Close Concerns: Bariatric CareFriday, April 27, 2012
Earlier this week, the influential healthcare information firm Close Concerns published a rather lengthy interview regarding my take on a wide range of issues related to the future of obesity management. The interviews were conducted by Joseph Shivers, Vincent Wu, Lisa Vance, and Kelly Close, who certainly challenged and stimulated my thinking with their well-informed questions.
The following is another excerpt from this interview published in their newsletter Closer Look:
JOSEPH: That certainly isn’t something that we hear talked about very much. It seems like stopping weight gain is much easier. How would you ballpark your own clinic’s success rate in that regard?
DR. SHARMA: We would be hitting 80%, if not more, on stopping the weight gain. In every single case where a patient continues to gain weight, we know there’s a problem that we’ve not yet identified and have not yet addressed.
JOSEPH: Like one of the underlying psychological or metabolic disorders that you talked about?
DR. SHARMA: Yes, there’s something going on; something happening with this patient such that they are trying things and coming to the clinic but not able to do what it takes to stop gaining weight. For these patients, there’s no way that you’re going to get sustainable weight loss. On the other hand, stopping the gain is actually quite easy, because when you stop gaining weight, your body doesn’t go into starvation mode, so you don’t have to deal with any of those counter-regulatory mechanisms that make it challenging to keep weight off. The minute I start losing weight, all those systems will kick in and try to get my weight back to where it was.
Hence, it is much, much easier and takes very little effort actually to stabilize people’s weight. If you look at any of the drug studies or even surgical studies over very long periods of time, you’ll see people’s weight stabilizing. For example, if you take SCOUT and forget about the sibutramine arm, and just look at the placebo arm, you’ve got people who’ve lost roughly 2 kg (4.4 pounds), and they’re keeping these 2 kg off for almost five years with virtually no intervention. The lifestyle intervention for both arms consisted essentially of seeing these patients, you’d give them a pedometer or a healthy eating brochure, but the key thing was that you were just seeing people. So you get some advice typically from the doctor and other people, and it keeps getting reinforced.
JOSEPH: Based on around 80% success at your Edmonton clinic in terms of stopping weight gain in patients, how would you define success rates in actually achieving and maintaining weight loss in these patients?
DR. SHARMA: Let’s come to the next piece, and that is the discussion that I think is ongoing. If you’re a surgeon coming into this from a surgical perspective, it’s all about weight loss. They define their success by the amount of weight loss that they get. They call their surgery “weight-loss surgery,” and although they’ll talk about incretins and metabolic surgery and all that kind of stuff, ultimately I think in their hearts they all believe that the main benefit of bariatric surgery is the fact that they’re getting weight loss.
They will consider people who are not losing weight as failures. So if you’re getting your bypass, they’ll want to see 60% excess weight loss; if they’re not seeing that, you’re only seeing 20% excess weight loss, then they would consider that surgery a failure. I would not. My definition of success in bariatric care in general is the improved health of the patient.
When I practice bariatric medicine, I say, “Well, here’s a patient who’s got all kinds of issues related to their size – comorbidities and functional limitations.” You can address a lot of those issues, including improving their diet and improving their physical activity, improving their sleep quality and managing the comorbidities with very little weight loss. In fact, even once these patients stop gaining weight, which they do once they’ve changed and improved their lifestyle, you find that many of their health problems are much better. They’re not gone, but they’re better managed.
So for example, if you take a patient with type 2 diabetes who’s continually gaining weight. We look at them and you say, “Well, what’s happening here? Why is this patient continuing to gain weight on the diabetes treatment and why has their A1c been so crappy?” If the reason they’re gaining weight is because they’re having hypoglycemic episodes – if every time they get hypoglycemic, their response is to eat – the question becomes, “Why are they having these hypoglycemic episodes?” Well, they’re having hypoglycemic episodes because they’re not eating regularly. They take their medications regularly, but then they skip breakfast and won’t have time for lunch and then they’re running around, and so they end up getting hypoglycemic and eat crap. Now, you recognize that and you say, “Listen, you’ve got to start eating regularly. When you take your medications in the morning, your insulin, you do have to have your breakfast and you do have to have your midmorning snack and you do have to have your lunch.”
So now, you’ve intervened and let’s say this patient starts doing all of those things. As a result, they no longer have those hypoglycemic episodes, so their weight is no longer increasing, and you’ll see that actually their diabetes control is now much better.
For me, that is successful obesity management. I don’t have a single lost pound here, but I’ve stopped the gain because I’ve found out what the problem was, we’ve fixed that problem, and now the patient is no longer gaining weight and their diabetes control is much better. Some people might call it diabetes management, and I call that obesity management, because the problem was that this patient was gaining weight.
My definition of bariatric care is to identify the key driver for weight gain and address that driver, thereby improving the overall health of the patient. That does not necessarily require weight loss.
JOSEPH: So, in terms of obesity being a risk factor, do you think that it is the state of regularly gaining weight, more so than being set at a certain size that is really what’s driving cardiometabolic risk?
DR. SHARMA: Oh, absolutely. It may not just be the fact that you’re gaining weight. Many of the underlying factors that cause weight gain are risk factors, and that’s always been the problem. EOSS [the Edmonton Obesity Staging System, which classifies the severity of overweight based on comorbidities rather than weight or BMI (Padwal et al., CMAJ 2011)] is the perfect example.
Let’s take two people who are exactly the same BMI, but one is EOSS 2 [with obesity-related comorbidities] and the other is EOSS 0 [no weight-related complications]. When you look at the two, what is the most common difference between them? In most cases it’s their lifestyles.
For the EOSS 0 patient, you’ve got an obese person who’s actually eating pretty healthfully, pretty active, and feeling good about themselves. They just happen to be big. They might be gaining weight, but even at the rate that they’re gaining weight they somehow manage to remain healthy. If you ask them about their quality of life, they say, “Well, it’s actually pretty good. I only wish everybody would stop bugging me to lose weight, because I’ve always been like this. I’m big. I feel healthy. I feel happy.” Or they say, “I feel healthy, but I’m not happy, because everybody is bugging me about losing weight. If I could just stop everybody from bugging me I would be both healthy and happy, and so I don’t even know why I’m here.”
Your EOSS 2 patient comes in and you will probably find that this is somebody who’s not eating regularly; they’re eating a lot of junk food, they’re eating out, their physical activity level is low, and they struggle with self-esteem. Most commonly, they’re having anxiety, depression, or some other things going on. That’s a sick person.
Now is their obesity causing that? Or is obesity just one of those things that they also have on top of everything else? That can be very hard to figure out. Bariatric care would be to say, “Let’s find all those things, and let’s try to fix as many of those things as we can. Then weight may go up, may go down, may stay the same, but it really doesn’t matter as long as your health gets better.”
That’s the underlying principle of the whole “Health at Every Size” movement. It says, ”Don’t make weight your outcome, make health and self-esteem your outcomes.” Then you actually end up improving their health. In many cases, their weight may not go down, but in many cases, it does. It never goes down by 100 pounds, but by four, five, six, seven, maybe 10 pounds. But that is all it takes to improve a lot of the metabolic issues.
To be continued…
Friday, April 27, 2012
I know this post is focused on management of post-bariatric care, but I am nonetheless disappointed with the example used regarding diabetics, particularly in light of the daily political constraints imposed on diabetics and obesetics. I think it warrants comment. I would have preferred an example speaking to insulin instead of hypoglycemia. Insulin. Excess weight in diabetics (and obesetics) can be attributed to having to “feed” inaccurate doses of insulin, often also associated with minute-to-minute stressors of daily living. I have seen huge weight losses in diabetics when these citizens are simply served with an insulin pump – up to 20% weight loss – with absolutely no forced behaviour change. This is where many Canadians, Albertans included, run into problems with public health care and the so-called “good of the people”. The evidence is already in from the United States, where private medicine allows for insulin pumps with ease (albeit for the predominantly rich) that the insulin pump offers superior benefit. Some provinces, far less wealthy than Alberta, have taken heed and are also serving diabetic citizens with insulin pumps via public health care. So why not use an example like this? And more importantly, why was it not used? Possibly because it doesn’t work to compare diabetics to “bariatrics” with the given example when insulin pumps come into the equation? But all the more reason to take the opportunity to advocate for current health care benefits for diabetics, particularly in light of what may prove to be an empty campaign promise. http://www.cbc.ca/news/canada/calgary/story/2012/04/12/albertavotes2012-tories-diabetes.html
Dr. Sharma, I am reminded of Martin Luther King when I consider some of the challenges and controversies facing doctors like you who are trying to ensure progressively advancing quality health care for each and every citizen. I urge you to continue to walk with the special passion and compassion that you bring to your field. But if you also bear in mind that great legal resources like Tim Caulfield, and others, are in your camp, then stressing the benefits of the insulin pump, instead of urging diabetics to be more aware of time management issues, should be something that more easily comes to mind, particularly within a public interview environment. Walking with such a mindset would also model and convey quality service through leadership for diabetics and obesetics alike.
As an aside, notice how “obesetics” is such a non-fit.
Sunday, April 29, 2012
These are really important concepts, thank you for sharing them