Sibutramine Lowers Blood Pressure in High-Risk Patients

Sibutramine (Meridia) is a serotonin and norepinephrine reuptake inhibitor (SNRI) licensed as a prescription drug for obesity treatment.

Although sibutramine has been available for around a decade in over 70 countries and has been shown to reduce weight and improve comorbidities and risk factors in patients with obesity, its potential to increase blood pressure in some patients has remained an important barrier to its widespread use.

In the most recent issue of Diabetes Obesity and Metabolism, together with other colleagues from the Executive Steering Committee, we now publish an analysis of blood pressure changes associated with sibutramine during the 6-week lead-in period of the sibutramine cardiovascular outcomes trial (SCOUT), an ongoing, double-blind, randomized, placebo-controlled trial in over 10,000 overweight/obese patients at high risk of a cardiovascular event.

During the 6-week lead-in period, 10,742 patients received sibutramine and weight management. At entry, approximately 50% of patients were hypertensive and 26% were high-normal.

In hypertensive patients, blood pressure decreased by median of -6.5 mmHg systolic and -2.0 mmHg diastolic (p < 0.001). Even hypertensive patients with no weight loss or with weight gain had median decreases of -3.5 mmHg systolic and -1.5 mmHg diastolic (p < 0.001). Approximately 43% of patients initially categorized as hypertensive had a lower blood pressure category at end-point.

On the other hand, normotensive patients had median increases of 1.5 mmHg systolic and 1.0 mmHg diastolic (p < 0.001) which was attenuated with increasing weight loss.

As expected, pulse rates were uniformly elevated (median 1-4 bpm, p < 0.001) across blood pressure and weight change categories.

Although it must be remembered, that all patients received sibutramine during the lead-in period and therefore some decrease in blood pressure may be due to regression to the mean, the data confirm that even in patients at high risk for cardiovascular events, the vast majority of patients (especially if hypertensive) will experience a reduction in blood pressure.

Whether or not treatment with sibutramine will also reduce cardiovascular mortality of course remains to be seen when the study finishes sometime next year.

In the meantime, these data reinforce the notion that sibutramine can indeed be used in the vast majority of patients with controlled hypertension without having to fear an increase in blood pressure.

Obviously, in the few patients who do happen to experience an increase in blood pressure, adjustments in antihypertensive medications or discontinuation of sibutramine should be considered.

AMS
Edmonton, Alberta

Conflict of Interest: I am on the Executive Steering Committee of the SCOUT trial and am reimbursed for my time and effort by Abbott Laboratories, the maker of sibutramine

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

Orlistat and Kidney Stones

Orlistat is a gastrointestinal lipase inhibitor sold as a prescription drug under the brand name Xenical and is also available in some countries (including the US) as an over-the-counter (OTC) weight-loss aid under the brand name Alli.

Orlistat has been around for almost a decade and has been extensively studied. No question, when used appropriately with recommeded dietary and lifestyle changes it aids in achieving about 5% weight loss and clinically relevant improvements in cardiometabolic risk factors (high blood pressure, low HDL, high blood sugars, etc.). As with all obesity drugs, weight is generally regained when the medication is discontinued - nothing new here!

Because the action of orlistat is limited to the gut (it is not absorbed in relevant amounts), it is promoted as not having any "systemic" side effects. The main side effects are fully explained by its impact on fat digestion and are generally limited to diarrhea, oily discharge and abdominal discomfort - unpleasant for sure, but certainly not a major health concern.

There is also some interference with the absorption of fat-soluble vitamins (ADEK) but this should not be a problem with a healthy balanced diet or proper intake of vitamin supplements. There is however, also a significant impact on lipid-soluble medications (e.g. ciclosporine A) and patients on these medication may need some readjustment of the dose.

All of the above is well known, extensively studied and not really of great concern for most patients.

But here is one side effect I'd be worrying about if I belonged to the people who tend to get kidney stones - there is a distinct chance that orlistat can increase urinary oxalate excretion thereby potentially promote formation of oxalate stones - anyone who's ever experienced a kidney colic knows exactly why this is something you want to avoid.

The cause of this potential side effect is related to the simple fact that the unabsorbed fat and bile acids resulting from the use of orlistat may react with calcium in the intestinal lumen, limiting the amount of free calcium binding with oxalate and thereby raising intestinal oxalate absorption leading to hyperoxaluria, which in turn can promote formation of oxalate stones.

This rather complex-sounding but rather straightforward state of affairs was first proposed based on a marked increase in urinary oxalate excretion observed in rats given orlistat together with a high-fat diet in a study by Renato Ribeiro Ferraz and colleagues from the Universidade Federal de São Paulo published in KIDNEY INTERNATIONAL in 2004.

In 2007, Ashutosh Singh and colleagues from the University of Tennessee described the case of a female patient with chronic kidney disease, who developed acute oxalate nephropathy with the use of orlistat (Am J Kidney Dis). Urine sediment showed abundant calcium oxalate crystals and 24-hour urine oxalate concentration was significantly elevated. Kidney biopsy showed deposition of calcium oxalate crystals within the tubular lumens. A repeat biopsy one month after discontinuing orlistat no longer showed signs of oxalate and renal function slowly recovered to baseline.

Now, in this month's issue of OBESITY, Kemal Sarica and colleagues from the Memorial Hospital in Istanbul, Turkey, report the data from a study in 95 obese patients (57 men, 38 women) randomly assigned to treatment with orlistat for 6 months vs. no specific medication. In the treatment group, two-thirds of patients showed a marked increase in urinary oxalate excretion at 3 months, which largely persisted at 6 months. Although no kidney stones were noted, the authors commented that the increase in oxalate excretion would have been enough to promote oxalate stone formation in susceptible individuals.

Nothing dramatic here - unless of course you are someone who happens to be at risk for oxalosis and oxalate kidney stones.

If you are, perhaps best to avoid orlistat or at least cut down on the concomitant use of high oxalate foods like rhubarb, spinach, strawberries, chocolate, wheat bran, nuts, beets, and tea and drink plenty of water.

AMS
Edmonton, Alberta

Sarcopenic Obesity and Cancer

We know now (although many still do not fully appreciate this) that obesity is a major risk factor for cancers. On the other hand in patients with many chronic diseases, larger patients tend to do better and live longer (the obesity survival paradox).

Last week researchers from the University of Alberta published a study in The Lancet Oncology, that adds another level of complexity to the relationship between obesity and cancer survival. Clarisse MirandaPrado together with other researchers from the UofA, including cancer cachexia researchers Vickie Baracos, studied 2115 patients with solid tumours of the respiratory or gastrointestinal tract, 325 (15%) of who were classified as obese (body-mass index [BMI] >/=30).

With the help of CT images, the researchers found that obese patients had a wide range of muscle mass, with 15% of analysed obese patients meeting criteria for "sarcopenic" obesity (sarcopenia is the medical term for low-muscle mass). By definition, sarcopenic obese patients have more body fat and less lean body mass than non-sarcopenic patients of similar weight.

Not only was sarcopenic obesity associated with poorer functional status compared with non-sarcopenic obese patients but these patients also had a 4-fold hgher risk of dying.

Incidentally, the researchers also used their data to calculate that using conventional dosing criteria for cytotoxic chemotherapeutic drugs, sarcopenic obese patients may be overdosed with a greater likelihood of toxicity.

Overall this study shows that obesity is never just obesity and that BMI in the clinic is a fairly useless concept (a point that I have argued before) and that without proper assessments of body composition rational management of large patients is just not possible.

A patient's size alone proves little in term of health or disease - remember, weight alone is a rather poor measure of health.

AMS
Edmonton, Alberta

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

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

Back Surgery Does Not Cure Obesity

Immobility, due to pain or otherwise, is certainly a major contributor to weight gain. Pain is indeed often presented by overweight and obese patients as a factor limiting their ability to lose weight.

Given the widely-held (but false!) belief that exercise is the most effective way to lose weight, the general expectation of both patients and health professionals is probably that restoring mobility by relieving pain will enable patients to be more physically active and thereby lose weight.

But is this actually the case?

This issue was recently addressed by Ryan Garcia and colleagues from the Department of Orthopaedic Surgery, Case Western Reserve University, Cleveland, OH in a study just out in the Journal of Bone and Joint Surgery.

Garcia and colleagues examined weight changes in 63 overweight and obese patients with neurogenic claudication who experienced substantial pain relief after lumbar decompression surgery for spinal stenosis. Although Zurich Claudication Questionnaire (ZCQ) Symptom Severity and Physical Function scores significantly improved by a mean of 56.4% and 53.0%, respectively, body weight and BMI significantly increased by 2.48 kg and 0.83 kg/m(2), respectively.

Overall, an average 34 months after surgery, 35% of the patients had actually gained at least 5% of their preoperative body weight while only 6% of the patients weighed at least 5% less than before their operation. The vast majority (59%) remained within 5% of their preoperative body weight.

This study, consistent with several previous studies on joint surgery, nicely documents that increased mobility after pain-alleviating surgery does not necessarily translate into weight loss - in fact, most people will either continue to gain weight or simply stay the same.

Obviously, this should not be an argument against alleviating pain in obese patients - no one deserves to live with pain. It just goes to show that increased mobility alone is not likely to substantially lower body weight - at best, it may prevent further weight gain (difficult enough even at the best of times).

This is probably something patients should be counseled about to not raise any false expectations.

On the other hand, it is important to note that this was not a weight-loss study. This means, that patients were not expressly counseled for weight loss or offered obesity treatments.

The question therefore remains whether or not improving mobility in patients by alleviating pain would improve efficacy of obesity management strategies (which I believe it would).

That is obviously a study that remains to be done.

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

Recognising Barriers Key to Obesity Management?

Most people fail to keep off any weight they lose.

This may in part be attributable to the substantial barriers that undermine long-term obesity management strategies.

In a paper I wrote with my colleagues Marina Mauro, Valerie Taylor and Sean Whartan just out in the European Journal of Internal Medicine, we highlight the importance of recognizing and addressing these barriers before embarking on obesity treatments.

Common barriers include lack of recognition of obesity as a chronic condition, low socioeconomic status, time constraints, intimate saboteurs, and a wide range of comorbidities including mental health, sleep, chronic pain, musculoskeletal, cardiovascular, respiratory, digestive and endocrine disorders.

Furthermore, medications used to treat some of these disorders may further undermine weight-loss efforts and promote weight regain.

Unfortunately, lack of specific obesity training of health professionals, attitudes and beliefs as well as coverage and availability of obesity treatments can likewise pose important barriers.

Health professionals need to take care to identify, acknowledge and, if possible, address these barriers in order to increase patient success as well as compliance and adherence with treatments.

Failure to do so may further promote the sense of failure, low self esteem and low self efficacy already common among individuals struggling with excess weight.

I have little doubt that addressing treatment barriers can save resources and increase the prospect of long-term success.

Identifying and discussing barriers with patients has to be a routine part of obesity care.

AMS
Edmonton, Alberta

Preventing Weight Gain is the First Step in Obesity Management

Overweight is the result of normal-weight people gaining weight.

Obesity is the result of overweight people gaining more weight.

Severe obesity is the result of people with obesity gaining even more weight.

The first step, common to both obesity prevention and treatment, is to stop further weight gain.

In fact, simply preventing weight gain at any weight may be preferable to losing weight just to gain it back. The more often you lose weight and gain it back, perhaps, the worse the consequences.

At least that is the message of a recent paper by Anne Claire Vergnaud and colleagues from the Centre de Recherche en Nutrition Humaine Ile-de-France, Bobigny, France, who studied the relationship between weight fluctuations and the risk for metabolic syndrome (International Journal of Obesity).

Metabolic syndrome status was assessed at baseline (1994/1995) and at the end of follow-up (2001/2002) in 3553 middle-aged subjects. Weight fluctuations were estimated with four weight measures during follow-up. Risk for developing metabolic syndrome was highest in the tertile with the greatest weight fluctuations, independent of whether these subjects gained weight overall or not. Of course, subjects who only gained weight (with no recorded losses) also had a higher risk than individuals whose weight did not change at all.

As in several previous studies on this issue (cited in the paper), it appears that losing and regaining weight (weight fluctuation) is worse than not losing weight at all.

Obviously, these findings have important implications for both public health messaging and clinical management. Although in both cases we propagate and promote "weight-loss" messages, the reality is that very few people who lose weight keep it off. This is true both for self-directed attempts as well as commercial weight-loss programs.

Sadly, even with clinical treatments (including obesity surgery), a substantial proportion of patients fail to keep the weight off, but indeed, success is greater the more intense the treatment and follow-up.

Given this poor success of weight-loss attempts, I cannot but wonder whether recommending weight loss to anyone who is overweight or obese is as beneficial as it is made out to be. This would be particularly true for people with what I prefer to call Stage 0 obesity.

Perhaps, with the exception of treatments with well-documented long-term outcomes, most people are best served with preventing further weight gain (difficult enough) rather than losing weight only to gain it back.

Clearly, the onus is on weight management programs, whether behavioural, medical or surgical, to document their long-term success in weight-loss maintenance.

Programs associated with a high rate of relapse probably do more harm than good.

Individuals with a high chance of relapse should not be subjected to weight-loss attempts without ongoing medical care and close follow-up.

While we await further research on this subject, we perhaps need to be a bit less casual about simply advising everyone with a "higher-than-normal" BMI to lose weight.

AMS
Edmonton, Alberta

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

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

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

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

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

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

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

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

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

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

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

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

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

AMS
Edmonton, Alberta

Obesity Classification: Time to Move Beyond BMI?

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

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

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

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

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

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

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

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

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

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

Axis II Personality Disorders and Mental Retardation

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AMS
Edmonton, Alberta

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

Orient Express

Yesterday we held another Orientation Forum for patients who have been referred to the Adult Weight Wise Program. Some have been waiting over a year for an appointment. Many are desperate for help. The average BMI of the 30 or so folks who attended the Forum was in the mid 40s - most have obesity-related comorbidities - clear indications for treatment.

So what did we orient them about?

Well, for one that obesity is a chronic disease and if they really want to deal with their weight problem, it will mean long-term if not lifelong treatment.

There are many factors contributing to weight gain and no treatment is going to work for everyone. Some may do well by simply making important changes to their lifestyles, some may need more intensive behavioural treatments, some may need medications, some may require surgery.

For some, the best they can realistically hope for is to stabilize their weight - i.e. stop gaining more weight every year.

For others, treatments may be more effective achieving 5, 10, 15 or even 20% weight loss that they may be able to keep off in the long term - but only if treatment continues. Stopping treatment will lead to relapse, or weight regain.

Tough words - tough decisions. No hope for cure, but certainly treatments that work and can effectively help manage weight and relieve comorbidities, i.e. if they stick with it.

No quick fixes, no magic pills, no miracle surgery and most of all - no false promises!

But also no blame, no pointing the finger, no sermons, no patronizing.

Just empathy and sound medical advice - the best we can offer!

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

Why Weight-Loss Challenges Send the Wrong Message

There appears to be a rather widespread notion out there that introducing a bit of competition into the affair may spurn people on to try and lose those "extra" pounds.

In fact, a quick google search on the term "weight-loss challenge" reveals an amazing array of challenges from voyeuristic and sadistic TV shows like the "Biggest Loser" to well-meant workplace wellness initiatives or fund raisers. I am sorry to admit that I recently even became aware of a weight-loss challenge within my own hospital - well intended, but useless in the fight against obesity.

So what's wrong with this idea? Isn't competition a great motivator?

Sure it is - and people will do anything to win a competition - including crazy stuff like starve themselves, exercise till they drop or even (God forbid) pop diet pills, diuretics or laxatives just to win.

All of this is in direct contradiction to a fundamental principle of obesity management: you do not do things to lose weight that you are unlikely to continue doing to keep the weight off.

Most people seem to think that if only they could lose some weight, they will somehow be able maintain that lower body weight in the long-term with less effort.

The reality unfortunately is (and most dieters have experienced this over and over again) that no matter what diet or exercise routine you chose, no matter how slow or fast you lose the weight, no matter how long you keep the weight off - the minute you relax your efforts, the weight simply comes back.

As I have blogged before: obesity is a chronic disease for which we have no cure - only treatments! When you stop the treatment the weight (and any related problem) simply comes back.

By now you will already have figured out the problem with these challenges - unless you are very modest and reasonable about your weight-loss target and are carefully making changes that you can reasonably sustain forever, you are simply setting yourself up for failure.

If you are indeed modest and reasonable - you've already lost the competition to all the crazy folks who'll do anything just to win.

My advise to anyone with a weight problem - the next time you see an invitation to a weight-loss challenge - simply ignore it!

If you really think you will benefit from obesity treatment - seek help from a trained and accredited health professional with experience in weight management - let's put an end to weight cycling!

AMS

Is Obesity a Question of Choice?

This is the title of a Canadian Institutes of Health Research (CIHR) Marketing & Communications and the Institute of Nutrition, Metabolism and Diabetes (INMD) 2008 Journalist Workshop being held in Toronto.

Speakers include INMD Director Diane Finegood, Angelo Tremblay, JP Despres, Gillian Booth, Kim Raine, Hertzel Gerstein, Mark Tremblay and JP Chanoine (all of whom are prominent Canadian Obesity Network members), very much reflecting the wide range of issues relevant to obesity.

I had the privilege of delivering the Keynote Lecture at the dinner event in which I focused on why I believe that patients with obesity deserve treatment like patients with any other chronic disease of our times. Even if we do not know how to cure obesity, we certainly have treatments that work and know the significant benefits that treatment can have on morbidity and quality of life.

As expected, this notion led to an interesting and extensive discussion with the usual challenges including not least the question why people with obesity cannot simply pull themselves together and make "healthy choices" to overcome their problem.

Well, of course that was the whole point of the symposium - to explain how complex the psychosocial and biological determinants of obesity actually are and why it is that individuals have such a hard time controlling their weight.

I emphasized all the usual points, well known to readers of my blog:

1) Weight is tightly controlled and cognition-driven changes in energy intake or output are immediately countered by the body's natural ability to restore energy stores making long-term weight-loss maintenance a life-long struggle

2) For obesity treatments to work (irrespective of whether they are behavioral, pharmacological and/or surgical) they have to be continued indefinitely to avoid relapse

3) Lack of adequate access to obesity treatments within the health care system is largely a reflection of the continuing bias that obesity is a self-inflicted condition that can be controlled by will-power alone

4) Because obesity is a remarkably heterogeneous condition, no single treatment fits all

5) The vast majority of health professionals are not trained to deal with this condition (which is why for example the University of Guelph and Humber College in Ontario have now decided to offer a course specifically for fitness professionals wishing to work in this area).

Lot's of great questions and note taking - curious to see what the media will do with all this information in the next few weeks.

AMS

Obesity Paradox also Holds in Denmark

Regular readers of this blog will have noted previous entries on the "paradoxical" reverse epidemiology of obesity and cardiovascular mortality, where risk is apparently higher in underweight compared to normal weight, overweight or even mildly obese individuals (for e.g. of previous blog entries on this click here, here or here).

Now a new Danish study by Jawdat Abdull and colleagues published in the European Heart Journal that looks at pooled data from 5 large registries with over 21,500 consecutive high-risk patients with myocardial infarction or heart failure finds essentially the same story:

After a follow-up of 10.4 years, compared with normal weight individuals (BMI 18.5-24.9) all-cause mortality was higher in underweight (BMI < 18.5) but not in overweight (BMI 25.0-29.9) or class I obese (BMI 30-34.9) individuals. Only with class II obesity (BMI 35-39.9) and higher was there a significantly increased risk for myocardial infarction and increased death risk.

This finding is very much in line with the mounting evidence that moderate overweight and mild obesity does not automatically translate into higher cardiovascular mortality in high-risk individuals with established heart disease.

As argued before, given that increased weight is a well-established risk factor for high blood pressure, diabetes, and other risk factors for cardiovascular disease, the reasons for this rather consistent "paradoxical" relationship are not clear.

Possible explanations include the idea that being underweight is a sign of general ill health and that thin people may be less able to cope with life-threatening illnesses like a heart attack at least compared to people with some extra "nutritional reserve". Of course there are a couple of more sophisticated theories out there that to me appear highly speculative (which is why I will not mention them today).

Nevertheless, in light of this "paradox", we may have to look beyond reducing cardiovascular morbidity and mortality to justify aggressive treatments of overweight and class I obesity with established cardiovascular disease - perhaps the aim of obesity treatment in high-risk individuals should simply be to prevent further weight gain rather than to reduce it?

I guess it would take intervention trials to find out - thankfully, these are already well underway.

AMS

Alberta: No Country for (Fat) Old Men

Last Saturday, apart from participating in the Super Size Me event, I also spoke at the 2nd Annual Endocrine Day for Family Physicians, organized by our division of endocrinology.

At this meeting Donald Morrish from our division presented a neat little update on Androgen Deficiency in the Aging Male (ADAM). This is what happens when guys' testosterone levels drop to below 10 mmol/L with age.

Typical symptoms include sexual dysfunction (decreased libido and erection problems), osteoporosis, gynecomastia and infertility often accompanied by fatigue and low-energy levels.

What makes this issue interesting to the bariatrician is the fact that male hypogonadism is also associated with loss of lean body mass and accumulation of abdominal fat.

Indeed, there is ample evidence to support the idea that testosterone substitution in hypogonadic men will increase muscle strength and decrease visceral fat. Without substitution, trying to lose weight, build muscle or finding the energy to exercise may be impossible.

Importantly, while these benefits have been shown for replacement doses, there is no proven benefit of using supra-physiological or "pharmacological" doses of testosterone.

Similarly, while replacing low levels of testosterone is probably without risk, the use of testosterone in males with normal testosterone levels is potentially problematic.

Unfortunately, the diagnosis of male hypogonadism is not straightforward. The most commonly used assay for testorsterone measures total testosterone, i.e. both free (active) testosterone and that bound to sex homone-binding globulin (SHBG). The latter, however, is commonly decreased in obesity, resulting in a falsely low level of total testosterone.

So to really know if someone with obesity who also has low total testosterone levels truly has hypogonadism, one has to order the more expensive bioavailable or free testosterone.

This test, at least in Alberta, is not covered by the public health system and will cost the poor fellow around $45 - by no means a trivial sum.

Furthermore, once you decide to substitute testosterone (of which the most convenient gel form is also not covered by Alberta Blue Cross), you again have to monitor the free-testosterone levels at regular intervals - overall a venture that may cost around $1500 a year - definitely not cheap.

I guess Alberta is no Country for Fat Old Men.

AMS

Opening Eyes to Obesity Management

Yesterday I had the privilege of speaking to around 400 dietitians (and other health professionals) at Capital Health's 12th Annual Regional Nutrition and Food Services symposium.

After my presentation, many of the attendees came up to personally thank me for such an "eye opening" take on obesity.

This of course is surprising, given that you'd think that, if anyone, dietitians would be the ones with the greatest knowledge and understanding of the issues around obesity management.

So I asked the folks who came up to me about what exactly they found so "eye opening".

The answers were pretty much the issues that I have so often blogged about:

- The problems with clinically defining exactly what obesity is and who really needs treatment (no, BMI is not the best criterium!).

- The fact that obesity is a chronic disease that requires life-long treatment - a condition for which we have no cure (with a few rare exceptions).

- The rather limited long-term success of lifestyle (3-5% sustained weight loss), pharmacological (5-15% sustained weight loss) and even surgical (20-30% sustained weight loss) treatments (and even these results only if you continue the treatments!).

- The fact that while maintaining energy balance appears simple (energy in must equal energy out), energy regulation is highly complex.

- The concept that pharmacotherapy and surgery are not a "substitute" for lifestyle change but in fact only work when patients really do make substantial changes to their lifestyle (click here for a previous entry on this topic).

So, to readers of my blog, nothing really new or enlightening - yet, "eye opening" to many in the audience.

I guess we have a long way to go before all health professionals (especially physcians!) understand these basic concepts of obesity management.

If only I could speak to 400 health professionals everyday!

AMS