Kennedy vs. Musk
Two competing views on our way out of the obesity epidemic
A few years ago, an economist I care for sent me an email asking if she could talk to me about a medical issue. She said she didn’t need to see me as the question was academic rather than personal. Her question had grown out of a conversation she had had with her students.
“When someone’s cholesterol is high, the standard of care seems to be to recommend a period of “lifestyle modification” before prescribing a statin. Why in the world is this the case? For an insured patient, the drug is basically free and its effect essentially guaranteed. Lifestyle modification is not free – the person has to change their behavior – and is unlikely to work, either because they will fail in behavioral change or they will succeed but their cholesterol will remain high.”
She argued that our approach was irrational, not considering the relative values of each strategy. She added that in a cost-effectiveness evaluation, immediate statin use, would clearly win out, as long as we were discussing people at reasonably high risk for cardiovascular disease.
I laughed, and told her she needed to get out more and talk to actual people rather than just to economists. If we are talking about “preventative treatment” in asymptomatic people, pretty much all of my patients (including economists and engineers), are resistant to starting medications. In fact, the only time asymptomatic people seek medications is, recently, when they are asking for a GLP-1 RA for weight loss.
My conversation with this economist patient came to mind yesterday when I saw this headline in The New York Times.
Kennedy’s approach to the obesity epidemic is clear: “The first line of response should be lifestyle.” Given the angst that RFK Jr. has caused in the halls of medicine with his anti-vaccine pronouncements, his approach here is totally in line with the current medical practice.
Musk’s approach is much more “economist-like:”
For me -- an avowed minimalist, medical conservative, and “EBM-guy” -- this is an interesting debate. Though I’d rather heed toward either of these two, my minimalism has me leaning toward RFK while dedication to evidence-based practice has me leaning toward Musk. For anyone who has practiced medicine, or followed the GLP1-RA literature, or tried to lose weight, it would seem that Musk’s approach is the correct one. Here is the weight loss figure from the semaglutide study in the NEJM from 2021, plotting the effect of semaglutide against that of placebo plus lifestyle intervention.
Now, certainly, the real winner is not clear. We have no idea if a greater commitment to lifestyle modification or adherence to GLP-1 RAs will win out.
We have not had the time or the medication supply to determine whether people on the GLP-1 RAs are willing to stay on them indefinitely. These drugs are a treatment for obesity, not a cure.
Only now, as we expose greater and greater numbers of people to long term GLP-1 RA treatment, will we really know the safety of these medications.
Weight loss is both an endpoint in itself and a surrogate for control of hypertension, diabetes, osteoarthritis, and overall mortality. It is the benefit in these latter endpoints that will save healthcare dollars.
Comparing the actual costs and benefits of these to two approaches to weight loss is unimaginably difficult. Sure the drugs are expensive but the savings from effectively managing obesity in 40% of Americans is sure to be enormous. But, imagine the savings that could be wrought by converting to a more natural food supply. Effectively managing obesity through the adoption of a less calorie dense, plant based diet would go a ways toward addressing the climate crisis.
So, where do you stand?
Are you a Kennedy – a dreamer, believing that we can lifestyle our way out of the obesity epidemic?
Or are you a Muskian rationalist, willing to extrapolate the data to national weight loss (and pharma riches)?
And, a reminder, if you are still short on holiday presents, there are still some Sensible Medicine T-shirts to be had!
As an Italian doctor and an atheist one at that, I'm just appalled. Human life, human health, human body, in Western culture have become nothing less nothing more than utilities, whose value is measured in dollars, healthcare dollars, and tax-payer dollars. As such, your life, health and body are not even yours, as the vaccine mandates have made clear during the pandemic. They are utilities whose protection is taken over by "authorities", be they scientists, politicians, administrators, or your employer. The embryo and the fetus can be lawfully terminated if their life is an inconvenience, your spermatozoa and egg cells can be sold, and your womb can be borrowed or lent, it's only a matter of dollars. If it's better for you to live a healthy life in order to have a healthy body (and a healthy mind) or to live a trashy one adding to it some chemicals to derange some specific bodily functions in order to lose weight, is only a matter of dollars.
I'm not appalled that this is the way of thinking that the super narcissist super rich want to force on us. I'm appalled that they are succeeding so well in the medical community.
Adam. 1) Cholesterol does not cause CVD. Any mention of it is irrelevant to this 'storm in a tea cup. 2) RFKjr is not and 'anti-vaxxer'. Any mention of it is unnecessary in this 'essay'. This could be so much better if not written at all. Where you copied that headline from says all. That medium is the message.