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There are many weight-loss interventions currently available; some effective, some ineffective, and some harmful. The current Evidence to Practice section synthesizes the evidence on surgical interventions, devices, and pharmacological therapy. Throughout the process of editing the Evidence to Practice submission, I came face to face with my own struggle with weight loss. With a body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) greater than 30 and “failed” attempts with lifestyle modifications, I am a candidate for all of the interventions assessed in the Institute for Clinical and Economic Review’s (ICER’s) report.1 However, what is missing, and rarely discussed, is the human perspective. Thus, in this perspective, I am writing about my personal experience and the information I would want presented before I made an informed decision to pursue any of the proposed interventions.
I have been obese since puberty but really only struggled with my weight since 2011, after my youngest son was born. Before then, I had just accepted being obese and thought I would remain so forever. As I watched my son play, I realized that if I continued at my current weight I was at significantly increased risk of fewer days like that. Something clicked, and I was motivated to try to shed the pounds. I began tracking my calories with an app on my phone, got into a consistent exercise program, and actually made the hard choices to skip dessert, wine, and other “empty calories.” I reached my lowest weight as an adult on September 9, 2013—83 kg (183 pounds)—putting my BMI at 27.8. I felt amazing both physically and mentally. I maintained that weight for a year and then gradually began to put the weight back on as I stopped paying so much attention and life happened. My current BMI is 31.8; a mere 4 pounds lighter than when I began.
Surprisingly, this article is the first time I have told my BMI to another soul. I have never shared my BMI with my husband, my friends, nor, importantly, my physician. Given that I am an otherwise healthy 35-year-old woman, it is shocking that what is probably my only health concern has never been talked about within the privileged space of my physician-patient relationship.
Obviously, this is an awkward conversation for both the patient and physician. Weight is a tough subject, loaded with stigma, self-esteem, worthiness, and beauty issues. Despite guidelines recommending weight management counselling, the conversation is not happening regularly.2,3 Like many hard conversations, it requires compassionate listening and sympathy on the part of the physician, courage and humility from the patient. These are not easily attained attributes within 10 minute-interactions while both parties are wishing to be elsewhere. With the implementation of tool kits, there have been moderate successes at increasing the number of physician-initiated conversations.4,5 Very little attention has been paid to how to enable the patient to initiate the conversation. If we are going to expect physicians to be able to address the issue of obesity, we will need to equip them and patients with skills to artfully negotiate this awkward space.
If we were to overcome this hurdle, the question I want answered is: What are the risks of continuing to go at this through diet and exercise vs the risks of the weight management intervention? The current Evidence to Practice section demonstrates that the answer is “we don’t know.” The evidence assessed in the ICER report1 demonstrates that surgical interventions generally achieve weight loss in the short term. For pharmacological interventions and devices, the evidence is limited and mixed. My personal experience has exactly that profile; limited success in the short term not sustained over time. However, I know the safety profile of diet and exercise, while very little is known about the safety profile of the devices and pharmacological therapies. The risks of surgery are minimal, but not insignificant.
None of the interventions are silver bullets. The clinical interventions may give an upfront kick start (at what price?) but, for long-term success, still require profound lifestyle changes. The California Technology Assessment Forum’s policy discussion, echoed through published evidence, recognized that obesity is a psychological, cultural, and social problem as much as a clinical one.2,6 A multipronged, multidisciplinary solution is required to support people to achieve and maintain a healthy weight. Behavior change is hard. I am encouraged by evidence that sustained behavior changes usually takes multiple attempts7; I am not alone in my struggles. If I can learn how to build healthier habits through my weight loss routine and be supported in my efforts, it should be easier to sustain. After much thought and brutal honesty with myself, I would not pursue any of the interventions; the risks outweigh the benefit. I’m off to the gym.
Corresponding Author: Fiona Clement, PhD, Department of Community Health Sciences, University of Calgary, GD3 No. 18, Third Floor TRW, 3280 Hospital Dr, Calgary, AB T2N 4Z6, Canada (firstname.lastname@example.org).
Published Online: January 4, 2016. doi:10.1001/jamainternmed.2015.7186.
Conflict of Interest Disclosures: None reported.
Clement F. My Weight Loss Journey: Unasked and Unanswered Questions. JAMA Intern Med. 2016;176(2):163–164. doi:10.1001/jamainternmed.2015.7186
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