Kudos to Dr. Padwal!

At least publication wise, this has been a great week for our Dr. Padwal.

In an article published in the BMJ he analysed the overall utility of anti-obesity drugs. The bottom line is that on average the results of using these drugs, when assessed by the magnitude of weight loss compared to placebo, is rather modest.

Of course this story was widely picked up by the media (click here for TIME Magazine's take on this).

In the October issue of IJO Dr Padwal also had a paper on adherence to anti-obesity meds (click here for the link to PubMed). The bottom line here was that although effective, most people take their medications only for a few months, after which weight comes back.

Both articles raise important issues regarding obesity treatments in general.

1) Should "average" efficacy determine choice of therapy?

When dealing with a condition that is as heterogeneous as obesity, can any single non-pharmacological (lifestyle) or pharmacological intervention be expected to produce dramatic average effects?

For e.g. cognitive behavioural therapy (CBT) appears to work well for people with binge eating, but there is little evidence that it works for obesity in general.

Similarly, sibutramine, which works largely by enhancing the physiological satiety response to eating, works in some patients but not in others. So for e.g. I frankly do not expect sibutramine to work in patients where poor satiety is not the problem (e.g. in hedonistic eaters), in people who are eating too fast to allow their physiological satiety response to kick in (by which time, they have already consumed too many calories), or in people who have no physiological satiety response (e.g. mutations in the MC4 receptor).

In clinical practice it is common experience that individual patients will do better on one treatment than on others (in fact, we call that "personalized" medicine).

It is important to realise that when dealing with an epidemic, even a small fraction becomes a large number of patients. So even if only 20% of obese patients do well on CBT, sibutramine or orlistat (and these are most likely a different 20% for each treatment), respectively - that still means that these approaches could be effective in millions of patients.

I believe that the problem with obesity treatments in general is not that they do not work - the issue is that all treatments just don't work for everyone!

Identifying patients for whom specific interventions work better than others remains a key challenge although there have been pragmatic suggestions: if one treatment does not work - try something else!

2) Should treatments be abandoned because patients don't stick with them?

This is not just an important question to ask about pharmacotherapy (as Dr. Padwal did in his IJO paper). The question is as relevant to non-pharmacological treatments.

So if the majority of patients will not adhere to a given treatment in the long-term (we call this attrition), should we completely abandon using this treatment?

Of course not! Thus, although there is little evidence that the majority of patients will stick to lifestyle treatments in the long-term, some people will (e.g. the folks on the National Weight Loss Registry) and for them this approach is reasonable. For the rest, we are going to have to do better.

The case for pharmacotherapy is not different. Just because most patients will not take their anti-obesity drugs forever, does this mean we do not use drugs at all? Some patients will stick to their medications and for them this is certainly an effective treatment.

Incidentally, it may be worth noting that there is nothing unique to obese patients in terms of not sticking to treatments - this problem is universal to all chronic diseases. Thus patients with hypertension, diabetes, high cholesterol and even patients with painful conditions such as rheumatoid arthritis are notorious for not sticking with their prescribed treatments for more than a couple of months.

I believe that as patients, health professionals and regulators move towards thinking about obesity as a chronic disease rather than something we can "fix" with a short-term approach and as we fully realise that in obesity management "one size will not fit all", we will eventually become more effective (and realistic) in dealing with this condition.

AMS

Should All Personal Trainers be Allowed to Treat Obesity?

In today's edition of CMAJ there is a statement worth noting regarding the qualifications that exercise professionals should have before being allowed to work with obese individuals.

The basic point of this statement (co-signed by a number of prominent Canadian Kinesiologists and Exercise Physiologists) is that because many overweight and obese individuals are at an increased risk of various co-morbidities, including cardiovascular disease, it is imperative that exercise professionals involved in treating such individuals have a clear knowledge of the absolute and relative contraindications to exercise for patients with obesity.

The authors strongly believe that such knowledge can only be developed through formal and rigorous post-secondary academic training within a faculty of exercise science, which is in clear contrast to some personal training designations provided by "for-profit" organizations that do not require advanced college or university education in health or exercise science. In their statement, the authors go on to describe what they feel is an acceptable standard of qualification and certification that will best ensure patient safety.

The points are certainly well taken and I fully agree that dealing with obese patients in particular requires sound medical knowledge and expertise in exercise physiology.

Not only are obese patients at increased cardiovascular risk, but they are also at extreme risk for mechanical injury due to lack of flexibility, balance and coordination, particularly during weight-bearing exercises. Existing back, hip and knee problems can easily be exacerbated by a misguided "boot-camp-drill-sergeant" approach to "let's-burn-off-those-calories".

Immobility resulting from musculoskeletal injury caused by improper and overzealous exercise routines can only exacerbate obesity and cardiovascular risk factors and will certainly pose a direct threat to effective weight management.

The much bigger question here is not just about personal trainers or self-appointed exercise gurus but rather about the entire for-profit "weight-loss industry".

While there is certainly an important and often invaluable role for lay-persons in peer-support groups, buddy systems and walking clubs, the fact that patients often have no way of recognizing qualified from unqualified health professionals can indeed pose a health hazard, particularly for obese individuals who will clutch at any straw for help.

The key question indeed is that if obesity is really a disease, should someone who is not a certified and regulated health professional be allowed to offer treatment? Can we forbid self-appointed "health advocates" to offer their services? Probably not. Would we recommend that our patients seek help or advise from individuals with "iffy" qualifications? Not likely.

An important function of WW will be to help patients find community services that help them improve their health (with or without weight loss!) without putting themselves at risk.

Clearly, the bigger the patient, the greater the risk - self-imposed limitations and/or legal restrictions on working with clients above a certain size may well be in the interest of anyone working in this industry who does not have the training and credentials to work with obese clients.

AMS

Maternal Obesity and Neonatal Risk

Many of you are probably aware of the increasing discussion on the role of maternal obesity and excessive pregnancy-related weight gain as a key risk factor for childhood obesity.

In fact, some folks now seriously believe that this is the real reason why the pediatric obesity epidemic appears to be spiraling out of control.

Both animal studies and human observational data strongly support the notion that intrauterine epigenetic modification together with early post-natal influences on brain development may play an important role. A joint researcher team from the UofA and the UofC currently has a team grant in on exactly this issue.

Now a recent study from Denmark delivers another important reason for addressing maternal obesity. Nohr and colleagues, examined the relationship between prepregnancy BMI and neonatal mortality in 85,375 liveborn singletons of mothers in the Danish National Birth Cohort (1996-2002). Information about pregnancy outcomes and neonatal deaths (n=230) was obtained from national registers. Compared with infants of mothers who were at a normal weight before pregnancy, neonatal mortality was increased in infants of mothers who were overweight or obese (adjusted hazard ratios 1.7 and 1.6, respectively).

This observation of increased infant risk with maternal obesity is very much in line with previous reports, for e.g. a study by Heddersen and colleagues, who analysed a cohort of 45,245 women who delivered singletons at Kaiser Permanente Medical Care Program Northern California in 1996–1998 in which women who gained more than recommended by the IOM were three times more likely to have an infant with macrosomia than women whose weight gain was in the recommended range.

This is relevant to us, because currently about 10% or mothers in our health region are obese. Should WW be working with the maternal and neonatal program on this? I reckon this is well worth looking at.

Indeed, if there is any merit to these recent findings then aggressively targeting maternal obesity may help break the trans-generational obesity cycle and prevent obesity in the next generation.

AMS

Does Weight Matter?

Some of you may have seen the news items in yesterday's media - a new study by Flegal et al. from the CDC, published in the Nov 7 Issue of JAMA, finds that overweight individuals (BMI 25 to <30) have significantly reduced mortality from non-cancer and non-CVD deaths and no increase in risk for death from all cancers or CVD (compared to normal weight (BMI 18.5 to <25) individuals). The results are based on an analysis of NHANES I, II & III.

I was interviewed on this paper by several media representatives and in general my take on this was:

1) BMI (a measure of weight) is a poor measure of overall health
2) More important than the amount of excess weight (especially for overweight individuals) is where it is located

Obviously, this study will lead to a lively discussion and provide to ammunition to all who claim that the obesity epidemic is being dramatized and overrated.

For us the implications are probably as follows:

1) let's remember that weight is just a number on the scale
2) healthy eating and active living is possible (and advisable) at any weight
3) skinniness is not a guarantee for longevity

This however, should not distract us from the fact that excess weight (fat) can significantly impact on health and that therefore preventing or treating obesity in individuals where excess weight threatens or affects health is important.

Hope you'll have time to catch the CFR,

AMS

Flying Blind?

I've posted before on the fact that Calories are the currency of weight management - if you don't know how many Calories are coming in and how many are going out, how can you actively manage your Calorie account (read: weight!)?

As most of us eat many of our meals outside the home, getting restaurants to post calories (not simply on some obscure website or on some pamphlets that you have to ask for) is a major topic of discussion amongst obesity experts.

I was therefore particularly pleased that the CBC yesterday chose to devote its edition of Marketplace to the fact that restaurants make it hard (if not impossible) for consumers to actually find out exactly what they are ordering from the menu.

For those of you, who missed it I suggest watching it online!

Those of you working on the "Finding Balance" module - take note - may find some interesting ideas here.

AMS

p.s. Dr. Yoni Freedhoff, author of "Weighty Matters" is featured on this show

Barriers to Bariatrics?

So today we discussed how to best rename the combined Adult Weight Management Clinic at the Alex, which would provide all aspects of tertiary obesity care (behavioural, medical & surgical).

An obvious suggestion was Weight Wise Adult Bariatric Clinic (WW-ABC).

The question was, would people then assume that this is a purely surgical clinic as the term "bariatric" is generally associated with surgery?

Well, the fact of the matter is that the term "bariatric" is actually simply the proper medical terminology for the branch of medicine that deals with the causes, prevention, and treatment of obesity. It stems from the Greek root baro ("weight," as in barometer) and suffix -iatrics ("a branch of medicine," as in pediatrics or geriatrics).

The term "bariatrics" is increasingly used to describe all aspects of obesity care including:

• bariatric nursing
• bariatric psychiatry
• bariatric pharmacology
• bariatric psychology
• bariatric furniture
• bariatric rehabilitation
• bariatric skin care
• bariatric research
• etc.

So if "bariatrics" is the official term for obesity care, then this should be an obvious choice as a name for the clinic (after all, that's what we do).

Will people understand what this means? I guess we'll have to teach them.

Appreciate all comments and takes on this!

AMS

Getting to Goal

This morning we had a "dry run" of the first module for the community "group visit" - the topic was identifying your goal. The idea is that patients need to think deeply about why it is they want to be in the WW program. Wanting to lose weight is not good enough - patients would need to be quite explicit on why they'd want to lose weight and what exactly it is they want to achieve by getting the pounds off. They also need to recognize potential barriers and plan strategies on how to overcome these.

The community team came up with a fantastic script - very well thought through, lots of interaction, great ideas - now we need a couple of pilot sessions to see how things flow, but I am confident that this group visit will make a big difference as we proceed with restructuring the WW program towards delivering effective bariatric care.

Great job everyone! Looking forward to the next "modules",

AMS