Friday, November 14, 2014

Video: Principles of Obesity Management

Arya Sharma Kingston Nov 2014Over the past weeks, I have given a rather large number of talks on obesity management to a variety of health professionals. Now, there is a recording of one of my talks (which I gave a few days ago in Kingston, Ontario) on Youtube.

Although the quality of the recording is perhaps not the best and the talk is rather long (about 100 minutes), for those of you, who would like to have a better grasp of how I think about and approach obesity management, here is the link.

Feedback is very much appreciated.

@DrSharma
Edmonton, AB

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Thursday, November 13, 2014

8 Ways In Which Nephrology Prepared Me For Bariatric Medicine

230px-Patient_receiving_dialysis_03Last night I gave McMaster University’s Karl E. Stobbe lecture on obesity management in St. Catherines, Ontario.

A commonly asked question is how my training in internal medicine and nephrology brought me to obesity.

While that story is rather simple (many problems in nephrology are related to people’s excess weight), the far more interesting aspect of this is how, over the years, I have realised how perfectly my experience in nephrology, especially working with patients who have chronic kidney disease, prepared me for my current work in bariatric medicine.

Here are some of the more salient reasons:

1) Both obesity and chronic kidney disease are complex often life-long disorders that can affect every aspect of a patients health and well-being.

2) Both necessitate a long-term (lifelong) management approach that must address both the underlying drivers as well as the health consequences of the problem as well as prevent further progression (whenever possible).

3) Both are best delivered in the context of multi-disciplinary care involving nurses, dietitians, physiotherapists, occupational therapists, social workers, mental health workers and many other allied health professionals.

4) Nephrologists are often the only doctors that patients with kidney failure see regularly  – this means that they have to deal with all aspects of patient care – both minor and major, not unlike family doctors. Indeed, nephrologists are often functioning as the “family docs” of their patients on dialysis.

5) Patients with kidney disease present with a wide range of health problems – cardiovascular, metabolic, infectious, auto-immune, respiratory, gastrointestinal, musculoskeletal, nutritional, and virtually every other kind of disease, including mental health problems.

6) Nephrologist often have to be aware of and help manage the many psychosocial problems that their patients can present with.

7) Nutrition plays a very significant role in  managing patients with kidney disease, especially in patients on dialysis. Management of macro and micronutrients is something nephrologists have to deal with on a daily basis whether it is protein intake, minerals (e.g. sodium, potassium, calcium, iron, etc.) or vitamins (e.g. Vit D, or water-soluble vitamins like B complex or Vitamin C).

8) Obsessing about body composition, fluid balance, sarcopenia and nutrition are all standard issues that nephrologists are trained to worry about.

I would not have know just how valuable my training in nephrology would have been for my current practice – but looking back, I don’t think I could have been better prepared for the challenges of bariatric medicine.

@DrSharma
Toronto, ON

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Wednesday, November 12, 2014

5As of Obesity Management in Primary Care

sharma-obesity-5as-booklet-coverThis week I am again touring Ontario to train health professionals in the 5As of Obesity Management (Kingston, Ottawa, St. Catherines).

It is heartening to see the tremendous interest in this topic and how the message about obesity as a chronic disease resonates with health practitioners, few of who have any prior training in obesity management.

It is particularly rewarding to see how well the Canadian Obesity Network’s 5As of Obesity Management framework is received and embraced by those working in the front lines of primary care, as this is exactly the audience for which this framework is intended.

Regular readers may recall that the 5As of Obesity Management framework was developed by the Canadian Obesity Network in an elaborate undertaking involving scores of primary care providers, experts and patients from across Canada. The tools were modelled using the latest in health information design technology and extensively field tested to ensure their applicability and adaptability to primary care practice.

Rather than overloading the tools with intricate algorithms, we opted for a rather general but insightful set of principles and recommendations designed to facilitate professional interactions that seek to identify and address the key drivers and consequence of weight gain as well as help tackle the key barriers to weight management.

Indeed, the 5As of Obesity Management are steeped in a deep understanding of the complex multi-factorial nature of obesity as a chronic (often progressive) disease for which we simply have no cure.

The framework recognizes that health cannot be measured on a scale, BMI is a poor measure of health and that obesity management should be aimed at improving the overall health and well being of those living with obesity rather than simply moving numbers on the scale.

Research on the use of the 5As in primary practice has already shown significant improvements in the likelihood of obesity being addressed in primary practice.

A large prospective randomized trial on the implementation of the 5As of Obesity Management framework in primary care (the 5AsT trial) is currently underway with early results showing promising results.

I, for one, will continue promoting this framework as the basis for obesity counselling and management in primary care – at least until someone comes up with something that is distinctly better.

If you have experience with this approach or have attended one of the many education sessions on the 5As of Obesity Management offered by the Canadian Obesity Network, I’d certainly like to hear about it.

To view an introductory video on the 5As of Obesity Management click here

@DrSharma
Ottawa, ON

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Tuesday, November 11, 2014

Does The Rate Of Weight Loss Predict Your Rate of Weight Regain?

scaleThe conventional wisdom, as reflected in almost all dietary recommendations for weight loss, is that it is best to lose weight slowly – the hope is that this will allow time for both your body to adjust to the change in caloric intake as well establishing new “habits”.

Now a study by Katrina Purcell and colleagues from the University of Melbourne, published in The Lancet Diabetes & Endocrinology challenges this dogma.

The researchers enrolled 204 participants (51 men and 153 women) aged 18—70 years with a BMI between 30 and 45 kg/m2 into a two phase, randomised, non-masked, dietary intervention trial.

During Phase 1, participants were randomly assigned to either a 12-week rapid weight loss or a 36-week gradual programme, both aimed at 15% weight loss. At the end of this phase, 51 (50%) participants in the gradual weight loss group and 76 (81%) in the rapid weight loss group achieved 12·5% or more weight loss in the allocated time and were then switched to Phase 2, which consisted of a weight maintenance diet for 144 weeks.

By the end of Phase 2, about 70% of both the rapid and gradual gainers had regained all their weight.

Thus, in this first randomised controlled trial of its kind, there does not appear to be any relevant benefit of losing weight faster or slower – in the end (about 2.5 years later), the vast majority of participants in either group will have regained any weight lost.

On a positive note, the study dismisses the dogma that weight lost quickly is regained just as fast.

On a negative note, the study also confirms just how dismal the results of dietary attempts to lose weight and keep it off really are.

I may sound like a broken record – but we do need better treatments for weight-loss maintenance!

@DrSharma
Kingston, ON

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Monday, November 10, 2014

How Does Weight Loss Affect Your Quality Of Life?

Lindsey Warkentin

Lindsey Warkentin, MSc, Lead Research Assistant – Acute Care and Emergency Surgery Service at University of Alberta, Edmonton, Canada

One of the most profound impacts of weight loss in people with severe obesity is on quality of life. But just how much weight loss is required for a clinically important effect?

We now examined this issue in a paper by Lindsey Warkentin and colleagues published in BMC Medicine and selected among the top 10 posters at Obesity Week (congratulations Lindsey!).

We determined the amount of weight loss required to attain established minimal clinically important differences (MCIDs) in health-related quality of life (HRQL), using three validated instruments (Short-Form (SF)-12 physical (PCS) and mental (MCS) component summary score, EQ-5D Index and Visual Analog Scale (VAS), Impact of Weight on Quality of Life (IWQOL)-Lite) over 24 months in 150 wait-listed, 200 medically managed and 150 surgically treated patients from the Alberta Population-based Prospective Evaluation of Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study.

In the overall cohort of 500 participants with a mean age of 44, 88% women, 92% white, and a mean initial BMI of 47.9, the percent weight loss required to achieve MCDs ranged between 9% and 25%, depending on the instrument used: 23% for PCS, 25% for MCS, 9% for EQ-Index, 23% for EQ-VAS, and 17% for IWQOL-Lite.

Thus, it appears that the percent weight loss to achieve MCIDs for most HRQL instruments are markedly higher than the conventional threshold of 5% to 10% often seen in the literature – i.e. well beyond what can generally be achieved with diet and exercise (or even pharmacotherapy) at 24 months.

Currently, surgery appears to be the only treatment for obesity that consistently delivers this amount of weight loss (compared to other interventions).

Given that surgery is not a realistic option for the millions of people living with severe obesity, we simply need to find better medical treatments that can deliver sustainable weight loss of this magnitude.

@DrSharma
Kingston, ON
ResearchBlogging.orgWarkentin LM, Majumdar SR, Johnson JA, Agborsangaya CB, Rueda-Clausen CF, Sharma AM, Klarenbach SW, Karmali S, Birch DW, & Padwal RS (2014). Weight loss required by the severely obese to achieve clinically important differences in health-related quality of life: two-year prospective cohort study. BMC medicine, 12 (1) PMID: 25315502

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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