Challenges in the Medical Management of Severe ObesityThursday, May 10, 2012
I am currently attending the 19th European Congress on Obesity, here in Lyon, France, where yesterday, I spoke on the medical management of severe obesity.
Rather than repeating my take on this, I would prefer to quote the following passage from today’s Close Concerns newletter, that covers my talk (and the rest of the session).
After characterizing the increasing prevalence of severe obesity (BMI >40 kg/m2), the burdens it places on patients and the healthcare system, and the challenges of its management, Dr. Sharma discussed potential lifestyle and pharmacologic for consideration for the treatment of severe obesity. He mentioned that medically supervised low-calorie diets could in rare cases be an option for long-term weight management for highly motivated patients with severe obesity, while pharmacologic agents in development are slowly getting to the point where they could be efficacious enough to move the needle.
Dr. Sharma noted that conservative management (using a combination of intensive lifestyle, medication, and a low-calorie diet) could help approximately 20-30% of individuals to achieve and sustain clinically meaningful weight loss in a clinical setting.
- Obesity places numerous burdens on patients, spanning the four M’s: metabolic, monetary, mental, and mechanical. Dr. Sharma noted that in his practice, severely obese patients who are referred for bariatric surgery undoubtedly face these burdens – 75% suffer from depression, approximately one-third experience mechanical problems (e.g., osteoarthritis, sleep apnea), a large percentage has cardiometabolic issues (e.g., diabetes and/or hypertension), and approximately one-fifth are on long-term disability or unemployed (even though it is a relatively young population; average age of 44 years).
- Dr. Sharma highlighted the burdens that severe obesity places on the healthcare system. Dr. Sharma noted that severe obesity decreases post-acute rehabilitation efficiency, increases hospital lengths of stay, and increases hospital costs. Specifically, at the Glenrose Rehabilitation Hospital in Canada, rehabilitation length of stay was on average 56 days for severely obese individuals compared to non severely obese individuals, and rehabilitation costs averaged $115,000 versus $44,000. These stem from the fact that severely obese patients waited on average 43 days to transfer to another facility, whereas other patients waited zero days on average.
- He emphasized that while bariatric surgery is the most effective option for the treatment of severe obesity, it is by no means a population-level solution for two reasons: 1) many do not want to undergo surgery, are ineligible to do so, or do not have access; and 2) if all individuals with severe obesity wanted surgery, the current healthcare system wouldn’t have nearly enough capacity to perform all those procedures. Dr. Sharma noted that currently an approximate 2.5% of the population in Canada is severely obese; the current surgical capacity in the country could only service 1/600 of the potential demand per year (Padwal and Sharma, CMAJ 2009). As such, for practical reasons, clinicians have to think about other ways to manage severely obese patients.
- Dr. Sharma stated that we need to stop thinking about obesity as a single condition; rather, “we need to start thinking of obesity as obesities” – heterogeneous, complex disorders of multiple etiologies characterized by excess body fat. Drawing an analogy to the treatment of cancer, Dr. Sharma noted that the treatment of obesity should depend on the type and stage of disease.
- He emphasized that BMI alone is not an adequate marker of cardiovascular risk; rather, one must also look at comorbidities. In the Edmonton Obesity Staging System (EOSS), the clinical staging system Dr. Sharma developed along with Dr. Kushner, patients are categorized from Stage 0 to Stage 4, based on their medical, mental, and functional health, with Stage 0 patients having no sign of obesity-related risk factors, psychological symptoms, or functional limitations, and Stage 4 patients experiencing end-stage disease. Dr. Sharma noted that the EOSS is a good predictor of mortality – applying the EOSS to NHANES III (1988-1994) data, there was a nice separation of mortality curves, whereas things were not as differentiated when using BMI as the criterion (Padwal et al., CMAJ 2011). He suggested that by using BMI cutoffs as a basis of treatment, clinicians run the risk of overtreating healthy but obese patients and undertreating overweight but metabolically unhealthy patients.
- Dr. Sharma stated that in rare cases, medically supervised low-calorie diets (LCD) could be an option for long-term weight management for highly motivated patients with severe obesity. That is, very few people will want to go on a long-term LCD and be able to tolerate doing so. He noted that at his clinic, eight patients started on low-calorie diets and were kept on them as long as they wanted to stay on them; one has been on an LCD for four years, while others have been on an LCD for three years. They’ve lost on average between 20-40% of their initial body weight, reversed their diabetes, and decreased the use of their blood pressure medications. Several of his patients stated that they plan to be on LCDs for the rest of their lives.
- He noted that pharmacologic options are slowly entering the 10% weight-loss range, which is the amount of weight loss he thinks is needed to move the needle. Dr. Sharma suggested that this 10% weight loss might be achievable with liraglutide, and that phentermine/topiramate brought about between a 12-14% weight loss (“getting into the gastric banding territory”) for severely obese patients on the high dose of phentermine/topiramate in the EQUIP trial (Allison et al., Obesity 2011).
Questions and Answers
Q: I disagree with the analogy you draw in the title of your article, “Bariatric Medicine Without Surgery Is Like Nephrology Without Dialysis.” Dialysis is treatment for end-stage kidney disease. If we applied surgery to patients with end-stage obesity, probably Stage 3 or Stage 4 in your Edmonton Obesity Staging Scale, we would probably do more harm than benefit.
A: Thank you for that remark. This editorial is five years old. I would not write it again, as I agree with you. I used to view surgery as a last resort, but I no longer think that. If you have a patient who needs to lose at minimum 15% body weight, the first thing you should discuss is bariatric surgery. Bariatric surgery is not the last option for these patients; it should always be the first option. If the patient does not want surgery, then we discuss other options. I think that is a change that has happened in the past five years.
Q: You mentioned that patients are using liraglutide for their obesity. What dose are you using in your practice?
A: The data that I showed you was data that is published in The Lancet. In our practice, we use liraglutide in obese patients who present with diabetes, as part of treatment for their diabetes. As you know, even those treated at the 1.8 mg dose will lose weight. We’ll have to wait until the SCALE study completes to find out more.
Thursday, May 10, 2012
Whoa! Dr. S, there is potentially new info in here that I find, er, discomfiting. Please clarify the 15% loss goal that triggers a discussion on surgery. That person would have to have confounding factors, right? (EOSS)
I guess, I’m confused because I’m thinking of myself. At my top I was at a BMI of 32.5 (have lost well more than 15% and am maintaining it) and I can’t imagine my doctor presenting surgery as a first resort. In my case, had the doctor even known about it, HAES would have been first resort, then weight-loss with a REALISTIC idea of what maintenance would entail (at various levels — 5%, 10%, 20%, 25%, etc.) would be second resort, and surgery wouldn’t have even been on the table, unless I had confounding factors (which I didn’t).
Friday, May 11, 2012
Great responses Dr. Sharma. I agree 100% that the option (empowering) needs to be given to the patient – even at stage 2!
One thing though – work on modeling anti-discrimination through specific use of language. The word “burden” implies unnecessary heaviness and is the last thing the obese patient needs to hear. It’s simply not an appropriate term to use. Is cancer carcinogenic to the health care system? Are mental health issues causing the health care system to go insane?
Similarly with the phrase “excess weight” . The weight is not “excess”. It is what it is. Interestingly, the “excess cells” in the cancer patient are a given – no need to dwell on them as if they are the patient’s fault. Be specific. In fact cancer has little to do with excess cells but rather with the mechanism causing the excess cells – the understanding of which may unravel umpteen secrets to improving quality of life. With the imposition of cancer awareness on the health care system, the health care system has been advantaged with marvelous insight and benefit – certainly not burdened.
Using “front of the bus” lingo has always been tough especially since much of it has yet to be invented. This is particularly challenging regarding adipose tissue and endocrine issues. But being sensitive to language has start somewhere and those who actually care are the most equipped to do it.
Saturday, July 21, 2012
@DebraSY: at a BMI of 32 with no health problems I am surprised any amount of weight loss would even be a a goal – most health benefits happen within the first 5-10% weight loss anyway – no one (hopefully) would ever consider surgery in this case.