When will Health Professionals Understand Obesity?Thursday, December 11, 2008
With all the talk about obesity and its increasing role as the root cause of many chronic diseases (type 2 diabetes, osteoarthritis, and sleep apnea to name a few), you would think that health professionals are now regularly counseling their patients to manage their weight.
Well, this clearly does not seem to be the case, at least according to a new study by Jean Ko and colleagues from Johns Hopkins, Baltimore, MD, just published in Preventive Medicine.
Not only does this national (US) cross-sectional survey in over 1800 obese adults show that only around 40% of individuals reported being advised by their physicians to lose weight (this advise was more likely to occur in women and in people who also had chronic diseases), but that the advice given clearly did not reflect much understanding of obesity management.
Thus, although ample data show that exercise is NOT the most effective way to lose weight, this was exactly the advise given to 86% of the subjects. In contrast, changing diet, the best way to lose weight, was only recommended in 64%. Overall only 60% received the recommendation to both change their diet and to increase physical activity.
But the really scary finding of this study was the amount of weight loss recommended: 21%!
To put this into perspective – the average long-term result of the best behavioral intervention studies is 3-5% weight-loss, while adding pharmacotherapy to lifestyle results in long-term weight loss (while treatment continues) of only 10-15%. Sustained weight loss of 21% is in fact at the lower end of the average weight loss achieved by bariatric surgery (long-term weight loss in the SOS study was only 16%), which is generally in the 20-30% range.
I can well understand, when patients have ridiculous ideas about sustainable weight loss, but for health professionals to be advising unrealistic weight loss targets that are inconsistent with the ample evidence to the contrary is simply embarrassing!
I am convinced that few health professionals actually appreciate that for a 200 lb individual to lose 20% (=40 lbs), they are talking about a SUSTAINED energy deficit of 140,000 KCal. For a daily energy deficit of 500 KCal – difficult enough to achieve, let alone sustain – this would require at least 280 days (~ 9 months) of “dieting”.
In reality, because of the obligatory homeostatic counter-regulation that occurs with weight loss, to sustain this degree of weight loss, patients would need to maintain a diet that is generally well over 500 KCal less than they started out with. Always remember, that many of the successful weight-loss maintainers of the National Weight Control Registry are surviving on 1200-1400 KCal per day! (not very different from the effective caloric intake of a post-bariatric surgery patient).
As I have blogged before, managing your patients’ weight-loss expectations is sometimes more difficult than managing their weight.
For those who are not familiar with my recommendations:
1. The first step in weight management is STOP THE GAIN!
2. 5-10% sustained weight loss has clear health benefits.
3. The challenge in weight management is not losing the weight – it is keeping it off!