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Close Concerns: Finding What Works For You



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.

AMS
Edmonton, Alberta

10 Comments

  1. The bottom line, Dr. Sharma, in my humble opinion and experience, is finding out what works for me (because what works for me, doesn’t necessarily work for the next person) and then just bloody well doing it for the rest of my life.

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  2. This all sounds pretty reasonable, but there’s one thing that bugs me about it. If someone’s weight is going up by two pounds a year, it’s impossible to know what to think about that unless you know their maximum weight. Have they gained two pounds beyond their old maximum weight, or are they just adjusting upwards in their normal weight range?

    For example, I refer to my weight as “reasonably stable.” This is because I’ve worn the same two sizes pretty much all my life. However, those two sizes represent a 30-pound weight range. My weight is wildly variable within its normal range. It can vary by 5 pounds or more in the course of a typical month and by up to 15 pounds in a typical year. When I used to weigh myself, it drove me batty. I can easily gain five pounds when I’m retaining water because of PMS – a difference in the place in my cycle that I visit the doctor in can make that much of a difference. A two pound shift is meaningless.

    I think that it would be really difficult to make a call on a small amount of weight gain without knowing someone’s full weight history.

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  3. Quote:
    ‘ 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.” ‘

    Intervention when someone is up 2 POUNDS a YEAR?? I think that’s great.
    I wish my doctor had done that.

    Now, how do we make that a public health campaign? What slogans, TV ads, print ads, special events, and whatever the marketing guys dream up, can be used to make this a cultural norm?

    Sample ad: Questioner:”How old do you weigh?”
    Answers: “I’m still 20!!” … “I was 26, but I’m back to 24 now” … ” I weigh 30 years old, but you know, for me, that’s better than I was at 18 years old!!”
    OK, I’ll never make it in the ad world, but clever marketers could make slogans for not gaining weight in adulthood as culturally pervasive as any product ad.

    How about having a special “Weigh Day”? Like the campaign to remind people to check their smoke detectors when the clock changes. (Just not Jan 1 – the day of doomed resolutions.) How about the May long weekend – everybody’s keen on better weather, sunshine, getting out, so if they’re’re up in weight, it’s a good time to get back to their right weight.

    How can this be integrated into present public programs?
    For example, the Canada Food Guide, which should have the goal of not gaining weight in adulthood stated clearly in the Guide, with specific recommendations for eating to achieve that.

    How about putting posters and information brochures in doctors’ offices, so both the doctors and patients will be reminded that this is an important medical issue.

    Probably there would be objections that these actions “stigmatized” people who did not avoid gaining weight, but this shouldn’t derail the program. There are people who object to vaccinations and people who think anti drunk driving laws are oppressive. Too bad, this is a medical issue. Not everybody will be pleased. Like smokers outside in bad weather, feeling unfairly put upon.

    This is a great focus point – it’s clear, it is understandable, and it lends itself to many approaches to reach a wide audience. It identifies a small problem people can solve, knowing they are preventing a huge health problem in their future.

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  4. I’m kind of hoping that the post above was meant ironically, but it’s hard to tell.

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  5. Great interview – fantastic message about the weight loss industry!

    So you are recommending that doctors act on a difference of two pounds? At what age? Weight is only a measurement of gravitational force. MRI is pretty much useless by itself. A change in weight is a symptom of something. How about creating a checklist for the patient to complete every week to give the to doc every 6 months. This would help educate the patient about the importance of symptoms rather than gravity. Is it muscle gain? Is it fat? Is it a massive tumor? Is it mindless overeating, are emotions involved, is it poverty related, is it rebound from drug withdrawal – nicotine or otherwise? And where is the weight gain? What do the tape measurements on the checklist indicate? Start measuring children’s girths at birth – ya seriously. Why measure height and not girth? Get a baseline. Moreover, help all children understand it is not gravity that is the problem and not weight that needs to be lost. The underlying symptom is what is important. It just has to be discovered and addressed if necessary. Educate. Empower. And along that line, why not give the patient a box to check off asking what their thoughts are on Bariatric surgery? After completing the checklist for the last 25 years, a 30 year old should have a pretty good idea of what’s up or down with his or her gravity symptoms. Maybe he or she will have a pretty good idea even at the age of 18, after having filled out the checklist for the past 12 years. Imagine the cost benefit of doing what you do Dr. Sharma, when the patient is 18 years of age. If you say you can’t know at 18 years of age, I think you are missing something. The question is what are you missing? I bet the answer to future excessive fat is already there, presenting as some kind of symptom, possibly in a subtle way. So the answer of what works or doesn’t work regarding excessive fat is already there too.

    And regarding the person who has a BMI of 50 and drops to 35 still needing the surgery. Likely he or she once had a BMI of 25. It would be interesting to see stats indicating at what age Bariatric surgery patients were at a BMI of 23? Gotta get that baseline again.

    Dr. Sharma, I take it you are qualifying your comment that those who drop from 50BMI to 35BMI still need the surgery – in that they ONLY NEED IT IF they are not able to expend the enormous physical and emotional energy it takes to maintain their loss?

    You have acknowledged that those who have dropped massive amounts of weight and maintained their loss have had to spend insurmountable/abnormal physical and emotional effort/energy to maintain their loss. There is a definite cost to their efforts. By your reasoning, should they not at least be given the option of surgery as well? Would you say to a group of people who have fallen overboard that those who are desperately treading water must remain in the water and that it is only those who are going to drown who will get plucked up onto the boat? And once on the boat, the obvious potential drowners will be monitored so as not to fall off the boat again? As for the rest of those who fell of the boat, keep treading water, keep putting your energy into staying afloat – you don’t even need a life jacket – make your way back to the boat as best you can – you have the energy to do it. Perhaps they do. But at what cost? Treading water may well be “what works for some” but it may not be what they would ideally opt for if given the same consideration/options as others. I would appreciate a piece on how and why the buck stops, and what you see in an ideal world of rescue and recovery. Maybe it call it “The Problem with Excess Fat Triage in A Thinning Public Health Care System”.

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  6. Sorry – in the last post I meant to say BMI instead of MRI.

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  7. Dr. Sharma, your ideas are really inspiring.

    So what’s the main practical difference concerning a GP to stop further weight gain versus to prevent weight regain after a weight loss ? Isn’t it in both cases, “the best achievable change in lifestyle” an individual patient (and his family) can afford ?

    Otherwise, simply talking about “preventing weight gain” seems to me a very realistic goal in a starting conversation about taking care of obesity. I’ve never thought like that , because like patients , a lot of medical professionals are still focussing weight loss in the case of adults.

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  8. No, that was not meant ironically.

    Well, I am being silly with my example of an ad,

    but I am totally serious about the general idea of adults keeping track of and controlling their weight, that doctors take creeping weight gain seriously, and that public health policy should use resources to promote keeping a healthy weight.

    Of course “weight” gain can be for many reasons. It could be a welcomed gain of 5 lbs of muscle after targeted exercise and diet. The point is to identify weight gain, and if there is a problem of undesirable accumulation of fat, then to deal with it before it becomes a major problem.

    I think using a small weight gain as a “red flag” is an excellent idea.
    And the more widely known and accepted we can make that idea among doctors and the public, the better.

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  9. I have a few issues on this posting:

    My weight gain came on while I was in group theropy an after that, perhpas when an idividual is in such a position the mental health care team should address weight to help from keeping it get out of hand.

    Perhaps, a public service campaign to encourage people and youths who are at a normal BMI to remain there while encouraging the overweight individuals not to gain–I put this limitation out because of the minority of people who “will” se any weight gain as “bad”. also the labeling of things like foods as “good”, “better”, “best” because good and bad is to broad spectrum for many of the choices we have available.

    With being on mental health medications that I will have to take for the rest of my life I know the challenges of life long medication needs there are always the group of mental health consumers who “oh I am not seeing or hearing things I am better and don’t need this stuff any more” only to relapse and end up back in the hospital sick. How would you go about preventing this, if there was a medication that would keep people from regaing the weight anyway?

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  10. DeeLeigh mentions a problem with weight tracking for many women
    ” I can easily gain five pounds when I’m retaining water because of PMS – a difference in the place in my cycle that I visit the doctor in can make that much of a difference. A two pound shift is meaningless.”

    Tip from a member of my Weight Watchers group:
    Weigh, first thing in the morning, before eating or drinking, naked or in undies, on the SECOND day of your period. Keep records of “second day” weight.

    Always weigh on the SECOND day of your period because to eliminate variation in weight due to clothes or what you eat or drink, you have to weigh naked first thing in the morning. If you try to weigh on the first day of your period you might miss the chance to weigh without clothes or food if your period starts unpredictably later in the day.

    Weight will fluctuate during the cycle, but over a long time, the “second day weight” should stay the same. If the “second day weight” gradually changes (going up or going down) something else besides the menstrual cycle is causing the change.

    If you have a record of “second day” weights to take to the doctor, s/he will be able to get a true picture of your weight, no matter what day of your cycle you happen to be at the doctor’s office.

    I thought that was a great tip. I was never organized enough to record weight/time of cycle every day, especially with an irregular period. This was simple and effective.

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