Dr. Sharma's Obesity Notes

Over the past few posts, I have been discussing the findings of the National Weight Control Registry, which found that the people, who successfully manage to keep weight off, fall into roughly four clusters.

As readers will recall, the prototypical representatives of these clusters (Golden Boy Mark, Fitness Enthusiast Julie, Poor Eater Gertrude, and Struggler Janice), all have lost considerable amounts of weight, but each is using a different approach and coping differently.

But why are they successful?

Frankly, I have no idea!

Of course, we now know “what” Mark, Julie, Gertrude and Janice are doing – we know “how” they are keeping the weight off – but nothing in the NWCR data tells us “why” they can do what they do.

Not only, do we not find any answers to why these folks are “successful” at something that the overwhelmingly vast majority of people with excess weight tend to fail at, nor does the data tell us how to take someone, who is not “successful” and lead them to “success”.

In fact, we do not even understand what makes Mark, Julie, Gertrude and Janice different from each other. Are the reasons for their different strategies genetic, physiological, psychological, social, or environmental?

Does Mark find it effortless to manage his weight because of the make up of his mitochondrial DNA, his mental resilience, his extra-ordinarily large frontal lobe, or simply the fact that he has a job that allows him ample of time to pursue his healthy eating and physically active lifestyle. Perhaps, he has a social support system that supports rather than sabotages his efforts. Perhaps he has a healthy dose of narcissism (some might call it “selfishness”) that allows him to put himself before others.

We don’t know.

What led Julie to take up her active lifestyle and why has she decided to devote such considerable energy to her sporting activities – has she perhaps simply transferred here addictions from food to workouts?

We don’t know.

Why can Gertrude get by by eating so little.

We don’t know.

So, while it is of considerable “academic” interest to know “what” successful weight-loss maintainers do, it is not at all clear how to turn an average Joe into Mark or an average Jane into Julie.

Which brings me back to clinical practice.

If I were simply to tell my patients that successful weight loss maintainers tend to eat 1400 Cal (reportedly!) and exercise 2800 Cal (so they say) and so all they have to do is to also only eat 1400 Cal and simply start exercising enough to burn off 2800 Cal, I do not think I would be of any use to them.

Unfortunately, we live in a culture that assumes that anyone can do anything if they really want it – in other words, if you can’t do it, you simply don’t want it enough – this is not a recipe for success, it is a recipe for self-blame, disappointment, and further damage to your self-esteem. It is a recipe for unrealistic expectations.

The folks in the NWCR are remarkable, exactly because they are so few and far between – if their “success” was more common, there would not be anything worth remarking on.

So, while I appreciate the effort that goes into maintaining the NWCR and the time that the registrants spend providing their data, I am not sure that I learn anything from this exercise apart from the fact that we need better treatments that go beyond “eat less – move more”.

But perhaps my readers see this differently?

AMS
Edmonton, AB

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Aug 27, 2008:

One of my all time favourite quotes is “No one is admired for failing to achieve the impossible.”

I have previously blogged about the issue around unrealistic expectations when it comes to weight management.

In fact, one of the principal reasons that we have successfully introduced the Orientation Sessions in the Weight Wise program, is to temper patients’ often ridiculously optimistic expectations about how much weight they can lose and keep off.

While a large proportion of patients are hoping to lose about 50% of their initial weight, the sad truth is that even with surgical treatment, the average patient can hope to lose only 25% – and that is when all goes well!

Why is managing expectations so important?

Because unrealistic expectations guarantee disappointment. (for my mathematical readers S=O/E where S=Satisfaction, O=actual Outcome, E=Expectations; if S<1 the patient is unsatisfied or disappointed).

The issue of ridiculous expectations is not limited to weight loss. In fact, Janet Polivy (University of Toronto), in a wonderful article published in the International Journal of Obesity (2001 – free PDF for download), termed this the “False Hope Syndrome”.

In the context of weight management, this syndrome is characterized by often completely unrealistic expectations as to:

1. the amount of weight loss that can be achieved (and maintained!)

2. the speed with which the weight can be lost

3. the ease with which lifestyle changes can be made

4. the effects that these changes (weight loss) will have on other (mostly non-health related) aspects of one’s life (e.g. finding a better job, attracting a partner, etc.)

When any of these unrealistic expectation are not met, the result is simply disappointment, discouragement and a sense of failure.

It is therefore a moral and ethical obligation for health professionals to actually talk patients out of thinking they can all become happy Ken and Barbie dolls if only they tried hard enough.

Unfortunately, it is very easy for health professionals to be caught up in the ridiculous expectations of their patients or even feed these expectations by demanding and expecting the impossible. Thus, for e.g. the orthopedic surgeon who expects his obese patients to lose 30% of their body weight before hip-replacement surgery is a “mental abuse” lawsuit waiting to happen (especially given that the evidence that obese patients benefit less from joint replacement surgery compared to non-obese patients is rather iffy).

There is little doubt that one of the major factors that drives these ridiculous expectations are the many commercial weight-loss programs, products, books and other scams that play on peoples’ fantasies, despite the reality that few (if any) users of these services or products actually achieve any of their long-term goals. Amazingly, these scams get away with it because the individuals strangely tend to blame themselves rather than the useless product or service for their failure, while in the rare cases of success, the programs take the credit.

Clearly, not a bad business to be in!

As for ethical programs, I would expect first and foremost that all possible effort is made to diagnose and manage the “False-Hope Syndrome” BEFORE embarking on any treatment – not doing so is simply guaranteeing failure, disappointment and relapse.

AMS
Edmonton, Alberta

One of the most common misconceptions about obesity management is that identifying and addressing a potential contributor to weight gain should automatically translate into weight loss – it does not!

As I pointed out in a recent post, when you identify and address the cause of weight gain – weight gain stops, and that’s usually it!

That many of us fail to recognize this rather simple principle, is again illustrated by a paper by Penner and colleagues published in the Journal of Joint and Bone Surgery, which found that successful ankle reconstruction surgery does not decrease BMI in overweight and obese patients.

According to their findings, the 145 patients with excess weight who underwent successful ankle replacement or ankle fusion, despite significant improvements in Ankle Osteoarthritis Scale (AOS) scores and increased physical activity scores, pretty much maintained their preoperative BMI levels at six months and one, two, and five years.

Based on these findings, the authors conclude that:

“Pain and disability are significantly reduced in overweight and obese patients after successful ankle replacement or fusion. Despite this, the mean BMI remains unchanged after the surgery, indicating that weight loss does not commonly occur following successful ankle reconstruction in this patient population. Obesity is likely attributable to factors other than limited mobility caused by ankle arthritis.”

Obviously, the authors assumed that if limited mobility caused weight gain, then increasing mobility should reduce it – that, however, is not what happens.

Rather, what they found, is exactly what I would expect – with regain of their mobility, patients stopped gaining weight – and that’s all.

Without a targeted obesity treatment strategy, there is indeed no reason to expect that these patients would now begin losing weight simply because their activity levels may now be somewhat higher than before. The few extra calories that they may perhaps now burn as a result of being more physically active would easily be compensated by an increased intake or other biological mechanisms that are there to ‘defend’ their current weight.

Thus, the observation that successful ankle surgery did not result in ‘spontaneous’ weight loss neither disproves nor proves that pain or disability may have contributed to weight gain in the first place – it probably did in some and probably did not in others.

Interestingly enough, I believe that this study also bears an important lesson for those attempting to address obesity at a societal level – even if we did know what exactly is driving the obesity epidemic – removing this cause does not necessarily mean everyone gets thinner – it just means that things may hopefully not get worse.

AMS
Berlin, Germany

Penner MJ, Pakzad H, Younger A, & Wing KJ (2012). Mean BMI of Overweight and Obese Patients Does Not Decrease After Successful Ankle Reconstruction. The Journal of bone and joint surgery. American volume, 94 (9) PMID: 22552679

.

Earlier this 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 brief excerpt from this interview published in their newsletter Closer Look:

JOSEPH: The prospect of long-term weight loss in the population as a whole seems very challenging based on most interventions for which we have long-term data. Assuming that we turn this around in the next 50 years, what do the turning points have to be? Will it be better therapy? Some really refined and effective surgery? Impacting childhood obesity?

DR. SHARMA: If I had to bet, I’d bet on drugs and not on surgery. I think surgery is a phase. It’s being done now; it’ll be around for probably another decade or so, maybe longer, until we get new drugs. I think that there are two things that may need to change in drug development, or even in the thinking about pharmacological treatment of obesity.

The first is starting to differentiate obese people into subsets of obese people. So a drug that doesn’t have to be for whoever has obesity, but rather for a subset of patients with obesity because they have a certain eating disorder or there’s a certain pathway in their brains that is promoting overeating or they have a certain lack of satiety. That is a group of patients for whom a given drug really works. They are the ones who should be getting it. The drug may not work for everybody else. You would start splitting down this whole indication into other groups.

That may or may not happen. In hypertension it never happened. We have 100 drugs for hypertension and people have always said, “Let’s break it down and let’s decide who’s the best patient for a diuretic and who’s the best patient for a beta blocker and who’s the best patient for an ACE inhibitor.” That actually never worked. In the end, even today, hypertension practice is pretty much trial and error, with fixed combinations becoming more and more accepted.

So, I’m not holding my breath that that will happen with obesity. I think if you find drugs that are overall effective and well tolerated in most people or at least half the people you treat with them, it probably doesn’t matter.

But I think the other piece that really matters is whether or not we can come up with a way to license drugs to help with weight-loss maintenance. The mechanisms that help you lose weight may not be the same mechanisms that help you keep weight off. Take leptin, for example. Leptin is not a great drug for losing weight, but it may be the perfect drug to keep weight off. But there’s no pathway. If I wanted to license leptin for weight management, I would have to go to the FDA and show that it helps people lose weight, which it doesn’t, and so I’d never be able to license it. I need a pathway that’s going to allow me to specifically get regulators to approve a drug that is efficacious for helping people maintain weight loss, even if it does not promote weight loss in itself.

So, the idea is you go lose weight and come back to the doctor’s office, and then he’ll put you on these drugs so that your weight doesn’t come back. That is a regulatory pathway that doesn’t exist right now.

JOSEPH: It seems like the standard of care for weight-loss, excluding drugs and devices in some patients, is intense diet and exercise as a starting point. What do you think about this approach?

DR. SHARMA: It’s simply not going to work. All that diet and exercise talk is like what we used to do for cholesterol and for diabetes. I’m not saying it’s not important, and there’s no question that if I get somebody to diet and exercise, they’ll lose weight. But it works for obesity in the same way that the DASH [Dietary Approaches to Stop Hypertension] diet works for hypertension. I can put people on the DASH diet and show that their blood pressure gets better. But if I were to take 100 people off the street, put them all on the DASH diet, and hope that everybody’s blood pressure’s going to be fine, it won’t be. Only five guys would actually stick to the diet, and they’d be fine, but the other 95 would not be fine. Obesity is pretty much the same; I don’t see any difference at all.

KELLY: Presumably weight-loss maintenance also goes back to improving the public’s understanding of obesity and addressing weight bias and discrimination.

DR. SHARMA: Absolutely, we are bombarded with anecdotal instances of how easy it is to lose vast amounts of weight – not just the ‘weight-loss industry’ – think of TV reality shows, popular magazines, and fad diets. We celebrate people for losing weight – we seldom check to see if they are still keeping it off. I am always asked by patients, “How much weight can I lose and how fast can I lose it?” I tell them that that’s the wrong question – the only weight loss that matters is the weight you can keep off – this is why we introduced the term ‘best weight’ – the lowest weight you can realistically maintain. Your ‘best weight’ depends on your individual circumstances – everyone’s ‘best weight’ will be different.

The public but also health professionals and policy makers need to understand that when you pay for ‘weight loss’ you get ‘weight loss’ – when you pay for ‘maintenance of weight loss’ you get ‘maintenance of weight loss’. As a health professional I’d rather see my patients or payors paying for the latter than the former.

Another point is that we often frame weight regain as ‘failure’ when it is really the only natural expected consequence of stopping the treatment for a chronic condition. Even worse, the failure is often framed in the context of the treatment. So if you take a drug – lose weight – stop the drug- regain the weight – we attribute the failure to the drug and not to ‘stopping’ the drug. No drug or treatment works when you don’t take it – when you have an obesity treatment that works, the question is not to find more effective weight loss drugs but to find a more effective way of ensuring that people continue taking it.

The same, incidentally, applies to treatments for hypertension or diabetes. For many conditions we don’t need more drugs (unlike for obesity) – we simply need to figure out how to get patients to continue taking the meds that are already out there – that’s where I’d be putting most of my research money.

To be continued….

AMS
London, UK

Given that the majority of folks with excess weight face weight bias and discrimination on a regular basis, it is not hard to imagine that the stronger the perceived weight bias, the greater the desire to lose weight.

One can also imagine that the lengths and perhaps risks that these individuals will go to, will be far greater than in people who are more comfortable with their excess weight and may have faced less societal pressure.

According to a study by Saaqshi Sharma (no relation) and colleagues from Ontario, published in Clinical Obesity, not only does the experience of weight bias apparently drive patients to seek out riskier and more drastic treatments but also perhaps promotes notions of weight loss that are even more unrealistic than harboured by most people seeking obesity treatments.

In this study, Sharma and colleagues studied 115 patients of the Wharton Medical Clinic with an average BMI of 40, 85% of who were female and 77% of who reported weight discrimination regarding their weight loss goals as well as their acceptance of different obesity treatments.

Specifically, the participants were asked to chose between increasingly ‘severe’ treatment options that they would consider:

Severity class I: Lifestyle changes (i.e. eat less, eat better, more physical activity, more will-power)
Severity class II: Pharmacotherapy and meal replacements
Severity class III: Bariatric surgery
Severity class IV: Genetic modification (i.e. something that is currently not even possible)

Overall, participants considered a weight loss of about 33% (or about 38 Kg) as ‘ideal’ and the majority thought that this could be achieved through lifestyle changes such as improved physical activity (80%) or diet (52%), with fewer reporting pharmacotherapy (8%), surgery (12%) or genetic modification (7%) as necessary for achieving this degree of weight loss.

Thus, participants selecting lifestyle changes or pharmacotherapy for weight loss reported ideal weight loss goals that would generally only be achievable through surgical means (i.e. 32% and 33%, respectively), and participants selecting surgical intervention reported ideal goals at the upper end of what is generally achievable even with surgery (38%).

Participants selecting surgery or genetic modifications were also more likely to report experiencing weight discrimination.

These findings have two important messages, which although perhaps not unexpected, should provide pause for discussion.

Firstly, it is evident that patients (and perhaps many health professionals) vastly overestimate the weight loss results of lifestyle interventions – an average outcome for these are in the 3-5% range – patients expect almost 10 times more than is realistically possible (anecdotal exceptions just prove how difficult this actually is).

Interestingly, even patients seeking surgery, grossly overestimate the degree of weight loss with this intervention.

Secondly, patients, who report weight bias not only have even more unrealistic weight loss expectations, they are also much more likely to opt for more drastic treatments.

To me, unrealistic expectations can only end in one way – disappointment!

Frankly, if I were to begin a treatment expecting a 40 Kg weight loss and find out that even 5 Kg (irrespective of any health benefits) is all that I can realistically hope to sustain, I would not be surprised if I fully abandon both hope and effort (especially if I also happen to be an ‘all-or-none’ thinker).

Indeed, I can only concur with the authors conclusions that:

“These findings may be explained by representations of obesity as easily modified with diet and exercise, which suggests that weight problems can be overcome through such modifications.

Patients and the public at large may need to be educated on realistic weight loss expectations for the various interventions in order to better balance the risk associated with each intervention against the risks associated with obesity, so that patients can make an informed and rational decision regarding their weight management.”

The latter can perhaps also be said for the majority of health professionals, decision makers, and funders of obesity services.

I wonder who the winner is.

AMS
Edmonton, Alberta