It is now widely recommended that addressing childhood obesity requires a whole-family approach with a focus on educating and helping parents provide a healthier environment for their children. This has sometimes resulted in the slogan, “treat the parents”.
But just how effective is this approach?
Now a study by Gisela Nyberg and colleagues from the Karolinska Institute in Stockholm, Sweden, published in the International Journal of Behaviour, Nutrition and Physical Activity, suggests that even this strategy may not be quite as effective as one would hope.
The study was designed to study the effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas in Stockholm.
The cluster-randomised controlled trial involved 31 school classes with 378 six-year-old children. The 6 month interventions were 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children.
Overall, while there was some effect of the intervention on eating behaviour, there was no overall impact on physical activity levels.
There was also no change in BMI for the whole group, although there was small drop in BMI in kids at the higher range of the BMI spectrum, which disappeared at 5-months post-intervention.
The authors grasp at the fact that the effects of the intervention were short-lived to recommend that the programme needs to be prolonged and/or intensified in order to obtain stronger and sustainable effects.
Just how much longer or how much more intense the intervention would need to be is unclear.
These findings certainly reflect the real-life problem that we currently have no universally effective approach to dealing with childhood obesity (with parents or without).
Sadly, no one has yet demonstrated that any type of intervention for childhood obesity, whether individual, family, shool or community based, despite occasional short-term improvements in health behaviours and body weight, ultimately translates into fewer adults with obesity.
Perhaps, the best time to intervene to prevent childhood obesity is even before the kids are born.
Now a study by Crump and colleagues published in JAMA Intern Medicine suggests that some of this risk may be mitigated by increased physical fitness.
The cohort study involving over 1.5 million Swedish young men in Sweden, who underwent standardized aerobic capacity, muscular strength, and BMI measurements obtained at a military conscription examination and were followed for up to 40 years.
Almost 100,000 men went on to develop hypertension, whereby both high BMI and low aerobic capacity (but not muscular strength) were associated with increased risk of hypertension, independent of family history or socioeconomic factors.
A combination of high BMI (overweight or obese vs normal) and low aerobic capacity (lowest vs highest tertile) was associated with the highest risk of hypertension.
The association with aerobic fitness was apparent at every level of BMI.
Form this study the authors conclude that high BMI and low aerobic capacity in late adolescence are associated with higher risk of hypertension in adulthood.
Although one must also be cautious in assuming causality with regard to associations found in such studies, the observations are certainly compatible with the notion that increased cardiorespiratory fitness may well mitigate some of the impact of increased BMI on hypertension risk.
There is no doubt that bariatric surgery is currently the most effective long-term treatment for severe obesity, however, there is also some evidence to suggest that patients seeking bariatric surgery (or for that matter any kind of weight loss) are more likely to have accompanying mental issues that individuals with obesity who don’t and that such issues may affect the outcomes of surgery.
Now, a paper by Aaron Dawes and colleagues from Los Angeles, CA, published in JAMA presents a meta-analysis of mental health conditions among patients seeking and undergoing bariatric surgery.
They identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65,363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50,182 patients).
Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, each affecting about one-in-five patients were depression and binge eating disorder.
However, neither condition was consistently associated with differences in post-surgical weight outcomes. Nor was there a consistent relationship between other mental health conditions including PTSD or bipolar disease and post-surgical outcomes.
Interestingly, bariatric surgery was consistently associated with a significant decrease in the prevalence and/or severity of depressive symptoms.
So what do these findings mean for clinical practice?
As the authors note,
“Guidelines from the American Society for Metabolic and Bariatric Surgery and the Department of Veterans Affairs/Department of Defense recommend routine preoperative health assessments, including a review of patients’ mental health conditions. Other groups advocate for a more comprehensive, preoperative mental health examination in addition to the general evaluation currently performed by medical and surgical teams. The results of our study do not defend or rebut such a recommendation.”
So why are these data not clearer than they should be? Here is what the authors have to offer:
“Much of the difficulty in determining the effectiveness of preoperative mental health screening is due to the limitations of current screening strategies, which use a variety of scales and focus on mental health diagnoses rather than psychosocial factors. Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks, and socioeconomic stability play major roles in determining outcomes after bariatric surgery. Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the optimal strategy for evaluating patients’ mental health prior to bariatric surgery.”
At this time, perhaps to err on the side of caution, our centre (like many others) continues to screen for and address any relevant mental health issues in patients wishing to undergo bariatric surgery.
Obesity, like most other chronic diseases, requires interdisciplinary approaches that involves a wide range of clinicians from different disciplines (e.g. physician, nurse, psychologist, dietitian, exercise physiologist, social worker, physiotherapist, occupational therapist, etc.).
But exactly how to get these teams to function efficiently and deliver timely and ongoing obesity management remains largely understudied.
In a paper by Jodi Asselin and colleagues, published in Clinical Obesity, we explore the challenges faced by members of multidisciplinary teams working in the setting of a large primary care network.
Participants (n = 29) included in this analysis are healthcare providers supporting chronic disease management in 12 family practice clinics randomized to the intervention arm of the 5As Team trial including mental healthcare workers (n = 7), registered dietitians (n = 7), registered nurses or nurse practitioners (n = 15). Participants were part of a 6-month intervention consisting of 12 biweekly learning sessions aimed at increasing provider knowledge and confidence in addressing patient weight management.
Qualitative methods included interviews, structured field notes and logs.
Four common themes of importance in the ability of healthcare providers to address weight with patients within an interdisciplinary care team emerged, (i) Availability; (ii) Referrals; (iii) Role perception and (iv) Messaging.
Availability (i) refers to the ability of two or more people to meet and communicate as needed within a reasonable amount of time. This included the interdisciplinary team members knowing and meeting each other, being able to consistently communicate during the work-day, or deliberately asynchronously, and having work schedules that allowed collaboration.
Availability was often affected by scheduling that limited face-to-face time between providers and subsequently limited the potential for collaboration or discussion. Another issue was lack of in-clinic time to speak to providers who were physically present but otherwise unavailable.
Referrals (ii) points to the need for weight management referrals to take place, for those referrals to be appropriate to provider ability and for the patient to be knowledgeable about, or in agreement with the reason for referral. Many practitioners felt they were not receiving the weight management referrals they could, or that the referrals often left the patient and provider unclear as to where to begin the conversation.
Role perception (iii) concerns the way a provider’s role is understood by other interdisciplinary team members. Issues pertaining to role perception were fairly consistent and strongly linked to concerns with referrals. Common examples included concern that they were not receiving the type of referrals they could, that other providers did not understand their role in weight management, or that they as providers did not understand the role of others.
Messaging (iv) refers to the overall approach to weight management that providers within the same clinic were using, as well as the key information being shared between providers and patients. Inconsistent messaging among providers within clinics, as well as with specialists seen by the patient, was a common concern raised during interviews. In such cases there was feeling that advice was not patient-centred, that efforts had not been taken to consider patient history and that as a consequence, the patient might suffer a setback, reduced interest, or reduced personal confidence. In these cases the message a patient had received from another provider was counter to the message or approach the interviewee was giving.
However, we find that what was key to our participants was not that these issues be uniformly agreed upon by all team members, but rather that communication and clinic relationships support their continued negotiation.
Our study shows that firm clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care in weight management.
Furthermore, there is a clear need for shared messaging concerning obesity and its treatment between members of interdisciplinary teams.
From the project it is evident that broad training in the various contributors to obesity enables providers to not only see their own role in treatment, but to better understand the role of others and therefore begin addressing problems in referrals, messaging and role perception.
One factor accounting for this may well be the lack of timely access to sleep testing.
Now, a study by Hirsch Allen and colleagues from the University of British Columbia Hospital Sleep Clinic, published in the Annals of the American Thoracic Society, examined the relationship between severity of sleep apnea and travel times to the clinic in 1275 patients referred for suspected sleep apnea.
After controlling for a number of confounders including gender, age, obesity and education, travel time was a significant predictor of OSA severity with each 10 minute increase in travel time associated with an apnea-hypopnea-index increase of 1.4 events per hour.
The most likely explanation for these findings is probably related to the fact that the more severe the symptoms, the more likely patients are to travel longer distances to undergo a sleep study.
Thus, travel distance may well be a significant barrier for many patients accounting for a large proportion of undiagnosed sleep apnea – at least for milder forms.
Given the often vast distances in Canada one can only wonder about just how much sleep apnea goes under diagnosed because of this issue.