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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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Arguments For Calling Obesity A Disease #3: Once Established It Becomes A Lifelong Problem

Continuing in my miniseries on arguments that support calling obesity a disease, is the simple fact that, once established, it behaves like a chronic disease. Thus, once people have accumulated excess or abnormal adipose tissue that affects their health, there is no known way of reversing the process to the point that this condition would be considered “cured”. By “cured”, I mean that there is a treatment for obesity, which can be stopped without the problem reappearing. For e.g. we can cure an ear infection – a short course of antibiotics and the infection will resolve to perhaps never reappear. We can also cure many forms of cancer, where surgery or a bout of chemotherapy removes the tumour forever. Those conditions we can “cure” – obesity we cannot! For all practical purposes, obesity behaves exactly like every other chronic disease – yes, we can modify the course or even ameliorate the condition with the help of behavioural, medical or surgical treatments to the point that it may no longer pose a health threat, but it is at best in “remission” – when the treatment stops, the weight comes back – sometimes with a vengeance. And yes, behavioural treatments are treatments, because the behaviours we are talking about that lead to ‘remission’ are far more intense than the behaviours that non-obese people have to adopt to not gain weight in the first place. This is how I explained this to someone, who recently told me that about five years ago he had lost a substantial amount of weight (over 50 pounds) simply by watching what he eats and maintaining a regular exercise program. He argued that he had “conquered” his obesity and would now consider himself “cured”. I explained to him, that I would at best consider him in “remission”, because his biology is still that of someone living with obesity. And this is how I would prove my point. Imagine he and I tried to put on 50 pounds in the next 6 weeks – I would face a real upward battle and may not be able to put on that weight at all – he, in contrast, would have absolutely no problem putting the weight back on. In fact, if he were to simply live the way I do, eating the amount of food I do, those 50 lbs would be back before he knows it. His body is just waiting to… Read More »

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Is ADHD Sabotaging Your Weight Management Efforts?

Are you an impulsive eater? Do you have a hard time meal planning or keeping a food journal? Do you find it hard to remember if you had breakfast or not (never mind what you actually ate)? Do you start every new diet or exercise program with super enthusiasm, only to lose interest a few days later? Does your day lack a routine (for no good reason)? These are just some of the ways in which Attention Deficit Hypertactivity or just Attention Deficit Disorder (ADHD/ADD) can sabotage your efforts to control your weight. Now, an article by Philip Asherson and colleagues from Kings College London, UK, published in The Lancet Psychiatry discuss important conceptual issues regarding the diagnosis and management of ADHD/ADD in adults. Although ADHD/ADD is largely thought to be a problem in kids and youth, it remains a considerable and often undiagnosed issue in adults. Thus, as the authors point out, “…treatment of adult ADHD in Europe and many other regions of the world is not yet common practice, and diagnostic services are often unavailable or restricted to a few specialist centres.” This is all the more surprising (and disappointing) given that adult patients respond similarly to current drug and psychosocial interventions, with the same benefits seen in children and adolescents. With regard to diagnosis it is important to note that, “Symptoms of ADHD cluster together into two key dimensions of inattention and hyperactivity-impulsivity, are reliably measured, and are strong predictors of functional impairments, but they reflect continuous traits rather than a categorical disorder.” “Of particular relevance to adult ADHD is the relative persistence of inattention and improvements in hyperactive-impulsive symptoms during development, so that many patients who had the combined type presentation of ADHD as children present with predominantly inattentive symptoms as adults.”  “In clinical practice, the continuous nature of ADHD should not present diagnostic difficulties in moderate-to-severe cases, but might cause difficulties in mild cases with more subtle forms of impairment. Careful attention is needed to assess the effect of ADHD symptoms on impairment and quality of life, including an understanding of the broader range of problems linked to ADHD (eg, executive function [self-regulation] impairments, sleep problems, irritability, and internal restlessness), in addition to functional impairments such as traffic accidents and occupational underachievement. Therefore, some individuals, who seem to function well, might nevertheless suffer from a substantial mental health problem related to ADHD.” Key criteria according to… Read More »

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Treating Obesity Like A Chronic Disease Leads To Better Weight-Loss Maintenance

The nature of chronic diseases is that they are (by definition) rarely (if ever) “cured”, meaning that the best you can generally hope for is “control”, which in some cases may only amount to “stabilisation” or “slowing of progression”. In the context of obesity, one could perhaps define “control” as achievement AND maintenance of your “best weight”; “stabilisation” could be defined as prevention of further weight gain; “slowing of progression” would be defined as continuing to gain weight but at a slower rate than before. Now, a paper by Janelle Coughlin and colleagues published in OBESITY, shows (surprise, surprise!) that continued intervention involving personal contact leads to better weight-loss maintenance (at five years) than time-limited self-directed management. The paper describes the results of the the Weight Loss Maintenance (WLM) Trial, in which participants were essentially randomised to either a personal contact (PC) intervention or a self-directed (SD) group over 30 months with continued follow-up for another 30 months (for a total of 5 years). Overall, the WLM had 3 phases. Phase 1 was a 6-month weight loss program. In Phase 2, those who lost ≥4 kg were randomized to a 30-month maintenance trial. In Phase 3, PC participants (n = 196, three sites) were re-randomized to no further intervention (PC-Control) or continued intervention (PC-Active) for 30 more months; 218 SD participants were also followed. In the study overall at 5 years, mean weight change was −3.2 kg in those originally assigned to PC (PC-Combined) and −1.6 kg in SD (this rather modest amount of weight loss maintenance is unfortunately typical for all behavioural weight-management interventions, highlighting the ongoing need for better treatments!). None of this is surprising. As with any chronic disease, personal contact interventions by a trained health professional are likely to be superior to patients trying to manage on their own (self-directed). At some point (the time may well be 30 months), continued regular intervention for everyone will likely provide diminishing returns. This is evident from the finding in this study that in the PC group, continued intervention after 30 months did not appear to provide a significant additional benefit in terms of weight-loss maintenance. In fact, one would probably want to vary frequency and intensity of any further intervention for patients who are relapsing (i.e. regaining their weight faster than expected). This is not unlike patients in a diabetes or hypertension clinic. After an initial phase of a more intense intervention during which patients… Read More »

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Why There Is So Much Confusion About Obesity And Mortality

Any follower of media reports or even research papers on the relationship between obesity and mortality should be righty confused by now. Not only are there publications suggesting that the relationship between obesity and mortality isn’t that strong after all and that perhaps the BMI levels associated with the longest survival are somewhere around 30 (and not below 25) but then there is the issue of the obesity paradox, or the finding that among people with chronic (and some acute illnesses), a higher BMI is associated with better survival than being of “normal” weight. On the other hand, there is overwhelming evidence that higher BMI’s are associated with an increased risk of a wide range of health problems – from diabetes to cancer. This is not to say that everyone with a higher BMI is sick – they are not! But there is no doubt that the risk of illness does increase with higher BMIs. In our own study on the Edmonton Obesity Staging System (EOSS), which classifies individuals based on their actual health rather on their BMI, we found that while about 50% of individual in the BMI 25-30 range can be considered healthy (EOSS Stage 0 or 1), this number drops to below 15% for individuals in the BMI 40+ range. So, if obesity is such a risk factor for disease, why do epidemiological studies struggle to consistently show an effect of obesity on mortality? Now, a paper by Andrew Stokes and Samuel Preston, published in the Proceedings of the US National Academy of Science, suggests that it is not current weight (as used in many studies) but rather the highest lifetime weight that is most clearly associated with mortality. Their reasoning is as follows. “Intentional” weight loss in the population is rare (very few people in the general population ever consciously manage to lose a significant amount of weight and keep it off) In contrast, “unintentional” weight loss, when it occurs is generally a bad sign. Indeed, one of the best indicators of poor prognosis (for almost any health condition) is when someone loses weight. In many cases, this “spontaneous” weight loss can precede overt illness or death by many years. Thus, the authors argue that most of the literature on this issue is simply confounded by the confusion caused by all the people who have unintentionally lost weight due to an underlying health problem (diagnosed or undiagnosed). As these people would… Read More »

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