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).

AMS

Obesity Classification: Time to Move Beyond BMI?

Current definitions of obesity based on BMI and waist circumference (WC), while widely accepted, are hardly helpful in counseling individual patients. Readers of my blog are probably quite familiar with my views on this.

As most clinicians will readily agree, when dealing with indiviual patients, both measures lack sensitivity and specificity with regard to identifying the presence or risk of obesity-related risk factors, comorbidities, psychopathology, global functioning or quality of life.

In fact recent epidemiological studies emphasize that good health including low morbidity and mortality is possible over a wide range of BMI. Thus, basing the decision on who to treat and who to leave well alone solely on measures of weight or size is neither sensible nor does justice to the complexity of the relationship between excess body fat and its impact on health and well-being. The well-established obesity-chronic disease paradox makes decisions on who to treat and who not to treat even more uncertain.

Telling healthy large people who have no apparent comorbidities, functional limitations or reduced well-being to lose weight may be counterproductive in that it can introduce and reinforce dissatisfaction with body image, foster frustrations and despair (given the poor long-term success of weight loss attempts) and lead to unhealthy behaviours focusing on weight loss (e.g. excessive exercise or dieting) rather than on healthy lifestyles (which are possible at almost any weight).

Thus, for practical purposes, it is important to move beyond defining who needs obesity treatment simply based on BMI and/or WC to a more clinically meaningful system.

Indeed, what we direly need is a classification of obesity that is clinically relevant in that it helps identify patients who have or are at high-risk of obesity-related complications and are most likely to benefit from treatment.

In this context, it may be worthwhile to look at the systems of classification and staging used for other disease states.

Oncologists have long used the TNM system to classify the extent of cancer spread. This system has established itself for the classification and staging of the vast majority of cancers not only because it is clinically meaningful in that it reflects extent of disease, indicates prognosis and allows evaluation of treatment response but also facilitates surveillance and research.

Psychiatrists and other mental health workers now routinely report on their patients using the five axes set out in the DSM-IV, each of which refers to a different domain of information that help the clinician plan treatment and predict outcome. The five axes are:

Axis I Clinical Disorders (all mental disorders except Personality Disorders and Mental Retardation)

Axis II Personality Disorders and Mental Retardation

Axis III General Medical Conditions (must be connected to a Mental Disorder)

Axis IV Psychosocial and Environmental Problems (for example limited social support network)

Axis V Global Assessment of Functioning (Psychological, social and job-related functions are evaluated on a continuum between mental health and extreme mental disorder)

While these systems are by no means simple or easy for the layman to understand, they are clinically useful and provide a standardized framework within which it is possible to describe the extent and impact of disease in a way that all clinicians, researchers and payors will understand.

Contrast these systems to the rather simplistic obesity classification, where knowing that a given person has Class II obesity (BMI 35-39.9) tells you virtually nothing about that person's health or well being. Furthermore, it provides no meaningful guide in determining outcomes: e.g. someone who weighs 120 Kg with a BMI of 39 (Class 2 obesity) despite losing 10 Kg (8% weight loss) still has Class II obesity (BMI 36). This classification neither tells us what (if any) comorbities were actually present or whether (or not) these actually got better.

Now I am no expert on disease classification and realise the large amount of work and consensus meetings that go into developing these classification systems. But I am a clinician, who regularly sees patients and would be happy to see even the simplest form of staging that provides a meaningful framework.

The simplest classification I can think of would be to use a staging system similar to the following:

Stage 0: no apparent obesity-related risk factors (blood pressure, lipids, glucose, etc.), physical symptoms, psychopathology, functional limitations, or impairment of well-being

Stage 1: presence of obesity-related sub-clinical risk factors (elevated blood pressure, impaired fasting glucose, fatty liver, etc.), mild physical symptoms (dyspnea on moderate exertion, occasional aches and pains, etc.), mild psychopathology, mild functional limitations or mild impairment of well-being

Stage 2: presence of established obesity-related chronic disease like hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, depression, anxiety disorder, moderate limitations in activities of daily living and/or well being.

Stage 3: established end-organ damage like myocardial infarction, diabetic complications, severe osteoarthritis, significant psychopathology, significant functional limitations and impairment of well-being

Stage 4: severe (end-stage?) disabilities from obesity-related chronic disease, severe disabling psychopathology, severe functional limitations and severe impairment of well-being

Thus for e.g. a 24 year-old physically active female with a BMI of 32 with no measurable risk factors, functional limitations or self-esteem issues would have Class I, Stage 0 Obesity - benefits of treatment will be marginal or non-existent.

A 32 year-old male with BMI of 36 with hypertension and sleep apnea would have Class III, Stage 2 Obesity - definite indication for obesity treatment.

A 45 year-old female with BMI of 54 who is in a wheel chair because of severe gonarthritis with severe hypoventilaltion would have Class III, Stage 4 Obesity - will require aggressive obesity treatment unless deemed palliative.

But this may not be the only conceivable system. In fact, given the significant importance of psychopathology, personality traits, physical disease, psychosocial and enviromental factors as well as global functioning, I wonder if an approach similar to the axes in DSM-IV may be best. Of course, one could easily envision combinations of both systems, e.g. applying staging to Axis III disorders.

Obviously any such system would need careful definitions and perhaps a complex manual of diagnostics and classifications similar to DSM-IV - but at least we would have a way to assess, describe, treat, monitor and research obesity in a way that goes beyond the relatively meaningless anthropometry-based classification, which is nothing short of useless in clinical practice.

I can see why health authorities, professional organisations and even clinicians may be reluctant to devise a more complex classification of obesity - all I can say is that the present classification does not provide a meaningful framework in which to make clinical decisions or evaluate outcomes. There is certainly a need for a more complex system to guide practice (and research).

More often than not in clinical medicine - simple is simply wrong!

AMS
Edmonton, Alberta

Rimonabant for CAD - it's Not Just About the Heart

The heart is an important organ. Heart disease kills millions every year. Abdominal obesity is an important risk factor for heart disease. Medical treatments for obesity should help reduce cardiovascular risk.

Not surprisingly, several large studies are examining the effect of anti-obesity drugs, both old (e.g. sibutramine) and new (e.g. rimonabant), on cardiovascular morbidity and mortality.

This week, one such study reported on its results. STRADIVARIUS, a double-blind randomized controlled trial with over 800 patients conducted at 112 centres in North America, Europe and Australia was designed to determine whether treatment with 20 mg of the CB-1 antagonist rimonabant (an anti-obesity drug now available in many countries but not in Canada or the US) would reduce progression of coronary artery disease (CAD) in patients with abdominal obesity and the metabolic syndrome. Progression of CAD was measured by intravascular ultrasound (IVUS) before and after 12 to 18 months of treatment.

On average, patients on rimonabant lost 4.5 Kg and as many cms off their waistlines. HDL cholesterol, triglycerides and HbA1c levels (in patients with diabetes) improved as expected. Although the primary endpoint (change in percent atheroma volume) was not different between rimonabant and placebo, other measures of atherosclerosis appeared to change favourably. Rimonabant was well tolerated although (as expected) there were more psychiatric and gastrointestinal side effects and discontinuations in the rimonabant group.

So why, with the significant reduction in weight and risk factors were the results not more positive? The authors speculate that this may have been because patients were already receiving effective treatment for CAD (e.g. 80% of patients were on statins). Therefore showing incremental benefits of adding rimonabant would have been difficult.

The real question to ask, however, is whether or not influencing heart disease is indeed the best and most important use of an anti-obesity drug. We already have a multitude of effective medications to reduce the progression of heart disease. When used according to current guidelines, these agents can indeed markedly reduce the risk of cardiovascular disease (obviously, this risk will never be zero, no matter how good the treatment).

So is reduction in heart disease really the great "unmet need" when it comes to obesity treatment? As a bariatrician, I would say NO!

Yes, while preventing heart disease (or its progression) is perhaps one benefit of treating obesity, I can think of many other benefits that are relevant to patients battling obesity-related comorbidities for which we currently have no effective medical treatments.

My short list would include sleep apnea, osteoarthritis, hepatic steatosis, polycystic ovary syndrome, infertility, pseudo tumor cerebri and many more. Sure, these conditions may not sound as dramatic as heart disease and may be less likely to kill you, but for the people who have these problems, these conditions are very real, distressing and affecting their quality of life. If obesity treatments can help alleviate these conditions, perhaps even just limit exacerbation by helping curb further weight gain, a lot would be won.

Remember, obesity is a chronic disease with virtually 100% rezidivism. It significantly affects many aspects of mental, physical and socioeconomic health. Effective treatments for obesity are required irrespective of whether or not they also help reduce heart disease.

Unfortunately, pharma companies, regulators and payors appear obsessed with the cardiometabolic consequences of obesity and fail to see the urgent need for treating obesity-related comorbidities beyond heart disease.

So, while the results of STRADIVARIUS are nice, I'd be far more interested in whether or not rimonabant reduces obesity-related comorbidities for which we have no alternative treatments - at least that's where I'd put my research money if I had any say in the matter.

AMS
Edmonton, Alberta

Walk and Work

Two days ago I reminded readers that not too long ago, people were actually paid to be physically active. Today, choosing to be physically active actually costs money (not to mention time).

So the big challenge is, how do we reintroduce activity into the work place so that people can actually be physically active at work again (allowing them to lounge around the couch in front of the TV when they get home).

Well, one obvious solution is to create a workspace where someone can get a workout in while on the computer. That is exactly the idea behind the "Walk Station" a desk that comes matched with a treadmill instead of a chair.

The device, the science (and the hype) behind it are described in an article from the Edmonton Journal from which I quote:

The device allows people to work on their computers while walking on a treadmill at a slow speed of up to three kilometres per hour, enabling small amounts of movement that supporters say have the potential to reap big health benefits.

The product, made by Details, a unit of Michigan-based office furniture maker Steelcase, is selling 30 to 40 units per week, according to company president Bud Klipa.

The Walkstation was unveiled last year based on research from James Levine, a researcher at the Mayo Clinic, who contends that fitness can be improved through small, modest movements for people who are otherwise sedentary.

Levine's research indicates that people who use the Walkstation can increase energy expenditure by 100 calories per hour when walking at a 1.6 kilometres (one mile) per hour, helping weight loss.

The treadmill, which costs around $4,500 for a base model, never exceeds a speed of three kilometres per hour, which, according to the manufacturer, allows most people to use it for a few hours each day.

So here are my questions:

Where is the evidence that this device will actually promote weight loss?

What will prevent this device from going down the same path as previous workplace health initiatives - embraced by the already fit, ignored by the people who need them most?

Will it increase weight-based discrimination at the workplace - the thin people are walking, the overweight are not - no one stops to ask why - back pain? osteoarthritis? depression? plantar fasciitis? - excuses, excuses! Who cares!

Although is seems like a good way to reintroduce activity into the workplace, it is still "useless" activity, i.e. you are not actually paid to walk - or in other words, you don't really have to walk to get your job done.

While I personally would probably not mind having this device, I can see all sorts of problems - anyone out there who's experienced this or a similar device - I'd love to hear how this has influenced intra-office dynamics.

I will maintain my scepticism on this being the answer till I see some actual data.

AMS
Edmonton, Alberta

Obesity and Hip Replacements

Overweight and obesity are well-established risk factors for osteoarthritis and a major factor in driving the increasing demand for hip and knee replacements.

How does being overweight or obese affect functional outcomes of hip surgery?

This question was addressed by André Busato and colleagues from the Institute for Evaluative Research in Orthopaedic Surgery, University of Berne, Switzerland in a paper just out in Obesity Surgery.

Busato and colleagues quantified the role of high preoperative BMI on long-term pain status and functional outcome after total hip replacements in a multi-center cohort of 20,553 primary hip replacements (18,968 patients) and 43,562 postoperative clinical examinations for a follow-up period of up to 15 years.

Despite equal pain relief in obese and lean patients, there was an almost perfect dose-effect relationship between preoperative BMI and decreased ambulation during the follow-up period.

This means that despite improvement in pain, patients with higher BMIs tend to regain less mobility following the hip replacement.

While the authors suggest that lifestyle management and pre- or post-surgical weight loss will improve outcomes, this has yet to be demonstrated in a large randomized trial.

It may well be that other factors unrelated to pain may be affecting mobility in heavier patients. In fact many factors that may have led to the weight gain in the first place may not be resolved simply by having a hip replacement.

This observation is not different from that of a previous study that I recently blogged on which reported that back surgery for pain relief in patients with spinal stenosis does not automatically result in increased mobility or weight loss.

Obesity is a multifactorial chronic disease and the long-term impact of educational and behavioural interventions is modest at best.

When present, obesity has to be addressed with the same interdisciplinary acumen and persistence as any other chronic disease.

AMS
Edmonton, Alberta

Recommend and They will Exercise - Or will They?

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

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

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

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

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

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

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

AMS

The Real Cost of Obesity May Not be in Health Care

When you follow the current public discussion on the consequences of obesity, the focus is most often on the potential costs for health care. This is not surprising, given that obesity is directly linked to a wide range of chronic diseases including hypertension, type 2 diabetes, sleep apnea, osteoarthritis and many forms of cancer.

But health risk are not the only cost of obesity. Even a cursory glance at the patients presenting in our clinic immediately makes it evident that a disproportionate number are on short or long-term disability, not working to their full potential or simply unemployed. If you take into consideration that the average age of patients in our clinic is in the lower 40s, it immediately becomes evident that there are economic losses to society here that go well beyond the simple costs of health care.

Numerous studies have in fact documented that obesity may have important economic consequences for individuals - and thus society.

This was once again demonstrated in the largest study on this issue to date. Nina Karnehed and colleagues from the Karolinska Institute in Stockholm examined social mobility in over 750,000 men born between 1951 and 1965. Subjects were studied at age 10 and again at age 30.

Men who were obese at age 18 were almost 30% less likely to be upwardly mobile (achieve a higher socioeconomic status than their fathers) and 30% more likely to be downwardly mobile (achieve a lower socioeconomic status than their fathers) compared to normal weight men. This finding was independent of childhood socioeconomic index (SEI), IQ or education, suggesting that societal factors (e.g. bias and discrimination) may be responsible.

This difference is substantial. Downward social mobility means less income and lower SEI with all its consequences. These costs to society may be far greater than any costs to health care.

I am no economist, but I don't find it difficult to imagine that when a substantial proportion of the population (currently 25% of all adults) are at risk of not realizing their full economic potential this could mean a huge loss for the overall economy.

Thus, apparently obesity not only affects mental or physical health but also socioeconomic health - an important consequence of the obesity epidemic that I have not heard much about in the media or elsewhere.

Perhaps the increased health care costs of obesity are the least of our worries.

AMS
Edmonton, Alberta

Obesity Treatment is Prevention!

In the August 4 issue of the Globe and Mail, the science journalist Andre Picard puts forth the argument (as discussed at the International AIDS conference) that AIDS treatment is prevention because treated patients are less likely to transmit the disease.

The same, if not more, could be said about treating obesity. Not only is obesity a major driver of a laundry list of mental and physical health issues, including type 2 diabetes, osteoarthritis, and cancer – its treatment has been well documented to help prevent, and in some instances, even cure these conditions. Thus, for example, obesity treatment not only prevents type 2 diabetes, but can often reverse it to the point of cure. Obesity surgery also reduces cancer deaths by 60%.

But obesity treatment is perhaps also the most effective prevention for obesity itself. There is now accumulating evidence that genetic modifications that occur in the womb and during the first months of life in the offspring of overweight and obese mothers, essentially programs their kids for obesity later in life. Perhaps the best example of how aggressive obesity treatment in women can prevent obesity in their kids comes from a Laval University study where the children of obese women, who had undergone obesity surgery, were far less likely to become obese than expected.

Many experts now believe that perhaps our best handle on the childhood obesity epidemic is to also aggressively target the parents for obesity treatments – indeed, there is little evidence that treating the kids without doing the same for the parents is likely to be successful in the long term.

Furthermore, the recent observation that obesity may be “contagious” amongst peers, has also prompted serious discussions about whether targeting obese individuals would prevent the spread of this disorder to friends and family.

Thus, while we wait for policy makers and individuals to make important inroads into obesity prevention by changing our obesogenic environment and lifestyles, we need to also seriously step up our investments in obesity treatments – not only for the sake of the individuals who struggle with this condition – but also for the sake of their families and friends.

AMS
Edmonton, Alberta

No Food For the Lazy!

Yesterday, newspapers reported widely about the UK conservative leader David Cameron calling on the obese, the idle, and even the poor to accept some responsibility for their plight.

According to Cameron, society has become "far too sensitive" to people's feelings, with no one prepared to say "what needs to be said." "We talk about people being 'at risk of obesity' instead of people who eat too much and take too little exercise".

Great stuff! So all fat people eat too much and are lazy - they deserve their plight! In other words, let's stop coddling them and let's certainly not bother providing them with any health services for their plight.

Perfect. Let's next stop providing services for all smokers who get heart attacks or cancer, no more trauma surgery for anyone who gets injured driving above the speed limit or, God forbid, gets run over jay walking. No more health services for anyone coming down with influenza who did not get his flu shot, no more medical freebies for people spraining their ankles at sports, and obviously definitely no more medical help with "lifestyle diseases" like diabetes, high cholesterol, hypertension, osteoporosis, osteoarthritis and back pain.

Everyone is the master of their own destiny.

Thank you Mr. Cameron for saying what needed to be said.

Anyone feeling depressed? Suck it up!

AMS
Edmonton, Alberta