Obesity medicine, which I define as the medical care of someone living with obesity, should approach patients holistically with the aim of improving their overall health and well-being. Advice to lose weight may or may not be part of obesity management – much can be gained for someone living with obesity by promoting their health behaviours, getting them to feel better about themselves, improving their mental health, and helping them better managing their health issues. Much of this can be achieved with no or very little weight loss.
Thus, we must consider the question of when weight loss would specifically need to be part of the treatment objectives.
In my own practice, I approach this problem by considering the following three questions:
- Is this a problem unrelated to abnormal or excess body weight?
- Is this a problem aggravated by abnormal or excess body weight?
- Is this a problem caused by abnormal or excess body weight?
From what I hear from my patients, the most common mistakes in medical practice fall into the first group – trying to address unrelated issues with weight loss recommendations. There are endless stories of patients going to see their health provider with problems clearly unrelated to their body fat (e.g. a broken arm, a sore throat, the flu, depression, migraines, etc.), who simply get told to lose weight. Indeed, there is evidence to suggest that patients with obesity are less likely to undergo diagnostic testing, most likely based on the assumption that their problems are simply related to their excess weight. This is not only where grave medical errors can be made (late or misdiagnosis), but also where the advice to lose weight is clearly wrong. If the presenting problem has nothing to do with excess weight, then no amount of weight loss will fix it.
The second category deals with issues that are not causally related to abnormal or excess body fat but where the underlying problem either causes more symptoms or is more difficult to treat because of the patient’s size or fat distribution. There are countless medical problems that fall into this category. For e.g. a heart or respiratory problem entirely unrelated to excess weight (e.g. a valvular defect or asthma) can become worse, cause more symptoms, or be much more difficult to treat simply because of the patient’s size. This group also includes issues like neck or joint pain from a trauma (e.g. a motor vehicle or skiing accident), reflux disease (e.g. from a hiatal hernia), urinary incontinence (from multiple child births), etc., etc., etc. – the list is long. Here, although obesity has nothing to do with the underlying problem, weight loss may alleviate the symptoms or at least make them more manageable (they are however unlikely to be fully resolved). These patients present with what may be described as a relative or “secondary” indication for weight loss. Of course, if there are viable treatments options for the primary problem, then this is where the emphasis should be. Weight loss can best be considered as “second-line” treatment. It would be completely unethical to withhold effective treatment for the underlying problem just because of the patient’s size (as in, “no treatment for you until you lose X lbs!”)
Finally, we have the third category of health issues that are directly causally linked to the excess weight – in most cases, the problem did not exist prior to weight gain and losing weight is often likely to completely resolve the problem (unless the patient has already sustained irreversible organ damage). This group of health issues not only includes the vast majority of cases of type 2 diabetes, hypertension, obstructive sleep apnea, fatty liver disease, infertility, etc. but also all of the functional limitations that people may experience simply because of their excess body fat. This is the only category of patients who would be deemed to have a “primary” indication for weight loss. Losing the weight literally solves their problem. Indeed, trying to manage the problem without weight loss is nothing less than “palliative” care. This is not to say that weight loss will always guarantee success even if the underlying problem is directly related to excess weight. For e.g. although there is ample evidence that excess weight is a prime risk factor for gall bladder disease, (rapid) weight loss may actually promote formation of gall stones. Similarly, although intertrigo (skin fold infections) can occur as a direct consequence of excess weight (e.g. chaffing), losing weight may actually make the problem worse by deepening the skin folds. Thus, even in this category, one needs to carefully consider risk-benefit ratios.
Of course, any recommendation to lose weight must take into account the complex nature of obesity in the first place and the fact that long-term weight-loss maintenance will require an approach (behavioural, medical, or even surgical) that takes into account the chronic relapsing nature of this disorder. Simply telling people with obesity to “eat less and move more” is about as medically sound and effective, as simply telling people with depression to “cheer up”.
Both, to avoid grave medical errors and to not insult their patients, I strongly recommend that medical practitioners first approach all their patients with obesity based on the assumption (that their presenting health issues are unrelated to their excess weight) before considering possibilities two (unrelated but aggravated) and three (causal). Advise to lose weight has no role in situation 1, can be considered in situation 2, and is clearly the best course of action for situation 3.
In the same manner in that there is not one predisposing factor for the development of obesity, the phenotypic clinical presentation of obesity is likewise extraordinarily heterogenous. (This has some authors speaking of “obesities” rather than “obesity”).
While it is now well established that BMI is a measure of size rather than health, it is perhaps less well recognised how the different types of body fat and their storage in various fat depots and organs can contribute to cardiometabolic disease (location, location, location!).
Now, a comprehensive review by Ian Neeland from the University of Texas Southwestern Medical Center, Dallas, together with my colleagues Paul Poirier and JP Despres from Laval University in Quebec, published in Circulation discusses the cardiovascular and metabolic heterogeneity of obesity.
As the authors point out,
“Although the BMI has been a convenient and simple index to monitor the growth in obesity prevalence at the population level, many metabolic and clinical studies have revealed that obesity, when defined on the basis of the BMI alone, is a remarkably heterogeneous condition. For instance, patients with similar body weight or BMI values have been shown to display markedly different comorbidities and levels of health risk.”
Not only has BMI never emerged as a significant component in risk engines such as the Framingham risk score, there are many individuals with obesity who never develop metabolic complications or heart disease during the course of their life.
The paper offers a good review of what the author describe as adipose dysfunction or “adiposopathy” = “sick fat”. Thus, in some individuals, there is an accumulation of “unhealthy” fat (particularly visceral and ectopic fat), whereas in others, excess fat predominantly consists of “healthy” fat (predominantly in subcutaneous depots such as the hips and thighs).
The authors thus emphasise the importance of measuring fat location with methods ranging from simple anthropometric measures (e.g. waist circumference) to comprehensive imaging techniques (e.g. MRI).
The authors also provide a succinct overview of exactly how this “sick fat” contributes to cardiometabolic risk and briefly touches on the behavioural, medical, and surgical management of patients with obesity and elevated cardiometabolic risk.
I, for one, was also happy to see the inclusion of the Edmonton Obesity Staging System in their reflections on this complex issue.
This paper is certainly suggested reading for anyone interested in the link between obesity and cardiovascular disease.
Another article in the 2018 JAMA special issue on obesity is one by Susan and Jack Yanovski and deals with the issue of using a precision or “personalised” approach to obesity prevention and management.
As we know, there are myriad factors that can lead to obesity (environmental, genetic, psychological, medical, etc., etc., etc.), with each patient having their own story and set of drivers and barriers.
Furthermore, we know that for any given treatment (whether behavioural, medical, or surgical) there is wide variation in individual outcomes.
So, being able to match the right treatment to the right patient, or even better, reliably predict a given patient’s response to a specific treatment could potentially improve outcomes and reduce patient burden and costs.
However, as the authors note, currently the only real predictor to treatment response is how well patients respond during the early part of treatment. Thus, we know that patient who lose a significant amount of weight during the first few weeks of medical treatment, tend to have the best long-term success in terms of weight loss.
However, this approach is also rather limited. In my own practice, I regularly see patients, who initially do well with behavioural, medical or surgical treatments, but eventually struggle, as well as patients who take longer to respond to a treatment before ultimately doing fine in the long term.
We are of course a long way off from having any kind of genetic or other testing that would reliably predict patient responses to treatment.
While this may become possible in the future, I am not holding my breath.
Not only is every patient’s story different, but the many factors that can determine response (societal, behavioural, psychological, biological, etc.) are almost endless and, moreover, can even vary over time in a given individual.
In fact, for most complex chronic diseases (e.g. diabetes, hypertension, depression, etc.), finding the best treatment for a given patient continues to be “trial and error”, or in other words, “empirical”.
Despite all the progress in genetic research, this has not really changed for most other complex chronic diseases like hypertension, type 2 diabetes, or dyslipidemia (despite a few rare but notable exceptions).
Moveover, as the authors point out, there are many other factors that will determine whether or not a given patient even has access to certain treatments, irrespective of whether or not that treatment is indeed the best treatment for them.
Currently, the best we can do, is to try to understand the drivers and barriers that each of our patients face and discuss with them the best treatment options available to them given their situation and circumstances.
Whether a more precise approach is ever likely (as the authors hope), clearly remains to be seen, but based on the progress made in for other complex chronic conditions, for which similar approaches have been tried, I am perhaps far less optimistic than the authors.
But, then again, I am happy to be proven wrong.
The assessment of weight history is no doubt a key feature of obesity assessment. Not only can weight history and trajectories provide important insights into obesity related risk but, perhaps more importantly, provide key information on precipitating factors and drivers of excessive weight gain.
Now, in a short article published in MedEdPublish, Robert Kushner discusses how the well-known OPQRST mnemonic for assessing a “chief complaint” can be applied to assess body weight.
In short, OPQRST is a mnemonic for Onset, Precipitating, Quality of Life, Remedy, Setting, and Temporal pattern. Applied to obesity, Kushner provides the following sample questions for each item:
Onset: “When did you first begin to gain weight?” “What did you weight in high school, college, early 20s, 30s, 40s?” “What was your heaviest weight?”
Precipitating: “What life events led to your weight gain, e.g., college, long commute, marriage, divorce, financial loss?” “How much weight did you gain with pregnancy?” “How much weight did you gain when you stopped smoking?” “How much weight did you gain when you started insulin?”
Quality of life: “At what weight did you feel your best?” “What is hard to do at your current weight?”
Remedy: “What have you done or tried in the past to control your weight?” “What is the most successful approach you tried to lose weight?” “What do you attribute the weight loss to?” “What caused you to gain your weight back?”
Setting: “What was going on in your life when you last felt in control of your weight?” “What was going on when you gained your weight?” “What role has stress played in your weight gain?” “How important is social support or having a buddy to help you?”
Temporal pattern: “What is the pattern of your weight gain?” “Did you gradually gain your weight over time, or is it more cyclic (yo-yo)?” “Are there large swings in your weight, and if so, what is the weight change?”
As Kushner notes,
“These features provide a contextual understanding of how and when patients gained weight, what efforts were employed to take control, and the impact of body weight on their health. Furthermore, by using a narrative or autobiographical approach to obtaining the weight history, patients are able to express, in their own words, a life course perspective of the underlying burden, frustration, struggle, stigma or shame associated with trying to manage body weight. Listening should be unconditional and nonjudgmental. By letting patients tell their story, the clinician is also able to assess the patients’ awareness, knowledge, motivation, decision-making, and resiliency regarding weight management. The narrative provides a basis for approaching the patients’ weight holistically, as well as beginning to formulate diagnostic and therapeutic options.”
There is no doubt much to be gained in understanding obesity by allowing patients to tell their own weight stories.
As readers will be well aware, n terms of health risks, fat is not fat is not fat is not fat.
Rather, whether or not body fat affects health depends very much on the type of body fat and its location.
While there have been ample attempts at trying to describe body fat distribution with simple anthropometric tools like measuring tapes and callipers, these rather crude and antiquated approaches have never established themselves in clinical practice simply because they are cumbersome, inaccurate, and fail to reliably capture the exact anatomical location of body fat. Furthermore, they provide no insights into ectopic fat deposition – i.e. the amount of fat in organs like liver or muscle, a key determinant of metabolic disease.
Recent advances in imaging technology together with sophisticated image recognition now offers a much more compelling insight into fat phenotype.
In this regard, readers may be interested in a live webinar that will be hosted by the Canadian Obesity Network at 12.00 pm Eastern Standard Time on Thu, Nov 23, 2017. The webinar provides an overview of a new technology developed by the Swedish company AMRA, that may have both important research and clinical applications.
The talk features Olof Dahlqvist Leinhard, PhD, Chief Scientific Officer & Co-Founder at AMRA and Ian Neeland, MD, a general cardiologist with special expertise in obesity and cardiovascular disease, as well as noninvasive imaging at the UT Southwestern Medical Center in Dallas, US.
Registration for this seminar is free but seats are limited.
To join the live event register here.
I have recently heard this talk and can only recommend it to anyone interested in obesity research or management.