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Canadians Have Virtually No Access To Interdisciplinary Obesity Care

Every single guideline on obesity management emphasises the importance of interdisciplinary obesity management by a team that not only consists of a physician and a dietitian but also includes psychologists, exercise specialists, social workers, and other health professionals as deemed necessary. As is evident from the evident from the 2017 Report Card on Access To Obesity Treatment For Adults, released last week at the 5th Canadian Obesity Summit, the overwhelming majority of Canadians living with obesity have no access to anything that even comes close. Thus, the report finds that Among the health services provided at the primary care level for obesity management, dietitian services are most commonly available. Access to exercise professionals, such as exercise physiologists and kinesiologists, at the primary care level is limited throughout Canada. Access to mental health support and cognitive behavioural therapy for obesity management at the primary care level is also limited throughout Canada. bariatric surgery programs often have a psychologist or a social worker that offers mental health support and cognitive behavioural therapy to patients on the bariatric surgery route, but the availability of these supports outside of these programs is scarce. Centres where bariatric surgery is conducted also have inter- disciplinary teams that work within the bariatric surgical programs and provide support for patients on the surgical route. Alberta and ontario have provincial programs with dedicated bariatric specialty clinics that offer physician-supervised medical programs with interdisciplinary teams for obesity management. Interdisciplinary teams for obesity management outside of the bariatric surgical programs are available in one out of five regional health authorities (RHa) in british Columbia, one out of 18 RHas in Québec, one out of two RHas in new brunswick and one out of four RHas in newfoundland and labrador. Among the territories, only yukon has a program with an interdisciplinary team focusing on obesity management in adults. I hardly need to remind readers, that this is in stark contrast to the resources and teams available to patients with diabetes, heart disease, lung disease, or any other common chronic disease, that are regularly available in virtually every health jurisdiction across the country (not to say that they are perfect or sufficient – but at least there is some level of service available). I understand that our current obesity treatments are extremely limited (at least when effectiveness is measured in terms of weight loss). But even if access to these resources could simply help stabilise and… Read More »

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High Time For Canadian Governments To Recognise Obesity As A Chronic Disease

It has now been almost two years since the Canadian Medical Association declared obesity to be a chronic medical disease. This declaration was widely praised by people living with obesity as well as healthcare and academic professionals (not least myself), who supported the notion that recognition of obesity as a disease would help precipitate a shift in thinking of obesity as just a lifestyle choice to a medical disease with an obligation to prevent and treat it as other chronic diseases. Not much has happened since then – at least not as far as Canadian policy makers are concerned. Thus, it is evident from the 2017 Report Card on Access To Obesity Treatment For Adults, released last week at the 5th Canadian Obesity Summit, that so far, neither the federal government nor any of the provincial/territorial governments in Canada have recognized obesity as a chronic disease. As discussed in the report, this has a significant negative trickle-down effect on access to obesity treatment for the over 6,000,000 Canadians living with this chronic disease, not to mention the millions of Canadians at high risk of developing this disease in the near future. As a reminder, in preparing the Report Card, the Canadian Obesity Network extensively reviewed all publicly accessible resources and documents for evidence of policies, guidelines and services for obesity treatment and management in each province and territory. In addition, the Canadian Obesity Network tried to identify and speak directly to government officials in each province and territory regarding their take on obesity as a chronic disease. This was by no means an easy task, “The search for information on the recognition of obesity as a chronic disease and treatment guidelines or recommendations by provincial/territorial governments and identifying appropriate policy makers in each province/ territory required significant effort. many provinces and territories do not have a person or department dedicated to the bariatric or obesity-treatment portfolio.”  As the Report Card highlights, “Since the declaration, none of the provincial or territorial governments have officially recognized obesity as a chronic disease.” “Health Canada has also not officially recognized obesity as a chronic disease and has continued to consider obesity as a lifestyle risk factor. There is no directive from Health Canada on the treatment and management of obesity in adults.” It also notes that the 2016 report of the senate standing Committee on social affairs, science and technology titled Obesity in Canada, referred to obesity as a… Read More »

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Another Canadian Obesity Summit Exceeds Expectations

Wow, what a week! Just back from the 5th Canadian Obesity Summit, there is no doubt that this summit will live long in the minds (and hearts) of the over 500 attendees from across Canada and beyond. As anyone would have appreciated, the future of obesity research, prevention and practice is alive and kicking in Canada. The over 50 plenary review lectures as well as the over 200 original presentations spanning basic cellular and animal research to health policy and obesity management displayed the gamut and extent of cutting-edge obesity research in Canada. But, the conference also saw the release of the 2017 Report Card on Access to Obesity Treatment for Adults, which paints a dire picture of treatment access for the over 6,000,000 Canadians living with this chronic disease. The Report Card highlights the virtually non-existant access to multidisciplinary obesity care, medically supervised diets, or prescription drugs for the vast majority of Canadians. Moreover, the Report Card reveals the shocking inequalities in access to bariatric surgery between provinces. Merely crossing the border from Alberta to Saskatchewan and your chances of bariatric surgery drops from 1 in 300 to 1 in 800 per year (for eligible patients). Sadly, numbers in both provinces are a far cry from access in Quebec (1 in 90), the only province to not get an F in the access to bariatric surgery category. The presence of patient champions representing the Canadian Obesity Network’s Public Engagement Committee, who bravely told their stories to a spell-bound audience (often moved to tears) at the beginning of each plenary session provided a wake up call to all involved that we are talking about the real lives of real people, who are as deserving of respectful and effective medical care for their chronic disease as Canadians living with any other chronic disease. Indeed, the clear and virtually unanimous acceptance of obesity as a chronic medical disease at the Summit likely bodes well for Canadians, who can now perhaps hope for better access to obesity care in the foreseeable future. Thanks again to the Canadian Obesity Network for hosting such a spectacular event (in spectacular settings). More on some of the topics discussed at the Summit in coming posts. For an overview of the Summit Program click here @DrSharma Edmonton, AB

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Do SGLT-2 Inhibitors Change Fat Metabolism?

Since the introduction of SGLT-2 inhibitors (“gliflozins” or “glucoretics), as an insulin-independent treatment for type 2 diabetes, that works by blocking glucose reabsorbtion in the kidney resulting in loss of glucose (and calories) through the kidney, much has been written about the (albeit modest) weight loss associated with this treatment. Several studies have documented that the weight loss leads to a change in body composition with an often significant reduction in fat mass. Now, Giuseppe Daniele and colleagues, in a paper published in Diabetes Care, show that treatment with these compounds may enhance fat oxidation and increase ketone production in patients with type 2 diabetes. The researchers randomized 18 individuals with type 2 diabetes to dapagliflozin or placebo for two weeks. As expected, dapagliflozin reduced fasting plasma glucose significantly (from 167  to 128 mg/dL). It also increased insulin-stimulated glucose disposal (measured by insulin clamp) by 36%, indicating a significant increase in insulin sensitivity. Compared to baseline, glucose oxidation decreased by about 20%, whereas nonoxidative glucose disposal (glycogen synthesis) increased by almost 50%. Moreover, dapagliflozin increased lipid oxidation resulting in a four-fold increase in plasma ketone concentration and and a 30% increase in fasting plasma glucagon. Thus, the authors note that treatment with dapagliflozine improved insulin sensitivity and caused a shift from glucose to lipid oxidation, which, together with an increase in glucagon-to-insulin ratio, provide the metabolic basis for increased ketone production. While this may explain the recent observation of a greater (albeit still rather rare) incidence of ketoacidosis with the use of these compounds, these findings may also explain part of the change in body composition previously noted with SGLT-2 treatment. While this still does not make SGLT-2 inhibitors “weight-loss drugs”, there appears to be more to the fat loss seen with these compounds than just the urinary excretion of glucose. @DrSharma Edmonton, AB

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Metformin Attenuates Long-Term Weight Gain in Insulin-Resistant Adolescents

The biguanide metformin is widely used for the treatment of type 2 diabetes. Metformin has also been shown to slow the progression from pre to full-blown type 2 diabetes. Moreover, metformin can reduce weight gain associated with psychotropic medications and polycystic ovary syndrome. Now, a randomised controlled trial by M P van der Aa and colleagues from the Netherlands, published in Nutrition & Diabetes suggests that long-term treatment with metformin may stabilize body weight and improve body composition in adolescents with obesity and insulin resistance. The randomised placebo-controlled double-blinded trial included 62 adolescents with obesity aged 10–16 years old with insulin resistance, who received 2000 mg of metformin or placebo daily and physical training twice weekly over 18 months. Of the 42 participants (mean age 13, mean BMI 30), BMI was stabilised in the metformin group (+0.2 BMI unit), whereas the control group continued to gain weight (+1.2 BMI units). While there was no significant difference in HOMA-IR, mean fat percentage reduced by 3% compared to no change in the control group. Thus, the researcher conclude that long-term treatment with metformin in adolescents with obesity and insulin resistance can result in stabilization of BMI and improved body composition compared with placebo. Given the rather limited effective options for addressing childhood obesity, this rather safe, simple, and inexpensive treatment may at least provide some relief for adolescents struggling with excess weight gain. @DrSharma Edmonton, AB

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