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We need to challenge “what is clinically relevant weight loss”?

By Dr Sean Wharton, MD, PharmD, FRCP(C)
Internal Medicine Specialist
Adjunct Professor McMaster University and York University, Ontario, Canada
Diplomat of the American Board of Obesity Medicine

Weight management is about addressing the complications of overweight and obesity, many of which are primarily managed with sustained weight loss. Although many discussions surround the fact that minimal weight loss is beneficial for a number of medical conditions, it is clear to me that for many complications, more than 5% weight loss is needed to see a clinically relevant benefit.1,4 Prevention of diabetes starts at 3% weight loss, yet this improves significantly with losses greater than 5%.1,3 Diabetes remission requires 10 to 15% weight loss.1,3 Conditions such as obstructive sleep apnea and osteoarthritis also require more weight loss than 5%.1

When we ask patients about their weight loss expectations, they state that they expect 30% weight loss.5  Although that much weight loss is often considered an unreasonable expectation for strategies outside of bariatric surgery, we question patients for considering such lofty goals. The medical field disagrees with such high expectations  primarily due to the fact that there have been no interventions, outside of bariatric surgery, that can attain this amount of weight loss over the long term.  We blame the patient for expecting too much.  We should blame the lack of effective non-surgical interventions for not getting us to that goal.

Patients should expect enough weight loss to correct their weight-related complications and that is, in most cases, more than 5%, as documented by the majority of studies looking at clinically relevant improvements or even resolution of complications related to obesity.1,4 Obesity medicine specialists should stop pretending that 5% is enough, and when all the available interventions are capable of achieving over 10% weight loss in patients, it is likely that they will.

We championed 5% weight loss as the reasonable goal, likely due to the fact that 5% was all that could be achieved in the long term with the most commonly used non-surgical treatments such as lifestyle intervention.  We should no longer accept long term weight loss of 5% as a minimum standard. The necessity of needing more weight loss - and the need for more effective medication in weight management - is evident.  Current anti-obesity medications can enable weight loss beyond 5%. We need to challenge current standards of clinically relevant weight loss to achieve real improvements in weight-related complications and our patients deserve that level of intervention.

References

1.    Garvey W, Mechanick J, Brett E, et al. American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocr Pract. 2016; 22(Suppl 3):1–203.
2.    Cefalu WT, Bray GA, Home PD, et al. Advances in the Science, Treatment, and Prevention of the Disease of Obesity: Reflections From a Diabetes Care Editors' Expert Forum. Diabetes Care. 2015; 38:1567-1582.
3.    Lean M, Leslie W, Barnes A, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018; 391:541–551.
4.    Hannah WN, Jr. and Harrison SA. Effect of Weight Loss, Diet, Exercise, and Bariatric Surgery on Nonalcoholic Fatty Liver Disease. Clin Liver Dis. 2016; 20:339-350.
5.    Foster GD, Wadden TA, Vogt RA, et al. What is a reasonable weight loss? Patients' expectations and evaluations of obesity treatment outcomes. J Consult Clin Psychol. 1997; 65:79-85.

HQ21OB00117, Approval date: July 2021

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