Yesterday’s post was about how we need to rethink and restructure obesity management in primary care. Today I discuss a primary care study that describes the outcome of non-surgical weight management in patients with extreme obesity.
The paper by Donna Ryan and colleagues published in this week’s edition of the Archives of Internal Medicine describes the results of the Louisiana Obese Subjects Study (LOSS), a 2-year randomised, controlled, “pragmatic clinical trial” conducted in seven primary care practices and one research clinic.
Around 600 Volunteers with BMIs in the 40-60 range were screened and randomized to intensive medical intervention (IMI) (n = 200) or usual care (UCC) (n = 190). The IMI group recommendations included a 900-kcal liquid diet for 12 weeks or less, group behavioural counseling, structured diet, and choice of pharmacotherapy (sibutramine, orlistat, or diethylpropion) during months 3 to 7 and continued use of medications and maintenance strategies for months 8 to 24. In contrast, the UCC group received guidance in an internet weight management program.
The mean age of participants was 47 years; 83% were women, and 75% were white. Retention rates over two years were 51% for the IMI group and 46% for the UCC group. After 2 years, 31% in the IMI group achieved a 5% or more weight loss and 7% achieved a 20% weight loss or more, compared with 9% and 1% of those in the UCC group. A total of 101 IMI completers lost an average of –9.7% of their initial weight whereas weight in the 89 UCC completers remained virtually unchanged (which over 2 years is actually not such a bad result at all - remember, successful weight management starts with stopping the gain!).
While the study can no doubt be criticized for high attrition rates and relatively modest weight loss in IMI completers (only around 10% of initial weight), the study does show that at least for some patients, aggressive management strategies in primary care may provide sustainable outcomes that can have clear health benefits.
Let us not forget that attrition rates in disease management programs for other chronic diseases (e.g. diabetes, dysplipidemia, hypertension, etc.) are also relatively high and that only a minority of patients with these other common chronic conditions are ever fully controlled in primary care practice (despite the wide range of medical treatments and resources available to patients with these conditions).
Thus, there is no reason to believe that chronic disease management for obesity, when implement in primary practice, must necessarily fare worse than chronic disease management for other conditions. The fact that obesity management in primary practice appears so unsuccessful is not because interventions don’t work (this study shows they do), but rather because no serious attempt is made to address obesity in the first place.
While the 900-calorie liquid diet followed by intense behavioural and pharmacological treatment may not be everyone’s cup of tea, and of course comes nowhere near the results with bariatric surgery, for some patients this is may well be a safe and cost-effective strategy that can be delivered in primary practice.
Remember, in obesity treatment, one size certainly does not fit all and having a breadth of strategies rather than a single intervention is probably the only way to go.
I would certainly like to hear from anyone who has been on a 900-kcal liquid diet or who uses this approach in their patients.
AMS
Edmonton, Alberta
In The News
January 28th, 2010 at 8:35 am
How about starting this with people who have BMI’s of 30 as a treatment option so that hopefully they won’t get to BMI of 40 or 50? I think this, and other treatments, should be offered long before people have serious medical complications, and have suffered with the emotional toll obesity takes. This saves health care dollars and supports people in a practical and respectful way. It seems like a win win to me.
January 28th, 2010 at 8:51 am
Thank you for this suggestion. I have one comment and one question:
*This nonsurgical Weight Loss may be a good basis for starting an individual with a problem of extreme obesity, but my concerned is the long term management. My point is I meet a lot of people…who after regain lost weight and more. I believe the nerve of the “war” is in the transition stage. For many patients return to life underlies one day return to “old” habits Because, I think, some patients don’t understand how to “domesticate” their new life. For a lot of person it sound if they switching (to bad//good//…and bad) rather then to assimilating new habits.
And I think it’s our job to guide them through this transition.
* Yesterday, I meet a lady whit BMI of 71 [5'6 at 437lb]. She is 41 years old. She has only one lung. She made three protein diets and no longer believes. She is a single parent whit 2 girls (11y and 13y). And she will not consider bariatric surgery; because she is convinced she will die on the operating table. After talking with her I came running out of arguments…Could you suggest me a site that could reassure (type user friendly) or blog who have already crossed the road?
Thank you for your cooperation.
Nathalie Dumas, Montréal
January 28th, 2010 at 9:24 am
Arya,
Thanks for bringing this article to my attention. As you know I am affiliated with a bariatric clinic which offers both surgical and medical intervention. I do agree that one intervention is not for all. This VLCD diet using liquid formulas does not have good long term data for efficacy, but there is promising data using liquid diets as meal replacements as in the LookAHEAD study. For selective patients who are severely obese along with intensive lifestyle intervention, there may be role for liquid formula diets.
January 28th, 2010 at 11:28 am
Dr Sharma,
I read regularly your posts. I cannot comment on 900 kacl diet ( I am in pediatrics, we had to use this option in one patient actually).
I want to comment on the most important, basic and critcal issue and to me as a pediatrician the only one that really matters as far as treatment goes
and I site you form this text: ” The fact that obesity management in primary practice appears so unsuccessful is not because interventions don’t work (this study shows they do), but rather because no serious attempt is made to address obesity in the first place” . The first line of care should be backed with 2dary and tertiary care.
Primary medical care should be seriously remodeled to allow adapted interventions for all chronic medical conditions, and obesity is one of those, the link with non-medical community services is essential, I personnally find it appauling that we are so desparately concerned about morbid obesity(I do not mean here not taking care of persons whom have reached that stage), and … not so concerned with a person developping obesity, this is when interventions should start. Proper adapted global medico(includes nutrition/kinesio)-pshycho-social care should start there in the primary care, and not only does primary delivery of care be adapted, but TEACHING it too. Competent primary care in medecine should be recognized as a very desirable “speciality”, which is not case yet !
We met in Geneva 2008, and you then presented to me your staging system, and agree very much with this system,
We are working on this in our clinic (and of course barriers are multiple), we have made significant progress, still so much needs to be done,
the next step is to assess this clinical work (in progress), and retain what works better.Hopefully we will have data for the Hamilton meeting,
Thank for this very useful blog for people like me who are not 100% in obesity with lots of clinical duty (still !)
January 28th, 2010 at 12:29 pm
As I understand it, the recidivism rate is typically measured over a five year period. So, maybe they have better outcomes at the two year point, but how will they fare even further down the road? Is the intense intervention only slowing the regain? And is that still considered effective if the regain is more gradual?
Peace,
Shannon
January 28th, 2010 at 9:30 pm
I agree with Robin Moore.
Treatment at BMI 30 so people don’t get to BMI 40.
February 1st, 2010 at 1:51 am
The above comments are reassuring that there is a understanding that most 900 cal meal plans result in long term weight regain, if the intervention is not followed by an intense intervention to keep the weight off. That intervention is surgery. I will only agree with a VLCD program that has surgery as an endpoint. That being said, there are many, many people with BMI greater than 40 who cannot go to surgery, and the results of the Look Ahead trial that used 2 meal replacements + 1 protein bar for the frist 3 months, and then 1 meal replacement and 1 protein bar after that, is reassuring, that these patients may be able to ameliorate disease and keep weight off in the long term. I agree with the use of meal replacements, for those not going to surgery, if this (Look Ahead) type of approach is used. We are using this approach in our diabetic patients, at the Wharton Medical Clinic and will publish results on this within the next year or so, and with almost 1500 diabetic patients at our clinic, we have quite a bit of data to present.
Sean Wharton, MD