Although the link between elevated blood pressure, stroke, heart disease, and kidney failure were well-recognised, there were no good treatments. In fact, the history of medical and surgical treatment of hypertension during the first part of the 1900s was so dismal, that many were opposed to treating hypertension with anything other than a highly restricted low-salt diet. Prior to the 1950s, pharmacotherapy included drugs like sodium thiocyanate, barbiturates, bismuth, bromides,

hexamethonium, hydralazine, or reserpine – drugs that were poorly tolerated and for which there was little evidence that they lowered mortality. In desperate cases, surgeons performed sympathectomies – a drastic and complex operation.

Given the dismal landscape of medication for hypertension, there were loud voices that challenged the whole concept of hypertension. After all, if there were no good treatments, would it not be best to leave the patients alone and perhaps just support them in other ways? There were prominent doctors who warned about the possible damage that lowering blood pressure could do (particularly to the elderly). Even those who supported treatment, suggested modest targets – 170/110 mmHh was deemed “not so bad”.

Then came the 50s. The first modern drug to be introduced was the oral-diuretic chlorothiazide. Then came, beta-blockers, ca-antagonists, ACE-inhibitors, ARBs, and renin blockers.

Now that effective medications were available, researchers could conduct long-term studies to prove that these medications were not only safe and effective in lowering blood pressure, but could actually drastically reduce the incidence of strokes, heart attacks, and kidney failure.

But even as these studies were ongoing, there were the “nay” sayers. People who pointed out that, given the dismal history of hypertension medications, these should have no place in the clinic. People, who, even if they conceded that the medications were more effective and safer that ever before, pointed out that there was not enough data to support their routine use. There were those, who warned against lowering blood pressure too far and those who decidedly did not consider elevated blood pressures in the elderly a worthwhile target. And of course, there continued to be those that felt that rather than trying to treat hypertension, we should focus all efforts on preventing it by declaring a war on salt.

How things have changed. Today, no doctor would think twice about prescribing anti-hypertensive medications to a patient with elevated blood pressure. No payer would refuse the coverage of anti-hypertensive medications. No medical student leaves medical school without training in hypertension management. In fact, the only excuse today for anyone walking around with elevated blood pressure is either that they have not been diagnosed or are not taking their medications as prescribed (of course there are still some patients for whom the existing treatments are not tolerated or do not work, but these are few and far between).

I still recall the debates at conferences (my first hypertension conference was the World Hypertension Conference in Kyoto in 1988) on whether or not hypertension is a disease or just a risk factor. I recall proponents suggesting that simply improving lifestyles (without lowering blood pressures) would be as useful if not better for patients than exposing them to life-long pharmacotherapy (after all essential hypertension is just a “lifestyle” disease). I remember arguments about definitions and targets, about diagnostic strategies and therapeutic pathways (e.g. is it better to increase the dose, switch, or add-on?).

Funnily enough, I am reliving much of this history with obesity. There are those who, given the dismal past of anti-obesity medications, are vehemently opposed to the very notion that anti-obesity medications will one-day have a place in clinical obesity management. There are those, who given the past failures with dietary approaches (not unlike the failure of low-salt diets to produce long-term blood pressure lowering in most people), are ready to abandon dietary approaches all together (at least in the context of weight loss). Indeed, there are those who continue to argue that obesity is not really a disease but simply a risk factor attributable largely to lifestyle “choices”.

It took about 100 years for us to get to hypertension management as it exists today. In obesity, I think the wheels are moving a lot faster, although to many living with this disease, movement may appear glacial. Remember, less than 30 years have passed since the discovery of leptin. Only now are we entering the “modern” era of anti-obesity medications.

Yes, the debates about definitions and targets and treatment plans will continue but I am confident that sooner or later, we will get to the point where helping patients manage their obesity will be as routine, free of bias or judgement, and accepted as helping patients manage their hypertension.

@DrSharma

Edmonton, AB