Is the treatment of obesity futile?

Treat the patient, not his weight

Telling an obese patient to lose weight is about as effective as telling an asthmatic patient to breathe better! Care consists of assessing the risks of excess weight to a patient’s health. The Edmonton Obesity Staging System recently proposed by Kuk et al is an interesting tool designed for this point of view.¹ This system includes recommendations for each level of intervention, ranging from simply recommending that the patient maintains his weight, to recommending bariatric surgery. This assessment is extremely important because the consequences of excess weight vary among patients. For example, it is possible for an obese patient to be metabolically healthy.² The Edmonton system consists of a clinical examination, the measurement of biochemical parameters, and in some cases an investigation of possible comorbidities such as sleep apnea. This process takes time; it is not possible to assess an obese patient in a single session. However, for physicians, this is familiar territory: approach obesity as you would any other chronic disease.

Treat any comorbidities

Comorbidities will create considerable roadblocks to any attempt on the part of the patient to lose weight. Severe sleep apnea and depression are examples of comorbidities that are frequently seen in men and women with a body mass index of greater than 40 kg/m²; however, neither is rare in less severe cases of obesity.³

Set a reasonable objective and period of time for weight loss

Few patients realize they can improve their health considerably by losing even a small percentage of their weight. For example, to prevent type 2 diabetes (at least temporarily), a patient need only lose 5% to 10% of his weight. These goals should be set with the physician, who will provide medical follow-up.

Inform the patient of the tools at his disposal for losing weight

This part of the treatment might take longer, but there is no reason it cannot be delivered over several visits. At this stage, a physician might feel ill-equipped without his usual box of tools: drugs. Yet, the history of treating obesity with drugs reads like a long list of catastrophes. Today, the only drug at our disposal is orlistat, which inhibits the absorption of fats in the intestine. Recently, glucagon-like peptide-1 analogues were brought to market for the treatment of diabetes; they are a new development because they cause weight loss. However, there are no long-term data for these drugs. Weight management remains a matter of education and permanent lifestyle changes. These changes are not part of the field of medicine and must be introduced by a multidisciplinary team of nutritionists, psychologists, and kinesiologists. Ideally, this team will be working in the same location as the physician. Long-term maintenance of weight loss by a professional working alone has a success rate of 5%; weight management by a multidisciplinary team has a success rate of 25% to 40%.⁴ The role of the physician is to refer the patient to this team and then provide medical follow-up. The cost of seeing a multidisciplinary team once a week or every 2 weeks for 6 months to a year is about $2000 to $3000, which can represent an insurmountable financial barrier. If this is the case, the patient can be referred to an organization in the community such as Weight Watchers or Choisir de maigrir.

Physicians have a responsibility to warn their patients about ineffective weight loss methods that can be dangerous such as high-protein fasts, natural products, and liposuction.

The surgical treatment of obesity is very popular and increasingly simple and safe.⁵ Physicians must be able to identify good candidates for this surgery and to refer them to reputable bariatric surgery centres. It should be noted that this surgery requires very close follow-up care for a period of 2 years, with an annual review thereafter.⁶