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Thursday, January 31, 2008

Obesity is Not Special

Most people either think that managing obesity is easy (just eat less and move more, Stupid!) or is extremely complicated (simply hopeless and a complete waste of time).

Fact is that managing obesity is actually not very different than managing many other chronic diseases.

Yes, we need to make the right diagnosis, yes, patients have to make lifestyle changes and yes, there are medical and even surgical treatments, but even these only work if patients are well managed in the long-term and follow the rules.

Relying on lifestyle counseling alone is probably as effective for obesity as it is for diabetes, hypertension or dyslipidemia. Medications for obesity, like medications for diabetes, hypertension or dyslipidemia, only work when you continue taking them. As with many chronic conditions, as patients get older, treatment gets more difficult.

The reasons why most physician's think that managing diabetes, dyslipidemia or hypertension is easier than treating obesity, are firstly because they have been extensively trained to treat these conditions and secondly because the treatments for these conditions are deemed more effective and better studied than treatments for obesity.

Actually, perhaps with the exception of statins for high LDL-cholesterol, the results of monotherapy for many chronic conditions like diabetes, hypertriglyceridemia or hypertension are pretty modest. Reducing HbA1c by 1% point, triglycerides by 10% or diastolic blood pressure by 5 mmHg is pretty much the average effect seen with antidiabetic, lipid-lowering or antihypertensive monotherapy - really not very impressive at all. Yes, some patients will respond better, but many will not.

Seen in that light, a 5-10% sustained weight loss with antiobesity monotherapy isn't that bad after all, given that lowering body weight may in fact be tougher than lowering blood sugars or blood pressures.

The problem with antiobesity medications is not that they don't work - the problem is that most people do not continue taking them once they stop losing weight. They are taking them for weight loss rather than for weight-loss maintenance. But even this is not that different from other chronic diseases. We know that adherence with antihypertensives, antilipids and antidiabetics is notoriously poor with few patients taking these medications for much longer than six months at a time.

As for other chronic conditions, taking an antiobesity drug for a few months just to lose weight makes absolutely no sense - the idea that something magical will then happen and the weight loss will be maintained after stopping treatment is idiotic and completely inconsistent with our current understanding of energy homeostasis.

Obesity is not special - it is simply a chronic disease which like all chronic diseases requires long-term (lifelong?) treatment.


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