Pentagon Seeks To Justify Syria Occupation Through More Raids On ISIS

 US Central Command announced Monday that US commandos conducted a successful early morning helicopter raid on an ISIS hideout in northern Syria, resulting in the death of a suspected senior Syrian ISIS leader.

CENTCOM said the target, Abd-al-Hadi Mahmud al-Haji Ali, has been confirmed killed, in an operation that was launched based on intelligence saying ISIS was plotting to kidnap officials abroad. But US officials didn't name any target countries where such plots might be executed.

"We know ISIS retains the desire to strike beyond the Middle East," CENTCOM spokesman Col. Joe Buccino asserted in a statement. "This raid deals a significant blow to ISIS operations in the region but does not eliminate ISIS’ capability to conduct operations."

"Two other armed individuals were killed on the target," the statement continued, and claimed that no civilians were killed or injured in the raid. Additionally, CENTCOM Commander Gen. Erik Kurilla described: "Though degraded, ISIS remains able to conduct operations within the region with a desire to strike beyond the Middle East," and vowed to "continue the relentless campaign against ISIS."

Lately there have been bipartisan efforts to force President Biden to pull all American troops out of Syria. So far these Congressional moves have failed, but it has increased the pressure on the administration and the Pentagon to seek to justify the years-long occupation. 

The "answer" has been to attempt to show the American public that ISIS remains a threat that "requires" the Pentagon's ongoing presence. But the reality is that the US is occupying the country's oil and gas producing region, effectively blocking the Assad government and population from accessing its own vital resources, also at a moment of Washington's far-reaching sanctions which has increased the suffering of common people. 

But it's also true that ISIS continues to strike, as international reports highlighted over the weekend:

A truffle hunter was killed Sunday by a suspected ISIS fighter in the Syrian desert.

The civilian was in the Hama province, east of the city of Hama when an unknown gunman shot and killed him, the Syrian Observatory for Human Rights reports. The killing is the latest example of the dangers of hunting for the edible underground desert fungus.

Twelve more civilians were also attacked in the area. They were said to be members of the Al-Bosraya tribe, according to SOHR. Four escaped while the other eight have not been unaccounted for. Hunters were also fired upon, again by suspected ISIS members, on Saturday.

Truffle trapping is a common practice in Syria where truffles command a high price on the market. They can be sold for up to $35 per kilogram, The New York Times reports. Hunters may earn more than $400 per day by selling what they find.

There have been other reports of a spate of killings related to impoverished Syrians collecting truffles, likely by ISIS:

The Syrian Army and its Russian and Iranian partner forces have also been directly waging war on remnant ISIS terrorists. All three countries have actually at various times accused the US of allowing ISIS and other Islamist terrorists cells to fester, in order to falsely justify the ongoing occupation of a sovereign country.

https://www.zerohedge.com/military/pentagon-seeks-justify-syria-occupation-through-more-raids-isis

LGBTQ+ Youth Consult Questions Remain Over the Use of Sex Hormone Therapy

 “They Paused Puberty but Is There a Cost?”

“Bone Health: Puberty Blockers Not Fully Reversible.”

M. Brett Cooper, MD

Headlines such as these from major national news outlets have begun to cast doubt on one of the medications used in treating gender-diverse adolescents and young adults. GnRH agonists, such as leuprorelin and triptorelin, were first approved by the Food and Drug Administration in the 1980s and have been used since then for a variety of medical indications. In the decades since, these medications have been successfully used with a generally favorable side effect profile.

GnRH agonists and puberty

In the treatment of precocious puberty, GnRH agonists are often started prior to the age of 7, depending on the age at which the affected patient begins showing signs of central puberty. These include breast development, scrotal enlargement, and so on. GnRH agonists typically are continued until age 10-12, depending on the patient and an informed discussion with the patient’s parents about optimal outcomes.^[1] Therefore, it is not uncommon to see these medications used for anywhere from 1 to 4 years, depending on the age at which precocious puberty started.

GnRH agonists are used in two populations of transgender individuals. The first group is those youths who have just started their natal, or biological, puberty. The medication is not started until the patient has biochemical or physical exam evidence that puberty has started. The medication is then continued until hormones are started. This is usually 2-3 years on average, depending on the age at which the medication was started. This is essentially comparable with cisgender youths who have taken these medications for precocious puberty. The second population of individuals who use GnRH agonists is transgender women who are also on estrogen therapy. In these women, the GnRH agonist is used for androgen (testosterone) suppression.

Concerns over bone health

One of the main concerns recently expressed about long-term use of GnRH agonists is their effect on bone density. Adolescence is a critical time for bone mineral density (BMD) accrual and this is driven by sex hormones. When GnRH agonists are used to delay puberty in transgender adolescents, this then delays the maturation of the adult skeleton until the GnRH agonist is stopped (and natal puberty resumes) or cross-sex hormones are started. In a recent multicenter study^[2] looking at baseline BMD of transgender youth at the time of GnRH agonist initiation, 30% of those assigned male at birth and 13% of those assigned female at birth had low bone mineral density for age (defined as a BMD z score of <–2). For those with low BMD, their physical activity scores were significantly lower than those with normal BMD. Thus, these adolescents require close follow-up, just like their cisgender peers.

There are currently no long-term data on the risk of developing fractures or osteoporosis in those individuals who were treated with GnRH agonists and then went on to start cross-sex hormone therapy. Some studies suggest that there is a risk that BMD does not recover after being on cross-sex hormones,^[3] while another study suggested that transgender men recover their BMD after being on testosterone.^[4] It is still unclear in that study why transgender women did not recover their BMD or why they were low at baseline. Interestingly, a 2012 study^[5] from Brazil showed that there was no difference in BMD for cisgender girls who had been off their GnRH agonist therapy for at least 3 years, as compared with their age-matched controls who had never been on GnRH agonist therapy. These conflicting data highlight the importance of long-term follow-up, as well as the need to include age-matched, cisgender control subjects, to better understand if there is truly a difference in transgender individuals or if today’s adolescents, in general, have low BMD.

Lingering questions

In summary, the use of GnRH agonists in transgender adolescents remains controversial because of the potential long-term effects on bone mineral density. However, this risk must be balanced against the risks of allowing natal puberty to progress in certain transgender individuals with the development of undesired secondary sex characteristics. More longitudinal studies are needed to better understand the long-term risks of osteoporosis and fractures in those who have undergone GnRH agonist therapy as part of their gender-affirming medical care, as well as any clinical interventions that might help mitigate this risk.

Dr. M. Brett Cooper is assistant professor of pediatrics at UT Southwestern, Dallas, and an adolescent medicine specialist at Children’s Medical Center Dallas.

https://www.medscape.com/viewarticle/990809

Social Media Is Fueling Enthusiasm for New Weight Loss Drugs. Are Regulators Watching?

 Suzette Zuena is her own best advertisement for weight loss.

Zuena, the "founder/visionary" of LH Spa & Rejuvenation in Livingston and Madison, New Jersey, has dropped 30 pounds. Her husband has lost 42 pounds.

"We go out a lot," Zuena said of the pair's social routine. "People saw us basically shrinking." They would ask how the couple did it. Her response: Point people to her spa and a relatively new type of medication — GLP-1 agonists, a class of drug that's become a weight loss phenomenon.

But she's not just spreading her message in person. She's also doing it on Instagram. And she's not alone. A chorus of voices is singing these drugs' praises. Last summer, investment bank Morgan Stanley found mentions of one of these drugs on TikTok had tripled. People are streaming into doctors' office to inquire about what they've heard are miracle drugs.

What these patients have heard, doctors said, is nonstop hype, even misinformation, from social media influencers. "I'll catch people asking for the skinny pen, the weight loss shot, or Ozempic," said Priya Jaisinghani, an endocrinologist and clinical assistant professor at New York University's Grossman School of Medicine.

Competition to claim a market that could be worth $100 billion a year for drugmakers alone has triggered a wave of advertising that has provoked the concern of regulators and doctors worldwide. But their tools for curbing the ads that go too far are limited — especially when it comes to social media. Regulatory systems are most interested in pharma's claims, not necessarily those of doctors or their enthused patients.

Few drugs of this type are approved by the FDA for weight loss — they include Novo Nordisk's Wegovy. But after shortages made that treatment harder to get, patients turned to other pharmaceuticals — like Novo Nordisk's Ozempic and Eli Lilly's Mounjaro — that are approved only for Type 2 diabetes. Those are often used off-label — though you wouldn't hear that from many of their online boosters.

The drugs have shown promising clinical results, Jaisinghani and her peers emphasize. Patients can lose as much as 15% of their body weight. Novo Nordisk is sponsoring research to examine whether Wegovy causes reductions in the rate of heart attacks for patients with obesity.

The medications, though, come at a high price. Wegovy runs patients paying cash at least $1,305 a month in the Washington, D.C., area, according to a GoodRx search in late March. Insurers only sometimes cover the cost. And patients typically regain much of their lost weight after they stop taking it.

Hype Is Driving Demand

But patients are not necessarily coming to doctors' offices now because of the science. They are citing things they saw on TikTok, like Chelsea Handler and other celebrities talking about their injections. It leads to the questions "how come she can get it" and "why can I not," said Juliana Simonetti, a physician and co-director of the comprehensive weight management program at the University of Utah.

The excitement — which doctors worry may cause some patients to use medications inappropriately — is coming also from business interests. Some are doctors promoting their venture-capital-backed startups. Others are spas hawking everything from wrinkle-smoothing and lip-plumping to, yes, weight loss benefits of semaglutide, the active ingredient in Wegovy and Ozempic; their prices, often in the hundreds of dollars, are well below what consumers would pay if picking up the prescription at a pharmacy.

In the U.S., the FDA has oversight over ads from the pharmaceutical industry, which must acknowledge risks and side effects of drugs. But ads from people who write prescriptions don't necessarily have the same restrictions. FDA regulations apply if the prescriber is working on behalf of a regulated entity, like a pharmaceutical manufacturer or distributor.

"The FDA is also committed to working with external partners, including the Federal Trade Commission (FTC), to address concerns with prescription drug marketing practices of telehealth companies on various platforms, including social media," agency spokesperson Jeremy Kahn emailed KFF Health News.

Pharma firms run campaigns to educate health care professionals or raise "awareness" that may indirectly tout drugs. Novo Nordisk has an ongoing internet campaign to redefine and destigmatize how Americans think of obesity — and, left unmentioned, the drugs that treat it.

KFF Health News also found that, beyond the industry group's examination, at least two other entities were promoting Novo Nordisk products in the United Kingdom.

Australian regulators have taken down nearly 1,900 ads as of early March for improperly plugging various GLP-1 agonists, an agency spokesperson told KFF Health News. Novo Nordisk says it didn't put up the ads, the majority of which were for their product Ozempic. The regulators are declining to say who's involved.

Doctors are also sounding alarms about the publicity. They believe patients will be driven to use these medications off-label, obtain unreliable forms of these drugs, or exacerbate other health conditions, like eating disorders. The drugs act in part as an appetite suppressant, which can dramatically reduce calorie intake to a concerning degree when not paired with nutritional guidance.

Elizabeth Wassenaar, a regional medical director for the Eating Recovery Center, believes the drugs and associated advertising buildup will inadvertently trigger eating disorders. KFF Health News found ads showing thin patients measuring themselves with a tape measure and stepping on the scale, with accompanying captions goading viewers into going on GLP-1s.

"They're being marketed very, very pointedly to groups that are vulnerable to experiencing body image dissatisfaction," she said.

Remi Bader, a curve model and TikTok creator specializing in documenting her "realistic" clothing buys, told one podcast her story of coming off a "few months" on Ozempic. She said she gained twice the weight back and that her binge eating disorder got "so much worse." One study, published in the journal Diabetes, Obesity and Metabolism, found two-thirds of lost weight came back after discontinuation of semaglutide.

But social media users and influencers — whether with white coats or ordinary patients — are hopping on every platform to spread news of positive weight loss outcomes. There are those, for instance, who had gastric bypass surgery that didn't work and are now turning to TikTok for guidance, support, and hope as they begin taking a GLP-1. There's even a poop-centric Facebook group in which people discuss the sometimes fraught topic of the drugs' effect on their bowel movements.

Commercialism and Compounding Spark Excitement and Concern

Some have been so delighted by their medication-assisted weight loss they have become brand ambassadors. Samantha Klecyngier has dropped at least 58 pounds since she started on Mounjaro. She heard of the drug and her telemedicine weight loss program, Sequence, on TikTok. She and many others who have experienced considerable weight loss since starting the medication regimen point to its positive impact and their improved quality of life. Now she officially promotes the company on the app.

Though Klecyngier, a mother of two from the Chicago area, is not diabetic, she uses Mounjaro. When she was growing up, her parents had Type 2 diabetes and other chronic diseases that led them both to have open-heart surgery. Her father lost his life to complications of diabetes. She wants to avoid that fate.

But Klecyngier's story — combining a personal journey with a profit-making entity — is symbolic of another trend on social media: commercialism. There's a spate of startups eyeing big money matching pharmaceuticals and related support with patients. (Sequence, the company Klecyngier pitches, just got acquired by WW, also known as WeightWatchers.)

Some doctors use social media to educate viewers about the drugs. Michael Albert, chief medical officer of telehealth practice Accomplish Health, says offering information to his more than 250,000 followers has helped point patients to the medical practice. It's received thousands of patient inquiries, more than the clinic can take on.

Companies like Accomplish — startups with well-credentialed doctors — are the glossy side of this social media boom.

But there are others — like many spas and weight loss centers — that offer the drugs, sometimes without much medical support, often alongside Botox and dermal fillers. Obesity doctors worry such marketing is creating unrealistic expectations.

Some spas and telemedicine operators claim to have "compounded" semaglutide. But compounding — when pharmacies, rather than drug manufacturers, prepare a drug — is a risky proposition, doctors caution. "The risks are enormous," Simonetti said, warning of potential contamination from poor compounding practices. "The risks of getting bacteria," she warned, "the risks include death."

Weight loss clinics also frequently tout unconventional additions to semaglutide, including vitamin B12 and amino acids. Some patients incorrectly believe the former helps with nausea, Jaisinghani said; other clinics tout greater weight loss.

Novo Nordisk spokesperson Allison Schneider told KFF Health News in an email that the company shares doctors' concerns about compounding and that it's begun sending letters warning "certain Health Care Providers" about the related risks.

Some operations defend their use of often-cheaper compounded drugs. LH Spa & Rejuvenation, founded by Zuena, offers a compounded semaglutide formulation from QRx Weight Loss for $500 over four weeks. The spa learned about the regimen from a doctor. "I'm purchasing it," Zuena said. "It comes next-day air in legitimate vials with lot numbers, expirations." Patients' injections and dosages are overseen by on-site medical staff.

Most operators in this burgeoning industry are keen to emphasize their products' high quality or their company's good works, as they seek money. Ro, a telehealth firm offering GLP-1s, said its marketing campaign in the New York City subway "aims to start an important, sometimes difficult, conversation focused on de-stigmatizing obesity as a condition."

This widespread tactic is nothing short of maddening for pharma industry critics. "They talk about trying to destigmatize obesity at the same time they're talking about losing weight. They're co-opting the concept," said Judy Butler, a research fellow at PharmedOut, a Georgetown University Medical Center project focusing on evidence-based practices for drugs. "They're trying to sell a weight loss drug."

https://www.medscape.com/viewarticle/990919

YouTube to Ban More Eating Disorder Content

 YouTube announced today it will screen more eating disorder content to reduce the potential for dangerous copycat behavior. The video-based social media platform will also implement age-based viewing restrictions for some eating disorder content.

In a statement, the director of YouTube Health, Garth Graham, MD, MPH, said the reason for the changes was "to create space for community, recovery and resources, while protecting viewers."

The changes were developed with input from the National Eating Disorder Association and other related groups. 

Lawmakers and advocates have called for social media companies to do more to protect people who may be sensitive to eating disorder content after the revelation that Meta officials knew in 2021 that its social media platform Instagram was influencing teens in concerning ways. The company's own internal research found that Instagram caused 1 in 3 teen girls to feel worse about themselves, and that the platform could lead a 13-year-old girl seeking diet tips to instructional eating disorder content.

Up to 30 million people in the U.S. have eating disorders, which can be fatal. The National Institute of Mental Health estimates 2.7% of people experience an eating disorder by the time they turn 18. Considered mental illnesses, eating disorders can include dangerous behaviors such as restrictive eating, binge eating, and purging. 

YouTube says billions of people worldwide log into the platform per month, and that more than 500 hours of content are uploaded each minute of the day.

YouTube already had policies for removing content that "glorified" or promoted eating disorders. Among the new policies is an additional ban of content about eating disorders that feature imitable behavior, which could include purging after eating, severely restricting calories, or weight-based bullying "in the context of eating disorders." 

For some content about eating disorders that is not blocked, YouTube may implement age-based viewing restrictions or add a "crisis resource panel," which lets people connect with live support from a YouTube partner. Age-based restrictions would apply to viewers under 18 years old and could also be triggered when someone is not signed into YouTube.

"We developed this age restriction approach for eating disorder-related videos in consultation with third-party experts to strike the right balance in our continuing efforts to protect younger viewers from content they may be more susceptible to imitating than adults," Graham said, adding that the changes will be implemented gradually.

Sources

YouTube: "An updated approach to eating disorder-related content," "Crisis resource panels," "YouTube By The Numbers."

CBS News: "Facebook knew Instagram was pushing girls to dangerous content: internal document."

Cleveland Clinic: "Eating Disorder Facts."     

National Institute of Mental Health: "Eating Disorders."

https://www.medscape.com/viewarticle/990928

USPSTF Releases Updated Recommendations on Skin Cancer Screening

 In an update to its 2016 recommendations for skin cancer screening, the US Preventive Services Task Force (USPSTF) has once again determined that there is not enough evidence to recommend for or against screening with a visual skin exam in adolescents and adults without symptoms.

This final recommendation applies to the general public and is not meant for those at higher risk, such as people with a family history of skin cancer or who have any signs or symptoms, such as irregular moles.

"The new recommendations are consistent with those from 2016, and we are unable to balance benefits and harms," said Task Force member Katrina Donahue, MD, MPH. "Unfortunately, there is not enough evidence to recommend for or against screening, and healthcare professionals should use their judgment when deciding whether or not to screen."

Donahue told Medscape Medical News that this is a call for more research. "Our recommendations are for patients who present to primary care without symptoms, and after a careful assessment of benefit and harms, we didn't have evidence to push us towards screening as a benefit," said Donahue, professor and vice chair of research in the department of family medicine at the University of North Carolina, Chapel Hill. "We did look at data from two large screening programs, but they were from Europe and not representative of the US population. They also did not show a benefit for reducing melanoma-related mortality."

The USPSTF final recommendation statement and corresponding evidence summary have been published online in JAMA, as well as on the USPSTF website.

Skin cancer is the most commonly diagnosed cancer in the United States, but there are different types that vary in their incidence and severity. Basal and squamous cell carcinomas are the most common types of skin cancer, but they infrequently lead to death or substantial morbidity, notes the USPTSF. Melanomas represent about 1% of skin cancer and cause the most skin cancer deaths. An estimated 8000 individuals in the United States will die of melanoma in 2023.

There are racial differences in melanoma incidence; it is about 30 times more common in White vs Black persons, but disease in persons with darker skin color tends to be diagnosed at a later stage. These disparities may be due to differences in risk factors, access to care, and clinical presentation.

In an accompanying editorial, Maryam M. Asgari, MD, MPH, of the Department of Dermatology, Massachusetts General Hospital, Boston, and Lori A. Crane, PhD, MPH, of the Colorado School of Public Health, University of Colorado, Aurora, point out that people with darker skin phenotypes also tend to be affected by skin cancers that are not associated with UV radiation, such as acral melanoma, which arises on the palms and soles, and skin cancers that arise in areas of chronic inflammation, such as wounds.

Thus, differences in anatomical distribution of skin cancers in in the various subpopulations needs to be considered when performing skin screening, they write. "Furthermore, while skin cancer risk is lower among people with darker skin pigmentation, survival is often worse for cancers like melanoma, highlighting the potential need for screening."

"More data are needed, particularly regarding genetic and environmental risk factors for skin cancer in people with darker pigmentation, to help inform guidelines that can be broadly applied to the US population," add Asgari and Crane. "The diversity of the US population extends also to geography, culture, and socioeconomic status, all of which affect skin cancer risk."

Review of Evidence

The USPSTF commissioned a systematic review to evaluate the benefits and harms of screening for skin cancer in asymptomatic adolescents and adults, including evidence for both keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma) and cutaneous melanoma.

Foundational evidence showed that the sensitivity of visual skin examination by a clinician to detect melanoma ranged from 40% to 70% and specificity ranged from 86% to 98%. Evidence that evaluated the diagnostic accuracy of visual skin examination to detect keratinocyte carcinoma was limited and inconsistent. There were no new studies reporting on diagnostic accuracy for an asymptomatic screening population.

The USPSTF also reviewed 20 studies in 29 articles (n = 6,053,411). This included three nonrandomized studies evaluating two skin cancer screening programs in Germany, but results were inconsistent. In addition, the ecological and nonrandomized design of the studies limited the conclusions that could be drawn and the applicability to a US population was difficult to assess because of differences in population diversity and healthcare delivery in the United States.

Other nonrandomized studies that looked at various outcomes, such as harms, and stage at diagnosis and melanoma or all-cause mortality also did not provide sufficient evidence to support screening.

Research Is Needed

In a second accompanying editorial, published in JAMA Dermatology, Adewole S. Adamson, MD, MPP, of the Division of Dermatology and Dermatologic Surgery at the University of Texas, Austin, pointed out that unlike other cancer screening programs, such as those for breast, colon, and prostate cancer, skin cancer screening programs are somewhat less organized. The other programs focus on defined groups of the population, generally with easily identifiable characteristics such as age, sex, and family history, and importantly, there are always defined ages for initiation and halting of screening and intervals for screening frequency. None of these basic screening parameters have been widely adopted among dermatologists in the United States, he wrote.

Adewole S. Adamson, MD, MPP

"One important reason why skin cancer screening has remained inconsistent is that it is not covered by Medicare or by many commercial insurance companies," Adamson told Medscape Medical News. "The test, in this case the skin exam, is often performed as part of a routine dermatology visit."

Dermatologists should take the lead on this, he said. "Dermatologists should push for a high quality prospective clinical trial of skin cancer screening, preferably in a high-risk population."

Donahue agrees that research is needed, as noted in the recommendation. For example, studies are needed demonstrating consistent data of the effects of screening on morbidity and mortality or early detection of skin cancer, and clearer descriptions of skin color and inclusion of a full spectrum of skin colors in study participants. Clinical research is also needed on outcomes in participants that reflect the diversity of the US population.

"I hope funding agencies will be interested in this area of study," she said. "We put out the whole systematic review and point out the gaps. We need consistent evidence in detecting cancer early and reducing complications from skin cancer."

The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF

None of the USPSTF authors report any disclosures. Asgari reported receiving royalties from UpToDate. Crane did not make any disclosures. Adamson reported serving as an expert reviewer for the US Preventive Services Task Force skin cancer screening report as well as support from the Robert Wood Johnson Foundation, the Dermatology Foundation Public Health Career Development Award, the National Institutes of Health, the American Cancer Society, and Meredith's Mission for Melanoma.

JAMA. Published online April 18, 2023. Full text; Editorial

JAMA Dermatol. Published online April 18, 2023. Editorial

https://www.medscape.com/viewarticle/990893

Optimal Time Period for Weight Loss Drugs: Debate Continues

 After bariatric surgery in 2014, Kristal Hartman still struggled to manage her weight long term. It took her over a year to lose 100 pounds, a loss she initially maintained, but then gradually her body mass index (BMI) started creeping up again.

"The body kind of has a set point, and you have to constantly trick it because it is going to start to gain weight again," Hartman, who is on the national board of directors for the Obesity Action Coalition, told Medscape Medical News.

So, 2.5 years after her surgery, Hartman began weekly subcutaneous injections of the glucagon-like peptide-1 (GLP-1) agonist semaglutide, a medication that is now almost infamous because of its popularity  among celebrities and social media influencers.

Branded as Ozempic for type 2 diabetes and Wegovy for obesity, both contain semaglutide but in slightly different doses. The popularity of the medication has led to shortages for those living with type 2 diabetes and/or obesity. And other medications are waiting in the wings that work on GLP-1 and other hormones that regulate appetite, such as the twincretin tirzepatide (Mounjaro), another weekly injection, approved by the US Food and Drug Administration (FDA) last May for type 2 diabetes and awaiting approval for obesity.

Hartman said taking semaglutide helped her not only lose weight but also "curb [her] obsessive thoughts over food." To maintain a BMI within the healthy range, as well as taking the GLP-1 agonist, Hartman relies on other strategies, including exercise, and mental health support.

"Physicians really need to be open to these FDA-approved medications as one of many tools in the toolbox for patients with obesity. It's just like any other chronic disease state, when they are thinking of using these, they need to think about long-term use...in patients who have obesity, not just [among those people] who just want to lose 5 to 10 pounds. That's not what these drugs are designed for. They are for people who are actually living with the chronic disease of obesity every day of their lives," she emphasized.

On average, patients lose 25% to 40% of their total body weight following bariatric surgery, said Teresa LeMasters, MD, president of the American Society for Metabolic & Bariatric Surgery. However, there typically is a "small" weight regain after surgery, she added.

"For most patients, it is a small 5 to 10 pounds, but for some others, it can be significant," said LeMasters, a bariatric surgeon at UnityPoint Clinic, Des Moines, Iowa.

"We do still see some patients — anywhere from 10% to 30% — who will have some [significant] weight regain, and so then we will look at that," she noted. In those cases, the disease of obesity "is definitely still present," she added.

Medications Can Counter Weight Regain After Surgery

For patients who don't reach their weight loss goals after bariatric surgery, LeMasters said it's appropriate to consider adding an anti-obesity medication. The newer GLP-1 agonists can lead to a loss of around 15% of body weight in some patients.

"The GLP-1 agonists have been very helpful for treating patients who've had bariatric surgery and had some weight regain, or even just to optimize their initial response to surgery if they are starting at a very, very severe point of disease," she explained.

She noted, however, that some patients shouldn't be prescribed GLP-1 agonists, including those with a history of thyroid cancer or pancreatitis.

Caroline M. Apovian, MD, codirector of the center for weight management and wellness and professor of medicine at Harvard Medical School, Boston, Massachusetts, told Medscape Medical News that the physiology behind bariatric surgery and that of the newer obesity medications is somewhat aligned.

"In order to reduce...body weight permanently you need adjustments. We learned that you need the adjustments of the hormones [that affect appetite, such as GLP-1], and that's why bariatric surgery works because...[it] provides the most durable and the most effective treatment for obesity...because [with surgery] you are adjusting the secretion and timing of many of the hormones that regulate body weight," she explained.

So, when people are taking GLP-1 agonists for obesity, with or without surgery, these medications "are meant and were approved by the FDA to be taken indefinitely. They are not [for the] short term," Apovian noted.

Benjamin O'Donnell, MD, an associate professor at The Ohio State University Wexner Medical Center, Columbus, agreed that the newer anti-obesity medications can be very effective; however, he expressed uncertainty about prescribing these medications for years and years.

"If somebody has obesity, they need medicine to help them manage appetite and maintain a lower, healthier weight. It would make sense that they would just stay on the medicine," he noted.

But he qualified: "I have a hard time committing to saying that someone should take this medication for the rest of their life. Part of my hesitation is that the medications are expensive, so we've had a hard time with people staying on them, mostly because of insurance formulary changes."

Why Stop the Medications? Side Effects and Lack of Insurance Coverage

Many people have to discontinue these newer medications for that exact reason.

When Hartman's insurance coverage lapsed, she had to go without semaglutide for a while.

"At that time, I absolutely gained weight back up into an abnormal BMI range," Hartman said. When she was able to resume the medication, she lost weight again and her BMI returned to normal range.

These medications currently cost around $1400 per month in the US, unless patients can access initiatives such as company coupons. Some insurers, including state-subsidized Medicare and Medicaid, don't cover the new medications.

O'Donnell said, "More accessibility for more people would help in the big picture."

Other patients stop taking GLP-1 agonists because they experience side effects, such as nausea.

"Gastrointestinal complaints...are the number one reason for people to come off the medication," said Disha Narang, MD, an endocrinologist and obesity medicine specialist at Northwestern Medicine Lake Forest Hospital, Illinois.

"It is an elective therapy, so it is not mandatory that someone take it. So if they are not feeling well or they are sick, then that's a major reason for coming off of it," she said.

Dan Bessesen, MD, professor of medicine at the University of Colorado Anschutz Medical Campus, Denver, and chief of endocrinology, agrees.

Patients are unlikely to stay on these medications if they feel nauseous or experience vomiting, he said. Although he noted there are options to try to counter this, such as starting patients on a very low dose of the drug and up-titrating slowly. This method requires good coordination between the patient and physician, he stressed.

Goutham Rao, MD, a professor of medicine at Case Western Reserve University School of Medicine Cleveland, Ohio, and head of the weight loss initiative Fitter Me at University Hospitals, said that prior to prescribing GLP-1 agonists for weight loss, he sets four basic, non-negotiable goals for patients: "to have breakfast within 30 minutes of getting up, to drink just water, no food or drink after 7:00 PM except for water, and 30 minutes of continuous exercise per day, which is typically, for older clientele, walking."

This, he said, can help establish good habits because if "patients are not engaged psychologically in weight loss...they expect the medication to do [all] the work."

Most Regain Weight After Stopping Obesity Medications

As Hartman's story illustrates, discontinuing the medications often leads to weight regain.

"Without the medicine, there are a variety of things that will happen. Appetite will tend to increase, and so [patients] will gradually tend to eat more over time," Bessesen noted.

"So it may take a long time for the weight regain to happen, but in every study where an obesity medicine has been used, and then it is stopped, the weight goes back to where it was on lifestyle alone," he added.

In the STEP 1 trial, almost 2000 patients who were either overweight or living with obesity were randomized 2:1 to semaglutide, titrated up to 2.4 mg each week by week 16, or placebo in addition to lifestyle modification. After 68 weeks, those in the semaglutide group had a mean weight loss of 14.9% compared with 2.4% in the placebo group.

Patients were also followed in a 1-year extension of the trial, published last year in Diabetes, Obesity, and Metabolism.

Within 1 year of stopping treatment, participants regained two thirds of the weight they had initially lost.

Hence, Bessesen stressed that a total rethink of how obesity is approached is needed among most physicians.

"I think in the future treating obesity with medications should be like treating hypertension and diabetes, something most primary care doctors are comfortable doing, but that's going to take a little work and practice on the part of clinicians to really have a comfortable conversation about risks, and benefits, with patients," he said.

"I would encourage primary care doctors to learn more about the treatment of obesity, and learn more about bias and stigma, and think about how they can deliver care that is compassionate and competent," he concluded.

https://www.medscape.com/viewarticle/990922

Then There Were 9: Comer Alleges Wider Potential Biden Beneficiaries from Possible Influence Peddling

 by Jonathan Turley via jonathanturley.org,

House Oversight Committee Chairman James Comer  has revealed that there are not three but nine members of the Biden family that may have benefitted from suspected influence peddling efforts. For those of us who have long criticized the corrupt practices of the Biden family, the identity of these other family members is intriguing after the Committee secured new bank and financial records. Democratic members again insisted that there is no need to investigate such influence peddling.

The new information on the Biden family is due largely to the takeover of the House by the GOP. Previously, Democrats blocked efforts to investigate influence peddling by the Biden family for years.

After assuming control of the Committee. Comer sought suspicious activity reports sent by banks to the Treasury Department alerting of potential criminal activity in transactions involving President Biden’s family.

He stated on Monday that “We’ve identified six additional members of Joe Biden’s family who may have benefited from the Biden family’s businesses that we are investigating, bringing the total number of those involved or benefiting to nine.” Those are six names beyond the previously discovered payments to linked to at least three Biden family members and two associates from China in 2017.  That $3 million was wired Biden family associate Rob Walker in March 2017, who then allegedly divided and distributed the funds later.

There remains an “Unknown Biden” who received four payments in 2017 totaling $70,000.

The investigation into the Bidens has made many in the Beltway uncomfortable. Influence peddling has long been the favored form of corruption in this city, but few families seemed to have cashed into the extent of the Bidens.

I frankly do not understand the willingness of so many Democrats to cover for the Bidens. Democratic members have gone all in with censorship, but this is an effort to scuttle investigations into corruption that may have resulted in millions of dollars going to Biden family members.

The Biden family has long been associated with influence peddling to the degree that they could add an access key to their family crest. Influence peddling has long been a cottage industry in Washington. For decades, I have written about this loophole in bribery laws. It is illegal to give a member of Congress or a president even $100 to gain influence. However, you can literally give millions to their spouses or children in the forms of windfall contracts or cozy jobs.

James Biden has been remarkably (even refreshingly) open about marketing his access to his brother. Former Americore executive Tom Pritchard and others allege the Biden openly referenced his access to his brother and his family name in his pitch for clients. James has faced a wide array of litigation over allegedly fraudulent activities as well as a personal loan acquired through Americore before it went into bankruptcy.

Hunter worked with his uncle but also branched off on his own in the family business. While his father recently emphasized that his son was a hopeless addict, that defense stands in glaring contradiction to the fact that he maintained a multimillion-dollar influence-peddling scheme. The question is why foreign figures (including some associated with foreign intelligence) rushed to him international money transfers and complex deals worth millions from Moscow to Kyiv to Beijing.

However, the Biden most concerned may be the president himself. Joe Biden has repeatedly denied knowledge of Hunter Biden’s business entanglements despite numerous emails and pictures showing him meeting with Hunter associates. That includes at least 19 visits to the White House by Hunter’s partner, Eric Schwerin, alone between 2009 and 2015.

While emails on Hunter Biden’s laptop make repeated reference to his father as a possible recipient of funds derived from influence peddling. Indeed, in one email, Tony Bobulinski, then a business partner of Hunter, was instructed by Biden associate James Gilliar that the Bidens wanted to avoid such references: “Don’t mention Joe being involved, it’s only when u [sic] are face to face, I know u [sic] know that but they are paranoid.”

In discussing these deals, Joe Biden is referenced with code names such as “Celtic” or “the big guy.” In one, “the big guy” is discussed as possibly receiving a 10% cut on a deal with a Chinese energy firm. There are also references to Hunter paying off the bills of his father from shared accounts. From his board memberships to venture deals to legal fees to his art deals, Hunter Biden is a tour de force of alleged corrupt practices used in Washington.

Many Democrats and legal experts have objected that influence peddling is not a crime. However, it is corrupt and squarely within the oversight authority of Congress. Indeed, if it is not a matter for criminal charges, such congressional action may be the only way to force accountability for corrupt efforts to sell influence and access.

https://www.zerohedge.com/political/then-there-were-nine-comer-alleges-wider-range-potential-biden-beneficiaries-possible