Saturday, August 18, 2012

Why Obesity Management and Weight Loss are NOT the Same

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Sep 29, 2009:

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.

AMS
Vienna, Austria

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10 Responses to “Why Obesity Management and Weight Loss are NOT the Same”

  1. katja sawitsky says:

    Right on! Your ideas are brilliant. Thanks for sharing them Dr. Sharma.

  2. sean wharton says:

    Great point Arya. I remind my patients of this all the time, in fact they remind me of htis point. Many patients who have not lost weight, but have stabilized tell me that they feel great, they are eating better, exercising, and their blood sugars improve, to the point of decreasing diabetic medication. If we can convince all patients and many clinicians that weight maintenance and improved health is also a win, and weight loss is not everything. You taught me this a years ago and I still preach it to whoever will listen. Also good to see it in print for others to benefit. thanks Sean

  3. wellroundedtype2 says:

    I wish this perspective was appreciated in the public health realm as well in terms of how we perceive population weight status.
    I think if health status of obese people were to be monitored and tracked rather than solely using weight as a proxy for health, we might be able to make some improvements.
    And, destigmatizing fatness would go a long way to allowing people to regard weight gain as a symptom that needs to be managed of an underlying propensity for weight gain, rather than fatness being a moral failing or a flaw of appearance, might allow for clinicians and individuals to take action earlier in the game.
    I know that when I was in my early 20s and gained weight rapidly, going from a BMI of around 39 to a BMI of close to 50 in a couple of years, I got the same old advice, and the same old threats, without anyone saying, “look, your being fat doesn’t make you ugly or incompetent, but if you want to slow down gaining weight or stop gaining weight, let me give you a hand with that” — that might have helped. Hard to say.
    I also think that weight loss medications, because they lead to a modest weight loss rather than “reaching ideal weight” are not used effectively early in the weight gain process. A close, ongoing relationship with a physician who knows what weight range a person normally occupies, and doesn’t give them a hard time about maintaining with a healthy diet and regular physical activity, also can help when a person starts to gain weight outside of that range for them. Coupled with an overall picture of health, and how the person feels about it — if a patient is overall healthy and engaging in healthy behaviors, and doesn’t wish to lose weight or take action to limit a relatively small weight gain, the physician can leave it alone.

  4. Aggie says:

    I thought you might find this article from the Clinical Journal of the American Society of Nephrology interesting: http://cjasn.asnjournals.org/cgi/content/full/3/1/159

  5. DeeLeigh says:

    Oh wow. So this is what you really think. Well, Linda Bacon and Marilyn Wann were right. You don’t get it at all. “Obesity” is neither progressive nor a disease. Fat people only get fatter when they attempt to lose weight by dieting. Non-dieting fat people generally don’t gain any more weight through the years than other people do. Jesus. Healthy people naturally come in a variety of sizes. Why is that so hard to understand?

  6. DeeLeigh says:

    I shouldn’t have said “Fat people only get fatter when they attempt to lose weight by dieting.” I should have said “Dieting is the main reason for weight gain.” Of course, there are other reasons, too: psychiatric drugs, fibro, PCOS and binge eating disorder, for example.

  7. DebraSY says:

    I think it is disconcerting for us lay people to see you equating “condition” and “disease.” I know you are speaking to your medical colleagues and trying to give them an analogy that they’ll find meaningful, but pathologizing (as opposed to merely medicalizing — and there is a difference) obesity may contribute to weight stigma and bias. It essentially puts obesity in the same category with smoking-induced lung cancer.

    Now, I would agree with this statement:

    “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.”

    It gave me a shiver and hit closer to home than most of your posts because the sister of a friend of mine died (in 2001) in a hospital at 550 pounds. Without getting into details, I would say the cause of death was a hospital that was unequipped to deal with obesity. The hospital called the cause of death “complications from obesity.” At any rate, my friend said her sister gave up on healthy behaviors shortly after 300 pounds. Someone made fun of her when she was out walking and, it was one straw too many. She just stopped trying to be healthy, and one result was that her weight destablized. She became reclusive and depressed and started eating mindlessly. She gained weight rapidly and then the hospital incident happened, where she died of an infection the hospital was unequipped to diagnose — MRI machines that couldn’t hold her etc.

    I think weight maintenance (or slowed gain) is a realistic marker that can help patients monitor other behavior goals — eating fresh foods, incorporating fun and active movement into their schedules, etc. Weight, however — gain, loss or maintenance — is only a marker, not a behavior in itself. It would be spectacular if all physicians understood this.

  8. Roberta Bibaud says:

    I do believe obesity is a disease. Two years ago I was 448 lbs. Today I am 200 lbs. I believe this has been success for me and my disease. I once read a statement of Dr. Sharma’s. Cant quote word for word, but it was along the lines of , we need to realize obesity is a disease, similar to diabetes, meaning it is controlable with treatment , but not curable. when we stop the treatment the simptoms of the disease come back. I get this and understand this as many obese people will. We know that we gained our weight back with every diet we tried and stopped.

    However, I also was frustrated at the clinic , when told that maintaining my weight was a success. I get why you Dr. Sharma would think so as my Dr. As a patient who knows I am going to die of an obesity related disease soon at 448 lbs, maintaining is not success to me. I am forever grateful for the discovery of all the things that led to my issues with food. I am forever grateful for the tool provided to me for successfully managing my condition. and I am forever grateful to you for your dedication to the management of my disease. I had Rny Gastric Bypass and it is the best decision I have ever made to the betterment of my life!!!

  9. devrie says:

    I found this website after searching “Constant Gain Theory,” because after noticing how much weight I and the people from my high school had gained at our 10th reunion, I wondered why so many young people were nearly obese. Now, many of us have reached obesity in our thirties. It dawned on me that we’re constantly gaining weight, and I wondered why. We didn’t start out eating 2300 calories a day, or whatever we eat now. I’ve noticed my portion sizes get bigger and bigger, yet unless I really think back to what I used to eat, they seem appropriate to me now (kind of like how your memory of a stuffed animal from childhood seems so big because you were so small). Why, then, if we start out with maybe a calorie surplus of only 100 or so calories, on average, per day, don’t we stop gaining weight at the end of the year once we’ve gain an extra ten pounds? My thought is that we’ve trained our hormonal cycle to move either sluggishly or to work toward demanding a surplus over our “current” caloric need. That’s why yo-yo dieting is so common. We go, “Oh, I’m 180 lbs. I need to lose weight. I wish I was 135 like I was 10 years ago.” Then we diet, lose some weight, but since we started NOT from a maintenance point, but from a gaining point, it’s that much harder to lose weight. We weren’t just eating what we needed to maintain 180. We were in the process of being 181, then 182…. So, not only is maintaining important for obese people, it is a step toward thwarting obesity in people who are or are at risk for being overweight. At what point can people notice “Uh oh, I’m on a cycle toward constantly gaining weight,” vs. “Uh oh, I’m obese, what do I do?”

  10. Suzan Nashashibi RNutr says:

    weight loss is totally different from obesity management from the point of view that weight loss may be fluid or muscle loss especially if starvation diets are implemented
    Obesity management targets fat mass and comorbidities and that s where its so difficult and if obese patients succeeded in stabilizing wt gain improved lipid profile irregularities maybe reduced dose of hypetension or diabetes medication i book that as success in my book still i realize how hard it is to convince people who suffer from obesity that this is a good enough success to build on

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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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