One of the key barriers to accessing obesity treatments in many countries (besides lack of training and common weight-bias of health professionals) is the lack of coverage for obesity treatments in public and private plans.
Thus, for example in the US, under the Medicare Modernization Act of 2003, Medicare is in fact prohibited from covering prescription obesity medicines.
Now, a US survey conducted by the Gerontology Society of America among 1,000 US Adults using online interviews shows a strong majority in favour of Medicare coverage for obesity medications.
Here is a summary of the main findings:
- 87 percent of Americans believe obesity is a problem in their state.
- 69 percent of Americans believe Medicare should expand coverage to include prescription obesity medicines.
- 77 percent were unaware that federal law specifically prohibits Medicare from covering patient costs for prescription obesity medicines.
- 69 percent of Americans were unaware that the FDA has found that current prescription obesity medicines are safe and effective in treating obesity. (In the last 5 years multiple medicines have been approved as safe and effective by the FDA)
To me these results are surprising as I would have expected that most Americans (like most everybody else) still believes that people with obesity need to overcome this by simply eating less and moving more rather than taking the “easy way out” by simply “popping a pill”.
Perhaps, the notion that obesity is a chronic disease and that people who have it deserve treatment the same as anyone else with any other chronic disease is starting to trickle through.
Then again of course, this survey (as so often with polls) may simply be completely off the mark.
Yesterday’s guest post on the issue of food addiction (as expected) garnered a lively response from readers who come down on either side of the discussion – those, who vehemently oppose the idea and those, who report success.
Fact is, that we can discuss the pros and cons of this till the cows come home, because the simple truth is that the whole notion lacks what my evidence-based colleagues would consider “strong evidence”.
Indeed, I did try to find at least one high-quality randomized controlled study on using an addictions approach to obesity vs. “usual” care (or for that matter anything else) and must admit that I came up short. The best evidence I could find comes from a few case series – no controls, one observer, nothing that would compel anyone to believe that this approach has more than anecdotal merit.
Yet, the biology (and perhaps even the psychology) of the idea is appealing. Self-proclaimed “food addicts” that I have spoken to readily identify with the addiction model and describe their relationship to “trigger foods” as an uncontrollable factor in their lives that calls for complete abstinence. Animal studies confirm that foods do indeed stimulate the same parts of the brain that are sensitive to other hedonic pleasures and substances.
So why the lack of good data? After all, the idea is hardly new – intervention programs for “food addicts” using the 12 steps or other approaches have been around for decades.
Can it be simply the lack of academic interest in this issue? I find that hard to imagine – but nothing would surprise me.
Is it perhaps because addiction researchers do not take obesity seriously and obesity researchers don’t like the addiction model?
I certainly don’t buy the argument that there is no commercial interest in such an approach – if there were strong and irrefutable evidence, I’m sure someone would figure out how to monetize it.
So again, I wonder, why the lack of good data?
Honestly, I don’t know.
I’m open to any views on this (especially if substantiated by actual evidence).
There are no doubt long-term “success stories” out there – people who just by making (often radical) changes in their diet and activity behaviours have lost a substantial amount of weight AND are keeping it off.
However, there is also no doubt that these people are rare and far between – which is exactly what makes each one of them so exceptional.
I am not speaking of all the people we hear or read about who have lost tons of weight – we hear about their spectacular weight loss – cutting carbs, cutting gluten, going vegan, going paleo, alternate day fasting, running marathons, training for iron man competitions, going on the Biggest Loser or eating at Subway.
What we don’t hear about is the same people, when they put the weight back on – which, in real life is exactly what happens to the absolutely vast majority of “losers”. We hear of their “success” and then we never hear from them again – ever.
Oprah is different! Different because, we have had the opportunity to follow her ups and downs over decades.
When Oprah “succeeds” in losing weight, she does not disappear into the night – no – she puts the weight back right in front of our eyes, again and again and again and again.
Now, comedy writer Caissie St.Onge, in a comment posted on facebook, pretty much summarizes what it is we can all learn (and should probably have learnt a long time ago) from Oprah:
“Oprah is arguably the most accomplished, admired, able person in the world. She creates magic for other people and herself on the regular. So, if Oprah can’t do permanent lifelong weight loss, maybe it can’t be done. Oprah is also crazy rich. If Oprah can’t buy permanent lifelong weight loss, maybe it can’t be bought.”
“I’m not saying you should give up on your dreams of having the body you want. I’m just asking, if you never get that waist, will your life have been a waste? (I see what I did there.) Every day we are bombarded with media, content and products. Special foods and drinks. Programs and plans. None of this shit has ever worked for Oprah and it probably isn’t gonna work for me or you.”
“I know the reason isn’t because you’re weak. If you’re carrying around 10 or 20, or 50 or 150 pounds more than the tiny friend who always calls herself fat in front of you and you don’t kick her in the back of the knee, you’re the opposite of weak. You’re very, very strong in at least two different kind of ways.”
“I realize there are people who are DYING to tell you what they think about what you should do with your body. It always starts with, “No offense but…” or “Not to be mean, but…” And it’s always offensive and mean, but also, you probably say things to yourself every day that are way meaner than what any “well-intentioned” “friend” or internet troll could come up with. You’re gonna have to try harder if you want to beat us at our own game, internet trolls. I would pop someone in the chops if they spoke to me the way I speak to myself. And I would bet all of Oprah’s money that Oprah says mean shit to herself too. Oprah does.”
“You can do what you want. You knew that. But I’m gonna stop wishing that I didn’t have dimples on the backs of my hands or that my ankles were more flattered by strappy shoes. I’m gonna stop telling people that they look great and start telling them what I really mean, that’s it’s nice to see them. And I see you. And I like you so much just how you are right now, and not a year or five years from now when you may or may not be smaller….. Oprah. I’ll love you either way.”
Cassie’s entire post is available here
This is even more true for children with physical disabilities, who face even greater challenges when it comes to preventing or managing excessive weight gain. Unfortunately, not much is known about the extent of this problem or possible solutions.
Now a group of Canadian experts in paediatrics and rehabilitation have put out a Call to Action, published in Childhood Obesity, for a research agenda that focuses on this important sub-group of kids.
The call is the result of a Canadian multistakeholder workshop on the topic of obesity and health in children with physical disabilities that was held in October 2014.
The participants in the workshop included researchers, clinicians, parents, former clients with disabilities, community partners, and decision makers.
Given the paucity of research in this area, it is not surprising that the participants identified over 70 specific knowledge gaps that fell into 6 themes: (1) early, sustained engagement of families; (2) rethinking determinants of obesity and health; (3) maximizing impact of research; (4) inclusive integrated interventions; (5) evidence-informed measurement and outcomes; and (6) reducing weight biases.
Within each theme area, participants identified potential challenges and opportunities related to (1) clinical practice and education; (2) research (subareas: funding and methodological issues; client and family engagement issues; and targeted areas to conduct research); and (3) policy-related issues and topic positioning.
Recommendations emerging from the workshop’s multistakeholder consensus activities included:
Children’s and families’ needs must be integrated into prevention and treatment programs, taking into account the additional caring commitments and environmental challenges often experienced by families of children with physical disabilities. Guidelines need to be developed regarding how best to engage children/families meaningfully in designing both clinical interventions and health promotion research initiatives.
Research in obesity and health in children with physical disabilities should be guided by a conceptual model, determining both common and unique determinants of health and obesity compared with their typically developing peers. A conceptual model enables existing knowledge about obesity prevention and management from other populations to be integrated into approaches for children with physical disabilities where appropriate, as well as the identification of areas where disability-specific knowledge is still needed. It is critical that any such model incorporates social and environmental factors that can affect both weight and health, rather than locating responsibility within the individual by default.45 The alignment of our model with the ICF ensures that our approach remains truly biopsychosocial.
Valid, reliable, clinically appropriate, and acceptable outcome measures are urgently needed in order to monitor children’s weight and health, and identify overweight and obesity, where conventional outcomes (e.g., BMI) alone have been shown as suboptimal.
As the authors note,
“Canadian researchers are now well positioned to work toward a greater understanding of weight-related topics in children with physical disabilities, with the aim of developing evidence-based and salient obesity prevention and treatment approaches.”
Hopefully, they will now find the funding required to do the work.
A key reason for the Canadian Obesity Network to roll out its public engagement strategy, is not just provide a source of credible information on obesity prevention and treatment but also to provide a forum for the prospective of those living with obesity.
That this perspective is often lost in the obesity debate, is highlighted by a thoughtful commentary published in JAMA Internal Medicine written by Fiona Clement, PhD, from the Department of Community Health Sciences, University of Calgary, and has herself struggled with excess weight for most of her adult life.
Clement, whose BMI (at 31.8 kg/m2) barely fits the “obesity criteria”, notes that,
“…this article is the first time I have told my BMI to another soul. I have never shared my BMI with my husband, my friends, nor, importantly, my physician. Given that I am an otherwise healthy 35-year-old woman, it is shocking that what is probably my only health concern has never been talked about within the privileged space of my physician-patient relationship.”
Her reasons for not talking about this are not surprising,
“Obviously, this is an awkward conversation for both the patient and physician. Weight is a tough subject, loaded with stigma, self-esteem, worthiness, and beauty issues. Despite guidelines recommending weight management counselling, the conversation is not happening regularly. Like many hard conversations, it requires compassionate listening and sympathy on the part of the physician, courage and humility from the patient.”
This problem is well recognized, which is exactly why the Canadian Obesity Network’s 5As approach to obesity management emphasizes the tact and skills needed to initiate this conversation (ASK for permission, be non-judgemental, do not make assumptions).
As to the use of appropriate obesity management strategies, Clement essentially opted for the most common “do-it-yourself” approach of “eat-less-move-more”, which as ample research shows is rarely a sustainable strategy. Not surprisingly, the weight she lost came back when, as she says, life happened.
Clement writes about the information she would want presented before she made an informed decision to pursue any of the proposed interventions.
This is exactly what the 3rd A in the 5As of Obesity Management is about – ADVISE. This is where, following the ASK and ASSESS, the health professional would offer their advice – tailored to the individual.
Given that Clement barely meets the BMI criteria for obesity and has, as she states, no weight related health issues, she would at best be considered to have Stage 0 obesity according to the Edmonton Obesity Staging system.
At this stage, the risk (not to mention the cost) of pharmacological or surgical treatments would by far outweigh any potential benefits. Indeed, the focus would be to first and foremost prevent further weight gain by addressing any underlying contributing factors while living the healthiest life she can enjoy (best weight).
This is apparently the course of action that she chose, wisely it seems.
Indeed, given that she has Stage 0 obesity, it is not clear that she would have any real health benefit from attempting to or sustaining weight loss – obesity management should never be about treating numbers on a scale.
Perhaps if Clement had a higher obesity stage, say Stage 2 with diabetes, fatty liver disease or sleep apnea, the advise may be different. In that case, given the substantial risk associated with these conditions, pharmacological or surgical options (especially if her BMI was higher that 35) may well be reasonable additions to her behavioural change.
Thus, Clement is right in noting that interventions have to be individually tailored and a frank conversation about the risks and benefits of treatment between her and a health professional who understands obesity needs to happen (unfortunately, the latter is difficult to find).
With obesity as with other diseases, the question is always the same – at what stage of the disease does the risk of treatment outweigh the risk of not-treating (or not-treating aggressively enough). Whether the problem is diabetes, arthritis, or cancer – the question of risk-benefit ratios must always be seen in the context of the individual.