The Downside of Weight Loss?
Yesterday, I posted about the debate on whether or not doctors should stop telling their patients to lose weight published in this months edition of Canadian Family Physician. Today’s post is about an article by John Bosomworth from the Department of Family Practice at the University of British Columbia in Vancouver, BC, published in the same issue of CFP, looking at the potential downsides of promoting weight loss for all. Based on his review of papers published over the past ten years, Bosomworth comes to the following conclusions: “Sustained weight loss is achieved by a small percentage of those intending to lose weight. Mortality is lowest in the high-normal and overweight range. The safest body-size trajectory is stable weight with optimization of physical and metabolic fitness. With weight loss there is evidence for lower mortality in those with obesity-related comorbidities. There is also evidence for improved health-related quality of life in obese individuals who lose weight. Weight loss in the healthy obese, however, is associated with increased mortality.” Thus, “Weight loss is advisable only for those with obesity-related comorbidities. Healthy obese people wishing to lose weight should be informed that there might be associated risks. A strategy that leads to a stable body mass index with optimized physical and metabolic fitness at any size is the safest weight intervention option.” Bosomworth also goes on to emphasize that the first goal of obesity management is to stabilize and prevent further weight gain. “Prescribed weight loss as a target for all-cause mortality reduction among the overweight and healthy obese is a failed concept both in terms of evidence for benefit and in terms of implementation. Weight reduction among obese individuals with comorbidities or diminished weight-related quality of life can be of demonstrated benefit. In all cases, the aim should be to avoid initial weight gain, prevent ongoing weight gain, and realize physical and metabolic fitness at any size.” As I have said before, obesity management should be about improving health and well-being and not about simply reducing numbers on the scale. Fortunately, in most cases, the former can be achieved without the latter. AMS Edmonton, Alberta
Should Doctors Stop Telling Patients to Lose Weight?
This Month’s edition of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, features a debate on whether or not family doctors should stop telling their patients to lose weight. On the Pro side, we have Jana Havrankova, an endocrinologist at Clinique familiale Saint-Lambert in Quebec, notes that keeping weight off is anything but simple. “The few patients who manage to lose weight and keep it off achieve something truly remarkable. From a public health standpoint, however, the treatment of obesity is a failure.“ Thus, rather than trying to treat obesity, Havrankova places her bets on prevention: “Efforts at prevention involve some degree of telling people what to do, and some people will criticize this. Screening and monitoring excess weight from early childhood, ensuring that physical activity is part of the curriculum right up to university, creating neighbourhoods that encourage people to get out and walk, and teaching people how to prepare healthy meals are just a few suggestions.” In the Contra corner we have Dominique Garrel, a specialist in endocrinology and metabolism and Full Professor in the Department of Nutrition at Université de Montréal, Quebec. Not only does Garrel argue that obesity must be treated, but also that the treatment of obesity can be simple and effective. However, treatment needs to focus on health and not on weight loss. “Treat the patient, not his weight. Telling an obese patient to lose weight is about as effective as telling an asthmatic patient to breathe better! Care consists of assessing the risks of excess weight to a patient’s health. The Edmonton Obesity Staging System recently proposed by Kuk et al [sic] is an interesting tool designed for this point of view. This system includes recommendations for each level of intervention, ranging from simply recommending that the patient maintains his weight, to recommending bariatric surgery.” He also points out the importance of recognising and treating comorbidities as these may often represent roadblocks to weight management, to set reasonable (read ‘modest’) objectives for weight loss, and inform the patient of the tools at his disposal for losing weight (as well as warn them against unhealthy weight loss efforts). In an accompanying editorial, Roger Ladouceur, Associate Scientific Editor of CFP, notes the following: “Why, then, do we tell our patients to lose weight? Why do we repeat, “You should lose weight”? What’s with that? Somewhat sadistic, don’t you think? Do we do this… Read More »
Gastric Bypass Reduces Bioavailability of Azithromycin
Bariatric surgery can profoundly affect how the body absorbs medications – this issue, however, remains largely understudied. In a paper, just published in the Journal of Antimicrobial Chemotherapy, we examine the effect of gastric bypass surgery, a procedure that circumvents the upper gut on the bioavailability (absorption) of azithromycin, a widely used treatment for community-acquired infections. We performed single-dose pharmacokinetic studies in 14 female post-gastric bypass patients and 14 sex- and body mass index (BMI)-matched controls (mean age 44 years and BMI 36.4). Azithromycin concentrations, following the administration of two 250 mg tablets were about 30% lower in gastric bypass patients compared with controls. This finding suggests that there may be a substantial risk for treatment failure with this antibiotic in and clinicians should consider dose modification and/or closer clinical monitoring of gastric bypass patients receiving azithromycin. AMS Calgary, Alberta Padwal RS, Ben-Eltriki M, Wang X, Langkaas LA, Sharma AM, Birch DW, Karmali S, & Brocks DR (2012). Effect of gastric bypass surgery on azithromycin oral bioavailability. The Journal of antimicrobial chemotherapy PMID: 22577100 .
FDA AdCom Strongly Supports Abandoning Excess Weight Loss
Regular readers may recall previous posts on the widespread reporting of weight loss in surgical studies as ‘excess weight loss’ – a meaningless number based on outdated concepts of ‘ideal weight’. In fact, not only is there is little correlation between the amount of weight lost and improvements in post-surgical morbidity and mortality but there is nothing to suggest that using this measure does anything more than amplify the numbers – after all a rather remarkable 60% EWL is little more than 20% of initial weight – but of course 60% sounds so much better. I was therefore happy to see that last week, at the FDA hearing on obesity devices, according to Close Concerns: “There was nearly unanimous support for using percentage of total body weight rather than percentage of excess weight loss as a study endpoint. Panelists cited the “significant flaws” in excess weight loss, especially the challenge of applying it to individuals with lower BMIs. In contrast, many believed that using percentage of total body weight loss provided a more valid metric for people at both high and low BMIs.” Hopefully, surgeons and surgical device makers will take note and comply with what I am hoping the FDA will from now on like to see in all future submissions – strict reporting of percentage of ‘total weight loss’ rather than the confusing, arbitrary, and scientifically unsound use of ‘excess weight loss’, which I fear the surgeons may find hard to abandon. AMS Brooks, Alberta
Weekend Roundup, May 11, 2012
As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts: Removing the Cause of Weight Gain Does Not Mean Weight Loss Why Stopping Weight Gain is More Important Than Losing Weight Institute of Medicine Big on BMI, Eat Less and Move More Challenges in the Medical Management of Severe Obesity European Joint Statement on Obesity and Hypertension Have a great Sunday! (or what is left of it) AMS Edmonton, Alberta
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