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Close Concerns: Weight Loss and Weight Loss-Maintenance



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 brief excerpt from this interview published in their newsletter Closer Look:

JOSEPH: The prospect of long-term weight loss in the population as a whole seems very challenging based on most interventions for which we have long-term data. Assuming that we turn this around in the next 50 years, what do the turning points have to be? Will it be better therapy? Some really refined and effective surgery? Impacting childhood obesity?

DR. SHARMA: If I had to bet, I’d bet on drugs and not on surgery. I think surgery is a phase. It’s being done now; it’ll be around for probably another decade or so, maybe longer, until we get new drugs. I think that there are two things that may need to change in drug development, or even in the thinking about pharmacological treatment of obesity.

The first is starting to differentiate obese people into subsets of obese people. So a drug that doesn’t have to be for whoever has obesity, but rather for a subset of patients with obesity because they have a certain eating disorder or there’s a certain pathway in their brains that is promoting overeating or they have a certain lack of satiety. That is a group of patients for whom a given drug really works. They are the ones who should be getting it. The drug may not work for everybody else. You would start splitting down this whole indication into other groups.

That may or may not happen. In hypertension it never happened. We have 100 drugs for hypertension and people have always said, “Let’s break it down and let’s decide who’s the best patient for a diuretic and who’s the best patient for a beta blocker and who’s the best patient for an ACE inhibitor.” That actually never worked. In the end, even today, hypertension practice is pretty much trial and error, with fixed combinations becoming more and more accepted.

So, I’m not holding my breath that that will happen with obesity. I think if you find drugs that are overall effective and well tolerated in most people or at least half the people you treat with them, it probably doesn’t matter.

But I think the other piece that really matters is whether or not we can come up with a way to license drugs to help with weight-loss maintenance. The mechanisms that help you lose weight may not be the same mechanisms that help you keep weight off. Take leptin, for example. Leptin is not a great drug for losing weight, but it may be the perfect drug to keep weight off. But there’s no pathway. If I wanted to license leptin for weight management, I would have to go to the FDA and show that it helps people lose weight, which it doesn’t, and so I’d never be able to license it. I need a pathway that’s going to allow me to specifically get regulators to approve a drug that is efficacious for helping people maintain weight loss, even if it does not promote weight loss in itself.

So, the idea is you go lose weight and come back to the doctor’s office, and then he’ll put you on these drugs so that your weight doesn’t come back. That is a regulatory pathway that doesn’t exist right now.

JOSEPH: It seems like the standard of care for weight-loss, excluding drugs and devices in some patients, is intense diet and exercise as a starting point. What do you think about this approach?

DR. SHARMA: It’s simply not going to work. All that diet and exercise talk is like what we used to do for cholesterol and for diabetes. I’m not saying it’s not important, and there’s no question that if I get somebody to diet and exercise, they’ll lose weight. But it works for obesity in the same way that the DASH [Dietary Approaches to Stop Hypertension] diet works for hypertension. I can put people on the DASH diet and show that their blood pressure gets better. But if I were to take 100 people off the street, put them all on the DASH diet, and hope that everybody’s blood pressure’s going to be fine, it won’t be. Only five guys would actually stick to the diet, and they’d be fine, but the other 95 would not be fine. Obesity is pretty much the same; I don’t see any difference at all.

KELLY: Presumably weight-loss maintenance also goes back to improving the public’s understanding of obesity and addressing weight bias and discrimination.

DR. SHARMA: Absolutely, we are bombarded with anecdotal instances of how easy it is to lose vast amounts of weight – not just the ‘weight-loss industry’ – think of TV reality shows, popular magazines, and fad diets. We celebrate people for losing weight – we seldom check to see if they are still keeping it off. I am always asked by patients, “How much weight can I lose and how fast can I lose it?” I tell them that that’s the wrong question – the only weight loss that matters is the weight you can keep off – this is why we introduced the term ‘best weight’ – the lowest weight you can realistically maintain. Your ‘best weight’ depends on your individual circumstances – everyone’s ‘best weight’ will be different.

The public but also health professionals and policy makers need to understand that when you pay for ‘weight loss’ you get ‘weight loss’ – when you pay for ‘maintenance of weight loss’ you get ‘maintenance of weight loss’. As a health professional I’d rather see my patients or payors paying for the latter than the former.

Another point is that we often frame weight regain as ‘failure’ when it is really the only natural expected consequence of stopping the treatment for a chronic condition. Even worse, the failure is often framed in the context of the treatment. So if you take a drug – lose weight – stop the drug- regain the weight – we attribute the failure to the drug and not to ‘stopping’ the drug. No drug or treatment works when you don’t take it – when you have an obesity treatment that works, the question is not to find more effective weight loss drugs but to find a more effective way of ensuring that people continue taking it.

The same, incidentally, applies to treatments for hypertension or diabetes. For many conditions we don’t need more drugs (unlike for obesity) – we simply need to figure out how to get patients to continue taking the meds that are already out there – that’s where I’d be putting most of my research money.

To be continued….

AMS
London, UK

10 Comments

  1. Amen, again! Especially to Leptin therapy for those maintaining radical losses. WE NEED ASSISTANCE, please!

    I cannot believe the overwhelming amount of evidence that smart, earnest, committed, disciplined people cannot maintain radical weight loss. And yet our culture SOOOOO wants to believe that all of them were ignorant, just thought it was a diet and not a “lifestyle change,” and now they’re paying the price for their own weakness and lack of willpower. And those of us who do maintain losses are held up as examples of success, against our will. It is so much more complex than all that. Grrrrrrrr.

    Obesity may be called a characteristic or a chronic condition, depending upon your perspective. Those of us who are disguising ours — through macronutrient management, calorie balancing, etc. — are working much harder and smarter than anyone cares to know (even the scientists at the NWCR), and we’re fighting endocrine imbalances that are barely understood (I call the resulting mental and physical cues “eat impulses” because they are different from insulin-triggered hunger, but my GP doctor and Gyno just look at me like I’m silly). “Just keep up the good work.” “Keep doing what you’re doing.” “You’re an inspiration.” NO NO NO. We maintainers are an exception that proves the rule, and some of us really want to tell our stories honestly (not through the biased lenses of Biggest Loser or the NWCR). We want our stories HEARD and not marginalized into fairy tales. It’s not “happily ever after” in our zippy new lifestyles. It’s vulnerable ever after to regaining weight, and all the social, physical and medical consequences that follow. And yet we aren’t seen as needing help. We’re cured, right?

    AAARRRRRGH!

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  2. “The public but also health professionals and policy makers need to understand that when you pay for ‘weight loss’ you get ‘weight loss’ – when you pay for ‘maintenance of weight loss’ you get ‘maintenance of weight loss’. As a health professional I’d rather see my patients or payors paying for the latter than the former.”

    This is excellent. But has your cynicism degraded to the point that you have given up on non-pharmacological and non-surgical approaches to weight loss? If so, this is disappointing and depressing.

    In the US, family physicians, by enlarge, do not counsel their patients about nutrition/lifestyle/weight loss, in part due to apathy, lack of understanding, and of course, patient compliance.

    Healthcare, as it relates to obesity, is as misguided as ever. I’m sympathetic to the idea that meds/surgery is far better than living with the health implications of obesity, but why is it just about every physician is giving up?

    Physicians are at the pinnacle in terms of how you can effect a patients life, whether it be through your own guidance, or a referral to a nutritionist/coach or other ancillary provider. Instead, most are just falling back on meds/surgery.

    Disappointing.

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  3. Very interesting, but I’m wondering why you don’t mention a generalised use of Motivational interview, Cognitive Behavioural therapy and Self Determination Therapy in Primary Care settings as a challenge to the future of obesity management ? Isn’t it reliable as prevention strategy to further weight regain and to succeed for weight maintenance ? “Medication”, surely, it will be helpfull, but never as “a cure”, rather as one element of multi-targeted therapy …. and who can afford expensive drugs ? (the social inequity linked to the obesity problem)

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  4. Please sign me up for the Leptin post-weight-loss trials when you frame a way to market the idea to the particular authorities in charge of controlling such matters. (An unavailable bureaucratic pathway? Really? Really?) Leptin could be administered to patients at the first signs of mental health problems correlated with significant weight loss and/or early regain–an assortment of painful conditions easily observed in the weight-loss blogosphere and (no doubt) in countless doctor’s offices when *successful* dieters become overwhelmed with needless shame, guilt, and self blame for not being able to ignore autonomic brain signals directing them to severely restrict activity levels, conserve energy, and/or increase food intake. Leptin does much much more in the body than help former obese folks cope with chronic “eat impulses” (but thanks DebraSY!), although that function alone should be worthy of medical assistance; for example, Leptin plays crucial roles in regulating energy expenditure, sleep, cognition/memory and other circadian dependent endocrine functions. Research has already shown that Leptin becomes depleted after weight loss. Correct? So, with adequate supplementation after weight loss, just think what might happen if all that lost human productivity (spent on weight loss maintenance activities and/or yo-yo self blame cycling) could be harnessed for other behaviors–such as creating great art, caring for humanity, etc. But no. There is no appropriate bureaucratic “pathway” to assist with such health problems linked to Leptin depletion. I suspect this gaping lack of compassion can be traced back to fat bias, weight stigma, and discrimination–fueled by false beliefs that sustained will power and permanent life-style changes can overcome physiology. Also fueled by multi-billion dollar interlocking industries hell bent on keeping profits that depend on these false beliefs. Tragic.

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  5. Just to clarify to some of the comments above: Close Concerns is mainly an information service to the pharmaceutical industry, which is why my responses in this interview focus on pharmacological interventions.

    There is no doubt that behavioural interventions (motivational interviewing, CBT, etc.) of course continue to play an important role in obesity management – they were just not the topic of these interviews.

    AMS

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  6. Thank you for that clarification. Makes total sense.

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  7. I was 250, lost 60 lbc to be 190.
    I gained 35 lbs., now I’m 225.
    But I don’t think losing that 60 lbs “doesn’t count”.

    The life stresses that got me back to my weight-gaining eating habits would have happened no matter what my weight.
    If I hadn’t lost 60 lbs a few years ago, I’d be at least 285 now.

    Sure, if I were perfect, I’d never regain, but until then, every bit I lose does count.

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  8. I strongly suspect that the pharmaceutical industry isn’t interested in trialling and marketing leptin to support weight loss maintenance, because there’s more profit in marketing drugs to manage chronic conditions like diabetes.

    Or as RNegade put it: I suspect this gaping lack of compassion can be traced back to fat bias, weight stigma, and discrimination–fueled by false beliefs that sustained will power and permanent life-style changes can overcome physiology. Also fueled by multi-billion dollar interlocking industries hell bent on keeping profits that depend on these false beliefs.

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  9. DebraSY and RNegade! Thank you for capturing what so needs to be acknowledged and authenticated by all, but particularly within the medical field. And it should be acknowledged and authenticated over and over and over and over. Relentlessly. In tandem with your perseverance.

    So disappointing that Leptin is not so forthcoming.

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  10. Hi there to every body, it’s my first go to see of this blog; this weblog carries amazing and truly good stuff designed for readers.

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