Dr. Sharma's Obesity Notes

…except perhaps that there is no universal causal theory of obesity.

In a world where everyone is looking for quick-fixes and approaches to dealing with almost any societal problem, quickly degenerate into opinionated activism, I often find it important to remind myself that obesity is not a simple problem where identifying (and eliminating) one cause will “solve” the issue.

I was reminded of this by some of the comments to yesterday’s post on emotional eating, which pointed out that too much emphasis on the emotional aspects of overeating simply adds another narrative to “pathologizing” people with excess weight.

In other words, not only are obese people gluttonous sloths without will power, they are now also emotionally-wounded wrecks (you can chose, which of these is worse).

The fact, however, is that the vast majority of people with excess weight are none of these.

There are countless people with excess weight, who eat as much or as little as skinny folks; the problem of inactivity and sedentariness in Canada affects 95% of the population (and not just the 60% who are overweight or obese); throughout history, overweight and obese individuals have expressed incredible feats of determination and will power; and psychiatric wards are full of skinny people with mental illness.

Thus, as I have often discussed in previous posts, the ‘root causes’ of obesity are as diverse as not having enough money or time to eat to taking medications for your allergies. Throw in an ounce of genetics (any of the the 1000s of genes involved in appetite, hunger, metabolism), and you have the perfect scenario for continuous and fruitless debates on what is really driving the obesity epidemic.

For those of us, who embrace activism, we can chose the target we happen to feel most strongly about and go for it with all our energy and passion.

The list of seemingly worthwhile and deserving targets is long: junk food, caloric beverages, TVs, computer screens, lost cooking skills, built environments, cars, automation, over-scheduled kids, poor parenting, sleep deprivation, environmental toxins, allergies, gut bugs, viruses, stress, dieting, fashion ideals, bullies, and probably a few more.

Which of these factors individually or in combination are most responsible for making us fat is anyone’s guess – what may have some evidence or support at a population level is often irrelevant when it comes to individuals (your reasons for being overweight are different from mine).

So, yes, my readers are right – most of the obesity epidemic is simply the natural response to living in an unnatural environment – or perhaps even just living.

For most people with excess weight, there is probably no real underlying “pathological” driver apart from being human.

This does not mean that obesity, once established, cannot become a pathological state in that it can adversely affect all dimensions of physical, emotional and functional health (or not).

After all, what do most thin people do to stay thin? The correct answer is probably, “not much”.

AMS
Edmonton, AB

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Last week, The Lancet published the first part of a monumental effort to describe the global burden of disease – I have not read the report.

But, from what I can garner by a cursory look at the abstracts and the many news articles, deaths from starvation are down, whereas deaths from obesity are up (the ratio apparently is now one to three – at least according to some media reports).

I cannot say that I am in any way surprised, not should any one else be.

It is also not surprising that when obesity rates increase hand-in-hand with increases in life-expectancy, then more people will be living longer with obesity related health problems (see my previous post on this).

While the report is descriptive and can neither make nor claim insights into what drives all of this, the warnings for our health systems and policy makers are clear – ignore obesity at your own risk.

In the same manner that obesity did not appear overnight, no public health measures can be expected to make it disappear any time soon (some predict this may be take several decades short of catastrophic and disruptive global events).

Over the last 50 years, we have made considerable strides in our ability to treat diabetes, hypertension, dyslipidemia, heart disease, and other obesity related health problems – one reason why people with these conditions live so much longer today than ever before.

The biology of glucose homeostasis is complex – yet we have effective treatments for diabetes.

The biology of blood pressure regulation is complex – yet we have effective treatments for hypertension.

The biology of cholesterol synthesis is complex – yet we have effective treatments for dyslipidemia.

The biology of coagulation is complex – yet we have effective treatments for blood clots.

The biology of energy homeostasis is complex – why do we not have effective treatments for obesity?

Is it because we simply don’t like fat people and think they deserve less?

AMS
Edmonton, Alberta

Reader may recall that the H1N1 flu outbreak in 2009 was particularly deadly to obese individuals.

This increased severity and fatality of H1N1 infections in obese patients became apparent early during the spring outbreak of the epidemic and prompted the Public Health Agency of Canada to recommend that individuals with severe obesity should be included amongst those to be given first access to the H1N1 influenza vaccine.

A paper by Chris Kaposy from Memorial University of Newfoundland, published in VACCINE, suggests that this PHAC recommendation was largely ignored by the provinces, who bear the responsibility for health care delivery in Canada.

In fact, only one province (Manitoba) followed the PHAC recommendations and considered all people under 65 with severe obesity eligible for H1N1 influenza vaccination on October 26 2009 – early in the vaccination campaign.

Alberta, Nova Scotia, and Saskatchewan, did list individuals with severe obesity, but placed narrow age restrictions on those who were given early access.

New Brunswick and Ontario listed severe obesity as a sequencing category late in the vaccination campaign (as late as November 2009).

In British Columbia, Newfoundland and Labrador, Prince Edward Island, and Quebec, obesity (or ‘severe’ obesity) was never specifically listed as a chronic health condition that qualified one for early access to the H1N1 influenza vaccine. In fact, it appears that ‘obesity’ was specifically removed from the list of eligible chronic conditions that warranted early access.

The author provides at least two pieces of evidence that weight bias may have played a role in the provinces’ decisions:

“First of all, consider that in every single province the H1N1 influenza vaccine was available to pregnant women over 20 weeks gestation very early in the mass vaccination campaign. In most provinces, the vaccine was available to this group from late October 2009 onward. Clearly there was a pan-Canadian commitment during the H1N1 influenza pandemic to offer early vaccine access to pregnant women – who were also listed in the PHAC categories as a vulnerable group. Every Canadian province could have similarly chosen to vaccinate people with severe obesity early in the campaign, but they did not.”

Secondly, the delay in access cannot be explained by scarcity of vaccine – in fact, in each of the four provinces (British Columbia, Newfoundland and Labrador, Prince Edward Island, and Quebec) that never listed people with severe obesity as eligible for early vaccination, school children were vaccinated early – prior to the availability of the vaccine to the general public despite the fact that the PHAC guidelines did not list school children as a vulnerable group and computer modelling did not support the priority use of vaccination in school children ahead of high-risk individuals.

Thus, this commentary argues, Canadian provinces demonstrated an ambiguous commitment to the early vaccination of people who were severely obese, despite clear and strong early evidence that individuals with severe obesity presented an especially vulnerable group and despite clear and timely recommendations by the federal public health agency to consider severely obese individuals for priority access.

Given that H1N1 influenza ultimately did result in significant number of fatalities (especially amongst people with severe obesity), I wonder if public outrage would have been greater had any other group of ‘vulnerable’ individuals been as overtly ‘overlooked’.

AMS
Edmonton, Alberta

Kaposy C (2011). The influence of the stigma of obesity on H1N1 influenza vaccine sequencing in Canada in 2009. Vaccine PMID: 22041304

A recent report commissioned by Alberta Health Services estimates that in 2005, the total direct and indirect costs of illnesses attributable to obesity in Alberta were $1.27 billion.

This represents 28.0% of the total direct and indirect costs attributable to obesity for 22 specific health conditions and 5.6% of the total direct and indirect costs for all health conditions in Alberta.

Coronary heart disease ($307.1 million) had the highest direct and indirect costs attributable to overweight and obese BMI status; osteoarthritis ($167.7 million), type 2 diabetes ($161.5 million), hypertension ($125.5 million), and the 14 cancer sites ($117.5 million) had the highest obesity-attributable costs after coronary heart disease. Among the 14 cancer sites, colorectal cancer ($31.6 million), postmenopausal breast cancer ($14.5 million), and leukemia ($11.0 million) had the highest costs attributable to overweight and obesity in Alberta.

While the direct health care cost attributable to overweight and obesity was $630.1 million, or 49.5% of the total cost of overweight and obesity, the indirect cost was $643.8 million including $63.1 million in short-term disability costs, $209.6 million in long-term disability costs, and $371.1 million in premature mortality costs.

As the report notes, these costs are conservative as the analysis did not include the costs for:

• Private out-of-pocket costs such as those paid for private caregivers, illness-related aids, and home modifications not reimbursed by governmental agencies;
• Costs associated with reduced production during work hours (presenteeism) as a result of a health problem;
• The value of time lost from work
• The value of lost leisure time of family members or friends who care for the patient;
• Intangible costs that involve pain and suffering borne by patients and their families.

The report also did not assess the cost of obesity in youth under age 15 or in the Aboriginal population living on reserves.

Although the report did not analyses how much of these costs could be reduced or avoided by providing effective obesity treatments, it is very likely (based on other estimates) that the savings could be substantial.

As I have said before, no health care system can afford not to tackle obesity.

AMS
Edmonton, Alberta

The Summary of The Cost of Obesity in Alberta Report is available here

Yesterday, as widely reported in national media, Statistics Canada and the US National Center for Health Statistics released a study that directly compares the prevalence of obesity among adults in Canada to the number in the US.

The good news is that the prevalence of obesity among adults in Canada is lower than it is in the US (24.1% of adults in Canada vs. 34.4% in the US).

The bad news is that during the past two decades, in both Canada and the US, the rates of adult obesity have been increasing at roughly the same rates (about 10% points overall) with small, but perhaps interesting, variations across age groups – in men the greatest increase was among those aged 60 to 74; among women, the increase was highest among those aged 20 to 39.

The latter figure is particularly alarming because, with all of the accumulating data on epigenetic programming, where maternal obesity is literally transferred to her offspring via actual modification of their genetic code, we are in for an ever burgeoning epidemic of childhood obesity – one that is unlikely to be stopped by taxing pop or reintroducing 20 mins of daily phys-ed into school curricula.

As blogged before, we should now be seriously talking about actually providing obesity treatments to those already struggling with excess weight – perhaps starting with providing treatments for young moms and dads and those with severe obesity, who need it most.

Once obesity is established, simply preventing further weight gain can be seen as success. Without treatment, the currently over 6,000,000 obese Canadians will simply continue gaining weight, with all of its economic and health consequences.

Note that the solution for many may not be weight loss -after all, if simply losing weight were the solution, then this problem would not exist – I have yet to meet an overweight or obese person, who has never lost weight.

What Canadians need is access to weight management in the same manner as they would seek and receive management for their diabetes, their hypertension, their asthma, their depression, or any other chronic condition that affects their health.

Currently such weight management resources in our healthcare systems are beginning to emerge but remain rare and hard to find amongst the deafening cacophony of the commercial weight-loss industry.

This is exactly where the Canadian Obesity Awareness and Control initiative for Health (COACH) comes in – providing Canadians struggling with excess weight with reliable and un-biased information on obesity management and pointing them to credible weight management resources in their healthcare systems and communities.

The time for COACH is now – not once we have caught up with our friends south of the border. If anything, this report should remind us that without immediate action, Canada may well soon be where the US is today.

If you have not already done so – please show your support for COACH and help spread the message by clicking here.

AMS
Edmonton, Alberta