For all my Canadian readers (and any international readers planning to attend), here just a quick reminder that the deadline for early bird discount registration for the upcoming 4th Canadian Obesity Summit in Toronto, April 28 – May 2, ends March 3rd.
To anyone who has been at a previous Canadian Summit, attending is certainly a “no-brainer” – for anyone, who hasn’t been, check out these workshops that are only part of the 5-day scientific program – there are also countless plenary sessions and poster presentations – check out the full program here.
To register – click here.
It would hardly come as a surprise to regular readers that I would be delighted to see the Edmonton Obesity Staging System featured quite prominently in the article on obesity management by Dietz and colleagues in the 2015 Lancet series on obesity.
Here is what the article has to say about EOSS:
“The Edmonton obesity staging system (EOSS) has been used to provide additional guidance for therapeutic interventions in individual patients (table 1). EOSS provides a practical method to address the treatment paradigm. In principle, EOSS stages 0 and 1 should be managed in a community and primary care setting. Recent data from the USA suggest that 8% of patients with severe obesity (BMI ≥35 kg/m²) account for 40% of the total costs of obesity, whereas the more prevalent grade 1 obesity accounts for a third of costs. These findings suggest that greater priority should be accorded to EOSS stages 3 and 4, resulting in greater focus on pharmacological and surgical management delivered in specialist centres.”
These recommendations are not surprising, as EOSS was specifically designed to provide a much better representation of how “sick” a patient is rather than just how “big” she is.
This is why EOSS has now found its way not just into the 5As of Obesity Management framework of the Canadian Obesity Network but also into the treatment algorithm of the American Society of Bariatric Physicians.
To download a slide presentation on how EOSS works click here.
Following the recent guest posts by Drs Vera Tarman and Pam Peeke on food addiction, many readers have left comments about how this notion rings true to them and how the ideas of treating their “eating disorder” as an addiction has helped them better control their diet and often lose substantial amount of weight.
Others have asked how to tell if they might be food addicts. For them, I am reproducing the following list of 20 questions taken from Food Addicts in Recovery Anonymous.
Although it is important to note that “food addiction” has yet to be officially recognized as a medical/psychiatric condition and the following questions are by no means “diagnostic”, I would still support the idea that the more of these questions you answer with yes, the more likely you may benefit from discussing this problem with someone who has expertise in addictions (rather than simply going of on another diet or exercise program).
1. Have you ever wanted to stop eating and found you just couldn’t?
2. Do you think about food or your weight constantly?
3. Do you find yourself attempting one diet or food plan after another, with no lasting success?
4. Do you binge and then “get rid of the binge” through vomiting, exercise, laxatives, or other forms of purging?
5. Do you eat differently in private than you do in front of other people?
6. Has a doctor or family member ever approached you with concern about your eating habits or weight?
7. Do you eat large quantities of food at one time (binge)?
8. Is your weight problem due to your “nibbling” all day long?
9. Do you eat to escape from your feelings?
10. Do you eat when you’re not hungry?
11. Have you ever discarded food, only to retrieve and eat it later?
12. Do you eat in secret?
13. Do you fast or severely restrict your food intake?
14. Have you ever stolen other people’s food?
15. Have you ever hidden food to make sure you have “enough?”
16. Do you feel driven to exercise excessively to control your weight?
17. Do you obsessively calculate the calories you’ve burned against the calories you’ve eaten?
18. Do you frequently feel guilty or ashamed about what you’ve eaten?
19. Are you waiting for your life to begin “when you lose the weight?”
20. Do you feel hopeless about your relationship with food?
Recently, I had the opportunity of meeting Vera Tarman, a Toronto addiction physician, who is also a self-proclaimed “food addict” and author of the book, “Food Junkies: The Truth About Food Addiction“.
It is fair to say that talking to Tarman and reading her book (of which she happily gave me a copy) has definitely given me food for thought.
To start with, her book “Food Junkies” is not a typical diet book or even a treatment guide to food addiction.
Rather, it is a rather compelling treatise in support of the existence of a discrete and definable subset of obese (and non-obese) individuals who may well be considered “food addicts” and for whom the only viable treatment is complete abstinence from their respective trigger foods.
To put things simply, Tarman (and her co-author Philip Werdell) describes three categories of “eaters” (the following words my attempt at paraphrasing the central ideas as I understand them):
Normal Eaters: this is by far the largest group of individuals with obesity, who may overeat for no other reason than that they like food, are surrounded by food, pay little attention to food, let themselves go hungry, have food pushed on them, and/or really don’t obsess or worry about food at all. Normal eaters can learn to control their eating through education and coaching and by changing the circumstances that foster poor willpower: better sleep, stress management, improving social skills, changing their personal food environment, etc.
People with Eating Disorders: for this group of individuals, obesity is not the primary problem, rather it is just another symptom of the underlying emotional disturbances that drives their “pathological” eating behaviour. The “spectrum” of these disorders ranges from rather mild “emotional eating” to full blown “binge eating syndrome”. The primary driver of their overeating is psychological (e.g. trauma, grief, abuse, etc.). Once the psychological problem is identified and resolved (or managed, e.g. though cognitive behavioural therapy), they can gain control over their eating behaviour, which in turn can help them control their weight problem.
Food Addicts: this group of individuals is literally “addicted” to certain foods (usually foods high in sugar, flour, fat and/or salt) in the same manner that a drug addict would be considered addicted to their drug, with the same clinical signs that range from denial and loss of control, to physical symptoms on “withdrawal” and relapse that can be prompted by minimal exposure, even years after being “clean” or “sober”.
According to Tarnan and Werdel, this grouping has important implications for clinical management.
While a “normal eater” and someone with an “eating disorder” can eventually learn to practice “moderation”, this is virtually impossible for the true addict – the only viable strategy for them is complete and lifelong abstinence (best coupled with a 12 steps program or something similar).
For the true “food addict”, no amount of education, psychological counselling or attempt at “moderation” will ever lead to success. Any attempt to get the “food addict” to learn how to “use” their “drug” in moderation will be as futile as trying to get a drug addict to learn how to use alcohol or heroin (or any other drug) in moderation (the vast majority will fail).
As to how the “food addict” can practice abstinence, the Food Junkie acknowledges that this is difficult but achievable. Obviously, the goal will be to completely eliminate and abstain from the “trigger foods”, which will vary from individual to individual (and people may well bounce around from one food to the next). Nevertheless, a good place to start is probably with foods that contain sugar, flour, are highly processed, high in fat or otherwise “addictive”.
For some it may mean a low-carb, for others a paleolithic diet, or simply a fruit and vegetable-based high protein diet with some fat thrown in for satiety – here Food Junkies discusses the various options, while acknowledging that there is no hard and fast rule – only, that it can be achieved (a point that the authors illustrate using their own stories and those of their patients).
All of this said, the authors are the first to acknowledge that there is much about food addiction that we don not yet know or fully understand.
For one, making the diagnosis is anything but easy – often, this “diagnosis” can only be made when all attempts at “moderation”, despite best efforts, fail.
The authors also accept that we do not know the prevalence of true food addiction – only, that it may be higher than we think.
If nothing else, the book is a quick and fascinating read for anyone interested in the issue – patient or professional.
It certainly has got me thinking about whether or not “abstinence” may indeed be a viable approach for some of my patients.
For anyone, who has questions regarding this concept, Dr. Tarman has kindly agreed to address these in a subsequent guest post on these pages – so please send me your comments/questions.
Research shows that many practitioners are surprisingly uncomfortable addressing the issue – most do not know how to bring up the topic, which is why they’d rather ignore it.
For clinicians, who simply do not know how to bring up the issue of weight, here is a simple tip: ask about appetite.
Indeed, we have all learnt that appetite is an important vital sign and should really be part of any clinical assessment (as should questions about mood or sleep). Often, a loss or increase in appetite can be a sign of other underlying health issues. As a corollary to this, as long as there is no change in appetite, things are probably not too serious.
No patient I know of has ever objected to being asked about their appetite.
But here is the catch – to really understand the relevance of the reported change in appetite, given that appetite is rather subjective – any question about appetite always needs to be followed by a question about body weight.
If appetite is reportedly bad – you would expect to see weight loss.
If appetite is reportedly increased – you would expect to see weight gain.
If appetite is unchanged – you would expect weight to be stable.
Thus, a question about appetite quite naturally opens the door to further questions about body weight.
Obviously, you would have to use your clinical judgement to decide whether or not the patient may have concerns about their weight and respond appropriately.
Incidentally, changes in body weight without subjective changes in appetite, should also prompt further investigation.
But remember, you can always get to discussing weight via questions about appetite (just remember A&W).