American Medical Association

The Ozempic Aesthetic: Can Anti-Obesity Medications Cause More Harm Than Good?

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Overweight-young-woman-in-glasses-admires-choice-of-clothes-standing-in-front-of-large-mirror-in-stylish-room-reflection-view.

The American Medical Association officially recognized obesity as a disease in June 2013 after decades-long controversy.1 Although lifestyle interventions are promoted as a first-line obesity treatment, the resultant short-term weight loss often fails to improve long-term outcomes.2 In the search for other solutions, glucagon-like peptide-1 (GLP-1) receptor agonists such as tirzepatide (Mounjaro™) and semaglutide (Wegovy® or Ozempic®) have greatly increased in popularity throughout the past year.

However, the media frenzy surrounding tirzepatide and semaglutide has raised concerns about this latest obesity treatment. Originally developed for diabetes, tirzepatide and semaglutide faced widespread drug shortages as celebrities such as Elon Musk and Chelsea Handler accredited the drugs for their weight loss. Resultant backlash attributed the anti-obesity medication boom to fatphobia.3

Still, the myriad of obesity’s biological and psychosocial obstacles can feel insurmountable after lifelong efforts to lose weight. But are GLP-1 receptor agonists the right solution for patients struggling to climb uphill to a “healthy weight”? Or do these injectables amplify disordered eating, weight stigma, and reliance on expensive pharmaceuticals? 

Perhaps it depends on who you ask.

For an insider’s view on this timely topic, we spoke with board-certified bariatric physician Kevin Huffman, DO and leading psychiatrist Michael Olla, MD, both of whom have decades of experience treating obesity and navigating its social implications.

Can BMI Justify Anti-Obesity Injections?

Although obesity is associated with higher risks for type 2 diabetes, certain cancers, mobility issues, and heart disease,1 some experts feel that anthropometric measures such as body mass index (BMI) fail to reflect true health status.

A veteran in his field, Dr. Huffman has treated more than 10,000 patients with obesity and trained and mentored hundreds of physicians and allied healthcare providers. He is also the CEO and founder of AmBari Nutrition and the founder and president of The American Bariatric Consultants. 

Dr. Huffman admits that BMI does not tell the whole story about whether anti-obesity medication makes sense for an individual patient.

“BMI, a useful initial screening tool, necessitates more nuanced considerations when prescribing injectable weight loss medications,” he explains. “We acknowledge the uniqueness of each patient; body composition, fat distribution, metabolic health, and underlying medical conditions significantly influence our decision-making process.” 

He continues, “For instance, certain patients may present with central obesity despite having a lower BMI — this suggests an escalated risk for obesity-related complications. Diabetes or hypertension, obesity-related health issues, may still qualify individuals for intervention despite a slightly lower BMI than the conventional threshold.”

Providing Quality Care in a “Fatphobic” Environment

Medical professionals are far from immune to stigmatizing patients with obesity. Research findings show that over 50% of healthcare professionals attribute obesity to a lack of willpower.4

In addition, more than half of adults with overweight in Western countries report experiencing weight stigma. As a result of this stigma, patients with obesity and overweight are more likely to avoid healthcare.2

According to Dr. Huffman, “Navigating through this deeply ingrained prejudice is crucial when prescribing injectable anti-obesity medications: potent tools in aiding patients on their weight loss journey. Unfortunately, many barriers arise due to the fear and stigma surrounding obesity — these factors tragically deter numerous individuals from pursuing these potentially life-altering treatments.”

https://e.infogram.com/949722e5-602d-4397-b2b2-5878eb0758dc?src=embed

He urges prescribers to approach these conversations with empathy, understanding, and a non-judgmental attitude to foster support and empower patients to access necessary, deserved care for a better quality of life.

Dr. Olla is the medical director at Valley Spring Recovery Center. He is a leading authority figure in the field of psychiatric medicine who focuses on holistic healing, patient well-being, and evidence-based practices.

“Believe it or not, fatphobia or weight bias is a common issue in plenty of medical professionals,” Dr. Olla explains. “Heavier patients tend to encounter lots of medical professionals with weight stigma. In these cases, doctors tend to focus so much on their weight that they ignore other symptoms these patients primarily come in for. This doesn’t just affect patients but also doctors who mean well.”

To address these biases, Dr. Olla encourages medical professionals to have honest conversations with patients before prescribing anti-obesity medications. He suggests openly discussing fatphobia’s potential influence on the decision-making process and explaining the medication’s benefits and risks without pressuring patients to use medication unless medically justified.

According to Dr. Olla, reviewing other treatment options respects a patient’s autonomy and right to make their own treatment decisions.

“The key is to focus on how the drug can help reverse or at least slow down the effects of obesity on the body,” he explains. “This can help the patient understand that their doctor is concerned about their overall health, rather than their weight.”

Weighing the Costs and Benefits of Anti-Obesity Medications

Prescribing anti-obesity medications in today’s cultural climate is no simple task. Physicians must carefully weigh the pros and cons to lead patients to the most appropriate and beneficial treatment path.

“As a doctor myself, I am 50/50 on prescribing weight loss medications,” Dr. Olla shares. “Obviously, you wouldn’t want your patients to develop metabolic or cardiovascular diseases caused by excess weight. However, at the same time, I don’t want to encourage a medication that can only cause more health problems to the patient. In my opinion, there should be more research on how anti-psychotics and weight loss medications could go hand in hand without putting an individual in further danger.”

A multidisciplinary approach is the key to ensuring that patients receive not just comprehensive care, but also unwavering support throughout their weight loss efforts.

According to research findings published in Endocrine Practice, over 70% of healthcare providers believe that anti-obesity medicine as an adjunct to lifestyle counseling is an appropriate therapy that can kick-start weight loss and give patients a greater sense of control over their weight.5

However, clinicans remain hesitant to prescribe anti-obesity medications, with some seeing anti-obesity medication as a short-term solution and others being concerned about safety, efficacy, and cost of staying on these medications. These barriers lead to low prescribing rates, which perpetuates a cycle of low perceived demand and lack of coverage by insurance carriers.6

Dr. Olla also explains how psychiatric comorbidities can complicate obesity treatment. He notes that anti-psychotics and antidepressants can raise hunger levels and cause unwanted weight gain.

“Some patients press for medications that can counteract the side effects,” he says.

He feels that it is not safe to prescribe anti-obesity medication to those with psychiatric conditions, particularly eating disorders. Doing so may increase body weight focus, promote disordered eating habits, increase anorexia risk, and lead to a psychological dependency on weight loss medication.

Aside from psychiatric comorbidities, clinicians must also consider whether a patient has diabetes or other physical conditions. As a bariatric physician, Dr. Huffman explains the counseling differences between those prescribed injectables for weight loss vs type 2 diabetes.

“In managing type 2 diabetes, the counseling provides specific guidance such as carbohydrate counting instructions, recommendations for blood glucose monitoring methods, advice on medication adherence — emphasizing its critical role in the effective management of this condition — and underlining consistency as key when maintaining stable blood sugar levels.”

Dr. Huffman emphasizes that, before prescribing injectables, clinicians should (1) take a holistic approach, (2) assess a patient’s motivation to implement lifestyle changes, and (3) monitor patient adherence to anti-obesity medication regimens. According to him, motivational interviewing and a tailored approach empowers patients to make lasting change.

Leveraging Collaboration to Ensure the Best Treatment

According to Dr. Olla, clinians should remember that they do not need to navigate the complexities of obesity treatment alone. For instance, psychiatrists may work with endocrinologists before prescribing weight loss medications to patients with mental health conditions.

“The expertise of an endocrinologist is needed because anti-psychotic drugs can cause significant weight gain, and careful health monitoring is required,” Dr. Olla explains.

In Dr. Huffman’s practice, prescribing obesity medication is far from the final step in a comprehensive approach to weight management.

“Prescribing patients with injectable weight loss medications necessitates crucial care elements: ongoing support, referrals, and follow-ups,” Dr. Huffman says. “Primarily, I guarantee comprehensive counseling and educational resources for the patients.” 

Dr. Huffman encourages prescribers to refer to registered dietitians for individualized meal plans and exercise specialists or physical therapists for safe and effective exercise programs. Mental health providers, behavioral therapists, and support groups can also play a pivotal role in a patient’s success.

“A multidisciplinary approach is the key to ensuring that patients receive not just comprehensive care, but also unwavering support throughout their weight loss efforts,” he says.

It remains to be seen whether anti-obesity medications will help or hurt in the fight against obesity and weight stigma. However, clinicians can build an army of specialists to not only optimize patient care but also help share the responsibility of treating this weighty issue.

American Medical Association votes to BAN prescription drug commercials.

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AMA board chair-elect Patrice Harris said that the vote “reflects concerns among physicians about the negative impact of commercially-driven promotions,” specifically railing on the drug companies getting people hooked on expensive drugs.

To this point, the United States and New Zealand are the only two countries in the world that allow direct-to-consumer advertising of prescription drugs.  With the push for the ban by one of the most prestigious medical establishments in the country, we should listen.

They are also demanding greater transparency in prescription drug prices and costs.

Other doctors are joining the cause.   Michael Carome, M.D., director of Public Citizen’sHealth Research division, stated: “We agree that such advertising is primarily promotional,” explaining that it is “not educational” and that it “drives up the cost of drugs.”

It is now up to the US Congress to pass the ban.

Watch the video. URL:https://youtu.be/88VEFX2qOIE

Importance of data sharing.

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Withholding information on the clinical significance of genetic variants from the scientific community impedes the progress of research and medicine.

Imagine you are a physician or researcher and seek to get more confirmation on the clinical impact of particular genetic variants. If your search of public databases comes up empty this does not necessarily mean that nothing is known about the mutations in question. Rather, the information may be locked away as a trade secret in a genetic testing company’s proprietary database.

Physicians and their patients are not able to independently verify the medical significance of a testing company’s finding, instead the results have to be taken on blind faith.  Researchers are limited in their knowledge of the vast mutational landscape in genes associated with diseases such as cancer which in turn may limit their understanding of the molecular underpinning of the disease.

Robert Nussbaum, at the University of California, San Francisco, recently pointed out that in other fields of medicine such an approach would be unthinkable. In a Technology Review he said, “Imagine if radiological images or histopathology slides of cancers were examined by a single monopoly holder without the medical community being able to assess and learn from what these images and tissue specimens teach us.” He launched  the Sharing Clinical Reports Project, an initiative to collect de-identified information on genetic testing data on the BRCA1 and 2 genes (as discussed in our August editorial).

With more genetic testing companies likely to enter the market, after the US Supreme Court invalidated some gene patents, the problems caused by proprietary data may increase. Clinicians may now have more options to obtain a genetic test, but, if they go with the less established testing company, they are then left with a suboptimal interpretation with possibly grave implications for the patient.

A resolution  from the American Medical Association passed in June 2013 supports public access to genetic data. The resolution calls for companies, laboratories, researchers and providers to publicly share data on genetic variants in a manner consistent with privacy and HIPAA protections.

Whether such calls will be heeded is another question. In a New York Times OdEd piece aptly named “Our genes, their secrets” the author wonders if the recent Supreme Court decision will prompt genetic testing companies to rely more on this strategy of treating information on the clinical impact of mutations as trade secrets and thereby try to deter competition and ensure revenue.

How can this be prevented? Cook-Deegan et al.  – in a recent article in the European Journal of Human genetics – call for joint action by national health systems,  insurers, regulators, researchers, providers and patients to ensure broad access to information about the clinical significance of variants. Some of their suggestions, besides the promotion of voluntary sharing, include sharing as a condition of payment or regulatory approval of the testing laboratories.

The battle about who may offer certain genetic tests is certainly heating up. Ambry Genetics and Gene by gene, two of the companies now offering BRCA1 and 2 testing, have been sued by Myriad Genetics for patent infringement.  A few days later, on July 12, US senator Patrick Leahy, a democrat from Vermont, wrote to Francis Collins, the director of the NIH, urging him to force Myriad to license the patent on reasonable terms to other parties to ensure affordable life-saving diagnostic tests.  As the federal  agency that provided the funding for the research behind Myriad’s patent  the NIH has the authority to do so, based on a provision in the Bayh-Dole Act that enabled universities to own inventions based on federal funding. Whether it will exercise this authority is unclear. Collin’s reply is still outstanding.

Ambry Genetics disputes that it infringes any of Myriad’s patents and a company spokesperson told Nature Methods that Ambry plans to share their testing data.

If enough companies follow suit, the desirable equilibrium of compensating a company fairly for the cost of its test and at the same time letting the public benefit from the results of these tests should be within reach.

Source: http://blogs.nature.com

 

Brain Imaging Study Confirms Addictive Nature of Processed Carbs.

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Story at-a-glance

  • Using brain imaging, researchers confirm that highly processed carbohydrates stimulate brain regions involved in reward and cravings, promoting excess hunger
  • Previous research has demonstrated that refined sugar is more addictive than cocaine, giving you pleasure by triggering an innate process in your brain via dopamine and opioid signals
  • Food manufacturers have gotten savvy to the addictive nature of certain foods and tastes, including saltiness and sweetness, and have turned addictive taste into a science in and of itself
  • Refined carbohydrates like breakfast cereals, bagels, waffles, pretzels, and most other processed foods quickly break down to sugar, increasing your insulin levels, which eventually leads to insulin resistance.
  • pretzel
  • A staggering two-thirds of Americans are now overweight, and one in four are either diabetic or pre-diabetic.
  • Carb-rich processed foods are a primary driver of these statistics, and while many blame Americans’ overindulgence of processed junk foods on lack of self-control, scientists are now starting to reveal the truly addictive nature of such foods.
  • Most recently, researchers at the Boston Children’s Hospital concluded that highly processed carbohydrates stimulate brain regions involved in reward and cravings, promoting excess hunger.1 As reported by Science Daily:2
  • “These findings suggest that limiting these ‘high-glycemic index’ foods could help obese individuals avoid overeating.”
  • While I don’t agree with the concept of high glycemic foods, it is important that they are at least thinking in the right direction. Also, the timing is ironic, considering the fact that the American Medical Association (AMA) recently declared obesity adisease, treatable with a variety of conventional methods, from drugs to novel anti-obesity vaccines…
  • The featured research is on the mark, and shows just how foolhardy the AMA’s financially-driven decision really is. Drugs and vaccines are clearly not going to doanything to address the underlying problem of addictive junk food.
  • The study, published in the American Journal of Clinical Nutrition3 examined the effects of high-glycemic foods on brain activity, using functional magnetic resonance imaging (fMRI). One dozen overweight or obese men between the ages of 18 and 35 each consumed one high-glycemic and one low-glycemic meal. The fMRI was done four hours after each test meal. According to the researchers:
  • “Compared with an isocaloric low-GI meal, a high-glycemic index meal decreased plasma glucose, increased hunger, and selectively stimulated brain regions associated with reward and craving in the late postprandial period, which is a time with special significance to eating behavior at the next meal.”
  • The study demonstrates what many people experience: After eating a high-glycemic meal, i.e. rapidly digesting carbohydrates, their blood sugar initially spiked, followed by a sharp crash a few hours later. The fMRI confirmed that this crash in blood glucose intensely activated a brain region involved in addictive behaviors, known as the nucleus accumbens.
  • Dr. Robert Lustig, Professor of Pediatrics in the Division of Endocrinology at the University of California, a pioneer in decoding sugar metabolism, weighed in on the featured research in an article by NPR:4
  • “As Dr. Robert Lustig… points out, this research can’t tell us if there’s a cause and effect relationship between eating certain foods and triggering brain responses, or if those responses lead to overeating and obesity.
  • ‘[The study] doesn’t tell you if this is the reason they got obese,’ says Lustig, ‘or if this is what happens once you’re already obese.’ Nonetheless… he thinks this study offers another bit of evidence that ‘this phenomenon is real.’”
  • Previously, Dr. Lustig has explained the addictive nature of sugar as follows:
  • “The brain’s pleasure center, called the nucleus accumbens, is essential for our survival as a species… Turn off pleasure, and you turn off the will to live… But long-term stimulation of the pleasure center drives the process of addiction… When you consume any substance of abuse, including sugar, the nucleus accumbens receives a dopamine signal, from which you experience pleasure. And so you consume more.
  • The problem is that with prolonged exposure, the signal attenuates, gets weaker. So you have to consume more to get the same effect — tolerance. And if you pull back on the substance, you go into withdrawal. Tolerance and withdrawal constitute addiction. And make no mistake, sugar is addictive.”
  • Previous research has demonstrated that refined sugar is more addictive than cocaine, giving you pleasure by triggering an innate process in your brain via dopamine and opioid signals. Your brain essentially becomes addicted to stimulating the release of its own opioids.
  • Researchers have speculated that the sweet receptors located on your tongue, which evolved in ancestral times when the diet was very low in sugar, have not adapted to the seemingly unlimited access to a cheap and omnipresent sugar supply in the modern diet.

    Therefore, the abnormally high stimulation of these receptors by our sugar-rich diets generates excessive reward signals in your brain, which have the potential to override normal self-control mechanisms, thus leading to addiction.

  • But it doesn’t end there. Food manufacturers have gotten savvy to the addictive nature of certain foods and tastes, including saltiness and sweetness, and have turned addictive taste into a science in and of itself.
  • In a recent New York Times article,5 Michael Moss, author of Salt Sugar Fat, dished the dirt on the processed food industry, revealing that there’s a conscious effort on behalf of food manufacturers to get you hooked on foods that are convenient and inexpensive to make.

    I recommend reading his article in its entirety, as it offers a series of case studies that shed light on the extraordinary science and marketing tactics that make junk food so hard to resist.

  • Sugar, salt and fat are the top three substances making processed foods so addictive. In a Time Magazine interview6discussing his book, Moss says:
  • “One of the things that really surprised me was how concerted and targeted the effort is by food companies to hit the magical formulation. Take sugar for example. The optimum amount of sugar in a product became known as the ‘bliss point.’ Food inventors and scientists spend a huge amount of time formulating the perfect amount of sugar that will send us over the moon, and send products flying off the shelves. It is the process they’ve engineered that struck me as really stunning.”
  • It’s important to realize that added sugar (typically in the form of high fructose corn syrup) is not confined to junky snack foods. For example, most of Prego’s spaghetti sauces have one common feature, and that is sugar—it’s the second largest ingredient, right after tomatoes. A half-cup of Prego Traditional contains the equivalent of more than two teaspoons of sugar.
  • Another guiding principle for the processed food industry is known as “sensory-specific satiety.” Moss describes this as “the tendency for big, distinct flavors to overwhelm your brain, which responds by depressing your desire to have more.” The greatest successes, whether beverages or foods, owe their “craveability” to complex formulas that pique your taste buds just enough, without overwhelming them, thereby overriding your brain’s inclination to say “enough.”
  • Novel biotech flavor companies like Senomyx also play an important role.
  • Senomyx specializes in helping companies find new flavors that allow them to use less salt and sugar in their foods. But does that really make the food healthier? This is a questionable assertion at best, seeing how these “flavor enhancers” are created using secret, patented processes. They also do not need to be listed on the food label, which leaves you completely in the dark. As of now, they simply fall under the generic category of artificial and/or natural flavors, and they don’t even need to be tested for safety, as they’re used in minute amounts.

·         Brain Imaging Shows Food Addiction Is Real

·         The Extraordinary Science of Addictive Junk Food

·         Novel Flavor-Enhancers May Also Contribute to Food Addiction

How to Combat Food Addiction and Regain Your Health

To protect your health, I advise spending 90 percent of your food budget on whole foods, and only 10 percent on processed foods. It’s important to realize that refined carbohydrates like breakfast cereals, bagels, waffles, pretzels, and most other processed foods quickly break down to sugar, increase your insulin levels, and cause insulin resistance, which is the number one underlying factor of nearly every chronic disease and condition known to man, including weight gain.

By taking the advice offered in the featured study and cutting out these high-glycemic foods you can retrain your body to burn fat instead of sugar. However, it’s important to replace these foods with healthy fats, not protein—a fact not addressed in this research. I believe most people may need between 50-70 percent of their daily calories in the form of healthful fats, which include:

Olives and olive oil Coconuts and coconut oil Butter made from raw, organic grass-fed milk
Organic raw nuts, especially macadamia nuts, which are low in protein and omega-6 fat Organic pastured eggs and pastured meats Avocados

 

I’ve detailed a step-by-step guide to this type of healthy eating program in my comprehensive nutrition plan, and I urge you to consult this guide if you are trying to lose weight. A growing body of evidence also suggests that intermittent fasting is particularly effective if you’re struggling with excess weight as it provokes the natural secretion of human growth hormone (HGH), a fat-burning hormone. It also increases resting energy expenditure while decreasing insulin levels, which allows stored fat to be burned for fuel. Together, these and other factors will turn you into an effective fat-burning machine.

Best of all, once you transition to fat burning mode your cravings for sugar and carbs will virtually disappear, as if by magic… While you’re making the adjustment, you could try an energy psychology technique called Turbo Tapping, which has helped many sugar addicts kick their sweet habit. Other tricks to help you overcome your sugar cravings include:

  • Exercise: Anyone who exercises intensely on a regular basis will know that significant amounts of cardiovascular exercise is one of the best “cures” for food cravings. It always amazes me how my appetite, especially for sweets, dramatically decreases after a good workout. I believe the mechanism is related to the dramatic reduction in insulin levels that occurs after exercise.
  • Organic black coffee: Coffee is a potent opioid receptor antagonist, and contains compounds such as cafestrol — found plentifully in both caffeinated and decaffeinated coffee — which can bind to your opioid receptors, occupy them and essentially block your addiction to other opioid-releasing foods.7 This may profoundly reduce the addictive power of other substances, such as sugar.

Source: mercola.com

 

Physician Groups Recommend Steps to Limit Overuse of Five Treatments.

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A physician consortium convened by the American Medical Association and the Joint Commission has released recommendations aimed at reducing the unnecessary use of five interventions. Here’s a quick look at the targeted interventions, including steps to limit their use:

  • Antibiotic therapy for viral upper respiratory infections: Develop clinical definitions for viral versus bacterial URIs.
  • Over-transfusion of red blood cells: Create a toolkit of educational materials for clinicians, broaden education on transfusion alternatives.
  • Tympanostomy tubes for short-duration middle ear effusion: Develop performance measures to assess appropriate use.
  • Early-term, nonmedically indicated elective delivery: Educate patients about the risks, standardize how gestational age is determined.
  • Elective percutaneous coronary intervention: Encourage patient understanding of both the benefits and risks.

“The recommendations … will raise awareness that will help both doctors and patients make better decisions going forward, and ultimately improve quality and patient safety,” the president of the Joint Commission said in a news release.

Source: Joint Commission news

Burnout burden high among US physicians.

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Burnout appears to be more common among physicians than among other adults working in the United States, with nearly half of those who participated in a national survey reporting at least one symptom of burnout, data published in the Archives of Internal Medicine suggest.

Previous studies have examined the link between burnout and quality of care, increased risk for error and its role in physicians’ relationships, alcohol abuse and suicidal ideation. However, according to the study researchers, the June 2011 national survey is the first to evaluate the rates of burnout among a large, diverse sample of US physicians.

Study results

Tait D. Shanafelt, MD, of the department of internal medicine at Mayo Clinic in Rochester, Minn., and colleagues obtained a sample of physicians from all specialties from the American Medical Association Physician Masterfile. Of the 27,276 physicians who received an initial invitation to participate, 7,288 physicians completed the surveys. To develop a comparison with the general US population, researchers also surveyed a probability-based sample of 3,442 working US adults aged 22 to 65 years.

 

Researchers measured three domains of burnout — emotional exhaustion, depersonalization and low personal accomplishment — using the Maslach Burnout Inventory. The Primary Care Evaluation of Mental Disorders assessment was used to measure symptoms of depression, and other questions were asked to assess work–life balance concerns.

According to data, 45.8% of physicians reported at least one symptom of burnout; 37.9%, high emotional exhaustion; 29.4%, high depersonalization; and 12.4% expressed a low level of personal accomplishment.

Study researcher Liselotte N. Dyrbye, MD, MHPE, associate director of research applications in the department of medicine program on physician well-being at Mayo Clinic in Rochester, Minn., told Endocrine Today that characteristics of the job may account for the high prevalence of burnout among physicians.

“Given that nearly 50% of physicians have burnout, the problem stems from environment/work-related factors rather than character flaws/personal characteristics of a few susceptible physicians,” Dyrbye said.

Physicians in emergency medicine (P<.001), general internal medicine (P<.001), neurology (P<.01), radiology (P=.02) and family medicine (P=.001) had the highest rates of burnout. Those in pathology, dermatology, general pediatrics and preventive medicine, including occupational health and environmental medicine, had the lowest rates, researchers wrote.

Moreover, compared with the general population control group, physicians were more likely to have symptoms of burnout (37.9% vs. 27.8%) and be dissatisfied with work–life balance (40.2% vs. 23.2%).

“The study confirms that there is an alarmingly high prevalence of burnout among physicians, with the highest among physicians who are in the front line of care (family medicine, general internal medicine, ER) and among those who work longer hours. Burnout and struggles with work–life balance are greater for physicians than other US workers,” Dyrbye said.

A pooled multivariate analysis adjusted for age, sex, relationship status and hours worked per week also revealed an association between level of education and burnout. When compared with workers with high school degrees, physicians with DO or MD degrees had a higher risk for burnout (OR=1.36; P<.001) than those with bachelor’s degrees (OR=0.8; P=.048), master’s degrees (OR=0.71; P=.01) or professional or doctoral degrees other than DO or MD (OR=0.64; P=.04).

Implications

Drybye said the researchers hope the study results will generate discussion on how to address the problem of burnout.

“We hope that this study will fuel a national dialogue about how to minimize burnout. Efforts are needed to identify and address the work-related factors that are contributing to burnout among physicians. To date, the issue of physician burnout has not surfaced in any meaningful way during discussions of how to reform health care delivery,” Dyrbye said.

Besides this study, Dyrbye said she and Shanafelt have also written an article on how burnout threatens the success of health care reform regarding the Affordable Care Act.

“It isn’t so much preventive medicine subspecialists, but rather general internal medicine, general pediatrics and family medicine physicians who are most likely to be seeing more patients. This will place an additional strain on physicians in the front lines — many of whom are already struggling with burnout,” Dyrbye said.

The researchers wrote that it is up to policymakers and health care organizations to address this problem “for the sake of physicians and their patients.” – by Samantha Costa

For more information:

Shanafelt TD. Arch Intern Med. 2012;doi:10.1001/archinternmed.2012.3199.

Andrew F. Stewart

  • This is an interesting and important paper documenting that burnout and adverse work–life balance issues affect physicians disproportionately as compared to other US workers; and to explore the reasons for this. The results suggest, with appropriate cautions regarding limitations and confounders, that certain specialties within medicine are more severely affected than others.

With regard to the field of endocrinology, no specific information is available, since the many disparate general internal medicine subspecialties are combined into a single group. Thus, high-earning proceduralists (eg, cardiology, pulmonary, GI physicians with better personnel support systems) are lumped together with lower earning RVU/E&M coding non-proceduralists (eg, rheumatology, endocrinology, infectious disease physicians with little personnel or other ancillary support). One might reasonably infer that endocrinologists are most akin to family practitioners and general internal medicine physicians who are disproportionately affected by burnout and work–life balance issues. The authors may want to share their database with subspecialties for subset analysis, or analyze it more deeply themselves to see whether trends exist in specific subspecialties. This information would be of value to the Department of Health and Human Services, the AMA and other agencies interested in managing and financing health care reform.

As the authors point out, most studies in this area offer little in the way as to guidance regarding burnout- and life balance-prevention measures, other than counseling and support measures, and fail to address the organizational, procedural and support issues that lead to the occurrence of what is an obvious problem.

As they also point out, work–life balance issues and burnout predict both work force dropout and lower levels of quality of patient care.  There is no attempt to quantify these in the current study. This would be an attractive area for further study.

Overall, this is a timely and important study, although much more remains to be done analytically, and also with regard to interventions.

Source: Endocrine Today.

 

Unplug! Too Much Light at Night May Lead to Depression.

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When you climb into bed for the night, is your bedroom “littered” with dim light from streetlights, passing traffic, a computer, night-light or television set?

Even if the light is so dim that you can easily sleep through it, light pollution can prompt biological changes that have a very significant, and potentially serious, impact on your physical and mental health.

Obvious examples would be the glow that can be seen from miles outside of a big city, or the absence of stars in the night sky if you live in an urban environment.

More subtle examples of light pollution are the strips of light that come in around your curtains at night, or even the glow from your clock radio.

All of these light sources disrupt the natural rhythms of nature, as like most other creatures, humans need darkness. When this natural rule is violated, the consequences can be steep …

Dim Light at Night May Lead to Depression

A study done with hamsters at Ohio State University Medical Center has found that chronic exposure to dim light at night can cause signs of depression after just a few weeks.1 The study also showed changes in the hamsters’ hippocampus similar to brain changes seen in depressed people.  They pointed out that rates of depression have risen along with exposure to artificial light at night:

“Exposure to artificial light at night (LAN) has surged in prevalence during the past 50 years, coinciding with rising rates of depression.”

The link could be due to the production of the hormone melatonin, which is interrupted when you’re exposed to light at night. There are many studies that suggest melatonin levels (and by proxy light exposures) control mood-related symptoms, such as those associated with depression — especially winter depression (aka, seasonal affective disorder, or SAD).

In a study published by researchers at the Oregon Health and Science University (OHSU), it was found that melatonin relieved SAD.2 The study found insomniacs have a circadian misalignment in which they are “out of phase” with natural sleeping times.

This misalignment can be corrected either by exposure to bright lights (during daylight hours), or by taking a melatonin supplement at a certain time of day. While your body will begin to produce melatonin only after it’s dark outside, the level of melatonin produced is related to the amount of exposure you have had to bright sunshine the previous day; the less bright light exposure the lower your melatonin levels.

Yet another study about melatonin and circadian phase misalignment found a correlation between circadian misalignment and severity of depression symptoms.3

Studies have also linked low melatonin levels to depression in a variety of populations, including multiple sclerosis patients4 and post-menopausal women.5 Clearly, anything that negatively effects melatonin production is likely to have a detrimental effect on your mood. Melatonin’s immediate precursor is the neurotransmitter serotonin, which is a major player in uplifting your mood.

Too Much Light at Night May Also Contribute to Cancer

Normally, your brain starts secreting melatonin around 9 or 10 pm, which makes you sleepy. These regularly occurring secretions thus help regulate your sleep cycle.

The good news is the condition appears to be reversible by simply going back to regular light-dark cycles and minimalizing exposure to artificial light at night. But when light receptors in your eyes are triggered, such as by the glow from your television set, they signal your brain to ‘stay awake.’ To do that, your brain stops secreting melatonin, which is not only a hormone but also a potent antioxidant against cancer.

Melatonin is secreted primarily in your brain and at night it triggers a host of biochemical activities, including a nocturnal reduction in your body’s estrogen levels. It’s thought that chronically decreasing your melatonin production at night — as occurs when you’re exposed to nighttime light – thereby allows your body to be exposed to higher estrogen levels, which increases your risk of developing estrogen-sensitive cancers, such as breast cancer.6

In addition to dampening your mood and increasing your cancer risk, a confused body clock from too much light exposure at night can result in increased appetite and unwanted weight gain.

Light at Night Might Even Make You Fat

Exposure to light during the night can seriously impact your body’s internal clock, even leading to metabolic changes and weight gain. In fact, mice that were exposed to dim light during the night gained 50 percent more weight over an eight-week period than mice kept in complete darkness at night.7 They also had increased levels of glucose intolerance, a marker for pre-diabetes.

The weight gain occurred even though the mice were fed the same amount of food and had similar activity levels, and the researchers believe the findings may hold true for humans as well.

When mice were exposed to nighttime light, they ended up eating more of their food when they would normally be sleeping and this lead to significant weight gain. However, in a second experiment when researchers restricted meals to times of day when the mice would normally eat, they did not gain weight, even when exposed to light at night.

This suggests that the timing of your meals, for instance eating late at night when you’d normally be sleeping, may throw off your body’s internal clock and lead to weight gain. In this case, the artificial light, such as a glow from your TV or computer, can serve as a stimulus for keeping you awake and, possibly, eating, when you should really be asleep.

In other words, while it’s typically thought that your biological clock is what tells you when it’s time to wake up or go to sleep, light and dark signals actually control your biological clock. In turn, your biological clock regulates your metabolism. So when your light and dark signals become disrupted it not only changes the times you may normally eat, it also throws your metabolism off kilter, likely leading to weight gain.

More Consequences of Nighttime Light Exposure

Your circadian rhythm has evolved over many centuries to align your physiology with your environment. However, it is operating under the assumption that you’re still behaving as your ancestors have for countless generations: sleeping at night and being awake during the day.

If you push these limits by staying up late at night, depriving yourself of sleep, or even being exposed to the glow from your computer when you should be sleeping, your body doesn’t know whether it should be producing chemicals to tell you to go to sleep, or gear up for the beginning of your day.

But maintaining this natural circadian rhythm affects far more than just your sleep pattern. Your body actually has many internal clocks — in your brain, lungs, liver, heart and even your skeletal muscles — and they all work to keep your body running smoothly by controlling temperature and the release of hormones.

Disrupting your natural rhythm can also make you more vulnerable to disease, including not only cancer, as mentioned above, but also many others. A report from the American Medical Association highlighted the health risks that changes in circadian rhythms pose: 8

  • Carcinogenic effects related to melatonin suppression, especially breast cancer
  • Obesity
  • Diabetes
  • Depression and mood disorders
  • Reproductive problems

Researchers concluded:

“The natural 24-hour cycle of light and dark helps maintain precise alignment of circadian biological rhythms, the general activation of the central nervous system and various biological and cellular processes, and entrainment of melatonin release from the pineal gland. Pervasive use of nighttime lighting disrupts these endogenous processes and creates potentially harmful health effects and/or hazardous situations with varying degrees of harm.”

The Damage is Reversible!

Even though too much light at nighttime causes undeniable health damage, it appears you can undo some of the harm by turning out the lights … in the featured study, the hamsters depressive symptoms went away when they were allowed eight hours of darkness each day.

For you, this may mean turning off your laptop and television earlier than normal, or conducting a light check of your bedroom to wipe out any light pollution creeping in. Even very low levels of light can be enough to suppress melatonin production, so it’s important to keep your sleeping environment as pitch-black as possible. If your bedroom is currently affected by light pollution, you will notice a major improvement when you eliminate it.  To get your room as dark as possible, consider taking the following actions:

  • Install blackout drapes
  • Close your bedroom door if light comes through it; if light seeps in underneath your door, put a towel along the base
  • Wear an effective face mask that blocks out light — a very inexpensive solution and very easy to implement when you are travelling. Many hotels I stay at during my travels do not have blackout drapes so I use this to get darkness at night. Also useful for sleeping on planes at night.
  • Get rid of your electric clock radio (or at least cover it up at night)
  • Avoid night lights of any kind
  • Keep all light off at night (even if you get up to go to the bathroom) — and this includes your computer and TV (computer screens and most light bulbs emit blue light, to which your eyes are particularly sensitive simply because it’s the type of light most common outdoors during daytime hours. As a result, they can disrupt your melatonin production)
  • If possible, avoid working any night shifts.
  • Please note that red light has a wavelength that has minimal impact on your melatonin production. I actually use a red LED alarm clock in my normally very dark room so I know what time it is, as the alarm will cause adrenal stress.

Source: By Dr. Mercola