Arya M. Sharma, MD

Today, I am going to throw out a bold statement on the state of overweight and obesity in Western societies: The time for primary prevention is over!

With two-thirds of the population now overweight or obese, we must accept that primary prevention has failed, the obesity horses are out of the the barn, there is no longer any point in locking the doors.

Rather, it’s now time to move on to secondary prevention; so let’s round up a posse and chase after the horses to catch them before they gallop off a cliff.

In developed countries around the world (including the US), we are beginning to see rates of overweight and obesity leveling off. This is not because these countries have now implemented strict measures to prevent obesity or to be taken as evidence that any such measures are working. I believe that the leveling off in the rates of overweight and obesity simply means that everyone in the Western world, who can be overweight or obese is now overweight or obese. The remaining third, that still has a normal weight, is overweight resistant and will never become obese, so let’s stop worrying about them.

Epidemiologists know, that in every epidemic comes a time when everyone who can be affected is affected. Even during the worst flu epidemic, a significant number of people will not come down with the flu no matter how much they are sneezed on or or how close they live to those who are affected. Yes, they may even have the virus circulating in their blood, but will yet have no sign of clinical disease nor will they develop it.

Obesity is no different. We are all exposed to the same societal factors that drive obesity. We are all surrounded by food (mostly unhealthy), we are all deprived of sleep, we all have sedentary jobs, we are all short of time, less than 5% of us eat the recommended diets or receive the recommended amount of daily activity. So why are we not all overweight or obese?

Because some of us are simply obesity resistant. For whatever reason (genetics, different metabolisms, distinct gut bugs, more brown fat, exercise addiction, etc.), some of us are either simply not obesity prone or are managing well to keep it at bay. Even if circumstances were to become more obesogenic, this proportion of our population would still not gain substantial amounts of weight - they are either truly (genetically) resistant, or would simply double their efforts to ward off those unwanted pounds - these people (I often refer to them as the “mutants”) will simply never become obese baring a catastrophe (e.g. an immobilising injury or illness, being put on an obesogenic drug, post-traumatic stress, severe depression, losing their income, etc.).

These are not the people we need to worry about. Educating them about the merits of eating healthier or being more active is a waste of time and resources - they are already eating just fine (or are resistant to their junk food diets) and are already getting plenty of exercise (or simply don’t need exercise because they are “natural-born” fidgeters). Any dollar spent on educating or incentivising them (e.g. tax breaks) is a dollar wasted.

Rather, it is now time to switch gears, time to call a spade a spade, and time to move on to secondary prevention. As my epidemiologist colleagues are well aware, in contrast to primary prevention, secondary prevention is not about preventing anyone from getting the condition; it is about ensuring that the problem does not get worse in the people who already have the problem.

Normally, in secondary prevention, you focus your efforts solely on the people who have the problem. However, when two-thirds of the population have it, you may as well treat the whole population, because making exceptions for those who don’t have the problem may simply not be practical. When most people have iodine deficiency, supplementing foods with iodine makes sense, even if this means that some people who do not need more iodine will get more iodine (thereby slightly increasing their risk for hyperthyroidism).

But moving to secondary prevention also means using different and more intense interventions. Thus in the secondary prevention of heart attacks, it is no longer simply enough to cut out the salt and add 20 mins of exercise to your day. After that first heart attack, you definitely want to make sure that your blood pressure and cholesterol levels are well controlled, even if this means increasing your dose of medications. And we are no longer talking about smoking less - no, after that heart attack, smoking is an absolute “no-no”.

Similarly, in the secondary prevention of obesity, simply eating more fruit and vegetables or walking more steps will not be enough. It is likely going to take far more drastic changes to your diet and to your activity levels to halt progression or reverse your condition. Effective weight management is neither easy nor simple (if it was simple for you, you’d be in the weight-resistant category in the first place). Now that you already have the problem, you will need special attention, special dedication, perhaps even special treatments to stop gaining more weight and hopefully lose some of that excess weight and keep it off. To some readers, secondary prevention may sound much more like treatment than prevention - this is because secondary prevention is in fact far closer to treatment than prevention.

Indeed, moving to secondary prevention requires a drastic rethinking in how we address the overweight and obesity epidemic at a population level. The question no longer is, how to help thin people stay thin. The question now is, how to help overweight and obese people not gain any more weight and perhaps receive treatments that will help them lose some of that excess weight and keep it off.

This may still mean we need to rebuild our neighbourhoods, deal with food insecurity, improve our diets, promote physical activity, and everything else that we should have done years ago at the first sign of the epidemic. But, because today we should no longer be worrying about primary prevention (which may have been easier had we actually done it), we will need far greater resolve and efforts to support far more radical changes at a societal level (not dissimilar the lengths we go to to remove peanuts from schools) to begin seeing clinically significant changes in weight at a population level - I purposely use the term “clinical”, because we now talking of disease control rather than disease prevention.

Skeptics may ask, “But what about the children? Is there not still time for primary prevention there?” To them my answer is that I do not for an instant believe that we will make a dent in the childhood obesity epidemic without first (or at least concurrently) addressing adult obesity (see previous post on this). Thus, probably the best primary prevention for childhood obesity simply takes us back to more secondary prevention for their parents.

Simply distributing more condoms in a population where most people already carry HIV is a waste of perfectly good condoms. It’s now time to put the anti-retrovirals in the drinking water.

AMS
Banff, Alberta

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Thorkild Sørensen

Yesterday, at the ongoing XI International Congress on Obesity, the 2010 ICO Award for Population Science and Public Health was awarded to Thorkild Sørensen from the University of Copenhagen. His studies from the early 70’s found early signs of the impending obesity epidemic in young Danish military recruits as far back as the 1960s.

His studies further suggest that this increase in obesity was related to “birth cohort” effects and can likely be traced to perinatal environmental factors rather than to influences acting on school age kids or adults. Indeed, based on his findings, Sørensen strongly recommends that we take a careful look at the historical dimension if we hope to identify the root causes of the current obesity epidemic.

As it so happens, I also had the pleasure of attending the launch of the new Wadd Society for the History of Obesity, with presentations from Professors George Bray, Stephan Rossner, and David Haslam at this meeting. The aim of the society is to promote interest in the history of obesity ranging from medical and pharmacological aspects to those of fashion, culture, art, and literature.

As all of this perhaps serves to remind those of us working in the field of obesity, that we must be very cautious before jumping to conclusions regarding whether or not recent environmental changes such as sedentary lifestyles, fast food, sugary soft drinks, television, or any of the many other factors that are being discussed are truly the root causes of the epidemic. While none of these development would be considered “healthy”, conclusive evidence as to their actual role in the epidemic of obesity is far from conclusive.

AMS
Stockholm, Sweden

For more posts on ICO 2010 click here

From time to time the media loves to write stories on the Obesity Myth.

These stories come in two flavours - the first one denies the very existence of an obesity epidemic, attributing the rise in obesity statistics to moving definitions that “suddenly” make everyone obese simply by shifting the goal post.

The second flavor of obesity myths acknowledges the increase in people with excess weight but states that carrying a few extra pounds or even having more severe obesity is not really detrimental to your health, ergo this whole obesity thing is vastly overblown.

Last week, news media around the world once again splashed Obesity Myth headlines on their front pages, this time of the second flavor - yes obesity exists, but it is really not a health risk.

These reports were based on a study by Brant Jarrett and colleagues from the Brigham Young University, Provo, UT, published in the International Journal of Obesity.

The researchers examined data from the 1988-1994, 2003-2004 and 2005-2006 US National Health & Nutrition Examination Surveys (NHANES) to determine the relationship between BMI, age, gender and current medication in 9071 women and 8880 men. Current medication (or medication loads) were considered a surrogate measure of current health status.

In both the 1988-1994 and 2003-2006 data sets, with few exceptions, medication loads did not increase significantly in overweight compared with normal-weight people, a finding that prompted the news headlines.

However, the paper did find increased medication load in people who were clinically obese (BMI>30), especially if they were 40 years of age or older.

In fact, the authors themselves conclude:

“Although obesity does not substantially affect current health in young people, it is likely that the increased medication loads in obese compared with normal-weight older people originates at least in part from an increased BMI starting at a younger age. Thus, age, gender and onset of high BMI all require consideration when using BMI to assess current health status.“

Given these findings, one can only wonder why the media chose to propagate the Obesity Myth based on this study, given that the authors themselves clearly found a relationship between excess weight and health status.

While the authors do emphasize that BMI is not a good measure of health risk, this is nothing new.

Regular readers of these pages will recall several previous posts on the limitations of BMI as an indicator of health and it were indeed these limitations that prompted us to develop the Edmonton Obesity Staging System as a more clinically relevant measure of obesity.

So, while moderate excess weight may not cause apparent health problems in the young, obesity remains a significant risk factor for poor health in middle-aged adults.

AMS
Vancouver, BC

Jarrett B, Bloch GJ, Bennett D, Bleazard B, & Hedges D (2010). The influence of body mass index, age and gender on current illness: a cross-sectional study. International journal of obesity (2005), 34 (3), 429-36 PMID: 20010903

Looks like the Europeans may be onto something here. The following is from the European Obesity Day website:

It’s estimated that over half of the European population is overweight or obese. Whilst it is often seen as something that affects body image and confidence, being overweight is extremely detrimental to health, causing huge personal and public health issues across Europe.

We’re not just talking about feeling sluggish and unfit. Being overweight or obese increases the risk of developing serious life-threatening illnesses such as type 2 diabetes and heart disease – two of the leading causes of preventable death worldwide.

However, what many people don’t know is that if you’re overweight, losing 5-10% in body weight can significantly improve your health.

That’s right – gradual, steady weight loss which results in a 5-10% decrease in body weight can help you feel fitter, healthier and reduce the likelihood of you suffering from high blood pressure, type 2 diabetes and stroke.

Europe’s obesity epidemic is already here – and we need to take the right action now!

Losing weight is really tough and helping people lose weight (not just preventing weight gain) is key. Governments are taking steps to prevent people becoming overweight, but we believe that to truly create a healthier Europe today, more effort is needed to help those who are already overweight or obese.

Through our campaign, 5-10 for a healthier Europe, we want to harness support and backing to help overweight and obese citizens lose 5-10% of their overall body weight, collectively improving the health of our nations and enriching the lives of people across Europe.

We want to raise public awareness of the need for action by all – from Governments to individuals –to make genuine and practical steps to help people reach a healthy weight in order to reverse Europe’s obesity epidemic.

What you can do?

Help our European friends by joining their citizens’ initiative petition, where they are hoping for 1 Million signatures!

Click here to sign the petition

Do you think it is time for our own petition here in Canada?

AMS
Frankfurt, Germany

Yesterday, I had the pleasure of spending a beautiful warm and sunny day ( in Whitehorse. Located around two flight hours north-east of Vancouver, Whitehorse is the capital of Canada’s north-western most territory. A city of roughly 22,000, Whitehorse is home to roughly two-thirds of the territory’s population.

I was invited by the Yukon Health and Social Services to meet with dietitians, physicians and other health professionals to discuss obesity management in the Yukon. My visit followed in the tracks of a recent visit by the Edmonton Weight Wise staff, a few weeks ago. Currently, the Whitehorse General Hospital, the only hospital in the Yukon, does not have the capacity to provide bariatric services although there is clearly an increasing recognition of the need for a local obesity program.

In the past years, many patients from the Yukon have been referred for bariatric assessment and surgery to our program in Edmonton, but the distances (especially for bariatric patients) make this a most expensive and ineffective endeavor. The aim of my visit was therefore to provide input into the possible creation of bariatric assessment and management services in Whitehorse itself.

Given the attendance and level of discussion, I have no doubt that there is an increasing recognition for the immense need for such services for the local population. Particularly given the large local aboriginal population, which appears particularly prone to obesity and its complication, there is no doubt that serious consideration of developing obesity management locally will in the end be cost-saving and likely the only feasible route to managing the obesity problem.

During my visit I not only visited the only long-term bariatric suite in Whitehorse but also saw, what I was told, was the only bariatric wheelchair in the city (I understand it is in high demand).

I am grateful to my most generous hosts for their kind hospitality and very much look forward to working with my new Yukon friends to help address this pressing and growing health issue in Canada’s North.

AMS
Edmonton, Alberta