Indications for Obesity TreatmentFriday, November 6, 2009
When an overweight or obese person presents with a sign or symptom of a disease in clinical practice, the clinician needs to always consider the following questions:
1) Is the presenting condition causally related to excess weight?
2) Is the presenting condition merely aggravated by excess weight?
3) Is the presenting condition unrelated to excess weight?
If the presenting condition is largely caused by excess weight (e.g. sleep apnea, type 2 diabetes, hypertension, gastroesophageal reflux disease, etc.) then there is a good chance that weight loss will reverse or “cure” this condition.
If, on the other hand, the condition is not caused by obesity but is merely aggravated by excess weight (e.g. COPD, congestive heart failure, urinary incontinence, etc.), then, although weight loss may not fully reverse this condition, it could very well reduce symptoms and make the condition more manageable.
In contrast, if the condition is unrelated to excess weight (e.g. a flu infection, migraine headaches, infectious hepatitis, etc.), then losing weight is unlikely to have any effect on this condition at all.
Accordingly, in the first case, if excess weight is indeed the causal factor, then not addressing obesity can only be considered “palliative care” (as in primarily managing an overweight Type 2 diabetic patient with hypoglycemic drugs or merely placing an overweight patient with obstructive sleep apnea on CPAP). In other words, symptomatic treatment without also targeting excess weight is unlikely to fully resolve the problem. These patients would have a primary indication for weight management – anything else is a “band-aid” solution.
When dealing with conditions not causally related to obesity, but where excess weight is a significant aggravating factor, the primary focus should of course be on treating the underlying condition. Only if this is not possible, will weight loss be an option to at least ameliorate the condition – this would be a secondary indication for weight management.
Obviously, for conditions presenting in overweight and obese patients that are unrelated to excess weight, weight loss is unlikely to have any impact on the problem. Thus, the focus should be on treating the underlying problem, which when solved, will still leave enough time to address the excess weight issue – if clinically indicated. These patients would have a tertiary indication for weight management.
Indeed, it is in cases 2 and 3 where mistakes are most often made; automatically assuming that all problems in overweight or obese patients must be a consequence of their excess weight can lead to delay of proper diagnostic procedures and treatments.
Thus, for example, assuming that the back pain in an obese patient is likely weight related can delay the diagnosis of osteoporotic fractures, spinal disc syndromes or even identification of metastasis. Similarly, simply assuming that exertional dyspnea in an obese patient is a consequence of excess weight may result in missing underlying interstitial, infectious or embolic disease.
It is therefore crucial that before jumping to the conclusion that excess weight is the primary problem for all symptoms and problems in overweight and obese patients, clinicians should maintain due diligence in terms of history, physical examination and diagnostic testing before simply recommending weight loss. This is not to say that these patients may not also benefit from weight management, but it certainly should not be the first priority before addressing the presenting complaint or condition.
Indeed, nothing frustrates overweight and obese patients more, than when every symptom or complaint is automatically blamed on their excess weight leading to the useless advise to simply “eat less and move more”.
Friday, November 6, 2009
Dr. Sharma, I think your reasoning is sound.
Where I am challenged is with the idea that in cases where the presenting condition is causally related to excess weight — what precisely can be done to decrease weight that is sustainable and does not cause more harm than good?
I cannot have you as my physician, I am not Canadian. So far, none of the physicians I have seen have offered me sustainable options that wouldn’t decrease, rather than increase or maintain, my quality of life overall, even with the conditions I am managing.
Whatever you are doing to manage the weight of your patients where treatment is called for needs to be widely disseminated so that physicians, such as my excellent family practice physican and endocrinologist, can utilize them when appropriate.
Thursday, November 12, 2009
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