The document discusses the contrasting definitions of success and failure in obesity care between healthcare professionals and patients, highlighting how traditional metrics largely focus on weight loss rather than broader health outcomes. It emphasizes the need for alignment in understanding these definitions to improve treatment and patient satisfaction, while also advocating for a shift towards chronic management of obesity as a disease. Ultimately, it argues that success should encompass a variety of health and quality of life measures, rather than solely body weight targets.

1. THINKING ABOUT
SUCCESS AND FAILURE
IN OBESITY CARE
Jacqueline Jacques ND

2. What’s in a word?
Success: Having a favorable or desired outcome
Failure: A person or thing that is unsuccessful or
disappointing
These are very powerful words!

3. We have a lot of expectations….
•Most people entering a medical or surgical weight
management program have lost and regained weight
before
• The expectation is that weight loss is hard and that they are
likely to regain weight
• May people already identify as failures
•Health professionals may also already have a high
expectation of failure for their patients

4. There is also the matter of perspective…

5. What outcomes are doctors looking at?
•Weight loss?
• Patient expectation?
• Comorbidity resolution
•Quality of life
• Psycho social improvements
•Resolution of serious complications

6. At what level are we assessing?
Who or what succeeds or fails?
• The individual
• Most common
• A procedure or treatment
•A group of patients
• The practice or program
•A health care system
• Society

7. Do you and your doctor think about success and
failure the same way?
•How do you think about
success?
• How does this inform your
decision making
•Do you know how your
doctor defines success?
•Which one is more
important to you?
•Do you agree?

8. Common ground?
• Health professionals tend to be very focused on the
patient, the treatment and “hard” outcomes:
• Labs
• History of disease
• Findings on examination
• Individuals seeking care might care about these things,
but they might also care about other things more:
• Feelings/emotions
• Lifestyle, quality of life
• Functioning
• Personal expectation
• Cosmetic appearance

9. What do you want to lose?
Of course people want to lose weight, but
it’s not everything!

10. Do we even agree on
how we talk about
weight loss?

11. According to NIH
“The amount of weight lost should not be
the primary gauge for successful obesity
treatment.”
NIH Pub #00-4084
But while medical thinking may be shifting towards
improvements in health and reduction of
comorbidity – do doctors and patients agree?

12. Successful Bariatric Surgery Outcomes

13. Successful Bariatric Surgery Outcomes (2)
The interpretation is that anything less than 50% EWL
= failure (of the patient or the procedure or both).
This criteria is used in almost 70% of published surgery
papers – and in NO non-surgical studies.

14. What is success in weight management?
• Traditionally – reaching an ideal weight as defined by
the Metropolitan Life Insurance height-weight charts
•More recently:
• Since 1995, a 10% reduction in total body weight has been
suggested as a target for success (based on health
improvements)
•Weight loss in the range of 5-10% has been shown to
significantly reduce comorbid conditions despite final weight.

15. What is success in weight management?
• FDA criteria for new drugs:
• In general, a product can be considered effective for
weight management if after 1 year of treatment
either of the following occurs:
• The difference in mean weight loss between the active-product
and placebo-treated groups is at least 5% and the
difference is statistically significant
• The proportion of subjects who lose greater than or equal to 5
percent of baseline body weight in the active-product group is
at least 35 percent, is approximately double the proportion in
the placebo-treated group, and the difference between
groups is statistically significant

16. From the AND
Goals of weight management
interventions may include:
• Prevention of weight gain or
stopping weight gain in an
individual who has been seeing a
steady increase in his or her
weight;
• Varying degrees of improvements
in physical and emotional health;
• Small maintainable weight losses
or more extensive weight losses
achieved through modified eating
and exercise behaviors; and
• Improvements in eating, exercise,
and other behaviors.

17. Do patients think this is successful?
• Poston et al found that patients who experienced 10%
weight loss after a 4 month clinical program were
disappointed and did not feel successful (Am Fam
Phys, 2000)
• Foster et al found that a group of 400 women
starting a weight management program defined
success as an average 38% reduction in total
bodyweight
• They called 25% “acceptable” and 16% “disappointing”
How would you feel about 10%
weight loss?

18. SOS – 10-Year Outcomes

19. Pharmacotherapy

20. Pharmacotherapy

21. Lifestyle Modification
• Comprehensive medical or commercial diet programs
lasting for about 6 months result in mean weight
losses of 15–25 lb. or about 9% of initial body weight
and are associated with a drop-out rate of 15–20%
• Less intensive programs have lesser results
• Studies indicate that weight regain in the first year
after treatment is about 30–35%. Behavioral therapy
delays weight regain, but 3–5 years later, at least 50%
of participants have returned to their initial weight or
more

22. How do we
manage this?
There appears to
be a real and
substantial mis-match
between
what medicine is
starting to define
as success and
what individuals
being treated think
is successful

23. What measurements
should we use for
success and failure?

24. Success can be thought of this way
A balance between
clear expectations
and reality

25. How should we define it?
•Measures:
• Actual weight loss – this always favors heavier patients (they
typically lose more)
• Excess weight loss always favors lighter patients (easiest to
reach 100% EWL is to be as close as possible to a BMI of 25 and
just lose a little weight)
• Percent Weight Loss – this is really the standard and is what is
accepted in the non-surgical world

26. How should we define it?
•BMI? – From a population standpoint we have
evidence that BMI 25 plus or minus a bit is linked to
better health outcomes – but varies much more at
the level of the individual
• Ideally – we want a weight loss that delivers optimal
health outcomes

27. How about failure?
•We have to have a definition of failure that is
actionable
• In surgery – if we use our current definition of EWL
more than half of surgeries are failures (and almost
all non-surgical treatment would be failure)
• If we use medical criteria:
•Weight gain or inadequate weight loss at 2-3 years
• Less than 25% EWL
• Or a loss of less than 10% if initial body weight
• 90% of surgical patients should be able to be successful based
on this!

28. Failure in surgery can also be:
• Primary failure – Never losing weight (non-response)
• Secondary failure – A significant regain of weight
after an acceptable weight loss, with a decline in
health
• Complications of the procedure that are not
manageable or are harmful to the patient
•When a surgery/procedure produces a substantial
decrease in quality of life
• Failure of a practice or program?
• High complication rates
• High loss to follow up

29. Moving to a Chronic
Care Model

30. Acute or chronic?
•How do doctors think about obesity in health care?
•We FINALLY think of it as disease (at least we
should…)
•We mostly treat it like an acute disease
• Expectation is that weight will come off and not return
• If weight returns patients still get blamed most of the time
• Or we blame the treatment
• Or both…

32. Goal of Chronic Disease Management
• Engage between doctor and patient to achieve care
goals that are agreed upon
•Optimize quality of life (QOL)
•Optimize healthy functionioning
•Reduce morbidity and mortality
•Minimize adverse events related to treatment
• Provide evidence-based improvement in health
“The right thing with the right patient
at the right time”

33. We have a long way to go
• In obesity treatment:
• “Even when continued therapy is available,
attendance at maintenance sessions declines over
time, and once treatment is ended, individuals regain
weight.”
• WADDEN, TA, et al. Journal of consulting and clinical psychology 62.1 (1994): 165-
171.
• Individuals have to stay in treatment or return to
treatment to have the best outcomes.
•We have NO treatment that CURES obesity

34. Set targets and measure progress
•Weight loss – yes
•But also:
• Comorbidity/health measures
• QOL
• Psychosocial change and function
• Complications
• Is more always better?

35. Best Weight = Whatever weight you
can reach while living the healthiest
life you can honestly enjoy.
~ Freedhoff and Sharma

36. In the end, we have to
remember that any
definition of success or
failure is arbitrary

38. THANK YOU!