As I attend the 45th Annual Meeting of the European Association for the Study of Diabetes (EASD) here in Vienna, I am not surprised to see many talks and abstracts related to obesity and weight loss on the program.
Time perhaps to muse on an important aspect of obesity management, namely that successful obesity management does not necessarily require any weight loss at all.
Obesity, as we all know, is a chronic progressive condition. Left untreated, patients generally continue to gain weight – those, who do not already have weight-related health issues, will eventually get them.
This situation is really not different from the situation in other chronic conditions.
As a nephrologist, I like to use the example of chronic renal failure. When I see a patient who has lost 50% of their kidney function, it is my job to make sure that this patient does not continue to lose kidney function year after year, as this patient would otherwise eventually require dialysis or a kidney transplant. The measure of success in treating chronic renal failure is therefore not to try and restore kidney function to 100% (virtually impossible without a transplant) but rather to slow or (even better) halt progression of kidney failure.
The same could be said for preventing the progression of other chronic diseases like diabetic retinopathy, artherosclerosis, osteoarthritis, etc. Stopping all of these conditions, for which we have no cure, in their tracks would certainly be considered a success and in fact, many treatments and medications are specifically indicated for halting progression of chronic conditions rather than reversing them.
Thus, for e.g. while laser ablation may halt the progression of diabetic nephropathy, it certainly does not restore eyesight. Similarly, while putting a patient on an ACE inhibitor or ARB may slow progression of chronic renal failure, it does not bring renal function back to normal.
If, as we now know, obesity is a chronic progressive condition, then simply halting progression (or even just slowing down the rate of weight gain) must already be considered a success. If I had a treatment that would allow all my patients who are currently at 300 lbs to simply stay at 300 lbs rather than continuing to gain weight year after year, I would consider this a pretty effective treatment.
So, even if a patient does not lose any weight, or in fact, continues to gain weight (but at a slower rate than before), I would consider this successful obesity management – the benefits of which could be substantial.
Obviously, if there is any chance that I can indeed help my patient lose weight and keep it off that would be even better, but for people with severe obesity, this may often mean resorting to bariatric surgery, certainly not an option for everyone.
As we know, the results of weight management by lifestyle intervention alone are modest and often unsustainable and prescription medications, although more effective than lifestyle change alone, are seldom used for long-term treatment.
For all of the above reasons, my primary aim in my patients is first and foremost to “stabilize” their weight by identifying and addressing (if possible) the underlying causal factors. This will most often requiresome lifestyle changes but in many cases will also call for optimal management of their comorbidities (e.g. sleep apnea, pain, depression, etc.).
As I constantly see in my practice, as a result of our interventions, many patients will subjectively and objectively be healthier and feel better, even with minimal or no weight loss – I have no hesitation calling this successful obesity management!
The importance of redefining obesity management along these terms is particularly important given our limited resources and lack of treatments that can truly provide long-term sustainable weight loss.
As a nephrologist, I knew I was successful every time I could slow or halt progression of chronic kidney disease, thereby delaying or in many cases completely avoiding dialysis or transplantation.
As a bariatrician, I know that my successful cases include those patients who have simply stopped gaining weight.
I believe it is time we redefined “success” in weight management.