Wednesday, June 18, 2014

4th Canadian Obesity student Meeting (COSM 2014)

Uwaterloo_sealOver the next three days, I will be in Waterloo, Ontario, attending the 4th biennial Canadian Obesity Student Meeting (COSM 2014), a rather unique capacity building event organised by the Canadian Obesity Network’s Students and New Professionals (CON-SNP).

CON-SNP consist of an extensive network within CON, comprising of over 1000 trainees organised in about 30 chapters at universities and colleges across Canada.

Students and trainees in this network come from a wide range of backgrounds and span faculties and research interests as diverse as molecular genetics and public health, kinesiology and bariatric surgery, education and marketing, or energy metabolism and ingestive behaviour.

Over the past eight years, since the 1st COSM was hosted by laval university in Quebec, these meetings have been attended by over 600 students, most presenting their original research work, often for the first time to an audience of peers.

Indeed, it is the peer-led nature of this meeting that makes it so unique. COSM is entirely organised by CON-SNP – the students select the site, book the venues, review the abstracts, design the program, chair the sessions, and lead the discussions.

Although a few senior faculty are invited, they are largely observers, at best participating in discussions and giving the odd plenary lecture. But 85% of the program is delivered by the trainees themselves.

Apart from the sheer pleasure of sharing in the excitement of the participants, it has been particularly rewarding to follow the careers of many of the trainees who attended the first COSMs – many now themselves hold faculty positions and have trainees of their own.

As my readers are well aware, I regularly attend professional meetings around the world – none match the excitement and intensity of COSM.

I look forward to another succesful meeting as we continue to build the next generation of Canadian obesity researchers, health professionals and policy makers.

You can follow live tweets from this meeting at #COSM2014

@DrSharma
Waterloo, Ontario

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Monday, May 5, 2014

We Don’t Know Much About Obesity

Nature Outlook Obesity 2014For a condition as prevalent and dangerous as obesity, we know surprisingly little about its causes and cures.

This is the first sentence by Nature Outlook Editor Tony Scully, in a special edition dedicated entirely to obesity.

The volume features both articles by science writers as well as a selection of original contributions on topics ranging from AgRP and the FTO gene to food addiction and the microbiome.

This edition also features and updated map of the worldwide prevalence of obesity – many readers may well be surprised to learn that obesity rates are now as high in parts of central America, northern and southern Africa and in parts of the middle East as they are in North America. Indeed, obesity rates in South Africa are “off the chart”, no approaching almost 40% of the entire population.

This leaves millions of people around the world in need of more effective treatments. Blue-eyed utopian notions that we can somehow help these millions by re-engineering societies to eat-less and move more (as suggested in a rather unfortunate contribution to this edition by David Katz), are naive at best and present a disservice to those hoping for real and practical solutions at worst.

The simple truth is that for the vast majority of the folks with obesity we simply have no effective treatments, let alone a cure.

As Tully notes,

“The best way to lose weight is to eat less and exercise more. But as a strategy to combat obesity at the population level, this common-sense prescription is proving ineffective over the long term.”

Sure, not everyone carrying a few extra pounds has a “disease” and we are doing an increasingly better job of managing obesity related health problems – certainly one reason why people with excess weight are today living far longer than a few decades ago.

But for those who would rather treat their obesity than be on medications for their high blood pressure, diabetes, and joint pain and perhaps rid themselves of their CPAP machines, there are few treatment options: diet and exercise, i.e if you wish to live off 1400 Cal with 400 Cals of daily exercise (as the folks in the National Weight Control Registry manage to do) or opt for bariatric surgery (a rather drastic measure by any stretch).

Indeed, there is currently no greater “therapeutic gap” for a common chronic disease, than there is for obesity.

Hopefully, as science advances we will eventually stop playing the “shame and blame” game and rightly abandon the utopians who sit awaiting the day when Big Food and Big Cars will finally see the light (by mercifully going out of business).

Stay tuned for more on the articles in this issue – stay tuned.

@DrSharma
Edmonton, AB

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Tuesday, April 29, 2014

The Fraser Institute Obesity Report: Being Right Does Not Make It Wrong

Fraser Institute Obesity in Canada 2014This week, the right-leaning Fraser Institute released a report with the rather provocative title, “Obesity in Canada: Overstated Problems, Misguided Policy Solutions“.

The Fraser Institute makes no secret or apology about its political ideology:

“Our vision is a free and prosperous world where individuals benefit from greater choice, competitive markets, and personal responsibility.”

This ideology alone, could make may of us simply dismiss the report as being tainted (conflict of interest) and one-sided. It is indeed easy to see why many in the obesity “establishment” would feel tempted to discredit the scientific accuracy of the report or even employ ad hominem attacks on the authors themselves.

A much more difficult task would be to fairly consider the arguments and counter with a scientifically sound rebuttal on issues where the report clearly deviates from scientific fact.

This may not be quite as easy as one might hope.

Not that there isn’t much about the tone of the report that could be criticized. The Fraser Institute being all about personal “choice”, it is not surprising that obesity is largely presented as the consequence of the “choices” that people with obesity make. There is ample talk of individual responsibility and of course, the simplistic notion of calories in and calories out (or eating and exercise) prevails throughout the report.

Indeed, I could find only one sentence in the report that suggests that things may be a bit more complex:

“The causes of obesity are multi- factorial, where obesity in each individual case may be influenced by literally dozens of physiological, psychological, and socioeconomic factors. These factors include breast feeding, cultural characteristics, diet, education, entertainment habits, exercise, family life and structure, genetics, income, peer pressure, and sleep patterns. Indeed, differences in genetics may mean that, for similar levels of energy input and physical activity, some groups of individuals may experience more weight gain and higher obesity prevalence than other groups.”

Despite this insight, “choice” and “responsibility” echoes throughout the report largely ignoring the notion of social determinants or the complex physiology of homeostatic and allostatic mechanisms that promote weight gain and ultimately make sustainable weight loss so difficult to achieve.

Thus, the report certainly conforms with most public health views of obesity as mainly a problem of individual volitional behaviours and the notion that anyone can be the master of their weight (if only they chose to do so).

This rather general criticism aside, there are indeed substantial areas of the report that warrant serious consideration.

A key argument as to why the authors think that the obesity problem is overstated relates to the observation of-late, that obesity rates appear to be stabilizing (or even declining) in parts of the population. Thus, the report notes that while obesity rates in men and children appear to be levelling off (or even decreasing), we are seeing a continued increase in obesity rates in women. In fact, the only indisputable trend is a continuing increase in the rates of severe obesity – those, who already have obesity are getting even bigger (a clear reflection of our failure to provide treatments to the people who need them).

While this depiction of the problem is not wrong, what it actually means is a matter of interpretation – depending on whether you belong to the church of “glass half-empty” or “glass half-full”.

Of course the report is right in that “alarmist” predictions that soon Canada will be a country where everyone has obesity and that our kids will not outlive their parents are considerably exaggerated. On the other hand, obesity rates of 20% are not exactly an excuse to sit back and call off the troops. If one in five Canadians was infected by a virus (say West Nile), we’d be setting up clinics at every street corner and pouring billions into better prevention and treatments.

A more controversial argument as to why the obesity issue is overstated relates to whether or not having obesity actually has all that much of an impact on health. As the report points out, recent evidence does indeed suggest that the optimal BMI for the best life expectancy may well be in the BMI 25-35 range. So carrying all those extra pounds may not be quite as bad for our health as we are often led to believe.

In this regard, the report is certainly preaching to the converted. Any regular reader of these pages will recall that I have described BMI as a “Basically Meaningless Integer” and have long promoted the use of the more sophisticated Edmonton Obesity Staging System to characterize obesity related health risks.

So, while the report is correct in that not everyone with a few extra pounds is about to drop dead (or even just suffer from a weight-related health problem), there is no doubt that a higher body weight does quite substantially increase the likelihood of having a health problem. Thus, as our own research shows, the chances of not having any obesity related health problem increases from 1 in 2 at a BMI of 25-30 to less than 1 in 20 at a BMI greater than 40.

This still does not make BMI a reliable measure of health. Fortunately, we have other tests for that.

But while we may quibble about what obesity rates based on BMI levels (self-reported or otherwise) may actually mean, areas of the report that I find far more interesting are those that discuss whether or not government should even be concerned about the obesity problem and whether or not it has any role to play in addressing it.

Given the political leanings of the Fraser Institute you may well predict its answers – but I do find the arguments interesting enough to warrant discussion in my next post.

@DrSharma
Edmonton, AB

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Thursday, February 6, 2014

Patients’ Acceptance of Prioritization for Bariatric Surgery

sharma-obesity-waiting-timeAs regular readers are well aware, bariatric surgery is still rather hard to come by in most Canadian provinces.

This prompted us to examine patients’ perspectives on wait-list prioritization and willingness to pay for bariatric surgery amongst patients waiting for surgery in our program.

The paper by Richdeep Gill and colleagues, published in the Canadian Journal of Surgery, examines the responses of wait-listed patients to nine hypothetical scenarios describing patients waiting for surgery.

Respondents were asked to rank the priority of these hypothetical patients on the wait list relative to their own.

Scenarios examined variations in age, clinical severity, functional impairment, social dependence and socioeconomic status. We also assessed willingness to pay for faster access using a 5-point ordinal scale.

Overall respondents assigned similar priority to hypothetical patients with characteristics similar to their own but higher priority (greater urgency) to those exhibiting greater clinical severity and functional impairment.

On the other hand, they assigned lower priorities to patients at the extremes of age, on social assistance, or of of higher socioeconomic status.

Most (85%) respondents disagreed with payment to expedite access, although participants earning more than $80 000/year were less likely to disagree.

These findings show that most patients waiting for bariatric surgery are OK with prioritization of patients with greater clinical severity and functional impairments but generally disagree with paying for faster access.

Thus, these findings certainly suggest that there would be general acceptance of giving priority to patients with higher Edmonton Obesity Stages, even if this would mean longer waits for themselves.

How Canadian is that?

@DrSharma
Edmonton, AB

ResearchBlogging.orgGill RS, Majumdar SR, Wang X, Tuepah R, Klarenbach SW, Birch DW, Karmali S, Sharma AM, & Padwal RS (2014). Prioritization and willingness to pay for bariatric surgery: the patient perspective. Canadian journal of surgery. Journal canadien de chirurgie, 57 (1), 33-9 PMID: 24461224

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Monday, November 12, 2012

Fixing the Canadian Health Care System

Readers may recall that last week I spoke on obesity at the Conference Board of Canada’s Summit on Sustainable Health Care.

The key learnings from this Conference are now elegantly summarized by Glen Hodgson, Senior VP and Chief Economist at the Conference Board on his blog

Five key priorities for reform emerged from the Summit.

  • Fix the gateway to the health care system. Primary care is the first contact point with the health care system. There was a strong consensus that interdisciplinary family care teams should be the standard model for primary care, and these teams should be expanded and strengthened in all provinces and territories.
  • Invest in and use technology more intensively in the health care system, particularly information technology. More intensive and standardized use of information technology would allow patient information to be collected and shared seamlessly, making treatment much more efficient and thereby boost productivity in the health care system.
  • Change health professional compensation. The compensation model for physicians and other health professionals should be linked to more patient outcomes, not to activities like treatment or consultation, within a clear accountability structure.
  • Build an appropriate support system to care for the elderly. Few older Canadians want to be hospitalized for chronic conditions. They want to be cared for and healed where they live: in their homes and communities.
  • Improve the state of Canadians’ overall health and wellness. A healthier population would slow the growth in chronic diseases and in health care demand—so Canada needs a “wellness system” as well as a health care system. Employers have an important role to play in supporting the wellness of their employees and their families.

One aspect that is missing in this discussion, is the realisation that the obesity epidemic will lead to an unprecedented epidemic of ‘chronic disease of the young’. This will require taking chronic disease management directly to the workplace, an effort that goes well beyond current workplace ‘wellness’ activities.

Rather, we should be looking at creating an infrastructure which (in collaboration with the primary care provider) takes chronic disease management directly to the workplace.

The rationale for this is the simple fact, that contrary to the problem of chronic diseases in the elderly, younger people, who are likely to bear the brunt of the obesity epidemic, can ill afford to sit around in doctor’s waiting rooms during normal office hours.

Even expecting them to show up in doctor’s offices or community clinics after a busy work day may prove an important deterrent.

Thus, I believe that we will need to explore ways in which to bring chronic disease management resources and expertise into the workplace in a fashion that goes well beyond simply providing a treadmill for employees or changing food options in the cafeteria.

AMS
Edmonton, Alberta

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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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