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Arguments Against Obesity As A Disease #3: Obesity Is Modifiable And Preventable

Continuing in my mini series on arguments that I often hear against considering obesity a chronic disease, I turn to another common argument, “Obesity cannot be a disease because it is preventable and modifiable.” That may well be the case (although, we must admit that we are doing a remarkably poor job of either preventing or modifying it), but so what? There are 100s of diseases that are both preventable and modifiable – and yet no one would argue that they should not be considered diseases. In fact, virtually all “lifestyle” diseases (by definition) are preventable and modifiable. Take for instance strokes and heart disease – most strokes and the vast majority of heart attacks are both preventable and modifiable (once they occur). So are diabetes, osteoarthritis, obstructive lung disease and many forms of cancer, not to mention the many infectious diseases that are both preventable and modifiable. There are even a number of in-born genetic diseases that may be preventable or modifiable (e.g. phenylketonuria). Thus, the fact that a disease can be prevented or modified (once it occurs) says nothing about whether something qualifies as a disease or not. That said, as recently pointed out by Ted Kyle, for all practical purposes, obesity is proving pretty hard to modify and even harder to prevent in real life. It may therefore be more accurate (and honest) to say that obesity is “theoretically” preventable and modifiable – while we await large-scale real-life examples demonstrating that this is in fact the case, and not just limited to relatively rare exceptions like the 1990’s catastrophic economic crisis in Cuba. Let’s remind ourselves that there is a vast difference between “efficacy” and “effectiveness” of proposed measures to “prevent” and “modify” obesity. But even if we did have ample proof that obesity can indeed be prevented or modified by most people, it still says nothing that would speak against recognising excess or abnormal body fat that affects your health as a disease. @DrSharma Berlin, Germany  

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Guest Post: Complications of Cardiac Surgery in Severe Obesity

Today’s guest post comes from Tasuku Terada, a postdoctoral research fellow with the Bariatric Care and Rehabilitation Research Group (BCRRG), a multidisciplinary research collaboration, focused on improving the care and rehabilitation outcomes of patients with obesity. Dr. Terada is an Exercise Physiologist and 2015 Canadian Obesity Network, Obesity Research Bootcamp alumni. His research interests include the role of exercise in counteracting chronic health conditions associated with obesity. Obesity is a risk factor for cardiovascular disease, and referrals for coronary artery bypass graft surgery (CABG) have increased in patients with severe obesity (body mass index: BMI ≥40 kg/m2). In our recent study published in the Journal of American Heart Association, using data from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, we show that patients with severe obesity were 53% more likely to have complications within 30 days of surgery and had three­fold higher risk of infection compared to patients without obesity. In addition, the median hospital stay was one day longer in patients with severe obesity compared to patients without obesity. In patients with severe obesity, those who had diabetes and experienced infection stayed 3.2 times longer days in hospital compared to patients without either condition. Taken together, these results highlight a need for attentive care in bypass patients with severe obesity. Strategies to minimize the risks of infection and efforts to ensure good glucose control for patients with diabetes may also be important for better patient care quality and to reduce the length of hospital stay. This type of information should be useful to caregivers and lead to prevention or preparation for possible adverse outcomes. This study was supported by a Partnerships for Research and Innovation in the Health System (PRIHS) award from Alberta Innovates – Health Solutions (AIHS). Tasuku Terada Edmonton, AB

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Are We Seeing An Upward Shift In Healthy Weights?

I don’t like the term “healthy” weights, because we have long learnt that good health is possible across a wide range of shapes and sizes. Nevertheless, epidemiologists (and folks in health promotion) appear to like the notion that there is such a weight (at least at the population level), and often define it as the weight (or rather BMI level) where people have the longest life-expectancy. Readers of this literature may have noticed that the BMI level associated with the lowest mortality has been creeping up. Case in point, a new study by Shoaib Afzal and colleagues from Denmark, published in JAMA, that looks at the relationship between BMI and mortality in three distinct populations based cohorts. The cohorts are from the same general population enrolled at different times: the Copenhagen City Heart Study in 1976-1978 (n = 13 704) and 1991-1994 (n = 9482) and the Copenhagen General Population Study in 2003-2013 (n = 97 362). All participants were followed up to November 2014, emigration, or death, whichever came first. The key finding of this study is that over the various studies, there was a 3.3 unit increase in BMI associated with the lowest mortality when comparing the 1976-1978 cohort with that recruited in 2003-2013. Thus, The BMI value that was associated with the lowest all-cause mortality was 23.7 in the 1976-1978 cohort, 24.6 in the 1991-1994 cohort, and 27.0 in the 2003-2013 cohort. Similarly, the corresponding BMI estimates for cardiovascular mortality were 23.2, 24.0, and 26.4, respectively, and for other mortality, 24.1, 26.8, and 27.8, respectively. At a population level, these shifts are anything but spectacular! After all, a 3.3 unit increase in BMI for someone who is 5’7″ (1.7 m) is just over 20 lbs (~10 Kg). In plain language, this means that to have the same life expectancy today, of someone back in the late 70s, you’d actually have to be about 20 lbs heavier. While I am sure that these data will be welcomed by those who would argue that the whole obesity epidemic thing is overrated, I think that the data are indeed interesting for another reason. Namely, they should prompt speculation about why heavier people are living longer today than before. There are two general possible explanations for this: For one these changes may be the result of a general improvement in health status of Danes related to decreased smoking, increased physical activity or changes in social determinants of health (e.g.… Read More »

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Weight Loss With Liraglutide Improves Sleep Apnea

The GLP-1 analogue liraglutide (Saxenda), recently launched in North America for the treatment of obesity, has now also been shown to improve symptoms (apnea-hypopnea index – AHI) of obstructive sleep apnea (OSA). This, according to a paper by Blackman and colleagues published in the International Journal of Obesity. This 32-week randomized, double-blind trial was conducted in about 360 non-diabetic participants with obesity who had moderate (AHI 15-29.9 events/h) or severe (AHI ⩾30 events/h) OSA and were unwilling/unable to use continuous positive airway pressure therapy (CPAP). After 32 weeks, the mean reduction in AHI was greater with liraglutide (3.0 mg) than with placebo (-12.2 vs -6.1 events/h). This improvement in sleep apnea was largely explained by the greater mean percentage weight loss compared with placebo (-5.7 vs -1.6%). Additional findings included a greater reductions in HbA1c and systolic blood pressure in the participants treated with liraglutide versus placebo. Liraglutide was generally well tolerated with no unexpected adverse effects. Thus, it appears that in addition to weight loss, treatment with liraglutide 3.0 mg results in clinically meaningful improvements in the severity of obstructive sleep apnea, an important issue that affects both the cardiometabolic risk and quality of life of so many individuals living with obesity. @DrSharma Copenhage, DK Disclaimer: I have received honoraria as a consultant and speaker for Novo Nordisk, the maker of liraglutide

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Overview of Obesity Management in Primary Care

Given the vast number of individuals who could potentially benefit from effective long-term obesity management, there is no option but to manage most of this problem in primary care settings. While this approach can be highly effective, it does require training, resources and ongoing (lifelong?) interventions (not unlike most other chronic diseases). Now a rather comprehensive paper by Soleyman and colleagues from the University of Birmingham, Alabama, published in Obesity Reviews provides an overview of obesity management in primary care. As readers are well aware, our body weight are tightly regulated by a complex neuroendocrine system and defends us agains weight loss through a multi-faceted physiological response to prevent further weight loss and restore body weight. As the authors note, “To maintain weightloss, individuals must adhere to behaviours that oppose these physiological adaptations and the other factorsfavouring weight regain. However, it is difficult for peoplewith obesity to overcome physiology with behaviour over the long term. Common reasons for weight regain include decreased caloric expenditure, decreased self-weighing frequency, increased caloric intake, increased fat intake and eating disinhibition over time.” The paper provides a succinct overview of the evidence supporting behavioural, medical and surgical obesity treatments. It also reiterates the basic principles of obesity management as outlined in the various guidelines: 1. Obesity is a chronic disease that requires long-term management. It is important to approach patients with information regarding the health implications. 2. The goal of obesity treatment is to improve the health of the patient, and it is not intended for cosmetic purposes. 3. The cornerstone of therapy is comprehensive lifestyle intervention from informed PCPs or other healthcare professionals. 4. The initial goal of therapy is a weight loss of 5–10% in most patients, as this is sufficient to ameliorate many weight-related complications. However, weight loss of ≥10% may be needed to improve certain weight-related complications, such as obstructive sleep apnoea. 5. Consideration should be given to the use of a weight-loss medication or possible bariatric surgery, as the addition of these treatment modalities to lifestyle therapy can promote greater weight loss and maintain the weight loss for a longer period of time. 6. It is important for clinicians to evaluate the patient for weight-related complications, that can be improved by weight loss, and to consider such patients for more aggressive treatment. These recommendations (with minor variations) are also very much in line with the 5As of Obesity Management framework… Read More »

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