Friday, November 28, 2014

When Something is Not Better Than Nothing

diet journalThis is the title of a recent article by Nikhil Dhurandar and other members of the Energy Balance Measurement Working Group (of which I am a member), published in the International Journal of Obesity and refers to the inadequacies of our current methods for assessing energy intake and expenditure.

In the paper, the authors argue that while an assessment of energy balance may well be a critical issue both for research and clinical practice, our current methods for assessing this are woefully inaccurate and may well be leading us in the wrong direction.

Thus, for example, there is no shortage of information on the fact that self-reported dietary energy intake (EI) is woefully inaccurate (despite all efforts over the past decades to try and make this more accurate) to the point of being near useless in individuals and even less meaningful in population studies – at least when it comes to the assessment of energy balance.

The same is unfortunately true for assessments of physical activity energy expenditure (PAEE) where errors ranging in the 100s of calories are the norm rather than the exception.

This leads the authors to the rather sweeping conclusion that,

“…self-reports of EI and PAEE are so poor that they are wholly unacceptable for scientific research on EI and PAEE. While new strategies for objectively determining energy balance are in their infancy, it is unacceptable to use decidedly inaccurate instruments, which may misguide health care policies, future research, and clinical judgment. The scientific and medical communities should discontinue reliance on self-reported EI and PAEE.”

While this may well hold true for research, I am not that sure about the implications for clinical practice.

This is because, the very act of self-monitoring has been shown to influence behaviour – irrespective of the precision of such monitoring (at least I am not aware of a single study showing that the accuracy of food records makes any difference to the outcome).

There is indeed overwhelming evidence that patients who use any form of self-monitoring (pen and paper or electronic) eat better and are more physically active than people who don’t.

While trying to determine someone’s precise energy balance by poring over these records is a rather futile exercise (the difference between the records and what actually happens may be in the 100s of calories), I do know that my patients who keep food and activity records do better than those who don’t.

Nevertheless, as far as research is concerned (or making clinical decisions based on assuming that the actual energy balance is anywhere close to the deceptively precise numbers calculated from such record), I agree with the authors that our current methods are highly inadequate and, what is worse, may well be misleading.

I, for one,happily ignore most of the data that comes from self-reported studies on diet or activity (which, incidentally is the vast majority of research on these issues), never mind that much of these data come from epidemiological studies, where any inference of causality is speculation at best.

On the other hand, precise or not, I do encourage all of my patients to self-monitor as I know this changes behaviour – no matter if these records are off by 100s of calories.

@DrSharma
Barcelona, Spain

ResearchBlogging.orgDhurandhar NV, Schoeller D, Brown AW, Heymsfield SB, Thomas D, Sørensen TI, Speakman JR, Jeansonne M, & Allison DB (2014). Energy balance measurement: when something is not better than nothing. International journal of obesity (2005) PMID: 25394308

 

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Thursday, November 27, 2014

Would You Like Some Guilt With That Popcorn?

popcornYesterday, I blogged about the McKinsey discussion paper that calls on governments to throw everything they’ve got at the obesity epidemic – proven or unproven – anything is better than nothing.

That said, it is indeed timely that this week, the US-FDA announced sweeping regulations on putting calories on menus, not just in fastfood restaurants but also in grocery stores, vending machines, and movie theatres.

Personally, I am all for it – never mind that we have yet to show that providing this information at the point of purchase actually changes behaviour of the target population (namely the people who do need to watch their calories) – I, for one, do find this information helpful.

Thus, every time I visit a McDonalds restaurant (yes, I do), I study the nutritional information that this restaurant chain has been making available to any customer who bothers to ask for decades.

Indeed, I do admit to deriving a kind of voyeuristic pleasure in seeing those astonishingly high numbers on certain food items and cannot help myself from inwardly shaking my head at the poor schmucks who order those foods.

What I do wonder, however, is whether knowing these numbers has ever actually changed my own behaviour.

Take movie popcorn for instance – I love it! (interestingly this is a habit that I only developed since moving to Canada).

Not that I am not aware that a large popcorn can easily have all the calories I need for the rest of the weekend – yup, I know that – indeed, I am making an “informed choice”.

In the few milliseconds I spend thinking about whether or not I may wish to skip the popcorn this time, those calorie numbers do regularly flash through my mind – in the end, the popcorn always wins.

So how will having the numbers up on the menu board staring in my face change things for me?

My guess is that I’ll still buy the popcorn, except now it will come with an even larger portion of guilt than before.

Obviously, with the numbers up there for everyone to see (including the people in line behind me), there may well now be an added tinge of embarrassment on top of the guilt.

Well, I may not be the typical consumer or even the target of these measures – after all these are meant for the people who could obviously do with some nudging towards eating a healthier diet (not really sure why I am excluding myself from this list).

Yet, I don’t mind these measures, I have always considered this a good idea.

But will having these numbers staring me in the face everytime I eat out change my consumption of popcorn? Probably not.

Will they make me think thrice (I already think twice)? Perhaps.

So to sum up, funnily enough, I find myself in full support of this measure – even if I am not really sure why.

I guess anything is better than nothing.

@DrSharma
Frankfurt, Germany

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Wednesday, November 26, 2014

McKinsey on Obesity: Doing Something Beats Doing Nothing

McKinsey Overcoming ObesityLast week the McKinsey Global Institute, with much media fanfare, released a 120 page discussion paper titled, “Overcoming obesity: An initial economic analysis“, which estimates that the economic cost of the global obesity epidemic is upwards of $2 trillion, a number similar to the economic cost of tobacco consumption or armed conflicts.

The report identifies 74 interventions in 18 areas (ranging from policy and population health to health care) deemed to be cost effective, which, if implemented, could lead to annual savings of $1.2 billion in the UK National Health Services alone.

However, when it comes to the actual impact of these 74 strategies, the report is far more sobering in that it notes that many of these interventions are far from proven:

“The evidence base on the clinical and behavioral interventions to reduce obesity is far from complete, and ongoing investment in research is imperative. However, in many cases this is proving a barrier to action. It need not be so. We should experiment with solutions and try them out rather than waiting for perfect proof of what works, especially in the many areas where interventions are low risk. We have enough knowledge to be taking more action than we currently are.”

In other words, let’s not wait to find out what works – let’s just do something – anything (and keep our fingers crossed).

Thus, the report urges us to

“(1) deploy as many interventions as possible at scale and delivered effectively by the full range of sectors in society; (2) understand how to align incentives and build cooperation; and (3) do not focus unduly on prioritizing interventions because this can hamper constructive action.”

I can see why politicians would welcome these recommendations, as they are essentially a carte blanche to either doing nothing (we don’t have the evidence) or doing whatever they want (anything is better than nothing).

The fact that,

“Based on existing evidence, any single intervention is likely to have only a small overall impact on its own. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to address the health burden.”

means that when any measure fails, it is not because it was the wrong measure but because there was either not enough of it or it was not complemented by additional measures.

Again, a free pass for politicians, who can pass whatever measures they want (based on their political ideologies or populistic pressure from their constituencies), without having to demonstrate that what they did, had any effect at all.

Of course, no report on obesity would be complete without also stressing the importance of “personal responsibility”, as if this was somehow more important for obesity than it is for diabetes, lung disease, heart disease, or any other disease I can think of.

Unfortunately, the report also includes rather nonsensical statements like,

“44 interventions bring 20% of overweight/obese Britons back to normal weight”

a sentence that defies the very chronic nature of obesity, where once established excess weight is vigorously “defended” by complex neuroendocrine responses that will counteract any change in energy balance to sustain excess body weight.

Thus, unfortunately, the authors fall into the common misconception about obesity simply being a matter of calories in and calories out, a balance that can be volitionally adjusted to achieve whatever body weight you wish to have.

Indeed, there is very little discussion in this “discussion paper” of the underlying biology of obesity, although it is acknowledged in passing:

“Even though there are important outstanding questions about diet composition, gut microbiome, and epigenetics, we are not walking blind with no sense of what to address. However, interventions to increase physical activity, reduce energy consumption, and address diet composition cannot just seek to reverse the historical trends that have left the population where it is today. For example, we cannot, nor would we wish to, reverse the invention of the Internet or the industrialization of agriculture. We need to assess what interventions make sense and are feasible in 2014.”

Will this report move governments to action? Or, even more importantly, will this report bring us any closer to reversing the epidemic or providing better treatments to people who already have obesity?

Readers may appreciate that I am not holding my breath quite yet.

ƒƒ@DrSharma
Edmonton, AB
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Tuesday, November 25, 2014

Obesity Myth: Success Is Measured In Pounds Lost

sharma-obesity-5as-booklet-coverFinally, in this series of common misconceptions about obesity management, discussed in our article in Canadian Family Physician, we address the notion that success in obesity management is best measured in the amount of weight loss:

“Given the importance of obesity as a public health problem, there is widespread effort to encourage people with excess weight to attempt weight loss.

However, a growing body of evidence suggests that a focus on weight loss as an indicator of success is not only ineffective at producing thinner, healthier bodies, but could also be damaging, contributing to food and body preoccupation, repeated cycles of weight loss and regain, reduced self-esteem, eating disorders, and social weight stigmatization and discrimination. 

There is also concern that “anti-fat” talk in public health campaigns might further promote weight bias and discrimination. 

Therefore, it might be time to shift the focus away from body weight to health and wellness in public health interventions.

Recently, the Canadian Obesity Network launched a tool called the 5As of Obesity Management (www.obesitynetwork.ca/5As) to guide primary care practitioners in obesity counseling and management. 

Minimal intervention strategies such as the 5 As (ask, assess, advise, agree, and assist) can guide the process of counseling a patient about behaviour change and can be implemented in busy practice settings.

Obesity management should focus on promoting healthier behaviour rather than simply reducing numbers on the scale. The 5As of Obesity Management is a practical tool to improve the success of weight management within primary care.”

@DrSharma
Edmonton, AB

 

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Monday, November 24, 2014

Obesity Myth: Anyone Can Lose Weight

scaleHere is another common misconception about obesity discussed in our article in Canadian Family Physician:

“It is common to hear that weight loss is a matter of willpower and compliance with the weight-reducing program.

However, the magnitude of weight loss is very different among individuals with the same weight-loss intervention and prescription, and the same compliance to the program—one size does not fit all.

Thus, for some people (especially those who have already lost some weight), simply putting more effort into a weight-loss program will not always result in additional weight loss given the different compensatory adaptations to weight loss.

For example, the decrease in energy expenditure that occurs during weight loss is highly variable between people and might dampen efforts to lose additional body fat.

Such compensatory mechanisms might sometimes fully counteract the 500 kcal per day decrease recommended in most dietary interventions, making it very difficult for such “poor responders” to lose weight.

Physicians should remember that obesity is not a choice and weight-loss success is different for every patient.

Success can be defined as better quality of life, greater self-esteem, higher energy levels, improved overall health, or the prevention of further weight gain.”

@DrSharma
Edmonton, AB

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