Obesity is Not Special

Most people either think that managing obesity is easy (just eat less and move more, Stupid!) or is extremely complicated (simply hopeless and a complete waste of time).

Fact is that managing obesity is actually not very different than managing many other chronic diseases.

Yes, we need to make the right diagnosis, yes, patients have to make lifestyle changes and yes, there are medical and even surgical treatments, but even these only work if patients are well managed in the long-term and follow the rules.

Relying on lifestyle counseling alone is probably as effective for obesity as it is for diabetes, hypertension or dyslipidemia. Medications for obesity, like medications for diabetes, hypertension or dyslipidemia, only work when you continue taking them. As with many chronic conditions, as patients get older, treatment gets more difficult.

The reasons why most physician's think that managing diabetes, dyslipidemia or hypertension is easier than treating obesity, are firstly because they have been extensively trained to treat these conditions and secondly because the treatments for these conditions are deemed more effective and better studied than treatments for obesity.

Actually, perhaps with the exception of statins for high LDL-cholesterol, the results of monotherapy for many chronic conditions like diabetes, hypertriglyceridemia or hypertension are pretty modest. Reducing HbA1c by 1% point, triglycerides by 10% or diastolic blood pressure by 5 mmHg is pretty much the average effect seen with antidiabetic, lipid-lowering or antihypertensive monotherapy - really not very impressive at all. Yes, some patients will respond better, but many will not.

Seen in that light, a 5-10% sustained weight loss with antiobesity monotherapy isn't that bad after all, given that lowering body weight may in fact be tougher than lowering blood sugars or blood pressures.

The problem with antiobesity medications is not that they don't work - the problem is that most people do not continue taking them once they stop losing weight. They are taking them for weight loss rather than for weight-loss maintenance. But even this is not that different from other chronic diseases. We know that adherence with antihypertensives, antilipids and antidiabetics is notoriously poor with few patients taking these medications for much longer than six months at a time.

As for other chronic conditions, taking an antiobesity drug for a few months just to lose weight makes absolutely no sense - the idea that something magical will then happen and the weight loss will be maintained after stopping treatment is idiotic and completely inconsistent with our current understanding of energy homeostasis.

Obesity is not special - it is simply a chronic disease which like all chronic diseases requires long-term (lifelong?) treatment.

AMS

Off-Loading Young Hips

It is no secret that obesity is a substantial driver of any hip and knee replacement program. Although all kinds of factors can promote degenerative joint disease, the excess weight bearing down on a given joint certainly doesn't help.

In adults, this is pretty much accepted and as there is no end to the obesity epidemic in sight, orthopedic surgeons are unlikely to be out of work anytime soon.

But now, there is increasing evidence that obesity may be driving an increase in joint problems in kids.

Slipped capital femoral epiphysis (SCFE), typically appearing around the time of the early-pubertal growth spurt in adolescents (twice as often in boys than in girls), is of growing concern.

In a recent article, Murray and Wilson from the Royal Hospital for Sick Children in Edinburg describe a 2.5-fold increase in SCFE in Scotland over the last two decades, but also that SCFE was now increasingly seen at younger ages. This increase remarkably parallels the substantial increase in childhood obesity in Scotland over this time period.

Typically patients present with a history of several weeks or months of hip or knee pain and an intermittent limp. Treatment requires surgical fixation of the femoral head to avoid further slippage.

With all the concern about increasing type 2 diabetes, dyslipidemia and hypertension in kids, let's not forget bone and joint health.

Missing the diagnosis can lead to irreversable damage with loss of function. Early recognition and surgical treatment (with or without weight loss) is essential.

AMS

Pass (up) the Salt

Monday (Jan 28) was the beginning of the World Salt Awareness Week.

To draw attention to this event, three National Centres of Excellence Networks got together to bestow the "Salt Lick Award" to A&W for the saltiest kids burger.

This initiative, led by the Canadian Stroke Network was both by the Advanced Food and Materials Network as well as the Canadian Obesity Network and received considerable attentions from national media.

As some of you may know, I have a special interest in this topic. In fact, much of my early research was on trying to understand why salt affects blood pressure in some people but not others.

Obesity is certainly one factor that can make you more "sensitive" to salt intake. This was elegantly demonstrated by Alberto Rocchini, who not only demonstrated this relationship in adolescents but also showed that weight loss can make them less sensitive to salt.

Clearly, there is good reason to avoid excess salt, especially if you have high blood pressure and carry around some extra weight.

Hopefully, the attention that salt receives this week will put some pressure on food producers and restaurants to do what they can to reduce salt in foods.

In the meantime be sure to pass (up) the salt.

AMS

Antipsychotics and Weight Gain

It is no secret that medications commonly used to treat psychosis can lead to remarkable weight gain. This is particularly true of the second generation antipsychotics clozapine (Leponex, Clozaril) and olanzapine (Zyprexa), but the mechanisms leading to weight gain are poorly understood.

In a recent study Kluge and colleagues from the Max Planck Institute of Psychiatry in Munich, ramdomised 30 patients with schizophrenia, schizophreniform, or schizoaffective disorder in a double-blind, parallel study comparing abnormal eating behavior using a standardized scale to clozapine and olanzapine.

In both treatment groups, there was a significant increase in cravings and in binge eating, whereby the rate of these effects was somewhat higher with olanzepine. Clinical improvements in psychiatric symptoms was comparable.

What the study does not disclose is what one could possibly do to help patients avoid weight gain. The evidence that "lifestyle" interventions are effective in preventing this weight gain is marginal at best. A recent randomized study published in JAMA showed some benefit of prescribing metformin alone or in combination with lifestyle advice.

An earlier double-blind placebo-controlled study in 37 patients on olanzepine showed greater weight loss with sibutramine (Meridia, Reductil) over 12 weeks than on lifestyle alone.

Amantadine, in an even smaller randomised placebo-controlled study in 21 patients, was at least somewhat effective in limiting olanzapine-induced weight gain.

Clearly, addressing weight gain in patients, who need effective antipsychotic medications remains challenging at best.

AMS

Walk or Wait?

Many of you may know that since moving to Edmonton and living downtown, I now try to rely on the Edmonton Transit System for getting around town (i.e. when I cannot hitch a ride with someone).

So obviously the issue of whether to wait for the next bus (when I don't see one coming) or to try and walk to the next stop (so I don't have to stand still in the cold) is a big one.

Gratefully, I am not alone with this dilemma. As commented on recently in the Globe and Mail, US mathematicians have come up with the formula that allows you to calculate the odds of missing the next bus (by being caught between two stops as it whizzes by you) - the math is complex (taking into account distance to be travelled, distance between stops, frequency and speed of the bus, your own walking speed), but the bottom line is that unless you are traveling less than a Kilometer and the buses are around an hour apart, it is mathematically better to wait.

What the formula does not take into account is freezing your butt off by standing still. It also does not take into account any health benefits to be derived from walking to try and make it to the next stop and then breaking into a short run when you see the bus coming (my kind of exercise!).

Anyway, why even bring this up? Well, partly because I m a big believer in public transportation for its health benefits (and stress relief).

In a recent analysis by Edwards from City University of New York, Taking public transit is associated with walking 8.3 more minutes per day on average, or an additional 25.7-39.0 kcal. Based on the estimate that an increase in net expenditure of 100 kcal/day can stop the increase in obesity in 90% of the population. Additional walking associated with public transit could save $5500 per person in present value by reducing obesity-related medical costs (US). Savings in quality-adjusted life years could be even higher.

Similarly new studies from Sweden and Australia show that using public transportation or riding a bike to work is significantly associated with lower weight and better health. Oddly, in both studies the benefits were evident only in men.

I, for now, will of course continue using the ETS and sneaking a run to next base when I don't see a bus coming. I may be late for meetings but at least I'll be a little healthier.

AMS

Tightening the Band on Diabetes

A study published in today's JAMA, found that obese patients with Type 2 diabetes who underwent laparoscopic adjustable gastric banding (LAGB) were five times more likely to have their diabetes go into remission than patients who engaged in conventional weight loss therapies, such as diet and exercise.

The four-year study, which was led by Drs. John Dixon and Paul O’Brien from Monash University’s Centre for Obesity Research and Education (CORE), monitored 60 volunteers for two years who underwent significant weight loss of more than 10 per cent of their body weight.

Of those who underwent gastric banding surgery, 73% achieved remission for Type 2 diabetes, compared to just 13% of the people who underwent conventional therapy. This was largely attributable to the far greater weight loss in the band patients, who lost on average 20% of their initial body weight.

What is remarkable about this study is not that bariatric surgery leads to remission of diabetes - this we've known for a while.

What is new, however, is the fact that the subjects in this study had a BMI in the 30-40 range, i.e. a range not normally considered for bariatric sugery (for e.g. the average BMI in the Adult WW Clinic is 57!).

Of course, there were the expected complications with the LABG, including one band removal. Nevertheless, the point is that a relatively simple surgical procedure (which can essentially be performed in under 60 minutes as day surgery in experienced centres) can "cure" a condition for which the alternative is lifelong medical treatment.

Should surgeons now rush in and operate on all patients with type 2 diabetes?

Certainly not (yet?).

Despite the ease of the actual surgical procedure, patient management remains complex. Not only do patients have to make significant (lifelong) changes in their diet and eating pattern, but the need for regular band adjustments also make regular follow-ups by physicians familiar in dealing with these patients mandatory.

My guess is that all of the usual caveats to bariatric surgery will apply to this population including on-going addictions, mental health problems, binge eating disorders, non-compliance, etc.

But for selected patients with recently-diagnosed type 2 diabetes at experienced centres, probably the way to go.

Perhaps time for some diabetologists to start honing their band management skills?

AMS

25,000 Reasons to Promote Bariatric Care

This evening, I presented my vision for the Weight Wise Program to the Capital Health Board of Directors. I set the stage by presenting recent data on the prevalence of obesity.

Extrapolating from the most recent available data, based on roughly a population of 1,000,000 in the Capital Health region, I estimated that around 500,000 or 50% of the population have overweight or obesity, around 250,000 or 25% have frank obesity and around 25,000 or 2.5% have severe or morbid obesity.

Not surprisingly, the numbers clearly shocked my listeners. While everyone was of course well aware that there was an obesity problem, it is probably fair to say that few fully appreciated how HUGE the problem really is.

My comment that at the current rate of obesity surgery in the region, it would take us several centuries to operate on everyone who is morbidly obese today, was visibly sobering.

Just to clarify, I am not a surgeon. I have nothing personally to gain from promoting obesity surgery. Indeed, I much rather wished we had medical treatments that could do the job - but I have to concede that at least for now, obesity surgery is by far the best option for eligible patients.

Believe me, if there was a way to avoid surgery, I'd be all for it. But just as I've had to accept that dialysis and transplantation are the best options for patients with kidney failure, I have to accept that bariatric surgery is currently the best treatment for severe obesity.

More power to anyone who can manage their massive excess weight by radically overhauling their lifestyles and sticking with it - realistically, however, I am painfully aware that this will always be a small minority - most will require medical and/or surgical help.

Denying this help is not an option - morbid obesity is NOT a rare disease!

AMS