Readers will recall previous posts on the STAMPEDE trial, an ongoing trial of 150 patients who had type 2 diabetes and a BMI of 27 to 43 who were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy.
Now the 5 year results of this trial have been published in the New England Journal of Medicine.
Of the 150 patients who underwent randomization, 1 patient in the medical-therapy group died during the 5-year follow-up period (from myocardial infarction during year 4) and 1 patient in the sleeve-gastrectomy group had a stroke; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. One patient in the medical-therapy group, underwent gastric bypass during year 3, owing to failure of the medical treatment. One patient in the sleeve-gastrectomy group underwent gastric bypass during year 4 for the treatment of a gastric fistula.
At 5 years, the criterion for the primary end point (Hba1c <6% without the use of anti-diabetic mediations) was met by 2 of 38 patients (5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass and 11 of 47 patients (23%) who underwent sleeve gastrectomy.
At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (−23%, −19%, and −5% in the gastric-bypass, sleeve-gastrectomy, and medical-therapy groups, respectively), triglyceride level (−40%, −29%, and −8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (−35%, −34%, and −13%), and quality-of-life measures.
Excessive weight gain was observed in 19% of the patients in the medical-therapy group and in no patients in either surgical group.
No major late surgical complications were reported except for the one reoperation mentioned above.
From these findings the author conclude that,
“…bariatric surgery was superior to intensive medical therapy in terms of glycemic control, weight reduction, medication reduction, improvement in lipid levels, and quality of life. Patients who underwent gastric bypass or sleeve gastrectomy were significantly more likely to achieve and maintain a glycated hemoglobin level of 6.0% or less, with or without medications, than were those who received intensive medical therapy alone…The surgically treated patients had superior glycemic control throughout the 5-year period while also using fewer diabetes medications, including insulin. More than 88% of the surgical patients had glycemic control that was considered to be very good to acceptable (average glycated hemoglobin level of 7.0%), without the use of insulin. A majority of the surgical patients who achieved a glycated hemoglobin level of 6.0% or less reached that target without the use of diabetes medications, whereas none of the patients in the medical-therapy group reached that target without the use of diabetes medications.”
No doubt this study supports the notion of long-term benefits of bariatric surgery (even in people with BMI in the 27-34 range) compared to intensive medical treatment alone. Clearly, this should be a treatment that may be considered for patients with type 2 diabetes, who struggle with glycemic control.
This award recognizes an individual for a singular achievement or their career contributions to research in the field of obesity. This award is made possible through an annual grant from the Take Off Pounds Sensibly (TOPS). The award recipient will receive a plaque, a $2,500 prize, and a travel grant to attend the Canadian Obesity Summit. The award will be presented during a plenary session at which the recipient will be invited to present the TOPS New Investigator Research Award Lecture. Award recipients must be able to attend the Canadian Obesity Summit, Banff Springs, Alberta.
The nomination should include:
1. A letter of recommendation (signed by two members of the Canadian Obesity Network, one of whom must hold a faculty position; contact information must be provided) stating:
a. Your reasons for nominating the individual
b. The nominee’s qualifications for the specified award
c. A summary of the nominee’s research contributions to the field of obesity
2. The nominee’s complete CV including nominee’s complete contact information, current position and academic affiliation.
3. Two (2) to three (3) manuscripts that highlight the nominee’s research
- hold a health professional degree or a PhD degree;
- demonstrated success as an independent investigator;
- not be registered for a higher degree at the time of receiving the award;
- hold an appointment as an independent investigator at the time of being nominated and taking up the award,
- have held a faculty or research appointment (e.g., faculty appointment providing eligibility to apply for grants and/or supervise trainees) for a period of no more than 10 years. Time spent in research appointments in a non-academic setting (e.g., industry, government) count towards the 10 year limit if the candidate has been actively engaged in research, as demonstrated by the candidate’s publication record, and the candidate was not considered to be in training (e.g., as a student or postdoctoral fellow). Maternity/paternity and/or sick leave will not count towards the 10 year limit.
Review Process and Evaluation Criteria
Four senior members (one from each CIHR pillar) of the CON Science Committee and/or membership will evaluate the application packages.
1. Acknowledgement of CON/TOPS Support
2. The official award name is TOPS New Investigator Research Award. The award name must be used in all communication and promotion relating to the award
Application Deadline: Monday January 23rd, 2016 at 4:00 p.m. Mountain Time. Applications should be assembled in a single PDF file and submitted to email@example.com at the Canadian Obesity Network (Phone:780-492-8361; Fax:780-492-9414).
If you’re wondering why, the answer is rather simple.
According to a paper by Robert Kushner and colleagues published in the journal Teaching And Learning In Medicine, competencies in obesity prevention, assessment, and treatment are apparently not really required, at least not based on the questions that young doctors can expect to be asked in licensing exams.
The researchers examined the coverage and distribution of obesity-related items on the three step United States Medical Licensing Examination (USMLE), which every practicing US physician (irrespective of the specialty or discipline) has to pass to qualify for licensing.
Although the USMLE question panel did include over 80o multiple-choice items containing obesity-related keywords, 58% of these items were represented by only 4 of 17 organ systems, and 80% of coded items were represented by only 6 of the 107 American Board of Obesity Medicine subdomains.
While the majority of obesity-coded items pertained to the diagnosis and management of obesity-related comorbid conditions, they did not directly address the prevention, diagnosis, or management of obesity itself.
In medicine (as in any other discipline), students focus on topics that they can expect to encounter in their exams – clearly, diagnosing obesity and managing it, is not one of them.
That said, readers may have noticed that over the past 6 months posts have been far more irregular – this is because after 10 years of daily blogging, no doubt, a certain weariness has set in.
Not because obesity is no longer interesting or there is less new research to report on – actually, the opposite is true.
Obesity continues to be a important as a global health problem as ever and there is more obesity research pouring out of research labs than ever before.
It is just that I feel that I’ve posted on almost all important topics and so, although there may be a torrent of new studies, the really new – i.e. research that has the potential to actually take obesity prevention or treatments to a whole new level, remains rather rare.
So my plan going forward with these Obesity Notes is to continue posting, albeit less regularly, whenever I come across studies that are of exceptional significance. I will also, from time to time, continue using these Notes as a venue for discussing new (or old) ideas on obesity that I find worth sharing. The latter may include reposting older posts on topics that remain important.
So hopefully readers will bear with me through 2017 as we continue on this journey of discovery.
Wishing all my readers a Happy and Peaceful 2017 – Also, Happy 150th Birthday Canada!
So, has increased recognition of this problem resulted in the incorporation of this topic in health care training programs?
This was the topic of a study by Shelly Russell-Mayhew from the University of Calgary and colleagues, published in the Canadian Journal for the Scholarship of Teaching and Learning.
The environmental scan looked at teaching curricula from 67 Alberta training programs (26 diploma programs, 41 degree programs) from 22 training institutions (16 colleges, 6 universities) in medicine (MD, MSc, PhD), family medicine residency, nursing (DPN, BN, BSc, MN, MSc), dietetics (BSc), pharmacy (BSc, PharmD), physical therapy (MSc), occupational therapy (MSc), clinical and counselling psychology (MEd, MSc, PhD), school psychology (MSc, PhD), and social work (DSW, BSW, MSW).
Despite including general course work on obesity (mainly about diet and exercise), only social work students and students in one graduate level nurse practitioner program included coursework specifically dedicated to bias, discrimination, or social justice issues.
As the authors note,
“These results provide preliminary support for previous assertions that systematic training in obesity and weight bias is overlooked, and that the training provided fails to meet the needs of practitioners once they enter the health care field.”
Although the study was limited to Alberta, there is little reason to hope that the situation elsewhere in Canada is any better.
Thus, it appears that training programs have yet to embrace the importance of preparing future health care workers for addressing the needs of clients living with obesity with appropriate sensitivity regarding weight and size.
Discrimination based on appearance, which includes size, are rampant and well documented in virtually all social, educational, and professional settings. Unfortunately, current legislation does not offer individuals who experience with this form of discrimination the same legal protection as it does to people, who are discriminated against due to colour, gender, sexual orientation, or a host of other factors.
Now, there are at least three ongoing public petitions in Canada calling upon the Human Rights commissioners to make size and appearance discrimination illegal (#SizeismSUCKS).
Thus, a recent petition in Ontario has currently garnered over 8,500 signatures – just short of 10,000.
Similar petitions in Alberta, Manitoba, and British Columbia are just beginning to gather momentum.
As Jill Andrews, the initiator of the Ontario petition notes:
“At 14, I was told by another teen that I was ‘as big as a Mack Truck’ and someone would only date me if ‘they put a paper bag over my head.’ I told my teacher and she told me to ‘be strong…it would pass with time.’ At 20, I was denied a job and told, I was ‘so very talented with an infectious personality . . . but just too big for the screen.’ I wasn’t even fat.”
As Jill further points out,
“Appearance-based protection would mean human rights protection against size, weight, height discrimination and other differences such as visible scars, alopecia or facial differences for instance. All too many of us live under a cloud of stereotypes and judgments made about us because of how we look, whether we’re big or small. These judgments often come with real social, mental, physical and economic consequences. Some of us don’t pursue the careers and the lives we want because we are simply too scared of being treated without humanity because of our size. Some of us are even too afraid to go to the doctors when we are sick in fear of further body-shaming. Some of us take our own lives.”
As in other provinces,
“The Ontario Human Rights Code (OHRC) recognizes this in regards to race, gender, sexual orientation and other necessary protected grounds but body size and physical appearance remains absent.”
You can help change this by supporting the various petitions (especially the one in your province):
To sign the petition in Ontario click here
To sign the petition in Alberta click here
To sign the petition in Manitoba click here
To sign the petition in British Columbia click here
To start a similar petition in your own province click here
You can make a difference!
In my two previous posts (here and here), I have discussed the urgent need for obesity treatments that are scalable to the size of the problem. I explained why neither “lifestyle” nor surgery are scalable to the millions of Canadians who would stand to benefit from obesity treatments.
No doubt, not everyone with a BMI over 30 needs treatment. As I also discussed, we should target treatments (especially with anti-obesity medications) to those who are actually experiencing an obesity related impairment in health, especially those with comorbidities that are not well controlled and who are otherwise good candidates for treatment.
As I calculated, this reduces the number of Canadians that would really need to be treated for obesity from about 7,000,000 to perhaps 1,250,000 – roughly half the number of Canadians currently living with diabetes, a chronic disease that is routinely managed with medical treatments.
Many of these would no doubt stand to benefit from surgical treatments, but at the current rate of about 10,000 surgeries a year (a number that is unlikely to dramatically increase in the foreseeable future), I see no alternative than the use of anti-obesity medications.
This is where we have a real problem.
While for any patient with diabetes or hypertension who walks through my door, I have over 100 possible prescription medications to pick from, including an almost limitless number of possible combinations, for obesity I have almost nothing.
The two only prescription medications for obesity currently approved in Canada are orlistat and liraglutide. The former is moderately effective but is handicapped by unpleasant side effects. The latter, is an injectable hormone-analogue, where access is limited by cost (in Canada about $15 a day).
Obviously, not everyone will tolerate or respond to either of these medications. This is not unexpected. In fact this is the very reason that we have so many different classes of drugs for the treatment of other chronic diseases like hypertension or diabetes – what works for one patient does not work (or is not tolerated) by another.
So why do we not have more therapeutic options for obesity treatment?
The only answer that springs to mind is that Big Pharma is not putting the same dedication and resources behind developing anti-obesity drugs compared to what they are pouring into other indication areas.
Thus, while Big Pharma is busy developing and appears to be launching new drugs for diabetes almost every other month, nothing remotely comparable is happening in the obesity space.
thus, virtually every multinational pharmaceutical company has active development programs for diabetes.
In contrast, almost no multinational pharmaceutical company has an active development program for obesity worth speaking of.
The only reason that I can think of why a Novartis, Pfizer, Roche, Sanofi, Merck or any of the other major pharmaceutical companies are not investing in finding, developing, and bringing new anti-obesity drugs to market to fill this gaping therapeutic gap, is that they do not expect to make money with anti-obesity drugs.
This is largely because, as we have seen with past introductions of anti-obesity drugs, medications for obesity are seldom covered by pharma benefit plans or public formularies, making access to these drugs for a relevant number of patients difficult.
This lack of coverage of obesity drugs has little to do with the actual cost of new medications. In fact, even the currently most expensive anti-obesity drug in Canada works out to only around $5,000 a year – a sum that drug benefit plans routinely spend on managing patients with diabetes year after year after year.
So if it is not the cost of treating obesity that is prohibitive, why do most people who would stand to benefit from obesity treatments (and remember, we are only talking about half as many people who are currently being treated for diabetes) not have access to obesity treatments?
My guess is that this has a lot to do with the fact that obesity (in contrast to hypertension or diabetes), is still not widely seen as a chronic disease requiring treatment in its own right.
For one, most doctors have never prescribed a medication for obesity – they were simply never trained to do so.
In addition, employers (who generally pay for their employee benefit plans) are offered the option of opting out of covering obesity treatments (drugs or otherwise) – unfortunately, most employers do.
Of course, I understand that prescriptions medications (even after their regulatory approval and meeting the relevant efficacy and safety standards) should only be covered if they promise real health benefits, which of course have to be demonstrated in clinical trials.
But we will never have those new medications or the trials that prove their efficacy, if companies believe that despite all efforts, their medications will not recoup the investments or make profits for their shareholders.
This is where policy makers need to step in.
For one, governments could consider providing significant incentives (e.g. tax breaks?) to Big Pharma to devote resources specifically towards developing new medications for obesity.
Secondly, governments must streamline the approval process for new obesity medications in a way that will ensure that these treatments become available to those who stand to benefit (and I don’t mean anyone who is hoping to lose a couple of pounds to fit into their wedding dress – I mean people with at least Edmonton Stage 2 obesity, especially those with poorly controlled obesity related health problems).
Thirdly, employers and benefit plans should no longer have the option of opting out of paying for obesity treatments (in the same manner that they cannot chose to simply not cover diabetes or hypertension or any other chronic disease).
I believe that if these measures were implemented, at least some of the big pharmaceutical companies will reassess their position on developing safe and effective anti-obesity medications.
With more pharmacological options (and more competition in the market place), I see no reason why the standard for obesity care cannot be on par with what is currently routinely offered for patients with diabetes, hypertension or most other chronic diseases.
Without these policy changes, I fear that we will never have obesity treatments that are scalable to address the size of the problem.
The time for policy makers to act is now!
Post script: I harbour no illusion that any change in policy in Canada alone will make any difference to Big Pharma – after all, the Canadian pharma sales are only about 2% of the global market. Rather, it would take a consortium of countries, including the biggest markets, to make a joint decision regarding any such policies. Sadly, I believe that the chances for this in the current political climate are rather remote – but, then again, we can always hope…