Germany Wakes up to Obesity

As elsewhere in Europe, obesity is on the rise in Germany. According to government statistics, two-thirds of all German men between the ages of 18 and 80 are overweight and almost half of all women have a weight problem. These numbers add up to about 37 million adults and 2 million children and teenagers suffering from some kind of weight related disorders.

In response, the German government has now embarked on a new obesity initiative prepared by Health Minister Ulla Schmidt in cooperation with Food, Agriculture and Consumer Protection Minister Horst Seehofer. The program's initiative is to cut diseases related to obesity drastically by the year 2020, and foresees spending 30 million euros ($46.7 million) over the next two years.

As everywhere else, in Germany too, the government recognizes that the epidemic is not only a result of poor nutritional habits and lack of exercise but also wide-ranging societal and infrastructural factors. It therefore calls on politicians, scientists, health-care providers, unions and the food industry to help educate and promote healthier lifestyle approaches. As one may guess the ideas include: education on healthy eating and physical activity, tougher standards on school food programs, better product labeling by the food industry, reduced advertising by the makers of sweets and junk food that target children, i.e. essentially the usual list of initiatives.

As everywhere else, in Germany too, the government largely ignores one major consequences of the fact that 37 Million Germans are already living with this chronic disease, namely that this also calls for an immediate need to provide improved access to evidence-based obesity treatments with expansion of the resources to do so.

As in most other countries (the UK being a remarkable exception), access to professional obesity treatment that includes behavioural therapy, anti-obesity medications and surgery remains limited to a ridiculously small number of individuals, mostly those who can afford "private" payments for these services.

As I have blogged before - promoting obesity prevention (and hoping for these to kick in) should not be an excuse to deny obesity treatments to those already affected by this condition.

AMS
Edmonton, Alberta

p.s. incidentally, my blog is now also available in German

Image Rainer Zenz

Does Metabolic Syndrome Predict Heart Disease?

Metabolic syndrome or syndrom X (recently refered to as Xyndrome) is the combination of abdominal obesity, high trigylcerides, low HDL cholesterol, high blood pressure and elevated levels of fasting blood glucose. This concept has been widely promoted as helping to clinically identify individuals at increased risk for heart disease.

While the concept appears intuitively sound (as all five components of this syndrome have been individually associated with increased cardiovascular risk), there is a continuing debate on whether the concept of this "syndrome" is any better in identifying individuals at risk for heart disease than looking at each individual risk factor on its own.

To address the issue of whether or not the "metabolic syndrome" is indeed a risk factor for heart disease, Naveed Sattar and colleagues from University of Glasgow examined the relationship between the metabolic syndrome and incident cardiovascular disease and type 2 diabetes in in 4812 non-diabetic individuals aged 70-82 years from the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). They corroborated these data in a second prospective study (the British Regional Heart Study [BRHS]) of 2737 non-diabetic men aged 60-79 years. (The Lancet)

In PROSPER, metabolic syndrome was not associated with increased risk of cardiovascular disease over 3.2 years but was associated with a 4-fold increased risk of diabetes. In contrast elevated fasting glucose alone was associated with an 18-fold increased risk for diabetes.

Likewise, in BRHS, metabolic syndrome was only modestly associated with incident cardiovascular disease despite a strong association with diabetes.

Importantly, in both studies, body-mass index or waist circumference, triglyceride, and glucose cutoff points were also not associated with risk of cardiovascular disease, but all five components were associated with risk of new-onset diabetes.

The authors conclude that while metabolic syndrome and its components are associated with type 2 diabetes, they only have a weak to no association with vascular risk in elderly individuals. Their recommendation is that the clinical focus should remain on establishing optimum risk algorithms for each individual risk factor rather than lumping them together as a putative "syndrome".

Obviously, one could argue that there may still be some use for the concept of the metabolic syndrome in younger individuals, but, as discussed in this paper, the same group (and others) have also not found the metabolic syndrome to be a strong predictor of heart disease in younger individuals.

Irrespective of whether or not the concept of the metabolic syndrome is helpful, it should be remembered that obesity treatment is the only intervention that can simultaneously have beneficial effects on all five components of this syndrome. Thus, while conventional care continues to aggressively target the individual risk factors, only aggressive obesity treatment will indeed improve all features of this putative syndrome.

Unfortunately, with the exception of obesity surgery, we still lack outcome studies confirming that obesity treatment will indeed decrease cardiovascular mortality.

Remember, the assumption that losing weight (without surgery) will save lives is not based on hard evidence from randomised controlled trials. My guess is that till we have better data on this issue, physicians, payers and policy makers will continue to question the benefits of tackling obesity with the same resources and enthusiasm as for other chronic diseases.

AMS
Edmonton, Alberta

Trendz in Cafeteria Food

Yesterday I had lunch at the Cafeteria of the Glenrose Rehabilitation Hospital just across the street from my office at the Royal Alexandra Hospital.

The cafeteria is built on Capital Health's own Healthy Choice Trendz(TM) philosophy that includes a Bistro concept that makes the healthy choice the easy choice. Not only is there no sign of a deep fryer (a rarity for North America) but one really has to look for the unhealthy stuff on the menu.

The standard meat servings are smaller and the plate comes heaped with stir fried vegetables (no oil!) and roast potatoes. Soups come in low-sodium versions, there are even low-fat biscotti, and all breads are whole-grain by default.

Finally, at the coffee outlet, you have a choice of skimmed and 2% milk - cream you have to ask for.

Yes there are some unhealthy choices like pop but the water and juices are up front - the pop you have to actually bend over to pick up.

No problem getting a healthy lunch there - of course, if you try hard, you can find the stuff that it's better to avoid - but they sure don't make it easy on you.

Obviously, Capital Health, which developed and is currently establishing the healthy Trendz concept in all of its food outlets, is not only proud of the concept but has assured me that they have even found that offering healthy choices is profitable.

Hopefully the role-out across the region and beyond will not take too long.

AMS
Edmonton, Alberta

p.s the picture is not of the actual food I got, but it certainly comes close

Don't Spare the Protein

To anyone trying to lose weight, avoiding the virtually obligatory reduction in lean body mass is always a challenge. Not only does "offloading" as the body gets lighter reduce the actual "weight-bearing" work resulting in loss of muscle mass, but also the fact that most dietary recommendations tend to also reduce protein intake to maintain a "balanced" diet can promote a protein catabolic state.

As skeletal muscle is a major determinant of energy expenditure, losing muscle mass eventually limits the amount of weight that can be lost at any given caloric deficit, resulting in an early plateau. Furthermore, as lost lean body mass tends to be replaced with fat during weight regain (catch-up fat), you end up with a greater fat mass than before your diet.

The importance of maintaining protein intake during diet-induced weight loss was again illustrated in a recent study by Melanie Bopp and colleagues from Wake Forest University School of Medicine, Winston-Salem, NC, published in the Journal of the American Dietetic Association.

The authors investigated the association between dietary protein intake and loss of lean mass during weight loss in postmenopausal women through a retrospective analysis of a 20-week randomized, controlled diet and exercise intervention in women aged 50 to 70 years. Weight loss was achieved by differing levels of caloric restriction and exercise. The diet-only group reduced caloric intake by 2,800 kcal/week, and the exercise groups reduced caloric intake by 2,400 kcal/week and expended approximately 400 kcal/week through aerobic exercise.

Lean mass was measured using DEXA. Average weight loss was 10.8+/-4.0 kg, with an average of 32% of total weight lost as lean mass. While protein intake averaged 0.62 g/kg body weight/day (range=0.47 to 0.8 g/kg body weight/day), participants who consumed higher amounts of dietary protein lost less lean mass. These associations remained significant after adjusting for intervention group and body size.

The authors conclude that inadequate protein intake during caloric restriction may be associated with adverse body-composition changes in postmenopausal women.

I would dare to add that the same is probably true for anyone undergoing a dietary weight loss intervention that does not maintain adequate protein intake.

AMS
Edmonton, Alberta

Count Those Liquid Calories!

Yesterday, the Edmonton Sun did a full-page feature on me because they find it kind of special that I ride my bike to work (guess it is special in car-loving Alberta).

Of course the article also includes the obligatory Dr. Sharma's tips which starts off with Tip #1: beware of liquid calories like in juices, pop or alcohol - at least, count them as part of your meal, as they can quickly add up.

Almost on cue, the Consumer Federation of America (CFA), in attempting to fill the void in consumer information on liquid calories, yesterday released Alcohol Facts, a side-by-side comparison of the alcohol, calorie and carbohydrate content per serving of the top 26 domestic and imported alcoholic beverage brands sold in the US.

Alcohol Facts reveals significant differences in the amount of calories and carbohydrates for beer, wine and distilled spirits both by category and by brand.

* Among spirits, calories per serving ranged from 86 calories for spiced rum to 120 calories for gin. The average (not including mixers) was 98 calories per serving;

* For wines, calories per serving ranged from 105 calories for a merlot to 125 calories for a cabernet sauvignon. The average was 118 calories per serving;

* The greatest variation in calories occurred among beers and flavored malt beverages. Light beers (5 brands) averaged 100 calories per serving, regular beers averaged 140 calories (5 brands) per serving, and the flavored malt beverages (3 brands) ranged from 190 calories per serving to 241 calories per serving; 

* Variations were greatest when analyzing carbohydrate levels. Compared to no carbohydrates in spirits, wines ranged from 0.8 grams per serving for chardonnay to 5.0 grams per serving for cabernet sauvignon. Among different beers and malt beverages, carbohydrates ranged from 3.2 grams per serving for light beer to 38 grams per serving for a flavored malt beverage.

The CFA is strong on promoting caloric labeling on alcoholic beverages, which till now only contain the alcohol in %. (to calculate the calories, you'd first have to calculate the grams alcohol per serving, multiply by 7 and then you are still missing the calories from carbs - so calculating the calories for alcoholic beverages for consumers is virtually impossible!)

From my own practice I can only confirm that it is not that unusual to find patients regularly consuming over half their caloric needs in fluids, including alcohol.

Putting calories on alcohol bottles may not stop people from drinking, but at least it allows them to count those calories in their daily allowance.

Happy Canada Day!

AMS
Edmonton, Alberta

Sarcopenic Obesity and Cancer

We know now (although many still do not fully appreciate this) that obesity is a major risk factor for cancers. On the other hand in patients with many chronic diseases, larger patients tend to do better and live longer (the obesity survival paradox).

Last week researchers from the University of Alberta published a study in The Lancet Oncology, that adds another level of complexity to the relationship between obesity and cancer survival. Clarisse MirandaPrado together with other researchers from the UofA, including cancer cachexia researchers Vickie Baracos, studied 2115 patients with solid tumours of the respiratory or gastrointestinal tract, 325 (15%) of who were classified as obese (body-mass index [BMI] >/=30).

With the help of CT images, the researchers found that obese patients had a wide range of muscle mass, with 15% of analysed obese patients meeting criteria for "sarcopenic" obesity (sarcopenia is the medical term for low-muscle mass). By definition, sarcopenic obese patients have more body fat and less lean body mass than non-sarcopenic patients of similar weight.

Not only was sarcopenic obesity associated with poorer functional status compared with non-sarcopenic obese patients but these patients also had a 4-fold hgher risk of dying.

Incidentally, the researchers also used their data to calculate that using conventional dosing criteria for cytotoxic chemotherapeutic drugs, sarcopenic obese patients may be overdosed with a greater likelihood of toxicity.

Overall this study shows that obesity is never just obesity and that BMI in the clinic is a fairly useless concept (a point that I have argued before) and that without proper assessments of body composition rational management of large patients is just not possible.

A patient's size alone proves little in term of health or disease - remember, weight alone is a rather poor measure of health.

AMS
Edmonton, Alberta

What's With the Guys?

So to finish this week on men's health let me pose a question:

According to the new numbers from the Canadian Community Health Survey released last week, men aged 25 to 44 were considerably more likely than their female counterparts to be obese. Even in the age group 45 to 64, men were slightly more obese than women.

So clearly, at least as many men as women should be worried about their weight and seeking help - especially since men, due to their greater likelihood to gain abdominal fat, are at much higher risk for weight-related diabetes and heart disease.

But when you look at any obesity program (including ours), the women seeking help by far outnumber the guys (probably by 4 to 1, if not more).

So the question is - how do you get the guys to realize that their increased weight is putting them at risk and that it is they rather than the women, who should be seeking help.

Any suggestions from my readers out there on how to increase "obesity-risk-awareness" amongst men would be most welcome.

I look forward to your thoughts on this,

AMS
Edmonton, Alberta