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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


  1. I’m really surprised by your words : “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”.

    Isn’t a “Mediterranean diet” – approach evidence based ?

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  2. @Thoelen: The Mediterranean diet has not been shown to reduce and sustain weight nor is there hard evidence for its impact on CV mortality from ntervention trials.

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  3. And what about the advice to GP’s in “Tools for Practice : diets for weight loss and prevention of negative health outcomes” in Canadian Family Physician, vol 57 August 2011 ? (I am an European GP, Belgium)

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  4. All this is wonderful for the treatment, but it does not cure the problem.

    One workable “cure” for the obese is to stop eating sugar, grains, manufactured oils, manufactured eatable products, and possibly seeds and nuts for the remainder of their lives. The obese have already pre-selected themselves for “carbohydrate intolerance”.

    This leaves real meats, vegetables, and a few fruits to live on. It will produce more variety than the grain and sugar diets most obese are living on now.

    Obese are being give the wrong advise as to what we all should be eating by advertising, “heart health whole grains”, cereal, and the like. They need to clearly understand “carbohydrate intolerance”

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  5. “. . .obesity is a heterogeneous and complex disorder and that it may be more important to spend time evaluating the ‘whys’ than the ‘whats’.”

    Perhaps, but here’s the problem: You can address the “whys” to attain a weight loss, but once a body is weight reduced it is barraged by dozens of new, different “whys” that challenge it in maintaining this loss. You have written on many of them: In weight-reduced people, leptin is chronically suppressed, ghrelin is chronically elevated, other hormones, gut peptides and natural chemicals are out of whack, and metabolic function is about 20% slower than a person whose nautral weight is the same as the reduced person’s current weight. Dieters are unprepared for these issues, and their doctors are ignorant of them. So, patients may resolve the problems causing, say, “emotional eating” (as an example), lose weight, feel completely in control of their situation, but then, shortly, regain their weight nevertheless. How discouraging!

    I have talked about “eat impulses” on my blog in the past. I don’t see these addressed anywhere. I just made up the terminology because I needed it. Hunger is portrayed most everywhere as a black or white condition, or, at most, something that can be graded on a scale of one to ten. It is not that simple. People gain weight and blame themselves because they “know what to do, but just didn’t do it.” Wouldn’t it be refreshing to ask “why” without assuming it’s because they returned to their initial “whys,” such as emotional eating. Let’s also give hunger a dimensional description and respect its complexity, so that people will stop assuming that they were utter failures because they ate when they weren’t “hungry.” I’m telling you, from my position as a success story, that’s not the case. Those impulses to eat are powerful, even if they don’t register as normal, recognizable, gut-growling “hunger.” People make jokes and laugh about night eaters unconsciously arising from bed to raid the refrigerator. We laugh because of the truth in it, but it’s not funny to someone trying to maintain weight loss. During the day, a weight-reduced person may find herself in front of an open refrigerator door with 200-calories of mixed nuts in her mouth before she becomes conscious of what she’s doing. Then she must decide: Wow, do I swallow or spit this out? What’s healthier? Is this disordered? The process of responding to “eat impulses” is almost mindless, but not entirely so. And therefore, people who regain weight only know to feel guilty. If weight-reduced people try to talk to their doctors, they’ll generally just hear platitudes: “You know what to do. Just keep doin’ it! Keep up the good work.” But most weight-reduced people cannot. And they regain. And they think, “Oh, well, Once again, I’ve failed. I’ve failed myself, my doctor, all the people who supported my weight loss.” It’s miserable and unfair.

    I think the best intervention a doctor can provide is knowledgeable honesty. How rare.

    To remain weight reduced requires so much more self knowledge and body wisdom than is currently acknowledged in our culture, even by our doctors. Doctors need to know and respect how difficult it is to continually outsmart our own bodies, and they need to STOP with the defeating platitudes that ring ugly in patients’ ears long after the weight is regained.

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  6. If one size fit all, and one solution worked for everyone, then by now there would be no fat people around. No diet is sufficient in and of itself. No exercise program is sufficient in and of itself. A combination of the two doesn’t cut it either. Humans are complex beings and trying to apply simplistic solutions is doomed to failure. I”m fat. I’m healthy. I’m fairly satisfied with my lot in life. Being healthy, happy and fat beats being fat and miserable so I don’t intend to torture myself with diet and exercise schemes with a 95% failure rate. I think I will stay where I am thanks, and work on staying healthy and happy.

    Thank you, Dr Sharma, for an informative, well thought out blog.

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  7. Dr. Sharma,

    What the heck IS happening with the Alberta Obesity Initiative? Not much at all that I can see.

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  8. I love rereading these posts, a reminder that we need to use the staging system very closely to help guide patients into possible and successful outcomes.

    When are you back on the horn?

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  9. fredt,

    I think there’s less of a problem with carbs and the obese. The problem is the carrier — the salt/oil combination that makes carbs ‘addictive’. When I am avoiding salt/oil (and in turn sugar) I’ve never had a desire for a carb. I *only* desire the salt/oil combination. Carbs just ain’t that tasty.

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