Thursday, January 16, 2014

Bariatric Care: What Can Behavioural Intervention Deliver?

sharma-obesity-exercise2Continuing 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 200 participants enrolled in the “medical” program.

This group of patients includes those patients, who at the time of entering the program were either not considering or interested in surgery. But it also includes 99 participants (50%), who changed their minds and opted for surgery after entering the program and ultimately went on to receive surgery within the 24-month follow up in APPLES. The data for these individuals was censored at the time they received surgery and was analysed as “last-observation-carried-forward”.

The Edmonton Bariatric program does not have separate entry streams for patient wanting surgery and those who don’t. Thus, all patients who enter the program, receive the same level of medical care that includes individualized intensive medical management consisting of lifestyle counseling (diet, exercise, behavioral modification), with visits every 4–8 weeks by a multidisciplinary staff (internists, endocrinologists, family physicians, psychiatrists, dietitians, nurses, physiotherapists, occupational therapists, and psychologists).

Behavioral modification focuses on teaching skills to help identify and modify eating and activity behaviors. Self-monitoring of weight, food intake and activity, stimulus control, and problem solving to help overcome barriers to weight loss are all key elements of behavioral modification.

Nurses and dieticians are the main care providers delivering intensive lifestyle counseling (diet and behavioral modification) and physiotherapists and occupational therapists provide activity counseling.

Visits with other providers are scheduled to address specific issues (ie, the internist, endocrinologist or family physician would address control of medical comorbidities, the psychologist addresses binge eating disorder, the psychiatrist assesses all patients felt to have unstable psychiatric disease).

Individualized one-on-one assessments are the norm; one exception is binge eating counseling, which is done in a group format.

Medical management is individually tailored to address root causes of excess weight and barriers to achieving weight management success. Antiobesity drug therapy (not available in Canada) and structured, very low-calorie protein-sparing diets were seldom used (< 4% of medically treated subjects received these) during the study.

Although not directly related to weight management, assessment of obesity-related comorbidities, including sleep disorders and mental health screening, is routinely performed.

Despite this rather intense and state-of-the-art “conservative” management – average weight loss over 24 months was rather modest.

While average weight loss was about 4 Kg (2.8%) – outcomes in specific individuals were more impressive. Thus, one in three (32%) patients experienced a 5% and one in six patients (17%) achieved a 10% weight loss at 24 months (LOCF).

However, even these modest changes in body weight were associated with significant improvements in cardiovascular risk factors (other health outcomes are yet to be fully analysed).

There are several important learnings from these findings:

1) Although the results may appear modest (certainly far less than the weight loss enthusiastically advertised in commercial programs), the degree of average weight loss is very much comparable to that reported at 24 months in non-pharmccological weight-loss studies in volunteers within research settings. Thus, the APPLES study demonstrates that a comparable degree of weight loss can be achieved in routine clinical practice in ‘all-comers”.

2) These findings certainly reinforce the refractory nature of severe obesity – while there is no doubt that some patients can lose a considerable amount of weight (as was the case in APPLES) – the average weight loss with behavioural modification, despite “state-of-the-art” medical care at a tertiary care centre, remains modest at best.

3) It is therefore not surprising that about 50% of severely obese patients will eventually need or opt for surgery (including those who had no interest in surgery when they entered the program).

The most important learning, however, is that overly optimistic notions that many providers (and patients) may have about how much weight the average obese individual (even with expert medical help) can hope to lose and keep off (even for just 24 months) need to be substantially recalibrated.

Clearly health providers (and policy makers), who expect that their obese clients can lose 20, 30, or even 50% of their weight by simply following their advice to “move-more and eat-less”, are kidding themselves. Evidently, this is something that even the best current medical care cannot deliver (remember treatments fail patients – patients never fail treatments).

This is not to say that the whole idea of medical bariatric care is a waste of time. For one, as regular readers will appreciate, bariatric care is far more about improving overall health and well-being than simply focussing on weight loss. Further analyses of the APPLES data to specifically examine outcomes such as improvements in quality of life, physical functioning, and specific co-morbidities including mental health are underway.

In tomorrow’s post we will look at outcomes in the surgically treated patients in the APPLES study.

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.

Edmonton, AB

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

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Friday, May 24, 2013

Ethical Obesity Management in India

Weight-Loss-Secret-IndiaThis evening, I will be presenting a brief talk on obesity to my colleagues here in New Delhi.

As readers will have noted, obesity is an increasing problem in the Indian subcontinent, with urban prevalence (based on the lower definition of BMI 25) reaching rates comparable to the West.

In the overwhelmingly private healthcare system in India, ethical and evidence-based obesity management becomes an even bigger challenge than in a country like Canada, where we have publicly funded healthcare.

While, in a public system, we can point to the health benefits of modest weight loss and take a long-term approach based on the principles of chronic disease management, in a private health care system, where the customer is king, people will only pay for what they want – and that is to lose as much weight as quickly as possible.

As in Canada, it is hard convincing patients (and even most health professionals) that just losing 5% of your weight has significant health benefit. Indeed few patients would be willing to pay for a 10-15 lb weight loss – and keep paying for your help to keep them off.

Unless you can (at least claim to) offer 25 or 50% weight loss, it is unlikely that you will have many clients – there is simply no money in ethical obesity management. I have yet to find the patient who would pay me to simply help them stop gaining weight.

In the end, weight loss is really what everyone is after – I guess this is why surgeons still refer to bariatric surgery as “weight-loss surgery” – weight-loss sells!

For my colleagues in India, where they have to compete with an entirely unregulated and ruthless commercial weight-loss industry that promises a seemingly unlimited number of “slimming miracles”, practicing “evidence-based” obesity management is simply not a viable way to make a living.

This, perhaps is the greatest challenge to health professionals who wish to offer ethical weight management to their clients – they simply have no treatments that can match the weight-loss expectations of their potential clients.

Thus, I know that my talk this evening will disappoint most of my listeners, who may well be hoping that I can reveal the latest “magic solution” for weight-loss.

I truly wish I had a happier message for them.

New Delhi, India

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Wednesday, April 24, 2013

Roads to Obesity: Social Environment

sharma-obesity-money1Continuing my discussion of the paper by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, on what causes some people to gain weight, we turn to what the authors describe as, “Gradual Processes”.

Thus, in their extensive interviews with individuals seeking bariatric surgery, although most interviewees focused on explanations with a considerable sense of self-blame, many did report social structural factors as playing an important role in their weight gain, without using these as “excuses”.

“Zoë pointed out that outdoor exercise was too difficult for her in winter conditions, and indoor exercise in a gym was out of her reach financially, and gave specific policy recommendations: “They’re always telling people to lose weight, that we’re an overweight province. Well, help out a bit. Make gym memberships a little more cheaper, make it a little more accessible to people.”

Other barriers included occupational and domestic work schedules:

“When you’re sitting at a desk 40, 45, or 50 hours a week, you’re trying to establish yourself so that people are looking to you, so you get promotions as opposed to someone else, so you’re putting in those extra hours and you’re coming home tired. You’re sitting down for supper, and then it’s 7:00 at night.Okay, when do I do anything now?”

“Wanda explained, “I got the two kids. I have a gym membership, a family gym membership; it’s just that we never get there. I work all day. When I get home I’m tired. … Just finding the time is hard.”

As the authors note, leisure time distribution is a social inequality that particularly affects those with less income as well as mothers of young children.

Furthermore, social inequality related to the risk for occupational injuries with subsequent weight gain are likewise often not seen as related to the social determinants of health.

Finally, built environments and the cost of weight-loss programs were seen as contributing factors that made weight management efforts difficult or unsustainable.

I am sure that readers will have their own social determinants to contribute to this list.

Berlin, Germany

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Wednesday, February 27, 2013

Obesity Fact #7: Provision of Meals Leads to Greater Weight Loss

sharma-obesity-jenny-craigObesity fact #7 in the New England Journal of Medicine paper on obesity myths, presumptions and facts, states simply that,

“Provision of meals and use of meal-replacement products promote greater weight loss.”

This “fact” is not surprising, as obviously if all you eat are the meals that are provided as part of a hypocaloric meal plan, then this is going to result in more weight loss than trying to compile those plans on your own.

Thus, as the authors rightly note,

“More structure regarding meals is associated with greater weight loss, as compared with seemingly holistic programs that are based on concepts of balance, variety, and moderation.”

While this may well be the case, the question ultimately is not just one of efficacy but also of effectiveness.

In other words, how likely, in the real world, is someone going to stick with a highly structured diet that essentially consists of meals delivered to your doorstep or even to meal replacements (rather than “real” food)?

While there are no doubt people who would fare well with such a regimen and would be willing to sacrifice variety for a plan that requires no effort in preparation and little effort in terms of decision-making, this may well be a minority of individuals.

While such strategies may well work to lose weight – the question really is whether such strategies results in long-term behaviour change that continues once you go back to eating “normal” foods in “normal” settings. Both cost and monotony could well be limitations of such approaches in the long term.

Nevertheless, I am certain that some of my readers will have their own experience with weight loss plans that either provide meals (e.g. Jenny Craig, Nutrisystem, etc.) or plans that involve replacing meals with bars or shakes (e.g. Slim-Fast).

That both strategies can be highly effective and promote weight loss is without question – they definitely work – whether such strategies are effective in the long-term (beyond the confines of a clinical trial) is perhaps less certain.

Obviously, any diet plan only works as long as you stick with it and there is probably nothing simpler or more convenient than having someone else prepare your meals for you.

Chicago, IL

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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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