Arya M. Sharma, MD

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

Yesterday, I had the pleasure of listening to Robert (Bob) Ross from Queen’s University, Kingston, Ontario, speaking at the 77th European Congress on Atherosclerosis, Istanbul. Turkey.

Here are his key messages:

1) Exercise helps reduce visceral fat even if you don’t lose much weight. Walking as little as 60 mins a weeks can have an effect - of course, the more the better

2) Measuring waist circumference can detect changes in abdominal fat even when overall weight does not change

3) People who are exercising to lose weight may lose their motivation if they solely focus on weight and fail to recognize the “other” health benefits of exercise

Anyone who has heard Bob speak, knows that he is a most eloquent and persuasive speaker.

Very much enjoyed his talk.

Great work Bob!

AMS
Istanbul, Turkey

Immobility, due to pain or otherwise, is certainly a major contributor to weight gain. Pain is indeed often presented by overweight and obese patients as a factor limiting their ability to lose weight.

Given the widely-held (but false!) belief that exercise is the most effective way to lose weight, the general expectation of both patients and health professionals is probably that restoring mobility by relieving pain will enable patients to be more physically active and thereby lose weight.

But is this actually the case?

This issue was recently addressed by Ryan Garcia and colleagues from the Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, OH in a study just out in the Journal of Bone and Joint Surgery.

Garcia and colleagues examined weight changes in 63 overweight and obese patients with neurogenic claudication who experienced substantial pain relief after lumbar decompression surgery for spinal stenosis. Although Zurich Claudication Questionnaire (ZCQ) Symptom Severity and Physical Function scores significantly improved by a mean of 56.4% and 53.0%, respectively, body weight and BMI significantly increased by 2.48 kg and 0.83 kg/m(2), respectively.

Overall, an average 34 months after surgery, 35% of the patients had actually gained at least 5% of their preoperative body weight while only 6% of the patients weighed at least 5% less than before their operation. The vast majority (59%) remained within 5% of their preoperative body weight.

This study, consistent with several previous studies on joint surgery, nicely documents that increased mobility after pain-alleviating surgery does not necessarily translate into weight loss - in fact, most people will either continue to gain weight or simply stay the same.

Obviously, this should not be an argument against alleviating pain in obese patients - no one deserves to live with pain. It just goes to show that increased mobility alone is not likely to substantially lower body weight - at best, it may prevent further weight gain (difficult enough even at the best of times).

This is probably something patients should be counseled about to not raise any false expectations.

On the other hand, it is important to note that this was not a weight-loss study. This means, that patients were not expressly counseled for weight loss or offered obesity treatments.

The question therefore remains whether or not improving mobility in patients by alleviating pain would improve efficacy of obesity management strategies (which I believe it would).

That is obviously a study that remains to be done.

AMS
Edmonton, Alberta

Yesterday we held another Orientation Forum for patients who have been referred to the Adult Weight Wise Program. Some have been waiting over a year for an appointment. Many are desperate for help. The average BMI of the 30 or so folks who attended the Forum was in the mid 40s - most have obesity-related comorbidities - clear indications for treatment.

So what did we orient them about?

Well, for one that obesity is a chronic disease and if they really want to deal with their weight problem, it will mean long-term if not lifelong treatment.

There are many factors contributing to weight gain and no treatment is going to work for everyone. Some may do well by simply making important changes to their lifestyles, some may need more intensive behavioural treatments, some may need medications, some may require surgery.

For some, the best they can realistically hope for is to stabilize their weight - i.e. stop gaining more weight every year.

For others, treatments may be more effective achieving 5, 10, 15 or even 20% weight loss that they may be able to keep off in the long term - but only if treatment continues. Stopping treatment will lead to relapse, or weight regain.

Tough words - tough decisions. No hope for cure, but certainly treatments that work and can effectively help manage weight and relieve comorbidities, i.e. if they stick with it.

No quick fixes, no magic pills, no miracle surgery and most of all - no false promises!

But also no blame, no pointing the finger, no sermons, no patronizing.

Just empathy and sound medical advice - the best we can offer!

AMS

There appears to be a rather widespread notion out there that introducing a bit of competition into the affair may spurn people on to try and lose those “extra” pounds.

In fact, a quick google search on the term “weight-loss challenge” reveals an amazing array of challenges from voyeuristic and sadistic TV shows like the “Biggest Loser” to well-meant workplace wellness initiatives or fund raisers. I am sorry to admit that I recently even became aware of a weight-loss challenge within my own hospital - well intended, but useless in the fight against obesity.

So what’s wrong with this idea? Isn’t competition a great motivator?

Sure it is - and people will do anything to win a competition - including crazy stuff like starve themselves, exercise till they drop or even (God forbid) pop diet pills, diuretics or laxatives just to win.

All of this is in direct contradiction to a fundamental principle of obesity management: you do not do things to lose weight that you are unlikely to continue doing to keep the weight off.

Most people seem to think that if only they could lose some weight, they will somehow be able maintain that lower body weight in the long-term with less effort.

The reality unfortunately is (and most dieters have experienced this over and over again) that no matter what diet or exercise routine you chose, no matter how slow or fast you lose the weight, no matter how long you keep the weight off - the minute you relax your efforts, the weight simply comes back.

As I have blogged before: obesity is a chronic disease for which we have no cure - only treatments! When you stop the treatment the weight (and any related problem) simply comes back.

By now you will already have figured out the problem with these challenges - unless you are very modest and reasonable about your weight-loss target and are carefully making changes that you can reasonably sustain forever, you are simply setting yourself up for failure.

If you are indeed modest and reasonable - you’ve already lost the competition to all the crazy folks who’ll do anything just to win.

My advise to anyone with a weight problem - the next time you see an invitation to a weight-loss challenge - simply ignore it!

If you really think you will benefit from obesity treatment - seek help from a trained and accredited health professional with experience in weight management - let’s put an end to weight cycling!

AMS