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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Tuesday, March 25, 2014

Challenges in Pediatric Obesity Management

sharma-obesity-kids-scale2If treating obesity in adults is challenging, managing obesity in kids is even more daunting.

Now, a seminal paper by Jill Avis and colleagues (representing a virtual who-is-who of pediatric obesity management in Canada), published in Expert Reviews in Diabetes and Metabolism, with the fitting title, “It’s like rocket science…only more complex“, explores the many challenges in pediatric obesity management in Canada.

The thoughts and analyses presented in this narrative review are largely based on the responses to a national survey of folks providing pediatric “weight-management” services across Canada. Responses were sought to a range of questions, including:

In regards to managing pediatric obesity in Canada, what lessons have you learned related to: Caring for children?; Collaborating with clinicians and/or researchers?; and Working within the health care system? In addition, what do you consider to be important future directions for clinical care and research in Canada?

Apart from noting the importance and challenges of adopting a family centred approach, the paper highlights the importance of factors that go well beyond “eat-less-move-more” platitudes.

Thus, the authors note that,

“Internalizing (e.g., anxiety, depression) and externalizing (e.g., hyperactivity, aggression) disorders are common in children and adolescents with obesity, which can make management strategies more difficult to implement…..these realities highlight the need for mental health professionals to assume active roles in pediatric obesity management to explore, identify and manage families’ unique mental health concerns.”

With regard to the importance of weight bias, the authors state,

“Many parents in our care have experienced shame and blame from other family members, friends, coworkers and health professionals regarding the weight status of their children….The underlying assumption in this instance is that individuals with obesity just need to eat less and move more….a sentiment that demonstrates a lack of understanding and empathy.”

Thus,

” There is a clear need to shift from a singular focus on physical weight status to define the health of individuals with obesity to a nonjudgmental and unbiased appreciation of the complex causes and consequences
of obesity.”

Despite all efforts, the authors describe the outcomes of childhood obesity interventions as “modest”.

This has prompted a number of collaborative research initiatives including the Canadian Pediatric Weight Management Registry (CANPWR), the Should I Stay or Should I Go study and (in partnership with the Canadian Obesity Network) the development of a national network called Treatment and Research of Obesity in Pediatrics in Canada (TROPIC), whose purpose is to promote knowledge translation and dissemination of issues related to pediatric obesity management in Canada.

All of these activities demonstrate a high degree of collaboration and coordination among the pediatric obesity management community in Canada.

The paper also addresses the challenges of providing childhood obesity management services within the health care systems (which vary across provinces).

“…there is substantial heterogeneity across the multidisciplinary clinics we lead and work within; some are well-resourced (i.e., physical space, clinical, and administrative personnel), while others struggle with limited budgets to provide comprehensive and long-term care for families.”

“…relatively small numbers of patients (compared with other outpatient pediatric clinics [e.g.,general pediatrics]) and a lack of substantial weight loss for most children and adolescents with obesity…necessitate education, contextualization and justification to colleagues and administrators within the health care system so that obesity is viewed not as a simple problem that requires a quick fix in order to achieve weight loss, but as a chronic disease that requires ongoing support and management.”

Important work to aid clinicians include the adaptation of the Edmonton Obesity Staging System for pediatric populations (EOSS-P), the family centred adaptation of the 5As of Obesity Management for managing pediatric obesity in primary care, and CONversation cards, a tool to facilitate discussions between clinicians, parents and kids on issues related to healthy lifestyle changes.

Finally, the paper discusses the many barriers to accessing timely obesity management including costs (travel, parking, time off work), geography (distances) and wait times.

Clearly, despite all progress, significant challenges remain to be addressed – “it’s like rocket science…only more complex.”

@DrSharma
Edmonton, AB

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Wednesday, March 19, 2014

Can Testosterone Lead to Weight Loss in Hypogonadal Men?

sharma-obesity-impotenceLoss of male gonadal function has been associated with weight gain (particularly visceral adiposity) as well as metabolic disturbances including dyslipidemia and insulin resistance.

However, wether or not hormonal substitution with testosterone (T) ameliorates these metabolic abnormalities or even leads to weight loss remains controversial.

Now a 6-year observational study by Ahmad Haider and colleagues from Germany, published in the International Journal of Endocrinology, strongly suggests that this may well be the case.

The authors analysed data from two prospective longitudinal studies that included 156 obese hypogonadal men, aged between 41 and 73 years (mean 61.17 ± 6.18) with previously diagnosed type 2 diabetes, who were seeking urological consultation for various conditions such as erectile dysfunction, decreased libido, questions about their T status, or a variety of urological complaints.

All subjects  had subnormal plasma total T levels and at least mild symptoms of hypogonadism assessed by the Aging Males’ Symptoms scale (AMS).

Treatment was started with parenteral T undecanoate 1000 mg (Nebido, Bayer Pharma, Berlin, Germany), administered at baseline and 6 weeks and thereafter every 12 weeks for up to 72 months. Subjects were also given general advice on healthy eating and physical activity.

This treatment resulted in an increase in total T levels from 8.9 ± 1.99 nmol/L to above 16 nmol/L within the first year of therapy, and remained at this physiological level throughout the course of treatment.

This change in T levels was associated with a progressive 12 cm decrease in waist circumference and weight loss of about 17.5 Kg (15% of initial weight) with BMI dropping from 36.5 to 31.2 at year 6.

Concomitantly, fasting glucose declined from 7.06 to 5.59 mmol/L and HbA1c decreased from 8.08 to 6.14%.

There were also favourable changes in systolic and diastolic blood pressure, lipid profiles including triglycerides and total cholesterol:HDL ratio, as well as CRP and liver enzymes.

While general caution is in order given that there was no control group, these finding certainly strongly suggest a possible role for T-replacement therapy in hypogonadal males presenting with symptoms of hypogonadism and weight gain.

Clearly, the 15% weight loss is impressive and well-exceeds what is generally seen with pharmacological obesity treatments.

If nothing else, these observations should prompt the conduct of a well-designed randomised controlled trial to confirm the effect and safety of T replacement therapy for obesity in hypogonadal men.

@DrSharma
Edmonton, AB

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Thursday, February 13, 2014

Guest Post: Everything You Must Know About Pregnancy and Weight Gain

Zach Ferraro, PhD, University of Ottawa

Zach Ferraro, PhD, University of Ottawa

Today’s post is from Zach Ferraro, PhD, a former CON-SNP National Executive member (2008-12), CON Boot Camper (2008) and Inaugural recipient of CON Rising Star Award (2012). Currently, Zach is a clinical research associate in the Division of Maternal-Fetal Medicine at the Ottawa General Hospital and PT Professor in Human Kinetics at the University of Ottawa. He is also a member of the CON 5 As for pregnancy working group.

Regular readers of these pages will recall that the intrauterine environment plays a vital role in healthy neonatal development and is directly influenced by maternal nutrition, physical activity, xenobiotics and pregnancy weight gain. This interaction is commonly referred to as ‘fetal programming’ or more appropriately termed fetal plasticity. That is, the ability of the developing fetus to grow and respond to external stimuli whether intrauterine or environmental. Thus, all prenatal exposures, positive and negative, have the potential to affect the short- and long-term health of the child.

It is now well-established that excess gestational weight gain (GWG) is an independent predictor of large for gestational age (LGA) neonates and postpartum weight retention (PPWR) in the mother. Simply, moms who gain greater than the recommended amount of weight, according to their pre-pregnancy BMI, subsequently carry this excess weight forward into the next pregnancy causing a rightward shift in their BMI after delivery. In addition, babies born large (LGA) tend to track their excess weight throughout life and are at greater risk of becoming obese as adults. Although the mechanisms explaining these associations are far from unraveled, both LGA and PPWR exacerbate what is referred to as the intergenerational cycle of obesity.

So what can care providers do to help minimize the ill-effects of excessive GWG? Several lifestyle interventions during pregnancy are reported in the literature and have yielded mixed results. This is largely due to heterogeneity in intervention type (diet or physical activity or psychological support or all the above) and intensity (intensive clinical intervention vs. hands off approach). We, in addition to others, have also reported that knowledge transfer between patients and providers may be partially responsible for the limited treatment effects seen in some interventions. Nonetheless, in the absence of any between group differences in GWG guideline adherence and maternal-fetal outcomes between lifestyle intervention and standard care, it is important to remember that healthy living behaviours were not harmful and may have resulted in increased fitness and/or alterations in body composition (which is rarely if at all ever measured). Thus, healthy living trumps numbers on the scale, something readers of these pages are all too familiar with.

Given the many known benefits of appropriate GWG how can we help providers implement, and patients adhere to, recommendations and in turn improve maternal-fetal outcomes? In the fall of 2013 the Institute of Medicine (IOM) chaired a workshop entitled “Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines” to help address this important clinical issue. A link to the 97 page report can be found at the end of the post. During the workshop the IOM heard from clinical experts, scientists, researchers and public health advocates on topics ranging from communicating the pregnancy weight gain guidelines, how to support behaviour change, implementing the guidelines, an overview of the importance of the first 1000 days and collaborating to increase messaging and uptake of the guidelines. Following the workshop it was concluded that strong and consistent messaging was required to assist with patient-provider uptake. Additionally, several resources including physical activity and GWG prescription pads were shared as examples of tools care providers could use with patients. A conceptual model, GWG poster, an easy-to-read information pamphlet, GWG tracker, 5 common myths heard from expectant mothers, and an interactive online tool were also highlighted.

To conclude the IOM committee recommended adopting a ‘before, between and beyond’ approach to connect pregnancy care with general health care to take advantage of the adage ‘prevention before conception’. Changing the structure of prenatal care was suggested to encourage visits earlier in pregnancy as a way that reflects each woman’s unique situation and risk profile; noting that the reversal of early excessive GWG is challenging at best. Lastly, recommendations to motivate women to adopt healthy behaviours by initiating a dialogue between patient and provider were suggested to leverage action across the continuum of prenatal care. It is important to note that many of these recommendations are included within the soon to be released CON 5 As for Healthy Pregnancy Weight Gain.

As the GWG research continues to mount and novel prenatal interventions using sophisticated technology attempt to facilitate behaviour change, care providers and patients require immediate tools/strategies to help improve maternal-fetal outcomes. In addition to the CON 5 As for Pregnancy, providers can be confident recommending routine physical activity (in those without contraindications), nutritional guidance and caloric literacy given that the caloric requirements of pregnancy are modest (~300 kcal/day in term 2 and 3), encouraging a food diary and physical activity log and tracking GWG on their own using the tools provided within the report. Collectively, patients and providers can work together with open dialogue to ensure optimal health and wellness for mom and baby.

You can follow Dr. Zach Ferraro on twitter @DrFerraro for frequent discussion on the topic. More details can be found at www.DrFerraro.ca

References:

Institute of Medicine (2013). Leveraging Action to Support Dissemination of Pregnancy Weight Gain Guidelines

Ferraro ZM, Boehm K, L Gaudet, KB Adamo. Counseling about gestational weight gain and healthy lifestyle during pregnancy: Canadian maternity care providers’ self-evaluation. International Journal of Women’s Health. 2013:5 629-636. 

Ferraro ZM, N. Barrowman D. Prud’homme, MW. Walker, M. Rodger, SW. Wen, KB. Adamo. Excessive gestational weight gain predicts large for gestational age neonates independent of maternal body mass index. Journal of Maternal-Fetal & Neonatal Medicine. 2012;25(5):538-542.

Institute of Medicine (2009). Weight Gain During Pregnancy: Reexamining the Guidelines

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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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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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