Arya M. Sharma, MD

One of the brochures that was freely distributed at the recent Journées annuelles de santé publique (Québec) meeting I spoke at yesterday in Montreal, is a pamphlet produced by the Québec Public Health Agency (with funding from the Public Health Agency of Canada) on the potential risks of dieting.

The pamphlet notes that:

• 1 woman out of 2 in Quebec wants to lose weight
• 45% of children aged 9 in Quebec aren’t happy with their figure
• Half of Quebec women try dieting more than twice a year
• Losing weight does not mean you are healthier (quite the statement coming from a public health agency)
• Many women mistakenly believe losing weight will improve their self-esteem, make them more attractive and make them sexier.

The pamphlet actually warns that:

“Always being on a diet might make you gain weight. The more you are preoccupied with your weight, the more you are at risk of suffering from depression and stress. Day-to-day activities like meals, getting dressed and playing sports can be transformed into major sources of anxiety.”

The pamphlet is also very clear about why most commercial diets don’t work:

Diets don’t take into account the reasons why you are gaining weight:

• Heredity, disease, medication, age, etc.
• Eating habits, physical activity, being obsessed with one’s own weight, etc.
• Perfectionism, low self-esteem, anxiety, stress, etc.
• Standards of beauty, the environment, the type of work we do, etc.

Finally, it offers the following points to consider when thinking about losing weight:

Weight-loss pace: Does my plan focus on losing more than 1-2 pounds per week?

Methods used: Does my plan focus on what food I eat, physical activity and changing my habits?

Is health professional support available?

Food intervention: Do you vary the meals you make, experiment with different flavours, colours and ingredients? Eating right is good for your health but it can also be fun and delicious!

Physical activity: Does my plan have an element of physical activity, the kind I enjoy?

Efficiency: Has the approach I am taking been scientifically verified, and is it efficient over the long term?

Danger: Is my plan safe, meaning is it devoid of danger and secondary effects?

Advertising: Are the ads related to my plan realistic?

What it costs: Can I realistically evaluate the total cost of my plan?

The brochure is available both in French and English.

Not sure that warning about the ‘dangers of weight loss’ is standard practice with other public health agencies - I certainly haven’t seen similar warning signs in other jurisdictions.

Obviously, the Agency is by no means implying that excess weight or obesity cannot be a health problem - it is simply warning about the possibility that ’self-guided’ non-evidence-based approaches, especially those often promoted by the commercial weight-loss industry, may in the end do more harm than good.

When weight loss is indeed medically indicated - treatment should perhaps be best left to ‘qualified‘ health professionals.

AMS
Toronto, Ontario

p.s. Hat tip to Chantal Bayard of the ASPQ for bringing these brochures to my attention

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

• Should We Outsource Obesity Treatments To Weight Watchers?
• Alberta’s Obesity Initiative: Not Just Diet and Exercise
• Is There Any Path For Approval of Anti-Obesity Drugs?
• GLP-1 Receptor Agonists, Obesity and Psoriasis
• Bariatric Surgery For Osteoarthritis of Hips and Knees?

Have a great Sunday! (or what’s left of it)

AMS
London, UK

You can now also follow me and post your comments on Facebook

Yesterday, I posted on Alberta’s plan to tackle obesity by beefing up prevention and treatment efforts across the province.

Today, I discuss a paper by Susan Jebb and colleagues, just published online in The Lancet, comparing weight loss in people randomised to either ’standard’ care with their physicians or to Weight Watchers.

An accompanying editorial, suggest that doctors (or health systems) should perhaps give up on obesity treatments, as commercial programs (e.g Weight Watchers, Jenny Craig, etc.) do a much better job of this and may cost less.

In this parallel group, non-blinded, randomised controlled trial, 772 overweight and obese adults were recruited by primary care practices in Australia, Germany, and the UK. Participants were randomly assigned with a computer-generated simple randomisation sequence to receive either 12 months of standard care as defined by national treatment guidelines (n=377), or 12 months of free membership to Weight Watchers (n=395).

While only 61% of Weight Watchers participants completed the 12-month assessment, even fewer (54%) of standard care participants showed up for their 12-month assessment.

Perhaps, not surprisingly, participants in the commercial programme group lost twice as much weight as did those in the standard care group (−5·06 kg vs. −2·25 kg) at 12 months.

Based on these findings, the authors enthusiastically conclude that:

“Referral by a primary health-care professional to a commercial weight loss programme that provides regular weighing, advice about diet and physical activity, motivation, and group support can offer a clinically useful early intervention for weight management in overweight and obese people that can be delivered at large scale.”

Sure, but the question here is, for whom (or, in other words, for which patients) and, perhaps more importantly, with what benefit?

So who took part in this study: it would probably be fair to describe the participants as essentially healthy, slightly overweight, pre-menopausal women - in fact, the usual people, who show up at most commercial weight loss programs.

To be exact, the participants were 85% female, in their mid-forties, mildly obese at best (BMI ~31), and had perfectly normal blood pressures (124/78 mmHg), the occasional diabetes (6%) and a metabolic profile that would hardly raise an eyebrow from most health professionals.

While weight loss appeared to move some of these variables in a ‘positive’ direction, one would be hard pressed to find the odd parameter that barely reached ’statistical’ significance (let alone ‘clinical’ significance) - most clinicians would probably consider these changes little more than ’rounding errors’.

So what the study really shows is that if you randomise a group of otherwise healthy low-risk marginally overweight/obese women to a (albeit, admittedly great) commercial weight loss program, they do better at losing weight than when told to do so by their doctors (or other health professional) - and I’ll certainly believe that.

While I can see why the sponsor (Weight Watchers) and the authors (for publishing in The Lancet) may be celebrating, I see nothing in this study that would make me more enthusiastic about ‘outsourcing’ obesity treatments to a commercial Weight-Loss program).

And here are my reasons:

1) The people, who typically seek out commercial weight loss programs (like the participants in this study) are not who the obesity epidemic is really about. As we recently demonstrated in our large Edmonton Obesity Staging System (EOSS) papers, ‘healthy’ overweight and obese people (male or female) have very little if any health risk from their extra weight and should probably be left alone (certainly not be encouraged to lose weight). No one has yet demonstrated any long-term benefit of weight loss in this ‘healthy’ (Stage 0) obese population and there is far more potential to do harm than good (especially, when the weight comes back, as it most likely will - often with a vengeance).

2) While there is no doubt that Weight Watchers probably offers one of the most evidence-based and effective weight management programs (and is to be highly commended for investing in this study), it is hardly a model for everyone. Very few people have time for weekly meetings and weigh ins and high drop-out rates are the rule rather than the exception - for those, who can do it and enjoy such meetings, great - for most people, this is simply not a realistic option.

3) For all of its competence, expertise, knowledge and investment into offering a high-quality program, the delivery is by trained (and certainly very enthusiastic) lay people - this is why this model works great for ‘healthy’ obese folks. The minute we begin looking at obese people with real health problems, who need lab work, adjustments to their medications, close monitoring of their exercise and nutritional status, the notion that a trained ‘lay person’ alone can be of help is naive at best. Thus, you would in the end be paying double - money to Weight Watchers for weight loss, and still have to see your physician or nurse for managing your comorbidity (albeit perhaps not quite as often as weekly). In fact both Weight Watchers and the authors are careful in pointing out that the study only shows that Weight Watchers in conjunction with a primary care practitioner may be the way to go.

4) Although, much effort has gone into developing the Weight Watchers program and they certainly touch on many of the important aspects of healthy eating, activity, sleep, emotional eating, etc., in the end there is no formal etiological assessment or consideration of the actual causes of excess weight in a given patient. Obviously, I would neither expect a ‘lay program’ to appropriately diagnose depression, anxiety disorders, ADHD, binge eating, chronic pain syndromes, PCOS, obesogenic medications, or any of the other 200 causes of obesity that I can think of. In the end commercial weight loss programs sell weight loss and not obesity treatment.

5) Rather than interpreting this study as showing how great the Weight Watchers program is (and it is without question by far one of the best commercial programs out there), this study actually shows how miserable ’standard’ care for obesity is - or not? Perhaps the health professionals were indeed smart enough to recognise that very few (if any) of the participants in this study had anything to gain in terms of improving their health from losing weight, and so put little effort into actually doing anything about it. Certainly, in my practice, I would not be wasting my nurses’, dietitians’, psychologists’, or anyone else’s time by referring the majority of these ‘participants’ to any weight loss interventions in our clinic.

The messages for me from this study are loud and clear:

1) ‘Standard’ care is clearly below standard (assuming that we’d see the same result if the participants actually did have a medical reason to lose weight).

2) We need to tell more people that losing weight when you are otherwise healthy may not actually be of any real benefit (of course, we could argue that if Weight Watchers just helped people eat healthier and be more active without any weight loss, they’d probably have the same impact on participants’ health (or not) - but then, who’d pay for that?)

The idea that, based on this study, anyone would even playfully (let alone seriously) suggest that obesity treatment should perhaps be best left to commercial weight loss programs, is not only ludicrous but reflects a rather simplistic view of what I (and many others) would consider a pretty complex and often complicated chronic disorder.

This is not to say that there is no role for Weight Watchers in helping people better manage their weight (and health?).

Weight Watchers, through its network of group meetings and online resources, certainly has the ability to reach far more people than doctors or nurses sitting in their offices.

I would also not be surprised if Weight Watchers has perhaps done more to educate people on healthy eating than anyone else.

Certainly, they have invested more in backing their program with hard evidence than any other commercial weight loss program.

But if Weight Watchers really wants to put their money where their mouth is, and help people not just lose weight but actually get healthier, I’d now like to see a similar study in EOSS Stage 2/3 patients.

I guess, they know where to reach me

AMS
Edmonton, Alberta

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

• Will Losing Weight Make You Fat?
• Is It Time To Abandon The Notion of Personal Choice In Dietary Counseling?
• Bariatric Surgery Reduces Response to Food Cues?
• Gastric Bypass Reduces Appetite for Fat?
• Stretching Beats Walking to Prevent Complictions of Pregnancy?

Have a great Sunday! (or what’s left of it)

AMS
Edmonton, Alberta

You can now also follow me and post your comments on Facebook

Weight loss is a multi-billion dollar industry, which, if it actually worked, should have put itself out of business by now.

Of course, anyone, who has ever lost weight (including probably patients who have been through our program), realises that losing weight is one thing - unfortunately, keeping it off is a whole different story.

So all that really counts in any program should be how patients do in the long term and how much weight (if any) participants can actually keep off.

Even more important perhaps would be the question whether clients actually get any healthier (if they do, then what ultimately happens to weight may not really matter that much).

I would argue that even more importantly, weight management programs should, if possible address the root cause of the problem (eating too much is a symptom, not a diagnosis!).

As my readers are well aware, there is certainly a wide range of commercial weight loss programs, services and products to chose from - while some have solid science and considerable evidence behind them, others promise quick and easy results that defy scientific rationale and good medical practice.

So how is the consumer to decide?

Some guidance is provided on Alberta’s MyHealth website, which has the following recommendations to offer (adapted):

Questions to ask before joining a weight loss program:

• Does the program provide counselling to help me change my eating activities and personal habits?
• Is the staff made up of qualified counsellors and health professionals, such as nutritionists, registered dietitians, doctors, nurses, psychologists, and exercise physiologists?
• Is training available on how to deal with times when I may feel stressed and slip back into old habits?
• Is attention paid to keeping the weight off? How long is this phase?
• Are food choices flexible and suitable?
• Are weight goals set with the help of a health professional?
• What percentage of people complete the program?
• What is the average weight loss among people who finish the program?
• What percentage of people have problems or side effects? What are the problems and side effects?
• Are there fees or costs for additional items, such as dietary supplements?

In addition programs should provide information on:

• The program and the staff qualifications, including a description of the program content and goals and information about the weight management training, experience, certification, and education of the staff.
• The risks associated with being overweight or obese and the potential benefits of modest weight loss.
• The risks associated with the product or program, such as with the program itself or any drugs, devices, dietary supplements, or exercise plans used in the treatment.
• The information should specify when to talk to a health professional and how much weight is healthy to lose and should explain that a very low-calorie diet may be harmful.
• Costs, including total program costs, attendance fees, re-entry fees, medical tests, and any nonrefundable costs.
• The success of the program, such as what percentage of clients meet their weight-loss goals, how much weight they lose, and how long they maintained their new weight.

The key of course is not to just accept boiler plate answers but to question those answers and do your own research on the claims and credentials of the program.

Remember - if it sound’s too good to be true - it is probably a lie!

I would certainly love to hear from my readers on how they were misinformed or duped by commercial weight loss programs - please do not name specific programs but rather describe in general terms some of the experiences you may have had with program X, Y, or Z in the past and the reasons why you think you fell for it.

I’d also be interested in any additional tips and rules that my readers may wish to propose on finding an appropriate program.

AMS
Edmonton, Alberta