BRIGHTON The choice of treatment for obesity depends on a number of factors but should primarily be based on understanding the patient and their needs and goals, addressing barriers and avoiding stigma if meaningful and sustained weight loss is to be achieved, says a UK expert.
Talking at Society for Endocrinology BES 2019, Dr Abd Tahrani, a National Institute for Health Research clinical scientist at the University of Birmingham, said that the patient should be treated "holistically" and placed at the centre of decision-making.
He said that the underlying causes of obesity need to be addressed to choose the "right treatment for the right patient needs," considering the severity of the disease, the magnitude of weight loss required and the timescale overweight to achieve that.
Moreover, "long term support, like any other chronic disease, is absolutely mandatory", with the input of a skilled multidisciplinary team.
Dr Tahrani began by stating that it is not him, as a clinician, who chooses the weight loss intervention, rather it is the patient who chooses with the help of the multidisciplinary team.
To achieve that, you have to "know your patient very, very well" and avoid stigmatising them, he said.
The was underlined by data from the 2018 All-Party Parliamentary Group on Obesity survey revealing that just 26% of people with obesity reported having been treated with dignity and respect by healthcare professionals when seeking advice or treatment.
Dr Tahrani said that clinicians therefore need to work with their patient, collaborating to motivate them and encourage self-efficacy, all delivered with compassion.
He characterised this as listening to the patient's "internal music", respecting their rhythm and timeframe, and, ultimately, guiding them.
This then informs the process of choosing the right treatment, Dr Tahrani said, as clinicians need to understand the underlying causes of the individual's obesity.
"The common concept is that they have obesity because they eat too much and they don't move," he said, but "this is a symptom".
"This is like saying you've got anaemia. If you have anaemia, I don't treat you with a blood transfusion, I want to know whether iron deficiency, or B12 or folate deficiency. Then I give you specific treatment."
Dr Tahrani added: "Obesity is exactly the same."
He said that obesity is a chronic, relapsing disorder that involves two stages:
Sustained positive energy balance, where intake exceeds expenditure over an extended period of time; and
Resetting the body's weight "set point" at an increased level, in which physiological processes then work to regain any weight following weight loss.
However, there are a multitude of factors that feed into this process, as outlined by the government's attempt to create an obesity system map.
This highlighted that social, psychological, economic, infrastructural, developmental, biological, medical, food- and activity-related, and even media-related factors, all play a role in the wider causation of obesity.
Within an individual, obesity can be related to genetic or syndromic causes, hypothalamic alterations, endocrine alterations, medications, mental health disorders, and lifestyle changes, all of which have their own signs and symptoms.
This still begs the question, however, of what to do about obesity.
Dr Tahrani said that this can be seen at the level of societal change, through alterations in the food and activity environments and addressing stigma, and on the individual level, through lifestyle and behavioural changes, as well as the use of medications and surgery.
He believes that first, the barriers a person has against tackling obesity need to be identified. These can be explored using the 4M approach, which looks at mental, metabolic, and monetary factors, as well as mechanical factors, such as osteoarthritis, pain, and oesophageal reflux.
In addition, the clinician should take into account the patient's expected treatment outcomes, working with them to develop realistic aims and expectations and align the treatment and patient outcomes.
For example, patients may want to lose weight for body image reasons, in which case rapid weight loss will be desired, while those wanting to lose large amounts of weight will require interventions that may take longer but have a more sustained effect.
Dr Tahrani said that lifestyle changes, as recommended by the National Institute for Health and Care Excellence (NICE), should result in a sustained weight loss of 35 kg in people with obesity.
However, he warned against placing too much faith in very low calorie diets, such as those used in the DiRECT study, as the evidence suggests that patients typically regain all the weight they lost over the next 2 years or so.
He continued that drug treatments tend to be associated with a weight loss of around 3%5%, which is additive to any weight loss achieved with lifestyle changes but is only sustainable "as long as the patient continues to take it".
Dr Tahrani pointed out, however, that the greatest and most sustained weight loss is achieved with bariatric surgery, with gastric bypass associated with reductions of 25%30% maintained up to 20 years, although it takes up to 2 years to see the full effect.
Most important is to understand previous successes and failures in managing obesity, and to address clinical inertia.
While treatments can be escalated, depending on the response, he underlined that there is no point in exposing patients to repeated cycles of ineffective treatments.
Dr Tahrani explained: "OK, you've tried a lifestyle intervention. You couldn't do it. Let's do it again...If it hasn't worked, it hasn't worked.
"There's no point in repeating the same thing again, which also demoralises the patient and sets them up for failure."
Finally, the clinician needs to be surrounded by a skilled multidisciplinary team, and to listen to them, he said.
To illustrate his point, he said that before his presentation, he asked Twitter for advice on how to choose between weight loss interventions.
He received responses from academics, physicians, nurses, surgeons, epidemiologists, dieticians, pharmacists, medical writers, and patients, incorporating their ideas and acknowledging them all by name in his slides.
Following the presentation, session co-chair Dr Annice Mukherjee, a consultant endocrinologist at Spire Manchester Hospital, said: "I just want to play the devil's advocate.
"You said, if lifestyle measures don't work for weight loss, don't tell them to keep up their lifestyle measures, but surely lifestyle measures are good for many other aspects of health not just weight loss."
She added: "Why don't you say keep going. It doesn't matter that you haven't lost weight, it's still going to be beneficial."
Dr Tahrani agreed, saying that, "you need to align your agenda with the agenda of the patient".
He said that clinicians need to take a "holistic approach to the patient", and "health is not only about weight loss".
He explained: "They can continue with the lifestyle intervention for the rest of the benefits, but for weight loss you need to add another treatment on top of that.
"Physical activity in particular is overrated for weight loss...but for the rest of metabolic health, it's fantastic."
Dr Tahrani reports research contracts, consulting and other support from Sanofi Aventis, Eli Lilly, BMS, BI, Novo Nordisk, AstraZeneca, MSD, Janssen, Resmed, Philips Resporinics, ImpetoMedical, ANSAR, Aptiva.
Society for Endocrinology BES 2019: HDI1.6. Presented 11th November.
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