New Obesity Numbers for Canada

Yesterday, Statistics Canada released the latest data from the 2007 Canadian Community Health Survey (CCHS) for obesity.

Overall 4 million Canadians aged 18 or older, 16% of the total, reported data on weight and height that put them in the obese category. Another 8 million, or 32%, were overweight.

Although between 2005 and 2007, rates of both overweight and obesity generally changed little, during that period, there was a slight increase in the proportion of women aged 18 to 24 who were obese, and a decrease in the proportion of senior men who were overweight.

Self-reported obesity rates were generally highest among individuals aged 45 to 64. One-fifth (20%) of men in this age group were obese, as were 18% of women. The proportion who were overweight also tended to peak in middle-age.

Men aged 25 to 44 were considerably more likely than their female counterparts to be obese.

Among the provinces, rates of obesity were highest in Saskatchewan, Alberta and Atlantic Canada, ranging from 18% in Alberta to a high of 22% in Newfoundland and Labrador. The lowest rates were in British Columbia where only 11% of adults were obese.

Overweight and obese adults were less likely to rate their health as excellent or very good than were adults not carrying excess weight.

Obviously, because of the tendency of respondents to over-report their height and under-report their weight, it is likely that these figures from the CCHS underestimate the actual prevalence of obesity and overweight.

Clearly, the obesity epidemic is alive and kicking. Delivering appropriate obesity treatments to one-fifth of the population is likely to remain a challenge for the forseeable future.

AMS
Edmonton, Alberta

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

Is Foie Gras Junk Food?

Yesterday, I gave a talk to Alberta Agriculture on my take of the obesity epidemic(thanks to Annette for the invitation) . Obviously, the best way to influence policy is to talk to policy makers, so an opportunity to present my views to policy makers is always appreciated.

Given that the audience was keenly interested in issues related to nutrition, it was not surprising that questions arose around the issue of junk food (actually this topic comes up at virtually every talk on obesity).

The discussion again made obvios the difficulty of the concept of junk food - i.e., when exactly is food junk? Now obviously, from an obesity perspective any form of "empty" calories would constitute junk food, that one is easy. But what about real food with more than just calories?

When I look to Wikipedia for a definition, I find the following (slightly paraphrased for brevity):

"Junk food is food that is unhealthy and/or has little or no nutritional value. It contains high levels of refined sugar, white flour, trans fat and polyunsaturated fat, salt, and numerous food additives such as monosodium glutamate and tartrazine; at the same time, it is lacking in proteins, vitamins and fiber, among other healthy attributes. It is popular because it is easy to purchase, requires little or no preparation, is convenient to consume and has lots of flavor. "

Clear enough, you'd think.

But the same post in Wikipedia also says why this definition is not easy (again paraphrased for brevity):

"What constitutes unhealthy food may be confusing and, according to critics, includes elements of class snobbery, cultural influence and moral judgement. For example, fast food in North America, such as as hamburgers and french fries supplied by companies like McDonald's, KFC and Pizza Hut, are often perceived as junk food, whereas the same meals supplied by more up-market outlets such as California Pizza Kitchen or Nando's are not, despite often having the same or worse nutritional content. Some foods that are considered ethnic or traditional are not generally considered junk food, such as falafel, gyro, pakora, gyoza or chicharron, though all of these foods have little nutritional value and are usually high in fat from being fried in oil. Other foods such as white rice, roast potatoes and processed white bread are not considered junk food despite having limited nutritional content compared to wholegrain foods. Similarly, breakfast cereals are often regarded as healthy but may have high levels of sugar, salt and fat."

So the question is, "what exactly constitutes junk food?". If French fries from McDonalds are junk food because they contain little nutritional value, what about the over priced "hand cut" deli fried served in high-class restaurants? Does charging more money make junk food less "junkie"? What about foods like foie gras, caviar, lard - foods with no nutritional value, but eaten simply for their taste? Are these junk foods?

I sure do not envy the policy makers who have to decide what exactly constitutes "junk" food and where exactly to draw the line for healthy vs. unhealthy foods (e.g. Exactly how many calories per gram of food are admissable caloric density? How much refined sugar/sodium/fat per what are acceptable? Are all fried foods automatically junk food? Does throwing in some vitamins, protein and fibre make an unhealthy food healthier? etc.).

Not questions that I want to answer or take a stand on.

As I blogged before, in the context of obesity it's the calories that count - discussing nutrients is out of my league.

AMS
Edmonton, Alberta

When Apple is a Bad Word

This weekend I experienced my first trip to the Yukon, where I attended the 2008 Conference of the Canadian Association of Occupational Therapists (CAOT) in Whitehorse.

CAOT is a partner of the Canadian Obesity Network and I believe that this was the first time that a CAOT conference featured a professional issue forum on Obesity and Healthy Occupation. Speakers in this session, chaired by Mary Forhan (McMaster), included Kim Raine (U Alberta), Gaye Hanson (Hanson & Associates) and myself.

While Kim talked about how obesity has to be seen in the context of societal changes and pressures and I presented the medical perspective on obesity as a chronic disease, Mary talked about the role and opportunities for occupational therapists in obesity prevention, treatment and in allowing patients with obesity to live complete and dignified lives (no matter how good our prevention or treatments, there will always be obese individuals in our society). Gaye, a former Midwife and ex-Deputy Minister of Health and Social Services in the Yukon, herself of Cree Ancestry, presented a most enlightening view of the challenges of addressing obesity in Aboriginal populations.

But for me the most moving insights came from the closing remarks by Madeleine Dion Stout (picture), who was also the keynote speaker at the conference. Born and raised on the Kehewin First Nation in Alberta and nursing graduate from the Edmonton General Hospital, Madeleine worked for many years in the Medical Services Branch of Health Canada and has been a member of dozens of First Nations health committees and task forces aimed at improving the health of First Nations, Inuit and Metis.

The one sentence that I found particularly enlightening was (in the context of obesity - "apple and pears") "don't ever refer to an Indian as an apple!". For an Indian, an apple implies being "red" on the outside but "white" on the inside - not a very polite thing to say! All goes to show how cultural context can fully change the meaning of even the most seemingly innocuous words.

Most interestingly, Madeleine, herself a "victim" of residential schools made the same connection between the pain, suffering, broken spirit and shame inflicted by residential schools and the increased risk for obesity that I had made in my blog posting a day earlier. Imagine my surprise, as Madeleine of course was unaware of my take on the "apology".

Overall a most insightful weekend - much to think about.

Thank you CAOT for inviting me to Whitehorse.

AMS
Edmonton, Alberta

Canada Says “Sorry”

On Tuesday, Prime Minister Harper, on behalf of all Canadians, said “We are sorry” to the Aborginal peoples of Canada for putting generations of them through residential schools aimed at removing them from the influence of the wigwam.

These residential schools began in 1920 and attendance for all aboriginal children ages 7-15 years was made compulsory. Children were forcibly taken from their families by priests, Indian agents and police officers. The last federally run residential school was in Saskatchewan and closed its doors in 1996.

In his address, Harper said:

“The Government of Canada built an educational system in which young children were often forcibly removed from their home, often taken far from their communities. Many were inadequately fed, clothed and housed. All were deprived of the care and nurturing of their parents, grandparents and communities.”

This disastrous and cruel policy resulted in much pain and despair in the First Nations’, Inuit and Metis people that lasts to this day (known as the “generational effect”). Sexual, physical and mental abuse was widespread; students were broken in heart and spirit; culture and identities were destroyed.

Much (if not all) of what ails the Aboriginal peoples of Canada can be traced back to this policy – including possibly issues that affect Aboriginal health to this day.

It is no secret that obesity and its consequences (e.g. diabetes) are rampant amongst the Aboriginal peoples of Canada. While poverty, breakdown of traditional lifestyle and culture and even genetic factors (thrifty genotype) have all been implicated in this, I wonder how much the misery caused by the residential school program had to contribute.

Early traumatic life experiences including sexual, mental and physical abuse as well as neglect and grief have all been implicated in binge eating disorder (BED) – in its purest form – the uncontrollable urge to devour large quantities of highly palatable high-caloric foods in response to emotional hunger. This behaviour has been interpreted as an emotional coping strategy, “filling the inner void”, building a physical protective barrier, etc., the ultimate result being excessive weight gain with all its consequences (the typical binger does not compensate by purging or excessive exercise).

In “treatment-seeking” patients with obesity, the prevalence of BED is estimated at 20-40%. Although I was unable to find a study that has applied the DSM-IV criteria for BED to an Aboriginal population – my guess is: the rates are probably high!

Given its distinct psychopathology, BED is highly responsive to psychotherapeutic approaches. In contrast, educational initiatives based on simply providing information on healthy lifestyles are useless.

Obesity is never an issue of “choice”. I have yet to meet anyone who “chooses” to be obese. This is most certainly also true for Canada’s Aboriginal population.

I look forward to perhaps one day reading a thesis on “The Role of Residential Schools in the Aboriginal Obesity Epidemic”.

I’d be surprised if the author failed to find a clear link.

AMS
Edmonton, Alberta

Gas Poor

So yesterday, I blogged about the fact that nothing short of a catastrophic crisis is likely to reverse the obesity epidemic any time soon. I used the example of $4/litre gas prices.

Today, I heard a term for the first time that kind of addresses this issue: "gas poor".

I've previously heard of "house poor" and "divorce poor" but "gas poor" - to me that was a new one.

So how is being gas poor going to affect obesity?

Here are some scenarios:

1) You decide to continue driving your truck or SUV no matter what - and save on foods - i.e. no more expensive fruits and veggies - more cheap junk food.

2) You decide to switch to the rather ineffective public transportation - your commute to work is now twice as long - you have even less time to exercise or prepare a healthy meal.

3) You decide to work from home - your risk for boredom, loneliness, snacking and even less physcial activity goes up.

4) You decide to walk or ride a bike to work (if you're lucky enough to live close enough) and you get fitter and healthier (even if you don't lose weight).

But seriously, how many of us actually have option 4?

There may be other options like car pooling, moving closer to work, getting a smaller car or Vespa, no idea how those will impact your health.

Interestingly, this week truck drivers in Spain went on strike against the high gas prices resulting in a nation-wide shortage of fresh fish, meat, fruits and vegetables - my guess is people are turning to conserves, chips and (salt-laden) frozen meals.

Perhaps even hope in a "catastrophic" event like astronomic gas prices to prevent and reduce obesity may be futile after all.

AMS
Edmonton, Alberta

Taming the Obesity Giant

This rather "dramatic" slogan was the title of a presentation that I held last night at a public forum on obesity held at the Maclab Centre for Performing Arts in Leduc, a city just South of Edmonton.

The forum was organized by the Leduc health council and was well attended.

My main messages:

1) Obesity is a widespread chronic disease that needs to be resourced in the same manner as other chronic diseases.

2) Although not curable, we do have treatments that are highly effective in reducing morbidity and (at least in the case of bariatric surgery) mortality.

3) Unless we appreciate the tremendous impact that obesity is having as a driver of a wide range of acute and chronic diseases as well as short and long-term disability, and develop the same infrastructure and access to obesity treatments as we do for other chronic diseases, the (avoidable?) spending on obesity-related comorbidities and disabilities (e.g. hip and knee replacements, diabetes, etc.) will simply continue to skyrocket.

4) In the short term, nothing less than a catastrophic event (e.g. gas prices of $4/litre, food shortage, etc.) is likely to reverse the current epidemic.

5) While we discuss how to rebuild our cities and change our food supply, we cannot continue to simply ignore the plight of the Millions already suffering the consequences of this disabling and cruel disease.

Hard words, perhaps not what the audience was ready to hear or digest - nevertheless enthusiastic compliments on talking about these issues without mincing words or providing unrealistic rosy outlooks.

There is an obesity crisis out there and it's not going away anytime soon!

AMS
Edmonton, Alberta