$75 Million for Bariatrics in Ontario

Big news for patients with severe obesity in Ontario. As part of a $741 Million announcement for a provincial diabetes strategy, the Ontario Health Minister yesterday announced $75 Million in funding for Bariatric Centres of Excellence.

As outlined in the press release:

"Obesity is one of the main risk factors associated with diabetes. More than 50 per cent of type 2 diabetes cases in Ontario are associated with obesity. The government is improving access to bariatric surgery - a procedure that modifies the gastrointestinal tract to reduce food intake. This $75 million initiative will increase Ontario's capacity for bariatric surgery several-fold within two years and it will continue to increase thereafter. In 2006/07 169 procedures were performed in Ontario and 485 patients were funded for surgery out of country.

Ontario will enhance capacity for bariatric surgery in the province by:

- Providing bariatric education and training to health care providers
- Expanding bariatric surgical capacity
- Establishing pre and post bariatric surgery programs that will be linked to surgical programs"

Clearly, a first sign of relief for Ontarians who have thus far had to travel South of the border or scrape together the money for private bariatric surgery.

What I particularly like about the announcement is the emphasis on training health care providers and making sure both pre- and post-surgical care is in place. As I have blogged before, obesity surgery is not just about surgery. The actual operation is only a small technical piece in a complex life-long management plan.

I am particularly pleased by the announcement, because I believe that my past efforts in Ontario, including lobbying of the Government to provide better bariatric care, may in part have led to this announcement. As some readers may know, not only have I been quite vocal about this, but I was also the Clinical Co-Chair of the Health Technology Utilization Guidelines group that was contracted by the Ontario Health Ministry to prepare recommendations for Bariatric Surgery in Ontario.

We made it clear in this guideline document that bariatric care requires an interdisciplinary team and needs to take a chronic disease management rather than an acute-care approach to dealing with this issue.

Given that there is nothing different in the magnitude of the problem or the desperate need for bariatric care between Ontario and other regions of Canada, I can only hope that this announcement will be rapidly followed by similar announcements from other provinces.

Here in Alberta, we certainly have many of the components already in place (at least in the Edmonton Region) - and of course we'd be more than happy to share our experience with our colleagues in Ontario - the sooner we can get the services in place across all of Canada, the better for everyone.

AMS
Edmonton, Alberta

Do Workplace Wellness Programs Promote Discrimination?

The obesity epidemic is costing employers. Earlier this year, The Conference Board estimated that obesity-related health problems cost US companies an estimated $45 Billion each year in medical coverage and absenteeism - more than smoking or problem drinking.

Not surprisingly, employers and health care plans have long recognized the importance of promoting and perhaps even coddling employees into participating in "wellness" efforts. The idea is a no-brainer: healthier employees are more productive - a great investment for any company.

But with any good idea, the devil is in the details. The legal limits and potential for well-meant wellness programs (especially when promoted by health-care plans and payers) for promoting discrimination are discussed in a recent article by Michelle Mello and Meredith Rosenthal from the Harvard School of Public Health published in the July 10 issue of the New England Journal of Medicine.

In their analysis, Mello and Rosenthal focus on the impact of the nondiscriminatory provisions of the US Health Insurance Portability and Accountability Act (HIPPA) of 1996, which bars health plans and issuers of group health insurance from discriminating on the basis of a health factor.

The general rule is that no person can be denied or charged more for coverage than other "similarly situated" persons because of health status, genetic history, evidence of insurability, disability, or claims experience. In this context "similarly situated" refers only to an employment-based classification, such as full-time or part-time, not on health factors.

As a result of this, health plans can only opt not to provide coverage for particular health conditions, if this applies to all "similarly situated" individuals and is not based on whether or not people actually have that health condition.

While HIPAA is designed to prevent health discrimination, it does allow insurers and health plans to reward members for participating in health-promotion programs (e.g. reduced premiums, payouts, etc.) as long as the reward is open to all members (irrespective of whether or not they actually have a health problem). HIPAA, however, makes it particularly difficult for plans to tie these rewards to actually achieving an individual health target - i.e. it allow rewards for participation but not success.

In the rare cases that insurers do tie rewards to achieving health targets, there are important restrictions in place. In this regard, the provision that in cases where it is "unreasonably difficult" or "medically inadvisable" for a person to satisfy the health standard owing to a "medical condition" must be offered a reasonable alternative standard.

As pointed out by Mello and Rosenthal, the problem with this restriction is that no definition of "medical condition" is provided. So whether or not someone with overweight or obesity can be expected to achieve a target weight ultimately depends on whether or not the prior presence of excess weight is defined as being a "medical condition" or not - obviously, this leaves the room wide open for weight-based discrimination. It is certainly easier for someone with little excess weight to achieve an arbitrary "ideal weight" than for someone with a lot to lose - no matter that actually keeping the weight off becomes an exponentially bigger challenge the more you lose.

It is clear that whether or not excess weight in a given individual is caused by genetic predisposition, psychosocial factors, comorbidities or obesogenic medications, or, is simply a matter of poor "choices" and "sloth" will in most cases remain a matter of debate.

To me, the overall problem remains in the focus of employers, insurers and policy makers in general on the promotion of individual changes rather on than shifting society as a whole to a healthier lifestyle for everyone.

Given the multidimensional sociocultural, psychological and biomedical nature of obesity, answering "chicken and egg" questions or trying to pinpoint the primary causal factor is nigh impossible.

Perhaps one solution is to take "weight" out as a measure of health - either as a promoting factor or as a target.

As I have pointed out repeatedly, good health is possible over a surprisingly wide range of body weights and there is a wide variation in individual susceptibility to "weight-related" health problems. No one weight cuttoff will work for everyone - clearly, we have no idea what a good weight target should be, as our definitions of healthy weight are entirely defined on the presence or absence of comorbidites and/or functional limitations in a given individual or on actuarial morbidity and mortality statistics that, in turn, are simply not helpful when dealing with individuals.

I certainly do not envy the lawyers and policy makers who have to address this complex issue with "legalese". I am glad I am just a simple clinician helping patients conquer their obesity one step at a time.

Look forward to any comments on workplace wellness and its legal framework in Canada (or in Germany from my German readers).

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

Germany Wakes up to Obesity

As elsewhere in Europe, obesity is on the rise in Germany. According to government statistics, two-thirds of all German men between the ages of 18 and 80 are overweight and almost half of all women have a weight problem. These numbers add up to about 37 million adults and 2 million children and teenagers suffering from some kind of weight related disorders.

In response, the German government has now embarked on a new obesity initiative prepared by Health Minister Ulla Schmidt in cooperation with Food, Agriculture and Consumer Protection Minister Horst Seehofer. The program's initiative is to cut diseases related to obesity drastically by the year 2020, and foresees spending 30 million euros ($46.7 million) over the next two years.

As everywhere else, in Germany too, the government recognizes that the epidemic is not only a result of poor nutritional habits and lack of exercise but also wide-ranging societal and infrastructural factors. It therefore calls on politicians, scientists, health-care providers, unions and the food industry to help educate and promote healthier lifestyle approaches. As one may guess the ideas include: education on healthy eating and physical activity, tougher standards on school food programs, better product labeling by the food industry, reduced advertising by the makers of sweets and junk food that target children, i.e. essentially the usual list of initiatives.

As everywhere else, in Germany too, the government largely ignores one major consequences of the fact that 37 Million Germans are already living with this chronic disease, namely that this also calls for an immediate need to provide improved access to evidence-based obesity treatments with expansion of the resources to do so.

As in most other countries (the UK being a remarkable exception), access to professional obesity treatment that includes behavioural therapy, anti-obesity medications and surgery remains limited to a ridiculously small number of individuals, mostly those who can afford "private" payments for these services.

As I have blogged before - promoting obesity prevention (and hoping for these to kick in) should not be an excuse to deny obesity treatments to those already affected by this condition.

AMS
Edmonton, Alberta

p.s. incidentally, my blog is now also available in German

Image Rainer Zenz

Count Those Liquid Calories!

Yesterday, the Edmonton Sun did a full-page feature on me because they find it kind of special that I ride my bike to work (guess it is special in car-loving Alberta).

Of course the article also includes the obligatory Dr. Sharma's tips which starts off with Tip #1: beware of liquid calories like in juices, pop or alcohol - at least, count them as part of your meal, as they can quickly add up.

Almost on cue, the Consumer Federation of America (CFA), in attempting to fill the void in consumer information on liquid calories, yesterday released Alcohol Facts, a side-by-side comparison of the alcohol, calorie and carbohydrate content per serving of the top 26 domestic and imported alcoholic beverage brands sold in the US.

Alcohol Facts reveals significant differences in the amount of calories and carbohydrates for beer, wine and distilled spirits both by category and by brand.

* Among spirits, calories per serving ranged from 86 calories for spiced rum to 120 calories for gin. The average (not including mixers) was 98 calories per serving;

* For wines, calories per serving ranged from 105 calories for a merlot to 125 calories for a cabernet sauvignon. The average was 118 calories per serving;

* The greatest variation in calories occurred among beers and flavored malt beverages. Light beers (5 brands) averaged 100 calories per serving, regular beers averaged 140 calories (5 brands) per serving, and the flavored malt beverages (3 brands) ranged from 190 calories per serving to 241 calories per serving; 

* Variations were greatest when analyzing carbohydrate levels. Compared to no carbohydrates in spirits, wines ranged from 0.8 grams per serving for chardonnay to 5.0 grams per serving for cabernet sauvignon. Among different beers and malt beverages, carbohydrates ranged from 3.2 grams per serving for light beer to 38 grams per serving for a flavored malt beverage.

The CFA is strong on promoting caloric labeling on alcoholic beverages, which till now only contain the alcohol in %. (to calculate the calories, you'd first have to calculate the grams alcohol per serving, multiply by 7 and then you are still missing the calories from carbs - so calculating the calories for alcoholic beverages for consumers is virtually impossible!)

From my own practice I can only confirm that it is not that unusual to find patients regularly consuming over half their caloric needs in fluids, including alcohol.

Putting calories on alcohol bottles may not stop people from drinking, but at least it allows them to count those calories in their daily allowance.

Happy Canada Day!

AMS
Edmonton, Alberta

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

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

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

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

Early Obesity Predicts Early Disability?

Given the strong relationship between excess weight and emotional, physical and economic health, it may be reasonable to pose the question whether obesity is a risk factor for early disability?

This question was just addressed by Martin Neovius and colleagues from the Karolinska Institute, Stockholm, Sweden, who examined the association between obesity status in young adulthood and disability pension in Sweden (International Journal of Obesity).

The aim of this study was to investigate risk of future disability pension according to body mass index (BMI) in young adulthood. BMI was measured at military conscription (1969-1994) in 1,191,027 young male recruits. Date and cause of disability pension, death and emigration dates were collected from national registers (1971-2006).

During 28.4 million person-years, 60,024 subjects were granted disability pension. The hazard ratios (HRs) for overweight (1.36), moderate (1.87) and morbid obesity (3.04) were significantly elevated compared to normal weight individuals.

Excess disability was associated with problems related to circulatory, musculoskeletal, tumor, nervous system, and psychiatric disorders.

Based on these data, the authors suggest that productivity losses associated with adverse BMI in young adulthood appear to be large (a rather stark understatement, if I ever heard one).

Remember, this was a study on people whose BMI's were high as far back as 1969. Given our present obesity epidemic in children and young adults, I wonder what disabilty rates will look like 20 years from now.

I don't want to be the fella spreading doom and gloom all over, but it sure makes me wonder whether, despite all the talk, we are really doing all we can to prevent and treat obesity.

AMS
Edmonton, Alberta

End of US Childhood Obesity Epidemic?

So the big news yesterday in the US media and elsewhere was that the increase in childhood obesity seen over the last two decades appears to be leveling off.

This "news" comes from a paper just out in JAMA by Cynthia Ogden and colleagues from the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland, who examined the prevalence of overweight among US children and adolescents based on data from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey (NHANES).

Overall, in 2003-2006, 11.3% of children and adolescents aged 2 through 19 years were at or above the 97th percentile of the 2000 BMI-for-age growth charts, 16.3% were at or above the 95th percentile, and 31.9% were at or above the 85th percentile.

But the key finding of this paper is that there was no significant increase in the prevalence of obesity over the 4 time periods (1999-2000, 2001-2002, 2003-2004, and 2005-2006) for either boys or girls.

From this the authors enthusiastically conclude that the prevalence of high BMI for age among US children and adolescents showed no significant changes between 2003-2004 and 2005-2006 and no significant trends between 1999 and 2006.

So what do we make of this?

The "glass-half-full" folks will of course see this as proof that public awareness and prevention interventions are working. The "glass-half-empty" folks will be sceptical, call this a statistical "blip" and point to the fact that even a true leveling off at such a high level is nothing to be complacent about.

The real cynics will say that this is no surprise at all because any kid who can potentially get obese already is - the rest are simply "obesity resistant".

So now what? Do we pat our US colleagues on the shoulder and compliment them on the great success of their prevention efforts or do we point out that irrespective of whether the trend is leveling off or not, the current obesity rates in kids are simply unacceptable and they need to double (if not treble) their efforts at combating this epidemic?

I tend towards the latter - I think that not only in the US but also here in Canada and elsewhere we need to continue increasing our prevention efforts (and actually show that they work!), while at the same time expanding treatment options for those already struggling with excess weight.

30% obesity in kids is simply unacceptable!

AMS
Edmonton, Alberta

image by Derek Jensen

Paternalism and Ethical Obesity Policies

Yesterday I attended a talk by Angus Dawson, Senior Lecturer and founding Director of the Centre for Professional Ethics, Keele University, UK, who is currently a Visiting Professor, Centre for Ethics, University of Toronto.

His presentation with the title: "Ethical Obesity Policy: Paternalism, Preference Change and the Good Life" was part of the University of Alberta Health Law Institute Research Seminar series.

Dawson's basic thesis was that when it comes to preventing obesity simply providing information does not work, some form or "paternalism" (not to use the term coercion) will be required to help people change behaviours.

This is in contrast to what is happening where most policy makers (and some public health workers) still treat obesity as a matter of individual choice and focus their prevention efforts at individuals rather than addressing this issue at the more complex system level.

This is unfortunate because there is little evidence that a key contributer to the obesity epidemic is indeed epistemic or lack of knowledge - therefore trying to remedy obesity by providing knowledge does not address the root cause of the problem.

In fact, Dawson argues, there is no evidence that people today are less knowledgeable about healthy behaviours than previous generations, nor are they weaker willed or more prone to obesity by "choice".

Rather, the obesity epidemic is a consequence of systemic factors such as removing physical activity from the workplace, less time to spend at home with the family, less physical demands on commute and travel and industrialisation of our food supply.

Thus, obesity is not a result of people making poor choices but rather the result of societal changes that leave most individuals with little choice (but to become obese or fight weight gain by swimming against the stream).

This raises the issue of collective action: individuals are limited in their choice by the choices that the majority makes. For e.g. if you live in a neighbourhood where people prefer to eat at fast food restaurants and drive cars then you may have no choice but to also eat fast food and drive a car unless you are prepared to leave your neighbouhood to find a healthier restaurant and are willing to risk being run over on your bike.

Getting the majority to change their behaviour is unlikely to happen without some form of paternalism, which raises the ethical dilemma of how much individual "freedom" society as a whole is willing to sacrifice for the common good.

Examples that were cited included laws requiring the use of seat belts or helmets - issues that are surprisingly still contended by some who reserve "the right to be foolish".

Overall, not much that I have not heard before but certainly a nice summary of how complex some of the issues around obesity prevention actually are.

When it comes to obesity prevention - don't hold your breath!

AMS
Edmonton, Alberta

Research Canada Looks at Science and Media

Yesterday, I blogged about how the Australian TV-media provides a rather nutrition-focused view of the obesity epidemic.

This raises the issue of how public media, especially in Canada, actually reports on science, especially obesity.

Those of you interested in this topic may wish to look at the just released report on Research Canada’s first Media Science Forum, Communicating Health Research in an Era of Headline News, which examined how best to communicate research findings and research issues to Canadians, elected officials and other stakeholders.

One full session was devoted to media discussion of obesity - the event was strongly supported by the Canadian Obesity Network.

The full report is available here.

A webcast of the event is available here.

Diane Finegood (picture), Director of CIHR-INMD summed the key issues around obesity as follows:

"There are barriers to really getting the change and momentum for change, as the public still sees obesity as a personal responsibility. In reality, it is a mix of societal and systemic issues. There will be no policy changes without societal demand. Scientists need to work together with the media to create this. "

I have little to add.

AMS
Edmonton, Alberta

Media on Obesity: Its Your Diet!

Clearly, judging by the daily media stories on obesity, one can hardly claim that this topic is being ignored.

But despite the barrage of reports, does the media really contribute to a better public understanding of obesity? What is being reported? And perhaps more importantly, what is not being reported?

I don’t have stats for Canadian media, but a recent study from Australia, if applicable to Canada, certainly raises a few flags.

Catrioni Bonfiglioli from the University of Sydney conducted an analysis of 50 representative TV news and current affairs items about overweight and obesity broadcast by five free-to-air television channels in New South Wales between May and October 2005.

According to the results published last year in the Medical Journal of Australia, the researchers found that the media tends to overwhelmingly focus on obesity as a problem of individuals with poor nutrition as the major cause.

I found the type of story themes noteworthy and have therefore copied them here:

Modern medical miracles: e.g Lapband surgery saves lives

Surprise or quirky news: e.g. wine may help with weight loss

Individual success stories: e.g. workplace weight-loss winner

Hunting the Holy Grail of weight loss: e.g. a diet that works

Danger in the familiar: e.g. coffee more fattening than a Big Mac

Health scare: e.g. obesity epidemic a danger to all

David and Goliath battle: e.g. McDonald’s sues activists for libel

Debunking myths: e.g. ten weight-loss myths debunked

The elixir of life: e.g. eating less and moving more is the key to living longer

Big bucks - obesity is big business: e.g. $3 mill spent on children’s survey

Government in bed with business: e.g. US government acts to stop fast food industry being sued over obesity

Celebrity: e.g. sportsman calls for activity to stop childhood obesity

Food fight: conflicts: e.g. ABC celebrates debate on food issues

Junk food TV advertising to blame: e.g. health experts and parents attack junk food advertising

Parents to blame: e.g. parents of overweight children accused of neglegt

Pester power: e.g. battle to get kids to eat healthy

Don’t brand fat children: e.g. labeling children as obese is cruel

Obesity is genetic: e.g. obesity runs in the family

The most common factor blamed for obesity was nutrition (72% of items) while inactivity (including computer games) was blamed in only 14% of items.

Individuals were blamed in 66%, industry in 8%, and society in 6%.

Overall, the general tenor of the media reports were on obesity essentially as a result of individual lifestyles and presented solutions that focused on personal responsibility for individual change – i.e. the rhetoric of “choice”.

Whether intended or unintended, clearly the Australian media reports take the spotlight off the idea that government and industry may share a responsibility for reshaping the obesogenic environment.

The focus on individual nutrition sure takes the focus off structural issues such as need to work long hours in sedentary jobs, poor urban planning, long commutes, lack of public transportation and other issues that may be key to solving the obesity epidemic, but are less comfortable to policy makers (and other stakeholders) than simply blaming the “victims”.

By promoting the idea of individual responsibility and individual solutions, the media certainly plays its part in promoting the widespread bias and discrimination against people with overweight and obesity by choosing which topics to report about and which to ignore.

I can only wonder if an analysis of the Canadian press’ reporting on obesity would reveal similar results.

AMS
Edmonton, Alberta

IFSO Guidelines for Bariatric Centres

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), at its Council Meeting in Porto, Portugal, September 2007, approved new guidelines for Bariatric Surgical Centres.

This not only reflects the global interest in this rapidly growing field of bariatric care, but also the need for guidelines that ensure at least a minimum standard of care for patients undergoing surgery for severe obesity.

The summary document, authored by John Melissas, IFSO President (2006-2007) and Head of the Bariatric Unit, at the University Hospital Heraklion, Greece, appears in this month's issue of OBESITY SURGERY.

While most of the recommendations make good sense - this document, not surprisingly, provides a view from the surgical perspective rather than providing a framework for overall bariatric care. There is no doubt that currently the surgeons have the upper hand in this discussion, given that the data increasingly supports the role of surgery as the most effective (if not only) treatment for severe obesity.

However, as I have blogged before, obesity surgery is not just about surgery!

The following are my comments on some of the IFSO recommendations:

"Ensure that individuals who provide services in the bariatric surgery program are adequately qualified to provide such services."

Fully agree, and would probably extend this recommendation to ANYONE dealing with bariatric patients - surgery or no surgery.

"Provide ancillary services such as specialized nursing care, dietary instruction, counseling, and psychological assistance if and when needed."

Another "no-brainer" - again, not only should these ancillary services be available, but health providers in these services should all have undergone basic training in bariatric care including sensitivity training and have at least a basic understanding of the nature of severe obesity, its complications and treatment.

"Have readily available consultants in cardiology, pulmonology, psychiatry, and rehabilitation with previous experience in treating bariatric surgery patients."

I would add to the list general internists, endocrinologists, gastroenterologists, intensivists, hospitalists, pharmacists and perhaps a few other specialities.

"Ensure that basic equipment necessary for the obese patients such as scales, operating room tables, instruments, and supplies specifically designed for bariatric laparoscopic and open surgery, laparoscopic towers, wheelchairs, various other articles of furniture, and lifts that can accommodate stretchers are available, as well as a recovery room capable of providing critical care to morbidly obese patients and an intensive care unit with similar capacity."

This should be an essential requirement for ANY hospital regularly admitting severely obese patients - unfortunately, this is now the case in virtually every hospital in the Western World.

"Have the complete line of necessary equipment, instruments, items of furniture, wheel chairs, operating room tables, beds, radiology facilities such as CT scan and other facilities specially designed and suitable for morbidly and super obese patients."

Same as above - should probably have such lists available in every hospital or medical facility in Canada.

"Have experienced interventional radiologists available to take over the non- surgical management of possible anastomotic leaks and strictures."

Good one! Sometimes these would be interventional gastroenterologists. As often some of these services can be urgently needed, it may not be enough to train only one individual to deal with these issues (travel, vacation, etc.). Obviously, radiology facilities for bariatric patients would be essential (see above).

"Has supervised support groups for bariatric patients."

I agree, support groups can be most helpful for these patients - but they do need supervision to not take off on "tangents".

"Provides lifetime follow-up for the majority and not less than 75% of all bariatric surgical patients."

Obviously, patients with bariatric surgery require life-long follow up - I only do not think that this is best done by the surgeon or "surgical" centres - in fact issues in follow-up are rarely surgical.

They are more often related to nutrition, rehabilitation and psychosocial issues that can ultimately determine outcome. Ideally counseling for these problems would be provided by primary care providers, who are adequately trained in looking after these patients - it is after all not "rocket science" - the majority of patients (if correctly selected prior to surgery) will probably do well with nutritional monitoring, regular lab work and access to psychosocial services as the need arises - all the job of primary care, not that of a surgeon.

Overall the IFSO recommendations are sensible and will hopefully be adopted by policy makers and health authorities in most countries, including Canada. Personally though, I prefer the route taken by the Canadian Association of Bariatric Physicians and Surgeons (CABPS), which ensures that ALL treatment options, both surgical and non-surgical find their place in the management of these complex patients - it is unlikely that surgeons will always provide the best "non-surgical" advise to their patients.

Obesity is indeed an ideal ground for fostering interprofessional practice.

AMS
Edmonton, Alberta

Interprofessional Approach to Obesity

Obesity is a complex and heterogeneous chronic condition that significantly affects many aspects of the mental, physical and economic well-being of Canadians.

The federally-funded Canadian Obesity Network with well over 2700 member, represents a wide range of obesity researchers, health professionals, policy makers and other stakeholders from across Canada and around the world.

How do these members see the role of interprofessional practice in dealing with obesity? This was the subject of a pilot survey conducted by Shelly Russell-Mayhew and colleagues from the University of Calgary at an obesity conference organized by the Obesity Network held in Kananaskis, Alberta, in May 2006.

The survey on interprofessional attitudes and relationships was conducted using semi-structured individual interviews with CON members attending the conference using established qualitative methodology. The researchers analysed the‘‘Who?, What?, When?, Where?, Why?, and How?’’ framework of interprofessional practice and obesity.

The results of the study just appeared in the March issue of the Journal of Interprofessional Care.

While the study makes interesting reading, the bottom line is relatively straightforward:

Both obesity prevention and treatment cannot be approached in silos. No single profession has all the expertise necessary to counter this epidemic.

Interprofessional collaborations and interactions will be key to the solutions.

I was particularly pleased to see that the interviewees consistently felt that the Canadian Obesity Network is strategically positioned to foster this interprofessional dialogue and to ensure that all relevant professions and stakeholders benefit and translate the rapidly emerging research in this field into effective prevention and treatment strategies.

In the meantime, the Canadian Obesity Network continues to evolve into a well-recognized and respected entity in the Canadian public health and healthcare landscape.

Membership is open to anyone with a professional interest in obesity by registering at www.obesitynetwork.ca

AMS
Edmonton, Alberta

Counseling the Community Health Councils on Obesity

Last evening I gave a presentation to members of the Strathcona County Community Health Council (CHC). The CHCs are advisory bodies appointed by the Capital Health Board, to provide community perspectives that support Board business planning and strategic direction.

Council members are volunteers with strong community linkages. Most have been involved with local groups or organizations where they receive community input on various health issues.

Input from CHCs helps the Board to update its business plan and meet the health needs of people in the Capital Health region.

Thus, informing the CHC members about the importance of the Weight Wise program and its relevance to improving the health of their communities is of utmost importance.

As anticipated, the interest in Weight Wise was keen. Not only were they interested in learning about my vision for the program but also in the challenges and possible solutions to the obesity crisis.

I emphasized that Weight Wise is in fact not a single program but rather a whole suite of programs and initiatives addressing both obesity prevention and treatments in the Capital Health Region and beyond.

I spoke about the unique opportunities here in Edmonton, where we can indeed create a seamless obesity program that provides services across the continuum of care.

I spoke to the need of providing obesity care to the over 250,000 people in the region already clinically obese and the over 25,000 with severe obesity.

I also spoke about the many excellent researchers here at the University of Alberta already working on important issues relevant to obesity prevention and care.

My guess is that my presentation was well received - indeed, I hope it was.

It will take all the support we can get to create a climate in which spending money on obesity prevention and treatments is not the exception but rather the rule.

AMS

How Far Will You Travel for Obesity Treatment?

One consequence of the rapid increase in obesity is that the vast majority of Canadians cannot rely on local facilities or expertise for obesity treatments. As a result, patients often have to travel long distances or even across borders to seek obesity treatments.

For example, our program has over 300 patients from other provinces awaiting assessment and hoping for treatment.

This throws up a number of logistical but also practical issues: how do you provide cross-border management for a chronic disease?

It is one thing to fly across the country to consult an expert for a diagnosis of a rare condition or a one-time specialized procedure. But what do you do for a common condition that requires on-going lifelong management? How do you provide education, counseling, monitoring and support across 1000s of kilometers?

Sure there are telephones, internet and telehealth but this does not entirely replace the need to actually see and examine a patient face-to-face.

Remember, obesity is a complex and heterogeneous condition - patients may require 10s of visits with a whole array of health professionals to determine the best treatment plan. Successful obesity management requires continued intervention and monitoring to keep the patient in remission. Early signs of relapse need to be recognized and dealt with to prevent weight regain. Surgical patients need band readjustments, dietary counseling and psychological support.

Much of this is theoretically possible across distances with modern communication technologies but in reality often impractical and inefficient.

On the other hand, how do you refuse to see patients who are clearly in dire straits for whom no local help is available or forthcoming any time soon?

Frankly, I see no alternative to rapidly ramping up obesity care across Canada - this will take both time and resources but most of all a change in attitude: ignoring obesity is no longer an option - limiting efforts to prevention is not helping the millions already struggling with this condition.

AMS