WHEREAS: The disease of obesity is a major source of concern across the nation. In California, the adult obesity rate is nearing a quarter of the population (24.7%) and in Los Angeles County, the percentage of adults affected by obesity continues its steady rise from 13.6% in 1997 to 24.3% in 2013, and
WHEREAS: Experts and researchers agree that obesity is not a lifestyle choice but rather, a complex disease influenced by various physiological, environmental factors, and
WHEREAS: While prevention programs, including the 2010 California Obesity Prevention Plan, have successfully established the seriousness of this public health crisis, it is also imperative that individuals and families currently affected by obesity receive comprehensive care and treatment, and
WHEREAS: Studies show that bias and stigma against people affected by obesity among general society and healthcare professionals are significant barriers to effectively treating the disease, and
WHEREAS: Healthcare professionals must treat patients with respect and compassion, and partner with patients to develop a comprehensive and individualized approach to weight-loss and weight management that considers all appropriate treatment options such as reduced-calorie diet and physical activity modifications, pharmacotherapy, or bariatric surgery, and
WHEREAS: It will take a long-term collaborative effort, involving partners from across all fields – individual, corporate and institutional – taking an active role, to ignite the betterment of obesity care and treatment:
NOW, THEREFORE, I, ERIC GARCETTI, as Mayor of the City of Los Angeles, and on behalf of its residents, do hereby proclaim the week of November 1-7, 2015 as Obesity Care Week in the City of Los Angeles, and encourage all our citizens to create the foundation of open communication to break barriers of misunderstanding and stigma, and improve the lives of all individuals affected by obesity and their families.
September 25, 2015
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In the context of severe obesity, this includes providing access to care in a setting that accommodates bariatric patients – larger blood pressure cuffs, larger gowns, larger scales and larger furniture.
But how is this viewed by the very people that these measures are meant to accommodate?
This is the topic of a thoughtful opinion piece by CON bootcamper Nicole Glenn and Marianne Clark, published in JAMA.
The paper describes comments of patients with severe obesity interviewed in a bariatric centre that tries its best to accommodate:
“Incredibly considerate and incredibly insulting at the same time.” This is how a woman describes the expanded chairs in the waiting room of the bariatric clinic….This woman is not describing the hospital administrators who purchased the chairs nor the designers from whose imaginations they sprung. Instead, she refers to the chairs directly, as if it were they doling out insults and praises in turn.
That these chairs were designed for the unique needs of these patients is obvious: they offer comfort and accommodation by way of sturdy metal arms and extended seats and backs. Nevertheless, these chairs are experienced in multiple ways; not all patients who encounter them find their welcome welcoming.
A woman waiting for her appointment at the bariatric clinic explains, “This giant chair makes me feel so very fat, and so very skinny at the same time…‘You are not normal,’ it seems to say to me.”
As the authors note,
By considering the experience of such ordinary things as enlarged chairs in the bariatric clinic waiting room, we must acknowledge how extraordinary these things actually are: how they have meaning and shape and are shaped by people’s lives. Listening to patients’ experiences allows us to see the world, if only momentarily, from their perspective, enabling deeper understanding of their lives, and ultimately leaving us better equipped to address their needs as they seek treatment and care.
At least it may be useful to consider that objects may be have unintended meanings and consequences:
Rather than finding chairs that accommodate larger bodies, these patients often seek a body that accommodates the world, one that slips easily and unthinkingly into “regular” chairs. Instead of providing rest and reprieve, the temporary comfort and accommodation afforded by the altered chairs in the bariatric clinic waiting room may act as a reminder of the shrunken world that exists outside these walls, ultimately marking a journey far from complete.
What are your thoughts on accommodation – what is the alternative?
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As Canada’s national representative in the World Obesity Federation (formerly IASO), the Canadian Obesity Network is proud to co-host the 13th International Congress on Obesity in Vancouver, 1-4 May 2016.
The comprehensive scientific program will span 6 topic areas:
Track 1: From genes to cells
- For example: genetics, metagenomics, epigenetics, regulation of mRNA and non–coding RNA, inflammation, lipids, mitochondria and cellular organelles, stem cells, signal transduction, white, brite and brown adipocytes
Track 2: From cells to integrative biology
- For example: neurobiology, appetite and feeding, energy balance, thermogenesis, inflammation and immunity, adipokines, hormones, circadian rhythms, crosstalk, nutrient sensing, signal transduction, tissue plasticity, fetal programming, metabolism, gut microbiome
Track 3: Determinants, assessments and consequences
- For example: assessment and measurement issues, nutrition, physical activity, modifiable risk behaviours, sleep, DoHAD, gut microbiome, Healthy obese, gender differences, biomarkers, body composition, fat distribution, diabetes, cancer, NAFLD, OSA, cardiovascular disease, osteoarthritis, mental health, stigma
Track 4: Clinical management
- For example: diet, exercise, behaviour therapies, psychology, sleep, VLEDs, pharmacotherapy, multidisciplinary therapy, bariatric surgery, new devices, e-technology, biomarkers, cost effectiveness, health services delivery, equity, personalised medicine
Track 5: Populations and population health
- For example: equity, pre natal and early nutrition, epidemiology, inequalities, marketing, workplace, school, role of industry, social determinants, population assessments, regional and ethnic differences, built environment, food environment, economics
Track 6: Actions, interventions and policies
- For example: health promotion, primary prevention, interventions in different settings, health systems and services, e-technology, marketing, economics (pricing, taxation, distribution, subsidy), environmental issues, government actions, stakeholder and industry issues, ethical issues
Early-bird registration is now open – click here
Abstract submission deadline is November 30, 2015 – click here
For more information including sponsorship and exhibiting at ICO 2016 – click here
I look forward to welcoming you to Vancouver next year.
However, now a human study by Valentina Tremaroli and colleagues published in Cell Metabolism, not only shows that bariatric surgery can induce distinct changes in gut bacteria but also that transferring stool from these individuals to germ-free mice changes their metabolism towards greater utilization of carbohydrates for fuel.
As a first step, the researchers examined the gut microbiota of 14 weight-stable women 9 years after randomization to either gastric bypass (n=7) or vertical banded gastroplasty (n=7) and matched for weight and fat mass loss.
As a control, they also analyzed the gut microbiota of two groups of non-operated women with a BMI matched to the patients’ pre-surgical BMI (OBS) and post-surgical BMI (Ob).
The gut bacteriome was significantly altered in both surgical groups with some difference between the two procedures: changes in the gastric-bypass patients suggest an increased energy flux into sugar metabolism and glycolysis, whereas the VBG patients showed an enrichment of pathways for amino acid uptake and metabolism and for glyoxylate metabolism pointed to the utilization of amino acids and acetate for energy production.
There were also important difference in bile acid metabolism in the surgery groups.
The authors are comfortable that these changes result from bariatric surgery and are not related to BMI per se, since the OBS and Ob microbiomes were similar. Also, similar changes in gut microbiota have not been seen during dietary interventions for weight loss.
Thus, the authors note that,
“…our results suggest that bariatric surgery produces a specific shift in the microbiota that persists for up to a decade after surgery and is different from shifts related to dietary interventions for weight loss.”
In a second set of experiments, the researchers transplanted the microbiome from the various groups to germ free mice.
Mice colonized with gastric-bypass and banding microbiota for 2 weeks accumulated 43% and 26% less body fat, respectively, than mice colonized with OBS microbiota despite the fact that body weight gain and food intake did not differ between the groups during the 2-week colonization period.
In addition, metabolic studies showed decreased utilization of carbohydrates and increased utilization of lipids as fuel in recipients of gastric-bypass microbiota.
“…this study clearly shows that bariatric surgery has long-term effects on the composition and functional capacity of the gut microbiota and that these changes have the potential to modulate host metabolic regulation, thus adding evidence for the transmissibility of the human adiposity phenotype through the gut microbiota.”
“Our results also show that two different bariatric surgery procedures, namely RYGB and VBG, have similar long-term effects on the gut microbiome in women matched for BMI and fat mass loss. However, the two bariatric surgery procedures might result in different functionality due to different intestinal environmental conditions…. Importantly, the changes in the microbiome were not dependent on BMI or degree of weight and fat mass loss, thus revealing shifts in the gut microbiota that were specific to bariatric surgery.”
These findings should certainly do away with the simplistic notions of how and why bariatric surgery works – perhaps it is high time we discarded the notions of “restrictive” or “malabsorptive” surgery.
Information On The Genetic Nature of Obesity Can Reduce Perceived Weight Discrimination and Increase Willingness to Eat Healthier
Continuing the theme of harmful effects of weight bias, a paper by Janine Beekman and colleagues published in Psychology & Health, suggests that providing patients information on the strong genetic nature of obesity may not only reduce perceived weight bias but also increase willingness to eat a healthier diet.
In this study 201 women with overweight or obesity aged 20-50 were allowed to interact with a virtual physician in a simulated clinical primary care environment, which included physician-delivered information that emphasized either genomic or behavioral underpinnings of weight and weight loss.
This research builds on previous evidence that provision of genomic information in a primary care context can reduce patients’ perceived stigma because they feel less blamed for their weight.
As the authors note,
“This relates to attribution theory, which posits that causal attributions play an important role in determining reactions to stigmatizing information. The more overweight is attributed to controllable causes (like diet and exercise), the more negative one’s reactions are to it.”
All aspects of the virtual encounter were identical except for the type of information given: Participants who received genomic information were told that body weight has a sizeable heritable component, and this may be relevant to their personal situation. Participants who received behavioral information were given a parallel message that it may be harder for those who are already overweight to lose weight (but with no mention of the role of genomics). Both groups were reminded of the importance of health-promoting behaviours related to physical activity and nutrition.
After controlling for BMI and race, participants who received genomic information stated that they perceived less blame from the doctor than participants who received behavioral information. In a serial multiple mediation model, reduced perceived blame was significantly associated with less perceived discrimination, and in turn, lower willingness to eat unhealthy foods.
“Providing patients with information about genomics and weight management reduced the extent to which they felt blamed for their weight, when compared to more traditional behavior-based information. Women who felt less blamed for their weight also felt less discriminated against based on their weight, and this reduced perceived discrimination was related to healthier eating and drinking cognitions”
These findings may not just have implications for clinical practice but also for public health messages about obesity:
“The proliferation of the “war on obesity” and social messages targeted at combating obesity are an attempt to tackle a public health problem by engaging stigma as a vehicle for social control, while stigmatizing individuals in the process. These messages, in turn, can lead self-perceived overweight women to, for example, consume more calories and feel more deflated about their prospects for weight loss. The present research provides another example of these ironic effects of stigmatizing weight – or, more specifically, the manifestation of that stigma as perceived blame and discrimination.”
Although the authors recognise that genomic information may in itself prove stigmatizing, in this context, they feel that the positive influence of genomic information provision in this context stems from its strong effect on reducing perceived blame.
Thus, for clinicians, the message may well be that acknowledging the importance of genetic factors (rather than simply diet and exercise) may positively influence interpersonal dynamics between patients and providers by reducing perceived blame and perceived discrimination. These improved dynamics, may in turn, positively influence health cognitions.