In the same manner in that there is not one predisposing factor for the development of obesity, the phenotypic clinical presentation of obesity is likewise extraordinarily heterogenous. (This has some authors speaking of “obesities” rather than “obesity”).
While it is now well established that BMI is a measure of size rather than health, it is perhaps less well recognised how the different types of body fat and their storage in various fat depots and organs can contribute to cardiometabolic disease (location, location, location!).
Now, a comprehensive review by Ian Neeland from the University of Texas Southwestern Medical Center, Dallas, together with my colleagues Paul Poirier and JP Despres from Laval University in Quebec, published in Circulation discusses the cardiovascular and metabolic heterogeneity of obesity.
As the authors point out,
“Although the BMI has been a convenient and simple index to monitor the growth in obesity prevalence at the population level, many metabolic and clinical studies have revealed that obesity, when defined on the basis of the BMI alone, is a remarkably heterogeneous condition. For instance, patients with similar body weight or BMI values have been shown to display markedly different comorbidities and levels of health risk.”
Not only has BMI never emerged as a significant component in risk engines such as the Framingham risk score, there are many individuals with obesity who never develop metabolic complications or heart disease during the course of their life.
The paper offers a good review of what the author describe as adipose dysfunction or “adiposopathy” = “sick fat”. Thus, in some individuals, there is an accumulation of “unhealthy” fat (particularly visceral and ectopic fat), whereas in others, excess fat predominantly consists of “healthy” fat (predominantly in subcutaneous depots such as the hips and thighs).
The authors thus emphasise the importance of measuring fat location with methods ranging from simple anthropometric measures (e.g. waist circumference) to comprehensive imaging techniques (e.g. MRI).
The authors also provide a succinct overview of exactly how this “sick fat” contributes to cardiometabolic risk and briefly touches on the behavioural, medical, and surgical management of patients with obesity and elevated cardiometabolic risk.
I, for one, was also happy to see the inclusion of the Edmonton Obesity Staging System in their reflections on this complex issue.
This paper is certainly suggested reading for anyone interested in the link between obesity and cardiovascular disease.
As readers will be well aware, n terms of health risks, fat is not fat is not fat is not fat.
Rather, whether or not body fat affects health depends very much on the type of body fat and its location.
While there have been ample attempts at trying to describe body fat distribution with simple anthropometric tools like measuring tapes and callipers, these rather crude and antiquated approaches have never established themselves in clinical practice simply because they are cumbersome, inaccurate, and fail to reliably capture the exact anatomical location of body fat. Furthermore, they provide no insights into ectopic fat deposition – i.e. the amount of fat in organs like liver or muscle, a key determinant of metabolic disease.
Recent advances in imaging technology together with sophisticated image recognition now offers a much more compelling insight into fat phenotype.
In this regard, readers may be interested in a live webinar that will be hosted by the Canadian Obesity Network at 12.00 pm Eastern Standard Time on Thu, Nov 23, 2017. The webinar provides an overview of a new technology developed by the Swedish company AMRA, that may have both important research and clinical applications.
The talk features Olof Dahlqvist Leinhard, PhD, Chief Scientific Officer & Co-Founder at AMRA and Ian Neeland, MD, a general cardiologist with special expertise in obesity and cardiovascular disease, as well as noninvasive imaging at the UT Southwestern Medical Center in Dallas, US.
Registration for this seminar is free but seats are limited.
To join the live event register here.
I have recently heard this talk and can only recommend it to anyone interested in obesity research or management.
The following is a guest post from my Australian colleague Dr. Georgia Rigas, who reports on the recent recognition of obesity as a disease by the Royal Australian College of General Practice (RACGP).
Last week, the Royal Australian College of General Practice (RACGP) President, Dr Seidel recognised obesity as a disease. The RACGP is the first medical college in Australia to do so.
This was exciting news given that we have just observed World Obesity Day a few days ago.
According to the Australian Bureau of Statistics1, over 60% of Australian adults are classified as having overweight or obesity, and more than 25% of these have obesity [defined as a Body Mass Index (BMI) ≥30] (ABS2012). Similarly in 2007, around 25% of children aged 2–16 were identified as having overweight or obesity, with 6% classified as having obesity (DoHA 2008). These are alarming statistics.
The recent published BEACH data for 2015-162, showed that the proportion of Australian adults aged 45-64yo presenting to GPs has almost doubled in the last 15+ years. Worryingly the numbers are predicted to continue rising, with 70% of Australians predicted to have overweight or obesity by 2025. Embarrassingly, the BEACH data also indicated that <1% of GP consultations centred around obesity management.
So obviously what we, as GPs have been doing..,or rather not doing…isn’t working!
The RACGP’s General Practice: Health of the Nation 2017 3report found Australian GPs identified obesity and complications from obesity as one of the most significant health problems Australia faces today and will continue to face in coming years as the incidence of obesity continues to rise.
But what are we doing about it?…. I think the answer is evident… clearly not enough!
Thus, we can only hope that this announcement by the RACGP will have a ripple effect, with other medical colleges in Australia and then the Australian Medical Association following suit.
So what does this mean in practical terms?
For those individuals with obesity (BMI ≥30) with no “apparent” comorbidities or complications from their excess weight…[though you could argue they will develop (if not already) premature osteoarthritis of the weight bearing joints…..] would be eligible for a chronic care plan [government subsidized access to a limited number of consultations with allied health services] given the chronic and progressive nature of the disease.
It also highlights the need for GPs to start screening ALL patients in their practice-young and old;
- for children their parameters need to be plotted on a BMI-for-age chart;
- for adults BMI & waist circumference, taking into account their ethnicity (as different cut- offs for different ethnic groups) and physical activity levels (if they are muscular or not) are important
This powerful statement should help clear any ambivalence.
Why is there a therapeutic inertia when it comes to treating people with obesity?
People with obesity suffer significant degrees of stigma, discrimination and weight bias and as a result may be reluctant to access healthcare. Today, we are giving these patients a voice.
As health care professionals, let’s not forget that the health message needs to change from “lose weight” to “gain health” in recognition that obesity is about more than body weight.
In closing, to effectively and equitably work towards reducing obesity in our communities, we need a balanced combination of both individual and public health measures. This media release by the RACGP shows their commitment to both the primary prevention and the treatment of this life- threatening disease, to ensure better health outcomes and quality of life for all Australians.
Dr Georgia Rigas, MBBS FRACGP
SCOPE certified obesity doctor
Bariatric Medical Practitioner
Achieving and maintaining competencies is an ongoing challenge for all health professionals. But in an area like obesity, where most will have received rather rudimentary training (if any), most health professionals will likely be starting from scratch.
So what exactly must you expect of a health professional involved in the care of individuals living with obesity.
This is the subject of a white paper on “Provider Competencies for the Prevention and Management of Obesity“, developed with support from the Robert Wood Johnson Foundation.
The panel of authors led by Don Bradley (Duke) and William Dietz (George Washington) included representatives from over 20 national (US) professional organisations.
The competencies expected cover the following 10 topics:
Competencies for Core Obesity Knowledge
1.0 Demonstrate a working knowledge of obesity as a disease
2.0 Demonstrate a working knowledge of the epidemiology of the obesity epidemic
3.0 Describe the disparate burden of obesity and approaches to mitigate it
Competencies for Interprofessional Obesity Care
4.0 Describe the benefits of working interprofessionally to address obesity to achieve results that cannot be achieved by a single health professional
5.0 Apply the skills necessary for effective interprofessional collaboration and integration of clinical and community care for obesity
Competencies for Patient Interactions Related to Obesity
6.0 Use patient-centered communication when working with individuals with obesity and others
7.0 Employ strategies to minimize bias towards and discrimination against people with obesity, including weight, body habitus, and the causes of obesity
8.0 Implement a range of accommodations and safety measures specific to people with obesity
9.0 Utilize evidence-based care/services for people with obesity or at risk for obesity
10.0 Provide evidence-based care/services for people with obesity comorbidities
Some of the topics include further subtopics that are deemed especially relevant.
Thus, for e.g., topic 6.o, regarding communication, includes the following sub-competencies:
6.1 Discuss obesity in a non-judgmental manner using person-first language in all communications
6.2 Incorporate the environmental, social, emotional, and cultural context of obesity into conversations with people with obesity
6.3 Use person- and family-centered communication (e.g., using active listening, empathy, autonomy support/shared decision making) to engage the patient and others
Similarly, topic 7.0, regarding the issue of weight bias and discrimination, includes the following sub-competencies:
7.1 Describe the ways in which weight bias and stigma impact health and wellbeing
7.2 Recognize and mitigate personal biases
7.3 Recognize and mitigate the weight biases of others
This is clearly a forward-thinking outline of competencies that we will hopefully come to expect of most health professionals, given that virtually every health professional, no matter their specialty or scope of practice, will likely be called upon to care for people living with obesity.
The full document can be downloaded here.
Last week I was an invited plenary speaker at the 1st International Diabetes Expert Conclave (IDEC2017) held in Pune, India.
This 3-day event, organised by Drs. Neeta Deshpande (Belgaum), Sanjay Agrawal (Pune) and colleagues, brought together well over 900 physicians from across India for a jam-packed program that covered everything from diabetic food disease and neuropathy to the latest in insulin pumps and devices – all in a uniquely Indian context.
I, of course, was there to speak on obesity, which featured prominently in the program. Topics on obesity ranged from the potential role of gut bugs to bariatric surgery. While Dr. Allison Goldfine, former Director of Clinical Research at the Joslin Diabetes Center in Boston spoke on the latest developments in anti-obesity pharmacotherapy (delivering her talk via Skype), I spoke about obesity as a chronic disease and the need to redefine obesity based on actual indicators of health rather than BMI.
During my visit in Pune, I also had the opportunity to visit with my friend and colleague Dr. Shashank Shah, whose bariatric surgical center in Pune alone performs about 75 to 100 bariatric operations per month – a remarkable number by any standards.
Of course, the overwhelming number of talks were given by Indian faculty (there being only a handful of select invited international faculty at the meeting), and I did come away most impressed by the breadth and depth of knowledge presented by the local speakers.
Diabetes care certainly appears to be in good hands although the sheer number of patients with diabetes (estimated at about 70 million, which I assume to be a rather conservative assessment), would provide a challenge to any health care system.
On the obesity front, things are a lot less rosy, given that (as everywhere else) obesity has yet to receive the same level of professional attention and expertise afforded to diabetes or other chronic diseases.
Thanks again to the organisers for inviting me to this exciting meeting and congratulations on an excellent event that bodes well for the 2nd Conclave planned for 2018.