Friday, January 17, 2014

Bariatric Care: What Surgery Delivers

sharma-obesity-bariatric-surgery21Continuing in my discussion of the weight and health outcomes of the APPLES study, reported by Padwal and colleagues in Medical Care, we now turn our attention to the 150 participants who underwent bariatric surgery in a publicly funded bariatric program.

As noted in yesterday’s post, all surgical patients underwent intensive medical assessment and behavioural interventions prior to undergoing surgery. Thus, the outcomes reported in this group of participants is on top of any weight loss or benefits that patients may have experienced as a result of this intervention prior to surgery. It is thus, not surprising that at the time of enrolment to the APPLES study, surgical participants were approximately 4 Kg lighter than the “medical” participants (this being the average weight loss seen in the “medically” managed group).

Of the 150 surgical participants, 129 (86%) completed their 24 month visit. Data for the “drop-outs” was analysed as “last-observation-carried-forward”.

Overall weight loss at 24 months for the surgical group was 22 Kg (16.3%) with 75% achieving more than 5% weight loss, and 63% achieving more than 10% weight loss.

There were distinct differences in weight-loss outcomes between the different surgical procedures (all of which were performed in approximately equal proportions).

While the average weight-loss at 24 months for patients undergoing adjustable gastric banding was a paltry 7 Kg (5.8%), sleeve gastrectomy patients lost 21 Kg (16%), whereas bypass patients lost 37 Kg (26%) of their initial body weight.

All of these weight-losses were associated with marked improvements in cardiovascular risk factors.

There are several important learnings from this data.

1) Surgical treatments were markedly more effective than behavioural intervention (no surprise here).

2) There are significant differences in the amount of weight lost with the different surgical procedures, with bypass patients losing almost five times more weight that those undergoing gastric banding (rather unexpected).

3) Even with the greater weight loss achieved through surgical treatment, the average weight loss is still well under 30% of initial weight – again speaking to the refractoriness of severe obesity even with surgery.

Thus, despite its greater efficacy, even bariatric surgery will still leave many patients obese (based on BMI).

For clinicians (and patients) this means that many patients undergoing bariatric surgery, despite significant weight loss and considerable improvements in health and quality of life, may still be disappointed to not achieve their “ideal” or “dream” weight.

In the next post, I will summarize the overall learnings from this study and what they mean for the current status of bariatric care.

@DrSharma
Banff, AB

ResearchBlogging.orgPadwal RS, Rueda-Clausen CF, Sharma AM, Agborsangaya CB, Klarenbach S, Birch DW, Karmali S, McCargar L, & Majumdar SR (2013). Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program: Prospective Cohort Study. Medical care PMID: 24374423

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Thursday, January 9, 2014

Results Not Typical: FTC Clamps Down on Fraudulent Weight-Loss Claims

sharma-obesity-weight-loss-supplementsOnce of the big news items this week was the announcement of a $34 million settlement with four marketers of weight-loss products that made misleading claims (L’Occitane, which claimed that its skin cream would slim users’ bodies but had no science to back up that claim, and HCG Diet Direct, which marketed an unproven human hormone that has been touted by hucksters for more than half a century as a weight-loss treatment, LeanSpa, LLC, an operation that allegedly deceptively promoted acai berry and “colon cleanse” weight-loss supplements through fake news websites).

According to the US Federal Trade Commission, this is part of its “Operation Failed Resolution” to stop misleading claims for products promoting easy weight loss and slimmer bodies. The FTC will make these funds available for refunds to consumers who bought these allegedly fraudulent products (although it appears that some of these companies may not have enough funds to pay up).

The agency also announced that additional charges have been made against the marketers of two other products.

The FTC is also calling upon broadcasters and other media outlets to stop promoting weight-loss products that promise results that defy science (and common sense) and has release a new guidance document to help spot such fraudulent weight-loss claims.

In a letter to be sent to US publishers and broadcasters, the FTC states that,

“Every time a con artist is able to place an ad for a bogus weight loss product on a television or radio station, in a newspaper or magazine, or on a legitimate website, it undermines the credibility of advertising and does incalculable damage to the reputation for accuracy that broadcasters and publishers work hard to earn.”

Here is the “business” rationale that the FTC has to offer to publishers and broadcasters for refusing to running such ads:

  • No legitimate media outlet wants to be associated with fraud. Accuracy is your company’s stock in trade. Why sully your good name by being known as a publication or station that promotes rip-offs?
  • If scammers are willing to cheat consumers, there’s a good chance they’ll cheat you by not paying their bills. By the time fly-by-nighters have made a quick killing, they’ve disappeared – and left you holding a stack of worthless receivables.
  • You want to protect loyal readers, listeners, and viewers from bogus products that can’t possibly work as advertised.
  • Reputable advertisers don’t want to associate their brands with media outlets used by con artists.

The FTC advises publishers to run a “Gut Check” and to think twice before running any ad that says a product:

  • Causes weight loss of two pounds or more a week for a month or more without dieting or exercise;
  • Causes substantial weight loss no matter what or how much the consumer eats;
  • Causes permanent weight loss even after the consumer stops using product;
  • Blocks the absorption of fat or calories to enable consumers to lose substantial weight;
  • Safely enables consumers to lose more than three pounds per week for more than four weeks;
  • Causes substantial weight loss for all users; 
  • Causes substantial weight loss by wearing a product on the body or rubbing it into the skin.

Furthermore, all weight-loss ads should include “clear and conspicious” disclosure of how much weight consumers typically can expect to lose. (emphasis mine)

Whether or not publishers and broadcasters will actually heed such advice remains to be seen. My guess is that running such ads may be far too lucrative a business for these agencies to simply give up.

To educate broadcasters and the public, the FTC has released an online “Gut Check” test, where you can check your own ability to spot false weight loss claims – to take the test click here

While the FTC is to be commended for taking these steps, we have yet to see similar punitive action against irrational and unscientific weight-loss claims here in Canada – I wonder why.

If you would like to see more regulation or have had your own experience with such products, I’d love to hear from you.

@DrSharma
Edmonton, AB

Hat tip to the many readers who sent in links to news articles about this announcement.

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Monday, October 7, 2013

Weight Loss is Not a Behaviour!

Football-penalty-kickLast week, I gave the plenary key note talk at the 2013 Obesity Help Conference in Anaheim. I also held a standing-room-only workshop in which I discussed behaviour change.

One of the points I made at the workshop, was to remind the audience that weight loss is not a behaviour.

Let me explain: when I tell patients to stop smoking – they know exactly what to do, namely to stop putting a cigarette in their mouth and inhaling its smoke. That’s a behaviour they can change. When they stop smoking they have “successfully” changed a behaviour – that’s behaviour change – end of story.

But, when I tell a patient to go and lose weight, I haven’t actually told them what BEHAVIOUR to change.

Rather – to use the smoking analogy – it is as though I had simply told my smoking patients to go out and reduce their cardiovascular risk, leaving it up to them to figure out how exactly to go about doing that.

Some of my patients may perhaps realize that quitting smoking is by far the most effective way to lower their risk – others may not and merely try to reduce their salt intake or start exercising – neither of which is likely to reduce their cardiovascular risk to the extent that smoking cessation would.

This is exactly why I would be very specific as to exactly what behaviour I want my smoker to change – namely to STOP smoking.

If I wanted them to eat less salt or start exercising – then that is exactly what I would tell them to do.

Those are BEHAVIOURS that they can change.

Contrast this to a doctor telling his patient to lose 20 pounds.

This may seem like a specific and achievable goal – but it is not a BEHAVIOURAL goal because the doctor has not “prescribed” a BEHAVIOUR – he have simply “prescribed” an outcome.

To use a sports analogy – kicking the ball at the goal is a BEHAVIOUR – scoring a goal is not!

In fact, with no further instructions, the doctor is leaving it up to his patient to figure out exactly what BEHAVIOUR they would perhaps need to change. Start eating breakfast? Eat more fruits and vegetables? Keep a food journal? Join an exercise program? Take a stress management course?

Of course, his patientss could “successfully” change their BEHAVIOUR and do all of the above only to find that not much happens to their weight.

Would they have “failed” at behaviour change? Of course not! After all they have “succeeded” in changing their behaviour.

But have they also “succeeded” in weight loss? Maybe – maybe not.

To be clear:

“I want to cut my daily caloric intake by 500 calories”, is a behavioural goal; “I want to lose one pound a week”, is not!

(indeed, you may well find yourself “successfully” cutting your daily intake by 500 calories without coming anywhere close to losing one pound a week – let alone 20 pounds any time soon).

Thus, we must remember that BEHAVIOURAL interventions can only aim to change behaviours (this is where SMART goals come in – more on this here).

The only real measure of “success” of a BEHAVIOURAL intervention is whether or not your patients have “successfully” changed their BEHAVIOUR.

There are many BEHAVIOURS that will make them healthier – but there is simply no BEHAVIOUR that GUARANTEES sustainable weight loss.

This is why weight loss is not a BEHAVIOURAL goal.

@DrSharma
Edmonton, AB

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Tuesday, January 15, 2013

Why Are Some People Successful At Maintaining Weight Loss?

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

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Friday, August 17, 2012

Unrealistic Weight-Loss Expectations Guarantee Disappointment

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

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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