Tuesday, June 17, 2014

US Obstetricians and Gynecologists Weight In On Ethical Obesity Care

ACOG_Logo.svg_This month the the Committee on Ethics of the American College of Obstetricians and Gynecologists released a position statement on obesity that advices its fellows to be prepared to meet the challenges of women with obesity with compassion and without bias.

The statement offers the following recommendations and conclusions:

  • Physicians should be prepared to care for obese patients in a nonjudgmental manner, being cognizant of the medical, social, and ethical implications of obesity.
  • Recommendations for weight loss should be based on medical considerations.
  • An understanding that weight loss entails more than simply counseling a woman to eat less and exercise more and a willingness to learn about the particular causes of a patient’s obesity will assist physicians and other health care professionals working with them in providing effective care.
  • Physicians can serve as advocates within their clinical settings for the necessary resources to provide the best possible care to obese women.
  • It is unethical for physicians to refuse to accept a patient or decline to continue care that is within their scope of practice solely because the patient is obese. However, if physicians lack the resources necessary for the safe and effective care of the obese patient, consultation or referral or both are appropriate.
  • Physicians should work to avoid bias in counseling regardless of their own body mass index status.
  • Obesity education that focuses on the specific medical, cultural, and social issues of the obese woman should be incorporated into physician education at all levels.

The entire statement is available here.

It would certainly be nice to see similar statements from other professional bodies (e.g. orthopedic surgeons).

Hopefully, these recommendations will soon be reflected in clinical practice.

@DrSharma
Edmonton, Alberta

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Thursday, April 10, 2014

Managing Weight Loss Expectations

sharma-obesity-great-expectationsWhile there are almost no limits to short-term weight loss goals (anyone can starve themselves thin) – the reality of long-term weight loss is rather sobering.

While diet and exercise generally provide an average long-term (3-5 years) sustainable weight loss or about 3-5% of initial weight, even bariatric surgery patients tend on average to sustain a weight loss of only 20-30% of their initial weight.

Surgery, although much safer than generally thought, still bears a risk of complications and the question is how much risk patients are willing to assume if they really knew and understood how much weight they are likely to lose with surgery.

This was the subject of a study by Christina Wee and colleagues, published in JAMA Surgery, in which they examined weight loss expectations and willingness to accept risk among patients seeking bariatric surgery.

The researchers interviews 650 patients interested in bariatric surgery at two bariatric centres in Boston.

On average, patients expected to lose as much as 38% of their weight after surgery and expressed disappointment if they did not lose at least 26%.

In fact, 40% of patients were unwilling to undergo a treatment that would result in only 20% weight loss.

Most patients (85%) accepted some risk of dying to undergo surgery, but the median acceptable risk was only 0.1%.

On the other hand, some patients (20%) appeared more desperate, willing to accept a risk of 10% or greater.

As one may expect, there were important gender differences in these findings: while women were more likely than men to be disappointed with a 20% weight loss, they were also less likely to accept a greater mortality risk.

An important finding for clinicians was that patients with lower quality-of-life scores and those who perceived needing to lose more than 10% and 20% of weight to achieve “any” health benefits were more likely to have unrealistic weight loss expectations.

This study not only shows that most patients seeking bariatric surgery have rather unrealistic weight loss expectations but also that   a substantial number may well be be disappointed with their weight loss after surgery.

It is also evident that many patients believe that they need to lose a rather substantial amount of weight to derive “ANY” health benefits, when in reality even rather modest (and certainly the average 20-30% weight loss seen with surgery) carries substantial health benefits for patients. (Many patients would in fact benefit substantially if they simply stopped gaining weight).

I certainly wonder what educational efforts may be necessary to align expectations with the clinical reality of bariatric surgery and whether better managing expectations is likely to alter current practice?

@DrSharma
Edmonton, AB

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Wednesday, March 19, 2014

Can Testosterone Lead to Weight Loss in Hypogonadal Men?

sharma-obesity-impotenceLoss of male gonadal function has been associated with weight gain (particularly visceral adiposity) as well as metabolic disturbances including dyslipidemia and insulin resistance.

However, wether or not hormonal substitution with testosterone (T) ameliorates these metabolic abnormalities or even leads to weight loss remains controversial.

Now a 6-year observational study by Ahmad Haider and colleagues from Germany, published in the International Journal of Endocrinology, strongly suggests that this may well be the case.

The authors analysed data from two prospective longitudinal studies that included 156 obese hypogonadal men, aged between 41 and 73 years (mean 61.17 ± 6.18) with previously diagnosed type 2 diabetes, who were seeking urological consultation for various conditions such as erectile dysfunction, decreased libido, questions about their T status, or a variety of urological complaints.

All subjects  had subnormal plasma total T levels and at least mild symptoms of hypogonadism assessed by the Aging Males’ Symptoms scale (AMS).

Treatment was started with parenteral T undecanoate 1000 mg (Nebido, Bayer Pharma, Berlin, Germany), administered at baseline and 6 weeks and thereafter every 12 weeks for up to 72 months. Subjects were also given general advice on healthy eating and physical activity.

This treatment resulted in an increase in total T levels from 8.9 ± 1.99 nmol/L to above 16 nmol/L within the first year of therapy, and remained at this physiological level throughout the course of treatment.

This change in T levels was associated with a progressive 12 cm decrease in waist circumference and weight loss of about 17.5 Kg (15% of initial weight) with BMI dropping from 36.5 to 31.2 at year 6.

Concomitantly, fasting glucose declined from 7.06 to 5.59 mmol/L and HbA1c decreased from 8.08 to 6.14%.

There were also favourable changes in systolic and diastolic blood pressure, lipid profiles including triglycerides and total cholesterol:HDL ratio, as well as CRP and liver enzymes.

While general caution is in order given that there was no control group, these finding certainly strongly suggest a possible role for T-replacement therapy in hypogonadal males presenting with symptoms of hypogonadism and weight gain.

Clearly, the 15% weight loss is impressive and well-exceeds what is generally seen with pharmacological obesity treatments.

If nothing else, these observations should prompt the conduct of a well-designed randomised controlled trial to confirm the effect and safety of T replacement therapy for obesity in hypogonadal men.

@DrSharma
Edmonton, AB

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Tuesday, January 7, 2014

15 New Year Health Resolutions That Might Just Work

Arya Sharma Globe&Mail CartoonYesterday, the Globe & Mail ran a full page of Health Tips, one each from what they call “leading experts” (of who, I just happen to be one).

Here’s what the experts had to recommend:

1) Eat a pickle (rationale: fermented and preserved foods often contain bugs that may be good for you)

2) Don’t drink your calories (rationale: no benefits from drinking your calories that you cannot get from eating them)

3) Relax your mouth (rationale: unclenching you jaw helps you relax)

4) Walk (rationale: myriad health benefits of being more active)

5) Unplug (rationale: time to try other stuff – like reading a book)

6) Stop doing situps (rationale: bad for posture and your pelvic organs – does nothing to flatten your tummy)

7) Go to bed (rationale: sleep does wonders for your metabolism)

8) But set your alarm (rationale: waking up at the same time every day helps set your master clock)

9) Eat slowly (rationale: mindful slow eating is your best bet against overeating)

10) Breathe (rationale: slow breathing will help calm your nerves)

11) Clean up your kitchen (rationale: unprocessed and unsprayed plant-based whole foods are better for you)

12) Shake a leg (rationale: same as 4)

13) Use protection (rationale: helmets prevent brain injuries)

14) Invest in yourself (rationale: you need to make time to live healthier)

15) Take it outside (rationale: sunlight will improve your mood, memory and weight)

So there you go.

Don’t ask me for the actual evidence behind each of these – I’m sure it exists for what it’s worth – most of this stuff is really just common sense.

But then again, if things were really that easy, we’d be a nation of health nuts.

If you’ve made a resolution (and a full week into the New Year are still sticking with it) please feel free to share.

@DrSharma
Edmonton, AB

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Thursday, December 5, 2013

At-Risk is Not The Same as Unhealthy

sharma-obesity-cardiometabolic-risk1Clearly, this week’s posts on the two articles suggesting that there is no such thing as “healthy obesity” have hit a nerve.

I do not wish to repeat my previous criticisms of these two articles, which you can read here and here.

But I do wish to take the opportunity to set the record straight, that I do indeed take obesity seriously!

I am certainly well aware of the many health problems, emotional pain and physical limitations that are commonly associated with excess weight.

After all, I work in a clinic that provides all forms of behavioural, medical and surgical treatments for obesity and can certainly attest to the substantial health benefits of successful obesity management.

I am also well aware that with increasing BMI levels, it becomes harder and harder to find obese people who one would consider to be perfectly healthy.

As we showed in our analyses of NHANES data, EOSS Stage 0 individuals make up only 15% of individuals in the BMI 25 to 30 range, decreasing to 8% of individuals in the BMI 30 to 35 range and dropping to less than 5% in those with a BMI greater than 35.

Although we regularly see individuals with EOSS Stage 0 even at BMI levels well beyond 40, these are indeed rare individuals – the vast majority of our patients present with EOSS Stage 2 or higher.

Thus, my “advocacy” for the existence of “healthy obesity” has nothing to do a lack of recognition or even underestimation of the considerable health risks and problems related to excess weight.

Rather, my insistence on not immediately assuming that everyone with a higher BMI is in immediate need of medical attention, is motivated by our ability to look at individual risk rather than having to simply rely on statistical probabilities.

Fortunately, we have a rather good understanding of the key underlying risk factors that mediate cardiometabolic risk (high blood pressure, dysglycemia and dyslipidemia), which, together with smoking, account for virtually 90% of all cardiovascular risk. There is nothing mysterious about these risk factors and all can (and should) be easily measured in clinical practice.

Thus, whether an obese person is actually at increased cardiometabolic risk or not does not have to be a guessing game – a few simple physical and laboratory tests will quickly provide a clear answer (whereas stepping on the scale will not!).

This is the whole point of the argument. Why should we jump to the conclusion that anyone with a higher BMI is unhealthy based on BMI alone, when it is so simple to determine actual risk?

A common counterargument is that, because the vast majority of people with higher BMI’s are at increased risk, it may be easier to simply tell everyone to lose weight.

But that is exactly where the problem lies. Losing weight is anything but easy and may in fact cause harm (if the methods employed are unhealthy and/or weight recidivism adversely affects emotional and physical health).

Based on our calculations in the US-NHANES data set, recommending that anyone with a BMI greater than 25 loses weight would include almost 10 million individuals in the US, who we would consider EOSS Stage 0, i.e. perfectly healthy.

Readers will hopefully agree that 10 million is not a trivial number by any standard – these are the people who stand to be harmed by blanket recommendations that label all overweight and obese people as unhealthy – the risk/benefit ration for these individuals may well be on the side of risk rather than benefit.

At a minimum, these 10 million people deserve the courtesy of health professionals actually measuring their actual risk before making pronouncement as to their prognosis.

I strongly feel that in our public health messaging (and clinical practice guidelines) – both sides can stand alongside each other.

Yes, excess weight can increase the risk of cardiometabolic risk factors (and other health problems) – simple tests in your doctor’s office can help determine these risks.

On the other hand, not everyone carrying a few extra pounds is at immediate risk of developing diabetes or heart attacks (or stands to benefit from obsessing about their weight) –  again, simple tests in your doctor’s office can help identify those at low risk.

To me the real question of interest is not whether or not “healthy obese” people exist – they do!

The interesting question is what these individuals can teach us about the sociopsychobiology of obesity. What behavioural or biological factors keep these individuals healthy? Perhaps there are learnings here that can help “unhealthy obese” individuals live healthier lives.

@DrSharma
New Delhi, India

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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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