Monday, August 18, 2008

Obesity Needs Treatment Forever

Anyone involved in chronic disease management is well aware how difficult it is for patients to stick with even the simplest of medical regimens – just taking a tablet once a day. This is even more difficult for patients with psychiatric issues (present in over 40% of treatment-seeking patients with obesity). Less than half of patients prescribed medication for depression will still be on their drug 3 months after initiation; with bipolar disorder, this rate drops to only 35%.

Pharmacological obesity trials regularly show high-rates of discontinuation (around 20-40% at 12 months), not very different from that seen in real life for blood pressure or lipid-lowering medications.

If simply taking a tablet is so hard to stick to, how much more difficult is it to actually make lifestyle changes and stick with them? No question, patients struggling with excess weight need constant coaching, reminders, self-monitoring, support systems – left to their own devices the vast majority of patients will fall back into their old patterns resulting in weight regain.

As I often say – there are only two types of obese patients – those that are untreated and those that are treated. The only difference between the two groups is the fact that patients in the treatment group are managing their weights – when treatment stops, group 2 reverts to group 1 – i.e. the weight comes back or continues to increase – there are no exceptions!

As with other chronic diseases, our challenge in obesity is not how to get patients to start treatment – the challenge is how to get patients to stick with the treatment forever.

Edmonton, Alberta

Schematic: World Health Organization, 2003

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One Response to “Obesity Needs Treatment Forever”

  1. Dr Barbara Mayr-Belic says:

    Dear Dr.Sharma,

    Regarding need for lifetime treatments for obesity:

    I agree, there will always be people, metabolically challenged obesity prone individuals, requiring lifetime treatment of their inborn error of metabolism. But we mustn’t give up hope. Even some of these forms of morbid obesity have been diagnosed and “cured”.

    We can rehabilitate our aging metabolisms also to a degree by forcing it into ketosis (either overt or subclinical) more often. Our heart muscles and a large portion of our skeletal muscles (the slow twitch muscles) actually prefer fat over glucose for fuel. Our brains prefer mostly quick glucose energy (and when all fat stores are depleted during famine we can still chew up our skeletal muscles and make and use glucose again by gluconeogenesis. The glycogen or glucose stores are the first to go and then the fat stores during food deprivation. Before end stage starvation our brains adapt and can function well and survive using mostly using fat/ketones for fuel. Some cultures such as Eskimos thrive on low carb high fat ongoing ketosis due to availability of fatty foods over carby foods and the brain is happy and can be so adaptively in all of us.

    Our bodies were “designed” over the course of 3.5 Billion years.
    The diet available to us up until the last century, just a measly couple of hundred years ago did not include bowls of sugar, baskets of glaring white bread and heaping platters of fruits 24/7/365.

    As long as we stress for maintenance dieting combining Atkins with Mediterranean style diets (without high processed foods, and of course none of the white poison) it is my experience that significantly large poundage of weight loss can be maintained easily without hunger and with healthy feelings of satiety. This is achieved by going heavy on those bulky gut satisfying low cal low carb green/multicoloured veggies and a good measure of healthy higher calorie satisfying unadulterated essential fats. By going low fat people were feeding their starving bodies with excess sugars which would cause a viscious circle of quick fixes of sugar highs followed by insulin spiked crashes. There is nothing like fats (without the starches) to keep one feeling full between meals.

    Barbara Mayr-Belic M.D.

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