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Rural Areas Drive Global Obesity

To anyone working in obesity, it is no secret that obesity is now far more common in rural (and suburban) areas (at least in industrialised countries) than in big cities. This may appear counterintuitive, as access to food services is much greater and easier in cities than in rural areas. In contrast, there is a wide-spread assumption that people living in rural areas mainly consume produce from their own farms and gardens, and have less access to ultra-processed and packaged food. Now, a paper by the international NCD Risk Factor Collaboration, published in Nature, shows that rural obesity, even in many low- and middle-income countries (LMICs), is rising much faster than in urban populations. The study collates 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017.  The data shows that, with the exception of women in sub-Saharan Africa, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in rural areas. Thus, “these trends have in turn resulted in a closing—and in some countries reversal—of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women.”  The authors attribute this trend to the urbanisation of rural life, which includes not only the decreased need for physical labour thanks to agricultural mechanisation, dependence on cars, rising income, and the increased availability and consumption of highly processed calorie-dense foods. In contrast, “The lower urban BMI in high-income and industrialized countries reflects a growing rural economic and social disadvantage, including lower education and income, lower availability and higher price of healthy and fresh foods, less access to, and use of, public transport and walking than in cities, and limited availability of facilities for sports and recreational activity, which account for a significant share of overall physical activity in high-income and industrialized countries.“ Clearly, this alarming trend poses new challenges for public health initiatives to curb the obesity epidemic, which have thus far largely (albeit with little effect), focussed on urban populations. Although not discussed in the paper, this trend also poses new challenges for the health care system, which… Read More »

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Obesity And Perinatal Care

Last week, I had the pleasure of sitting on the thesis defence committees of two extraordinarily dedicated young trainees, currently completing their medical residencies in obstetrics and gynaecology. Both theses focussed on issues related to obesity within the obstetric community as well as the implications of obesity for the care of women during the gestational period and during delivery (more on these theses in coming posts). For those interested in this topic, I would like to draw your attention to a short review paper by Cecilia Jevitt, Chair of the Midwifery Program at the University of British Columbia, published in the Journal of Perinatal and Neonatal Nursing. Although the paper focusses on the social determinants of health that underly a substantial proportion of the risk for developing obesity (these include socio-economic disparities in employment, education, healthcare access, food quality, and availability), the paper also looks at many of the environment and biological factors that may promote obesity including environmental toxins, epigentics, and the microbiota. As for the impacts of excess body fat on pregnancy, Levitt lists over 30 conditions that can affect the pregnancy, delivery, and the post-partum period, threathening the health of mother and child, which are far more common in women with obesity. This is not to say that many of these problems can not also be encountered in the care of women without obesity, however, excess body weight makes these conditions far more likely and often much more difficult to manage. As Levitt points out, reducing the risk for obesity in the first place would need comprehensive changes at the policy level that not only address issues related to food and activity but also the socio-economic and other social determinants of health that disproportionately affect women of lower socio-economic status. As currently, no such policies are in sight, those charged with the care of women of childbearing age will continue having to watch for and deal with the increased risk for adverse outcomes in women with excess weight – a challenge that is only slowly (as evidenced by the theses mentioned above) coming to the centre of attention of obstetric health professionals. On the positive side, Levitt reminds us that, “Although obesity places women at risk for numerous morbidities, most women with obese BMIs [sic] complete pregnancy and birth without complications.” Improved training of health professionals in the care of women with obesity can no doubt further… Read More »

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Ethical Dilemmas in Obesity Prevention and Management

Later this week, I have been invited to present the opening address at the 7th Annual Meeting of the Association for the Study of Obesity on the Island of Ireland in Dublin. The topic I was asked to speak about, concerns some of the ethical dilemmas we face in trying to address the prevention and management of obesity. The following is the abstract of my presentation, which will hopefully stimulate some interesting discussion on this important issue: Obesity is highly stigmatised and people living with obesity face bias and discrimination in virtually all societal settings including education, professional life, and even health care. Although obesity is now increasingly recognised as a complex chronic disease (not unlike hypertension or type 2 diabetes), both the public health and clinical approaches to obesity prevention and management embrace a rather simplistic narrative of “eat-less-move-more”, which fails to fully acknowledge that complex interaction between environmental and neurobiological mechanisms play a large role in determining body shape and size, much of which is beyond the control of the individual. Thus, there is currently no proven public health approach to reducing obesity in a population, nor does diet and exercise help sustain long-term weight loss in the vast majority of people living with obesity. Despite an abundance of weight loss attempts and a diversity of diets and weight-loss programs, sustained weight loss over years remains the exception – for most people, weight regain (relapse) is just a matter or time.  This is in contrast to medical or surgical treatments of obesity, which have proven to be far superior to behavioural interventions alone in sustaining long-term weight loss. Given that obesity now affects almost one in four adults in most Western countries, health administrators face important dilemmas regarding how to best provide access to effective treatments to the millions of people living with this chronic disease. In this regard, learning from other chronic diseases like type 2 diabetes can be helpful and will be discussed. @DrSharmaBerlin, Germany

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Does A New Canadian Study on Cancer Inadvertently Make a Strong Case For Treating Obesity?

Last week, a series of papers by a pan-Canadian team of cancer researchers, published in Preventive Medicine, looks at the current and future burden of more than 30 different cancer types due to more than 20 different modifiable cancer risk factors. Not surprisingly, the ComPARe study shows that currently the top five leading preventable causes of cancer in Canada are smoking tobacco, followed by physical inactivity, excess weight, low fruit, and sun – factors that have long been implicated in the development of a wide range of cancers. According to the researchers, overweight and obesity now rank just behind smoking as a key driver of cancer risk. Obviously, this makes a strong case for increasing efforts at obesity prevention – the caveat being that thus far, no society has yet figured out exactly how this can be effectively achieved at a population level. While, for obvious reasons, the papers focus on preventative approaches to reduce the burden of cancer, there is little mention of the potential benefits in terms of cancer prevention that could come from offering more effective obesity management to the 8,000,000 Canadians are already living with this chronic disease, who are unlikely to substantially benefit from population strategies to prevent obesity. Fortunately, there is now a growing body of evidence showing that effective obesity treatment, including bariatric surgery, can substantially reduce cancer risk in people living with obesity. Thus, if anything, these data provide even more reason to get serious about treating obesity (not just hoping that it will somehow disappear if we just keep talking about prevention). Obviously, even without effective obesity treatments, Canadians living with obesity (like everyone else) will likely benefit from smoking cessation, reducing sedentariness, and increasing their fruit and vegetable consumption (most of them already stay out of the sun). However, effective obesity management aimed at both preventing further weight gain as well as reducing excess body weight (in a sustainable manner) will potentially have even greater benefits in this population. Unfortunately, as evidenced in the recent 2019 Obesity Canada Report Card on Access to Obesity Treatments, the vast majority of Canadians have little, if any access to obesity treatments within their health care systems – this needs to change if we are to not only reduce the burden of cancers but also of obesity related cardiometabolic disease, arthritis, sleep apnea, and a host of other medical complications. While we wait for… Read More »

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2019 Obesity Canada Report Card on Access To Obesity Treatments For Adults Shows Much Room For Improvement

Obesity Canada’s second report card assessing access to treatment concludes Canadians living with obesity continue to be ignored by healthcare systems and health policy makers, as well as employers, compared to those requiring support for other chronic conditions  The disparity exposes the roughly six million Canadians who may be affected by this disease to negative health effects such as type 2 diabetes and hypertension, sleep apnea, reflux, depression, anxiety and more. It also puts them at risk for the effects of weight bias and discrimination at home, in the workplace, media and at school. Key findings of the Report Card on Access to Obesity Treatments for Adults in Canada 2019include: Every province and territory receive a grade of ‘F’ for public coverage of obesity medications; the federal government receive a ‘C’.  All provinces that offer bariatric surgery except Quebec receive an ‘F’ for overall access to surgery, as does Canada as a whole. Quebec receives a ‘D’.   No province or territory officially recognizes obesity as a chronic disease. There is a profound lack of interdisciplinary teams for obesity management in Canada, despite their recognized benefits in obesity treatment guidelines. Contrasting with other chronic diseases, Canadians who may benefit from medically supervised weight-management programs with meal replacements are expected to pay out-of-pocket for meal replacement products.  Take a look at the complete Report here. Obesity Canada makes five key recommendations based on the 2019 report card: 1.    Governments, employers and the health insurance industry should officially adopt the position of the Canadian Medical Association that obesity is a chronic disease and orient their approach/resources accordingly. 2.    Governments should recognize that weight bias and stigma are barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems and education. 3.    Governments should include anti-obesity medications, weight-management programs with meal replacement and other evidence-based products and programs in their provincial drug benefit plans. 4.    Employers should recognize and respond to obesity as a chronic disease and provide coverage for evidence-based obesity programs and Health Canada approved treatments for their employees through health benefit plans. 5.    Governments and health authorities should increase the availability of interdisciplinary teams and increase their capacity to provide evidence-based obesity management. Let’s make obesity a priority in Canada! Please take a minute to write your federal and provincial members of parliament to demand better access to obesity treatments. Obesity Canada has launched an… Read More »

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Polygenic Prediction of Weight and Obesity Trajectories from Birth to Adulthood

Just in time for the start of Obesity Canada’s Biennial Canadian Obesity Summit in Ottawa (April 23-26, 2019), where the issue of obesity as a multifactorial complex disease will be front and centre of discussions (both in terms of prevention and management), comes a landmark publication by a team of US obesity researchers published in CELL. The paper describes the development and validation of a cumulative “obesity score” based on the presence of common DNA variants that can affect body weight. This polygenic predictor, looking at over 2.1 million common variants to quantify this susceptibility was tested in more than 300,000 individuals ranging from middle age to birth. Among middle-aged adults, the researchers found a 13 kg gradient in weight and a 25-fold gradient in risk of severe obesity across polygenic score deciles. Most interestingly, in terms of childhood obesity, a longitudinal analysis of a birth cohort, showed minimal differences in birthweight across polygenic score deciles, but a significant gradient in early childhood that reached 12 kg by 18 years of age.  These observations not only support the notion of the polygenic nature of “garden-variety” obesity, but also, that having more of the obesity susceptibility alleles dramatically predisposes individual to the future development of obesity. In fact, as the authors point out, the effect of a high polygenic score can be similar to having a rare, monogenic form of obesity. So while it may well be the environment that pulls the trigger, it is most certainly the genes that load the gun. Clearly, it is high time we abandon the judgemental “shame and blame” approach to dealing with obesity, where people who are at a “healthy” weight are held up as “model citizens”, versus the “irresponsible” people with excess weight, who simply chose to be fat. Obviously, whether or not in our current obesogenic environment someone develops obesity, is largely the “luck of the (genetic) draw”. @DrSharmaOttawa, ON

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The Edmonton Obesity Staging System for Pediatrics (EOSS-P) better defines health risk than obesity class

As readers may recall, based on our findings that the Edmonton Obesity Staging System (EOSS) is a far better predictor of long-term mortality than BMI in adults, my pediatric colleagues developed an adaptation of EOSS for use in kids (EOSS-P). Now, Stasia Hadjiyannakis and a consortium of pediatric colleagues from across Canada, in a paper published in The Lancet Child & Adolescent Health, show that EOSS-P is superior to BMI class (based on weight curves) in determining the burden of disease in kids. The authors looked at data from the from the Canadian Pediatric Weight Management Registry (CANPWR), a cross-sectional study of children with obesity aged 5–17 years recruited from ten multidisciplinary paediatric weight management clinics in Canada. The researchers classified the almost 850 participants into WHO BMI classes (class I as 2–3 SD scores, class II as >3 SD scores, and class III as >4 SD scores above the WHO growth standard median), and then applied the EOSS-P staging system (stages 0, 1, and 2/3) based on the clinical assessment of coexisting metabolic, mechanical, mental health, and social milieu issues. Based on BMI, 64% or participants had severe obesity (ie, class II or III) and 80% were EOSS-P stage 2/3. Overall, mental health concerns were most common (61% of participants), followed by metabolic (41%), adverse social milieu (21%), and mechanical (10%) health issues. While mental health issues (eg, anxiety and attention-deficit hyperactivity disorder) were equally distributed across BMI classes, metabolic health issues were slightly more common in higher BMI classes, and mechanical (eg, musculoskeletal issues and sleep apnoea) and social milieu (eg, bullying and low household income) issues increased with increasing BMI class. Of children with class I obesity, 76% had overall EOSS-P stage 2/3, compared with 85% of children with class III obesity. Thus, although kids with class III obesity do on average have higher EOSS-P stages, over 3 in 4 kids with class I obesity also carry a high burden of risk (especially mental health and metabolic risk). Thus, as in adults, BMI levels alone do not accurately reflect the actual health risk of individual kids, supporting the notion that the use of EOSS-P can better guide clinicians in managing kids presenting with obesity than BMI class alone. @DrSharmaBuenos Aires, Argentina

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Why You Need To Be At The 6th Canadian Obesity Summit in Ottawa, April 23-26

Last week, I was on a “Blues Cruise” that featured some of the best blues musicians in the world, and, as evidenced by this image, I actually got to jam with some of the best! Now, I’m back, fully recharged and ready to work on my own playing with tons of new ideas and heaps of motivation. Bottom line, if you’re really passionate about something, you want to be where the action is, so you can learn from and network with the best of the best. So if obesity is your topic – you most certainly do not want to miss the upcoming 6h Canadian Obesity Summit, which only comes around every two years – as you would guess, a lot happens in two years! This year’s Canadian Obesity Summit features well over 200 oral and poster presentations on every conceivable topic from health policy and prevention to pre-clinical and clinical obesity research, as well as updates on current obesity treatments for children and adults living with obesity – all presented by leading Canadian scientists and clinicians from coast to coast. But, there is more! The Summit also features interactive workshops on a wide range of topics, including, how to make your hospital or clinic “bariatric friendly”, how to approach “behaviour change” in children and adults, and how to manage excess weight gain during pregnancy. The Summit will also present Obesity Canada’s first national Public Obesity Workshop, aimed at Canadians living with obesity and policy makers. But, perhaps most important of all (as anyone, who has ever been to a Canadian Obesity Summit is well aware), the Summit is your opportunity to meet, catch-up, and mingle (not to mention party!) with your colleagues from across Canada and beyond. Pre-registration at reduced rates for individuals and groups is open till March 14 – hotel space is already tight – so don’t wait – this is not getting better! If I learn half as much about the latest developments in obesity at the Summit as I learnt about the blues on the cruise, the four days will be well spent – be there or be square! To register – click here To view the programme at a glance – click here @DrSharmaEdmonton, AB p.s. If any one is interested in following my musical escapades on Facebook – click here

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