Tuesday, January 21, 2014

Quality of Life in Obesity is Determined by Health, Not Size

weight scale helpOver the past few days, I have been posting on the results of the APPLES study – a prospective 24-month assessment of patients wait-listed for or undergoing treatment at a publicly funded bariatric centre in Alberta, Canada.

In a separate analysis, just released in OBESITY, Lindsey Warkentin and colleagues present the baseline quality of life (QoL) data for the 500 patients enrolled in this study.

As noted previously, the average BMI of participants in this study was 47.9, 90% were female with an average age of 43.

Quality of life was assessed at the time of enrolment in the study using several standardized and validated instruments (Short-Form (SF)-12 [Physical (PCS) and Mental (MCS) component summary scores], EuroQol (EQ)-5D [Index and Visual Analog Scale (VAS)], and Impact of Weight on Quality of Life (IWQOL)-Lite).

As may be expected, the overall QoL of these patients was substantially lower than the general population in Alberta.

Thus, the mean physical and mental component summary scores in the SF-12, were both substantially lower (by about 10 points) than general population scores in Albertan adults. Similar reductions in QoL were found with the other instruments.

Key predictors of poor QoL included fibromyalgia, pain, depression, sleep apnea, coronary artery disease and stroke (among others).

Interestingly, however, despite a wide range of body weights in this study, BMI itself had almost no predictive value in terms of health status or quality of life.

This is perhaps not surprising, as we have previously shown that BMI alone is not a reliable or even sensitive measure of health (which is why we developed the Edmonton Obesity Staging System to better characterize the health status of individuals with obesity).

Thus, it is the actual presence of related illnesses that determine the quality of life – not simply the amount of excess body fat.

This finding has important implications for treatment and prioritization.

For one, as noted previously, BMI or other measures of size alone are a poor guide as to how sick your patient is – determining the health impact of excess weight actually requires assessing the presence of physical and mental comorbidities (of which there are many).

Conversely, as QoL is largely dependent on the presence of related illnesses – it may well be that treating and controlling these illnesses may have a great impact (and perhaps be far more effective and practical) than simply focussing on weight loss.

Thus, for example, it may be far more cost effective and practical to treat the symptoms of severe osteoarthritis (by replacing a knee or hip) or the symptoms of sleep apnea (with CPAP) than simply focussing all attention on dropping the numbers on the scale.

As much as losing weight may be the preferred option (if we had better treatments), better management of relevant comorbidities could perhaps result in substantial greater improvements in health-related quality of life than struggling to lose a few pounds.

Thus, an important tenet of bariatric care has to focus on better managing the health problems that obese patients present with even if significant and persistent weight loss remains elusive in most patients.

Bariatric care is so more than just running a weight-loss clinic.

@DrSharma
Edmonton, AB

ResearchBlogging.orgWarkentin LM, Majumdar SR, Johnson JA, Agborsangaya CB, Rueda-Clausen C, Sharma AM, Klarenbach SW, Birch DW, Karmali S, McCargar L, Fassbender K, & Padwal RS (2014). Predictors of health-related quality of life in 500 severely obese patients: An assessment using three validated instruments. Obesity (Silver Spring, Md.) PMID: 24415405

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Tuesday, January 14, 2014

Bariatric Care: How Sick is Big?

weight scale helpYesterday, I posted about the recent paper by Padwal and colleagues on the weight loss outcomes in a publicly funded multi-disciplinary tertiary care bariatric program, published in Medical Care.

Before going into details of the outcomes, I thought it prudent to first describe the patient population seen in this program.

Thus, the typical patient in the APPLES study is a Caucasian (92%) woman (88%) in her early forties (43 y), weighing 132 kg (BMI 47.9), nonsmoker (90%), married or in a common-law relationship (58%), with some or completed post-secondary education (71%), currently in full-time employment (60%), with a household income greater than $50,000 per year (66%).

She is also likely to have depression (62%) and/or anxiety (46%), hypertension (65%), type 2 diabetes (44%), dyslipidemia (60%), gastro-esophagial reflux (38%), osteoarthritis (29%) and sleep apnea (29%).

Although not reported in this paper, we also know that individuals in this BMI category have markedly impaired quality of life (comparable to that of patients with coronary artery disease and marginally better than those living with chronic obstructive lung disease).

We have also previously reported that many of these patients (20%) report a previous history of sexual trauma.

Thus, the vast majority of individuals seen in the APPLES study are not only severely obese but also present with a wide range of physical and mental health problems.

What stands out to me from these baseline demographics are the following:

1) We are not reaching the men – given that there is little difference in obesity prevalence between the sexes, once can only assume that the men are either less concerned about their weight or (even if concerned) far less likely to consider seeking bariatric care.

2) Two-thirds of the patients have at least some post-secondary education – well above the 53% average of Canadians who have trade certificates, college diplomas or university degrees – suggesting that better educated individuals may be better able to access the clinic.

3) Two-thirds of patients have a household income of more than $50,000 a year – while this may seem much, it is important to note that the average household income in Alberta is currently around $85,000 a year. This suggests that, despite the rather high degree of post-secondary education, bariatric patients may be making less in their jobs than their normal-weight peers.

In tomorrow’s post, I will discuss what happens to weight and health status in these patients as they linger on the waiting list to be seen in the program.

@DrSharma
Edmonton, AB

ResearchBlogging.orgPadwal RS, Rueda-Clausen CF, Sharma AM, Agborsangaya CB, Klarenbach S, Birch DW, Karmali S, McCargar L, & Majumdar SR (2013). Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program: Prospective Cohort Study. Medical care PMID: 24374423

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Thursday, December 5, 2013

At-Risk is Not The Same as Unhealthy

sharma-obesity-cardiometabolic-risk1Clearly, this week’s posts on the two articles suggesting that there is no such thing as “healthy obesity” have hit a nerve.

I do not wish to repeat my previous criticisms of these two articles, which you can read here and here.

But I do wish to take the opportunity to set the record straight, that I do indeed take obesity seriously!

I am certainly well aware of the many health problems, emotional pain and physical limitations that are commonly associated with excess weight.

After all, I work in a clinic that provides all forms of behavioural, medical and surgical treatments for obesity and can certainly attest to the substantial health benefits of successful obesity management.

I am also well aware that with increasing BMI levels, it becomes harder and harder to find obese people who one would consider to be perfectly healthy.

As we showed in our analyses of NHANES data, EOSS Stage 0 individuals make up only 15% of individuals in the BMI 25 to 30 range, decreasing to 8% of individuals in the BMI 30 to 35 range and dropping to less than 5% in those with a BMI greater than 35.

Although we regularly see individuals with EOSS Stage 0 even at BMI levels well beyond 40, these are indeed rare individuals – the vast majority of our patients present with EOSS Stage 2 or higher.

Thus, my “advocacy” for the existence of “healthy obesity” has nothing to do a lack of recognition or even underestimation of the considerable health risks and problems related to excess weight.

Rather, my insistence on not immediately assuming that everyone with a higher BMI is in immediate need of medical attention, is motivated by our ability to look at individual risk rather than having to simply rely on statistical probabilities.

Fortunately, we have a rather good understanding of the key underlying risk factors that mediate cardiometabolic risk (high blood pressure, dysglycemia and dyslipidemia), which, together with smoking, account for virtually 90% of all cardiovascular risk. There is nothing mysterious about these risk factors and all can (and should) be easily measured in clinical practice.

Thus, whether an obese person is actually at increased cardiometabolic risk or not does not have to be a guessing game – a few simple physical and laboratory tests will quickly provide a clear answer (whereas stepping on the scale will not!).

This is the whole point of the argument. Why should we jump to the conclusion that anyone with a higher BMI is unhealthy based on BMI alone, when it is so simple to determine actual risk?

A common counterargument is that, because the vast majority of people with higher BMI’s are at increased risk, it may be easier to simply tell everyone to lose weight.

But that is exactly where the problem lies. Losing weight is anything but easy and may in fact cause harm (if the methods employed are unhealthy and/or weight recidivism adversely affects emotional and physical health).

Based on our calculations in the US-NHANES data set, recommending that anyone with a BMI greater than 25 loses weight would include almost 10 million individuals in the US, who we would consider EOSS Stage 0, i.e. perfectly healthy.

Readers will hopefully agree that 10 million is not a trivial number by any standard – these are the people who stand to be harmed by blanket recommendations that label all overweight and obese people as unhealthy – the risk/benefit ration for these individuals may well be on the side of risk rather than benefit.

At a minimum, these 10 million people deserve the courtesy of health professionals actually measuring their actual risk before making pronouncement as to their prognosis.

I strongly feel that in our public health messaging (and clinical practice guidelines) – both sides can stand alongside each other.

Yes, excess weight can increase the risk of cardiometabolic risk factors (and other health problems) – simple tests in your doctor’s office can help determine these risks.

On the other hand, not everyone carrying a few extra pounds is at immediate risk of developing diabetes or heart attacks (or stands to benefit from obsessing about their weight) –  again, simple tests in your doctor’s office can help identify those at low risk.

To me the real question of interest is not whether or not “healthy obese” people exist – they do!

The interesting question is what these individuals can teach us about the sociopsychobiology of obesity. What behavioural or biological factors keep these individuals healthy? Perhaps there are learnings here that can help “unhealthy obese” individuals live healthier lives.

@DrSharma
New Delhi, India

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Wednesday, December 4, 2013

New Meta-Analysis Adds To Meta-Confusion About Healthy Obesity

sharma-obesity-cardiometabolic-risk1Earlier this week, I posted on a study suggesting that “metabolically healthy” obese individuals are at increased risk for diabetes and heart disease – except that the definition of “metabolically healthy” in this study included people with one metabolic risk factor, i.e. people, who would be considered at least EOSS Stage 1 or 2 – not exactly healthy in my books.

Now, a study, by Caroline Kramer and colleagues from the University of Toronto, published in the Annals of Internal Medicine, unfortunately, adds to the confusion.

The researchers conducted a meta-analysis of data from over 60,000 individuals derived from 12 cross-sectional and prospective studies, varying in duration from 3 to 30 years of follow-up.

Their comparison of metabolically “healthy” and “unhealthy” obese individuals lead the authors to declare that, “there is no healthy pattern of increased weight”.

But of course any meta-analysis can only be as good as the original studies included in it.

And herein lies the problem.

As shown in Table 1 of the study, 9 of the 12 studies defined “healthy” as not having the metabolic syndrome (either based on ATP III or IDF criteria), while the remaining studies defined “healthy” as having less than 2 metabolic risk factors.

As readers will perhaps recall, the ATP III defnition of “metabolic syndrome” actually requires the presence of at least 3 of 5 of the components of the metabolic syndrome, while the IDF definition actually requires abdominal obesity AND at least two other risk factors.

Thus, someone with just hypertension or just elevated triglycerides or even just elevated fasting glucose would be considered to be “healthy” in these studies.

This of course is nonsense. The term “healthy” should mean just that – “healthy”.

In the Edmonton Obesity Staging System healthy is defined as the absence of medical, mental or functional risk factors or limitations related to excess weight. According to this rather “stringent” definition, our analysis of NHANES and other data sets, showed virtually no increased risk associated with increased BMI or waist circumference over as long as 200 months.

In contrast, in our analyses, obese individuals with even just one metabolic (or other risk factor) were considered to have EOSS Stage 1 or 2 had clearly elevated risk.

Thus, this meta-analysis simply adds to the confusion on this topic by defining “healthy obesity” that we would consider anything but “healthy”.

Nevertheless, the paper does make two interesting points – neither of which are novel or unexpected:

1) There is considerable metabolic heterogeneity amongst people with elevated BMI.

2) People with elevated BMI (including those at lower risk) are at a higher risk of eventually developing metabolic problems (with increasing age and BMI).

Thus, for clinicians, the message really remains the same:

1) BMI is a lousy measure of metabolic risk in individuals.

2) Even those with elevated BMI who appear at lower risk, should work on maintaining that lower risk (as should everybody else).

Unfortunately, studies such as this, by mislabelling unhealthy obese individuals as supposedly “healthy”, do little than further confuse the literature and promote weight bias while reinforcing the widespread misconception that you can measure health by simply stepping on a scale.

If you are an obese person with Stage 0 obesity and have maintained that “healthy obese” status for years, I’d like to hear about it (yes, these people do exist).

@DrSharma
New Delhi, India

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Monday, December 2, 2013

Metabolically Unhealthy Obese Individuals Are Not Healthy

sharma-obesity-cardiometabolic-risk1Regular readers are quite familiar with the concept of the Edmonton Obesity Staging System, which ranks obese individuals based on how “sick” rather than on just how “big” they are.

To be at Stage 0, obese individuals have to be not only free of any medical abnormalities (e.g. in their labwork) but also have no associated impairment of mental health or quality of life – in other words, Stage 0 = healthy – end of story!

We have previously shown that Stage 0 obese individuals, even with a BMI Of 40 or greater, have virtually no increased risk of dying even over a 20 year period.

Unfortunately, many authors chose to use less-stringent definitions of “healthy”, which serves only to confuse the literature on this issue.

Thus, a paper by KoKo Aung and colleagues from the University of Texas Health Science Center, San Antonio, Texas, published in the Journal of Clinical Endocrinology and Metabolism, based on an analysis of over 5,000 participants in the San Antonio Heart Study, suggests that “metabolically healthy” obese individuals have a significant risk for developing type 2 diabetes and cardiovascular disease.

Unfortunately, the authors chose to define “metabolically healthy” was as follows:

“We used the presence of two or more metabolic abnormalities as the threshold to define metabolically unhealthy individuals. Thus, we defined MUH-NW as individuals with normal weight and two or more metabolic abnormalities; MHO as individuals with obesity and no more than one metabolic abnormality.”

Thus, by EOSS standards, the so-called “metabolically healthy” individuals in this study would be anything but “healthy”. Even having just one metabolic risk factor or comorbid condition, would already put you at a EOSS Stage 1 or even a 2, a stage for which we have shown a clearly elevated risk for cardiovascular mortality.

In fact, while Aung an colleagues, considered 44% of their obese subjects as “metabolically healthy”, in our NHANES analysis less than 15% of obese individuals qualified as having EOSS Stage 0.

Thus, all this paper really shows is that if you already have at least one metabolic risk factor (and are thus EOSS 1 or even 2) you are at increased risk for diabetes (and CVD).

No surprise there!

Unfortunately, due to the misleading definition of “healthy obese”, this paper has already received considerable media attention, suggesting that obesity is a risk factor even in those who are metabolically healthy – this of course is not at all what the paper shows, given that the so-called metabolically healthy were anything but healthy.

As readers will appreciate, EOSS also considers non-metabolic comorbidities as well as mental and functional health in its definition, all of which have to be absent to be considered EOSS Stage 0.

Clearly, metabolically unhealthy obese individuals are not healthy – but then, we already knew that.

@DrSharma
Edmonton, AB

ResearchBlogging.orgAung K, Lorenzo C, Hinojosa MA, & Haffner SM (2013). Risk of Developing Diabetes and Cardiovascular Disease in Metabolically Unhealthy Normal-Weight and Metabolically Healthy Obese Individuals. The Journal of clinical endocrinology and metabolism PMID: 24257907

 

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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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