Bariatric Care: What Can Behavioural Intervention Deliver?

Continuing in my discussion of the weight and health outcomes of the APPLES study, reported by Padwal and colleagues in Medical Care, we now turn our attention to the 200 participants enrolled in the “medical” program.

This group of patients includes those patients, who at the time of entering the program were either not considering or interested in surgery. But it also includes 99 participants (50%), who changed their minds and opted for surgery after entering the program and ultimately went on to receive surgery within the 24-month follow up in APPLES. The data for these individuals was censored at the time they received surgery and was analysed as “last-observation-carried-forward”.

The Edmonton Bariatric program does not have separate entry streams for patient wanting surgery and those who don’t. Thus, all patients who enter the program, receive the same level of medical care that includes individualized intensive medical management consisting of lifestyle counseling (diet, exercise, behavioral modification), with visits every 4–8 weeks by a multidisciplinary staff (internists, endocrinologists, family physicians, psychiatrists, dietitians, nurses, physiotherapists, occupational therapists, and psychologists).

Behavioral modification focuses on teaching skills to help identify and modify eating and activity behaviors. Self-monitoring of weight, food intake and activity, stimulus control, and problem solving to help overcome barriers to weight loss are all key elements of behavioral modification.

Nurses and dieticians are the main care providers delivering intensive lifestyle counseling (diet and behavioral modification) and physiotherapists and occupational therapists provide activity counseling.

Visits with other providers are scheduled to address specific issues (ie, the internist, endocrinologist or family physician would address control of medical comorbidities, the psychologist addresses binge eating disorder, the psychiatrist assesses all patients felt to have unstable psychiatric disease).

Individualized one-on-one assessments are the norm; one exception is binge eating counseling, which is done in a group format.

Medical management is individually tailored to address root causes of excess weight and barriers to achieving weight management success. Antiobesity drug therapy (not available in Canada) and structured, very low-calorie protein-sparing diets were seldom used (< 4% of medically treated subjects received these) during the study.

Although not directly related to weight management, assessment of obesity-related comorbidities, including sleep disorders and mental health screening, is routinely performed.

Despite this rather intense and state-of-the-art “conservative” management – average weight loss over 24 months was rather modest.

While average weight loss was about 4 Kg (2.8%) – outcomes in specific individuals were more impressive. Thus, one in three (32%) patients experienced a 5% and one in six patients (17%) achieved a 10% weight loss at 24 months (LOCF).

However, even these modest changes in body weight were associated with significant improvements in cardiovascular risk factors (other health outcomes are yet to be fully analysed).

There are several important learnings from these findings:

1) Although the results may appear modest (certainly far less than the weight loss enthusiastically advertised in commercial programs), the degree of average weight loss is very much comparable to that reported at 24 months in non-pharmccological weight-loss studies in volunteers within research settings. Thus, the APPLES study demonstrates that a comparable degree of weight loss can be achieved in routine clinical practice in ‘all-comers”.

2) These findings certainly reinforce the refractory nature of severe obesity – while there is no doubt that some patients can lose a considerable amount of weight (as was the case in APPLES) – the average weight loss with behavioural modification, despite “state-of-the-art” medical care at a tertiary care centre, remains modest at best.

3) It is therefore not surprising that about 50% of severely obese patients will eventually need or opt for surgery (including those who had no interest in surgery when they entered the program).

The most important learning, however, is that overly optimistic notions that many providers (and patients) may have about how much weight the average obese individual (even with expert medical help) can hope to lose and keep off (even for just 24 months) need to be substantially recalibrated.

Clearly health providers (and policy makers), who expect that their obese clients can lose 20, 30, or even 50% of their weight by simply following their advice to “move-more and eat-less”, are kidding themselves. Evidently, this is something that even the best current medical care cannot deliver (remember treatments fail patients – patients never fail treatments).

This is not to say that the whole idea of medical bariatric care is a waste of time. For one, as regular readers will appreciate, bariatric care is far more about improving overall health and well-being than simply focussing on weight loss. Further analyses of the APPLES data to specifically examine outcomes such as improvements in quality of life, physical functioning, and specific co-morbidities including mental health are underway.

In tomorrow’s post we will look at outcomes in the surgically treated patients in the APPLES study.

@DrSharma
Banff, AB

Padwal RS, Rueda-Clausen CF, Sharma AM, Agborsangaya CB, Klarenbach S, Birch DW, Karmali S, McCargar L, & Majumdar SR (2013). Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program: Prospective Cohort Study. Medical care PMID: 24374423