Monday, September 29, 2014

Does Lean Tissue Have More To Say About Your Health Than Your Body Fat?

Carla Prado, PhD,  Assistant Professor and CAIP Chair in Nutrition, Food and Health, University of Alberta, Edmonton, Canada

Carla Prado, PhD, Assistant Professor and CAIP Chair in Nutrition, Food and Health, University of Alberta, Edmonton, Canada

The common assumption is that people with more body fat are at greater risk for illness and overall mortality.

Surprisingly, an increasingly robust body of evidence now suggests that how much lean tissue you have may be far more important for your health than the amount of body fat.

This evidence as well as the methodologies used to study lean body mass are discusses in a paper by Carla Prado (University of Alberta) and Steve Heymsfield (Pennington Biomedical Research Center), in a paper published in the Journal of Parenteral and Enteral Nutrition.

As the authors point out,

“The emerging use of imaging techniques such as dual energy x-ray absorptiometry, computerized tomography, magnetic resonance imaging, and ultrasound imaging in the clinical setting have highlighted the importance of lean soft tissue (LST) as an independent predictor of morbidity and mortality.

The paper discusses in depth the advantages and limitation of the many methods that can be used to assess body composition in research and clinical settings.

The paper also discusses the current definition and importance of sarcopenic obesity and notes that,

“The identification of different body composition phenotypes suggests that individuals have different metabolism and hence utilization of fuel sources.”

Thus,

“It is clear from emerging studies that body composition health will be vital in treatment decisions, prognostic outcomes, and quality of life in several nonclinical and clinical states.”

My guess is that it will not just be the absolute or relative amount of lean tissue mass that is important. Rather, similar to the increasingly recognised role of differences amongst fat depots, I would assume that different lean soft tissue depots may well play different roles in metabolic health.

@DrSharma
Charlottetown, PEI

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Wednesday, September 24, 2014

Obesity Tip Sheet For Physiotherapists

PT Tip Sheet Octb2013

Many people living with obesity experience significant physical limitations that can be addressed with appropriate physical therapeutic approaches.

Now, the Bariatric Resource Team of Alberta Health Services has compiled a “Tip Sheet that briefly highlights the role of physiotherapeutic interventions in the care of people with obesity.

The sheet includes recommendations on the following topics:

- Challenges With Movement, Pain or Daily Function

- Obesity Related Co-morbidities that Affect Daily Function

- Energy Management

- Posture and Positioning Issues

- Activity Counselling Needs

- Equipment Issues

- Access to Community Resources

This “Tip Sheet” should be helpful to anyone involved in the care of bariatric patients.

@DrSharma
Winnipeg. MB

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Friday, September 19, 2014

Does Mandatory Weight Loss Before Surgery Harm Patients?

weight scale helpMany surgical clinics require “mandatory” weight loss before approving patients for surgery, a requirement for which there is very little evidence that it influences post-surgical outcomes (despite the rather firm belief of many that it does).

While one may perhaps accept the need for pre-surgical weight loss when the primary objective is to make the surgery easier for the surgeon and safer for the patient, of greater concern is the practice in many centres that require “mandatory” weight loss based on the notion that patients need to demonstrate their “suitability” for surgery by achieving an arbitrary amount of weight loss in order to “qualify” and prove themselves “fit” for surgery.

That this latter requirement is not without actual risk for the patient and can lead to significant frustration and disruption of the patient-provider relationship is described in a phenomological study by Nicole Glenn and colleagues, published in Qualitative Health Research.

The study is based on in-depth interviews with seven candidates considering bariatric surgery and describes their lived experience and views about what the requirement to lose weight in oder to obtain surgery meant for them.

The article begins with a touching account of one patient:

“The surgeon says, “We need you to get your weight down a little more before we can approve you for surgery.” I fight back the tears as I drive home. Then I think, “I have to do this. I need this surgery.” I work my ass off; I eat nothing but salad for three weeks while I prepare real food for the rest of my family. I go to the gym late at night and settle for five hours sleep because there is no other time in my day with two small children to care for and a husband who works long hours. I struggle, but I’ll do whatever I have to. I come back for my next visit with the surgeon, and I’ve lost more than he had asked me to, yet he doesn’t even notice. He doesn’t comment on my weight at all! He says, “You’ll hear from my office with a surgical date.” That’s it?”

The paper focusses on four themes that emerge from the narratives.

1. Nod your head and carry on:

“[I know a few people who’ve had the surgery, and they all tell me that same thing—just do what you are told! I ran into a friend who had the surgery and was telling him about my frustrations. He said, “If the clinic staff want you to lose five pounds then you need to get the five pounds off and don’t put your personal opinion in there. Just nod your head and carry on.”]“

This behaviour, while understandable, can have unintended consequences for the patient-client relationship:

“To become perfect, to appear to be the ideal patient, a person might find it necessary to act the part. Is it possible to show who one really is when it is the ideal patient who needs to be seen? A person who waits to have bariatric surgery, who feels the need to prove him- or herself to access the surgery, might also find it necessary to hide or become secretive, to leave things out of the food journal or the stories told.”

“Imagine if one awaiting a hip replacement, for example, was first obligated to walk without pain? Why then would one be required to lose weight before weight loss surgery—to do the very thing the surgery provides? To get help, a person must reveal her struggle to the nurse, to name it, and in so doing to show herself as a failure. Such a person finds that she has no other choice. Alone, she cannot lose the weight, and without weight loss, the surgery will not happen. Nevertheless, in revealing this struggle, she risks losing the very thing she hopes to gain.”

2. Waiting and Weighing: Promoting Weight Consciousness to the Weight Conscious:

This section deals with the negative impact that this practice has by reinforcing focus and obsession with numbers on the scale when the real focus should be on health behaviours.

3. Paying For Surgical Approval Through Weight Loss:

“[I feel as if the surgery is being held for ransom, and if I don’t behave perfectly, I won’t get a chance. I mean, I see them obsessing over my charts and journal. No one even tries talking to me. The nurse and psychologist tell me, “No black or white thinking,” but here they are practicing exactly that!]“

“The irony of the perfect behavior required to lose weight and ultimately access weight-loss surgery amid suggestions to reject black and white thinking is not lost on the woman who waits. She should resist the urge to see the world as all or nothing, either this or that, and instead accept the complexities of the grey that exists in the world between black and white, yet she knows that she either loses weight or she loses surgery. It is black or white.”

4. Presurgical Weight Loss and Questioning the Need for Weight-Loss Surgery Altogether:

This section addresses the issue that patients, who do manage to lose substantial weight before surgery, may be faced with having to reconsider the need for surgery altogether thereby increasing internal conflict and enhancing uncertainty as to whether they have made the right decision to have surgery in the first place.

This is clearly a paper that all practitioners in bariatric clinics should read and be aware of.

As the authors point out, given the lack of good evidence that presurgical weight loss has any relevant impact on surgical or post-surgical outcomes, it may be high time to reconsider this potentially harmful practice.

@DrSharma
Edmonton, AB

ResearchBlogging.orgGlenn NM, Raine KD, & Spence JC (2014). Mandatory Weight Loss During the Wait For Bariatric Surgery. Qualitative health research PMID: 25185162

 

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Thursday, September 18, 2014

Efficacy of Vagal Blockade For Obesity Treatment Remains Vague

VBLOC

VBLOC

Regular readers may recall past posts on the use of intermittent electrical blockade of the vagus nerves (VBLOC) as a means of reducing food intake to promote weight loss.

Now a large randomised controlled study of vagal blocakade, published by Sayeed Ikramuddin and colleagues, published in JAMA, reports on rather disappointing outcomes with this treatment.

In this study (ReCharge), conducted  at one of 10 sites in the United States and Australia between May and December 2011, 239 participants with a BMI greater than 40 (or greater than 35 with at least one comorbidity), were randomised to receiving an active vagal nerve block device (EnteroMedics’ Maestro® Rechargeable (RC) System, n=162) or a sham device (n=77).

Over the 12-month blinded portion of the 5-year study (completed in January 2013), the vagal nerve block group lost about 9% or their initial body weight compared to only 6% in the sham group.

In addition to this rather modest difference in weight loss between the groups (about 3%), participants in the active treatment group also experienced a number of clinically relevant adverse effects (heartburn or dyspepsia and abdominal pain).

Thus, overall these rather disappointing results are in line with the previously disappointing observations in the smaller MAESTRO trial.

Based on these findings, it seems that intermittent electrical blockade of the vagal nerve may not hold its promise of a safe and effective long-term treatment for severe obesity after all.

@DrSharma
Edmonton, AB

ResearchBlogging.orgIkramuddin S, Blackstone RP, Brancatisano A, Toouli J, Shah SN, Wolfe BM, Fujioka K, Maher JW, Swain J, Que FG, Morton JM, Leslie DB, Brancatisano R, Kow L, O’Rourke RW, Deveney C, Takata M, Miller CJ, Knudson MB, Tweden KS, Shikora SA, Sarr MG, & Billington CJ (2014). Effect of reversible intermittent intra-abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial. JAMA, 312 (9), 915-22 PMID: 25182100

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Monday, September 15, 2014

Update on New Medications for Obesity

sharma-obesity-fda4Last week, while I was off on a brief holiday, two important events took place in the US with regard to obesity medications.

On September 10, the US-FDA granted approval for Contrave, a fixed combination of bupropion and naltrexone, two centrally active compounds, also used in the treatment of addictions.

Then, on September 11, an advisory panel appointed by the FDA, voted strongly in favour of approving the GLP-1 agonist liraglutide at the 3.mg dose for the treatment of obesity.

These two new entities would bring the currently approved prescription medications for the treatment of obesity in the US to six – a dramatic change from just a couple of years ago.

This is still a long shot away from the many effective treatments we have for treating other common conditions (e.g. there are more than 20 prescription medications approved for treating diabetes and almost 100 compounds for the treatment of hypertension).

Why would we need this many different medications for obesity? For the simple reason that not everyone will respond favourably or tolerate all of these compounds.

Given that obesity is a remarkably heterogeneous disorder and that these drugs have distinctly different modes of action, I would not expect all of these medications to work in all individuals.

It is also important to note that all of these drugs work best when combined with intense behaviour modification – no pill will ever serve as a substitute for a healthy diet and a daily dose of moderate to vigorous physical activity. But we also know that the latter alone, will rarely produce sustainable weight loss in the long-term.

Obviously, given the chronic nature of obesity, medications for obesity will need to be used long-term in the same manner that we use medications to treat other chronic conditions (e.g. diabetes, hypertension, etc.).

This means that we will need more long-term data on the efficacy and safety of these compounds.

Nevertheless, there is reason to hope that for many people with obesity related health problems, these new obesity medications will provide much-needed therapeutic options.

@DrSharma
Vienna, Austria

Disclaimer: I have served as a paid consultant and/or speaker for the makers of Contrave and liraglutide.

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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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