Arya M. Sharma, MD

Early this year, as part of the Alberta-Saxony Obesity Research and Training Alliance (ASORTA), we hosted the first International School on Obesity Research and Management (ISORAM).

This event was attended by over 50 faculty and trainees from Alberta and Germany.

In a follow-up to this immensely successful event, we are now planning ISORAM ‘12, which will be held from March 25-30, 2012, at the Chateau Lake Louise, in Alberta, Canada.

This time the focus will be on all aspects of metabolic and bariatric research as well as medical and surgical management of patients with severe obesity.

The course is open to all health professionals from around the world, who would like to hone their expertise in bariatric medicine and metabolic surgery.

The program, which will offer more than 40 hrs of teaching and interactive workshops, will also include ample time for informal networking and scientific exchange with the international faculty in the unique picturesque surroundings of one of Canada’s premier ski resorts.

Specifically, ISORAM ‘12 has the following objectives:

• To provide participants with a sound understanding of the scientific and methodological issues in bariatric medicine and surgical practices.

• To build participants knowledge in the areas of:

a. Clinical assessment and management of bariatric patients
b. Current best practices in dietary, psychological and behavioural management of bariatric patients
c. Current best practices in patient selection and preparation
d. Current understanding of the biology of metabolic and bariatric surgery patients
e. Interdisciplinary obesity research and practice.

• To educate participants in new developments in:

a. Medical and behavioural management of severe obesity
b. Nutritional and psychosocial complications in bariatric patients
c. Emerging devices in obesity management
d. Rehabilitation issues in bariatric care

• To give participants an understanding of health services/health systems impact on issues related to bariatric care

More information on this event can be here.

Please indicate your interest in learning more about and perhaps participating in this event here.

AMS
Edmonton, Alberta

Dr. Yves Bolduc (centre) Quebec Minister for Health and Social Services, Dr. Arya Sharma (left) Scientific Director CON-RCO, Dr. Angelo Tremblay (right) 2011 CON-RCO Distinguished Lecturer Award Recipient, at the opening of the 2nd National Obesity Summit, Montreal

Regular readers may recall a previous post on a workshop organised by the Canadian Institutes of Health Research (CIHR) Institute for Nutrition, Metabolism and Diabetes (INMD) and the Canadian Obesity Network held in Montreal last year.

The objectives of this workshop, with experts from across Canada, were to

1. define strengths, gaps, and opportunities in Canadian bariatric care research.

2. develop a Canadian bariatric care research agenda that will ultimately improve
health services available to morbidly obese patients.

3. identify opportunities for international collaboration in the area of bariatric care.

4. engage potential research funders that can support an emerging bariatric care research agenda in Canada.

Yesterday, at the opening of the 2nd National Obesity Summit here in Montreal, CIHR-INMD released the final report from this workshop with the following recommendations for a bariatric research agenda.

The following were the top three research priorities identified in terms of knowledge gaps for bariatric care:

Intervention research: understanding variation in response to treatment intervention, matching treatment to need; phenotyping; complications of care; role of co‐morbidity. Topic areas include research on both children and adults.

Health Services and Health Policy research: understanding optimal systems of care focused on continuity of care and integration of pediatric and adult services (i.e., cradle to grave); medical/surgical/rehabilitation/mental health/self‐care; primary care, including collaborative models and intervention strategies for practitioner and practice change.

Access and barriers to treatment: understanding what brings people to treatment and what are the major barriers; weight bias and discrimination including causal factors, impact, and interventions; evaluation of wait‐list management strategies and decision rules for access to bariatric surgery; understanding factors driving demand; forecasting models based on need and demand analyses and projections.

The following were the top three priorities identified in terms of building Canadian research capacity:

Research consortia/collaborations: includes a shift in emphasis to multi‐site, collaborative studies; database development and other capacity building for longitudinal studies.

Outcome and cost assessment: includes an assessment of metabolic and health outcomes beyond weight reduction, such as effects on blood pressure and glucose levels; longer term outcomes includingeconomic impact assessments of both intervention and systems research.

Qualitative/participatory research: required for an exploration of the patient’s lived experience, empowerment, knowledge base and satisfaction with health services and health service models.

The following were the three themes identified in terms of priorities for knowledge translation:

National strategy and standardization of care: decision‐trees for access to surgery; assessment and outcome measures; waiting list prioritization; guidelines for bariatric care team size and composition; accreditation and evaluation; and remuneration of health care providers for delivery of obesity care.

Environmental scans: assessing “what is out there”, who is doing what beyond surgery; level of collaboration and partnerships; building upon the pediatric scan undertaken in Alberta and the adult scan in Quebec.

Engaging policy makers: improving access to existing data; engaging earlier in the research process, including study design; providing better costing data for the development of relevant business cases, including cost effectiveness of treatment interventions (health costs, productivity).

It is anticipated that CIHR-INMD will now prepare targeted requests for applications to address these identified research and capacity building priorities.

The release of this report certainly demonstrates the intent of CIHR to take the needs of the the bariatric population in Canada very seriously.

Even a quick glance at the research excellence present here at this Summit should certainly reassure CIHR that Canadian researchers are ready and willing to address this important research agenda.

Reader can follow events happening here at Montreal on Twitter #con11

AMS
Montreal, Quebec

This week, I am co-hosting a workshop to develop a research agenda for bariatric care in Canada.

This National Workshop is co-organised by the Canadian Institutes of Health Research’s (CIHR) Institute of Nutrition, Metabolism, and Diabetes (INMD) and the Canadian Obesity Network.

As readers may be well aware, CIHR is the federal agency that funds health research in Canada while the Canadian Obesity Network represents over 5000 researchers, health professionals and other stakeholders working to reduce the mental, physical and economic burden of obesity on Canadian children and adults.

The objective of this workshop are as follows:

1) To identify strengths, gaps and opportunities in Canadian bariatric research.

2) To develop a Canadian bariatric care research agenda that can ultimately improve health services available to obese patients.

3) To identify opportunities for international collaborations in the areas of bariatric care.

4) To engage potential research funders that can support an emerging bariatric care research agenda in Canada.

The 2-day workshop features presentations from Canadian researchers on topics ranging from behavioural, medical and surgical treatments to issues related to health systems and health care delivery for patients with excess weight.

The workshop also specifically addresses some of the ethical, legal and gender barriers to bariatric care as well as the needs of special populations, who may be disproportionately affected by obesity and its many consequences.

But the attendees will also hear from patients, who themselves have had to cope with excess weight and are wiling to share their personal stories, wishes, hopes and needs to inform this important research agenda.

Hopefully, the research themes and topics that will be identified at this workshop will not only lead to new research funding and projects but will ultimately result in addressing the very real needs of the over 11,000,000 Canadian adults and over 1,000,000 Canadian children already suffering the dire consequences of excess weight.

As blogged before, efforts targeted at obesity prevention are unlikely to help the people who already have the problem - they will, unfortunately, need treatments - treatments that will hopefully be based on the best scientific research and evidence.

AMS
Montreal, Quebec

With the ever-increasing number of patients undergoing bariatric surgery, it is not surprising that professional organisations around the world are publishing a slew of recommendations and guidelines on how best to manage these patients.

The latest guideline on this topic appears this month in the Journal of Clinical Endocrinology and Metabolism, the official journal of The Endocrine Society.

The 20-page guideline, authored by a panel led by David Heber (University of California), focusses on the immediate postoperative period and long-term endocrine and nutritional management of the post-bariatric surgery patient.

As expected, the key challenges are to prevent complications, weight regain, and progression of obesity-associated comorbidities.

As the panel notes, bariatric surgery is by no means a guarantee of successful weight loss or maintenance and all patients require care from a multidisciplinary team including an experienced primary care physician, endocrinologist, or gastroenterologist (I would add a general internist to this list) and must consider enrolling postoperatively in a comprehensive program for nutrition and lifestyle management.

The guidelines also point out that while nutritional risks are greatest with malabsorbtive procedures (e.g. Roux-en-Y gastric bypass), the risk for weight regain are highest for purely restrictive procedures (e.g. adjustable gastric banding).

Nutritional education and clinical management to prevent and detect nutritional deficiencies are recommended for all patients undergoing bariatric surgery (including those with purely restrictive procedures) and should focus on adequate protein, vitamin, and mineral intake.

The guidelines contain particularly comprehensive sections dealing with the causes of weight regain, management of patients with diabetes mellitus, and issues related to bone health, gout, gastrointestinal problems, and eating behaviour.

All clinicians involved in this rapidly evolving field of medicine will likely find these latest guidelines a quick and worthwhile read.

AMS
Edmonton, Alberta

Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J, & Still C (2010). Endocrine and nutritional management of the post-bariatric surgery patient: an endocrine society clinical practice guideline. The Journal of clinical endocrinology and metabolism, 95 (11), 4823-43 PMID: 21051578

As I was flying out to the 4th Annual Obesity Network Obesity Boot Camp yesterday (more on the camp later), I happened to read this week’s Globe Essay by Arthur Kleinman titled, “Health Care’s Missing Care”.

Arthur Kleinman is professor of medical anthropolgy at Harvard University and in his essay, he deplores the loss of caregiving in today’s clinical practice. He calls this the lost art of medicine, displaced by ever-more emphasis on economically-driven concepts of “evidence-based” rationalisation and increasing reliance on science and technology for diagnosis and treatment.

He asks:

“What time has been allotted for aquiring this skill [of caregiving] in medical school and residency training? What has been done to evaluate future doctors’ skills in this respect? Has medicie turned its back on the medical art and the thousands of years of humanistic approaches to medical practice?”

In his essay he focuses on the frail and elderly, but much of what he discusses is as applicable to my bariatric patients, as it is to patients in many other fields of medicine:

“…for example, we can say that caregiving begins with the ethical act of acknowledging the situation of the sufferer, affirmig his or her efforts and those of family and friends to respond to pain and impairment, and demonstrating emotional and moral solidarity with those efforts.”

“It moves on to involve the physician in pain management, symptom relief, treatment of other “intercurrent” diseases (such as depressive disorder) that may arise during the first disease, and judicious management of the use of pertinent technology and control of unnecessary or futile interventions.”

“It includes working with a network of other health care professionals (such as physical therapists, occupational therapists, nurses, social workers, and home health-care assistants), and family and network of care givers.”

“It means spending real time with patients, empathically listening to their illness narratives, eliciting and respondig to their explanatory models, and engaging the psychosocial coping processes involved in enduring or ending life.”

I can only concur with Kleinman as he concludes that,

“The physician’s art - now so circumscribed by bureaucratic, political and economic forces - turns on both the professionalization of these inherently human resources and the impact of their routine use on the doctor’s own moral life.”

Working in a clinic where we currently look after over 1,500 patients (not to mention the over 2,000 patients on the waiting list) struggling with body weights, not seldom well over 400 lbs, these words ring only too true.

While we may not have the “magic bullet” for severe obesity, we can certainly offer compassion and understanding on how living with this cruel and devastating condition requires unbelievable daily courage and struggle.

Let us never forget who we serve!

AMS
Station Dushesnay, Quebec