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Wednesday, December 19, 2007

Fat Free Media?

A couple of days ago I was interviewed by Judith Timson, a columnist for the Globe & Mail, who wanted to know if all the talk about obesity in the media was actually helping anyone. You can read her take on this here.

So Judith is going to go on an Obesity Media Diet - i.e. she is not going to read any more media reports on obesity.

While that may or may not help Judith, she does raise a couple of important points in her column:

1) Bombarding the public daily with supposedly new findings on obesity is probably not helpful - only adds to the noise, confusion and fatigue (a la Yellow/Amber/Red Alert! In the end who cares?)

2) Let's make sure that we don't throw out the baby with the bathwater - the problem is not simply excess weight and not everyone with a couple of extra pounds is "obese" or needs "obesity treatment". (You need more than a scale or tape measure to diagnose obesity).

3) Let's not underestimate the negative effect that "healthy-weight" messaging may have on eating and exercise behaviour - if you are looking for "cosmetic" weight loss - you need help with your self esteem and body image - not help with losing weight!

Great points - very much part of a healthy discussion.

I of course will continue reading new stuff on obesity - after all, what could be more interesting?


Tuesday, December 18, 2007

What do Patients Expect of Bariatric Surgery - Too Much or Not Enough?

There is no question that with improved results, patients and physicians are beginning to look at bariatric surgery as a realistic and definitive option for the treatment of morbid obesity.

However, do even well-informed patients have the right expectations? This issue was recently addressed by Andrea Bauchowitz and colleagues from the University of Virginia, who examined weight loss expectations of 217 consecutive preoperative patients.

It turns out that over two-thirds of patients (65%) had misconceptions about the amount of weight they would lose after surgery. On average, patients thought that they would lose around 80% of excess weight, when in fact a good response to surgery is probably anything greater than 50% of excess weight.

Almost one-third of patients did not look at surgery as a tool to help make dietary changes and increase physical activity - rather, they thought that surgery would merely prevent overeating.

There were likewise misconceptions regarding length of hospital stay and the importance of post-surgical depression.

Overall, the results of this study show that many patients have misconceptions about the amount of weight loss they can expect from surgery and do not appreciate the need for lifestyle changes after surgery.

Therefore, implementing a thorough patient education program that fosters adequate knowledge about the nutritional and behavioural aspects of surgery as well as the amount of weight loss to be expected may be an important part of preparing patients for surgery.

A previous paper by Bauchowitz, where she examined how bariatric programs evaluate and interpret the psychosocial situation of patients with regard to surgery is available online (click here for full-text). While this study does not tell us whether centres which demand more of their patients have better outcomes, it does provide a list of common practices and things to think about when preparing patients for surgery.


Monday, December 17, 2007

Caps off to CABPS

It is now widely agreed that looking after obese patients is far more sophisticated than simply advising patients to "eat less and move more".

In fact, the field of bariatrics is rapidly growing into an entity of its own, not just with regard to bariatric surgery but also with regard to bariatric medicine, bariatric nursing, bariatric psychology, bariatric nutrition and other relevant aspects of bariatric care.

It is therefore with great pleasure that I announce the launch of the Canadian Association of Bariatric Physicians and Surgeon's (CABPS) new website at

The mandate of CABPS is:

- To bring together Canadian Physicians and Surgeons with a special interest in Bariatric Medicine and Surgery in order to maintain and improve the standards of Bariatric care in Canada.

- To support both primary and continuing educational programs in Bariatric Medicine and Surgery.

- To advance knowledge in the field of Bariatric Medicine and Surgery.

- To facilitate and promote research in the field of Bariatric Medicine and Surgery.

- To develop policies and new ideas in the areas of clinical care, education, and research in Bariatric Medicine and Surgery.

- To represent the views of the Bariatric Physicians and Surgeons of Canada.

- To facilitate communication between the public, the medical community and the ministries of health at the provincial and federal level so as to promote awareness of the health risks of obesity and severe or morbid obesity, the financial and health burden to the individual and to society, and the efficacy of medical and surgical treatment options.

Membership in this organisation is open to all physicians and surgeons with an interest in bariatric care.

Membership (at reduced cost) is also open to all allied health professionals, residents and trainees working in related areas.

Membership forms can be downloaded from the site.


Tuesday, December 11, 2007

Obesity in Pre-Schoolers: Dads Matter Too!

Those of you following my blog may have noticed my concern about how maternal obesity and lifestyles seem to impact future risk of childhood obesity.

Well, apparently it's not just Mom's "fault" - Dads matter too!

Melissa Wake and colleagues from the Royal Victoria Hospital in Victoria (AUS) studied the relationships between BMI status at ages 4 to 5 years and mothers' and fathers' parenting dimensions and parenting styles.

Participants were composed of all 4983 of the 4- to 5-year-old children in wave 1 of the nationally representative Longitudinal Study of Australian Children with complete BMI and maternal parenting data.

Mothers and fathers self-reported their parenting behaviors on 3 multi-item continuous scales (warmth, control, and irritability) and were each categorized as having 1 of 4 parenting styles (authoritative, authoritarian, permissive, and disengaged) using internal warmth and control tertile cut points.

They found that while mothers' parenting behaviors and styles were not associated in any model with higher odds of children being in a heavier BMI category, higher father control scores were associated with lower odds of the child being in a higher BMI category.

Thus, compared with the reference authoritative style, children of fathers with permissive and disengaged parenting styles had higher odds of being in a higher BMI category (~30-50% greater risk depending on the statistical model).

Apparently these findings are consistent with a previous intervention study by Stein et al., which showed that fathers' but not mothers' parenting (warmth and support) predicted better maintenance of weight loss after a behavioral parenting intervention for pediatric obesity.

These authors suggest that fathers' parenting may well be an important determinant of the extent to which the family environment as a whole is supportive of children's attempts to lose weight.

Message to Dads: "Get involved - you count!"


Monday, December 10, 2007

Recommend and They will Exercise - Or will They?

A major strength of the Weight Wise program lies in our links to Community Partners, who offer all forms of exercise ranging from walking clubs to personal trainers.

The question however is - how many patients, who get exercise recommendation from their doctors (or other health professionals), will actually follow through?

This issue was recently addressed by Willams and colleagues from the Centre for Health Sciences Research, Cardiff University, UK, in a Systematic Review. The eighteen studies reviewed included six RCTs, one non-randomised controlled study, four observational studies, six process evaluations and one qualitative study. Results from five RCTs were combined in a meta-analysis. There was a statistically significant increase in the numbers of participants doing moderate exercise with a combined relative risk of 1.20 (95% confidence intervals = 1.06 to 1.35).

This means that 17 sedentary adults would need to be referred to an exercise program for one of them to become moderately active.

On one hand this may sound frustrating (imagine the time spent on advising exercise to patients), on the other hand a Numbers Needed to Treat (NNT) of 17 is actually not worse than many of our medical treatments.

Of course the obvious barriers were identified: time, cost, distance, motivation, etc. Furthermore, exercise behaviour depended upon physical capacity to exercise; exercise beliefs and other factors such as enjoyment, social support, priority setting and context.

Interestingly, in another paper, the same group identified four types of patients: ‘long-term sedentary’ who had never exercised; ‘long-term active’ who continued to exercise; ‘exercise retired’ who used to exercise, but had stopped because of their symptoms (e.g. osteoarthritis), and because they believed that exercise was damaging their joints; and ‘exercise converted’ who recently started to exercise, and preferred a gym because of the supervision and social support they received there. This article is very much worth reading and the full text can be accessed by clicking here.


Saturday, December 1, 2007

421 Pounds

Anyone interested in the trials, tribulations and catastrophic untimely death of one of my Hamilton patients, can read about her in a Special Report (4 parts) starting today in the Hamilton Spectator.

The story illustrates not just how complex treating morbid obesity really is but also demonstrates how failing to deal with obesity as a chronic disease early in its course can only lead to catastrophic outcomes. 

The fact that in the end Cheryl died soon after receiving the long-awaited by-pass surgery should not dispel the benefits to be derived from this procedure. As the story illustrates, outcomes are as (if not more) dependent on proper follow-up and the infrastructure to deal with complications (when they arise) as on finding a willing and able surgeon. 

In isolation, obesity surgery is doomed to failure. On the other hand, as part of a comprehensive program that ensures appropriate patient selection, preparation and long-term follow-up, the results are nothing short of spectacular.

As anyone who has heard me speak about the Weight Wise program should appreciate by now - obesity surgery, even when necessary, is NEVER just about surgery!