Nonsurgical Weight Loss for Extreme Obesity

Yesterday’s post was about how we need to rethink and restructure obesity management in primary care. Today I discuss a primary care study that describes the outcome of non-surgical weight management in patients with extreme obesity.

The paper by Donna Ryan and colleagues published in this week’s edition of the Archives of Internal Medicine describes the results of the Louisiana Obese Subjects Study (LOSS), a 2-year randomised, controlled, “pragmatic clinical trial” conducted in seven primary care practices and one research clinic.

Around 600 Volunteers with BMIs in the 40-60 range were screened and randomized to intensive medical intervention (IMI) (n = 200) or usual care (UCC) (n = 190). The IMI group recommendations included a 900-kcal liquid diet for 12 weeks or less, group behavioural counseling, structured diet, and choice of pharmacotherapy (sibutramine, orlistat, or diethylpropion) during months 3 to 7 and continued use of medications and maintenance strategies for months 8 to 24. In contrast, the UCC group received guidance in an internet weight management program.

The mean age of participants was 47 years; 83% were women, and 75% were white. Retention rates over two years were 51% for the IMI group and 46% for the UCC group. After 2 years, 31% in the IMI group achieved a 5% or more weight loss and 7% achieved a 20% weight loss or more, compared with 9% and 1% of those in the UCC group. A total of 101 IMI completers lost an average of –9.7% of their initial weight whereas weight in the 89 UCC completers remained virtually unchanged (which over 2 years is actually not such a bad result at all – remember, successful weight management starts with stopping the gain!).

While the study can no doubt be criticized for high attrition rates and relatively modest weight loss in IMI completers (only around 10% of initial weight), the study does show that at least for some patients, aggressive management strategies in primary care may provide sustainable outcomes that can have clear health benefits.

Let us not forget that attrition rates in disease management programs for other chronic diseases (e.g. diabetes, dysplipidemia, hypertension, etc.) are also relatively high and that only a minority of patients with these other common chronic conditions are ever fully controlled in primary care practice (despite the wide range of medical treatments and resources available to patients with these conditions).

Thus, there is no reason to believe that chronic disease management for obesity, when implement in primary practice, must necessarily fare worse than chronic disease management for other conditions. The fact that obesity management in primary practice appears so unsuccessful is not because interventions don’t work (this study shows they do), but rather because no serious attempt is made to address obesity in the first place.

While the 900-calorie liquid diet followed by intense behavioural and pharmacological treatment may not be everyone’s cup of tea, and of course comes nowhere near the results with bariatric surgery, for some patients this is may well be a safe and cost-effective strategy that can be delivered in primary practice.

Remember, in obesity treatment, one size certainly does not fit all and having a breadth of strategies rather than a single intervention is probably the only way to go.

I would certainly like to hear from anyone who has been on a 900-kcal liquid diet or who uses this approach in their patients.

Edmonton, Alberta