The Six Natural Laws of Weight Gain

With all the talk of "thrifty genes" and how our "hunter-gatherer genome" is overwhelmed by the "obesogenic" environment, it may be time to revisit my favorite theories about the "Natural Laws of Weight Gain".

This is something I came up with almost 10 years ago and have used in a lot of talks over the years. I've always wanted to put these ideas into a book but somehow never got around to it.

Simply stated, my Six Natural Laws of Weight Gain are as follows:

1. Always eat when food is around
2. Always go for the gravy
3. Always eat as fast as possible
4. Always eat as much as possible
5. Don't move if you don't have to
6. When fuel runs short, turn down the furnace

If anyone is thinking, "hey, that's me", you're probably not alone (in fact it's me too!).

If you take a minute to think about it, you'll probably recognize just how deeply these Natural Laws are engrained in our biology and culture and may realize how we've actually designed much of our environment to accommodate these laws.

Suddenly terms like "mindless eating", "fast"food restaurants, "all-you-can-eat" buffets, "poutine", "super-size it" and "couch potato" take on a whole new meaning.

While through the millennia of evolution these Natural Laws guaranteed the survival of our species, in our current obesogenic environment, they also pretty much guarantee weight gain.

As I have often pointed out in my talks: "In today's obesogenic environment, people have to develop "abnormal" behaviors to avoid gaining weight".

Doing things that came "naturally" to most of us is a surefire recipe for weight gain - in today's enviroment, fighting obesity literally means going against our "nature"! No wonder it is so hard to do.

OK, I realize that by now some of you are screaming that this must be wrong, that I am grossly oversimplifying the complex psychosociobiology of obesity, and that I am just providing obese people with an easy "excuse" to blame it all on nature.

Of course I realize that in reality things are way more complex and that there are many paths that lead to obesity ranging from childhood molestation to antipsychotics or from genetic defects to endocrine abnormalities (the list of possible causes if far longer than you may think!).

Nevertheless, I do believe that perhaps with the exception of such "special causes" the Natural Laws do provide a reasonable and useful framework for thinking about the root causes of the current obesity epidemic.

So in the next couple of weeks, I will be occasionally revisiting this theme and hope to explore some of these laws and how they apply to our current dilemma.

Perhaps the title of my book should be: "The Six Natural Laws of Weight Gain and How to Break Them"!

I wish someday to actually find time to write it - I could probably have a lot of fun with this.

AMS

Dr. Kushner's Personality-Type Diet

At the recent Obesity Society meeting in New Orleans, I had a long chat with Dr. Robert Kushner, Professor of Medicine, Northwestern University Feinberg School of Medicine, Medical Director, Northwestern Memorial Hospital Wellness Institute and Past President, American Board of Nutrition Physician Specialists. He is also the incoming President of the Obesity Society (formerly NAASO).

The reason I bring this up is because I has the opportunity to listen to Dr. Kushner's ideas on "personalizing" obesity treatments. As I understand it, his point is that it is not enough to consider motivation or readiness for change. One also has to consider personalities, as no matter whether or not someone is ready or not, their personality cannot be ignored and may pose an important barrier.

This is not simply about "high achievers" or "low achievers" or "introverts and extroverts". It is more about whether or not you are a:

• Hearty Portioner or an Unguided Grazer?
• Hate-to-Move Struggler or a No-Time-to-Exercise Protester?
• Can't-Say-No Pleaser or an Emotional Stuffer?

Dr. Kushner has a whole bunch of categories (if I recall correctly there are 17 types!) that need to be considered in order to appropriately counsel for weight management. All of this comes with an elaborate personality type test that one can take (66 questions in all) on his website, which also promotes his best-selling book.

I must admit that I have neither read the book nor taken the personality test - but the idea that people's personalities must be considered when counselling on weight management intuitively makes sense.

What I'd like to see now is a study on whether or not including counseling strategies based on Dr. Kushner's personality types actually yields better long-term results than conventional approaches. Knowing Dr. Kushner, I expect that such studies are underway.

AMS

Does Exercise Help With Weight Loss?

This morning, I debated the award-winning US science journalist Gary Taubes on the CBC Sunday TV News about one of the central theses of his new book (Good Calories, Bad Calories) where he challenges the widely held view that exercise is the best way to lose weight.

Actually, Gary and I did not have much of a debate around this issue, as for years I have been telling my obese patients that exercise ALONE will seldom do it for them - weight loss requires negative energy balance, which is hard to achieve without also restricting caloric intake (we did not get into the discussion about which calories to restrict - another interesting discussion altogether).

The normal response to exercise is hunger, which if you respond to, essentially restores your energy balance back to “normal” - so don’t expect to lose weight.

Now of course, this should not be taken as an excuse to stay on the couch - the benefits of a physically active lifestyle are manifold:

• improved insulin sensitivity
• less intra-abdominal (bad) fat
• less stress
• cardiovascular fitness
• better coordination and balance
• less osteoporosis
• less dementia
• etc, etc, etc.

Just don’t expect to see massive (or even any) weight loss - you are more likely to see inches disappear from your waist (as abdominal fat is replaced by muscle and perhaps some subcutaneous fat) but the numbers on the scale will not change - will you be healthier? Most likely!

By the way, although exercise may not be the best way to lose weight - people who are more active are more likely to keep the weight off - and after all, that’s what obesity treatment is all about - if you can’t keep it off, why lose it at all?

Better still to be as physically active as you possibly can and not gain the excess weight in the first place (yes, I know that there are many active people who still put on weight - but just imagine where they would be without that activity?)

AMS

Transforming "Wait" Wise

With over 250,000 obese people living in the Capital Health Region, it should be no surprise that there is currently a waiting list of over 2000 people to be seen in the Adult Weight Management Program (as this is less than 1% of all obese people in the CH Region, I am frankly surprised the list is not far bigger!).

So perhaps it is timely that several of us from WW just spent the last two days at the first of a series of workshops called Alberta AIM (Access Improvement Measures) that should take us from an 18 month waiting list to a "same-day" appointment over the next year or so.

If anyone thinks that this is impossible, you are probably not alone in thinking so, because I am a big a sceptic myself. On the other hand, there is no question that WW could be made a lot more efficient and significantly improve not just the throughput of patients but also the quality of care (however we decide to measure it).

There is no question that much of the effort that goes into managing a waiting list (and the angry, frustrated, disappointed and frantic patients who are in it) could be channelled into better access.

In order to do this we need to look at both macro an micro factors that affect the list. I guess some of the basic questions to ask are:

• Who is waiting?
• What are they waiting for?
• Are they in the correct line?
• Can they be doing things while in the line?
• Do we even need a line?

Well, we've taken back a bit of homework from the workshop (which is just the first in a whole 18 month process of change):

We need to look at "demand", determine our "supply", and look at where we can eliminate inefficiencies that are clogging up the system.

While I may have been sceptical when I first heard I was attending this workshop, I must admit my scepticism has been tempered - in fact, I believe it is fair to say that all of us, who on behalf of WW had the opportunity to attend this workshop, have come away with a huge surge of enthusiasm and optimism that we can turn things around - we have a whole slew of interesting ideas that we will be discussing with all of you over the coming weeks and months.

This will not be a "top-down" change. The biggest (or rather the many small) changes that will really make a difference will be at the front line and will need your help and support. It is going to be a most exciting journey.

AMS

Why health professionals don't like obese clients

It is probably not news to anyone working in a health care setting that dealing with obese clients can be frustrating and at times infuriating. Why can't these people just eat less and move more? How can anyone let themselves get so large? Why can't they simply be "wise" about their weight?

Well, if you or some health professional you know has difficulty in dealing with obese clients, you are not alone. In fact you may be interested that the Obesity Society just released a new slide deck on Weight Bias in Health Care Settings.

In this new slide talk, Rebecca M. Puhl, PhD, and Kelly Brownell, PhD, present the growing body of scientific evidence which demonstrates that weight bias among healthcare professionals has serious, negative impacts on the quality of healthcare services provided to overweight and obese patients in healthcare facilities. They also discuss what providers can do to reduce any bias which they may have in their practice.

This is why we are keen to develop a CH-wide sensitivity training intiative, spearheaded by the WW program, to ensure that no obese client experiences weight-bias or discrimination in the CH region.

AMS

Why I don't like BMI

I often get asked to explain or define the term "obesity". This is when, as a clinician, I am reminded that the conventional BMI-based definition of obesity is problematic.

To be fair, the concept of BMI has been most useful for population studies and there is no doubt that it reasonably reflects average body fat in a given group of people.

Yes, on average someone with a BMI of 30 will probably have more body fat than someone with a BMI of 25, but does this mean that everyone with a BMI of 30 needs obesity treatment and everyone with a BMI of 25 is safe? The diplomatic answer of course is "it depends"!

"Depends on what?" you may ask. Well, it depends on whether or not a) the higher BMI actually reflects more body fat in that individual and b) the person with the BMI of 30 actually needs treatment.

So the question really comes down to - does a given BMI level help me decide who needs obesity treatment? Well, most clinicians will probably agree that taken alone it doesn't. You probably also need to know the age, gender, ethnic background, waist circumference, family history, current complaints (if any) and risk factor profile to decide who needs obesity treatment.

For example, a young pre-menopausal Caucasian woman, physically active, healthy diet, no risk factors with a BMI of 30 may be safe, whereas a 50 year old South Asian male with elevated triglycerides, hypertension, waist circumference of 95 cms, family history of premature heart disease and BMI of 25 may in fact significantly benefit from losing a few pounds (and keeping them off!).

Well, that is not what the current guidelines or regulators tell me - according to them, our BMI 30 lady has "obesity" and would thus qualify for obesity treatment; our BMI 25 male is not obese and would not qualify - nonsense!

So what is obesity? My rather simple clinical definition is the following:

Obesity is that level of excess fat that threatens or affects someones socioeconomic, mental or physical health - obviously, the level of excess fat that does that will vary from individual to individual depending on their "global risk".

In fact, even with other risk factors such as dyslipidemia, diabetes or hypertension, we have now moved towards "global risk" where we factor in age, gender, co-existing disease, past history, etc. If this makes sense for dysplipidemia, diabetes or hypertension, why not adopt the same strategy for excess fat? - too complex for the busy practitioner?

Well, who said medical decision making has to be easy?

AMS

Moving obesity care into the community

With over 250,000 obese people in the region, there is no way that specialists or tertiary care centres like the Adult Weight Management Clinic at the Royal Alexandra Hospital can even begin having an impact on reducing the burden of obesity in the region - there is no question that much of obesity treatment has to happen in the primary care networks and community classes and take full advantage of whatever resources there are for this in the community.

As with all chronic diseases, empowering patients to help themselves requires teaching them the insights and skills to deal with their condition. They also need to be aware of the realistic treatment options in order to make informed choices on what treatments work and how to distinguish weight-loss scams from professional help. This is a huge challenge!

Not only will we need to educate our patients but we also have to educate our health professionals to better understand obesity and teach them how to approach it with the same knowledge base, understanding, compassion and attention that they pay to other chronic conditions. Without a concerted effort at all levels of care, we are not going to provide obesity treatments to a meaningful proportion of the population struggling with excess body weight.

In the end, whether or not we can provide effective obesity treatments in the community will make or break the WW program. Not only do I not see an alternative, but fortunately, I am also confident that it can be done - the sooner we move on this the better.

Obviously, while we think about how to provide better obesity treatments, we should by no means ignore the very urgent task of preventing further spread of this epidemic. This will require both changes in individual behaviours but also massive and profound changes in the current "obesogenic" environment.

Using the analogy of water-borne communicable diseases: yes, we need to get more people washing their hands but we also need to ensure a clean water supply and a functional sewage system.

AMS

Homeostatic Hyperphagic Obesity

Recently I had the pleasure of enjoying a 2 hr walk-'n'-talk with John Blundell (perhaps known to many of you as the ingestive behaviour "guru" from Leeds). He talked to me a lot about his research and how his group had developed a series of tools that would help distinguish "homeostatic" from "hedonistic" eating.

I must admit, that although the concepts were intuitively familiar to me, I had not thought about these issues in such clear terms.

The basic idea is as follows:

There are essentially two different kinds of eating:

1) homeostatic eating - regulated by "hunger" and "satiety"

and

2) hedonistic eating - regulated by "appetite" and "reward"

Let me give you examples:

When you skip breakfast, have a small salad for lunch, and then arrive home "starving" and barely make it to the refrigerator in time to polish off last night's leftover pizza, before going on to eating everything else in sight before that comfortable feeling of "fullness" (read: "satiety") sets in, then you have just experienced "homeostatic" eating - you ate because you were "starving" and rapidly eating large amounts of (junk?) food is nothing but the normal response to being hungry.

On the other hand, when you've just had a three-course lunch and return to your desk only to find that the work you left lying around is still waiting for you as a result of which you suddenly feel the urge to open the secret drawer and finish the bag of chocolates - that is "hedonistic" eating - you ate because of the "pleasure" (read: "reward") that comes from eating a bag of chocolates - this has nothing to do with hunger or energy regulation.

Why is the difference important? Well for one, we know that there are different molecules and receptors responsible for "hunger" and "satiety" than there are for "appetite" and "reward". These systems are in fact so different that the therapeutic approaches to deal with "homeostatic" vs. "hedonistic" eating are bound to be different (will save my thoughts on this for another day).

In any case, the bottom line is that we probably need to actually figure out why a given individual is "hyperphagic" (i.e. eating too much) in order to provide the proper counseling and treatment. Simply put, the solution for "homeostatic" eating may be to correct the eating pattern, thereby avoiding hunger; the solution for "hedonistic" eating may be to develop coping strategies that will help "apease" the reward system without calories - very different approaches indeed.

Well, in real-life things are of course far more complex - most people (like myself?) are probably both "homeostatic" and "hedonistic" eaters - more of one or the other depending on your day.

OK, so who said real-life has to be simple?

In any case, I can't wait to try out John Blundell's "hedonistic tool-box"!

AMS

Weight Wise Integration Tool

OK, the challenge is: can we create a simple tool that will allow busy primary care docs (and non-obesity specialists) to screen for and address obesity management issues in their patients?

The keywords in the last sentence are "simple" and "busy"! No point having a tool that takes 30 mins to work through - let's remember, the average PCP-patient encounter is presumably less than 10 mins.

So what would be a reasonable start? Well for one, it may be worth posing the question of whether or not this patient actually needs obesity management:

Is excess weight currently threatening or affecting this patient’s socioeconomic, mental and/or physical health?

1) Not threatening or affecting
2) Somewhat threatening or affecting
3) Quite threatening or affecting
4) Very much threatening or affecting
5) Definitely threatening or affecting

My guess is that if the answers are 1 or 2, then obesity management should be put on the backburner - monitor weight, counsel on avoiding weight gain, healthy eating, activity, etc. If the answers are 3-5, definitely need to consider addressing obesity management and move to the next question:

Does this patient present barriers to weight management?

1) Insurmountable barriers
2) Strong barriers
3) Moderate barriers
4) Minimal barriers
5) No barriers

I'd assume if the answers are 1 or 2 that this may not be the best time to begin thinking about weight management; if the answer is 3 one needs to see if the barrier can be overcome, if the answer is 4 or 5, well looks like there is no excuse to not start by asking the next question:

Is this patient ready to address excess weight?

1) Not thinking about change, resigned or in denial (Pre-contemplation)
2) Weighing benefits and costs of proposed change (Contemplation)
3) Experimenting with small changes (Preparation)
4) Taking definitive action to change (Action)
5) Maintaining new behavior over time (Maintenance)
6) Experiencing relapse (Relapse)

This one is pretty much based on the Prochaska and diClemente's Transtheoretical "Stages of Change Model" - I like the stage by stage intervention strategies suggested on the UCLA Nutrition site (and undoubtedly countless other sites):

Pre-contemplation:
- Validate lack of readiness
- Clarify: decision is theirs
- Encourage re-evaluation of current behavior
- Encourage self-exploration, not action
- Explain and personalize the risk

Contemplation:
- Validate lack of readiness
- Clarify: decision is theirs
- Encourage evaluation of pros and cons of behavior change
- Identify and promote new, positive outcome expectations

Preparation:
- Identify and assist in problem solving re: barriers
- Help patient identify social support
- Verify that patient has underlying skills for behavior change
- Encourage small initial steps

Action:
- Focus on restructuring cues and social support
- Bolster self-efficacy for dealing with barriers
- Combat feelings of loss and reiterate long-term benefits

Maintenance:
- Plan for follow-up support
- Reinforce internal rewards
- Discuss coping with relapse

Relapse:
- Evaluate trigger for relapse
- Reassess motivation and barriers
- Plan stronger coping strategies

All of this can probably be evaluated and addressed in a couple of mins - if not - it's unlikely to be practical for the busy family doc.

AMS

WW Orientation Workshop

If my information is currect, there are currently over 2000 people waiting to be assessed in the Adult Weight Management Clinic!

Talking to the folks in the clinic made it quite evident that many of these patients, when they finally get an appointment, are not quite sure what to expect. Many realise that this is not exactly what they want, or the assessing staff quickly finds out that these patients have a lot of other issues that may need to be sorted out first before there is a realistic chance of tackling their obesity.

It is clear that having some form of Orientation Session that will inform potential patients about what the WW program can and cannot offer, what the treatment options are and how much commitment it will take to succesfully conquer their obesity (remember we are dealing with a life-long chronic disease), may help reduce the disappointments and frustrations.

Plans on how best to run these sessions and how best to provide relevant information on the scope of the WW program are currently under development - thanks to everyone who's involved in this! - appreciate any suggestions in this regard.

Happy Thanksgiving everyone,

AMS

New Faculty Orientation

Today was "New Faculty Orientation" day for the Dept of Medicine. Most informative - tons of info - but very useful (though slightly overwhelming). Again, amazed by the friendliness, enthusiasm and the great "can-do" attitude of the folks here in Edmonton.

How does this impact my role as WW-MD? Well, for one, I learnt about the importance of job descriptions and the significance of matching those to my performance review - just double-checked my contract - turns out I have 30% admin in my contract - right now feels like 100% admin - but guess what, I am having a ball!

Every meeting I've been to so far (first one this morning was at 7 - hey, its starting to get CHILLY that early in the morning!) have been helpful and I've come out of every single one of them with the feeling that we are moving things forward - again - great team, great inputs, great enthusiasm!

Thanks everyone - apologies to anyone who thinks today's post is a bit "cheesy" - must be getting soft!

AMS

WiKi Wise

Some of you may be wondering why I would have started this blog in the first place - perhaps unusual for a new director of a healthcare program to want to share my thoughts and seek input from all of you at Weight Wise plus anyone from the general public who should care to comment.

Well - the reason is that I am true "believer" in peer production or "peering". As most of you know, I am also the Director of the Canadian Obesity Network. However, what most of you perhaps don't know is that back in 2005, the entire Network application was written on a "WiKi", created just for the purpose of writing the 30 page grant in less than six weeks! Using an open source WiKi seemed to me quite simply the most sensible way of preparing an application with 120 co-applicants - just imagine the chaos, had we tried to e-mail around various versions of the word document, trying to figure out which version was the latest. To my knowledge this was the first grant application (at least in Canada) to ever have been written using a WiKi.

Those of you who know of Wikipedia, probably appreciate the power of WiKis - but that is just the start - today, WiKis are used by 100s of small and large companies to work collaboratively both within as well as outside the company - and the reason for this is quite simply economic gain - this concept has even spawned the term "Wikinomics" (a must read by Tapscott and Willams!).

The basic idea is that thanks to the internet, the production of goods and services today has become a collaborative activity in which a virtually unlimited number of individuals can participate. Properly implemented, this technology can unlock innovative potential and resources both within and outside an organisation.

The ability fo integrate talents of countless individuals and allow them to participate has been also referred to as Web 2.0. In succesful companies today, employees have an unprecedented knowledge about their firm's strategy, management and challenges - and an unprecendented opportunity to contribute their unique ideas and expertise to their solution. In the end, radical sharing and openness is a win-win for everyone.

"Today", in the words of Tapscott and Williams, "openess, peering, sharing, and acting globally - defines how 21st century corporations compete - very different from the hierarchical, closed, secretive and insular [mentality] that dominated the previous century. The old, harwired "plan and push" mentality is rapidly giving way to a new dynamic "engage and cocreate" economy".

For Weight Wise to become a global leader, this is the kind of philosophy I am keen to adopt.

After only four weeks with Capital Health, I can only be amazed by the enthusiasm, dedication and excitement of the almost 60-70 people who directly or indirectly make up the Weight Wise team (I still don't know quite how many are actually involved). The range of expertise is mind-boggling - a shame not to use every last bit of it to build a truly world class beacon of obesity prevention and care.

Those of you watching us closely will rapidly see an implementation of a variety of Web 2.0 tools that will foster openness, collaboration, information and "participaction". We will have both open and closed systems - all of you will be asked to provide input. There are a number of web-based platforms that allow this type of interaction - I am particularly looking at Socialtext - currently the world leader in open-source WiKi-based collaboration and project management software platforms - but there are others.

In the end, whatever platform we decide to use, all that matters is that all of you can contribute and take true ownership of Weight Wise. Remember, we are up against the biggest chronic disease epidemic ever experienced by mankind - we can certainly use every mind and bright idea that we can muster, if we are to stand a chance in providing prevention and treatments to 100s of 1000s of individuals struggling with overweight and obesity - this blog is only the start of the level of interaction that I seek to implement - look out for more to come.

AMS