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

Does Obesity Surgery Convert "Bingers" to "Grazers"?

Classical Binge Eating Disorder (as defined by DSM-IV) is found in around 20-40% of severely obese patients presenting at bariatric centres (including ours). Numerous studies have shown that patients with BED can achieve significant weight loss, resolution of comorbidities and improvement in quality of life with obesity surgery and therefore should not generally be denied surgery.

Nevertheless, many centres (including ours) are reluctant to operate on patients with active BED fearing poorer outcomes and greater distress. It turns out that we really don't know much about how bariatric surgery affects eating patterns in patients with BED.

This question was now addressed by Susan Colles and colleagues from Monash University in Melbourne in a study published in the March issue of OBESITY. Colles and colleagues planned to study eating behaviours in 180 patients before and 12 months following laparoscopic adjustable gastric banding (LABG). Of these, 6 did not receive surgery, 1 died of a myocardial infarct and 44 (25% of eligible subjects) did not return for the 12-month survey (more on this later).

While only 14% of patients had BED at baseline, 31% were described as "uncontrolled eaters", 40% had night eating syndrome (NES) and 26% were "grazers".

Although all groups, including the "bingers" lost similar amounts of weight and BED reduced to 3% in this group, patients with preoperative BED were most likely to develop uncontrolled eating or grazing. Patients who reported uncontrolled eating or grazing after surgery tended to lose less weight and reported greater psychological distress.

Interestingly, the authors report that the 12-month non-responders were more likely to have had presurgical BED, have lost less weight and attended less clinic appointments. This may be due to patients with these behaviours feeling more ashamed about their "loss of control" and therefore avoiding follow-up visits.

This study highlights the risk of preoperative "bingers" to become "uncontrolled eaters" or "grazers" resulting in psychological distress and poorer weight outcomes. As these patients are more likely to drop out of follow-up they may also be at increased long-term risk of nutritional deficiencies and other long-term complications of bariatric surgery.

In an accompanying paper in the same issue of OBESITY, Colles and colleagues describe how "loss of control" may be at the root of the significant psychological distress of patients with BED resulting in their greater likelihood of seeking out bariatric surgery as a means to control their eating behaviour. This may well in part explain the high prevalence of BED in patients presenting in bariatric clinics.

Clearly, we need to learn more about how to pre-screen patients for potentially poor outcomes and how best to monitor post-surgical patients for the development of aberrant eating behaviours.

Given that BED, once diagnosed, is actually quite responsive to psychological treatments resulting in a remarkably high rate of resolution, I wonder about the rational for operating on patients with active BED - after all weight loss should not be the only parameter by which results of obesity surgery are measured.

AMS
Edmonton, Alberta