Over the past few months, I have been working with mdBriefCase, a major provider of free online accredited continuing medical education, to produce interactive modules for obesity management.
The modules are aimed at practitioners working in primary care and pharmacists and align closely with the Canadian Obesity Network’s 5As of Obesity Management framework.
The accredited course (Mainpro M1 and MOC Section 1 or 3 credits) is available free of charge to all Canadian Health Professionals.
To access the course for physicians and allied health practitioners on mdBriefCase – click here
To access the course for pharmacists on rxBriefCase – click here
Regular readers will recall that for the past 9 years, I have spent 10 days each summer at the Canadian Obesity Network’s 9-day obesity training camp for students and new professionals (post-docs, residents, etc). This year’s camp will again be held in the attractive setting of the Canadian Rockies.
The Camp is a unique research training activity designed to help trainees advance their careers and continuing engagement in the obesity field and promotes a better understanding of the multi-disciplinary aspects of obesity.
The curriculum covers all aspects of obesity ranging from epidemiology and public health to cell biology, energy, regulation, clinical management. The program has a strong practical component that allows participants to integrate the learnings into their research and/or practice. Opportunities for formal and informal interactions between participants and senior faculty are a key factor in determining the success of the camp.
One of the most important outcomes of this activity is the establishment of a community of young researchers and practitioners that can respond to the growing obesity epidemic in Canada and around the world. A formal social networking analysis of Boot Camp graduates indicates that the boot camp supports the advancement of trainees’career and contributes to ongoing engagement in the obesity field.
The Obesity Boot Camp consists of nine days of intensive teaching and networking, offered to Canadian and international young obesity researchers and new professionals. Young professionals include individuals in their last year, or within five years of, completing their MSc/PhD training. The program is also open to health practitioners and/or clinician scientists such as physicians, dietitians, and exercise specialists.
Participants must submit a completed registration form, a letter of recommendation from their supervisor, a copy of their curriculum vitae and a single-spaced page summary of their research interests or area of practice, and a brief explanation of what they hope to get out of the boot camp.
Cost: $2500 (includes shared accommodation, syllabus, full program, meals, breaks and select social events).
Space is limited. Click here to see the most recent boot camp announcement
Today I will be attending a Summit on Weight Bias at the University of Calgary, that will explore the the issue of weight-based discrimination and ways to address this – especially in health care settings.
It should come as no surprise that weight bias and discrimination are a major barrier to providing proper preventive and therapeutic health care due to the widespread attitudes and beliefs about obesity that exist amongst health professionals and decision makers.
The scientific summit, co-sponsored by the Canadian Obesity Network, Campus Alberta, and the Canadian Institutes of Health Research (CIHR), is complemented by a public Cafe Scientifique that will be held on Thursday, March 12, 7.00 at the Parkdale Community Association, 3512 – 5 Ave NW, in Calgary.
For more information and pre-registration for this free public event, which features
Leora Pinhas, MD
Child & Adolescent Psychiatrist, Physician Lead, Eating Disorders Unit, Ontario Shores Centre for Mental Health Sciences Assistant Professor, University of Toronto
Tavis Campbell, PhD
Professor, Department of Psychology and Oncology & Director, Behavioural Medicine Laboratory, University of Calgary
Yoni Freedhoff, MD, CCFP
Medical Director, Bariatric Medical Institute, Assistant Professor, University of Ottawa
That there are no easy solutions to obesity and managing your weight is challenging at the best of times. But trying to find manage it without understanding even the basics of how your body works to defend its weight is hopeless at best.
A sort paper by Christopher Ochner and colleagues, published in The Lancet Diabetes and Endocrinology, succinctly describes the challenges, and appeals to clinicians (and decision makers) to take this problem seriously (instead of trivialising it as a simple “lifestyle” issue).
“Many clinicians are not adequately aware of the reasons that individuals with obesity struggle to achieve and maintain weight loss, and this poor awareness precludes the provision of effective intervention.”
As readers of these pages are well aware,
“Irrespective of starting weight, caloric restriction triggers several biological adaptations designed to prevent starvation. These adaptations might be potent enough to undermine the long-term effectiveness of lifestyle modification in most individuals with obesity, particularly in an environment that promotes energy overconsumption.”
But is is not just about the body’s defense mechanisms.
“Additional biological adaptations occur with the development of obesity and these function to preserve, or even increase, an individual’s highest sustained lifetime bodyweight. For example, preadipocyte proliferation occurs, increasing fat storage capacity. In addition, habituation to rewarding neural dopamine signalling develops with the chronic overconsumption of palatable foods, leading to a perceived reward deficit and compensatory increases in consumption.”
“…improved lifestyle choices might be sufficient for lasting reductions in bodyweight prior to sustained obesity. Once obesity is established, however, bodyweight seems to become biologically stamped in and defended. Therefore, the mere recommendation to avoid calorically dense foods might be no more effective for the typical patient seeking weight reduction than would be a recommendation to avoid sharp objects for someone bleeding profusely.”
As the authors point out,
“…there is now good evident that these biological adaptations often persist indefinitely, even when a person re-attains a healthy BMI via behaviourally induced weight loss….Thus, we suggest that few individuals ever truly recover from obesity; individuals who formerly had obesity but are able to re-attain a healthy bodyweight via diet and exercise still have ‘obesity in remission’ and are biologically very different from individuals of the same age, sex, and bodyweight who never had obesity.”
To overcome these biological adaptations it is not enough to appeal or rely on will-power alone to sustain long-term weight loss. Rather, treatments need to address these biological adaptations and homeostatic mechanisms, which is exactly what anti-obesity drugs or surgery does.
Thus, the authors have the following advice for clinicians:
“Specifically, clinicians should be proactive in addressing obesity prevention with patients who are overweight and, for those who already have sustained obesity, clinicians should implement a multimodal treatment approach that includes biologically based interventions such as pharmacotherapy and surgery when appropriate.”
“We urge individuals in the medical and scientific community to seek a better understanding of the biological factors that maintain obesity and to approach it as a disease that cannot be reliably prevented or cured with current frontline methods.”
In last week’s 2015 Lancet series on obesity, the majority of papers focus on policy interventions to address obesity. It suggests that a reframing of the obesity discussion, that avoids dichotomies (like nature vs. nurture debates) may provide a path forward – both in prevention and management.
The policy framework presented by Christina Roberto and colleagues in The Lancet, is based on the NOURISHING framework, proposed by the World Cancer Research Fund International to categorise and describe these actions.
Together, the actions in this framework address the food environment (e.g. food availability, taxation, restrictions on advertising, etc.), food systems (e.g. incentives and subsidies for production of healthier foods) and individual behaviour change (e.g through education and counselling).
This “food-centric” view of obesity is complemented by recognising that physical activity, much of which is dictated by the built environment and captivity of the population in largely sedentary jobs, also has a role to play.
On a positive note, the Christina and colleagues suggest that there may be reasons for careful optimism – apparently 89% of governments now report having units dedicated to the reduction of non-communicable diseases (including obesity), although the size and capacity of many of these units is unknown.
On the other hand, despite an increasing number of such efforts over the past decades, no country has yet reversed its epidemice (albeit there is a flattening of obesity growth rates in the lower BMI ranges in some developed countries – with continuing rise in more severe obesity).
Despite the potential role of government policies in reducing non-communicable diseases (including obesity) by “nudging” populations towards healthier diets and more physical activity, the authors also note that,
“…the reality is that many policy efforts have little support from voters and intended programme participants, and although the passage of policies is crucial, there is also a need to mobilise policy action from the bottom up.”
Indeed, there is growing list of examples, where government policies to promote healthy eating have had to be reversed due to lack of acceptance by the public or were simply circumvented by industry and consumers.
Nevertheless, there is no doubt that policies in some form or fashion may well be required to improve population health – just how intrusive, costly and effective such measures will prove to be remains to be seen.
All of this may change little for people who already have the problem. As the article explains,
“There are also important biological barriers to losing excess weight, once gained. Changes in brain chemistry, metabolism, and hunger and satiety hormones, which occur during attempts to lose weight, make it difficult to definitively lose weight. This can prompt a vicious cycle of failed dieting attempts, perpetuated by strong biological resistance to rapid weight loss, the regaining of weight, and feelings of personal failure at the inability to sustain a weight-loss goal. This sense of failure makes people more susceptible to promises of quick results and minimally regulated claims of weight loss products.”
Not discussed in the article is the emerging science that there may well be other important drivers of obesity active at a population level that go well beyond the food or activity environment – examples would include liberal use of antibiotics and disinfectants (especially in agriculture), decreased sleep (potentially addressable through later school start times and mandatory afternoon naps in childcare settings), increasing maternal age at pregnancy (addressable by better access to childcare), time pressures (e.g. policies to address time-killing commutes), etc.
Perhaps what is really needed is a reframing of obesity as a problem where healthy eating and physical activity are seen as only two of many potential areas where policies could be implemented to reduce non-communicable diseases (including obesity).
Some of these areas may well find much greater support among politicians and consumers.