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World Health Organisation Warns About The Health Consequences Of Obesity Stigma

Yesterday (World Obesity Day), the European Regional Office of the World Health Organisation released a brief on the importance of weight bias and obesity stigma on the health of individuals living with this condition. The brief particularly emphasises the detrimental effects of obesity stigma on children: “Research shows that 47% of girls and 34% of boys with overweight report being victimized by family members. When children and young people are bullied or victimized because of their weight by peers, family and friends, it can trigger feelings of shame and lead to depression, low self-esteem, poor body image and even suicide. Shame and depression can lead children to avoid exercising or eatng in public for fear of public humiliation. Children and young people with obesity can experience teasing, verbal threats and physical assaults (for instance, being spat on, having property stolen or damaged, or being humiliated in public). They can also experience social isolation by being excluded from school and social activities or being ignored by classmates. Weight-biased attitudes on the part of teachers can lead them to form lower expectations of students, which can lead to lower educa onal outcomes for children and young people with obesity. This, in turn, can affect children’s life chances and opportunities, and ultimately lead to social and health inequities. It is important to be aware of our own weight-biased attitudes and cautious when talking to children and young people about their weight. Parents can also advocate for their children with teachers and principals by expressing concerns and promo ng awareness of weight bias in schools. Policies are needed to prevent weight-victimization in schools.” The WHO Brief has important messages for anyone working in public health promotion and policy: Take a life-course approach and empower people: Monitor and respond to the impact of weight-based bullying among children and young people (e.g. through an -bullying programmes and training for educa on professionals). • Assess some of the unintended consequences of current health-promo on strategies on the lives and experiences of people with obesity. For example: Do programmes and services simplify obesity? Do programmes and services use stigmatizing language? Is there an opportunity to promote body positivity/confidence in children and young people in health promotion while also promoting healthier diets and physical activity?• Give a voice to children and young people with obesity and work with families to create family-centred school health approaches that strengthen children’s resilience and… Read More »

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Residential Schools And Indigenous Obesity – More Than Just Hunger?

A recent CMAJ article, by Ian Mosby and Tracey Galloway from the University of Toronto argues that one of the key reasons why we see obesity and diabetes so rampant in Canada’s indigenous populations, is the fact that widespread and persistent exposure to hunger during the notorious residential school system may have metabolically “programmed” who generations toward a greater propensity for obesity and type 2 diabetes. There is indeed a very plausible biological hypothesis for this, “Hunger itself has profound consequences for childhood development. Children experiencing hunger have an activated hypothalamic–pituitary–adrenal stress response. This causes increased cortisol secretion which, over the long term, blunts insulin response, inhibits the function of insulin-like growth factor and produces long-term changes in lipid metabolism. Through this process, the child’s physiology is essentially “programmed” by hunger to continue the cycle of worsening effects, with their bodies displaying a rapid tendency for fat-mass accumulation when nutritional resources become available.” While the impact of hunger may well have been one of the key drivers or metabolic changes, the authors failed to acknowledge another (even more?) important consequence of residential schools – the impact on mental health. Oddly enough, in a blog post I wrote back in 2008, I discussed the notion that the significant (and widespread) physical, emotional, and sexual abuse experienced by the generations of indigenous kids exposed to the residential school system would readily explain much of the rampant psychological problems (addictions, depression, PTSD, etc.) present in the indigenous populations across Canada today. The following is an excerpt from this previous post: This disastrous and cruel [residential school] 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… Read More »

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New Course: Adult Obesity Management in Brazil

For my many colleagues in Brazil, there is now a free accredited online continuing professional development (CPD) program developed in a collaboration between ABESO and the Canadian Obesity Network. “Adult Obesity in Brazil” is a free, online continuing professional development (CPD) program that provides 1 hour of accredited learning on the following topics:   The importance of managing obesity   How to manage obesity to reduce disease burden   Behaviourial and pharmaceutical management The program was developed in collaboration my Brazilian colleagues Cintia Cercato, Bruno Halpern, and Nelson Nardo Jr. You can access the “Adult Obesity in Brazil” program online at no charge to receive one hour of accredited learning. Registration is free. For more information click here @DrSharma Edmonton, AB

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Even Correlations Based On Billions Of Data Points Do Not Prove Causation

Readers may have already heard about a recent study by Tim Althoff and colleagues from Stanford University, published in Nature, that analyses physical activity data collected from smart phones consisting of 68 million days of physical activity for 717,527 people, in 111 countries (only 46 of which were included in the study). As one may expect, not only do activity levels vary widely across countries but also substantially within countries (which in general terms, the authors refer to as “activity inequality”). It turns out that activity inequality and not actual levels of activity predict obesity rates (based on BMI). Furthermore, “By quantifying the relationship between activity and obesity at the individual level, we were able to determine why a country’s activity inequality is a better predictor of obesity than average activity level. We find that the prevalence of obesity increases more rapidly for females than males as activity decreases. And while lower activity is associated with a substantial increase in obesity prevalence for low-activity individuals, there is little change in obesity prevalence among high-activity individuals. So given two countries with identical average activity levels, the country with higher activity inequality will have a greater fraction of low-activity individuals, many of them female, leading to higher obesity than predicted from average activity levels alone. These findings are analogous to the phenomenon revealed in past studies of the effects of income inequality on health, whereby a relatively small change in income (in our case, activity) for an individual at the bottom of the distribution can lead to substantial improvements in health. On the basis of our model relating activity inequality to obesity prevalence, we also performed a simulation experiment which, assuming perfect information (Methods), suggests that interventions focused on reducing activity inequality could result in a reduction in obesity prevalence up to four times greater than in population-wide approaches.” The authors go on to discuss various limitation of their study but fail to mention the biggest limitation of all, the simple fact that correlations, no matter how strong or how large the data set, simply cannot prove causality. Thus, while the data does prove the point that you can do all sorts of interesting analyses when you have large data sets, it simply does not not prove that activity levels (or activity inequality for that matter) actually has much to do with obesity at all. Indeed, one could think of a number of confounders… Read More »

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Weight Change (Not Weight!) Is A Vital Sign

Why do doctors weigh people? Because, very early in medical school, we are taught that body weight is an important indicator of health. While one may certainly argue about the value of a single weight measurement at any point in time (especially in adults), there is simply no denying that weight trajectories (changes in body weight – up or down) can provide important (often vital) clinical information. Let’s begin with the easiest (and least arguable) situations of all – unintentional weight loss. Among all clinical parameters one could possibly measure, perhaps non should be as alarming as someone losing weight without actively trying. In almost every single instance of “unintentional” weight loss, the underlying problem needs to be found, and more often than not, the diagnosis is probably serious (cancer is just one possibility). As with any serious condition, the earlier you detect it, the sooner you can do something about it, therefore, the more often you weight someone, the more likely you will detect early “non-intentional” weight loss. The contrary situation (un-intentional weight gain) is as important. When someone is gaining weight for no good reason, one needs to look for the underlying cause, which can include everything from an endocrine problem to heart failure. On the other hand, weight stability, is generally a sign that things are probably “under control”, as they should be when energy homeostasis works fine and people are in energy balance. Perhaps my own obsession with weighing people comes from my work in nephrology, where we obsess about people’s “dry weight” and use weight as a general means to monitor fluid status. The same is true for working with patients who have heart failure. Note for all of the above, that while a single (random) weight measurement tells you very little (almost nothing) about anybody’s health status, unexplained changes in body weight are one of the most useful and important clinical signs in all of medicine. Obviously, to plot a trajectory, one has to start somewhere, which means that every patient needs to have a “baseline” body weight recorded somewhere in their chart. While this value may not provide any valuable information, the next one may. This is why every single patient needs to be weighed at least once in a clinical setting. As you will imagine, both the context and interpretation of serial weight measurements becomes most challenging in the setting of obesity… Read More »

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Congratulations to Canadian Obesity Network Summer School Class of 2017

All of last week (now for the 11th time), I was teaching at the Canadian Obesity Network’s Obesity Summer School (formerly known as “boot camp”). As always, it’s just wonderful to meet such a group of young and enthusiastic trainees, who (as most past “campers” have experienced) have such a bright future ahead of them. Obesity research, prevention, and management will certainly be in good hands. Congratulations to all graduates – you’ve joined a pretty exclusive group of colleagues from around the world. @DrSharma Edmonton, AB

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The Key To Obesity Management Lies In The Science Of Energy Homeostasis

If there is one thing we know for sure about obesity management, it is the sad fact, that no diet, exercise, medication, not even bariatric surgery, will permanently reset the body’s tendency to defend and regain its body weight to its set point – this generally being the highest weight that has been achieved and maintained for a notable length of time. Thus, any effective long-term treatment has to offset the complex neurobiology that will eventually doom every weight-loss attempt to “failure” (no, anecdotes don’t count!). Just how complex and overpowering this biological system that regulates body weight is, is described in a comprehensive review by the undisputed leaders in this field (Michael Schwartz, Randy Seeley, Eric Ravussin, Rudolph Leibel and colleagues) published in Endocrine Reviews. Indeed the paper is nothing less than a “Scientific Statement” from the venerable Endocrine Society, or, in other words, these folks know what they’re talking about when it comes to the science of energy balance. As the authors remind us, “In its third year of existence, the Endocrine Society elected Sir Harvey Cushing as President. In his presidential address, he advocated strongly in favor of adopting the scientific method and abandoning empiricism to better inform the diagnosis and treatment of endocrine disease. In doing so, Cushing helped to usher in the modern era of endocrinology and with it, the end of organo-therapy. (In an interesting historical footnote, Cushing’s Energy Homeostasis and the Physiological Control of Body-Fat Stores presidential address was given in , the same year that insulin was discovered.)” Over 30 pages, backed by almost 350 scientific citations, the authors outline in excruciating detail just how complex the biological system that regulates, defends, and restores body weight actually is. Moreover, this system is not static but rather, is strongly influenced and modulated by environmental and societal factors. Indeed, after reading this article, it seems that the very notion, that average Jane or Joe could somehow learn to permanently overcome this intricately fine-tuned system (or the societal drivers) with will power alone is almost laughable (hats off to the very few brave and determined individuals, who can actually do this – you have climbed to the top of Mount Everest and decided to camp out there for the foreseeable future – I wish you all the best!). Thus, the authors are confident that, “The identification of neuromolecular mechanisms that integrate short-term and long-term control… Read More »

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Alternate Day Fasting Is No Better Than Any Other Fad Diet

It seems that every year someone else comes up with a diet that can supposedly conquer obesity and all others health problems of civilization. In almost every case, the diet is based on some “new” insight into how our bodies function, or how our ancestors (read – hunters gatherers (never mind that they only lived to be 35) ate, or how modern foods are killing us (never mind that the average person has never lived longer than ever before), or how (insert remote population here) lives today with no chronic disease. Throw in some scientific terms like “ketogenic”, “guten”, “anti-oxidant”, “fructose”, or “insulin”, add some level of restriction and unusual foods, and (most importantly) get celebrity endorsement and “testemonials” and you have a best-seller (and a successful speaking career) ready to go. The problem is that, no matter what the “scientific” (sounding) theories suggest, there is little evidence that the enthusiastic promises of any of these hold up under the cold light of scientific study. Therefore, I am not the least surprised that the same holds true for the much hyped “alternative-day fasting diet”, which supposedly is best for us, because it mimics how our pre-historic ancestors apparently made it to the ripe age of 35 without obesity and heart attacks. Thus, a year-long randomised controlled study by John Trepanowski and colleagues, published in JAMA Internal Medicine, shows that alternate day fasting is evidently no better in producing superior adherence, weight loss, weight maintenance, or cardioprotection compared to good old daily calorie restriction (which also produces modest long-term results at best). In fact, the alternate day fasting group had significantly more dropouts than both the daily calorie restriction and control group (38% vs. 29% and 26% respectively). Mean weight loss was virtually identical between both intervention groups (~6 Kg). Purists of course will instantly critisize that the study did not actually test alternative-day fasting, as more people dropped out and most of the participants who stayed in that group actually ate more than prescribed on fast days, and less than prescribed on feast days – but that is exactly the point of this kind of study – to test whether the proposed diet works in “real life”, because no one in “real life” can ever be expected to be perfectly compliant with any diet. In fact, again, as this study shows, the more “restrictive” the diet (and, yes, starving yourself… Read More »

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