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Are You Living With Obesity? Time To Speak Up

Yesterday, at Obesity Week, I co-chaired a symposium on how stigma and weight-bias directly affects the health and health care of people living with obesity. As several of the speakers pointed out, the prevailing false narrative that obesity is simply a matter of lifestyle “choices” that people make and that there are easy solutions (just eat-less move-more) is so dominant, that it has even been internalized by people living with obesity – they also believe that they have “done this to themselves” and “know what to do” (just eat less and move more), which is why they generally don’t reach out to health professionals and “demand” the standard of care and support that they would expect if they were living with a less stigmatized condition. Indeed, in any other health area, people (and their family members) would hardly accept the almost complete lack of support or access to care (as for e.g. the grotesquely long wait-times for bariatric surgery) as people living with obesity are apparently willing to put up with. Unfortunately, not speaking up and demanding the same level of health care as people living with other chronic diseases, is by far the #1 barrier to getting policy makers to move on this issue – as long as people living with obesity continue to blame themselves, feel “undeserving” of care, and are too ashamed to stand up for themselves, not much is going to change. At Obesity Week, I also attended a full-day workshop of the international OPEN coalition, where I listened to experts on advocacy explain that the only way to ever effectively change policy is to speak up and speak out – not something most people living with obesity are comfortable with. Unfortunately, there is no alternative – as long as people living with obesity are “OK” with being treated as “second-class” citizens and are “OK” with not having better access to proven and evidence-based obesity treatments, nothing will change. If you are someone living with obesity who feels strongly that you should have the same right to supportive health care and treatments as people living with other chronic diseases, seek out and engage with organisations, who are there to help (e.g. Obesity Canada). Fortunately, you are not alone – there are millions of people living with obesity – if only a fraction of them stood up for themselves and demanded action – no politician seeking re-election… Read More »

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ABOM Master of Obesity Medicine

Yesterday, at the 2019 Obesity Week in Las Vegas, I had the honour of receiving the 2019 American Board of Obesity Medicine “Master of Obesity Medicine” award. This is indeed a remarkable privilege, given that many of the previous distinguished award winners were folks that I have always looked up to, who have always offered their friendship and advice, and without whose mentorship, I would certainly not have developed the ideas or had the influence in obesity medicine that regular readers of these pages will be familiar with. It was particularly humbling to see so many of my Canadian colleagues in the audience, who have always supported my endeavours and, in true Canadian fashion, have welcomed me to the Canadian research and practice community since I moved to Canada in 2002. Finally, I owe this award to the many patients who have taught me much of what I know about obesity over the years. If nothing else, this award will serve as a constant reminder that we continue to do what we can as researchers, clinicians, and advocates to make a difference in the lives of the millions of children and adults living with this complex chronic disease. @DrSharmaLas Vegas, USA

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Report: ACTION on Obesity – it’s about time!

Today is officially World Obesity. As pointed out in the 252-page OECD report on “The Heavy Burden of Obesity: The Economics of Prevention”, Canada, like most OECD countries is not doing a great job at it (nor are others!). This leaves us with the fact that there are currently well over 6 million Canadian adults and children living with what the World Obesity Federation (and the Canadian Medical Association) calls a complex chronic disease. So what is obesity and what does obesity care look like from the perspective of Canadians living with obesity (PwO), health care providers (HCPs), and employers? This is the topic of the Canadian ACTION Study, released today by Obesity Canada. Conducted as a nationally representative survey, the ACTION study reveals that although people living with obesity, health care providers, and employers all agree that obesity is a significant health problem (on par with heart disease, diabetes, or even cancer), their views vastly differ when it comes to what to do about it. Responses to the survey also suggest that people with obesity, health care providers and employers don’t fully understand the complexity of obesity, and believe that, contrary to current research findings, diet and exercise are sufficient approaches to managing it. Based on the findings of the report, Obesity Canada makes the following recommendations: For People Living with Obesity: Learn evidence about obesity causes and treatments and understand that obesity management is a lifelong process that requires medical intervention. Find health professionals who have been trained in obesity management. Self-advocate for support and access to treatments and supports with Obesity Canada’s online resources. For Health Care Providers: Understand recent research supporting obesity’s complex etiology and heterogeneity. Learn more about current evidence-based approaches to treating obesity (see Obesity Canada website). Treat obesity as a chronic disease using available treatments (new Clinical Practice Guidelines available in 2020). Include obesity in the training program curricula for health professionals. For Employers: Treat obesity as a chronic disease and move obesity out of the lifestyle category in bene ts plans. Offer meaningful obesity services/coverage that move beyond healthy eating and exercise programs. The Full ACTION Report ist available here. An Infographic summarizing the key findings of the ACTION study is available here. @DrSharmaEdmonton, AB

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The Clinical Importance Of The Limbic Dump

This week I am speaking at the LATAM Obesity Summit in Santaigo, Chile, where I again had occasion to hearing my Canadian colleague Michael Vallis (Halifax), speak about behavioural change. In his talk, he discussed an important strategy in counselling patients, whch he referred to as the “limbic dump”. As readers will know, the limbic system is responsible for holding our emotions – anxiety, fear, apprehension, disappointment, frustration, but also, joy, optimism, anticipation, motivation. In a classical doctor-patient encounter, the doctor generally focusses on analysing the problem (making the diagnosis) and giving advice (providing treatment) – both are functions that largely rely on the cognitive or “logical” part of our brains. The general idea is that, the doctor will provide rational information and advice to the patient, and the rational part of the patient’s brain will take in this advice and “follow instructions”. Unfortunately, in most situations, this “rational” approach is overriden by the limbic or “emotional” part of the patient’s brain, which is far too busy dealing with feelings (shame, fear, anxiety, disappointment, frustration, etc.) to take in the “rational” information that is being provided. This is where the “limbic dump” comes in. As Vallis points out, before getting into the “rational” part of any encounter, it is far more useful to begin by allowing the patient to first “dump” their concerns (or successes) on the table. Once these are out in the open, have been duly acknowledged, and discussed, the conversation can move on to the more “logical” transactional part of the encounter. Now, after the “limbic dump” you actually have a patient who is able to listen to what you have to say. Of course, all experienced clinicians probably already know this. I, for one, generally start any patient encounter with an open ended question as to how the patient is feeling about how things are going. This gives them the opportunity to “dump” their feelings on the table – positive or negative. Only after acknowledging these (sometimes prompting them for details), do we move on to the more objective part of the encounter (I’m a big believer in motivational interviewing, so generally, I let my patients do most of the talking). Now, thanks to Vallis, I have an explanation and term for what I have been doing all along – long-live the “limbic dump”. @DrSharmaSantiago, Chile

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2nd International Symposium on Obesity Mechanisms, Leipzig 2019

For the past 10 years, I have had the rather exclusive privilege of being on the External Advisory Board (which I have chaired for the past five years) of the Integrated Research and Treatment Center (IFB) AdiposityDiseases, a multi-million Euro a joint research and clinical center of the University and the University Hospital Leipzig – sponsored by the German Federal Ministry of Education and Research. This funding period has now come to term (although obesity research will remain alive and kicking in Leipzig) and the 2nd International Symposium on Obesity Mechanisms, marks an important celebration of this milestone. The three-day symposium, at which I will be presenting the Key Note Lecture, is held in collaboration with the DFG-funded SFB1052 and focuses on central obesity mechanisms, brain periphery crosstalk, adipose tissue heterogeneity, adipokines, and the clinical consequences of obesity.  The findings and publications emanating from this research consortium over the past decade are far too numerous to mention in this post (publications appeared in the New England Journal of Medicine, The Lancet, Cell, Nature, Nature Medicine, and other top international journals). As Matthias Blüher remarked in his opening address, many of these findings are now finding their way into translational research, including the testing of novel anti-obesity compounds and behavioural interventions based on findings from neuroimaging studies. I, for one, have very much enjoyed being associated with these important efforts here in Leipzig and look forward to continuing involvement in the exciting work that continues to advance our understanding of this complex chronic disease. @DrSharmaLeipzig, Germany

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Polyagonists for the Treatment of Obesity and Diabetes

This morning, I spoke at the German Diabetes Congress in Berlin on the issue of whether or not metabolic surgery offers a cure (or just remission) in patients with type 2 diabetes. I also had the pleasure of attending the Hans Langerhans Award Lecture, the highest distinction awarded by the German Diabetes Society, given by my colleague Matthias Tschöp, who is also the Director of the Helmholtz Centre for Diabetes Research in Munich. Tschöp focussed his acceptance speech on his ground-breaking work on polyagonists, i.e. molecules that can co-stimulate two or more peptide receptors (e.g. for GLP-1, GIP, and glucagon). Tschöp began his presentation by declaring that we could almost completely reverse the global epidemic of type 2 diabetes, if only we had more effective treatments for obesity. As we now know, appetite and energy regulation is tightly controlled by a host of neuroendocrine signals, which act on the central nervous system as part of a complex homeostatic system that acts to sustain and defend body weight. Based on these findings, Tschöp’s work has pursued the notion that effective obesity treatments require targeting of the homeostatic centres in the brain. As we have learnt from the extensive research on bariatric surgery, there are a number of signal molecules released by the gut (incretins) that directly affect central mechanism of appetite and satiety. However, given the complexity and redundancy of the system, just targeting one of these molecules may not be effective enough to counteract the powerful mechanisms that defend against long-term weight loss. This insight, led Tschöp to pursue the idea that developing single synthetic molecules, that could simultaneously stimulate  several distinct but synergistic pathways, may prove to be more effective than targeting a single molecular target. This idea, ultimately led to the development of molecules that simultaneously act as dual co-agonists (e.g. for GLP-1 and glucagon or for GLP-1 and GIP ) or even tri-co-agonists (e.g. for GLP-1, GIP, and glucagon). These co-agonists appear to have potent metabolic and anti-obesity effects both in animal models and in early human studies. Indeed, this approach is now being actively pursued by a number of pharmaceutical companies hoping for more effective anti-obesity medications. While these studies are currently underway, they certainly hold great promise for the future of medical treatments for obesity and diabetes. Congratulations to Matthias Tschöp and his team for this most well-deserved award. @DrSharma Berlin, Germany p.s. As an… Read More »

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Bariatric Surgery For Adolescents – 5 Year Outcomes

Given that our efforts to stop the childhood obesity have so far yet to show any signs of success and that treatment efforts of kids already struggling with excess weight have been sketchy at best, there is unfortunately a growing number of adolescents living with severe obesity, for who we have very little choice but to consider bariatric surgery. As drastic as surgery may seem, it is important to recognise that for adolescents weighing in at 250 lbs or more, waiting and hoping for obesity to spontaneously resolve, while these kids miss out on opportunities ranging from education to social relationships (never mind the bullying and discrimination), is hardly an acceptable option. Thus, a study by Thomas Inge and colleagues published in the New England Journal of Medicine, showing that 5-year outcomes of adolescents undergoing bariatric surgery are as positive as in (most) adults, is heartening. The study looks at 5-year outcomes in 161 adolescent patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009) undergoing Roux-en Y gastric bypass surgery. Overall, the extent of weight loss 5 years after surgery in the adolescents (-26%) was similar to that in adults (-29%). Adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%) and of hypertension (68% vs. 41%). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. In the adolescent cohort, one death was attributed to suspected sepsis in a patient with type 1 diabetes who had multiple complications after a hypoglycemic episode 3 years after surgery, and features of the other two deaths in adolescents, both of which occurred 4 years after surgery, were consistent with overdose (acute combined drug toxicity). Among the adults, three died of early complications of surgery, one died of colon cancer, one of suicide, and the cause of death in the two remaining cases was unclear. Adolescents experienced a greater rate of abdominal reoperations than the adults (19 vs. 10 reoperations per 500 person-years). As a possible explanation for this, the authors offer: “…closer monitoring for complications in adolescent patients and the potential for a lower threshold to reoperate for suspected complications in younger patients, which would lead to the capture of more events.” Nutritional deficiencies were slightly more common in adolescents compared to adults, which the authors attribute to less compliance with recommended… Read More »

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A Non-BMI-Centric Approach To Diagnosing And Managing Obesity

Regular readers will be well aware of the limitations of applying BMI to obesity diagnosis – after all, BMI is a measure of size, not health. If there is one thing we have learnt, it is that good health is possible over a wide range of shapes and sizes and that using a static measure like BMI, will mean overdiagnosing obesity in people who have no relevant impairment in health and underdiagnosing obesity in people who would in fact stand to gain from obesity treatments. As I have noted before, in a medical context, obesity should be defined as, “the presence of excess or abnormal fat tissue that impairs health“. In clinical practice this would mean asking the question (irrespective of BMI), “does this patient have a health impairment that is likely to get better with obesity treatment?” If yes, the patient most likely has obesity and should be offered obesity treatment. If not, the patient does not have obesity and will be unlikely to benefit from obesity treatment. This approach would identify both the “high-BMI” individuals with medical issues likely to get better with obesity treatment, as well as the “normal-BMI” individual, who may stand to benefit from obesity management. Not only will this “common-sense” approach to diagnosing obesity identify individuals over the entire BMI range, who would potentially benefit from obesity treatments, but will also help set specific targets for assessing the success of treatment. Thus, if the presenting problem is hypertension (say in a patient with a BMI of 24 with clear signs of increased belly fat – but skinny arms and legs), then the goal of obesity treatment would be to lower blood pressure, rather than to simply reduce body weight. Similarly, a patient with a BMI of 24 with type 2 diabetes would likely benefit from obesity management in terms of better diabetes control. If, in these patients, effective obesity treatment (as measured by weight loss) does not lead to better hypertension or diabetes control, then their health issues are probably not related to their body fat, meaning that they probably don’t have obesity. Thus, the obesity diagnosis and management algorithm would look something as follows: Does the patient have any impairments in health likely to improve with obesity treatment? (list impairment/s) if no, patient does not have obesity and does not need any obesity intervention (irrespective of BMI). If yes, offer obesity treatment to… Read More »

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