Irrespective of the fact that bariatric surgery has now become so safe (at high-volume centres) that it compares well with other common surgical procedures like having your gall bladder removed, it is still surgery.
As even the safest surgery carries risk, it should never be taken lightly and thus the question of whether or not people with obesity but no related comorbidities stand to benefit from bariatric surgery is an important question.
One of the key outcomes (at least for patients) is the impact on quality of life which is why Hilde Risstad and colleagues from the University of Oslo, studied the effect of bariatric surgery on patients presenting with obesity related comorbidities and those without, published in Obesity Surgery.
They studied 232 patients with severe obesity before and 2 years after Roux-en-Y gastric bypass.
Obesity related disease was defined as having at least one of the following conditions: type 2 diabetes mellitus, hypertension, dyslipidemia, coronary heart disease, obstructive sleep apnea, gastroesophageal reflux disease, or osteoarthritis.
Not only was baseline quality of life similar in patients with and without obesity-related disease prior to gastric bypass but it also improved equally in both groups.
This may not be entirely surprising.
Readers may recall that the Edmonton Obesity Staging System (EOSS), specifically designed to asses obesity related health risks, does not just consider medical comorbidities (as in this study) – EOSS gives as much importance to mental and functional health (not assessed in this study).
Thus, it is not surprising, that even without the presence of an obesity related medical complications like diabetes or sleep apnea, health (and thus quality of life) can be significantly affected by mental health and/or functional status, both of which can markedly improve after bariatric surgery.
This is why, pre-assessment or triaging patients for bariatric surgery should not only consider medical problems but also mental and functional health – as in EOSS.
Regular readers will be well of the very real social and health impact of weight bias and discrimination.
Now, Sara Kirk of Dalhousie University, Halifax, NS, invites you to join her free Massive Open Online Course (MOOC), on weight bias and stigma in obesity, which will be starting on April 20th 2015 (just a week before the Canadian Obesity Summit in Toronto).
The course builds on Kirk’s extensive research in this area and the dramatic presentation that was created from her findings.
Participants will be able to explore some of the personal and professional biases that surround weight management and that impact patient care and experience.
This will hopefully give health professionals better insight into how to approach individuals experiencing obesity in a respectful and non-judgmental manner and provide strategies to build positive and supportive relationships between health care providers and patients.
While targeted at health care providers, the course should also be of interest to anyone interested in learning more about what weight bias is and how it can impact health and relationships.
Participants who complete the course requirements can apply for a citation of completion (for a nominal fee).
Following the recent release of the Canadian Task Force on Preventive Health Care guidelines for prevention and management of adult obesity in primary care, the Task Force yesterday issued guidelines on the prevention and management of childhood obesity in the Canadian Medical Association Journal (CMAJ).
Key recommendations include:
- For children and youth of all ages the Task Force recommends growth monitoring at appropriate primary care visits using the World Health Organization Growth Charts for Canada.
- For children and youth who are overweight or obese, the Task Force recommends that primary health care practitioners offer or refer to formal, structured behavioural interventions aimed at weight loss.
- For children who are overweight or obese, the Task Force recommends that primary health care practitioners not routinely offer Orlistat or refer to surgical interventions aimed at weight loss.
The lack of enthusiasm for the prevention of childhood obesity is perhaps understandable as the authors note that,
“The quality of evidence for obesity prevention in primary care settings is weak, with interventions showing only modest benefits to BMI in studies of mixed-weight populations, with no evidence of long-term effectiveness.”
leading the Task Force to the following statement,
“We recommend that primary care practitioners not routinely offer structured interventions aimed at preventing overweight and obesity in healthy-weight children and youth aged 17 years and younger. (Weak recommendation; very low-quality evidence)”
Be that as it may, the Task Force does recommend structured behavioural interventions for kids who already carry excess weight based on the finding that,
“Behavioural interventions have shown short-term effectiveness in reducing BMI in overweight or obese children and youth, and are the preferred option, because the benefit-to-harm ratio appears more favourable than for pharmacologic interventions.”
What caught my eye however, was the statement in the accompanying press release which says that,
“Unlike pharmacological treatments that can have adverse effects, such as gastrointestinal problems, behavioural interventions carry no identifiable risks.” (emphasis mine)
While I would certainly not argue for the routine use of orlistat (the only currently available prescription drug for obesity in Canada) in children (or anyone else), I do take exception to the notion that behavioural interventions carry no identifiable risks – they very much do.
As readers may be well aware, a large proportion of the adverse effects of medications is attributable to the wrong use of these medications – problems often occur when they are taken for the wrong indication, at the wrong dose (too high or too low), the wrong frequency (too often or too seldom), and/or when patients are not regularly monitored. In a perfect world, many medications that often lead to problems would be far less problematic than they are in the real world.
Interestingly, the same applies to behavioural interventions.
Take for example diets – simply asking a patient to “eat less” can potentially lead to all kinds of health problems from patients drastically reducing protein, vitamin and mineral intake as a result of going on the next “fad” or “do-it-yourself” diet. Without ensuring that the patient actually follows a prudent diet and does not “overdo” it, which may well require ongoing monitoring, there is very real potential of patients harming themselves. There is also the real danger of promoting an eating disorder or having patients face the negative psychological consequences of yet another “failed” weight-loss diet. Exactly how many patients are harmed by well-meant dietary recommendations is unknown, as I am not aware of any studies that have actually looked at this.
The same can be said for exercise – simply asking a patient to “move more” can result in injury (both short and long-term) and coronary events (in high-risk patients). Again, ongoing guidance and monitoring can do much to reduce this potential harm.
In short when patient apply behavioural recommendations at the wrong dose (too much or too less), wrong frequency (too often or too seldom), and/or are not regularly monitored, there is indeed potential for harm – I would imagine that this potential for harm is of particular concern in kids.
This is not to say that we should not use behavioural interventions – we should – but we must always consider the potential for harm, which is never zero.
I’d certainly be interested in hearing from anyone who has seen harm resulting from a behavioural intervention.
Now a study by Jennifer Fenn and colleagues from the University of Vermont report significant weight gain with methadone treatment for opioid addiction in a paper published in the Journal of Substance Abuse Treatment.
The retrospective chart review included 96 patients enrolled in an outpatient methadone clinic for ≥ 6 months.
Overall mean BMIs increased by about 3 units (from 27.2 to 30.1), which corresponds roughly to an 18 lb or 10% increase in body weight.
Interestingly, the weight gain was predominantly seen in women, who gained about 28 lbs or 17.5% body weight compared to men, who only increased their weight by about 12 lbs or 6.4%.
As the study did not have access to food records, one can only speculate as to the causes. While better nutrition may well play a role, one could also speculate that there may be some addiction transfer from opioids to calorie-dense foods.
Whatever the cause, clinicians should probably be aware of this potential impact of methadone treatment on body weight, as prevention of excess weight gain may be easier than treating obesity once it is established.
Now, Mary Boggiano and colleagues from the University of Birmingham, Alabama, in a paper published in Appetite, report that using tasty foods as a coping strategy is associated with weight gain.
The study administered the Palatable Eating Motives Scale (PEMS), which assesses eating for coping motives (e.g., to forget about problems, reduce negative feelings), to 192 college students, who were reexamined after two years (with a few measures in between).
Not too surprisingly, PEMS scores predict changes in BMI over two years.
On a positive note, however, the researchers found that PEMS scores (i.e. using food for coping) can change over time and a reduction in PEMS scores was also associated with a lesser weight gain. In overweight subjects, a reduction in PEMS scores was even associated with modest weight loss.
Thus, the authors suggest that interventions aimed specifically at reducing palatable food intake for coping reasons, should help prevent obesity if this motive-type is identified prior to significant weight gain.