Arya M. Sharma, MD

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

CARDIOVASCULAR AND/OR RESPIRATORY DISEASES

Patients with chronic cardiopulmonary disease (angina, heart failure, chronic obstructive pulmonary disease [COPD] and reactive airways disease) are often inactive and may be unable to follow recommendations to increase physical activity. Combining cardiopulmonary rehabilitation and exercise training may therefore help patients increase their daily energy expenditure and improve quality of life.

Weight gain and central adiposity independently contribute to increased risk for hypertension, dysglycemia, dyslipidemia, left-ventricular heart disease, ventricular dysfunction, coronary heart disease, congestive heart failure, arrhythmias, peripheral artery disease, deep vein thrombosis, pulmonary embolism, stroke, and sudden death. Consequently, impaired cardiovascular function is common in obese patients. Symptomatic cardio-pulmonary disease affects a patient’s lifestyle, and treatment may both dramatically improve their quality of life and motivate them to undertake lifestyle changes.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

CHAPTER 5: MEDICAL BARRIERS

Physical co-morbidities are common in people with obesity and need to be addressed as part of any weight-management plan. Co-morbidities associated with obesity will improve as weight is controlled, but often make it difficult for patients to undertake the effort required for lifestyle-based weight management. In some cases, these physical barriers to weight loss may be insurmountable and the focus of treatment should, from the outset, aim to prevent weight gain rather than achieve weight loss. Strategies for obesity treatment should always be adapted to the patient’s particular situation to make it easier for them to cope with required changes over the long-term.

SLEEP DISORDERS

Sleep disorders are very prevalent among obese people. Obstructive sleep apnea is the most common disorder, but disturbed sleep may also be due to primary insomnia, or insomnia secondary to medications, medical or psychiatric disorders.

Sleep deprivation is linked to obesity. The primary putative connection can be found in the neuroendocrine regulation of appetite and food intake. Neuroendocrine regulation appears to be influenced by sleep duration and sleep restriction, with sleep deprivation favouring obesity as it increases serum cortisol and decreases serum leptin levels. Another reason for the sleep disorder-obesity connection may be simply that the more time a person spends awake, the more time they have in which to eat.

Insufficient sleep causes important neurocognitive changes such as excessive daytime sleepiness, fatigue and altered mood. These may, in turn, have a significant impact on the patient’s ability to persist with healthy lifestyle changes such as increasing their level of physical activity or taking the time to cook a healthy meal.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Regular readers of these pages will recall the recent article series on the pros and cons of bariatric surgery.

As I pointed out, this is a rapidly evolving field of medicine and new data is now accumulating at an unprecedented pace.

Yesterday, JAMA released a new study in which Matthew Maciejewski and colleagues report the results of a large retrospective propensity-matched case-control analysis of patients who underwent Roux-en-Y bariatric surgery at Veteran Administration (VA) centres across the US.

This study is remarkably different from previously reported bariatric surgical studies in that it involves a predominantly male (74%), older (mean age 49 years - if you consider that old?!?), heavier (>30 had a BMI > 50), and sicker patients.

Overall, the study shows that over an almost seven-year follow-up, bariatric surgery compared to usual care, did not significantly reduce the mortality risk of these older, severely obese high-risk men.

These results contrast strongly with the consistently positive outcomes that have now been reported in younger, healthier, and predominantly female populations.

Thus, contrary to expectations, where greater benefits are generally expected with greater disease burden, this study does not support the use of roux-en-y bariatric surgery in older severely obese men.

The authors attribute this lack of positive effect of surgery in part to the rather high surgical risk of these patients. In fact, 11 of the 847 (1.3%) cases died within 30 days of surgery, a rate that is four times that reported in lower risk populations.

As this surprisingly high perioperative mortality essentially cancels out any potential survival benefit, the authors suggest that lower-risk procedures like adjustable gastric banding or sleeve gastrectomies, which have considerably lower perioperative risk than Roux-en-Y gastric bypass, may need to be considered in these patients.

However, the authors also note that reduction in comorbidities, medication use, and over all costs, were not significantly reduced in these patients - a finding for which they offer no ready explanation.

These findings, that follow closely on previous week’s post on the paucity of obesity studies in men, highlight that it may be wrong to simply expect men to have the same benefits of bariatric surgery commonly reported in women.

While the authors caution that roux-en-y bariatric surgery may confer no survival benefit in older and sicker severely obese men, performing such surgery may still be an option as the associated weight loss at least results in an improved quality of life for these individuals.

Clearly, as outlined in my recent series, bariatric surgery is not for everyone and should always involve a careful discussion of risk/benefit ratio - apparently not just in women.

AMS
Edmonton, Alberta

So, just to wind down this series, I would like to finish with an aspect of bariatric surgery that is seldom talked about. It is particularly relevant to patients at the extreme end of obesity.

Many of these patients will have lived with severe obesity for a long time. They will have very few social contacts (except perhaps on the internet).

Many will not have partaken in what others would consider very ‘normal’ activities: going to a cinema, strolling around in a mall or park, shopping for shoes or clothes, having a mani-pedi or even just their hair done, getting on an airplane or even just into a regular car (let alone drive one).

As they lose weight, gain back their health and energy, and begin venturing out again, they will face all kinds of challenges both physically and mentally.

Many will have the support they need and do just fine.

But others, will flounder, feel socially incompetent - like a new immigrant to a foreign country.

Trips to a supermarket or the public library can be daunting.

It even takes time to recognize that that person reflected in the store window is really and actually you!

This process of ‘rehabilitation’, which eventually can encompass issues like facing the job market or considering going back to school is not easy.

Very little research seems to have been done on these issues - I can only imagine a whole new field for occupational and recreational therapists and social workers.

Bariatric surgery is truly life changing - in the real sense of the word.

I hope that this series of articles has perhaps touched on some issues that many may not have considered before.

I hope that those who have themselves experienced some of these issues or have seen them in their own patients can relate to some of these difficulties and see them reflected in my posts.

Bariatric surgery is about far more than finding a competent surgeon.

it is a very individual and personal decision - one that can empower - one that requires courage and determination.

It is definitely not a ‘cop-out’ or ‘conceding defeat’ or even remotely ‘taking the easy way out’.

It is most certainly not just about surgery.

Never have so many people around the world been in the need of or decided to undergo surgery - this is work in progress. As for most conditions mistakes are made, new research and greater experience changes and improves practice.

There is no quick or magical fix for obesity - surgery is currently perhaps the best option for most patients with severe obesity - hopefully, it will not remain the only one.

For many patients, surgery is definitely not the right option - hopefully, these patients can be identified and counseled accordingly.

For those, who are most likely to benefit, timely access is important - life is short enough without having to lose years of it to a condition that can perhaps not be cured but is definitely treatable.

AMS
Toronto, Ontario

p.s. Meet and greet with Dr. Sharma and friends: Toronto, Friday, June 3, 5.00-6.00 pm, L’Espresso Bar Mercurio at 321 Bloor Street West, (southeast corner of Bloor & St. George) - the more the merrier!

Today’s post is not so much about a complication that arises when bariatric surgery fails, but rather an issue that can become a real problem the more successful it is - the problem of excess skin.

As most readers will perhaps readily appreciate, losing a lot of weight can leave patients with very significant amounts of extra skin - not just on their abdomens, but their thighs, their hips, their arms, their breasts and chest, their necks - pretty much everywhere.

This excess skin can be both aethetically distressing but also cause functional and dermatological problems.

Although this should not be that ‘unexpected’, it does appear to be something that many patients can’t really imagine before it happens to them.

Concern over appearance can, in some cases, vastly outweigh the joy over the ’success’ and I have seen patients in deep distress over this problem.

This problem is in fact so common and so extensive that it has spawned a whole new field of post-bariatric plastic surgery, which specialises in extensive ‘body-contouring‘ surgery. These operations, can be far larger and more complicated in terms of risks and recovery time than the original bariatric surgery.

Different body parts require different sittings. Surgeon experience is critical to ensure cosmetically acceptable outcomes.

Unfortunately, no medical system that I know of covers much of this surgery (an exception being the abdominal apron or pannus, which can sometimes cause significant dermatological and functional problems).

Arm-, butt-, and thigh-lifts are almost never covered by health plans and can cost some very serious money to have done.

Thus, although not, strictly speaking, a ‘complication’ of bariatric surgery itself, it is something that patients need to be prepared for and dealing with the psychological impact of considerable excess skin is anything but easy.

It is perhaps therefore not surprising that various organisations and patient groups have called for this ‘reconstructive’ surgery be covered by medical plans in the same manner that other forms of reconstructive surgery are covered (e.g. breast reconstruction after mastectomy).

But given the widespread prejudice and discrimination that bariatric patients already face, I am not holding my breath to see payers stepping forward to take on these costs anytime soon.

AMS
Edmonton, Alberta

p.s. Meet and greet with Dr. Sharma and friends: Toronto, Friday, June 3, 5.00-6.00 pm, L’Espresso Bar Mercurio at 321 Bloor Street West, (southeast corner of Bloor & St. George) - the more the merrier!