An Interview with Dr. Arya Sharma (Continued)
Weight Loss and Weight-Loss Maintenance
Joseph: It seems like the standard of care for weight-loss, excluding drugs and devices in some patients, is intense diet and exercise as a starting point. What do you think about this approach?
Dr. Sharma: It's simply not going to work. All that diet and exercise talk is like what we used to do for cholesterol and for diabetes. I'm not saying it's not important, and there's no question that if I get somebody to diet and exercise, they'll lose weight. But it works for obesity in the same way that the DASH (Dietary Approaches to Stop Hypertension) diet works for hypertension. I can put people on the DASH diet and show that their blood pressure gets better. But if I were to take 100 people off the street, put them all on the DASH diet, and hope that everybody's blood pressure's going to be fine, it won't be. Only five guys would actually stick to the diet, and they'd be fine, but the other 95 would not be fine. Obesity is pretty much the same; I don't see any difference at all.
Kelly Close: Presumably, weight-loss maintenance also goes back to improving the public's understanding of obesity and addressing weight bias and discrimination.
Dr. Sharma: Absolutely. We are bombarded with anecdotal instances of how easy it is to lose vast amounts of weight — not just the "weight-loss industry" — think of TV reality shows, popular magazines, and fad diets. We celebrate people for losing weight, but we seldom check to see if they are still keeping it off. I am always asked by patients, "How much weight can I lose and how fast can I lose it?" I tell them that that's the wrong question — the only weight loss that matters is the weight you can keep off — this is why we introduced the term "best weight" — the lowest weight you can realistically maintain. Your "best weight" depends on your individual circumstances, and everyone's "best weight" will be different. The public but also health professionals and policy makers need to understand that when you pay for "weight loss" you get "weight loss" — when you pay for "maintenance of weight loss" you get "maintenance of weight loss." As a health professional I'd rather see my patients or payers paying for the latter than the former.
Additionally, we often frame weight regain as "failure," when it is really the only natural expected consequence of stopping the treatment for a chronic condition. Even worse, the failure is often framed in the context of the treatment. So if you take a drug, lose weight, stop the drug, and regain the weight, we attribute the failure to the drug and not to "stopping" the drug. No drug or treatment works when you don't take it — when you have an obesity treatment that works, the question is not to find more effective weight loss drugs but to find a more effective way of ensuring that people continue taking it. The same, incidentally, applies to treatments for hypertension or diabetes. For many conditions, we don't need more drugs (unlike for obesity) — we simply need to figure out how to get patients to continue taking the meds that are already out there — that's where I'd be putting most of my research money.
Joseph: You've talked about many different causes for initial weight gain. Would you say that those are truly all different, or might they all be manifestations of an underlying disorder that shows up in different ways but ultimately motivates overeating?
Dr. Sharma: No, I think that you've got two things. One is a genetic predisposition, where people who have the same stressors and same behaviors, will have a different rate of weight gain. But even when you take people who are just overeating, you will find lots of different reasons why people will overeat: time management, using food as a coping strategy, lack of knowledge about how many calories they're consuming, peer pressure, customs, beliefs, culture, not enough money, food insecurity, etc. Those are the social drivers of obesity, some of which you can approach with drugs. But for a lot of these, the underlying problem is not an obesity problem. So, if you take somebody who is self-medicating their depression with food, after getting treatment and better control of their depression, they'll get better control of food intake. Simply slapping on a drug that, say, increases their metabolism or reduces their appetite, without addressing their mood problem, isn't a medically sensible thing to do.
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Most of the time, we bash the lastest news about a "diabetes cure" because it is neither a cure, nor often even a significant improvement in diabetes treatment. Usually these "cures" are tested in mice, but fail to make the leap over to human physiology. Devices may work in the lab, but take decades to pass through FDA review, and still not be much better than what we already have. It's enough to make us all jaded. I know I am. But I saw something...