Fallacy of yes or no choices

The debate “Should family physicians prescribe medication for obesity?”^1,2 misses the mark completely in both points of view. As is too often the case, the question is too simple and does not address the reality of actual patient care. There is no good evidence at all, so we are left with making sense of a clinical picture and acting in the best interest of an individual patient with no good scientific reference point.

The correct answer to the debate is “sometimes.” I have patients who are obese by body mass index standards, but who are fit, exercise regularly, have no family history of diabetes or vascular disease, no lipid disorder, good renal function, and normal blood pressure. These patients need diet counseling and follow-up but nothing more. I have others who have the precise opposite problem—family histories of diabetes or vascular disease, with evidence of a lipid disorder and hypertension. The answer here is yes ... I prescribe metformin because of its proven ability to delay or prevent frank diabetes.^3,4

There are other patients with a less clear risk pattern, but if I see obesity with low high-density lipoprotein and high triglyceride levels it takes very little to tip me into the “treat” column. In my opinion, true metabolic syndrome needs early intervention, even in the absence of good evidence. It is pretty clear what road these patients are walking down, and to do nothing to avert a catastrophe is unethical too.

Without evidence one way or another we need to make the best decisions we can respecting the known pathophysiology of disease and intervene where these mechanisms can be modified. By all means let’s do a randomized controlled trial, but let us also be practical and scientific and patient-centred while we wait.

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