Arya M. Sharma, MD

This week, while I am attending Obesity 2011, the 29th Scientific Meeting of The Obesity Society here in Orlando, back home, the Canadian Obesity Network is busy conducting a photo shoot with the goal to create a library of images of people with obesity that can be used by the media and others reporting on this issue.

As readers will recall, I have previously commented on the fact that ‘obese people have heads too‘ - a fact that could easily be missed given the usual depiction of headless fat people in the media. Together with the usual images of these anonymous torsos sitting on couches and eating chips, this typical depiction of obesity not only serves to reinforce the stereotypical image of the gluttonous and slothful obese person but is in fact simply wrong in that it does not show the true face of obesity (no pun intended).

As outlined in the “Guidelines for the Portrayal of Obese Persons in the Media” developed by the Rudd Center for Food Policy and Obesity at Yale University and The Obesity Society (TOS):

When selecting an image, video, or photograph of an obese person, consider the following questions:

1. Does the image imply or reinforce negative stereotypes?

2. Does the image portray an obese person in a respectful manner? Is the individual’s dignity maintained?

3. What are the alternatives? Can another photo or image convey the same message and eliminate possible bias?

4. What is the news value of the particular image?

5. Who might be offended, and why?

6. Is there any missing information from the photograph?

7. What are the possible consequences of publishing the image?

Media aside, I think these guidelines should be considered by anyone given a talk on obesity that involves the use of media (slides, videos, etc.).

Unfortunately, as I know all too well, it is not easy to find such images.

This is why, the Canadian Obesity Network has invited volunteers to be photographed in pictures that will be offered to the media and anyone else for non-commercial use in reports, talks, presentations, and publications on obesity. This royalty free library will soon be available through the Canadian Obesity Network.

For more details and examples of some of the shots, head over to a post by DR EyeCandy, who co-ordinate this shoot for the Network.

Thanks to everyone involved - it looks like you had a great time for a great cause.

AMS
Orlando, Florida

One of the reasons that many health professionals do not bring up the issue or weight, is simply because they feel uncomfortable doing it.

So what is the best strategy and what does the research on this issue actually show?

This topic is a significant part of a new Scientific Statement From the American Heart Association, endorsed by the Society of Behavioral Medicine, published in the latest issue of Circulation.

Based on a systematic search of the literature on this topic (published between 2002 and 201), it is clear that patients describe a need for empathy, nonjudgmental interactions, and specific personalized recommendations.

As regular readers will recall, this is actually rule 1 of my 10 tips for family docs, and if nothing else, this is the only rule that all health professionals should adhere to - always!

While some patients associate even the word “obese” with discrimination, patients rate “‘weight” as the most desirable term, and “fatness” as the most undesirable term.

In my practice, I often also use the terms ‘large’, ’size’, or ‘big’ and have never had a negative response - much of how you use the language is determined by the general ‘non-judgemental’ manner in which the words are used. When I do use the term ‘obese’, I generally explain that I am using this ‘clinically’ as the ‘medical’ definition.

“Patients also express a preference for clinicians taking time to deliver weight loss counseling, rather than offering weight loss advice as an afterthought as they leave the room.”

“The importance of verbally recognizing patients’ small weight losses as well as their unsuccessful weight management efforts was also noted, because nonrecognition by providers was seen as a judgment that the patient did not care or was not making an effort toward weight loss.”

I generally do acknowledge changes in weight, but do not make them the topic of discussion unless I am specifically asked. Any comment would always be objective, non-judgemental and generally encouraging, no matter what - even a small weight gain could be worse!

When the patient brings up and insists on discussing the weight - this is always a good opportunity to explain (once again) that obesity management is not about weight loss and what is really important are the behaviours (weight loss is NOT a behaviour).

“Patients expressed an interest in hearing about how their weight was affecting their specific medical conditions (or risk for conditions) and an interest in receiving specific recommendations from the individual provider on how to lose weight rather than just broad statements about the need to lose weight.”

“Finally, physician recommendations related to diet and physical activity were more effective (ie, associated with greater likelihood of patient behavior change) if patients were given the chance to reflect on causes of their overweight during counseling visits and their own perceptions about weight management were incorporated into the recommendations.”

Yup, it never hurts to ask and listen to your patient.

“Beginning a conversation about weight is challenging and may be especially difficult if there are no readily available and affordable resources for patients genuinely interested in losing weight.”

This is definitely a problem, as most resources are either generically useless (focussing almost exclusively on “eat-less-move-more” platitudes) or consist of BMI charts and other material that is hardly useful. Of course, the fact that the ‘weight-loss’ industry is in the business of selling ‘weight-loss’ and is not in the business of providing obesity treatments, is a fine point that many patients (and professionals) find difficult to understand.

Overall, this is certainly an issue that will continue to prove challenging simply because most health professionals do have significant weight bias, tend to stereotype their obese patients, and too often have little more than a lay man’s knowledge of obesity themselves.

I am sure that readers will readily recall instances where communication on this topic could have been better.

AMS
London, UK

Rao G, Burke LE, Spring BJ, Ewing LJ, Turk M, Lichtenstein AH, Cornier MA, Spence JD, Coons M, & on behalf of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Nursing, Council on the Kidney in Cardiovascular Disease, and Stroke Cou (2011). New and Emerging Weight Management Strategies for Busy Ambulatory Settings: A Scientific Statement From the American Heart Association * Endorsed by the Society of Behavioral Medicine. Circulation, 124 (10), 1182-1203 PMID: 21824925

Regular readers will be aware that we currently have virtually no effective drugs for the treatment of obesity (which, interestingly, leaves the field wide open for the snake oil pedlars, who, in addition, enjoy an apparently ‘free-for-all’ unregulated scam-artist utopia).

That said, one can only wonder why, despite billion dollar investments, the pharma industry has not been able to bring a single new anti-obesity drug to market in North America since 1999. Is perhaps the regulatory bar simply too high?

This issue is the subject of a discussion paper by Morgan Downey (author of the Downey Obesity Report), Christopher Still (Geisinger Obesity Institute) and myself, published in the latest issue of Current Opinions in Endocrinology, Diabetes & Obesity.

As we point out, since July 2010, the FDA’s Endocrine and Metabolic Advisory Committee has reviewed three new drug applications and one previously approved drug for the treatment of obesity - all three new drug applications were declined while the one existing drug (sibutramine) was ‘voluntarily’ pulled from the market despite a split vote by the Advisory Committee.

In this paper we examine in detail the Advisory Committee’s consideration of the risk–benefit equation of the four drugs, especially in light of its decision on sibutramine and the results of the SCOUT study.

Currently, the FDA’s criteria for effectiveness for anti-obesity drugs has two alternatives: The first is a mean efficacy defined as medication-associated weight reduction of 5%. The alternative criteria is a categorical efficacy endpoint defined as a significantly greater proportion (at least 35%) of those individuals receiving the medication, compared with controls, maintaining a 5% weight loss from their initial weight. Demonstrating the resolution of any obesity associated comorbidities is not a requirement (although, it perhaps should be - see below).

These effectiveness criteria are certainly not the rate limiting step - at least one of these effectiveness criteria was met by all of the existing or newer medications.

The problem appears to lie rather in the FDA’s apparent ‘zero-tolerance’ for adverse effects, clearly holding anti-obesity drugs to far higher standards than any other prescription medications currently on the market.

Curiously enough, while the components in two of the combination medications (Qnexa and Contrave), have been around for decades and are widely used for depression or smoking cessation (bupropion), seizures or migraines (topiramate), narcotic and alcohol dependency (naltrexone), or short-term weight loss (phentermine), these drugs were deemed too ‘dangerous’ for the treatment of obesity.

Unless, the Advisory Committee (which notably lacked any members with clinical expertise in obesity management), does indeed believe that obesity in itself is not a condition worthy of pharmacological treatment, one can only speculate whether the FDA and its advisors believe that both health professionals and obese patients are largely incompetent when it comes to ascertaining risk/benefit rations for themselves or in following prescription information.

Thus, as we point out:

“…panelists expressed doubts as to the reliability of physicians to prescribe an antiobesity drug appropriately, the reliability of patients to take the drug as prescribed, the limited value of the label information, the limited value of primary care providers to work with patients on complex problems like obesity, the lack of predictability that a REMS program, or a program of limited distribution would be successful and whether insurance companies would reimburse for the drug.”

This, attitude unfortunately reeks of bias and discrimination against both health professionals who treat obesity, as well as people who have this problem.

After all, for every other indications, the FDA appears perfectly happy with approvals that include all kind of warnings and caveats - apparently these ‘warnings’ work fine for other indications like high blood pressure, diabetes, or heart failure - it is only when used for obesity treatment that suddenly all these regulatory measures are ineffective.

“One can ask, therefore, whether this skepticism extends to other areas of medical practice or are these concerns sui generis to obesity. If so, are they based on evidence or assumptions about the behavior of patients with obesity and the doctors who treat them?”

On the other hand, it may simply be that the FDA

“…currently does not view obesity as a serious disease and so any risk is too great.”

If this is indeed the case, our recent publication of the Edmonton Obesity Staging System may provide a ready solutions - as our studies show, while for some individuals carrying a few (or even substantially more) extra pounds may have little or no health risk, for others obesity related health problems pose very severe risks, shortening 20 year survival by 10 years!

So while ‘no-risk’ is acceptable for using drugs to treat obesity in ‘healthy’ overweight or obese individuals, considerable risk (as long as it is less than the natural risk of this condition) may well be acceptable for patients with higher Stage obesity.

In addition, as pointed out before, much needs to be done to prospectively define specific target populations based on an etiological framework rather than simply on the presence of excess body fat.

Will the FDA and other regulators change their views on this?

I don’t know. What I do know is that until that happens, few pharma companies will dedicate the necessary resources or invest in the large and extensive trials needed to bring new anti-obesity drugs to market.

In the meantime the beneficiaries of this lack of insight will be the snake oil pedlars on the one hand and bariatric surgeons on the other. The clear losers will be the millions of people struggling with obesity and its consequences.

AMS
Calgary, Alberta

Disclaimer: I have received speaking and consulting honoraria from makers of anti-obesity drugs.

Downey M, Still C, & Sharma AM (2011). Is there a path for approval of an antiobesity drug: what did the Sibutramine Cardiovascular Outcomes Trial find? Current opinion in endocrinology, diabetes, and obesity, 18 (5), 321-7 PMID: 21878755

Continuing our discussion on the implications of the recent publication of our two studies showing that the Edmonton Obesity Staging System (EOSS), which actually measures how ’sick’ patients are rather than just how ‘big’ patients are, is a better predictor of mortality than BMI, I’d like to briefly discuss a potential implications for public health messaging around obesity and health promotion.

In contrast to what some media commentators have chosen to imply (’It is now OK to be fat’), EOSS actually takes a very differentiated view of the complexity of the relationship between excess weight and illness.

In fact, one key learning for public health messaging from our EOSS papers, would clearly be to re-evaluate the entire notion of a ‘healthy weight’, an outdated and misleading concept that harks back to the rather simplistic idea of ‘ideal’ weight.

Indeed, we previously criticized the notion of ‘ideal’ weight in an article published in 2009 in SOARD, in which we lamented the use of ‘Excess Weight Loss’ in the bariatric surgical literature.

As we noted in that article:

…“ideal weight” is synonymous with the term “desirable weight,” first introduced in 1943 by the Metropolitan Life Insurance Company (MLIC) in their standard height-weight tables for men and women. These tables were determined from actuarial data indicating the lowest mortality risk related to a range of weights for a given height in the studied population. Recognizing that the relationship between mortality and body weight is anything but simple, the MLIC life tables also introduced the concept of frame size, a concept that was hard to understand and implement and was therefore largely ignored. In fact, the current common use of “ideal weight” generally refers to the medium frame category, regardless of the patient’s actual size or form. Nevertheless, it is important to recognize that for a 170 cm (5’ 7”) woman, depending on her frame size, the MLIC “ideal weight” can range from 56 kg for a small frame to 74 kg for a large frame, or a difference of 18 kg. This translates into a body mass index (BMI) range of 19.3–25.6 kg/m2, or more than 6 BMI points.”

Thus, not only was this notion of ‘ideal’ weight based on an unrepresentative actuarial sample but there was actually a weight range of about 18 kg (or about 40 lbs) over which a person’s weight for the same height could be considered ‘ideal’.

Our recent EOSS data shows that for some people (albeit a minority at higher BMI levels), this range of ‘ideal’ weight based on mortality can indeed be even larger.

Thus, recognizing that weight (or BMI) is indeed such a crude (some would say irrelevant) measure of ‘health’, the entire concept of ‘healthy weights’ may need to be abandoned in favour of a more differentiated look at the rather complex relationship between health and weight.

At a minimum, public messaging around obesity, may need to make it very clear that ‘health’ can be achieved and maintained across a wide range of weights and that it is probably far more important to focus on health behaviours and other indicators of health than to jump to conclusions about someone’s health based solely on their weight.

Obviously, I fully appreciate that public health messages need to be kept simple but there are certainly arguments to be made that, given the rather loose relationship between health and weight, continuing to promote the notion of ‘healthy weights’ may do more harm than good, as such messaging would simply continue to promote obesity related stereotypes and can potentially set people off on paths of unhealthy weight loss in the firm belief that losing weight is equivalent to improving health.

On the other hand, none of this should distract from the fact that we do have an obesity epidemic and that the vast majority of people with ‘excess’ weight do indeed have relevant comordibities that put them in higher EOSS categories - for these individuals, improving access to evidence-based preventive and treatment resources must be a priority of any healthcare system.

I can certainly see how dealing with this rather complex problem in public health messages and policies will likely lead to a most interesting discussion in the months to come.

AMS
Edmonton, Alberta

That overweight and obese individuals face weight-bias and discrimination is no secret. It is also no secret that individuals who lose weight often experience significant positive changes in how they are treated by family, friends, colleagues and perfect strangers.

Interestingly, however, it turns out that these ‘positive’ attitudes to people, who lose weight, may very much depend on how these individuals actually managed to do so.

Thus, a study by Jasmine Fardouly and Lenny Vartanian from Sydney, Australia, just published in the International Journal of Obesity, suggests that knowing how the weight loss came about significantly determines the changes in weight bias following weight loss.

Participants (N=73) were first shown an image of an obese woman or a thin woman and asked to indicate their perceptions of the target with respect to the target’s behaviors (for example, how often she exercises), as well as some personality characteristics (for example, lazy, sloppy and competent).

Participants were then shown a more recent image of the obese target in which she had lost weight, and were informed that the target had lost weight through diet and exercise or through surgery, or were not provided with any explanation for the weight loss.

Regardless of the method of weight loss, all targets were rated as eating more healthily, exercising more, and being more competent and less sloppy after having lost weight.

However, participants also rated the target as less lazy when they learned that she had lost weight through diet and exercise, or when no information was provided about the method of weight loss, than if they were informed that the target had lost weight through surgery.

Or, as the authors point out:

“Weight-loss surgery patients may not be able to overcome the obesity stigma as surgery may be perceived as the lazy weight-loss option because of an assumption that it does not require effort and discipline that losing weight through exercise and dieting does. Thus, despite choosing to undergo weight-loss surgery to reduce weight stigma, obese individuals may continue to be viewed as conforming to the obesity stereotype, and hence be considered lazy and lacking in willpower.”

This certainly explains why many, who have successfully lost weight with bariatric surgery, will often not mention this to even their closest friends and why it may be awhile before gastric bypass surgery becomes to be viewed as as acceptable a treatment for severe obesity and its complications, as coronary bypass surgery is viewed as an acceptable treatment for heart attacks.

AMS
Edmonton, Alberta

Fardouly J, & Vartanian LR (2011). Changes in weight bias following weight loss: the impact of weight-loss method. International journal of obesity (2005) PMID: 21364528