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Thursday, January 31, 2008

Obesity is Not Special

Most people either think that managing obesity is easy (just eat less and move more, Stupid!) or is extremely complicated (simply hopeless and a complete waste of time).

Fact is that managing obesity is actually not very different than managing many other chronic diseases.

Yes, we need to make the right diagnosis, yes, patients have to make lifestyle changes and yes, there are medical and even surgical treatments, but even these only work if patients are well managed in the long-term and follow the rules.

Relying on lifestyle counseling alone is probably as effective for obesity as it is for diabetes, hypertension or dyslipidemia. Medications for obesity, like medications for diabetes, hypertension or dyslipidemia, only work when you continue taking them. As with many chronic conditions, as patients get older, treatment gets more difficult.

The reasons why most physician's think that managing diabetes, dyslipidemia or hypertension is easier than treating obesity, are firstly because they have been extensively trained to treat these conditions and secondly because the treatments for these conditions are deemed more effective and better studied than treatments for obesity.

Actually, perhaps with the exception of statins for high LDL-cholesterol, the results of monotherapy for many chronic conditions like diabetes, hypertriglyceridemia or hypertension are pretty modest. Reducing HbA1c by 1% point, triglycerides by 10% or diastolic blood pressure by 5 mmHg is pretty much the average effect seen with antidiabetic, lipid-lowering or antihypertensive monotherapy - really not very impressive at all. Yes, some patients will respond better, but many will not.

Seen in that light, a 5-10% sustained weight loss with antiobesity monotherapy isn't that bad after all, given that lowering body weight may in fact be tougher than lowering blood sugars or blood pressures.

The problem with antiobesity medications is not that they don't work - the problem is that most people do not continue taking them once they stop losing weight. They are taking them for weight loss rather than for weight-loss maintenance. But even this is not that different from other chronic diseases. We know that adherence with antihypertensives, antilipids and antidiabetics is notoriously poor with few patients taking these medications for much longer than six months at a time.

As for other chronic conditions, taking an antiobesity drug for a few months just to lose weight makes absolutely no sense - the idea that something magical will then happen and the weight loss will be maintained after stopping treatment is idiotic and completely inconsistent with our current understanding of energy homeostasis.

Obesity is not special - it is simply a chronic disease which like all chronic diseases requires long-term (lifelong?) treatment.


Wednesday, January 30, 2008

Off-Loading Young Hips

It is no secret that obesity is a substantial driver of any hip and knee replacement program. Although all kinds of factors can promote degenerative joint disease, the excess weight bearing down on a given joint certainly doesn't help.

In adults, this is pretty much accepted and as there is no end to the obesity epidemic in sight, orthopedic surgeons are unlikely to be out of work anytime soon.

But now, there is increasing evidence that obesity may be driving an increase in joint problems in kids.

Slipped capital femoral epiphysis (SCFE), typically appearing around the time of the early-pubertal growth spurt in adolescents (twice as often in boys than in girls), is of growing concern.

In a recent article, Murray and Wilson from the Royal Hospital for Sick Children in Edinburg describe a 2.5-fold increase in SCFE in Scotland over the last two decades, but also that SCFE was now increasingly seen at younger ages. This increase remarkably parallels the substantial increase in childhood obesity in Scotland over this time period.

Typically patients present with a history of several weeks or months of hip or knee pain and an intermittent limp. Treatment requires surgical fixation of the femoral head to avoid further slippage.

With all the concern about increasing type 2 diabetes, dyslipidemia and hypertension in kids, let's not forget bone and joint health.

Missing the diagnosis can lead to irreversable damage with loss of function. Early recognition and surgical treatment (with or without weight loss) is essential.


Tuesday, January 29, 2008

Pass (up) the Salt

Monday (Jan 28) was the beginning of the World Salt Awareness Week.

To draw attention to this event, three National Centres of Excellence Networks got together to bestow the "Salt Lick Award" to A&W for the saltiest kids burger.

This initiative, led by the Canadian Stroke Network was both by the Advanced Food and Materials Network as well as the Canadian Obesity Network and received considerable attentions from national media.

As some of you may know, I have a special interest in this topic. In fact, much of my early research was on trying to understand why salt affects blood pressure in some people but not others.

Obesity is certainly one factor that can make you more "sensitive" to salt intake. This was elegantly demonstrated by Alberto Rocchini, who not only demonstrated this relationship in adolescents but also showed that weight loss can make them less sensitive to salt.

Clearly, there is good reason to avoid excess salt, especially if you have high blood pressure and carry around some extra weight.

Hopefully, the attention that salt receives this week will put some pressure on food producers and restaurants to do what they can to reduce salt in foods.

In the meantime be sure to pass (up) the salt.


Monday, January 28, 2008

Antipsychotics and Weight Gain

It is no secret that medications commonly used to treat psychosis can lead to remarkable weight gain. This is particularly true of the second generation antipsychotics clozapine (Leponex, Clozaril) and olanzapine (Zyprexa), but the mechanisms leading to weight gain are poorly understood.

In a recent study Kluge and colleagues from the Max Planck Institute of Psychiatry in Munich, ramdomised 30 patients with schizophrenia, schizophreniform, or schizoaffective disorder in a double-blind, parallel study comparing abnormal eating behavior using a standardized scale to clozapine and olanzapine.

In both treatment groups, there was a significant increase in cravings and in binge eating, whereby the rate of these effects was somewhat higher with olanzepine. Clinical improvements in psychiatric symptoms was comparable.

What the study does not disclose is what one could possibly do to help patients avoid weight gain. The evidence that "lifestyle" interventions are effective in preventing this weight gain is marginal at best. A recent randomized study published in JAMA showed some benefit of prescribing metformin alone or in combination with lifestyle advice.

An earlier double-blind placebo-controlled study in 37 patients on olanzepine showed greater weight loss with sibutramine (Meridia, Reductil) over 12 weeks than on lifestyle alone.

Amantadine, in an even smaller randomised placebo-controlled study in 21 patients, was at least somewhat effective in limiting olanzapine-induced weight gain.

Clearly, addressing weight gain in patients, who need effective antipsychotic medications remains challenging at best.


Sunday, January 27, 2008

Walk or Wait?

Many of you may know that since moving to Edmonton and living downtown, I now try to rely on the Edmonton Transit System for getting around town (i.e. when I cannot hitch a ride with someone).

So obviously the issue of whether to wait for the next bus (when I don't see one coming) or to try and walk to the next stop (so I don't have to stand still in the cold) is a big one.

Gratefully, I am not alone with this dilemma. As commented on recently in the Globe and Mail, US mathematicians have come up with the formula that allows you to calculate the odds of missing the next bus (by being caught between two stops as it whizzes by you) - the math is complex (taking into account distance to be travelled, distance between stops, frequency and speed of the bus, your own walking speed), but the bottom line is that unless you are traveling less than a Kilometer and the buses are around an hour apart, it is mathematically better to wait.

What the formula does not take into account is freezing your butt off by standing still. It also does not take into account any health benefits to be derived from walking to try and make it to the next stop and then breaking into a short run when you see the bus coming (my kind of exercise!).

Anyway, why even bring this up? Well, partly because I m a big believer in public transportation for its health benefits (and stress relief).

In a recent analysis by Edwards from City University of New York, Taking public transit is associated with walking 8.3 more minutes per day on average, or an additional 25.7-39.0 kcal. Based on the estimate that an increase in net expenditure of 100 kcal/day can stop the increase in obesity in 90% of the population. Additional walking associated with public transit could save $5500 per person in present value by reducing obesity-related medical costs (US). Savings in quality-adjusted life years could be even higher.

Similarly new studies from Sweden and Australia show that using public transportation or riding a bike to work is significantly associated with lower weight and better health. Oddly, in both studies the benefits were evident only in men.

I, for now, will of course continue using the ETS and sneaking a run to next base when I don't see a bus coming. I may be late for meetings but at least I'll be a little healthier.


Tuesday, January 22, 2008

Tightening the Band on Diabetes

A study published in today's JAMA, found that obese patients with Type 2 diabetes who underwent laparoscopic adjustable gastric banding (LAGB) were five times more likely to have their diabetes go into remission than patients who engaged in conventional weight loss therapies, such as diet and exercise.

The four-year study, which was led by Drs. John Dixon and Paul O’Brien from Monash University’s Centre for Obesity Research and Education (CORE), monitored 60 volunteers for two years who underwent significant weight loss of more than 10 per cent of their body weight.

Of those who underwent gastric banding surgery, 73% achieved remission for Type 2 diabetes, compared to just 13% of the people who underwent conventional therapy. This was largely attributable to the far greater weight loss in the band patients, who lost on average 20% of their initial body weight.

What is remarkable about this study is not that bariatric surgery leads to remission of diabetes - this we've known for a while.

What is new, however, is the fact that the subjects in this study had a BMI in the 30-40 range, i.e. a range not normally considered for bariatric sugery (for e.g. the average BMI in the Adult WW Clinic is 57!).

Of course, there were the expected complications with the LABG, including one band removal. Nevertheless, the point is that a relatively simple surgical procedure (which can essentially be performed in under 60 minutes as day surgery in experienced centres) can "cure" a condition for which the alternative is lifelong medical treatment.

Should surgeons now rush in and operate on all patients with type 2 diabetes?

Certainly not (yet?).

Despite the ease of the actual surgical procedure, patient management remains complex. Not only do patients have to make significant (lifelong) changes in their diet and eating pattern, but the need for regular band adjustments also make regular follow-ups by physicians familiar in dealing with these patients mandatory.

My guess is that all of the usual caveats to bariatric surgery will apply to this population including on-going addictions, mental health problems, binge eating disorders, non-compliance, etc.

But for selected patients with recently-diagnosed type 2 diabetes at experienced centres, probably the way to go.

Perhaps time for some diabetologists to start honing their band management skills?


Monday, January 21, 2008

25,000 Reasons to Promote Bariatric Care

This evening, I presented my vision for the Weight Wise Program to the Capital Health Board of Directors. I set the stage by presenting recent data on the prevalence of obesity.

Extrapolating from the most recent available data, based on roughly a population of 1,000,000 in the Capital Health region, I estimated that around 500,000 or 50% of the population have overweight or obesity, around 250,000 or 25% have frank obesity and around 25,000 or 2.5% have severe or morbid obesity.

Not surprisingly, the numbers clearly shocked my listeners. While everyone was of course well aware that there was an obesity problem, it is probably fair to say that few fully appreciated how HUGE the problem really is.

My comment that at the current rate of obesity surgery in the region, it would take us several centuries to operate on everyone who is morbidly obese today, was visibly sobering.

Just to clarify, I am not a surgeon. I have nothing personally to gain from promoting obesity surgery. Indeed, I much rather wished we had medical treatments that could do the job - but I have to concede that at least for now, obesity surgery is by far the best option for eligible patients.

Believe me, if there was a way to avoid surgery, I'd be all for it. But just as I've had to accept that dialysis and transplantation are the best options for patients with kidney failure, I have to accept that bariatric surgery is currently the best treatment for severe obesity.

More power to anyone who can manage their massive excess weight by radically overhauling their lifestyles and sticking with it - realistically, however, I am painfully aware that this will always be a small minority - most will require medical and/or surgical help.

Denying this help is not an option - morbid obesity is NOT a rare disease!


Thursday, January 17, 2008

No Time to be Thin?

This morning I spent time calling people on our waiting list. The idea was to find out exactly what they were expecting from coming to the Weight Wise program and whether they were ready and likely to be successful.

The bottom line was that the only patients, who after talking to me decided to have their names taken off the list, were those unable to commit the time to engage in an obesity treatment now or in the near future.

Once they heard that treatments would involve several visits with various health professionals, attending community classes and having diagnostic tests, they decided they simply could not make the commitment at this time.

Let's not kid ourselves - obesity management needs time.

Shopping and preparing healthy meals, eating slow, making time for exercise, relaxation, getting enough sleep, all of this requires time, dedication, focus and hard work. Anything less is not enough - at least not to achieve and maintain significant weight loss.

The reality is that if you are a single mom of three kids working 2 jobs and spending 60 mins a day on your commute, you simply may not have the time to do what it takes to seriously commit to an obesity program - and remember for this to be successful, any changes you make are for life - simply finding the time for the next 12 weeks won't do it either.

Thinking that getting a few healthy eating "tips" from a dietitian or slapping on a pedometer to monitor your steps (without actually increasing them) will make a difference to your weight is like believing in Santa Claus.

This is not a blame game - it is simply the reality of our times.

After all, fast food is just a symptom of a society that does not take enough time to eat.


Wednesday, January 16, 2008

Psychogenic Classification of Obesity

There is a widespread notion that all obese people must have mental health problems that make them eat.

This notion is WRONG!

As discussed in a recent article by my good friend Tessa van der Merwe from the University of Pretoria, one psychological classification of patients with obesity is as follows:

Schizoid Obesity: this is a small minority of patients who display a lack of autonomy, have difficulty establishing boundaries between self and non-self and experience surreal feelings of being governed by external forces. These patients tend to become unbalanced in the long-term with a continuous psychopathological process after weight-loss treatments and will invariably fail most programs.

Egodystonic Obesity: this relatively large group of patients is characterised by living with their obesity in a conflicted way. They often display reactive depression and anxiety and have the continuous need for comfort eating, repeated dietary attempts at weight loss and a high degree of restraint eating.

Egosyntonic Obesity: this may be the majority of patients who develop obesity for a variety of reasons that might be personal, familial, hereditary or cultural. Despite their obesity, they live without psychological problems. They are often extrovert, talented people with a good sense of reality and body image, but with a total inability to resist social eating cues.

Does this classification help in practice? Appreciate any thoughts and comments on this.


Tuesday, January 15, 2008

Big Problems need Big Solutions

This morning I spoke at the Public Health's WORK Lecture series on the Health Consequences of Obesity.

While I focused my presentation on the fact that obesity is a chronic disease and discussed some of the current treatment options, I also pointed out that there are currently no "proven" prevention strategies.

This is very much in line with the suggestion in the recent "Tackling Obesities Report" that perhaps some of the solutions to address the obesogenic environment would require substantial changes in major contributors such as transportation infrastructure and urban design. While more difficult and costly than targeting interventions in individuals or groups, such changes are more likely to affect multiple pathways in a far more sustainable way. (Similar things could be said about our food supply)

The challenge of course is creating public demand for such changes - as long as people prefer to drive their cars (or trucks) and prefer to live in low-density suburban neighbourhoods, we are a long way from any such changes.

Perhaps by more clearly aligning the health benefits with those arising from other socioeconomic goals such as reducing energy consumption, pollution, traffic congestion and crime rates we will not only reduce obesity but also produce a more environmentally sustainable society.

Is this likely to happen any time soon? Probably not.

Things may have to get a lot worse before they get better.


Monday, January 14, 2008

Exercise Resistance

Recently I blogged about how few people actually take up the advise to be physically active, even when delivered by a health professional (e.g. click here).

A new study in the Lancet now shows how difficult it is, even with the greatest effort, to get a substantial proportion of people moving.

In this study by Kinmonth and colleagues from the General Practice and Primary Care Research Unit, University of Cambridge, 365 sedentary adults with a parental history of type 2 diabetes were randomly assigned to either receiving just a brief advise leaflet in the mail or a 1-year behaviour-change program, delivered either by trained facilitators in participants' homes or to the same program delivered by telephone. The program was designed to alter behavioural determinants, as defined by the theory of planned behaviour, and to teach behaviour-change strategies.

Surprisingly, at 1 year, the physical-activity ratio of participants who received the intervention, by either delivery route, did not differ from the ratio in those who were simply given the brief advice leaflet.

The bottom line of this relatively large randomised trial is clear: A facilitated theory-based behavioural intervention, even when delivered with professional home trainers and individual counseling is no more effective than simply providing an advice leaflet for promotion of physical activity in an at-risk group.

I can only imagine how disappointed the investigators must have been having to conclude that health-care providers should remain cautious about commissioning behavioural programmes into individual preventive health-care services.

This seems very much in line with the large body of evidence that states that people will either exercise or they will not - those who like activity and have done it before will do it again - those who don't - will refuse to do it (in the long term), no matter what.

Of course there will always be some exceptions, but these are likely to be few and far between - the majority is simply resistant to change.

Having predictors of who is likely to adopt exercise and who is not may be important in order to target advise (and resources) to those most likely to actually do it (and persist).

Once again - one-size is unlikely to fit all.


Thursday, January 10, 2008

Food Cravings and Weight Loss

OK, here's a new piece of research from Tufts University whose results I would probably have predicted:

1) People crave energy-dense foods low in fibre and protein

2) Losing weight increases those cravings - the more weight you lose, the greater the cravings

3) People who give in to these cravings lose less weight (or gain it back)

Carrot sticks will simply not replace chocolate cake. The question is, how much chocolate cake can you still eat while trying to lose/maintain weight?

I guess the answer is: how ever much chocolate you need to still or manage those cravings.

If you are not a complete control freak those cravings will drive you nuts and you'll probably give in sooner or later.

Rule of Thumb: if you feel you are depriving yourself you are unlikely to stick with it (or feel unhappy and frustrated).

Let's never forget that food serves biological, psychological and sociological purposes that have nothing to do with maintaining energy balance, nutrient intake or good health.

The powers that regulate the hedonic aspect of food intake are always lurking and ready to sabotage any weight loss attempt.

Ignoring these "powers" is doomed to failure - let's embrace them and find creative ways to work around them.


Wednesday, January 9, 2008

Obesities and What to do About Them

Over the last couple of days I have been reading a new 160 page report on "Tackling Obesities: Future Choices" produced by the UK Government's Foresight Program which is run under the Government Office for Science.

The report was prepared by some 200 experts (mostly from the UK) and ends with several "what if" scenarios that model the outcomes of possible policy decisions.

The first point of note is that the title of the work refers to "Obesities" rather than "Obesity", thereby formally recognizing that this is a heterogeneous entity and that there are many forms of obesity.

Over all the work is impressive and discusses obesities in all their complexities - the biological and environmental system map is enough to let anyone serious about trying to understand the causes of the epidemic throw up their hands in despair and flee the room.

Nevertheless, the work is useful in that it contains a lot of interesting bits that are "quotable" and deserve discussion.

Sentences like:

"The forces that drive obesity are, for many people, overwhelming."
are notable because they depart from the usual idea that obesity is essentially a consequences of individuals' choices and decisions and all anyone has to do is to be "smarter" about their health.

This obviously we know is not true - in fact, if, as stated elsewhere in the report,
"People [in the UK] today don't have less willpower and are not more gluttonous than previous generations."
"...for an increasing number of people, weight gain is the inevitable - and largely involuntary - consequence of exposure to a modern lifestyle."
we need to be careful not to blame the victims.

It will rather be changes in social values and the way society as a whole chooses to respond to this epidemic that will make a difference. Amongst the experts, there was clearly no expectation of any spontaneous reversal of obesity trends.

The report is a challenging but fun read. I will probably be posting more on stuff I find in it over the next few weeks.

For those wanting to read the full report, you can download it by clicking here.


Monday, January 7, 2008

Young Mothers: Lose Weight While You Sleep!

OK, here is another interesting observation on weight and sleep:

Erica Gunderson and colleagues from the Kaiser Permanente Research Foundation, in an observational study of 940 young mothers, found that mom's lack of sleep at 6 months post partum was directly correlated with weight retention. (click here for reference)

Mothers, who at six months post partum reported five hours of sleep or less, had a three-fold greater risk of substantial weight retention at 12 months than mothers who reported sleeping seven hours (lucky them!).

The authors conclude, and I concur, that we now need an intervention study to see if "prescribing" more sleep to young moms leads to less weight retention.

Looks like we're going to need young dads to take on more of the "night shift" and let the poor moms sleep.

Wonder though if this will then lead to weight gain in young dads?


Friday, January 4, 2008

Please Pay Attention - You May be Obese

There are over 50 recent publications in PubMed on the possible link between Attention Deficit Disorder (ADD) and obesity. In my own anecdotal experience I continue to be surprised on how many patients presenting with obesity have clear signs of this disorder.

They are usually the patients who show up late for appointments because they locked their keys in their cars, did not fill the last prescription for their metformin because they lost it, started filling out food records but never got past the first day, used their new bike only once because they never got around to fixing the flat tire from their first ride, take a packed lunch to work but forget to eat it, enthusiastically start a new diet but lose interest three days later because weight loss is too slow - I could go on forever - you probably get the picture.

In my practice I have come to recognize that ADD is probably one of the most common and frustrating barriers to obesity management. By definition, individuals with ADD lack the ability to plan ahead and to follow through on their plans, easily lose interest, and are constantly sabotaged by their impulsiveness when it comes to making healthy choices.

There is now evidence to support the notion that alterations in the dopaminergic reward system may be common to both ADD and hedonistic hyperphagia. Not surprisingly there is some work showing that methylphenidate (ritalin) can sometimes reduce cravings for sweet and fatty foods.

It does not surprise me that someone with ADD is probably more prone to "mindless eating" and thus more likely to gain weight than someone with proper impulse control.

One of the most remarkable cases I recall was a patient, who after being started on ritalin, at his next visit for the first time brought in and proudly presented meticulously completed food records (he was also a couple of pounds lighter).

In medicine it is always easiest to blame the patient - not motivated, not interested, not focused, not following instructions, not compliant, not adherent, etc.

Recognizing that this behavior may be due to ADD and providing proper treatment for this condition may in these cases be the first step to obesity management.


Thursday, January 3, 2008

To Have is Not to Be

Would you refer to someone with atherosclerosis as an "atherosclerotic"?

Would you refer to someone with renal failure as an "uremic"?

Would you call someone with osteoarthritis an "arthritic"?

I know that it is common to speak of diabetics, hypertensives, psychotics, etc. but it is not polite. In fact many journals emphatically forbid the use of these terms - the proper language would be diabetic, hypertensive, or psychotic patient, but even that may not be polite enough.

This issue is particularly relevant when speaking of obesity. There is a subtle but important difference between someone "being" obese or "having" obesity - Mr. Jones "is" obese vs. Mr. Jones "has" obesity.

Why is this important? When we use terms which have negative connotations like "obesity" it is important that we do not define our patients based on this condition - obesity is not a character trait - it does not define who our patient is - it is something our patient has and is seeking our help to get rid of.

Mr. Jones "is" Mr. Jones irrespective of whether he has obesity or has lost the excess weight.

I suggest that we do not speak of obese patients - let us show our compassion by speaking of patients who have obesity (as they may have atherosclerosis, uremia, osteoarthritis, diabetes, hypertension, or psychosis).


Wednesday, January 2, 2008

New Near Resolutions: Why Bother?

What could be more expected than a call from a local TV station today asking for my take on New Year resolutions? What should people do who want to lose weight and be more healthy?

Well, readers of this blog would already predict my answer: do not resolve to do anything that you do not enjoy and are unlikely to stick with.

There is absolutely no evidence that two weeks of avoiding fast food or four weeks of daily exercise will do you any good in the long run - except perhaps increase your experience of just "failing" again when you fall back into your old lifestyle.

People are too smart to stick with doing things they don't enjoy, especially if it takes an effort to do so. This is especially true if the rewards are distant, uncertain and vague.

But even experiencing the benefits is no guarantee for adherence. How many people do you know who have lost weight, felt fantastic - so full of energy - just great, only to gain the weight back?

So here's my two bits on New Year resolutions: if it's not sustainable don't bother.

Drastic and radical changes are rarely sustainable - remember: the benefits of even miniscule daily bouts of exercise are incremental - the health benefits of running a marathon once in a lifetime are irrelevant!

Happy 2008!