Last week, the influential healthcare information firm Close Concerns published a rather lengthy interview regarding my take on a wide range of issues related to the future of obesity management. The interviews were conducted by Joseph Shivers, Vincent Wu, Lisa Vance, and Kelly Close, who certainly challenged and stimulated my thinking with their well-informed questions.
The following is another excerpt from this interview published in their newsletter Closer Look:
JOSEPH: We talked a bit already about weight-loss drugs in the pipeline. In general, what sort of framework do you use to think about new therapies?
DR. SHARMA: You know what? I’m excited about any compound that I think addresses the mechanisms of weight regain. If a drug is not addressing what we think are the mechanisms of weight regain, I’m not very excited. For me, the study design would be to take a bunch of people and get them all to lose weight with a liquid diet or something like that. Then I would randomize them to receive the drug or placebo, and then see if the people on the drug can keep their weight off better than the one on the placebo. Remember, the clinical problem we’re trying to solve is not weight loss. I do not need a drug for weight loss; nobody needs a drug for weight loss. Anybody can lose weight. The unmet need in obesity is not finding a way to help people lose weight. The unmet need in obesity is helping people to keep weight off.
Similarly, the reason to perform surgery on somebody is not to help them lose weight, but to help them keep weight off. If I have a patient who’s got a BMI of 50 kg/m2 and they go on an Optifast diet or any kind of diet and they manage to reduce their body weight to a BMI of 35 kg/m2, I would still ask my surgical colleagues to operate on that patient. The reason he needs the operation is to make sure the weight doesn’t come back.
JOSEPH: What do you see as the role of these drugs that are coming down the path? You were talking earlier about lorcaserin, and you spoke to the FDA panel on behalf of Qnexa. What will be the role of these drugs in clinical practice? When you say you don’t need a drug for weight-loss, are you talking about your own clinic – in which case maybe primary care providers and other clinicians might still find purely weight-loss drugs helpful?
DR. SHARMA: No, anyone can get weight loss. Managing obese patients is more difficult than that. You’re trying to figure out what the problem is, address it, weight-stabilize them, etc. But I can get anybody to lose weight and at every commercial weight-loss center, that’s what they do all the time. Every patient has lost weight on their own. They just open any magazine, and there’s a seven-day-diet they can follow to lose weight. The problem with all of these diets is not that they don’t help you lose weight, it is that they don’t help you keep the weight off because you can’t stay on them forever.
JOSEPH: So when you look at the weight-loss drugs and devices in development now, you’re looking only at how sustainable they are?
DR. SHARMA: That’s all I care about. I do not care about a weight loss treatment that is not sustainable.
JOSEPH: You said that in clinical trials the placebo arm generally maintains their weight as long as the trial’s running, and that your own clinic is also good at getting stabilization. Do you think it is possible to achieve this across the whole population?
DR. SHARMA: Absolutely. Preventing weight gain generally does not require a lot of resources. I think there’s something in the Foresight Report on the substantial savings that would be seen down the road if people would just stop gaining weight (Jebb et al., Obes Rev 2007). I think prevention of weight gain does not even require 20% of the resources you would require if you were trying to get people to lose weight and keep it off. Losing weight and keeping it off is extremely expensive; prevention of further weight gain is cheap.
If the 70 million obese people in the US could all stop gaining weight – and the other 200 million who don’t have obesity but might be overweight – could stop gaining weight, 10 years from now we would have a huge population impact without anybody losing any weight. I think that is very achievable with not a lot of resources. If you start looking at it in the same way that you would look at halting progression of any chronic disease, you would probably be able to stop weight gain in most people. Now, nobody’s trying to do it and so I haven’t seen the studies on it, but my guess is that that is not difficult to do and realistically could be doable.
It may not be what the patient wants, because the patients all want to lose weight. I don’t know how many people will actually pay to simply not gain weight. I don’t see that there’s a big market there. From a medical perspective, if I were a family doctor, I’d say, “I see you once a year, and every time I see you, you’re up two pounds. That’s got to stop. Instead of seeing you once a year, I’m going to start seeing you once every three months. Here’s all the things that I think could do that could stop weight gain and that’s what we’re going to be focused on.” I think that’s very doable.
JOSEPH: It seems that this could also increase the demand for clinical contact outside regular doctors’ visits. We’ve heard a lot of enthusiasm for mobile-health interventions: various iPhone apps and web-based programs that help you track what foods you’re eating, etc. What do you think about these sorts of interventions?
DR. SHARMA: The people who’ve been using an iPhone app – not just for a while, but who will continue using an iPhone app – are doing it right. Can you get the entire population using an iPhone app? No, in part because that starts with having an iPhone.
We have all of these different approaches. For one guy, it’s just showing up at the doctor’s office. For another guy, it’s: “I’ve got a scale at home that I get on every day and I automatically send my body weight straight to my doctor’s office.” Another guy says, “Well, I go Tweet my body weight to the doctor’s office, it goes on to my Facebook profile, or it gets Tweeted to my buddies.” The next guy says, “My thing is that at the end of every week, I read my food diary.” And the other guy says, “Well, you know what? I’ve started Weight Watchers. I go there once a week, and I sit there and I get weighed.” I don’t actually care. Whatever works for you.
We all live in a mobile world and there is a huge potential not just for spreading information but for providing immediate feedback to what is going on. So an app that tells me how much I have eaten, reminds me to get up and walk around a few steps every hour or so (and actually measures if I do), tracks my medications and perhaps sends this info straight to my doctor or pharmacist, lots of possibilities here.
The question is more whether enough people will use such services in the long term – in the short-term I have no doubt that such interventions work – but like all interventions they only work when people stick with them. That’s not different from taking a drug. I tell my patients, stopping your food journal it is like stopping your medication.
The principle is that you’re never done. The idea you’re going to do something for a while and then stop doing it is not going to work. So you’ve got to find something that works for you that you can keep doing.
For those people who’ll say, “You know what, I can do this for myself,” that’s great, perfect, do it for yourself. Some people say, “I’m much better when I have somebody watching me or when I have this external accountability.” Okay, fine, if that’s what you need, our office can provide that.
The bottom line is that obesity is a chronic condition that requires lifelong management. So don’t do anything that you can’t afford to do, or that is so time-intensive that you’re just going to run out of time to do it, or so onerous that you’re just not going to stick with it. But if you’re going to stick with it, then do it.