Wednesday, January 21, 2015

Activity Trumps Weight Loss For Health?

Despite the sharma-obesity-exercise2The fact that it is better to be fit and fat than skinny and unfit is not new – indeed, I would regard the evidence on this as pretty conclusive.

Nevertheless, for those, who still harbour any remaining doubts, the study by Ulf Ekelund on behalf of the EPIC Investigators, recently published in the American Journal of Clinical Nutrition should drive this message home.

This analysis looks at the relationship between physical activity and all-cause mortality in 334,161 European men and women followed for about 12.4 y (corresponding to 4,154,915 person-years).

No matter how the researchers looked at the data, activity levels appeared a better predictor of mortality than BMI or waist circumference.

Thus the authors calculated that while avoiding all inactivity would theoretcally reduce all-cause mortality by 7.35%, trying to maintain a “normal weight” (or rather a BMI less than 30) would reduce mortality by only 3.66% (although avoiding obesity AND inactivity did have the greatest effect).

Despite the limitations of these type of cross-sectional analyses, which as a rule, tend to overestimate the potential benefits of an actual intervention, the message is clear – it appears that even small increases in physical activity in inactive individuals can have substantially greater benefits to health than obsessing about losing a few pounds.

This is indeed useful information, as we have long known that increasing physical activity in most cases does surprisingly little in terms of weight loss but rather a lot in terms of increasing health and fitness.

So do not despair if the hours your patients are putting in at the gym are not changing those numbers on the scale – the health benefits are still worth the effort.

@DrSharma
Reykjavik, Iceland

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Monday, January 19, 2015

Sleep Apnea And Quality Of Life In Iceland

Laugarvatn Fontana Geothermal Baths, Iceland

Laugarvatn Fontana Geothermal Baths, Iceland

This week, I am in Reykjavik on behalf of the Icelandic Medical Association to speak at their 2015 Annual Conference.

Despite its proverbial rugged outdoorsy lifestyle with ample time spent in natural hot spring spas and saunas (both of which I enjoyed yesterday, thanks to my excellent hosts), Iceland has a significant obesity problem of its own – reason enough for this problem to be taken seriously (I will be meeting with the Icelandic health minister and his staff to discuss this issue later this week).

There is indeed a small but active obesity research community in Iceland with growing experience in the management of this disease.

One important contribution, for e.g. is the recent paper by Erla Bjornsdottir and colleagues from the University of Iceland, published in the Journal of Sleep Research, that examines the impact of two years of treatment vs. non treatment of moderate to severe obstructive sleep apnea (OSA) on quality of life in over 800 overweight or obese individuals newly diagnosed with this condition.

The comparator group consisted of 750 randomly selected Icelanders. The researchers also compared users and non-users of CPAP treatment within the individuals diagnosed with sleep apnea.

Overall, as one might expect, the quality of life (measured by the SF-12 questionnaire) of untreated individuals with OSA was markedly worse that of the general population, even when matched for age, body mass index, gender, smoking, diabetes, hypertension and cardiovascular disease.

Surprisingly, however, despite a positive trend towards improvement in physical quality of life from baseline to follow-up in users and the most obese individuals, there were no significant overall differences between full and non-users.

This is particularly surprising as I have often seen dramatic changes in the quality of life and general well-being in patients with OSA, who started on CPAP treatment in my practice (but I guess anecdotes are always tempered by averages).

Based on their findings, the researchers conclude that the co-morbidities of obstructive sleep apnea, such as obesity, insomnia and daytime sleepiness (often not fully controlled by CPAP), appear to have a substantial effect on life qualities and may need to be taken into account and addressed with additional interventions.

The message here, I believe, is that despite its effectiveness for better control of breathing, simply putting patients on CPAP and hoping for the best may not be quite enough to improve the substantially reduced quality of life associated with this disorder.

@DrSharma
Reykjavik, Iceland

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Friday, January 16, 2015

The Physiological Benefits Of Laughter

theater_masksAs regular readers are well aware, over the past year, I have been exploring the use of stand-up comedy in communicating about the science of obesity to anyone who cares to listen.

While preparing for this new venture included working with professional comedians, taking improv classes, and, yes, impromptu appearances at local “open-stages”, I have also delved into the (sometimes rather serious) literature on the science of comedy and laughter.

Indeed, as one may suspect, there is indeed a rather large and growing body of scientific literature on humor, comedy and laughter – including its physiological and psychological effects, its therapeutic use (in everything from depression and chronic pain to cancer and obesity), and as a communication tool for health professionals.

Anyone interested in this topic, may wish to refer to a recent article by Dexter Louie and colleagues from the University of California, Harvard Medical School and the Joslin Diabetes Centre on laughter as a tool for lifestyle medicine that recently appeared in the American Journal of Lifestyle Medicine (btw – a term that I really don’t like).

The article begins with a brief discussion of the three preeminent theories (out of over 100 competing ideas) of why we laugh, which are summarized as follows (the examples are mine):

1. Release theory, which argues that laughter is the physical manifestation of repressed desires and motivations (which explains potty jokes).

2. Superiority theory, which posits that laughter is a means of increasing one’s self-esteem at the expense of others (which is probably why most people laugh at fat jokes).

3. Incongruity theory, which states that humor is created by a sense of incongruity between two or more objects within a joke (e.g. an obesity doctor making jokes about obesity doctors).

The article then goes on to briefly review the physiological effects of laughter, whereby it makes a clear distinction between spontaneous and and self-induced laughter:

“The former refers to “genuine” or unforced laughter, often in response to a stimulus, whereas the latter describes laughter that is simulated de novo. Spontaneous laughter is often associated with positive mood, whereas simulated laughter is primarily physical and is not necessarily associated with positive emotions or feelings. Neuroimaging suggests that different neural pathways are used in these 2 forms of laughter.”

The researchers review a range of studies documenting the positive effects of spontaneous laughter on stress hormones, endorphins, immune response, pain tolerance, anxiety as well as studies showing that the cardiovascular response to a good laugh are virtually identical to those elicited by a bout of physical exercise (exercise physiologists take note!).

Despite these promising findings, the authors are also quick to point out that,

“There is great potential for future research in laughter. Randomized controlled large-scale trials are needed to further elucidate the physiologic effects of laughter.”

In the second part of the article, the authors discuss whether or not physicians should use humor as a tool to induce therapeutic laughter?

“Of course, health is a serious and often grave matter, and humor delivered at inappropriate times can be devastating, insensitive, and crass……Within the bounds of appropriateness, however, both humor and laughter can be beneficial. For one, laughter shared between the provider and patient conveys a measure of trust and light-heartedness. Furthermore, humor can improve communication, as a joke can signal a transition in the conversation from the serious to more benign topics.”

The authors even have suggestions on how to address the issue of laughter in clinical practice:

“Providers can ask, “What has made you laugh recently?” or “How often do you laugh?” Inquiring about laughter opens the door to light heartedness and also could lead to counseling on laughter and sharing the latest research with the patient. More important, it allows the provider to determine what the patient finds funny, thereby allowing the provider to tailor recommendations to better fit the patient’s needs and preferences. This also contains the potential to deepen the therapeutic relationship between patient and provider. Put together with a more structured approach, the health care provider could consider prescribing laughter to patients.”

And here is what a laughter prescription could look like (directly borrowed from exercise prescriptions):

(F) Frequency: once a week
(I) Intensity: belly laughing
(T) Time: 30 minutes

(T) Type: your favorite sit-com

While much remains to be studied in terms of the therapeutic use of laughter (e.g. spontaneous vs. self-induced, individual vs. group laughter, dose-response relationships, laughter yoga, etc.), as the authors point out, there is an increasing body of evidence pointing to potential benefits for health and well-being.

Or, as the authors put it,

“With no downsides, side-effects, or risks, perhaps it is time to consider laughter seriously.”

@DrSharma
Edmonton, AB

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Wednesday, November 12, 2014

5As of Obesity Management in Primary Care

sharma-obesity-5as-booklet-coverThis week I am again touring Ontario to train health professionals in the 5As of Obesity Management (Kingston, Ottawa, St. Catherines).

It is heartening to see the tremendous interest in this topic and how the message about obesity as a chronic disease resonates with health practitioners, few of who have any prior training in obesity management.

It is particularly rewarding to see how well the Canadian Obesity Network’s 5As of Obesity Management framework is received and embraced by those working in the front lines of primary care, as this is exactly the audience for which this framework is intended.

Regular readers may recall that the 5As of Obesity Management framework was developed by the Canadian Obesity Network in an elaborate undertaking involving scores of primary care providers, experts and patients from across Canada. The tools were modelled using the latest in health information design technology and extensively field tested to ensure their applicability and adaptability to primary care practice.

Rather than overloading the tools with intricate algorithms, we opted for a rather general but insightful set of principles and recommendations designed to facilitate professional interactions that seek to identify and address the key drivers and consequence of weight gain as well as help tackle the key barriers to weight management.

Indeed, the 5As of Obesity Management are steeped in a deep understanding of the complex multi-factorial nature of obesity as a chronic (often progressive) disease for which we simply have no cure.

The framework recognizes that health cannot be measured on a scale, BMI is a poor measure of health and that obesity management should be aimed at improving the overall health and well being of those living with obesity rather than simply moving numbers on the scale.

Research on the use of the 5As in primary practice has already shown significant improvements in the likelihood of obesity being addressed in primary practice.

A large prospective randomized trial on the implementation of the 5As of Obesity Management framework in primary care (the 5AsT trial) is currently underway with early results showing promising results.

I, for one, will continue promoting this framework as the basis for obesity counselling and management in primary care – at least until someone comes up with something that is distinctly better.

If you have experience with this approach or have attended one of the many education sessions on the 5As of Obesity Management offered by the Canadian Obesity Network, I’d certainly like to hear about it.

To view an introductory video on the 5As of Obesity Management click here

@DrSharma
Ottawa, ON

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Tuesday, October 28, 2014

Should A Political Prescription For Obesity Not Also Include Better Treatments?

sharma-obesity-policy1In the latest issue of the Canadian Medical Association Journal, the editors opine on the need for a political prescription for obesity – in short taxation and regulation of  high-calorie and nutrient-poor food products as the only viable approach to the obesity epidemic. As may be expected, they use the analogy of tobacco as a justification for this approach (given that actual data from government intervention on reducing the consumption of the said foods is so far lacking).

Be that as it may, what caught my attention in the article was the following passage:

“Treating obesity does not work well; preventing it would be better. The global failure to manage obesity, now considered by the American Medical Association to be a disease, may be considered a failure of the evidence-based medicine approach to treating disease….We know that most restrictive diets result in only short-term weight loss that frequently reverses and worsens in the long term, but dietary changes that are sustainable as a lifestyle choice may work. Physical activity is not enough to prevent or treat obesity and overweight, unless it is combined with some kind of dietary intervention. Family and community interventions may work somewhat better than interventions aimed at individuals, but their implementation is patchy. Bariatric surgery has good results in the treatment of morbid obesity, but its use is always going to be limited and a last resort. Pharmaceutical agents may work to some extent, but may have nasty adverse effects.”

The interesting thought here is that the authors parade the lack of effective treatment as a justification for prevention, when I would rather have used this state of affairs to call for greater investments in finding better treatments.

Not that I am not in favour of prevention – indeed, I am all for preventing heart disease, diabetes, cancer, depression, bone and joint disease and everything else.

But, at no point would I ever call for prevention as an alternative to finding better treatments for any of these conditions.

The fact that people still die of cancer should never justify us abandoning the search for better treatments – indeed, as far I can see, the whole Pink Ribbon Industry apparently focusses on “finding the cure” – not on “finding better ways to prevent breast cancer” (even if most experts believe that much of breast cancer is indeed preventable).

Just because  we still have no effective treatments for a host of other conditions, should we abandon the search for better treatments for these conditions?

In short, what irks me most about this article is not the call for prevention – indeed I am all for it!

But when the lack of effective (or safe) treatments is used to justify this call, I must disagree.

No matter how much we restrict and tax the food industry, there will always be people around, who despite their best efforts, will struggle with excess weight. Indeed, there is no reason to believe (at least not for anyone who understands the physiology of obesity) that any form of “prevention” will reverse the epidemic in those who already have the problem – i.e. in about 6 Mill Canadians. (even if we somehow miraculously reduced obesity in the population by 30% through “preventive measures” (well beyond even the most optimistic predictions) – we would still need treatments for 4 Mill Canadians – adults and kids!)

The longer we wait to find and implement effective treatments, the longer these individuals will struggle with a condition that should deserve the same efforts at treatment as we afford individuals with other “lifestyle” diseases (including heart disease, diabetes and cancer).

Let us not forget that treatments for other common conditions (e.g. hypertension, hypercholesterolemia and diabetes) were once lacking – today millions around the world benefit from these treatments – indeed, it is probably safe to say that these medications probably save more lives each year than any known efforts at regulating industry that I know of.

Indeed, if we wish to find more effective ways to manage obesity, we need to vastly increase our efforts at finding better treatments – not abandon them.

Prevention is never an alternative to also having effective treatments. The two go hand-in-hand.

@DrSharma
Edmonton, AB

 

 

 

 

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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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