The Uncertainty Of Behavioural Obesity Management

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Aug 21, 2011:

In the past few posts, I have discussed some of the recommendations in the recent Scientific Statement on New and Emerging Weight Management Strategies for Busy Ambulatory Settings From the American Heart Association.

The Statement includes a number of suggestions on how to assess eating behaviour and physical activity in a busy clinical setting and touches on the use of internet and other electronic resources for assessment and management.

In summary, the Statement concludes that:

– Discussions of weight should be performed in a nonjudgmental, respectful, and unhurried manner.

– Readiness and self-efficacy to change behaviors should be assessed before weight loss strategies are initiated, and this information should be factored into decisions about what type of approach to use.

– Validated tools such as the Eating Pattern Questionnaire, the Starting the Conversation tool, and the WAVE and REAP-S tools should be used to assess behaviors that contribute to excess body weight gain.

– Central planning and training should be incorporated into collaborative approaches that involve physicians, nurses, or other providers.

– Studies of Internet and other technologies for weight loss have shown promise, but at this time, there is insufficient evidence to make recommendations about their use in busy clinical settings.

The authors also make the following pertinent suggestion:

“…because many weight management interventions involve understanding and applying detailed and sometimes complex information by patients, the health literacy of patients should be taken into account in the design and selection of interventions.”

While all of this is a good start, I do wish that the statement had given greater emphasis to the fact that obesity is a heterogeneous and complex disorder and that it may be more important to spend time evaluating the ‘whys’ than the ‘whats’.

Thus, while it is certainly informative to assess ‘what’ people are doing, it is perhaps of even greater value to evaluate the underlying drivers (the ‘whys’) of these behaviours, be they environmental, cultural, biological or psychological.

Unfortunately, the Statement remains largely locked into the ‘how-do-we-get-obese-people-to-eat-less-and-move-more‘ paradigm, an approach that has so far largely failed to deliver.

Indeed, there is yet no convincing evidence that ‘traditional’ approaches to ‘lifestyle’ intervention for obesity can produce lasting effects – nor is there hard evidence that any such approaches will actually reduce morbidity or mortality in the long term.

Recognizing this lack of evidence should be humbling to anyone making enthusiastic suggestions on how to change people’s lifestyles to better manage obesity or related health problems.

In Alberta’s Obesity Initiative, we have therefore chosen to speak of ‘promising’ rather than ‘proven’ interventions when it comes to many aspects of dealing with this problem. Unfortunately, whether we like it or not, the best ‘hard-evidence’ of long-term health benefits and cost-effectiveness of obesity management are still largely limited to the bariatric surgery literature.

It is now upon both the prevention and medical management communities to demonstrate the long-term efficacy and cost-effectiveness of their efforts.

Or, as the authors of the Statement rightly conclude:

“In particular, larger studies of longer duration are needed to evaluate the effectiveness of the chronic care model as a framework for weight management interventions.”

Fully acknowledging this ‘uncertainty’ in how best to conservatively prevent and manage obesity should not prevent us from trying ‘promising’ approaches, but should certainly remind us of the importance to objectively measure and evaluate each step that we take in order to determine whether or not it actually offers a good ‘return on investment’.

Edmonton, Alberta