Wednesday, April 16, 2014

Shame And Blame Has No Role In Addressing Obesity

Balancing the scales Kirk et alAs a regular reader you will be well aware of my recent excursions into the use of comedy to promote a better public understanding of obesity.

A very different (and I dare say more scientific) approach to harnessing the performing arts to promote a discourse on obesity is that taken by Sara Kirk and colleagues, Balancing The Scales, now described in a paper published in Qualitative Health Research.

Their approach is based on the recognition that,

“…individuals living with obesity are caught in the middle, facing judgment by society if they fail to manage their weight successfully and exposing themselves to health professionals who are unable to fully support them…if an individual is unable to make the changes prescribed for weight loss, resentment builds on both sides of the therapeutic relationship.”

This led Kirk and colleagues to extensively explore the issue of obesity from a variety of perspectives resulting in rather unique insights into similarities, differences, points of consensus, and tension associated with values, beliefs, perceptions, and practices among key stakeholders.

The 42 semistructured interviews were conducted in 22 individuals living with obesity, 4 policy makers, and 16 health professionals (8 dietitians, 4 family physicians, and 4 nurses).

Three major themes emerged from the analysis of the interviews:

Blame as a Devastating Relation of Power

“Individuals living with obesity shared feelings of shame and embarrassment with their inability to control their weight on their own. This blaming discourse can easily be seen in messages of “eat less, move more” promoted by health professionals, the health system, and wider society.”

“Individuals living with obesity spoke about the complexities of trying to lose weight, inclusive of cultural, social, and organizational barriers. Despite this insight, however, they placed the final explanation for their weight status on themselves and expressed immense feelings of guilt and shame.”

“All of the individuals living with obesity had tried multiple methods to manage their weight, with limited or no success. This was extremely frustrating for them and compounded their tendency, wholly or at least partially, to blame themselves for this perceived failure.”

“Similar to individuals living with obesity, health professionals struggled to understand the complexity of the issue, which often led to blaming the individual. Health professionals commented on the unrealistic expectations of people who wanted to lose weight quickly and how their role as a health professional could not possibly be supportive of this.”

“The health professionals we interviewed also blamed themselves for not having the answers, and described feeling ill-equipped to assist individuals to make successful changes.”

Tensions in Obesity Management and Prevention

“Both the individuals living with obesity and the health professionals did not feel supported by the health care system. Health professionals [and policy makers] also struggled to know how to approach the issue.”

“Individuals living with obesity also experienced exclusion when attempting to find appropriate support within the health care system. Most individuals in the study began to access this system when they believed they could no longer manage their weight by themselves.”

The Prevailing Medical Management Discourse

“Health professionals experienced many frustrations and contradictions in their experiences with obesity management, and at times questioned the notion of obesity as a disease. Being obese was often in itself not enough to receive health care. Health professionals in this study found it easier to work with individuals living with obesity when they also had another diagnosed chronic condition, such as diabetes or cardiovascular disease. They could then more confidently prescribe a specific treatment regime.”

As for policy makers,

“[One] policy maker questioned whether medical treatment for individuals living with obesity is necessary…. As an alternative to medicalizing obesity, the policy maker suggested addressing the issue of population health and using health promotion to support the majority of people who are not morbidly obese but are still struggling with weight problems.”

“Overall, individuals living with obesity sought validation for requiring support in a system that currently does not provide the support they need.”

Based on these findings, the authors note that,

“…our findings highlight the need to reframe the public debate on obesity. However, we suggest that rather than choosing one discourse over another (management vs. prevention; system vs. individual), we should engage aspects of both. This requires not only consideration of socioecological perspectives, but also a greater awareness among health professionals of the need to offer support, not advice.”

“Furthermore, relationships between patients and health care providers should be supportive (not blaming), recognizing the widespread prevalence of weight bias in society and working hard to challenge the stereotypes that dominate the discourse on body weight”

“It was also evident in the language and experiences provided by health care providers that training, resources, and support for weight management were a substantive part neither of their professional training nor of the health care system.”

To facilitate improved training of health professionals, the authors have developed the rich narratives obtained in this study into a dramatic presentation, depicting the relationship between a health professional and an individual living with obesity.

This narrative can be viewed here.

For interviews with the researchers – click here.

Clearly, it is work like this that is essential to understanding the current discourse (or rather lack of it) about obesity and finding strategies that do justice to those living with obesity.

There is simply no room for “shame and blame” in such a discourse.

@DrSharma
Edmonton, AB

ResearchBlogging.orgKirk SF, Price SL, Penney TL, Rehman L, Lyons RF, Piccinini-Vallis H, Vallis TM, Curran J, & Aston M (2014). Blame, Shame, and Lack of Support: A Multilevel Study on Obesity Management. Qualitative health research PMID: 24728109

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Wednesday, April 9, 2014

Reserve Your Spot At The Obesity and Mental Health Conference, Toronto, May 14, 2014

smaller_CON_OMH_program_2014_2_Page_014614As a regular reader you may recall a previous conference on obesity and mental health which saw the release of the Toronto Charter on Obesity and Mental Health.

A follow up to this conference will be held in Toronto on May 14, 2014.

This time the focus is on clinical management of people with mental health issues presenting with weight gain as well as people with obesity presenting with mental health problems.

This one-day program features a rather distinguished roster of speakers, the full program can be downloaded here.

Registration for the conference is now open to all health professionals with an interest in obesity and/or mental health – click here

For more information on this conference – click here

@DrSharma
Edmonton, AB

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Thursday, April 3, 2014

Why Coverage Of Anti-Obesity Medications For Federal Employees Is Only Fair

OPM-logo

One of the rather explicit biases that has hindered greater investment into finding more effective obesity medications, has been the unwillingness of many health care plans to cover the cost of such medications for their members.

Indeed, many private and public health plans around the world explicitly exclude obesity medications (and other obesity treatments) from coverage.

This is clearly a double standard, given that the very same plans have no problem covering medications for other “lifestyle” diseases such as type 2 diabetes, hypertension, or high-cholesterol.

Now, in a rather dramatic move last month, the US Office of Personnel Management (OPM), responsible for health insurance coverage for  over 2.7 million Federal Employees, ruled in support of health coverage for FDA-approved weight-loss treatments stating that obesity exclusions are no longer permissible in health plans for federal employees.

This move should set an important precedent for other health plans to follow.

In the March 20th letter to all FEHB carriers, John O’Brien, the Director of Healthcare and Insurance at OPM, agrees that while

“diet and exercise are the preferred methods for losing weight, …drug therapy can assist [those] who do not achieve weight loss through diet and exercise alone.”

In the letter, O’Brien provides further clarification:

“It has come to our attention that many FEHB carriers exclude coverage of weight-loss medications. Accordingly, we want to clarify that excluding weight loss drugs from FEHB coverage on the basis that obesity is a “lifestyle” condition and not a medical one or that obesity treatment is “cosmetic”- is not permissible. In addition, there is no prohibition for carriers to extend coverage to this class of prescription drugs, provided that appropriate safeguards are implemented concurrently to ensure safe and effective use.”

This ruling should end the long-standing practice of discrimination against people with obesity who require and are willing to take medications for their condition.

Obviously, medications for obesity need to always be used as an “adjunct” to diet and exercise, in the same manner that medications for diabetes, hypertension or high-cholesterol should always be used as an adjunct to diet and exercise.

It goes without stating that prescription medications for obesity, diabetes, hypertension or high-cholesterol should only be made available to those who fail to control their weight, blood sugar, blood pressure, or cholesterol levels with diet and exercise alone. (there is no “special case” for the role of diet and exercise in obesity management that does not also apply to these other conditions).

And of course, as for any prescription drug, means and measures must be in place to avoid misuse and monitor safety of such treatments.

That said, recognizing that prescription obesity drugs, deemed both effective and safe by the FDA should be made available to patients in the same manner as drugs for other chronic conditions, is only fair to patients and represents a major step towards decreasing bias and discrimination against those suffering the health consequences of excess weight.

@DrSharma
Edmonton, AB

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Wednesday, April 2, 2014

Trotting Out STAMPEDE

sharma-obesity-blood-sugar-testing2In the obesity world, this week’s big news is the publication of the three year results of the STAMPEDE trial in the New England Journal of Medicine.

As a regular reader, you may recall my previous post on this randomised controlled trial of bariatric surgery for the treatment of type 2 diabetes.

STAMPEDE involved the randomisation of 150 obese patients with uncontrolled type 2 diabetes to either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy.

Rather than weight loss, the primary end point of STAMPEDE was a glycated hemoglobin (HbA1C) level of 6.0% or less (from a mean baseline of 9.3%).

For the 91% of the patients who completed 36 months of follow-up at three years, 5% of the patients in the medical-therapy group achieved an HbA1c of 6.0% compared to 38% of those in the gastric-bypass group and 24% of those in the sleeve-gastrectomy group.

In addition, surgically treated subjects overall had far lesser need for glucose-lowering medications, including insulin than those receiving medical treatment.

Weight was reduced by 20-25% in the surgical groups compared to a 4% weight loss in the medical arm of the study.

Quality-of-life was also significantly better in the two surgical groups than in the medical-therapy group.

There were no major late surgical complications.

By any reasonable standard, there cannot be any remaining doubt in anyone’s mind that surgical treatment for type 2 diabetes is vastly superior to anything that medical treatment has to offer.

Diabetologists and, in fact, all physicians, diabetes educators, dietitians and other health professionals, who fail to inform and counsel their type 2 patients with regard to surgical treatment options for their condition, risk being accused of malpractice.

Whether patients want surgery for diabetes or not is ultimately their choice – being informed of the potential benefits of surgery should not be a matter of choice – it should be good clinical practice.

@DrSharma
Edmonton, AB

Disclaimer: I am NOT a surgeon!

ResearchBlogging.orgSchauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, Aminian A, Pothier CE, Kim ES, Nissen SE, Kashyap SR, & the STAMPEDE Investigators (2014). Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 3-Year Outcomes. The New England journal of medicine PMID: 24679060

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Tuesday, April 1, 2014

Dr. Oz’s Next Miracle Obesity Cure: Ginger?

ginger-health-benefits-usesA recent article in Forbes Magazine noted at least 16 nonsensical “weight-loss miracles” discovered by Dr. Oz.

Well, allow me to be the first to predict another weight-loss miacle that may soon make the airwaves (or rather your cable): ginger.

And this would by no means be a surprise given that Saravanan and colleagues from Tamil Nadu, India, in a paper published in the Journal of the Science of Food and Agriculture, note the anti-obesity effects of ginger, especially in the face of a high-fat diet.

Unfortunately (not that Dr. Oz would care), this finding was in rats, who were given varying amounts of gingerol for 30 days.

And indeed, at the highest dose (75 mg/Kg), animals did have lower glucose level, body weight, leptin, insulin, amylase, lipase plasma and tissue lipids when compared to controls.

As the authors show, this was about as much of an effect as seen in animals treated with lorcaserin, an anti-obesity drug recently approved by the FDA.

While, to their credit, the authors make only generically optimistic claims as to the use of these findings rather than proclaim  another “weight-loss miracle”, they also fail to tell us exactly how many kilograms of fresh ginger (or even ginger extract) one would have to eat every day to come anywhere close to reaching an effective dose of gingerol.

Never mind that we also have no idea how such a dose would be tolerated in humans (yes, natural products have side effects!), or even whether or not ginger would in fact have any similar effects on body weight or metabolism in humans.

Surely, there is nothing wrong with this line of research. Many medical discoveries (e.g. aspirin) were made through the isolation of pharmacologically active moieties from plants.

What is wrong, however, is when such basic findings are overhyped and presented as “miracles” with claims of curing everything from obesity and heart disease to cancer and Alzheimer’s (surprisingly such claims often fail to include world peace).

Will Dr. Oz pick up on ginger? I don’t know. But if he does, remember you heard it here first.

@DrSharma
Edmonton, AB

ResearchBlogging.orgSaravanan G, Ponmurugan P, Deepa MA, & Senthilkumar B (2014). Antiobesity action of gingerol: Effect on lipid profile, insulin, leptin, amylase and lipase on male obese rats induced by a high-fat diet. Journal of the science of food and agriculture PMID: 24615565

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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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