The News Section of this week’s edition of the Canadian Medical Association Journal (CMAJ) features an article by Roger Collier, in which I am extensively quoted with regard to wether or not health professionals should use the term “obesity”.

Regular readers of these pages will be quite familiar with my views on this issu. Readers may also recall that there is indeed a medical definition of obesity and that this condition has long had its own code in the International Statistical Classification of Diseases (ICD 10 E66.0).

Here a few quotes from the CMAJ article:

Doctors are also aware that patients don’t like to be labelled as obese, even if the label is accurate. Dr. Arya Sharma, chair for cardiovascular obesity research and management at the University of Alberta in Edmonton, says he never refers to a patient as an obese individual, which implies they are defined by their condition. Instead, he will use phrases such as “person with obesity.” He also prefaces the word “obese” with “medically.”

“When you put the word ‘medically’ in front of it, it implies you are talking about a medical condition,” says Sharma, who is also the scientific director of the Canadian Obesity Network.

In a recent paper, Sharma explored historical approaches to classifying obesity. Some descriptive terms once used in medicine, he noted, were far from kind. “Although some earlier descriptions of obesity used less pejorative synonyms such as stout and corpulent (meaning excessively fat), other terms such as mammoth, monstrous and grotesque clearly reflect societal stigmatization against the obese individual and, although the stigma remains, these terms have long been abandoned,” he wrote.

Though he takes care not to offend patients, Sharma advocates for the use of the word “obesity” because it has a precise clinical definition. In fact, he was one of the few founding members of the Canadian Obesity Network who insisted the word be included in the organization’s name. Others, Sharma says, feared it would repel sponsors and harm funding, and suggested names along the lines of “The Healthy Network.”

Sharma also says the word “obesity” should be entered into medical records if a person’s BMI is 30 kg/m2 or higher. To just record the BMI, he says, would be akin to recording a patient’s blood pressure without noting the presence of hypertension.

Some health experts believe the stigma associated with certain conditions can have a positive effect, serving as a powerful motivator for people to improve their health. But when it comes to obesity, Sharma says, stigma does nothing but harm. It can deter people from seeking medical care and lead to depression, anxiety, poor body image and suicidal thoughts.

“These are concrete health risks,” says Sharma. “It’s not just about not being kind to people.”

But of course not everyone agrees with these views.

The article goes on to quote a Dr. Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute in Washington, DC, who has the following views with regard to stigma (at least in the context of addiction):

In an article titled “In Praise of Stigma,” she argued that stigma reflects a societal norm and can motivate people to change their behaviour. Though “stigma abolitionists” have good intentions, for the most part, Satel wrote that the fear of attributing blame for destructive behaviour can itself be destructive. There is much about addiction that is voluntary, she writes, and to dispel the concept of willpower will only deter the recovery process.

“There is nothing unethical — and everything natural and socially adaptive — about condemning the reckless and harmful behaviours that addicts commit,” she wrote. “This need not negate our sympathy for them or our duty to provide care.”

I would beg to argue that I yet to see any evidence in favour of the notion that societal stigma is an effective tool in getting people to live healthier. If this was true, given the widespread bias and discrimination that people with excess weight experience everyday, we should truly be a nation of rakes.

I wonder what my readers have to say about this.

For a link to the full article click here

AMS
Edmonton, Alberta

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Sharma AM, & Kushner RF (2009). A proposed clinical staging system for obesity. International journal of obesity (2005), 33 (3), 289-95 PMID: 19188927

From time to time the media loves to write stories on the Obesity Myth.

These stories come in two flavours - the first one denies the very existence of an obesity epidemic, attributing the rise in obesity statistics to moving definitions that “suddenly” make everyone obese simply by shifting the goal post.

The second flavor of obesity myths acknowledges the increase in people with excess weight but states that carrying a few extra pounds or even having more severe obesity is not really detrimental to your health, ergo this whole obesity thing is vastly overblown.

Last week, news media around the world once again splashed Obesity Myth headlines on their front pages, this time of the second flavor - yes obesity exists, but it is really not a health risk.

These reports were based on a study by Brant Jarrett and colleagues from the Brigham Young University, Provo, UT, published in the International Journal of Obesity.

The researchers examined data from the 1988-1994, 2003-2004 and 2005-2006 US National Health & Nutrition Examination Surveys (NHANES) to determine the relationship between BMI, age, gender and current medication in 9071 women and 8880 men. Current medication (or medication loads) were considered a surrogate measure of current health status.

In both the 1988-1994 and 2003-2006 data sets, with few exceptions, medication loads did not increase significantly in overweight compared with normal-weight people, a finding that prompted the news headlines.

However, the paper did find increased medication load in people who were clinically obese (BMI>30), especially if they were 40 years of age or older.

In fact, the authors themselves conclude:

“Although obesity does not substantially affect current health in young people, it is likely that the increased medication loads in obese compared with normal-weight older people originates at least in part from an increased BMI starting at a younger age. Thus, age, gender and onset of high BMI all require consideration when using BMI to assess current health status.“

Given these findings, one can only wonder why the media chose to propagate the Obesity Myth based on this study, given that the authors themselves clearly found a relationship between excess weight and health status.

While the authors do emphasize that BMI is not a good measure of health risk, this is nothing new.

Regular readers of these pages will recall several previous posts on the limitations of BMI as an indicator of health and it were indeed these limitations that prompted us to develop the Edmonton Obesity Staging System as a more clinically relevant measure of obesity.

So, while moderate excess weight may not cause apparent health problems in the young, obesity remains a significant risk factor for poor health in middle-aged adults.

AMS
Vancouver, BC

Jarrett B, Bloch GJ, Bennett D, Bleazard B, & Hedges D (2010). The influence of body mass index, age and gender on current illness: a cross-sectional study. International journal of obesity (2005), 34 (3), 429-36 PMID: 20010903

In most countries the ratio of obesity between men and women is approximately equal. Yet, the clients in most obesity clinics and weight loss centres are mainly women.

So what is with the guys?

This question was now examined by Jane deVille-Almond and colleagues from the UK in a paper just published online in the American Journal of Men’s Health.

For this study, 266 male drivers were randomly recruited from motorway service stations and asked about body weight perception and awareness of the relation between adiposity and diabetes as well as weight loss attempts.

The median age of participants was 52 years, and 46% were obese based on BMI and 73% based on waist circumference.

Of participants with normal BMI, 18% thought they were overweight, whereas 26% of overweight participants thought they were “just right” and only 19% of obese participants recognized their obesity.

Based on WC, 30% of participants with normal waist circumference thought they were obese and 9% of obese participants realized they were obese.

Only 25% and 42% of participants recognized that diabetes is associated with large waistlies and obesity, respectively.

A total of 81% of overweight and 62% of obese participants (based on BMI) believed that they were not at increased risk of diabetes.

Perhaps not surprisingly, self-perception of adiposity in men was only a weak predictor weight loss attempts.

I guess a lot more has to be done to bring obesity awareness to menfolk’s attention - especially given that their risk for metabolic complications and early infarcts associated with excess weight is as high if not higher than that of women.

AMS
Edmonoton, Alberta

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Deville-Almond J, Tahrani AA, Grant J, Gray M, Thomas GN, & Taheri S (2010). Awareness of Obesity and Diabetes: A Survey of a Subset of British Male Drivers. American journal of men’s health PMID: 20413385

Yesterday, I chaired a round table organised by the Canadian Obesity Network on behalf of the Public Health Agency of Canada on the development of tools and aids that would help Canadian primary care physicians and other health professionals improve their ability to prevent and treat obesity.

Among the many topics discussed, one of the suggestions that found the most support was to encourage physicians to actually note the diagnosis of “obesity” in their charts. As many readers may know, obesity has long been considered a disease by the World Health Organisation and in fact has its own code in the International Classification of Diseases 9 system (ICD9): 278.

(Just to confuse things, the numbers for obesity in ICD 10 are E65-E68)

The idea here is that unless physicians actually begin recording the diagnosis of ”obesity” in their notes, charts and other records, they will not address obesity with the attention it deserves.

Thus, as one attendee commented, “No doctor would ever dream of leaving out a mention of diabetes, hypertension, COPD or any other disease in their notes, but hardly any physcian ever records the diagnosis of obesity in their charts”.

Simply put, when physicians examine a patient who has obesity and fail to put down “obesity” in their medical chart, they are in fact committing an important breach in their obligations to correctly document their patient’s health status. This would in no way be different from failing to note the presence of diabetes, hypertension, or any other medical diagnosis in their records.

By failing to routinely document the medical diagnosis “obesity” in their records, the physicians are not only commiting an important error of ommission, they are, by the same token, actively ignoring one of the most important and common medical health problems in their patients.

Encouraging, or in fact, requiring physicians to actually note the diagnosis of “obesity” (ICD 278) in their medical records for all patients who meet the WHO criteria for obesity, would not only ensure a proper documentation of their patient’s medical problems, it would also (hopefully) increase the likelihood that they will address this issue with their patients.

I wonder how many of my health professional readers routinely note the diagnosis of “obesity” (ICD-9 278) in their charts when they see it in their patients and I wonder how many patients with excess weight have actually seen their physician record this diagnosis in their chart.

I am often reminded by patients when I ocassionally fail to list one of their many medical conditions in my notes or letters - interestingly, no patient has ever pointed out that I have missed the mention of their diagnosis “obesity” in my letters - I wonder why!

AMS
Edmonton, Alberta

In clinical practice, it is not uncommon to meet individuals who, despite meeting the BMI criteria for obesity, appear metabolically healthy: their glucose, lipid and blood pressure levels are well within the normal range. According to the Edmonton Obesity Staging System (EOSS), we would refer to these individuals as having “Stage O” obesity.

But are these apparently metabolically healthy obese individuals really healthy in that they have a lower mortality risk than obese individuals with metabolic abnormalities?

This question was addressed by Jennifer Kuk and colleagues from York University, Toronto, Canada, in a paper just published in Diabetes Care.

Kuk and colleagues examined data from 6,011 men and women from the Third National Health and Nutrition Examination Survey (NHANES III) where metabolically abnormal was defined as having insulin resistance (IR) or two or more metabolic syndrome (MetS) criteria.

A total of 30% of obese subjects had IR, and 38.4% had two or more MetS factors, whereas only 6.0% (or 1.6% of the whole population) were free from both IR and all MetSyn factors.

Based on the mortality data over 8 years, both the metabolically healthy and metabolically abnormal obese individuals had around the same roughly 2.5 to 3-fold elevation in mortality risk compared to the metabolically normal normal-weight individuals.

The authors conclude that even in the absence of overt metabolic aberrations, excess weight is associated with increased all-cause mortality risk.

Thus, as I’ve said before, it appears that there is no such thing as “benign” obesity. Eventually excess weight will increase the risk for a wide range of health problems including cancers, osteoarthritis and obstructive sleep apnea. This is why it is critical to include the assessment of all four Ms in patients presenting with excess weight.

So how do these findings impact on weight loss recommendations in obese individuals who appear metabolically normal (EOSS 0)?

As blogged before, the first step in weight management is prevention of weight gain. As a rule, this will require substantial changes in diet and activity levels as well as mitigation of any underlying root causes of positive energy balance - this alone can be difficult enough to achieve.

With current conservative obesity treatments only a small minority of patients will achieve and maintain clinically relevant weight loss - the vast majority of weight-losers will simply yo-yo back to their excess weight. I therefore maintain that for most obese individuals weight stabilization may be a far more realistic and sustainable goal than losing weight and keeping it off.

It is also important to remember that associations (as in this paper) do not imply causality and that these new findings therefore cannot be seen as certain proof that weight loss will decrease risk or increase longevity. This question can only be resolved with appropriately designed and conducted intervention trials.

Nevertheless the data should give caution to the notion that excess weight in metabolically healthy adults is harmless.

Prevention of weight gain is likely beneficial irrespective of obesity stage and should be the primary goal of all weight management interventions.

AMS
Edmonton, Alberta