Links for Wednesday, September 5, 2018: docs are nervous about weight loss meds, risky low-carb diets, why I'm not a pediatrician, and continuity of care is good

Why don't more docs prescribe weight loss medications?

Speculation: 1) cost (and by extension, prior authorization requests); 2) residual fear from fen-phen, as one of the docs interviewed alluded to. We can surely put this to bed, since the current crop of meds has been on the market much longer than fen-phen had been when its harm was revealed; 3) nihilism. Five percent weight loss is meaningful from a medical perspective, but unless the doc is consciously, prospectively measuring outcomes like blood pressure, lipids, and fasting sugars, it won't knock her socks off. Patients won't be thanking her for getting them ready for bikini season; and 4) the old Risk Evaluation and Mitigation Strategy (REMS) for Qsymia was such a PIA that it scarred some docs to prescribing these meds.

Can we stick a fork in low-carbohydrate diets? (Ba Dum Tss)

What's a 32% increase in mortality among friends? Investigators (in a study that, to my knowledge, has not yet been published, so caveat emptor) found an association between the lowest quartiles of carbohydrate intake and death:

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

NHANES data. Model 1 is unadjusted for other risk factors. Model 2 is adjusted. These are ugly, ugly numbers. 

Remember: we can't draw causality from this. There is some chance that people who are sick and more likely to die from heart disease, cancer, or stroke are more likely to adopt low-carbohydrate diets. But it doesn't seem likely. The people at highest risk in this study were those over age 55 and "non-obese."

Reason # 1,001 I'm not a pediatrician:

Can. Not. Do. It.

Special shout-out to the 100 cell phone text alerts during the video. 

If lack of continuity is a mark against telemedicine, then it's a mark against the hospitalist model in general

Weekend links for Saturday, August 17, 2017: post-apocalyptic Rio, money makes the Mediterranean diet work, DNA testing may not change behavior, and the folly of clean eating

A year later, the Rio Olympic sites are ruin porn

Is money the secret to making the Mediterranean diet work? 

To be fair: I don't know a lot about this literature at all, but I suspect that the same claim could be made of many interventions, dietary and otherwise, were the data known. The more money you have, the healthier you are in general. (link via

Knowing our DNA risk doesn't make us change our behaviors.

I need to investigate this further. The thrust of this article--that knowing our risky mutations doesn't make us behave any differently--flies in the face of some data I've presented in the past. 

Have we all fallen for "clean eating?"

I remain convinced that eating food that looks like food, in the Michael Pollan sense, is generally what we should all be doing. Like most ventures that people look to capitalize on, though, it has been taken too far: see the "influencers" in this article that actually make themselves sick with adherence to an irrationally vegetable-based, uncooked diet. (link via

Don't wanna see the sausage links made, July 7, 2017: New endocrine society statement on obesity pathogenesis and the danger (danger!) of placenta capsules (placenta capsules?)

"...obesity is caused by two distinct processes: energy homeostasis and energy imbalance – specifically, energy intake greater than expenditure."

This is an excerpt from the Endocrine Society's new statement on obesity pathogenesis. I'm relieved to see it. In the past couple of years, as investigators have (rightly) cast light on some of the shortcomings of the calorie as a measure of energy consumption or energy expenditure, the internet has drowned in chatter about how obesity isn't a matter of energy in versus energy out. When of course it is. You simply can't make fat out of air or sunshine. At some level, people who carry more weight than they'd like are eating an excess amount energy or expending an insufficient amount of energy or both. The fact that we don't have a perfect way to measure or quantify it doesn't change that fact. So this nugget from the Endocrine Society's press release is welcome, too: 

“Because of the body’s energy balance adjustments, most individuals who successfully lose weight struggle to maintain weight loss over time,” said Michael W. Schwartz, M.D., of the University of Washington in Seattle, Wash., and the chair of the task force that authored the Society’s Scientific Statement. “To effectively treat obesity, we need to better understand the mechanisms that cause this phenomenon, and to devise interventions that specifically address them. Our therapeutic focus has traditionally been on achieving weight reduction. Most patients can do this; what they have the most trouble with is keeping the weight off. Healthcare providers and patients need to view this tendency as the body’s expected response to weight loss, rather than as a sign of a failed treatment regimen or noncompliance with treatment,” Schwartz said."

In case you were wondering, the CDC is warning against the consumption of dried placenta capsules because of a risk of group B streptococcal infection.

Why am I so late getting to this news? Anyway: there goes my best baby shower side-hustle idea...