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

Obesity and Prostate Cancer

Looks like this week is about obesity and men's health. So after blogging about male self-esteem and erectile dysfunction, what about obesity and risk for prostate cancer?

Well, after a quick search of the literature, I can happily state that the data on this is pretty inconsistent.

Probably the best study, a prospective cohort study in 34,754 men residing in Washington State (aged 50-76 years at baseline) studied by Alyson Littman and colleagues from the Fred Hutchinson Cancer Research Center, Seattle, WA, published in the American Journal of Epidemiology, succeeded in confusing me more than providing any definitive answers.

Thus, while on one hand obese men had a reduced risk of nonaggressive disease, overweight (but not obese) men, had an increased risk of aggressive disease. Body mass index of >25 at age 18 years was associated with increased risk of aggressive prostate cancer; obesity at ages 30 and 45, but not 18, years was associated with reduced risk of nonaggressive prostate cancer.

I can only concur with the authors, who conclude that this study demonstrates the complexity of prostate cancer epidemiology and the importance of examining risk factors by tumor characteristics.

So is obesity a significant risk factor for prostate cancer? I guess the answer is "depends".

AMS
Edmonton, Alberta

Obesity and Erectile Dysfunction

Yesterday, I ended my posting on the Megasexual MEGARS on the rather sobering note of erectile dysfunction.

Yes, obesity is an important risk factor for this rather embarassing and annoying, but seldom talked-about complication of obesity. (I continue to be amazed by just how many grateful male patients have thanked me for the great improvements that they experienced in their sex lives as a result of obesity treatment.)

Some, if not most of this may be related to the hypogonadotrophic hypogonadism that I have blogged about before.

Indeed, healthy lifestyle factors are strongly associated with maintenance of erectile function in men - and in obese men with erectile dysfunction - weight loss sure helps.

Perhaps the best study on this issue was done by Katherine Esposito and colleagues from the Second University of Naples, Naples, Italy (published in JAMA). They conducted a randomized, single-blind trial of exercise and weight loss in 110 obese men (BMI > or =30) aged 35 to 55 years, WITHOUT diabetes, hypertension, or hyperlipidemia, who had erectile dysfunction as determined by a score of 21 or less on the International Index of Erectile Function (IIEF).

The 55 men randomly assigned to the intervention group received detailed advice about how to achieve a loss of 10% or more in their total body weight by reducing caloric intake and increasing their level of physical activity. Men in the control group (n = 55) were given general information about healthy food choices and exercise.

After 2 years, BMI decreased more in the intervention group (from 36.9 to 31.2) than in the control group (36.4 to 35.7) while the IIEF score improved significantly in the intervention group (from 13.9 to 17.0), but remained unchanged in the control group. Remarkably, 17 men in the intervention group but only 3 in the control group reported an IIEF score of 22 or higher at the end of the study.

The authors thus concluded that in about one third of obese men with erectile dysfunction, increased physical activity and weight loss can markedly improve sexual function.

So to all obese men: if sexual function is fine - GREAT! If erectile dysfunction is an issue - obesity treatments may just be worth a shot.

AMS
Edmonton, Alberta

Megasexual

This story is almost not worth posting on given the media attention it received across Canada. And yet, as I was widely quoted on this, I feel obliged to bring it up.

As Canadian readers probably know by now, there is a new French-Canadian group called MEGARS (a French acronym for "elegant male who enjoys social recognition") launched by Daniel Lafond and François Provost (two elegant big guys who obviously enjoy social recognition) to promote self-esteem and ensure that large, “overweight” men live their lives to the fullest. They coined the term "megasexual" as an oversized analogy to "metrosexual" - I guess it's what some women out there apparently do find attractive.

I was quoted as saying,

“There's no question that many people who are obese have self-esteem issues. A lot of the bias and discrimination that obese people face in their daily lives makes living in a large body quite difficult.
(on the other hand) This does not mean that when you are large and have significant medical problems related to your size, you don't worry about your size and just take tablets to treat no matter what complication you have."

Just to rule out any misunderstanding, I’d like to reemphasize my take on this – yes, you certainly can be big AND healthy (in our Edmonton Obesity Staging System, we call this Stage 0 Obesity).

If you happen to be big and REALLY have no health issues whatsoever, there is certainly nothing to stop you from having fun and living your life to the fullest – don’t let poor self-esteem stop you. In fact, if it is only your poor self-esteem that makes you worry about your weight – get over it – you don’t have a weight problem, you have a body-image problem!

On the other hand, even Lafond and Provost agree that they are not out to promote obesity. Provost is quoted as saying:

"Surely, if someone has excess weight to the point it's unhealthy, something has to be done about it."

It all comes down to the simple fact: don’t judge someone’s health (or lifestyle) by their weight.

If your weight is not affecting your health or well-being – eat healthy, be active and please don’t smoke – losing a few pounds (or obsessing about losing them) is unlikely to make you much healthier.

Unfortunately, however, many of the risk factors associated with excess weight (especially in men with big waistlines) are “silent”, i.e. unless you actually regularly do the measurements, you may not know that your blood pressure or blood cholesterol and glucose levels are not where they should be.

If all’s fine, then that’s great!

If not, perhaps treating your obesity may be a good idea – after all there is nothing sexy or elegant about getting a stroke, heart attack or even just erectile dysfunction.

AMS
Edmonton, Alberta

Xyndrome Blues

Almost 20 years ago, just out of medical school, I wanted to measure the effect of salt intake on insulin sensitivity in healthy volunteers. I reviewed the literature and soon found an article by Richard Bergman that described a piece of software he had developed for assessing insulin sensitivity (SI) by a computed mathematical analysis of the relation between the change in insulin and glucose clearance after a bolus of iv glucose.

At the time (this was years before e-mail), I called his office at the University of Southern California, Los Angeles, and found out that he was on sabbatical in Phoenix. When I finally tracked him down and got him on the phone, I explained who I was and what I wanted and he was most kind and actually sent me his software, which arrived a couple of weeks later in the mail on a 3.5-inch floppy (how did anyone do research before the internet?).

Anyway, this weekend, for the first time, I finally met Richard at the International Chair on Cardiometabolic Risk (ICCR) meeting in Quebec City. Of course he did not remember speaking to me on the phone 20 years ago - but we did laugh about it.

Today, as some of you may know, Richard is the Editor-in-Chief of OBESITY and still extremely active in the field of insulin resistance.

At the Chair symposium, which focussed on various aspects of the endocannabinoid system in obesity and metabolism, Richard introduced the term "Xyndrome", a clever contraction of the terms "metabolic syndrome" and "syndrome X" (both terms are used to describe the cluster of abdominal obesity, hypertension, hypertriglyceridemia, low HDL and elevated glucose associated with insulin resistance).

More interestingly, on Sunday, after the symposium, Richard and I got to play a set of blues at the post-symposium barn party hosted by my good friend Jean-Pierre Despres in his hometown just outside Quebec City. As many of you may know, JP Despres is perhaps the most prominent obesity researcher in Canada (nearly 500 papers at last count), who coined the term "hypertriglyceridemic waist". He is also the Scientific Director of ICCR and Head of the Canadian Obesity Network's Section on Heart Lung and Blood Vessels. More relevant in the context of this post, JP is also a singer and guitarist and recently recorded his first album.

Anyway, I not only finally got to meet Richard Bergman 20 years after speaking to him on the phone but also (even better) got to jam with him for a full set (he really is an awesome blues player!).

Thanks Richard for a great Jam! Thanks JP for bringing us together and making this happen!

AMS
Quebec City, Quebec

Metabolic Surgery

This week we were reminded that almost 1 in 5 Canadian adults are obese. Readers of my blog will know why this is a challenge - once established, obesity becomes a chronic disease that requires lifelong management (irrespective of whether behavioural, medical or surgical - in all cases treatment is long-term or rezidivism is guaranteed!).

Clearly, for folks with severe obesity, surgery provides the best long-term results. Not only does it reduce mortality by 30-40%, it also leads to marked improvement in virtually all comorbidities while spectacularly improving quality of life.

That is, of course, when all goes well.

But even the safest surgery can result in problems when things go wrong. Recognizing and dealing with complications of obesity surgery is therefore a huge part of the program here at the 25th Annual Meeting of the American Society for Metabolic and Bariatric Surgery that I am currently attending at the Gaylord National on the Potomac River, on the outskirts of Washington D.C.

(My plenary "Keynote Lecture" on Friday morning is on the regulation of hunger and appetite)

No question, world wide obesity surgery is booming. As its value for severe obesity is now well beyond dispute, surgeons are turning to patients with ever lower BMIs - in some cases even below 30. The indication here is no longer weight loss, but rather type 2 diabetes, hence the term "metabolic surgery". Indeed, from everything I have seen and heard, surgery is probably the only known treatment for type 2 diabetes to result in extended remission - in short: highly effective, reasonably safe, and, given the high cost of diabetes complications, certainly cost-effective.

Obviously, the same contraindications apply to metabolic surgery as to obesity surgery, and yes, all patients need lifelong follow up to prevent nutritional deficiencies and ensure persistance with behavioural change (without which surgery does not work). And yes, surgery even at lower BMI's has complications (after all it is still surgery).

As evidenced by the many presentations here, the major determinants of complications are improper patients selection and preparation, low surgical volumes and lack of follow up. A clear warning to any policy makers and payers anxious to increase surgical volumes by simply throwing money at surgeons without providing resources to ensure competent lifelong follow-up.

As blogged previously, obesity surgery is not just about surgery - the actual surgery is simply a small (but important) technical part of a lifelong treatment plan.

AMS
National Harbor, Maryland

New Obesity Numbers for Canada

Yesterday, Statistics Canada released the latest data from the 2007 Canadian Community Health Survey (CCHS) for obesity.

Overall 4 million Canadians aged 18 or older, 16% of the total, reported data on weight and height that put them in the obese category. Another 8 million, or 32%, were overweight.

Although between 2005 and 2007, rates of both overweight and obesity generally changed little, during that period, there was a slight increase in the proportion of women aged 18 to 24 who were obese, and a decrease in the proportion of senior men who were overweight.

Self-reported obesity rates were generally highest among individuals aged 45 to 64. One-fifth (20%) of men in this age group were obese, as were 18% of women. The proportion who were overweight also tended to peak in middle-age.

Men aged 25 to 44 were considerably more likely than their female counterparts to be obese.

Among the provinces, rates of obesity were highest in Saskatchewan, Alberta and Atlantic Canada, ranging from 18% in Alberta to a high of 22% in Newfoundland and Labrador. The lowest rates were in British Columbia where only 11% of adults were obese.

Overweight and obese adults were less likely to rate their health as excellent or very good than were adults not carrying excess weight.

Obviously, because of the tendency of respondents to over-report their height and under-report their weight, it is likely that these figures from the CCHS underestimate the actual prevalence of obesity and overweight.

Clearly, the obesity epidemic is alive and kicking. Delivering appropriate obesity treatments to one-fifth of the population is likely to remain a challenge for the forseeable future.

AMS
Edmonton, Alberta

The Pap Gap

Previous studies have shown that patients with obesity may not be receiving the same quality of health care as non-obese patients.

Reasons for this are likely to be complicated: yes, there is a provider bias - health professionals are likely to blame most complaints on the presence of obesity and perhaps not order the same tests that they may for the same complaints in a non-obese individual - on the other hand, patients with obesity may be more reluctant to go to their family physician because of embarrassment, frustrations about only being told again and again to simply lose weight, or fear of furniture or equipment that's too small.

How do these circumstances affect the rates of preventive screening?

This was addressed in a study by our own Rebecca Mitchell and colleagues from the University of Alberta, who examined the relationship between body weight and cancer screening in data from the 2003 Canadian Community Health Survey 2003. (The paper will appear in the August issue of the American Journal of Preventive Medicine).

Of the nearly 38,000 women participants, 82.6 percent reported having cervical cancer screening (Pap test) within the past three years. However, women with a BMI of 35 or higher, were nearly 40 percent less likely than others to have had a Pap test.

The findings were not explained by differences in socioeconomic status, health habits, chronic medical conditions or health care access. Reasons for less tests were more likely attributable to fear of pain, embarrassment or of finding something wrong.

Obesity did not alter mammogram or colorectal screening.

This study is only the latest in a number of studies that have looked at this issue before. Thus, Sarah S. Cohen and colleagues from the University of North Carolina in their review of 32 relevant published studies (10 breast cancer studies, 14 cervical cancer studies, and 8 colorectal cancer studies) found that in women obesity most likely is a barrier to screening for breast and cervical cancers whereas the evidence for colorectal cancer screening was inconclusive.

These finding certainly send a message to health care providers to be vigilant that their larger patients receive the same level of screening as their leaner patients - especially since obesity has been noted as a risk factor for both breast and cervical cancers.

AMS
Edmonton, Alberta

Is Foie Gras Junk Food?

Yesterday, I gave a talk to Alberta Agriculture on my take of the obesity epidemic(thanks to Annette for the invitation) . Obviously, the best way to influence policy is to talk to policy makers, so an opportunity to present my views to policy makers is always appreciated.

Given that the audience was keenly interested in issues related to nutrition, it was not surprising that questions arose around the issue of junk food (actually this topic comes up at virtually every talk on obesity).

The discussion again made obvios the difficulty of the concept of junk food - i.e., when exactly is food junk? Now obviously, from an obesity perspective any form of "empty" calories would constitute junk food, that one is easy. But what about real food with more than just calories?

When I look to Wikipedia for a definition, I find the following (slightly paraphrased for brevity):

"Junk food is food that is unhealthy and/or has little or no nutritional value. It contains high levels of refined sugar, white flour, trans fat and polyunsaturated fat, salt, and numerous food additives such as monosodium glutamate and tartrazine; at the same time, it is lacking in proteins, vitamins and fiber, among other healthy attributes. It is popular because it is easy to purchase, requires little or no preparation, is convenient to consume and has lots of flavor. "

Clear enough, you'd think.

But the same post in Wikipedia also says why this definition is not easy (again paraphrased for brevity):

"What constitutes unhealthy food may be confusing and, according to critics, includes elements of class snobbery, cultural influence and moral judgement. For example, fast food in North America, such as as hamburgers and french fries supplied by companies like McDonald's, KFC and Pizza Hut, are often perceived as junk food, whereas the same meals supplied by more up-market outlets such as California Pizza Kitchen or Nando's are not, despite often having the same or worse nutritional content. Some foods that are considered ethnic or traditional are not generally considered junk food, such as falafel, gyro, pakora, gyoza or chicharron, though all of these foods have little nutritional value and are usually high in fat from being fried in oil. Other foods such as white rice, roast potatoes and processed white bread are not considered junk food despite having limited nutritional content compared to wholegrain foods. Similarly, breakfast cereals are often regarded as healthy but may have high levels of sugar, salt and fat."

So the question is, "what exactly constitutes junk food?". If French fries from McDonalds are junk food because they contain little nutritional value, what about the over priced "hand cut" deli fried served in high-class restaurants? Does charging more money make junk food less "junkie"? What about foods like foie gras, caviar, lard - foods with no nutritional value, but eaten simply for their taste? Are these junk foods?

I sure do not envy the policy makers who have to decide what exactly constitutes "junk" food and where exactly to draw the line for healthy vs. unhealthy foods (e.g. Exactly how many calories per gram of food are admissable caloric density? How much refined sugar/sodium/fat per what are acceptable? Are all fried foods automatically junk food? Does throwing in some vitamins, protein and fibre make an unhealthy food healthier? etc.).

Not questions that I want to answer or take a stand on.

As I blogged before, in the context of obesity it's the calories that count - discussing nutrients is out of my league.

AMS
Edmonton, Alberta

When Apple is a Bad Word

This weekend I experienced my first trip to the Yukon, where I attended the 2008 Conference of the Canadian Association of Occupational Therapists (CAOT) in Whitehorse.

CAOT is a partner of the Canadian Obesity Network and I believe that this was the first time that a CAOT conference featured a professional issue forum on Obesity and Healthy Occupation. Speakers in this session, chaired by Mary Forhan (McMaster), included Kim Raine (U Alberta), Gaye Hanson (Hanson & Associates) and myself.

While Kim talked about how obesity has to be seen in the context of societal changes and pressures and I presented the medical perspective on obesity as a chronic disease, Mary talked about the role and opportunities for occupational therapists in obesity prevention, treatment and in allowing patients with obesity to live complete and dignified lives (no matter how good our prevention or treatments, there will always be obese individuals in our society). Gaye, a former Midwife and ex-Deputy Minister of Health and Social Services in the Yukon, herself of Cree Ancestry, presented a most enlightening view of the challenges of addressing obesity in Aboriginal populations.

But for me the most moving insights came from the closing remarks by Madeleine Dion Stout (picture), who was also the keynote speaker at the conference. Born and raised on the Kehewin First Nation in Alberta and nursing graduate from the Edmonton General Hospital, Madeleine worked for many years in the Medical Services Branch of Health Canada and has been a member of dozens of First Nations health committees and task forces aimed at improving the health of First Nations, Inuit and Metis.

The one sentence that I found particularly enlightening was (in the context of obesity - "apple and pears") "don't ever refer to an Indian as an apple!". For an Indian, an apple implies being "red" on the outside but "white" on the inside - not a very polite thing to say! All goes to show how cultural context can fully change the meaning of even the most seemingly innocuous words.

Most interestingly, Madeleine, herself a "victim" of residential schools made the same connection between the pain, suffering, broken spirit and shame inflicted by residential schools and the increased risk for obesity that I had made in my blog posting a day earlier. Imagine my surprise, as Madeleine of course was unaware of my take on the "apology".

Overall a most insightful weekend - much to think about.

Thank you CAOT for inviting me to Whitehorse.

AMS
Edmonton, Alberta

Canada Says “Sorry”

On Tuesday, Prime Minister Harper, on behalf of all Canadians, said “We are sorry” to the Aborginal peoples of Canada for putting generations of them through residential schools aimed at removing them from the influence of the wigwam.

These residential schools began in 1920 and attendance for all aboriginal children ages 7-15 years was made compulsory. Children were forcibly taken from their families by priests, Indian agents and police officers. The last federally run residential school was in Saskatchewan and closed its doors in 1996.

In his address, Harper said:

“The Government of Canada built an educational system in which young children were often forcibly removed from their home, often taken far from their communities. Many were inadequately fed, clothed and housed. All were deprived of the care and nurturing of their parents, grandparents and communities.”

This disastrous and cruel policy resulted in much pain and despair in the First Nations’, Inuit and Metis people that lasts to this day (known as the “generational effect”). Sexual, physical and mental abuse was widespread; students were broken in heart and spirit; culture and identities were destroyed.

Much (if not all) of what ails the Aboriginal peoples of Canada can be traced back to this policy – including possibly issues that affect Aboriginal health to this day.

It is no secret that obesity and its consequences (e.g. diabetes) are rampant amongst the Aboriginal peoples of Canada. While poverty, breakdown of traditional lifestyle and culture and even genetic factors (thrifty genotype) have all been implicated in this, I wonder how much the misery caused by the residential school program had to contribute.

Early traumatic life experiences including sexual, mental and physical abuse as well as neglect and grief have all been implicated in binge eating disorder (BED) – in its purest form – the uncontrollable urge to devour large quantities of highly palatable high-caloric foods in response to emotional hunger. This behaviour has been interpreted as an emotional coping strategy, “filling the inner void”, building a physical protective barrier, etc., the ultimate result being excessive weight gain with all its consequences (the typical binger does not compensate by purging or excessive exercise).

In “treatment-seeking” patients with obesity, the prevalence of BED is estimated at 20-40%. Although I was unable to find a study that has applied the DSM-IV criteria for BED to an Aboriginal population – my guess is: the rates are probably high!

Given its distinct psychopathology, BED is highly responsive to psychotherapeutic approaches. In contrast, educational initiatives based on simply providing information on healthy lifestyles are useless.

Obesity is never an issue of “choice”. I have yet to meet anyone who “chooses” to be obese. This is most certainly also true for Canada’s Aboriginal population.

I look forward to perhaps one day reading a thesis on “The Role of Residential Schools in the Aboriginal Obesity Epidemic”.

I’d be surprised if the author failed to find a clear link.

AMS
Edmonton, Alberta

Gas Poor

So yesterday, I blogged about the fact that nothing short of a catastrophic crisis is likely to reverse the obesity epidemic any time soon. I used the example of $4/litre gas prices.

Today, I heard a term for the first time that kind of addresses this issue: "gas poor".

I've previously heard of "house poor" and "divorce poor" but "gas poor" - to me that was a new one.

So how is being gas poor going to affect obesity?

Here are some scenarios:

1) You decide to continue driving your truck or SUV no matter what - and save on foods - i.e. no more expensive fruits and veggies - more cheap junk food.

2) You decide to switch to the rather ineffective public transportation - your commute to work is now twice as long - you have even less time to exercise or prepare a healthy meal.

3) You decide to work from home - your risk for boredom, loneliness, snacking and even less physcial activity goes up.

4) You decide to walk or ride a bike to work (if you're lucky enough to live close enough) and you get fitter and healthier (even if you don't lose weight).

But seriously, how many of us actually have option 4?

There may be other options like car pooling, moving closer to work, getting a smaller car or Vespa, no idea how those will impact your health.

Interestingly, this week truck drivers in Spain went on strike against the high gas prices resulting in a nation-wide shortage of fresh fish, meat, fruits and vegetables - my guess is people are turning to conserves, chips and (salt-laden) frozen meals.

Perhaps even hope in a "catastrophic" event like astronomic gas prices to prevent and reduce obesity may be futile after all.

AMS
Edmonton, Alberta

Taming the Obesity Giant

This rather "dramatic" slogan was the title of a presentation that I held last night at a public forum on obesity held at the Maclab Centre for Performing Arts in Leduc, a city just South of Edmonton.

The forum was organized by the Leduc health council and was well attended.

My main messages:

1) Obesity is a widespread chronic disease that needs to be resourced in the same manner as other chronic diseases.

2) Although not curable, we do have treatments that are highly effective in reducing morbidity and (at least in the case of bariatric surgery) mortality.

3) Unless we appreciate the tremendous impact that obesity is having as a driver of a wide range of acute and chronic diseases as well as short and long-term disability, and develop the same infrastructure and access to obesity treatments as we do for other chronic diseases, the (avoidable?) spending on obesity-related comorbidities and disabilities (e.g. hip and knee replacements, diabetes, etc.) will simply continue to skyrocket.

4) In the short term, nothing less than a catastrophic event (e.g. gas prices of $4/litre, food shortage, etc.) is likely to reverse the current epidemic.

5) While we discuss how to rebuild our cities and change our food supply, we cannot continue to simply ignore the plight of the Millions already suffering the consequences of this disabling and cruel disease.

Hard words, perhaps not what the audience was ready to hear or digest - nevertheless enthusiastic compliments on talking about these issues without mincing words or providing unrealistic rosy outlooks.

There is an obesity crisis out there and it's not going away anytime soon!

AMS
Edmonton, Alberta

Mood & Food

This weekend (June 8) I was part of a lunch symposium on the Complex Depressed Patient at the 30th Annual Meeting of the Canadian College of Neuropsychopharmacology (CCNP), held in Toronto.

Other members of the panel were Claudio Soares (McMaster), Pierre Blier (Ottawa) and Valerie Taylor (McMaster).

While Soares and Blier focused their discussion on a case of peri-menopausal depression, Taylor and I discussed a patient who was non-compliant with her antidepressant medication due to weight gain.

As blogged previously, weight gain is a common complication of neuropsychiatric medications and there are few proven strategies to treat or prevent it. While there is some data to support co-prescription of metformin or sibutramine with some of the psychotropic medications, this is clearly not current medical practice.

As always, prevention of weight gain may be easier than treating obesity. Thus it may perhaps be advisable to start patients on weight-gain prevention strategies (which may include both behavioural interventions and antiobesity medications) right off the bat rather than trying to treat the excess weight gain or risk non-compliance resulting from the weight gain.

As pointed out by Taylor, based on her own (unpublished) observations and other studies, weight gain with psychotropic medications is by no means benign, resulting in all of the usual complications of weight gain.

We know that simply telling people to eat less and move more is as effective for treating obesity as simply telling people to cheer up is for depression.

Both are complex multifactorial conditions that need to be addressed by behavioural, psychological and often medical interventions - not uncommonly for life!

AMS
Edmonton, Alberta

Hat tip to Bryan Ashuk for suggesting the title for this post

Fracture Non-Union in Obesity

On Saturday (June 7), I presented at a session on How Obesity Affects Orthopaedic Care at the 2nd joint meeting of the American and Canadian Orthopaedic Associatons in Quebec City.

Despite being on the last day of this meeting, the session was surprisingly well attended, probably a reflection of the increasing awareness of issues around orthopaedic care for patients with severe obesity.

While I presented my usual take on how obesity is now a widespread chronic disease, I did take away some interesting aspects related to orthopaedic care of patients with obesity that I was unaware of.

For example, George Russell (Jackson, Mississippi) in his talk mentioned the issue that in severely obese patients immobilization of fractures with a plaster cast poses a significant problem due to the "cushioning" effect of the surrounding adipose tissue. This results in an increased risk of "non-union", often requiring additional internal or external fixation to ensure healing.

Russell also presented an interesting view of how differences in body fat distribution pose specific problems in orthopedic surgery on hips and knees. Thus, in patients with the "large belly - thin limb" phenotype, the operation on the limbs is relatively easy, but, given the association between large bellies and cardiometabolic risk, these patients are at greater risk for poor wound healing and cardiovascular problems. In contrast, patients with "large limbs - thin bellies" present problems related to the size of the limbs resulting in a greater risk for bleeding and wound infections. Obviously, patients with "large bellies - large limbs" are at increased risk for both types of complications.

In a talk on orthopaedic problems in childhood obesity, Benjamin Alman (Sick Kids, Toronto) mentioned the issue of "relatively" (i.e. in relationship to their body mass) lower bone density in children with overweight and obesity, an issue that may increase the likelihood of traumatic fractures in these kids - again, something I had not previously thought much about.

Bassam Masri (UBC, Vancouver) confirmed that despite slightly greater risk and less functionality following joint replacement in patients with severe obesity, their satisfaction is no smaller than that or non-obese patients - clear indication that obese patients should not be denied surgery simply because of their size. But don't expect to see spontaneous weight loss after surgery - in fact weight sometimes even goes up in overweight patients following surgery (I have blogged on this before).

I was particularly happy to note that all three surgeons called upon their colleagues to show compassion and deliver care with the same professional attitudes with which they approach their non-obese patients.

Overall, a most interesting session. I am delighted to see the orthopaedic surgeons taking this great interest in these (unfortunately) increasingly important issue.

AMS
Edmonton, Alberta

Cell Biology to City Building

Yesterday I spent all day listening to student presentations at the 1st Canadian Obesity Student Meeting in Quebec City.

The topics literally ranged from cell biology to city building. All presentations were by students from across Canada, selected and moderated by students. Because there are so few "old" folks like me in the audience, the students actually have the guts to stand up and ask questions - something they may not do at "regular" conferences.

And the quality of the data (all original) is as good as at any "regular" meeting I've ever been to. This of course is not surprising since it is exactly the same data being presented at other meetings, except that at those meetings it is often the supervisor presenting rather than the young students, who actually did most of the work.

You can sense the excitement and enthusiasm in the room. The nervousness, the pride, the sincerity of the presenters.

For many, it is the first time they expierence themselves as organizers, moderators, chairs, jurors, and even interviewees in front of a camera.

I am not going to mention any of the actual findings - all I will say is that anyone interested in obesity can look forward to a whole slew of great papers coming out of Canada in the near future.

I cannot but feel proud that this meeting would not have happened without the strong partnership between the Canadian Obesity Network and the Merck-Frosst/CIHR Obesity Chair, Laval University.

I am also grateful to all the supervisors and senior researchers for sending their students to this meeting and allowing them to present their data at such a "minor" forum.

I sincerely hope that this will only be the first in a whole series of student meetings and already look forward to the next one.

AMS
Quebec City, Quebec

Obesity Network Students

Last night I presented a talk on Developing Research Careers in Obesity to the over 150 attendees of the 1st National Obesity Student, Meeting held at Laval University, Quebec. This meeting is co-organized by the CIHR/Merck-Frosst Chair for Obesity at Laval University, Ste.-Foy, Quebec and the Canadian Obesity Network. The students who come from universities across Canada are currently working on their Masters or PhDs in areas ranging from cell biology to city building.

The meeting is not only intended for students but is also entirely organized by CON students and new professionals (CON-SNPs): they chose the abstracts, chair the sessions, decide on the awards and everything else that goes into running a meeting.

Not only is this an opportunity for the next generation of obesity researchers in Canada to present their data but also an opportunity for them to gain first-hand experience in chairing and moderating sessions and interacting with their peers.

As I emphasized in my talk, developing a career in any field not only depends on doing good original work but also often depends on who you know and (sometimes more importantly) who knows you. The student meeting provides ample opportunity for students to practice their social skills in getting to know their peers but also to build relationships that will serve them in the future.

Needless to say, the senior faculty present at this event are happy to take a back seat and watch the future generation of Canadian obesity researchers and practitioners take the stage and run this event.

I, for my part, am happy to be part of this and to meet all these young attendees and watch them do their thing.

By the looks of it, obesity research in Canada is alive and kicking.

AMS,
Quebec City, Quebec

Pharmacists in Obesity Management

Tuesday I spoke on obesity treatment to around 100 pharmacists from the Capital Health Region. For many of the attendees, this was the first time they heard a formal "CME" on obesity. This is unfortunate.

Pharmacists are the frontline health professionals who are probably most often asked about weight management. They are accessible, well versed in practice guidelines and of course dispense and sell both prescriptions and non-prescription remedies for weight management.

Pharmacists also regularly dispense the host of medications that can promote weight gain and they could therefore also play an important role in preventing iatrogenic obesity by warning their clients about potential weight gain and recommending preventive strategies- after all preventing weight gain is always easier than trying to lose those extra pounds once they're there.

The idea of engaging pharmacists in weight management is very much in line with the role for Pharmacists promoted by Alberta Health and Wellness, which in its recent Action Plan on Health 2008-2009 calls for immediate actions in expanding the role of pharmacists in preventing and managing chronic diseases.

The notion of engaging pharmacists in obesity management is also the goal of the National Obesity Certification Program for Pharmacists offered by the Ontario Pharmacist Association in collaboration with the Canadian Obesity Network.

Given the magnitude of the obesity epidemic - there is a role for ALL health professionals in promoting evidence-based obesity prevention and treatments.

AMS,
Edmonton, Alberta

June is Bike Month

I've always liked biking. Back in med school, I biked straight across Berlin (Neukoelln to Dahlem) and back every day and on certain days all the way from Neukoelln to Dahlem to Wedding and back to Neukoelln (probably around 70 Km or so). The funny thing was, I thought nothing about it - it was simply the easiest and quickest way to get around.

That's the kind of "exercise" I like - physical activity that you have to do to actually do something - very different from "non-utilitarian/recreational-type" stuff that most people seem to be into (honestly, I can think of a million things I'd rather do in the little free time I have than to exercise simply for the sake of exercising).

So of course, now that Summer is almost here (yes, there actually is a Summer in Edmonton), I've gone out and bought a bike and ride it to work everyday (at least I did all of last week - so far, so good). It's only 25 mins one way - faster than ETS and not much slower than by car at rush hour (hey and parking's free!).

All of this just in time for Bike Month in Edmonton. As the "City of Festivals", it should be no surprise that there actually is a Bikeology Festival here. Tons of cool events like ride to work challenges, bikey breakfasts, ride-in outdoor movies, bike salons, guided tours and even a "make your own jewelry out of bicycle trash" class.

Not sure I'll be taking part in all of this but I sure will be out there riding my bike to work and back.

Living within walking distance to work - luxury!

Living within biking distance to work - bliss!

AMS
Edmonton, Alberta

Image by Paul Turnbull

Little Big Run 2008

I am not a runner - I prefer walking. So yesterday, I participated in the 5 K walk at this year's Little Big Run.

The hardest part was getting up at 6.30 on a Sunday to actually get to the start. In fact, I had to first ride 7 K on my bike to get to the "run" and of course I rode my bike back after that (more on the bike stuff in tomorrow's post).

The Little Big Run was founded by The University of Alberta, Capital Health and the City of Edmonton and the idea is to get people moving. This year, there was even a 1 K walk, especially for those folks for whom even that is a challenge - some of my patients actually did this one - pretty much a "miracle" for some.

Of course there were all the usual "fitness types" out on the course, but more importantly, I was happy to see how many "normal" folks showed up, kids, walkers, pets and all. I am sure, for some, this was the first time they'd ever actually walked downtown.

Congrats everyone for showing up! Thanks to the organizers for pulling this off! Thanks to all the sponsors for their great support!

AMS
Edmonton, Alberta