Arya M. Sharma, MD

Klinikum Benjamin Franklin, Charite, Berlin

Continuing in my series of past publications on obesity, today’s post is special, because it is about an event that ‘officially’ launched my shift from hypertension into obesity research and for the first time made some of the leading obesity researchers of the time aware of my very existence.

Back in 1998, I had already well-established myself in the hypertension field, being widely recognized as an expert on salt-sensitive hypertension. I was already being invited to speak at various hypertension meetings around the world and was nationally and internationally recognized for this work.

However, it would be fair to say that despite having published a few minor papers on obesity, no one in the obesity arena had ever heard of me. This was by no means surprising as, having attended a few obesity conferences by then, it was evident that few hypertension researchers interacted with obesity researchers and vice versa. Apparently, no one had yet thought of bringing the two research communities together - surprising perhaps, given the fact that obesity is the most common and powerful risk factor for hypertension.

So, perhaps for the first time demonstrating my potential talent as a ‘networker’, I decided to organize the 1st International Symposium on Obesity and Hypertension (ISOH), to which I rather cheekily ventured to invite some of the most distinguished researchers from the obesity field - cheeky, because these folks had certainly never heard of me and I was not offering any honoraria or expensive airplane tickets. I just looked for big names in obesity on the internet and sent out the invitations.

Little would I have imagined that I would assemble a roster of cutting edge ‘big names’ from both the hypertension and obesity communities for a tightly packed two day event in Berlin.

To my lay readers, the names may mean nothing, but to my professional colleagues, the following list probably reads like a ‘who-is-who’ of obesity.

W. P. T. James (Chairman, International Obesity Task Force, Aberdeen, UK) presented new data suggesting that obesity-associated comorbidity may increase rapidly in non-Caucasians with a body mass index as low as 18 kg/m2.

M. E. J. Lean (Department of Human Nutrition, University of Glasgow, UK) presented new data indicating that waist circumference (measured midway between the lowest rib and the iliac crest) is the best clinical marker of intraabdominal fat accumulation and that risks are high enough to warrant professional guidance with a waist over 102 cm in men or 88 cm in women.

R. Negrel (Centre de Biochimie, UMR6543CNRS & IFR349, Faculty of Sciences, Nice, France) and G. Löffler (University of Regensburg, Institute of Biochemistry, Regensburg, Germany), who provided convincing evidence on the presence of the renin-angiotensin system in adipose tissue.

D. L. Crandall (Wyeth Ayerst Research, Radnor, PA, USA) presented a comprehensive review, inncluding historical review of the classical experiments that identified early hemodynamic changes observed in obesity and the important role of neovascularization for the growth and development of adipose tissue.

H. Hauner (Diabetes Research Institute at the University of Düsseldorf, Germany) stressed the point that stromal cells from adipose tissue can undergo differentiation in the presence of defined adipogenic factors, including a variety of hormones and cytokines.

T. Unger (Institute for Pharmacology, Christian-Albrechts University of Kiel, Germany) presented evidence that the AT1 and AT2 angiotensin receptors may play an important role in the growth and development of a variety of tissues, including cardiac, endothelial, and neuronal cells.

F. C. Luft (Franz Volhard Clinic and Max Delbrück Center, Humboldt University of Berlin, Germany) presented the results of linkage analysis in an Arab pedigree with familial hypercholesterolemia in which heterozygous persons with normal LDL levels were identified.

T. W. Kurtz (University of California, San Francisco, CA, USA) and M. Pravenec (Czech Academy of Sciences, Prague, Czech Republic) presented data indicating that a Cd36 Mutation in some strains of spontaneously hypertensive rat may be associated with insulin resistance in these strains.

X. Jeunemaitre (INSERM U36, College de France, Paris, France) provided new evidence indicating that several polymorphisms located in the 5’ region and in the first intron of the angiotensinogen gene may contribute to the variability of plasma angiotensinogen levels.

M. L. Tuck (Veterans Administration Medical Center, Sepulveda, CA, USA) presented an up-to-date review on the role of the systemic renin-angiotensin system in obesity-related hypertension.

A. Natali (Department of Internal Medicine, University of Pisa, Italy) discussed the role of insulin resistance in obesity-related hypertension and provided data that suggesting that the sympatho-adrenergic system plays an important role in the development of obesity hypertension.

W. G. Haynes (Department of Internal Medicine, University of Iowa, Iowa City, USA), who discussed the important role of leptinergic and melanocortin influences on the sympathetic nervous system in obesity-related hypertension.

G. Seravalle (Clinica Medica, University of Milan, Italy) studied the effects of the acute blockade of corticotropin-releasing hormone (CRH) secretion induced by dexamethasone (DEX) on the sympathoexcitatory response elicited by insulin.

A. D. Strosberg (Institut Cochin de Génétique Molèculaire, Paris, France) discussed the potential role of beta-3 adrenergic receptors in the development of obesity.

S. L. H. Schiffelers (NUTRIM, Department of Human Biology, Maastricht University, Maastricht, The Netherlands) on the effects of beta 1- and beta 2-adrenoreceptors–stimulated thermogenesis and fat oxidation in lean and obese men.

S. Rössner (Huddinge University Hospital, Sweden) presented the first clinical data on a new lipase inhibitor orlistat which reduces the absorption of dietary fat by 30% and reduces weight and blood pressure.

R. Donelly (University of Nottingham, Division of Cardiovascular Medicine, Nottingham, UK) reviewed the pharmacological treatment of obesity-related hypertension.

P. G. Kopelman (St. Bartholomew’s Hospital and The Royal London School of Medicine, University of London, UK) provided an outlook of the management problems that will become apparent in the early part of the 21st century.

With this roster of leading experts, it was perhaps not surprising that we attracted over 150 attendees from over 30 countries to his ‘impromptu’ meeting.

It turns out that this was to be only the first of a total of four ISOH meetings, the last held in 2005, by which time I had not only made a name for myself in obesity (having been appointed to a Tier 1 Canada Research Chair in Cardiovascular Obesity Research and Management at McMaster University in 2002), but had also managed to build professional and personal relationships around the world that last to this day.

I also learnt important lessons that formed the very basis for eventually creating the Canadian Obesity Network, now with almost 7,000 members, by far the largest national professional obesity association in the world.

For those, who would like to read more about the symposium, the proceedings were published in Kidney and Blood Pressure Research in 2000.

For anyone who may have attended the event (or any of the subsequent ISOH meetings), I’d love to hear about your recollections of these Symposia.

AMS
Edmonton, Canada

Sharma AM, Distler A, & Hauner H (2000). International symposium on obesity and hypertension genetics and molecular mechanisms. Genetics and molecular mechanisms Kidney & blood pressure research, 23 (1), 49-72 PMID: 10567854

.

Obesity is complex. Few health professionals are specifically trained in obesity management - few health systems have invested in managing it.

As regular readers will recall, Alberta Health Services recently launched a province-wide obesity initiative ranging from population health and community projects, across primary care, to establishing speciality centres for complex medical and surgical management of kids and adults with severe obesity.

Currently, around 100 health professionals and administrators from across the province, working on getting this initiative off the ground are meeting in Edmonton to discuss details of the plan. Many have already worked in obesity and chronic disease management and bring their own views and experience to the table. This is immensely important as sharing of best practices is one of the key mechanisms to ensure that we do more of what works and less of what doesn’t.

It is also essential that we establish common ground on the basic principles and practice of addressing this health problem - the sooner we are all on the same page, the sooner we can begin working towards consistency in obesity prevention and care across the province.

This will not happen overnight - there will be learnings, there will be things that work well and things that don’t.

But I am fully confident that in the end we will be moving in the right direction towards reducing the emotional, physical, and economic burden of obesity on all Albertans.

We may not be able to cure obesity, but we can certainly do a much better job at preventing and treating it.

AMS
Edmonton, Alberta

Yesterday, I applauded the Canadian Obesity Network for being internationally recognised as Canada’s official professional obesity association.

This is important because, although obesity now affects one in four adult Canadians, we are by no means alone with this problem.

Indeed, as noted by the Lancet in 2006,

“No health system is yet meeting the challenges of managing obesity, and no society has developed an effective strategy to prevent it.”

This is both a challenge and an opportunity for Canada. Challenge because our problem cannot be solved by simply importing successful models from elsewhere - there are none!

Opportunity, because we may well be the first to develop promising approaches that could serve as a ‘made in Canada’ solution to others.

Indeed, today I will be speaking at a Caribbean obesity conference in Bridgetown, Barbados, where obesity is rampant and diabetes is endemic. While the health care models that we are adopting in Canada to deal with our own obesity problems may not be easily transferable to Barbados, the same principles will likely hold true.

Public health measures based on the principles of shame, blame, tax, and ban, will prove as unhelpful here as they have proven unsuccessful everywhere else - not surprising as these measures fail to address the psychosocial and biological root causes of the problem.

There is also no doubt that health services approaches that do not embrace the complexity, heterogeneity, and chronicity of obesity, will be doomed to fail - obesity management has to be fully integrated into a chronic disease management framework that includes professional assessment, patient education, and lifelong self-management.

While not everyone with excess body fat needs to lose weight - many do. This will not be achieved by promoting endless cycles of yo-yo dieting with little or no professional help - there may well be far more harm in this than any potential benefit.

The causes of obesity are complex - the solutions cannot be simple.

Doing nothing is clearly not an option but let us at least stop doing things that have already been shown to fail (like simply telling people to eat less and move more).

AMS
Bridgetown, Barbados

Yesterday, the Canadian Obesity Network announced that it is now Canada’s official representative in the International Association for the Study of Obesity (IASO), the umbrella organization for 52 national obesity associations, representing 56 countries.

Click here for a brief history of IASO.

Canada was previously represented at IASO by The Obesity Society (TOS), formerly known as the North American Association for the Study of Obesity (NAASO), which continues to be the leading scientific society dedicated to the study of obesity in the USA and Mexico and will remain as the regional representative for North America within IASO.

According to IASO President Prof. Philip James,

“With a diverse and active professional community in place and a successful track record in obesity, the time was right for the Canadian Obesity Network to become a member of IASO and represent Canada.”

TOS President Dr. Patrick O’Neil adds that

“This decision has the full support of both the TOS and IASO governing councils as well as the CON-RCO board of directors. The three organizations believe this will benefit all our members, and we look forward to close collaboration as we work towards improving obesity prevention and treatment globally.”

Membership in IASO offers members of the Network a number of benefits including:

- Discounted fees for the Specialist Certification in Obesity Professional Education (SCOPE) education program
- Discounted fees to IASO events, including ICO and Hot Topic Conferences
- Substantially discounted fees for IASO journals (Pediatric Obesity, Clinical Obesity and Obesity Reviews)
- Access to an exclusive repository of obesity prevalence data

More importantly, perhaps, the many excellent obesity research programs and other initiatives happening across Canada will now gain even more international visibility and attention through this membership in IASO.

I, for one, certainly look forward to this new and expanded role for the Canadian Obesity Network on the global stage.

AMS
Dallas, TX

As regular readers will recall, this week I am attending the World Diabetes Congress - with well over 14,000 attendees, the largest ever world congress on this issue.

For readers, who are not familiar with the International Diabetes Federation (!DF), it may be worth pointing out that the IDF is an umbrella organization of over 200 national diabetes associations in over 160 countries. IDF’s national diabetes associations are divided into the following regions: Africa (AFR),Europe (EUR),Middle East and North Africa (MENA), North America and Caribbean (NAC),South and Central America (SACA), South East Asia (SEA) and Western Pacific (WP).

Thus, the IDF, which has been in operation since 1950, represents the interests of the growing number of people with diabetes and those at risk.

The mission of IDF is to:

“advance diabetes care, prevention and a cure worldwide.”

Its strategic goals are to:

Drive change at all levels, from local to global, to prevent diabetes and increase access to essential medicines.

Develop and encourage best practice in diabetes policy, management and education.

Advance diabetes treatment, prevention and cure through scientific research.

Advance and protect the rights of people with diabetes, and combat discrimination.

(interestingly, these goals are reminiscent of those of the Canadian Obesity Network, Canada’s National Obesity organization, with the difference perhaps that obesity is a much larger issue than just diabetes).

Amongst the many activities and resources provided by the IDF, one that readers may find of particular interest (and one that can be a great time waster for readers who are looking for new ways to procrastinate) is the interactive World Diabetes Atlas, now in its 5th edition (just released last month).

The atlas exemplifies just how many folks around the work (especially in South Asia) are affected by type 2 diabetes - interesting, an obesity map of the world would look almost identical, except that the numbers would be far greater (only about 15-20% of obese people actually go on to develop diabetes - but may well have other weight-related health problems).

One of the notable features of this congress is the massive industry exhibit - not quite as extensive as those at cardiology or oncology meetings but, by a significant magnitude of scale, larger than any industry exhibits seen at obesity meetings. This is of course because diabetes management (although never curative) is big business, with countless new classes of anti-diabetic drugs in the pharma pipelines to add to the many oral and injectable treatments that are already out there (not to mention the vast blood glucose monitoring and insulin pump industries).

While there is no doubt that these companies are providing excellent products and services that make the life of people with diabetes so much easier and help reduce the horrible risks of this condition, one can only wish that in the not too distant future, a similar arsenal of treatments and management tools may become available for those struggling with obesity and its myriad sequelae (EOSS 2-4).

While the hope is not to ‘cure’ obesity (I am not sure we can actually do that), having effective obesity treatments that fill the vast therapeutic gap between ‘eat-less-move-more’ and bariatric surgery are urgently needed.

Not only would this reduce the global burden of diabetes but hopefully also the global burden of the over 20 other chronic conditions that are strongly associated with excess weight (including many cancers).

Unfortunately, neither the current regulatory framework for new launching new obesity medications nor the necessary investment into training health professionals to better manage obesity or into research to find better treatments comes close to the actual size of the problem (just count how many Canadian medical schools actually have a chair in obesity - I know of two).

So although there is an appreciable number of talks and sessions on obesity (including the ones the I am giving and chairing), the focus of this congress is of course on managing diabetes and its complications.

Unfortunately, as I have said before, managing type 2 diabetes without addressing obesity is largely ‘palliative’ care.

Obviously, not a popular view at this conference.

AMS,
Dubai, UAE