1. Myths and Facts about Obesity Treatment: An Interactive Lecture
September 22, 2016
Julie Lewis Rickert, Psy.D. and Eman Jammali, MD
UND Center for Family Medicine - Minot
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2. Disclosures
None

3. Goals and Objectives Participants will
Identify the impact of preconceptions and biases on learning from research and practice guidelines
List two common weight management misconceptions and three data supported clinical interventions.
Identify specific factors in obesity treatment research that influence real life clinical usefulness.

4. Mountains of conflicting data
PubMed
247,144 citations for obesity (+19,000 in 12 months)
46878 for obesity review
115,831 for obesity treatment
Obesity is bad for your health and there are things that seem to help.

5. “Weight-loss Industry” estimated to be worth $61 billion in 2010
Funding research, click-bait science
We are inundated with information

6. We are also flooded with opinions about what we should do about it.
Wondering who this s? Mark Hyman is a Family Physician who writes in the Huffington Post about nutrition and health. This is what he wrote about research in a post about mercury. (2011)

7. Most of us also have personal experiences with weight loss (and gain)
Obesity is not a value neutral condition
Provider weight loss
Provider interactions with others losing weight
Provider’s developmental experiences in regards to weight.

8. Dueling perspectives on obesity and mortality
Calle, E. E., Thun, M. J., Petrelli, J. M., Rodriguez, C., & Heath Jr, C. W. (1999). Body-mass index and mortality in a prospective cohort of US adults.New England Journal of Medicine, 341(15),
Orpana, H. M., Berthelot, J. M., Kaplan, M. S., Feeny, D. H., McFarland, B., & Ross, N. A. (2010). BMI and mortality: results from a national longitudinal study of Canadian adults. Obesity, 18(1),

9. Common misconceptions and oversimplification about obesity treatment.

10. Small group activity
Sort your patient vignettes with underlying assumption into piles: red for myth, green for fact, and yellow for presumptions (with insufficient or conflicting data).

11. How did that go? Was there much disagreement?
We will go through them later.

12. Common Misconceptions
Obesity is caused primarily by lack of physical activity or by unhealthy dietary practices.
Overly simplistic
Neglect other “putative contributors” (sleep, fatigue, stress, endocrine disruptors)
Overeating and reduced caloric expenditure should be seen as symptoms not causes.
Don’t oversimplify!
Chaput, J. P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician,60(11),

13. Common Misconceptions
Obese individuals are less active than normal-weight counterparts.
Nope – they seem to have similar activity levels – way below what they need but no different than normal weight individuals.
Encourage physical activity for the direct health benefits, not weight loss.
Chaput, J. P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician,60(11),

14. Common Misconceptions
Diets work in the long term
Diets work in the short run.
2/3 relapse within 12 months.
Nearly all within 5 years.
Nearly 2/3 will regain more than they lost. (Mann)
Sustained weight-loss is possible for some but is not the anticipated outcome.
Weight regain is the expected consequence of dealing with a chronic and complex condition.
Chaput, J. P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician,60(11),

15. Common Misconceptions
Everyone can lose weight with enough willpower.
Not supported
A successful obesity management program is measured by the amount of weight lost.
Chaput, J. P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician,60(11),

16. Myths and misconceptions are a problems because they are difficult to change
Cognitive ease
Confirmation Bias
Anecdotes and experience loom large in decision-making

17. American Family Physician Update
Hot off the press this month
Update on Office-Based Strategies for the Management of Obesity
Erlandson, M., Ivey, L. C., & Seikel, K. (2016). Update on Office-Based Strategies for the Management of Obesity. American family physician, 94(5), 361.

18. What is a Family Physician’s Role in screening and managing obesity?
Family physicians can help patients to set weight loss goals, improve nutrition education, increase physical activity, address barriers to change, and develop strategies to help maintain long-term lifestyle changes.
Physicians should screen all patients for obesity with measurement of BMI or waist circumference
Obese => Diet + behavioral modifications

19. Dietary modifications Found to be Most Effective
Deficit of 500 Kcal/day regardless of macronutrient composition
Avoid high-intensity intervention unless under close supervision
Using a single adjustment may provide weight loss similar to more complex plans.
Increase fiber intake VS AHA diet

20. Behavioral Interventions Helpful for Weight Loss
Motivational interviewing ( can also have a positive effect on reducing CVS factors)
Worksite interventions
Exercise = mins of moderate-intensity exercise/week or mins of vigorous activity/ week

21. Role of Medications in the Treatment of Obesity
First consider the effect of other medications prescribed for other medical conditions that may affect weight.
Consider below medication in patients with a BMI of 30 or greater, or 27 or greater with comorbidities and have unsuccessfully tried diet and lifestyle modification first.
orlistat (Xenical), lorcaserin (Belviq), liraglutide (Saxenda), phentermine/topiramate (Qsymia), and naltrexone/bupropion (Contrave) = approved for use for long-term treatment of obesity but optimal duration of treatment is still unclear

22. Role of Bariatric Surgery in Treatment of Obesity
Referral of patients with BMI of 40 or greater and patients with BMI greater than 35 with obesity-related comorbidities for bariatric surgery.
Bariatric surgery is more effective than diet, behavioral modifications, and pharmacotherapy in the management of obesity, and it leads to improvement in obesity-related comorbidities.

23. Keep in Mind
These recommendations all have SORT ratings of B (inconsistent or limited) and C (consensus, expert opinion, or usual practice)

24. Sexual Activity Burns 100 – 300 KCal
Some pharmaceutical agents can be moderately helpful with weight loss and maintenance as long as they are continued.
Sexual Activity Burns 100 – 300 KCal
Continuing the conditions that led to weight loss promotes maintenance of lower weight. Obesity is a chronic disease.
Large, rapid weight-loss is associated with poorer long-term weight-loss outcomes
Increased structure in the form of meals and meal replacement promotes greater weight loss than holistic programs that promote balance, variety, and moderation.
Eating more fruits and vegetables will result in weight loss or less weight gain, regardless of other changes
Weight cycling (yo-yo) is associated with increased mortality
Increased exercise improves health outcomes regardless of weight or weight loss.
Diets effectively reduce weight, but trying to go on a diet or recommending that someone go on a diet generally does not work well in the long-term.
Small sustained changes in energy intake or expenditures will produce large, long-term weight changes.
In appropriate patients, bariatric surgery results in long-term weight-loss and reduction in the rate of diabetes and mortality.
Although genetic factors play a large role, heritability is not destiny. Moderate environmental changes = most efficacious pharmaceutical interventions.
Snacking contributes to weight gain and obesity
Setting Realistic Goals is important because patients become frustrated and lose less weight.
Assessing Stage of Change of patients seeking help with weight-loss can help predict outcomes of behavioral or surgical weight-loss interventions.
Built Environment (sidewalks, park availability) influences incidence and prevalence of obesity.
For physical activity to affect weight loss and maintenance, the amount and intensity must be substantial.
When treating overweight and obesity in children, including parents and the home setting promotes more weight loss and maintenance.
Breastfeeding is protective against obesity
Early childhood is the period in which we learn exercise and eating habits that influence our weight throughout life.
Regularly eating breakfast is protective against obesity
Physical Education Classes play an important role in reducing or preventing childhood obesity
Casazza et. al (2013) Myths, Presumptions, and Facts about Obesity. NEJM 368(5):
MYTHS
Presumptions not supported not disproven
FACTS
Bariatric surgery for BMI>40/35 →LT wt loss and ↓ M&M
Small changes lead to big results with time
Snacking contributes to weight gain and obesity (RCT-no, Obs mixed)
Heritability is not destiny
Setting realistic goals is important
Paradox: Dieting (↓caloric intake) = ↓weight. Going on a diet or recommending dieting does not help in the long run.
Weight cycling is associated with increased mortality (?confounding variables?)
Sexual activity burns 100+ KCal
To maintain weight loss, continue to do what you did to lose it.
Built environments influence obesity (data doesn’t support)
It is better to lose weight slowly
Structured nutrition helps more with weight loss
Stage of change is predictive of outcomes of behavioral or surgical weight-loss interventions
Eating more fruits and vegetables will help as a solo intervention
↑ exercise = ↑ health regardless of weight or weight loss.
Exercise dose and intensity must be substantial to impact weight
Physical Education (as evaluated) interventions in schools can impact obesity
Early childhood  lifelong exercise and eating habits = weight (BMI tracking may be more genetics than learning*)
Family / home involvement ↑↑↑ pediatric weight outcomes.
Breast feeding is protective against obesity
Regularly eating breakfast is protective against obesity (mixed)
Meds may help if they are maintained

25. Strong reactions?

26. What are some problems with much of the available data?
Many correlational
12 week to 18 month duration
Participants non-representative and/or false equivalence across groups.
Bias in who is lost to follow-up
Publication bias
Outcome is typically weight, inferred to have health benefits from correlational studies.
Most studies do not gather data about actual morbidity and mortality.
Costs, NNT/NNH, are not always easy to pin down.
Most recommendations end up having SORT ratings of B (inconsistent or limited) and C (consensus, expert opinion, or usual practice)

27. Evaluating research about pharmaceuticals for weight loss
Always keep in mind what are we trying to treat with a weight loss intervention: the number on the scale or disease management/prevention? Little data that any of these improved M&M.
Are used with diet.
Small but significant effect on weight. No data about long-term outcomes.
5% loss is considered “robust”– 10 pounds in a 200 pound person.
When medications are d/c, patients regain the weight lost.
Best efficacy for overweight and stage 1 obesity

28. What type of patient would benefit from this?
Drug (listed as on-label)
NNT for 1 patient to have 5% weight loss at a year
# stopped due to SE
Weight loss at 1 yr
Cost/year
Notes
Qsymia (phentermine/ topiramate ER) 2
1 in 12
19 lbs
$2,400
Impaired cognition, metallic taste, paresthesia, monitor heart rate, special licensing
Saxenda (liraglutide) 4
1 in 18
12 lbs
$13,200
nausea, rare hypoglycemia
Contrave (naltrexone/ buproprion ER)
4-5
1 in 9
9 lbs
Nausea, seizures. Avoid with opioids, seizure disorders, and hypertension
Belviq (lorcaserin)
1 in 53
8 lbs
Dizziness, fatigue, caution with other serotonergic drugs
Orlistat (Xenical, Alli)
1 in 26
7 lbs
$540
Nausea diarrhea, fecal urgency. Avoid in gallbladder disease, malabsorption
Phentermine ?
5 lbs
$360
agitation, insomnia
Diethylproprion (Amfepramone)
Schedule IV, consider ECG due to cardiac risks, not recommended for long-term
What type of patient would benefit from this?
What would you tell them about costs, weight outcomes, and benefits?
Source: Pharmacist’s Letter “New guidelines will encourage using weight loss drugs to control weight-related conditions.”

29. Remission of diabetes: bariatric surgery vs
Remission of diabetes: bariatric surgery vs. conventional medical treatment for morbidly obese patients.
Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Nanni G, Castagneto M, Bornstein S, Rubino F. Bariatric-metabolic surgery versus conventional medical treatment in obese patients with type 2 diabetes: 5 year follow-up of an open-label, single-centre, randomised controlled trial. Lancet 2015;386:964–973.

30. Keep your eyes on upcoming research
Bariatric surgery currently has best POEM outcomes for BMI >35.
There are some very interesting and promising areas of investigation that may yield good interventions.
As they are published, look for the qualities that suggest the data is clinically useful.

31. What are the qualities of good research that can inform obesity treatment?
Representative of our patients
RCT
Minimal bias
Assess impact on POEMs over time
Enables us to identify who may benefit.
Enables us to weigh costs vs. likely benefits.

32. Questions to ask when using obesity research to inform care decisions
Is the research itself good science?
Are the subjects representative of patients I would apply the data with?
Costs ($, side effects, iatrogenic) and availability?
What benefits (in addition to weight loss) can be expected and NNT?
How long are those benefits sustained?

33. What reactions did you have to each of the following?
Myth, fact, or presumption activity – especially the paradox
Problems with obesity data
Pharmaceuticals for obesity
No data to support multiple attempts at behavioral or pharmaceutical interventions for morbid obesity: refer to bariatric surgery

34. Discussion

35. Take home Preventing and treating obesity is important.
Our current knowledge is not sufficient to do a good job at this.
There are a lot of myths, conflicting assertions, and unsupported suppositions presented as fact.
Address bias and mindfully evaluate research.
Stop using exceptions as evidence.
Help patients with decisional balance.
No intervention is perfect

36. Take home
The best diet is the one the patient can sustain over years but the typical patient will regain more weight than they lost on their diets.
Overweight Obesity Morbid Obesity
Small changes like adding fiber and keeping a food journal can be helpful, especially BMI
Keep your eye on the prize: improved health outcomes may be impacted with minimal weight loss.
Above all, be empathic and supportive.

37. Take home
There is little benefit to making more than one intensive lifestyle intervention for patients with a sustained BMI > 40.
Bariatric surgery is clinically-effective and cost-effective for these patients.

38. Primary Content References
Brownell, K. D. (2010). The humbling experience of treating obesity: Should we persist or desist?. Behaviour research and therapy, 48(8),
Casazza, K., Fontaine, K. R., Astrup, A., Birch, L. L., Brown, A. W., Bohan Brown, M. M., ... & McIver, K. (2013). Myths, presumptions, and facts about obesity. New England Journal of Medicine, 368(5),
Chaput, J. P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician,60(11),
Erlandson, M., Ivey, L. C., & Seikel, K. (2016). Update on Office-Based Strategies for the Management of Obesity. American family physician, 94(5), 361.
Hebert, J. R., Allison, D. B., Archer, E., Lavie, C. J., & Blair, S. N. (2013, June). Scientific decision making, policy decisions, and the obesity pandemic. In Mayo Clinic Proceedings (Vol. 88, No. 6, pp ). Elsevier.
Loveman, E., Frampton, G. K., Shepherd, J., Picot, J., Cooper, K., Bryant, J., ... & Clegg, A. (2011). The clinical effectiveness and cost-effectiveness of long-term weight management schemes for adults: a systematic review.
Mann, T., Tomiyama, A. J., Westling, E., Lew, A. M., Samuels, B., & Chatman, J. (2007). Medicare's search for effective obesity treatments: diets are not the answer. American Psychologist, 62(3), 220.

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