421 Pounds
Anyone interested in the trials, tribulations and catastrophic untimely death of one of my Hamilton patients, can read about her in a Special Report (4 parts) starting today in the Hamilton Spectator. The story illustrates not just how complex treating morbid obesity really is but also demonstrates how failing to deal with obesity as a chronic disease early in its course can only lead to catastrophic outcomes. The fact that in the end Cheryl died soon after receiving the long-awaited by-pass surgery should not dispel the benefits to be derived from this procedure. As the story illustrates, outcomes are as (if not more) dependent on proper follow-up and the infrastructure to deal with complications (when they arise) as on finding a willing and able surgeon. In isolation, obesity surgery is doomed to failure. On the other hand, as part of a comprehensive program that ensures appropriate patient selection, preparation and long-term follow-up, the results are nothing short of spectacular. As anyone who has heard me speak about the Weight Wise program should appreciate by now – obesity surgery, even when necessary, is NEVER just about surgery! AMS
Weighing in on Green Health Care
Despite the risk of being considered a “left-wing tree hugger” here is a post on how health care can go green. Many of us may not realise this, but health care is a considerable source of environmental pollution and waste. As discussed in a recent Perspectives article in JAMA, a variety of organizations and coalitions are now coming together to help the growing number of hospitals and clinics that are adopting ways to become more efficient and less detrimental to the environment. For e.g. Kaiser Permanente in the US, is now following the Green Guide for Health Care and has in the last 5 years chosen ecologically sustainable materials for 2.7 million sqm in new construction, preventing 70 billion lbs of air pollution each year. They have also eliminated the purchase and disposal of 40 tons of hazardous chemicals and saved more than $10 million per year through energy-conservation strategies. Interestingly, they are also making a concerted effort to buy food and products locally. (regular readers of this blog will recognize the importance of this last point – if not, click here). Not to be outdone, Capital Health’s own Mazankowski Heart Institute, due to open in 2008, will be a “green building,” equipped with energy-saving equipment like occupancy sensors that turn off lights in empty rooms and giant heat recovery wheels that strip heat from air before it is exhausted to the outside. Capital Health estimates that these features can reduce costs to run the building by $1 million per year. The energy-saving features will also increase the likelihood of the Heart Institute becoming the first hospital in Canada to achieve LEED silver certification (Leadership in Energy and Environmental Design). To be LEED certified, a building earns points for innovative design features that promote a healthy environment, reduce costs and prevent wastage. For example, green spaces on the Heart Institute’s various rooftops will reduce heat reflection, and underground water tanks will collect runoff rainwater so it can be used for non-sterile tasks like hosing down sidewalks. The building will also get points for encouraging alternative, environmentally-friendly transportation through its proximity to Edmonton’s new subway station and for providing lockups for bicycles. It will have bright, open stairwells which promote use for staff and able-bodied visitors, rather than energy-expending elevators. Although WW is certainly eons away from being the prime source of waste in the CH system, we certainly produce a lot of paper, educational… Read More »
Certification of Exercise Physiologists
My recent post on the role of personal trainers in obesity management elicited a number of e-mail responses. From the mail that came in, the following information is perhaps especially worth noting: As many of you know, The Canadian Society for Exercise Physiology (CSEP) is a voluntary organization composed of professionals interested and involved in the scientific study of exercise physiology, exercise biochemistry, fitness and health. On November 17, 2007 (at the national CSEP conference in London, Ontario) the following supplement was released: Advancing the Future of Physical Activity Measurement and Guidelines in Canada: a scientific review and evidence based foundation for the future of Canadian physical activity guidelines. To view the supplement click here If you are a CSEP member, you will be receiving a hard copy of the supplement in the mail. Hat Tip to Taniya Birbeck, Exercise Specialist, Capital Health Weight Wise Program, for bringing this to my attention. AMS
Is Reducing Global Warming the Key to Preventing Obesity?
The link between two major problems of our times, global warming and the obesity epidemic, may be closer than we think. The following are a few random thoughts on why I believe solving one will go a long way to solving the other. If we accept that a major contribution to the rising incidence of obesity is (energy) overconsumption and lack of physical activity, then reducing consumption and increasing physical activity will be important. But reducing consumption and increasing physical activity will also help reduce global warming – here is why: Over the past century, fossil fuels have increasingly displaced food as the energy source for human movement. Both occupational and domestic physical activity has been replaced by automation and labor-saving devices, all of which consume energy from fossil fuels. But not just automation, also the physical effort to move from one place to another is today largely dependent on fossil fuels. As people get larger the fuels consumed to move the extra weight around only adds to the problem. It was estimated that in 2000, US airlines spent $275 million to burn 350 million more gallons of fuel just to carry the additional weight of Americans. Obviously, it also takes more fuel to move heavier people around on the ground whether this is in cars or on elevators, escalators or amusement park rides. But increased use of fossil fuels is not just part of the activity equation. The use of fossil fuels is also intimately linked to our food. World-wide, agricultural activity, especially livestock production (including ruminant methane production, transport and feed), accounts for about one fifth of total greenhouse-gas emissions. In most industrialised countries today the total energy put into food production vastly exceeds the food energy yield [see McMichael et al. for in depth discussion of this topic]. As energy inputs, mainly in the form of fossil fuels, have gradually increased, the energy ratio (energy out/energy in) in agriculture has decreased from being close to 100 for traditional pre-industrial societies to less than 1 in the present food system. Each calorie of food you eat may have consumed 10 to 50 calories in fossil fuels (the exact number depends on how you calculate this relationship – but no matter how you do it, the numbers are scary). Processing 1 pound of coffee requires more than 8,000 calories of fossil fuel, the equivalent of one quart of crude oil, 30 cubic feet… Read More »
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… Read More »
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