Dr. Sharma's Obesity Notes

In contrast to Mark (the Golden Boy), Julie (the Fitness Enthusiast) and Gertrude (the Poor Eater), who all appear to be managing rather well, Janice, is having a hard time and continues to struggle with her weight.

Janice (whose story I made up), represents the fourth cluster in Lorraine Ogden’s analysis of weight-loss maintainers in the National Weight Control Registry, published in OBESITY.

While the folks in the other clusters had either no (Mark) or rather mild (Julie and Gertrude) family histories of obesity and did not have a significant weight problem till their late teens or adulthood, Janice’s mother and older brother are both severely obese. As Janice clearly recalls, teasing and bullying about her weight started back in Kindergarten.

Not surprisingly, Janice, at 45, is younger than most NWCR registrants and despite having lost over 100 lbs, still has a BMI of 29 (down from 45). Although, she has maintained a significant amount of weight loss for the past 5 years, she continues to weight cycle often regaining 10 or more pounds, before getting “back on track”.

Janice is single, has a few years of college (which she never finished), and works as a stocker at a local super market.

Despite her relatively young age, Janice has struggled with hypertension, type 2 diabetes, sleep apnea, arthritis and major depression.

Janice has tried almost every commercial weight loss program, has taken over-the-counter diet-pills and prescription anti-obesity medication (which she can ill afford), and has even seriously considered bariatric surgery (but lacks coverage).

Her current “success” is the result of continuing struggle using virtually every trick in the book (keeping meticulous food and exercise records, counting calories, limiting her intake of many high-caloric foods, occasionally using meal replacements and low-calorie diets, regularly weighing herself, not eating out).

She struggles to maintain an exercise routine of about 2500 Cal per week and tries to limit her caloric intake to about 1500.

She is the first to admit that any challenge like vacation, illness, change of season, or increased stress at work is likely to make her “fall off” her diet.

Despite her considerable weight loss, she is anxious to lose even more weight, is very dissatisfied with her appearance and feels stressed out about most things in her life.

While Janice makes up about 25% of registrants in the NWCR, she is clearly the kind of patient, most likely to be seen in a bariatric centre (where average BMIs tend to be around 50 and childhood onset obesity is the rule rather than the exception).

Having met many patients like Janice in my practice, I would not be surprised if Janice also has a history of childhood trauma or abuse, an alcoholic dad, has struggled with anxiety and panic attacks most of her life and has more than once contemplated putting an end to it all.

I am certain that many readers of these pages will immediately recognize patients like Janice and it is no surprise that these are not the people for whom simplistic “Eat-Less-Move-More” mantras are likely to work.

Indeed, I am surprised that Janice has even managed to make it into the NWCR; very few people in her situation do.

Whilst, Mark, Julie, and Gertrude, may well have found their “Best Weight”, Janice, even at a BMI of 28 is well below a weight that would be considered reasonably sustainable. This is clearly evident in her constant and daily struggle.

Thus, although, Mark, Julie and Gertrude may seem to have “conquered” obesity and are often held up as exemplary “success stories”, it is Janice who commands my deepest admiration and respect.

Of all clusters in the NWCR, it is clearly Janice who has fought the greatest battle and continues to put in the greatest effort (in my books, if you spend a lot of time doing something you either don’t mind or even like doing, it does not count as “effort”).

It is clearly people like Janice who will likely benefit most from ongoing interdisciplinary medical and perhaps surgical care as well as psychosocial support.

Now that we have met the typical “success” stories in the NWCR, we should discuss what this exercise perhaps teaches us about obesity management – but I’ll save that for next week.

AMS
Edmonton, AB

The US National Weight Control Registry (NWCR) is an ongoing registry of individuals successful at maintaining weight loss. Participation is voluntary and individuals have to have maintaine a weight loss of at least 13.6 kg (30 lb) for a minimum of 1 year to qualify.

Registrants are invited annually to respond to a battery of questionnaires in which they self-report various aspects of their lifestyle and health conditions.

In a recent paper in OBESITY, Lorraine Ogden and colleagues from the University of Colorado, present the results of a multivariate latent class cluster analysis in an attempt to identify unique clusters of individuals within the NWCR with regard to their experiences, strategies, and attitudes with respect to weight loss and weight loss maintenance.

Based on the analyses of 2,228 participants enrolled between 1998 and 2002, the researchers found four distinct clusters:

Cluster 1 (50.5%): represents a weight-stable, healthy, exercise conscious group who are very satisfied with their current weight.

Cluster 2 (26.9%): has continuously struggled with weight since childhood; they rely on the greatest number of resources and strategies to lose and maintain weight, and report higher levels of stress and depression.

Cluster 3 (12.7%): represents a group successful at weight reduction on the first attempt; they were least likely to be overweight as children, are maintaining the longest duration of weight loss, and report the least difficulty maintaining weight.

Cluster 4 (9.9%): represents a group less likely to use exercise to control weight; they tend to be older, eat fewer meals, and report more health problems.

So what can we learn from this analysis?

As a clinician, I don’t worry about Cluster 1 too much – these folks are healthy, exercise conscious, and apparently happy – they seem to be at their ‘best weight’ – good for them!

I am also less concerned about Cluster 3 – they apparently had no problem losing weight (which they mostly gained as adults) and don’t seem to have a big problem keeping it off. Unfortunately, they are only about a tenth of the folks in the NWCR, but nevertheless, good for them too! Like those in Cluster 1, they’ve achieved their ‘best weight’.

The people I do worry about, however, are the folks in Clusters 2 and 4. Together, they make up almost 40% of the maintainers, but are clearly struggling, using a lot of support, and have more mental or medical problems – these are the folks who, by definition, are now probably below their ‘best weight’.

But what else can we learn from these findings? Unfortunately, not much.

This is because the study largely tells us ‘what’ people are doing and not ‘why’ they do what they do.

So yes, some people who are healthy, exercise conscious, and generally happy can keep their weight off. But the question really is how or why they become exercise conscious and what exactly makes them happy. Only if I understand the answer to those two questions will I have found a strategy that may work for others – it is probably not simply enough to tell everyone to become exercise conscious and happy (and also, it helps if you happen to be healthy!).

Does it help me to know that even if you don’t exercise and happen to be depressed, you can still keep weight off, but you’ll require a lot of support and may end up quite stressed about it? Perhaps.

Or, if you’re older and have more health problems, your best bet is to simply eat fewer meals? (Now I worry)

While this information may be helpful in a conceptual sort of way, what is really lacking is any insight into the actual biology of what is going on.

Do successful weight maintainers have different genes, less leptin suppression, a less active hedonic system, a lesser starvation response, or simply a more active prefrontal cortex?

What I really want to know is how the biology and/or psychology of ‘maintainers’ differs from that of most people?

Or do they simply have more time on their hands and better support systems and biology doesn’t really matter?

As I’ve said before – studying the ‘whats’ is nice but what we really need to understand are the ‘whys’.

AMS
Edmonton, Alberta

Ogden LG, Stroebele N, Wyatt HR, Catenacci VA, Peters JC, Stuht J, Wing RR, & Hill JO (2012). Cluster analysis of the National Weight Control Registry to identify distinct subgroups maintaining successful weight loss. Obesity (Silver Spring, Md.) PMID: 22469954

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Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

SKIN PROBLEMS

Obesity is associated with a number of dermatoses. It affects cutaneous sensation, temperature regulation, foot shape, and vasculature.

Acanthosis nigricans is the most common dermatological manifestation of obesity and it appears as velvety, light brown-to-black markings usually on the neck, under the arms, or in the groin. Skin tags are more commonly associated with diabetes than with obesity, but may be an early clue to the presence of hyperinsulinemia.

Obesity increases the incidence of cutaneous infections such as candidiasis, intertrigo, candida folliculitis, furunculosis, erythrasma, tinea cruris, and folliculitis. Less common infections include cellulitis, necrotizing fasciitis, and gas gangrene.

Leg ulcerations, lymphedema, plantar hyperkeratosis, and striae are all more common with obesity.

Contrary to popular belief, cellulite is not related to obesity. It is part of normal female physiology and is present to some extent in over 95% of all adult women.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

NEUROLOGICAL ISSUES

Pseudotumour cerebri is a syndrome involving raised intracranial pressure without clinical, laboratory or radiological evidence of intracranial pathology. It is usually seen in young obese women. Long a relatively rare disease, incidence is growing rapidly along with increasing rates of obesity. The cause is unknown but it is thought to be related to increased intracranial pressure that produces symptoms such as headache, nausea, vomiting and pulsatile tinnitus. Permanent visual defects are serious and not infrequent complications. Weight loss can usually reverse symptoms of pseudotumour cerebri and prevent the onset of permanent complications. Fundoscopic examination of patients with pseudotumour cerebri may reveal what appears to be papilledema.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

ENDOCRINE SYSTEM

Although they are rare, we need to be careful not to miss endocrinal causes of obesity. These include hypothyroidism and Cushing’s syndrome (see page 32), as well as growth-hormone and testosterone deficiencies.

For some patients, knowing there is no endocrinal cause for their obesity can remove a psychological barrier to adopting a weight management effort.

While an increasing number of hormone-like substances released from various organs (leptin from adipose tissue, ghrelin from the stomach, PYY 3-36 from the colon) are recognized as playing an important role in the regulation of energy balance, diagnostic tests for disorders involving these novel hormones have not yet found their way into clinical practice, nor are there therapies available to address these specific contributors.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.