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!
AMS
Edmonton, Alberta
In The News
December 11th, 2008 at 9:59 am
Very interesting article - thanks for writing this. The medical community is very far behind the fitness community in providing solid weight loss advice with sustainable results. Clearly creating a calorie deficit is the key to any weight loss - how you go about doing that is much more than just “eating less”. By building muscle through resistance training and performing interval-style cardio training you can contribute to the calorie deficit by experiencing elevated calorie burn for as much as 36 hours after exercise completion. Combine that with calorie reduction, and eating every 3-4 hours to take advantage of the Thermic Effect of Feeding, and adding a protein source to every meal and you have a tried-and-true weight loss program.
December 11th, 2008 at 10:44 am
Thanks Dr Sharma, I think I’ll get a copy of this article. I wonder what the sitation is for children and teens? Our experience at the Pediatric Centre for Weight and Health is that many families have had negative encounters with doctors (and other health professionals such as RDs) when talking about weight and prescribing treatment. How many families never make it to the conversation at all, I dont know. I’ll let you know if I find any research on this.
By the way, your PCN education day was a great step in addressing this, assuming of course this problem is also occuring in Edmonton.
December 11th, 2008 at 11:20 am
As a dietitian involved with weight loss counselling, I agree that managing expectations for weight loss is often difficult. After explaining realistic goals, clients frequently appear discouraged and disappointed and are less interested to hear any more from you. I frequently get the comment, “but what can I do to lose weight faster?”
It’s a real challenge.
December 11th, 2008 at 12:26 pm
Dr. Sharma, your article is so true.I wrote on my blog a short time ago stating that Doctor’s do not know what to do when you talk about weight control.My wife and I are babyboomers and we made our own plan and have lost and average of a little more tahn 1 to 1.5 lbs per week over the last year.My Doctor is amazed and asks me how!!
You look at all the element in weight management and I rspect your openion very much.Keep up the great work you do and hope more people need you.Pierre Trudel from the THEE QUEST team of Pierre & Pierre.Montreal Canada
December 11th, 2008 at 8:08 pm
It´s very important what you wrote about today, I think it´s one of the main factors that has allowed the problem of obesity to grow as it has. In my opinion some people (including doctors) still dont´t recognize obesity as a chronic and potentially severe disease and a lot recognize it but don´t know what to do about it or think that someone else has to solve it so guidelines and policies to control obesity that are very available to everyone I think are only a start. What worries me most is that besides adults I have experienced a lot of rejection and the hardest to make awareness when discussing childhood obesity to parents and doctors also.
December 14th, 2008 at 6:17 pm
Great posting Arya. The concept of caloric deficit with proper eating regimens, sustained over many months as the KEY element to weight loss and maintenance is a central theme that needs to be taught in medical school, or family medicine residency. Exercise is necessary, but the simplistic statement, “exercise more” - leaves out the fact that it is very difficult for obese patients to exercise, due to mechanical challenges and pain, and the message that exercise is the only method of weight loss, is often what the patient hears, and then they are disappointed, when they cannot achieve or sustain the exercise and their weight goes up. The bottom line is that education to all doctors surrounding energy balance is crucial. I am glad that CON is continuing to tackle this.
December 29th, 2008 at 7:04 pm
I think Never is your answer….Health Professionals will never understand obesity.
Also, “:1. The first step in weight management is STOP THE GAIN!” And that is done by CHANGING what you eat. Going from Stupid Foods to Real Food. But 99.9999% don’t get this and never will.