Arya M. Sharma, MD

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

Obstructive sleep apnea (OSA) is one of the most common respiratory problems in overweight and obese individuals. The poor quality of life, daytime somnolence, fatigue, memory loss, and increased risk for metabolic and cardiac complications makes OSA a significant health problem. Habitual snoring, witnessed apneas, or excessive daytime sleepiness should always prompt further investigation for OSA in anyone with overweight or obesity.

While more severe forms of OSA often require continuous positive airway pressure ventilation, milder forms may be amenable to even modest weight loss (higher degrees of weight loss resulting from bariatric surgery virtually cure OSA).

The effect of dietary weight loss was now for the first time tested in a randomized controlled trial in a new study just out in the American Journal of Respiratory and Critical Care Medicine.

In this study, Henri Tuomilehto and colleagues from the University of Kuopio, Finland, randomized 72 consecutive overweight patients (BMI 28-40) with mild OSA to a very low calorie diet (VLCD=600-800 KCal for 12 weeks) with supervised lifestyle counseling vs. routine lifestyle counseling (general oral and written information about diet and exercise).

While the VLCD group lost about 10% of their initial weight, the control group lost around 3%. The VLCD intervention resulted in a 75% reduced risk for OSA at the end of the year-long study. OSA was objectively cured in 63% of patients in the intervention group, but only 35% of patients in the control group. As expected, improvements in the apnea-hypopnea index (AHI) were strongly associated with changes in weight and waist circumference.

This study demonstrates that weight loss induced by a hypocaloric diet together with lifestyle counseling is feasible and effective in reducing symptoms in in the majority of subjects with mild OSA and that these outcomes are maintained at 1-year follow-up.

Indeed, these findings are very similar to the previous report of marked improvements in OSA in patients achieving an approximately 10% weight loss with sibutramine and lifestyle intervention published by Brendon Yee and colleagues from the University of Sydney in the International Journal of Obesity (2007).

Overall it appears that even a moderate 5-10% weight loss can lead to remarkable improvements in OSA - certainly an intervention worth considering prior to investing in an expensive CPAP machine. 

AMS
Edmonton, Alberta

Obesity is a chronic disease and needs long-term treatment. Weight gain doesn’t happen overnight and obesity treatment is not about how much and how fast you can lose it.

Yet, there are situations where rapid and substantial weight loss may be indicated.

For example, patients with severe obesity who require urgent diagnostic procedures; patients with severe obesity needing elective surgery; patients with life-threathening medical issues made intractable by obesity; obese patient following acute illness, where recovery and rehabilitation is hampered by excess weight.

All of these situations may warrant “urgent” weight loss. The aim is not so much to provide long-term weight management - the aim is to acutely reduce weight to solve an immediate problem and get out of a tough spot.

In these situations, and only these, radical weight loss measures may be in order. This is where methods aimed at safe short-term weight loss are indicated. This is where treatments such as very low calorie diets, that may have limited efficacy in producing sustained weight loss, but can provide safe and immediate weight loss, can be helpful.

There is a wealth of literature supporting the safety and weight-loss efficacy of low calorie diets such as Optifast. While hardly sustainable in the long term, total meal replacements can provide a rapid and relatively safe strategy to substantially reduce body weight in the short term.

I have no doubt that the majority of patient will probably rapidly regain much of the weight lost, unless transitioned into a more sustainable form of obesity treatment - however, in the short term, this approach may help solve an otherwise intractable problem.

There are few published studies, let alone randomised trials on this concept. However, I have little doubt that given the dramatic increase in the number of severely obese patients in the health system, this approach will in clinical practice prove a rational and tangible path out of otherwise difficult situations.

AMS