This will not be welcome news for all of us who resolved to eat less and move more this year, but still secretly hoped that maybe medicine would step in. Maybe some novel treatment would reach maturity just as our willpower waned — a drug, a device, some new twist on surgery.
Sigh. The journal JAMA Internal Medicine is just out with an up-to-date analysis of options for treating obesity, accompanied by editor Fiona Clement’s vivid personal account of her own struggles with weight. The conclusion she draws from the latest data: “After much thought and brutal honesty with myself, I would not pursue any of the interventions; the risks outweigh the benefit,” she writes. “I’m off to the gym.”
I spoke with Dr. Clement, an assistant professor in the Department of Community Health Science at the University of Calgary, about her take on the data and her decision to discuss her own obesity — and even reveal her Body Mass Index — in print. “This is by far the bravest thing I’ve ever written, and perhaps ever done,” she says.
“After much thought and brutal honesty with myself, I would not pursue any of the interventions; the risks outweigh the benefit.”
But first, a distillation of the data from lead author Dr. Dan Ollendorf, chief scientific officer at the Institute for Clinical and Economic Review in Boston. The review is actually geared for doctors, but here’s his summary for the general public:
• Surgery: “The evidence is pretty consistent that these procedures do lead to significant weight loss in the short-term, up to about two years of follow-up. The challenge with the evidence available is that after two years, it’s a a bit of a black box. It’s unknown what actually happens. There’s some suggestion that in a pretty significant number of situations, patients actually regain weight. In cases where other conditions related to obesity, like diabetes, have improved or resolved as a result of surgery, that can be reversed in some individuals. And so that is the really big unknown with surgery: What are the longer term outcomes for patients?”
• New drugs: “The bottom line is that this is sort of more of the same. A number of drugs have been used — some FDA-approved and labeled for weight loss, others used off-label for weight loss. The new drugs result in relatively modest reductions in weight, really not very different from the existing medications that have been available for decades. They are very high cost and in some cases have the potential for really significant side effects. So there really is mixed evidence, and the benefit, if any, that appears to be available with the current evidence is pretty modest.”
• Devices: “This is kind of a heart-wrenching situation because surgery is a major step for people. Most of the advanced surgical programs in the U.S. have been able to reduce their complication rates, but this is still a risky surgery, and there are some major complications that can occur. And given that medications have produced only modest weight reductions, there’s been a lot of interest in trying to produce something that may be less invasive than surgery but more effective than medication.
“So the devices range from liners and balloons that are intended to reduce the size of the stomach to an FDA-approved device that acts on the vagus nerve, which has an association with appetite suppression. But again, these devices have produced very mixed evidence. They have their own possible complications that are a big challenge. The FDA-approved device was approved despite the fact that the weight loss target in the major clinical trial was not achieved. So it was more of an effort to try to produce some sort of intervention in between medication and surgery that could be an option for patients rather than because of an overwhelming evidence of benefit.”
Big picture: “This is a complex problem; this is a public health problem. It is also a lifetime chronic condition for patients that needs constant vigilance. So even if the best intervention in the world appeared down the pike, if it were applied without the kind of support patients need to change their lifestyle, change their eating cues, change what kinds of food they eat — even that best intervention will have very limited effects.”
And now back to Dr. Clement, who is used to wading into complex health decisions — she advises the Alberta government on which treatments should be covered, for example — but not so used to writing about herself in the process. (And yes, I did ask her the glaring question: She’s 5-foot-10 and 230 pounds, so her BMI is currently in the obese range at around 33.) Our conversation, edited:
I imagine that as you examined this up-to-the-minute data on obesity treatments, you were hoping for a magic bullet. But you reached the conclusion that there isn’t one — or how would you sum it up?
Yes — losing weight is something that I’ve had a very, very hard time with, and keeping the weight off is not something I’ve succeeded with. So if there were a silver bullet, I would be very interested in that — something that didn’t involve that hard choice of being the one person at the party who isn’t drinking, or the one who has to miss dessert while the whole table gets to enjoy this nice-looking chocolate cake.
It’s really hard to be so focused on your body all the time, on what’s going into your mouth and your output through your exercise. And so as I was reading through this report, I started it thinking, ‘Maybe I’m kind of tempted here. I know there’s a risk with any kind of surgery or any kind of drug in your body, but if this gets the weight off and keeps it off, that’s worth thinking about.’ And when I got to the end, I said, ‘OK, there are significant risks with those kinds of interventions, and they don’t really know how well they work — particularly in the long-term — so I think it’s back to lifestyle modifications and watching what you eat, hard as it may be.’
So did editing this report affect your resolve on making lifestyle changes?
It did. Before this piece, I’d never spoken my BMI out loud to another soul. If you met me, it’s very obvious that I’m obese. But one of the other things I learned through my own weight-loss journey is that people really have no idea what obesity looks like on a body. I think they can discern what we would call morbidly obese, but I think to the eye — maybe people are too polite — but they really can’t tell, at least on my body, the difference between an obesity BMI of 35 and a BMI of 30. To be more concrete, I lost 40 pounds and nobody noticed. So I don’t think we’re very good at looking at a body and knowing what a healthy weight would be for that size and body type.
“I don’t really see a magic bullet around the corner. I don’t think one will ever exist.”
So the first line I wrote when I was writing this paper was my BMI. And it took me about an hour and a half to get it on the blank screen, and that’s all I could do. I just had to walk away and clear my head, because it was such a huge thing for me to say out loud: ‘I am obese.’ So writing this piece has really changed my resolve, and I have been off to the gym every day since I submitted it. I’m very proud of that fact.
So the writing was cathartic, and the data convinced you there’s no magic bullet around the corner?
I think our best bet — though it won’t help people who are already obese — is to stop people from becoming obese. Because the easiest pound to lose is the one you’ve never gained. I don’t really see a magic bullet around the corner. I don’t think one will ever exist.
You write that your doctor has never brought up your weight, and that patients may need some help bringing it up — how do you imagine that sounding? What are you calling for?
For myself, for me to admit to someone else that I am obese and that I need help with that, or that I’d like some support systems, takes a lot of courage and humility on my part. The thoughts that go through my mind are that somehow, I’m not as beautiful, or I’m not as smart, or I’m not as worthy, because I’ve said out loud that I’m obese. It’s a big hurdle for me to admit that to someone else.
So for myself, I need to reframe that to: ‘I am still all of those things. I am still beautiful, I am still worthy, I am still a very smart woman and I am obese,’ and that’s the part that I need to work on. I need some help getting over that hurdle. I also think that for me to be able to do that, I need to feel safe and valued and listened to, and sometimes in a doctor’s office, maybe you don’t have a particularly strong relationship with your doctor, or maybe you feel like you’re being rushed. I need a little bit of time to build up to being able to share that kind of intimate information, and sometimes in the 10 minutes, ‘Just get to the point’ is the vibe you’re getting. And you’re nervous anyway, so it’s very easy to say, ‘OK, I’ll just talk to you about my cold and we’ll get to this another day.’
So I do think there needs to be training on both sides. As a patient, how can I build the strength in myself to be able to share this kind of feeling with my doctor and ask for help, which is not an easy thing for a lot of people? And on the doctor’s side, work on how big a hurdle this is. This isn’t just, ‘I have a cold, can you help me with some medication?’ This is a really big emotional thing that your patient is trying to work through. And you need to work on building some compassion and empathy.
This personai approach is quite a departure from the usual health policy analyses you do…
I’ve published a lot of things that I feel are very impactful but this is by far the bravest thing I’ve ever written and perhaps ever done. One of the pieces I feel is the most important is this: When I was struggling with my weight — and I continue to struggle — it’s very isolating, and I’ve felt very alone. And I don’t think I’m the only person that’s gone through this, and I’m probably not the only person who ever will. So i hope this enables somebody else to speak out about their journey, too.
And back from the personal to the policy level: Given this latest review, what would you recommend to a government in terms of paying for obesity treatments?
I do think surgery has a place in a suite of options that we offer people, but I do feel that it should be, if you will, a last resort, and it needs to be placed in a program that is all-encompassing. So it should have dietitian support, some exercise regime support, some behavioral change support, some mental health support. Because offering someone surgery and doing the surgery and then letting them go back to their normal life without any support — it seems to me very obvious that this patient is going to experience weight gain again. Changing your life is not easy.
So I do think that surgery does have a place. But the drugs and devices — I personally don’t feel the government should be paying for them yet.
Readers, reactions? Read Fiona Clement’s full piece here: My Weight Loss Journey: Unasked And Unanswered Questions.