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Wednesday, February 27, 2008

CBC's "The National" Takes on Obesity Surgery

So while I was cruising the Tasman Sea, CBC TV’s “The National” aired a report on the state of obesity surgery in Canada.

The story is about how, despite its proven safety and benefits, obesity surgery in Canada is hard to come by.

One patient featured in the report decided to go to India for a gastric bypass rather than waiting in Ontario.

A complete transcript of my take on this issue, bits of which can be seen in the CBC broadcast, can be read by clicking here.

Incidentally, the CBC site contains a neat little interactive tool that provides information on the state of obesity surgery in each province.

For e.g. it reveals that while the public system on Prince Edward Island pays for both gastric bypass and adjustable gastric banding (minus the cost of the tubing), no hospital on the island performs these procedures.

On the other hand, while Quebec performs the greatest number of operations, the waiting lists are also the longest in this province.

The North West Territories does not consider obesity surgery an insured service and Nunavut will not send patients South for obesity surgery, as it does not have the resources to provide the complex follow-up needed after surgery.

The main article on the CBC website also has other information on obesity surgery that may be of interest to patients and practitioners alike.

I have little doubt that this topic is going to attract much more attention from the media in the future – as I have blogged before: done in the right patients in the right setting with the right follow up, the impact of obesity surgery on the health and quality of life of patients affected by severe obesity can be nothing short of spectacular.

The key, however, lies in selecting the right patients and ensuring proper life-long follow-up - simply paying for surgery will not be enough.


Tuesday, February 26, 2008

Heavy Cruising

After traveling exactly 3082 Nautical Miles (=3586 Statute Miles = 5707 Kilometers) in 12 days on the Sapphire Princess from Aukland to Sydney I am back in Canada having hopefully put on no more than a couple of lbs and aquired a substatial tan.

As predicted, food was abundant and rich - clearly "regular eating" and "grazing" are both doomed as weight-control strategies aboard cruise ships.

For anyone interested, here is my emperical formula for weight gain on cruise ships: ~ 0.5 to 1.5 g / Nautical Mile.

The fact that I had to deliver over 15 hrs of CME on obesity did not appear to help (facit: giving obesity lectures on cruise ships is not a viable strategy to prevent cruise-related weight gain).

Daily participation in early morning exercise classes also do not appear to have dropped weight gain to zero.

In any case, I am back, had a great time - thanks to the folks at CME@Sea (Sanjay, Gwen & Catherine), to the fellow physicians and their partners, my fellow faculty (Michael Gard, Carmelle Paisah, Peter Everett and Greg Hilderman) and of course to the entire crew of the Sapphire Princess for making this a great trip.


Sunday, February 10, 2008

Cruising Away from the Buffet

The next two weeks are going to be tough!

Believe it or not, I am off to a "working vacation" on a 12-day cruise from Aukland to Syndey.

As the keynote speaker of an event organised by CME@Sea, I will be presenting six 90 minute talks and six 60-min journal clubs on obesity to family physicians and other health professionals who have chosen this as a way to fulfill part of their continuing education obligations.

Many of you may think that a cruise is the obvious place to hold an obesity CME, given the high-risk of weight gain associated with this form of vacation. In fact, I am quite nervous, as I know that the limited activity and plentiful food will be hard to resist.

The medical literature on this issue is astoundingly sparse (you'd think that someone would have discovered this most interesting opportunity for "field studies" by now).

The only scientific publication that comes close is an intervention study conducted on the USS Enterprise CVN-65 in sailors who failed their Physical Readiness Test due to excess weight during a six month deployment in the Mediterranean (click here for abstract). The results of the intervention were actually not that bad (5-8% weight loss).

Given this rather modest yield of scientific studies, I also spent some time browsing "preventing-weight-gain-on-cruise-ship" websites, of which there are an astounding number (for e.g. click here).

Lots of helpful tips:

1) eat only oysters and lobster tails

2) avoid colourful cocktails (colourless alcohol is OK I guess?)

3) don't eat after sundown (I'll make sure I catch the "Early Seating")

4) dance till dawn

5) etc.

Sounds easy enough - we'll see how it goes. Will report back approximately two weeks from now.

---stay tuned---


Saturday, February 2, 2008

Bariatric Nephrology

This morning, I am presenting at the Nephrology Educator's Forum in Lake Louise. The audience are nephrologists from across Canada.

The fact that I was invited to speak on obesity is of course related to the fact that nephrology, as practically all fields of medicine, are beginning to see the impact of the obesity epidemic.

Indeed, from a nephrologist's perspective (remember - I am one), not only is obesity a major driver of the most common causes of end-stage renal failure (i.e. type 2 diabetes and hypertension), it also complicates things for patients on dialysis (especially peritoneal dialysis) and renal transplantation.

While there is an apparent survival paradox, whereby obese patients with end-stage renal failure seem to do better than leaner patients (a similar paradox is seen for other chronic diseases including heart failure and chronic obstructive lung disease), there is a high likelihood that this paradox is largely explained by malnutrition or more severe comorbidities than by a true protective effect of the extra weight. Perhaps, maintaining a higher weight or even gaining more weight is simply a sign of adequate nutrition and therefore a surrogate marker for "better health" and thus better outcomes.

On the other hand, in dialysis patients awaiting transplantation or patients who have had transplants, severe obesity and/or further weight gain can be a major problem. Not surprisingly, there is now an increasing number of reports on patients with end-stage renal failure undergoing bariatric surgery either prior to or following kidney transplantation - apparently with great success.

Clearly, the brunt of the obesity epidemic on nephrology is still ahead - nephrologists, like everyone else, will probably have to brush up on the essentials of bariatric care.


Don't Shoot the Messenger

Here is an interesting Editorial in the Globe and Mail on not being judgmental about people with obesity. The author is Irving Gold, Chairman of the Canadian Obesity Network's Board of Directors.

The editorial speaks for itself and there is little point in repeating it here.

The reason for my post is mainly to point out the interesting discussion with 100s of comments that were provoked by this Editorial. The range of comments very much reflects the nature of the current discussion on obesity by the general public and nicely shows how emotional people can get when discussing this subject (both on the pro and con side).

To me, the increase in obesity has always been just a symptom of living in an obesogenic environment.

The fact that this environment affects some people more than others is not different from other situations, where for the same level of exposure some suffer the consequences while others get home free.

Not every smoker gets a heart attack, not everyone who eats a ton of salt gets a stroke and not everyone who breathes in polluted air gets an asthma attack. But yes, more smoking means more heart attacks, more salt means more strokes, more pollution means more asthma.

Similarly, not everyone who indulges in junk food or lies on the couch becomes severely obese. In fact, we all know people (I call them the mutants), who can eat ridiculous amounts of food and never seem to gain a gram of fat. In fact, there is a whole "weight-gain" industry out there catering to young men who are tired of having sand kicked in their face by the jocks.

Obviously, the people likely to be affected most by our obesogenic environment are those that have familial, emotional, sociocultural or medical reasons for eating too much and not moving enough - the same people, who would have been the largest even 100 years ago. They are the magnifying glass through which we fully realise the profound impact of our environment on population weight.

The fact that we have more people with obesity is sending us a clear message: let's clean up our act and address the issues that are causing our obesogenic enviroment and provide help to those who are struggling the most.

Don't shoot the messenger!


Urgent Weight Loss

Obesity is a chronic disease and needs long-term treatment. Weight gain doesn't happen overnight and obesity treatment is not about how much and how fast you can lose it.

Yet, there are situations where rapid and substantial weight loss may be indicated.

For example, patients with severe obesity who require urgent diagnostic procedures; patients with severe obesity needing elective surgery; patients with life-threathening medical issues made intractable by obesity; obese patient following acute illness, where recovery and rehabilitation is hampered by excess weight.

All of these situations may warrant "urgent" weight loss. The aim is not so much to provide long-term weight management - the aim is to acutely reduce weight to solve an immediate problem and get out of a tough spot.

In these situations, and only these, radical weight loss measures may be in order. This is where methods aimed at safe short-term weight loss are indicated. This is where treatments such as very low calorie diets, that may have limited efficacy in producing sustained weight loss, but can provide safe and immediate weight loss, can be helpful.

There is a wealth of literature supporting the safety and weight-loss efficacy of low calorie diets such as Optifast. While hardly sustainable in the long term, total meal replacements can provide a rapid and relatively safe strategy to substantially reduce body weight in the short term.

I have no doubt that the majority of patient will probably rapidly regain much of the weight lost, unless transitioned into a more sustainable form of obesity treatment - however, in the short term, this approach may help solve an otherwise intractable problem.

There are few published studies, let alone randomised trials on this concept. However, I have little doubt that given the dramatic increase in the number of severely obese patients in the health system, this approach will in clinical practice prove a rational and tangible path out of otherwise difficult situations.


Obesity Surgery is not Just About Surgery

With the "sensational" results of obesity surgery being publicized in the media, it is not surprising that expansion of bariatric surgery is receiving increasing support. In every province, health plans are carefully looking at expanding access for their populations.

In light of these development it may be time for a word of caution.

Obesity surgery is not just about surgery. In fact, even the most enterprising bariatric surgeons will readily agree that the actual surgery is just a small (but important) technical piece in the overall treatment plan.

No doubt, good surgical outcomes require well-trained experienced surgical teams but we know that much of the long-term outcome depends on what happens before and after surgery.

Done in the wrong patients with no or little long-term follow up, what could be a life saving operation can become a disaster - and weight regain is perhaps the least that can go wrong. Much more severe and potentially devastating are the nutritional deficiencies and the psychological and social consequences that are not seldom after surgery.

For surgery to produce good long-term results it is absolutely essential that as access to surgery expands, so does the pre-surgical selection and education process as well as the access to life-long post-surgical monitoring.

Expansion of surgical programs does not just need more surgeons and OR time - it needs dietitians, psychologists, physicians, occupational therapists, social workers and other health professionals who are trained and qualified to prepare and follow-up surgical patients.

In the end it will be family doctors who have to look after the 1000s of patients who will be asking for and undergoing surgery. Given the numbers of eligible patients and the geographic distances in Canada, this task of preparing and following patients for life cannot be performed by a handful of Centres of Excellence. This is particularly true for the adjustable gastric band, which while offering a simpler and safer surgical procedure, does require regular and ongoing adjustments to be fully effective.

If we hope to see the spectacular results from the published studies on bariatric surgery replicated in daily practice, we must start bringing primary care providers up to speed on counseling, preparing and following their patients.

Ignoring this task will leave 1000s of Canadians stranded post-surgery with nowhere to go when things go wrong.

Obesity surgery is NOT just about surgery.


Does the Focus on Obesity Prevention Promote Bias and Discrimination?

Imagine walking into an emergency room with chest pain and simply being sent away with a leaflet advising you to quit smoking.

Imagine arriving at a hospital with signs of stroke and simply being referred to a lecture on reducing sodium intake.

Imagine being diagnosed of colon cancer and just receiving well-meanining advise on the virtue of eating more fibre.

What is fundamentally wrong with the above scenarios? The simple fact that they are confusing prevention with treatment.

While giving up smoking, excessive salt and eating more fibre may be valuable in preventing heart disease, stroke and cancer, as treatments (at least in the short term) they are near to useless.

Once patients present with the disease, they need treatment.

This is not to say that lifestyle changes are not as important for secondary prevention - but they are rarely enough.

While many may agree with the above, they seem to have a hard time applying this knowledge to obesity.

While every politician, non-government organization and legions of health workers are campaigning for more efforts on preventing obesity, rarely do I hear the cry for more treatments - this is blatant discrimination!

When a quarter of the population or around 11,000,000 Canadians already have the "disease" focussing all available resources solely on prevention is a joke.

Not that efforts at prevention are not important - of course they are. Yet, even the most optimistic experts do not think that the current epidemic can be reversed in the forseeable future. It will take time to rebuild our cities, force people to abandon their cars, regulate our food chain, focus on calories and change our culture of overconsumption and sedentariness.

Even if any of these measures worked, no one expects them to have an immediate impact on those struggling with obesity today.

A 200 lb 17 year-old does not have 10 years to wait for "prevention" to kick in - he/she needs help today.

Even if treatment focussed only on providing minimal obesity treatments to those who most need them, i.e. those already experiencing the complications of diabetes, knee pain, sleep apnea, fatty livers, infertility - we would still need to provide obesity treatments for millions of Canadians.

Ignoring their plight and focussing all resources on "prevention" is not only demeaning and in-human, it also perpetuates the wide-held notion that obesity is entirely preventable and that anyone who has obesity has obviously "failed" at doing the right thing and therefore simply deserves no better.

The more we promote the idea that all it takes to prevent obesity is simply for individuals to eat less and move more - the more we can rest in our armchairs and blame people with obesity for just eating too much and not moving enough.

What message could be more powerful in cementing the already widespread bias and discrimination against individuals struggling with this condition?

Perhaps only worse is the message that anyone can become masters of their own weight if they only tried hard enough (as in Biggest Loser?). This idea is even more discriminating, because it implies that anyone who is too heavy is simply not making the effort.

All of this flies in the face of the fact that recidivism of obesity in our current obesogenic environment is almost 100%.

No matter how much weight people lose and irrespective of the weight-loss method (perhaps short of surgery) weight sooner or later comes back. In the exceptional few who do manage to keep the weight off, it remains nothing short of a daily obsession, where the slightest slip-up is punished with immediate weight re-gain.

Simply losing weight is not treatment for obesity - keeping it off is!

Continuing to channel all our efforts solely into prevention and ignoring the plight of the millions who have no where to turn for help except to commercial weight-loss scams is a direct reflection of and only promotes the bias and discrimination against people with obesity.

Fortunately, treating obesity is not more difficult or even more expensive than dealing with other chronic conditions - but it does require at least the same attention and commitment of resources as we devote to other chronic diseases. Not providing treatment is perhaps only a reflection of the bias and discrimination towards people struggling with this condition (they deserve no better!).

We cannot afford to simply write off a quarter of all Canadians. Health ministers, health authorities, NGOs and health professionals now have to step up to the plate!