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

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

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

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

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

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

Do School-Based Obesity Interventions Work?

In light of the increasing number of overweight and obese kids, demand and focus on interventions aimed at school kids is increasing.

The questions, however, are:

1) is the school really the best place to intervene - or in other words, can the school compensate for poor environments in the home and the often poor parenting skills that may promote childhood obesity?

and perhaps more importantly,

2) do school-based invterventions actually work?

The latter issue was recently studied by Jonathan Kropski and colleagues from the Vanderbilt Centre for Evidence-Based Medicine, Nashville, Tennessee in a paper just out in OBESITY.

Kropski and colleagues performed a systematic review of all research published on this issue since 1990 and found only fourteen studies that were of sufficient quality to draw any conclusions. These included one nutrition-only progam, two physical activity promotion inverventions and eleven studies that combined both nutrition and activity interventions.

Based on the quality and results of these studies, only one study was designated as providing strong (grade 4 = randomzed controlled trial) evidence for the prevention of excessive weight gain in girls. Four weaker studies (observational data) provided some evidence of efficacy in boys and girls. The rest of the studies provided even weaker evidence for significantly improving measures of dietary intake, physical activity or both.

The bottom line is that from the current data, no conclusive evidence can be drawn regarding either the benefit or lack thereof for school-based intervention programs. There is certainly no evidence whatsoever that school-based interventions will indeed translate into less overweight or obesity in young adults.

Does this mean we sit back and give up? Certainly not - however, we must realise that pouring all our money into school programs as our primary approach to taming the obesity giant is based more on wishful thinking than on hard evidence.

The authors believe that despite the rather poor body of evidence, schools will play an important role in stemming current trends in overweight and obesity in children - but that is exactly it - for now this is nothing more than a "belief".

Clearly, we need more high-quality studies to determine whether or not investing in school programs is indeed cost-effective.

My guess is that without parents taking on an active role and policy makers doing all they can to reduce our current obesogenic environment, schools will have little say in the matter - but of course, I am happy to be proven wrong.

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

I'll Take Catch-Up With Those Fries

Yesterday, I attended the "Crosstalk" symposium at ECO 2008 here in Geneva.

Once again, I was fascinated by Abdul Dulloo's (Co-Chair of the Symposium) talk on the phenomenon of "catch-up" fat.

Simply stated, this phenomenon describes the preferential accumulation of fat tissue as part of any weight-gain process that follows an energy deprived state (See Dulloo's excellent 2008 review for more on this topic).

Interestingly, this phenomenon occurs irrespective of whether the energy-deprived state is caused by voluntary or enforced starvation, dieting, anorexia or severe illness including sepsis or cancer.

In fact, it even occurs in small-for-gestational-age babies, who manage to rapidly make up for their low birth weight by rapidly tucking away those calories in those chubby fat depots.

Even more interestingly, data suggest that the excess calories that are tucked away are only partly derived from increased caloric intake. Most of them come from preferential partitioning of energy to the fat stores, largely by dramatically turning down skeletal muscle thermogenesis.

This means than even if you are careful not to "overfeed", your lean tissue will happily deprive itself for the benefit of those fat depots.

In animal experiments, high-fat refeeding appears to make this phenomenon even more pronounced.

All of this appears to be related to substantial insulin resistance that occurs during this "regain" phase and researchers are still trying to figure out what exactly makes the muscle "slow down" in order for the fat to accumulate.

Teleologically all of this makes sense. The idea perhaps is to rapidly take up those calories (following the famine or illness) and store them away - let's worry about rebuilding the lean mass later.

Unfortunately, at least in animals, this process may be detrimental in the long term. There is now a fairly consistent body of evidence that shows "catch-up" growth to be a risk factor for the development of cardiometabolic risk factors including abdominal obesity, type 2 diabetes, and dyslipidemia - all eventually leading to heart disease.

As regular readers may recall, I recently blogged about the apparent increased risk for the metabolic syndrome with weight cycling - perhaps a reflection of this phenomenon.

Whatever the causes and consequences of catch-up weight, the phenomenon is very real - people tend to get fatter with every diet; patients recovering from cancer tend to put on massive amounts of fat when they recover - most interesting indeed.

What if abdominal obesity is not a consequence of overeating alone but rather a result of past deprivation?

I guess I was not too far off the mark, when the New York Times recently quoted me as saying,"You might want to focus on being as healthy as you can and not obsess about your weight”.

Certainly no point losing weight if it just comes back as fat - i.e. unless you seriously believe you can keep it off by sticking to your weight management strategy for life!

AMS
Geneva, Switzerland

In Obesity Variety is Bad

Humans are omnivores and apparently our hunter-gatherer ancestors ate an extraordinary range of plant and animal foods.

The advent of culinary skills and use of spices and seasonings further enhanced the variety, taste, flavour, appearance, texture and consistency of foods.

Today, the apparently limitless choice of foods in our supermarkets, restaurants and homes is a sure sign of the importance we place on variety and variation when it comes to eating.

When trying to manage your weight, however, variety may be your downfall.

This at least is the gist of a recent study by Ramona Guerrieri and colleagues from the Department of Experimental Psychology, Maastricht University, in The Netherlands, who examined the interaction between impulsivity and a varied food environment and its influence on on food intake and overweight, published in the International Journal of Obesity.

The study is based on two observations:

1) Our current food environment offers a large variety of cheap and easily available sweet and fatty foods

and

2) Impulsive people may be reward sensitive and are generally less successful at inhibiting prepotent responses (i.e. a response that is or has been previously associated with positive reinforcement)

Using a rather complicated experimental design masquerading as a taste test, Guerrieri and colleagues studied 78 healthy primary school children (age: 8-10 years) regarding two aspects of impulsivity: reward sensitivity and deficient response inhibition.

The kids were studied in two groups: one was offered rather monotonous foods; the other was offered foods varied in colour, form, taste and texture.

As expected, reward sensitivity interacted with variety. In the "monotony group" there was no difference in food intake between the less and more reward-sensitive children (183 kcal+/-23 s.d. versus 180 kcal+/-21 s.d.).

However, in the "variety group" the more reward-sensitive children ate almost 70% more calories than the less reward-sensitive children (237 kcal+/-30 s.d. versus 141 kcal+/-19 s.d.).

While reward sensitivity in itself was not linked to overweight, deficient response inhibition (a measure of impulsivity) was.

Clearly, the kids with poor impulse control were handicapped when it came to dealing with variety.

Why is this important?

What the data suggest is that kids (and adults?) who have poor impulse control are more likely to overeat when faced with variety. Therefore, the incredible variety and choices of food that we have available to us, may indeed be a major factor in the problem of overeating.

As blogged previously, attention deficit disorders (ADD) are surprisingly common in obese children and adults - in our currently environment, this increased impulsivity may be an important factor contributing to their weight gain.

If your problem is impulse control - the less choices you give yourself the better.

AMS
Edmonton, Alberta

Lifestyle not a Determinant of Obesity in Teens?

Now here is a counter intuitive finding from Catherine Sabiston, of McGill University, and P.R.E. Crocker, of the University of British Columbia (UBC) published in the Journal of Adolescent Health earlier this year.

In their study of 900 Vancouver-area 16-18 year-old teenagers in Grades 10 through 12, neither was there a link between body mass index (BMI) values and levels of physical activity nor did the physically active teens eat a markedly healthier diet than their less-active counterparts.

If anything, the heavier teens were actually the ones making healthier food choices while the teens with “healthier” BMI values were no more likely to be physically active than those with higher, “unhealthier” values.

According to Dr. Sabiston (quoted in a press release from McGill University)

“A lot of people are surprised, but when you think about it, BMI doesn’t have a huge impact on physical activity. And in terms of diet, it actually makes sense that someone who is not happy with their body might try to eat more healthily. What this study really says, is that one cannot assume that someone who is physically active necessarily eats a healthy diet – or the reverse, that someone who is more sedentary or has a high BMI by definition eats a diet of junk food."

To me the findings aren't all that surprising. I have always maintained that health cannot be simply deducted from the number on your scale and that for every overweight kid who eats mostly junk food and spends every spare minute on his Xbox, there's a skinny kid out there who's no better.

The simple truth is that eating healthy and exercising is important at any weight!

On the other hand, just as simply eating poorly and not exercising by no means guarantees weight gain - simply eating healthy and exercising does not guarantee a so-called "healthy" weight.

When everyone eats too much and no one moves, it's likely the poor kids with the "wrong" genes that pack on the pounds - the kids with the "right" genes are simply lucky and can apparently get away with their lousy lifestyles - who says life has to be fair!

Of course, the words "wrong" and "right" in the previous sentence refer to these genes in today's world. Until not all too long ago in the history of mankind, the "wrong" genes would have been just "right" and vice versa (talking of thinking in circles).

AMS
Edmonton, Alberta

[Hat tip to Michael Dwyer of CIHR for sending me the McGill press release]

Waist Loss Trumps Weight Loss

Yesterday, I had the pleasure of listening to Robert (Bob) Ross from Queen's University, Kingston, Ontario, speaking at the 77th European Congress on Atherosclerosis, Istanbul. Turkey.

Here are his key messages:

1) Exercise helps reduce visceral fat even if you don't lose much weight. Walking as little as 60 mins a weeks can have an effect - of course, the more the better

2) Measuring waist circumference can detect changes in abdominal fat even when overall weight does not change

3) People who are exercising to lose weight may lose their motivation if they solely focus on weight and fail to recognize the "other" health benefits of exercise

Anyone who has heard Bob speak, knows that he is a most eloquent and persuasive speaker.

Very much enjoyed his talk.

Great work Bob!

AMS
Istanbul, Turkey

Does Surviving Cancer Lead to Weight Gain?

Yesterday's big news was the study by Kerry Courneya, professor and Canada Research Chair in Physical Activity and Cancer at the University of Alberta, published in CANCER.

I am not going to repeat the findings or the data here because this was nicely summarized by Sharon Kirkey from Canwest News Service in the Edmonton Journal.

The bottom line is that cancer survivors are apparently not exercising more or eating healthier than everyone else, and are therefore at least as, if not even more, likely to develop obesity than the average Canadian.

This is particularly true for survivors of breast and colon cancer, which are particularly likely to recur with lack of physical activity, unhealthy eating and weight gain.

The dramatic impact of weight on cancer risk is perhaps best demonstrated by the observation that obesity surgery, which on average reduces body weight by 25%, results in an almost 60% reduction in cancer mortality! (see Adams et al. for an example of such a study).

I guess it just goes to show that cancer survivors are no less susceptible to the consequences of our obesogenic environment, which certainly does not make weight control easy, even at the best of times.

That is of course, unless there is something special about surviving cancer that makes you more likely to gain weight - an interesting hypothesis pursued by other researchers here at the University of Alberta.

I can think of a number of reasons why surviving cancer could predispose to weight gain: "catch-up" fat, depression, "post-traumatic" stress, anxiety, susbtance abuse, "overfeeding", immobility, medications, and perhaps a few others.

Whatever the reasons, it looks like we may now need intervention programs to specifically address weight gain and obesity in cancer survivors?

For one, educating cancer survivors about the links between excess weight and cancer would be a start.

My sense is that most people still don't fully appreciate the close link between obesity and cancer - all the more reason to promote healthy eating and active living for all.

Obesity prevention (and treatment?) may well turn out to be the most effective cancer prevention strategy (short of smoking cessation) - looks like a whole new field for bariatric health professionals?

I guess we'd call them Bariatric Oncologists?

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

Stop Walking to Gain Belly Fat

As regular readers of my blog know, I love walking (at least when I have to!).

To find out how important walking actually is to help control your weight, apparently all you need to do is stop.

This was exactly what Rasmus Olsen and colleagues from the University of Copenhagen convinced 18 healthy male subjects to do. Participants were instructed to reduce daily steps by using elevators instead of stairs and riding in cars instead of walking or bicycling while maintaining their habitual food intake (JAMA, March 19).

The first set of eight men decreased their pedometer recorded daily steps from a mean value of 6,203 to 1,394 over 22 days. The second set of ten men decreased their mean daily steps from 10,501 to 1,344 over 2 weeks.

While body weight was not reported for the first eight men, they had a marked rise in insulin area-under-the-curve (AUC) following the glucose tolerance test (interpreted as reduced insulin sensitivity).

But even more interestingly, in the second group, although BMI DECREASED(!) from 22.1 to 21.8, intra-abdominal (visceral) fat INCREASED by 7% (as measured by MRI). Lean body mass (as measured by DEXA) decreased by 1.2 Kg while both the insulin and triglyceride response to the tolerance tests were adversely affected.

Not bad for just two weeks of not walking! And these were healthy lean young men to start with - my guess is that the effects in older overweight folks would be even more dramatic.

So why spend money at McDonalds? Just walking less will "supersize" your abdomen as nicely.

AMS
Edmonton, Alberta

Employees' Obesity Costs Employers

This week, The US Conference Board released a report called "Weights and Measures: What Employers Should Know about Obesity" on the financial and ethical questions surrounding whether, and how, US companies should address the obesity epidemic.

Apparently employees' obesity-related health problems cost US companies an estimated $45 Billion each year in medical coverage and absenteeism - more than smoking or problem drinking.

Given the high costs of obesity, the report estimates the return on investment for employee wellness programs from zero to $5 per $1 invested. ROI aside, these programs may give companies an edge in recruiting and retaining desirable employees. The report also looks at the issue of awarding employees cash and prizes for weight loss rather than devoting resources to long-term wellness programs.

Interestingly the report also discusses the benefits of paying for employees' obesity surgeries. Apparently 9% of the US workforce would be eligible for such surgery, but because people often change jobs (e.g. in the retail industry), employers may not always recoup the full costs of supporting obesity surgery in their employees.

One big concern of course is how employers can address this issue without seeming intrusive or discriminatory. It is recommended that companies should involve employees in planning health initiatives, rather than working from the top-down, and should make sure personal privacy is protected.

While this report focuses on the US, and for obvious reasons cannot directly be transferred to the Canadian situation with its more or less universal health coverage, it is unlikely that obesity, at least with regard to absenteeism and early disability, is any less expensive to Canadian employers.

While preventive "wellness initiatives" may work for the 3/4 of the workforce, which does not yet have obesity, how do you provide effective obesity treatments to the employees who already have the problem?

Allow me to offer a few pointers:

1) Inform employees about evidence-based treatment options for this condition.

2) Encourage employees to seek treatments for obesity like they would seek treatments for any other chronic disease (e.g. diabetes, hypertension, etc.).

3) Supplement costs for evidence-based obesity treatments (including behavioural interventions, special diets, medications and surgery) as prescribed by qualified health professionals.

As I have blogged before - we may not have a cure for obesity - but we sure have treatments that work!

AMS
Edmonton, Alberta