As regular readers may know, the Canadian Obesity Network is currently promoting the creation of local chapters across Canada. This is part of the Network’s strategy to continue growing and engaging researchers, health professionals, and others with an interest in obesity prevention and management to network and break down silos.
Following the very successful launch of local Obesity Network chapters in Calgary and Hamilton, last night saw the inaugural meeting of the Toronto Chapter (CON-YYZ), which got together to appoint their new executive and to exchange ideas on local activities that this chapter can pursue in the future.
I had the opportunity of joining in for part of this meeting via Skype and was delighted to see the diversity of attendees and their enthusiasm – certainly a promise of great things to come.
For anyone interested in learning more about how to start your own local CON chapter, more information is available here.
I look forward to seeing a number of new Obesity Network chapters created across Canada, as we continue to seek better ways to fight weight-bias, discrimination and find better ways to prevent and manage obesity.
Last week I posted on the importance of non-acoholic fatty liver disease as one of the most common yet insidious consequences of obesity.
Now, a paper by Bower and colleagues from Imperial College London, published in Obesity Surgery, provides a systematic review of the impact of bariatric surgery on liver biochemistry and histology.
The review clearly shows that bariatric surgery is associated with a significant reduction in the steatosis, fibrosis, hepatocyte ballooning and lobular inflammation. Surgery is also associated with a reduction in liver enzyme levels, with statistically significant reductions in ALT, AST, ALP and gamma-GT.
However, there is considerable variability in these outcomes and between different types of interventions – clearly suggesting that more research on this issue is needed.
Nevertheless, at this time it appears that bariatric surgery may well be the most effective treatment for fatty liver disease.
Of all of the common complications of obesity, fatty liver disease is perhaps the most insidious. Often starting without clinical symptoms and little more than a mild increase in liver enzymes, it can progress to inflammation, fibrosis, cirrhosis and ultimate liver failure. It can also markedly increase the risk for hepatocellular cancer even in patients who do not progress to cirrhosis.
Now, a paper by Mary Rinella from Northwestern University, Chicago, published in JAMA provides a comprehensive overview of what we know and do not know about early detection and management of this condition.
The findings are based on a review of 16 randomized clinical trials, 44 cohort or case-control studies, 6 population-based studies, and 7 meta-analyses.
Overall between 75 million and 100 million individuals in the US are estimated to have nonalcoholic fatty liver disease with 66% of individuals older than 50 years with diabetes or obesity having nonalcoholic steatohepatitis with advanced fibrosis.
Although the diagnosis and staging of fatty liver disease requires a liver biopsy, biomarkers (e.g. cytokeratin 18) may eventually help in the detection of advanced fibrosis.
In addition, non-invasive imaging techniques including vibration-controlled transient elastography, ultrasound with acoustic radiation force impulse or even magnetic resonance elastography are fairly accurate in the detection of hepatic fibrosis and are the most reliable modalities for the diagnosis of advanced fibrosis (cirrhosis or precirrhosis).
Currently, weight loss is the only proven treatment for fatty liver disease. Pharmacotherapy including treatment with vitamin E, pioglitazone, and obeticholic acid may also provide some benefit (none of these treatments currently are approved for this indication by the UD FDA). Futhermore, the potential benefits of existing and emerging anti-obesity treatments on the incidence and progression of fatty liver remains to be established.
As Rinella points out,
“It is important that primary care physicians, endocrinologists, and other specialists be aware of the scope and long-term effects of the disease.”
Clearly, screening for fatty liver disease needs to be part of every routine work up of individuals presenting with excess weight.
Irrespective of the fact that bariatric surgery has now become so safe (at high-volume centres) that it compares well with other common surgical procedures like having your gall bladder removed, it is still surgery.
As even the safest surgery carries risk, it should never be taken lightly and thus the question of whether or not people with obesity but no related comorbidities stand to benefit from bariatric surgery is an important question.
One of the key outcomes (at least for patients) is the impact on quality of life which is why Hilde Risstad and colleagues from the University of Oslo, studied the effect of bariatric surgery on patients presenting with obesity related comorbidities and those without, published in Obesity Surgery.
They studied 232 patients with severe obesity before and 2 years after Roux-en-Y gastric bypass.
Obesity related disease was defined as having at least one of the following conditions: type 2 diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, obstructive sleep apnea, gastroesophageal reflux disease, or osteoarthritis.
Not only was baseline quality of life similar in patients with and without obesity-related disease prior to gastric bypass but it also improved equally in both groups.
This may not be entirely surprising.
Readers may recall that the Edmonton Obesity Staging System (EOSS), specifically designed to asses obesity related health risks, does not just consider medical comorbidities (as in this study) – EOSS gives as much importance to mental and functional health (not assessed in this study).
Thus, it is not surprising, that even without the presence of an obesity related medical complications like diabetes or sleep apnea, health (and thus quality of life) can be significantly affected by mental health and/or functional status, both of which can markedly improve after bariatric surgery.
This is why, pre-assessment or triaging patients for bariatric surgery should not only consider medical problems but also mental and functional health – as in EOSS.
The recent appointment of the Hon. Sarah Hoffman (NDP) to the post of Health Minister in Alberta has (as expected) prompted a wide range of remarks regarding her suitability for the job – not because of her qualifications as an administrator (these are uncontested) – but her size!
In a slurry of comments ranging from misguided misogynistic remarks (sadly, including by members of the former government) to outright personal insults, the social media frenzy around this topic is anything but unexpected.
The general story line is that someone living with obesity, who is thus obviously “unhealthy”, is not qualified be a health minister.
Indeed, one letter writer in the Edmonton Journal likens putting someone living with obesity in this position, to appointing a health minister who smokes – a fatal (but common) misconception of what obesity actually is.
For one, smoking is a behaviour – living with obesity is not!
When you inhale the smoke of a cigarette you are doing something (a behaviour) – when you gain (or lose) weight, it is something your body does (whether you want it to or not).
This distinction is fundamental: when I stop smoking, I become a non-smoker – end of story!
When I try to lose weight, my body will do everything it possibly can to resist losing weight. My appetite will increase, my metabolic rate will slow down, my body temperature will decrease, my thyroid function will decrease, my sense of taste and smell will increase, as will my risk-taking behaviour and my susceptibilty to stress. All of these changes (often referred to as the “starvation response”) will work day-and-night to “sabotage” my efforts and in 95% of people who set out to lose weight, these mechanism will eventually win out – even years after starting on their diet.
Every person I know who has ever lost a considerable amount of weight and is keeping it off, describes this as a daily on-going struggle. They are well aware that even the slightest interruption to their routine, an illness, an injury, a new medication, even just relationship issues or financial stressors and – boom – their weight is back, whether they like it or not.
This is why the WHO, the FDA, the AMA and a growing number of health organisations around the world are now calling obesity a chronic disease, because sadly, we have yet to find a cure for this condition.
Despite what celebrity pundits and the weight-loss industry may want you to believe, there are no easy solutions and try as they may, most people with excess weight will have to fight hard simply not to get any heavier.
So for one, even if Sarah Hoffman wanted to lose a few pounds, the chances that she will keep them off on her own in the long term are slim (unless of course she happens to belong to the lucky 5%). If she is looking for medical treatment, even surgery, I wish her good luck trying to access those services here in Alberta – welcome to the waiting list!
The other assumption underlying the criticism of Minister Hoffman, is the notion that obesity is a direct reflection of someone’s health behaviours – i.e. eating too much junkfood or not exercising.
Believe me that I have seen many patients in my clinic, who rarely (if ever) touch junk food, who spend hours in the gym, and still weigh in at 350 lbs or more. There is (and has been for a long time) enough scientific evidence to support the fact that people vary remarkably in their susceptibility to weight gain (and weight loss). The amount of weight gained by eating exactly the same amount of excess calories can vary as much as 5-fold between individuals.
So for all we know, Sarah Hoffman (like most people living with excess weight) is already well-informed and concerned about her diet and I’d hardly be surprised if, despite her busy schedule, she does manage to squeeze in as much physical activity into her daily routine as she possibly can.
But, irrespective of all of the above, there are simply so many different causes of weight gain (from genetics, to mental health, to sleep deprivation, to stress, to eating norms and culture, adverse childhood experiences, to medications – even perhaps the bugs that happen to live in your gut), that judging someone about their health knowledge or behaviours by looking at their size is truly laughable.
Indeed, who better to have as a health minister, than someone living with a chronic disease?
Would anyone seriously object to Sarah Hoffman’s appointment as Health Minister, were she living with diabetes, chronic kidney failure, coronary artery disease, HIV/AIDS, depression or for that matter cancer (even lung cancer)?
The only real difference between obesity and any of the above conditions is that obesity is visible for anyone to see (and apparently fair game for anyone to comment on).
Whether or not Sarah Hoffman turns out to be a capable and competent health minister remains to be seen – I am certain that neither her success nor failure will have anything to do with her size.
Perhaps it will take a Health Minister living with obesity, to finally create a health system, where people living with obesity are treated with compassion and respect and, most importantly, can find the help and treatments that they need.