Weekend Roundup, August 24, 2012
As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts: Listen to Your Patients How To Measure Outcomes in Obesity Treatments How Effective is Lifestyle Management of Obesity? The Uncertainty Of Behavioural Obesity Management How To Discuss Weight With Your Patient Have a great Sunday! (or what is left of it) AMS Vancouver, BC
Hindsight: Managing Weighty Issues on Lean Evidence
In 2005, I wrote an article for the Canadian Medical Association Journal (CMAJ), in which I highlighted that fact that in light of the obesity epidemic, physicians and other health care workers will be delivering health care to a growing number of obese and severely obese patients. “Diagnosing many common medical conditions, although straightforward in nonobese patients, can be fraught with difficulty in morbidly obese people because little is known about the sensitivity and specificity of diagnostic tests in this population. …obtaining imaging studies such as CT or MRI is often impossible for morbidly obese patients because of the size and weight limitations of the machines. Oversized equipment is unavailable in most hospitals. These limitations call for more research into diagnostic algorithms, tests and reference ranges for morbidly obese patients, to avoid misdiagnoses and to ensure optimal care.” I also noted that with the exception of ‘weight-loss studies’, people with obesity are generally underrepresented in clinical trials. “As a result, the majority of clinical practice guidelines, even for conditions commonly found in obese patients (e.g., hypertension, diabetes mellitus, asthma, ischemic heart disease, venous thrombosis and neuropsychiatric disorders) fail to make specific recommendations for patients with morbid obesity that go beyond a rather general appeal for weight loss. This issue is far from trivial, as obesity significantly affects the pathophysiology and pharmacodynamic response in a multitude of medical conditions. For example….gastroesophageal reflux disease, where the pathophysiology in obese patients (increased intra-abdominal pressure, hiatal hernia, vagal abnormalities) may be distinctly different from that in nonobese patients. Responses to medications may be different, as metoclopramide may fail to decrease gastric volume or raise pH in obese patients. Similarly, although self-reported asthma is more frequent at higher BMI levels, obese individuals paradoxically are at lowest risk for significant airflow obstruction, and much of the respiratory symptoms may indeed be due to nocturnal aspiration of gastric reflux. Thus, asthma not only may be overdiagnosed in the obese population but, if present, may require a different approach to management.” I also commented on the need for studies that examine the effects of excess weight on pharmacokinetics and pharmacodynamics of medications commonly used in obese patients. “Virtually all existing diagnostic criteria and algorithms will need to be revalidated in the obese population, and where physical limitations hinder the use of diagnostic imaging technology, new strategies will have to be developed to deal with very obese people…. In… Read More »
How To Measure Outcomes in Obesity Treatments
Regular readers will be well aware that the goal of obesity treatment is not simply to lose weight. Rather, the whole point of treating obesity is to improve health and well-being. Thus, although excess weight is a risk factor and contributor to a wide range of health problems, not everyone who meets BMI criteria for obesity necessarily has (or will develop) these problems. Also, simply losing weight does not necessarily translate into better health. These facts provide a particular challenge when it comes to assessing the benefits and risks of obesity treatments – a problem of considerable interest to regulators, who have to make decisions about whether or not new obesity treatments provide important health benefits or not. In an effort to explore the pressing issues and challenges surrounding FDA approval and appropriate use of drugs to treat obesity, The George Washington University School of Public Health and Health Services Department of Health Policy convened the “Obesity Drugs Outcome Measures Dialogue Group,” a group of diverse stakeholders who met to identify the key issues surrounding the evaluation of pharmaceutical interventions for the treatment of obesity. Members of the group included clinicians specializing in adult and pediatric obesity; leaders from patient and consumer groups; public health organizations and industry representatives; and researchers from academia (see list on page two). Officials from the FDA, CDC, and NIH also observed and provided background information to the group to help inform the process (government officials were not asked to endorse or sign on to this final report). The consensus report of this group has now been released and should be of interest to any one involved in the design and interpretation of obesity interventions. The report is structured as a series of “Findings” and “Considerations” grouped into six general categories. The following summarises the ‘Considerations’ for each of these categories: 1. Understanding Obesity: Pharmacological interventions under investigation for the clinical treatment of obesity should be approached as obesity treatments rather than weight loss agents. 2. Characterizing the Population: More sophisticated criteria should be employed to characterize individuals at different levels of health, feeling, and functioning impairment, to determine appropriate patient-centered benefits and risks analysis. 3. The Need for Additional Treatments for Obesity: When the FDA determines that the benefits of taking a particular drug outweigh its risks in treating obesity, that drug should be available for clinical use in patients where such use is… Read More »
Listen to Your Patients
One of the benefits of taking a few days off and reposting old posts is that I get to reread and review some of the previous comments. I also receive new comments on old posts and see that not much has changed. Although, I do not generally respond to most comments, I read all of them and, unless they are clearly defamatory or thinly veiled promotions for commercial weight loss scams, I let them pass. In fact, for me, reading the comments to my posts is the most rewarding part of writing this blog. I’d be the first to admit that reading these comments (like listening to my patients) has thought me more about obesity than any textbook or research article. Indeed, if nothing else, the comments reassure me that many of the topics I choose to write about are indeed relevant to the patients we are trying to serve. Here is just one example of a comment that one reader (TinaUK) sent me in response to a post on weight bias: “I was constantly frustrated by visits to doctors which involved me being lectured about my weight; disbelieved when I told them the problems I was having; having health issues constantly being put down to weight issues; gaining weight while following their advice, but having them disagree that what I said was happening was happening and the general failure to take my issues seriously enough to investigate them properly. I was told to eat a low fat diet which I had been doing for some time. I was told to get exercise when I was going to the gym 3 times a week and walking 4 miles most days. I was told that the pain I experienced in my lower legs when walking was due to the female skeleton being inferior for walking purposes and that extra weight was compounding this ‘fact’. I was tired all the time and hungry too. My stress levels were very high and I believe that I may have been suffering from PTSD (never investigated despite enough information being available to indicate that this was a reasoable thing to look into).” This comment highlights a number of the issues that I so frequently write about: 1) We should never assume that any complaint in an obese person is simply because of their weight. 2) We should not advise patients to just eat healthier and… Read More »
How Effective is Lifestyle Management of Obesity?
Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Apr 15, 2011: Perhaps one of the most overused (and many would say ‘useless’) pieces of advise is that obesity management requires a lifestyle change. While this may be true – there is nothing special about obesity when it comes to this recommendation, because guess what: living with diabetes requires lifestyle change, living with high blood pressure requires lifestyle change, living with asthma requires lifestyle change, living with celiac disease requires lifestyle change, in fact living with any chronic health problems requires lifestyle change. So although, there is nothing special about recommending lifestyle change to help people better manage their weight, the question remains whether simply giving such lifestyle advise or following it actually works. This was the topic of a paper just published by Sara Kirk (Dalhousie University, Halifax) and colleagues in the International Journal of Obesity, which presents an extensive review of the literature on lifestyle interventions for obesity with the aim to determine the most effective and promising practices for obesity management in adults. From this review, three themes were derived from the highest level of available evidence. These were targeted multi-component interventions for weight management, dietary manipulation strategies and delivery of weight management interventions, including health professional roles and method of delivery. Not surprisingly, individually tailored multi-component long-term interventions were found to be the most effective (in fact there is little data to suggest that single (e.g. diet or exercise alone) or even double (e.g. diet + exercise) component interventions delivered in the short term are of any use at all). This is of course very much in line with the fact that obesity should be viewed as a complex, chronic condition, requiring sustained contact with and support from trained health professionals (whether delivered in person or through web-based technologies). The authors identified an important limitation of all intervention studies and thus any emerging remommendations in that: “All of the current recommendations essentially look at obesity as a homogeneous condition that is amenable to treatment either simply by caloric reduction and/or increasing activity. No attempt is made to distinguish between different causes of obesity or even stages of obesity. The importance of identifying and thereby addressing the etiological determinants of positive energy balance is… Read More »
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