Dr. Sharma's Obesity Notes

There is no shortage of health conditions that are either directly or indirectly related to excess body fat. Thus, it is of particular interest, when researchers find conditions for which the risk may actually be lower in obese individuals.

One such condition is hip fractures.

Thus, a meta-analysis by Tang and colleagues from Shanghai, published in PLoS One, demonstrates a substantially lower risk of hip fractures in individuals who are overweight and obese.

These findings were supported by an analysis of 15 prospective cohort studies involving over 3,000,000 participants.

Overall, adults with obesity had a 35% lower risk of sustaining hip fractures compared to normal weight individuals.

While obesity may well be a protective factor for hip fractures, unfortunately, obesity remains a significant risk factor for joint problems in both hips and knees.

So this finding may not be quite enough to write home about.

AMS
Banff, Alberta

Regular readers may recall a previous post outlining the importance of obesity as a key driver of osteoarthritis and perhaps even of other inflammatory forms of joint disease.

Yesterday, I had the privilege of attending a membership meeting of the Arthritis Alliance of Canada on behalf of the Canadian Obesity Network – a new member of this alliance.

With now more than 35 member organizations, the Alliance brings together arthritis health care professionals, researchers, funding agencies, governments, voluntary sector agencies, industry and, most importantly, representatives from arthritis consumer organizations from across Canada to provide a central focus for national arthritis-related initiatives.

The Alliance focuses on three distinct strategies:

• Advance knowledge and awareness of arthritis
• Identify opportunities and prescribe plans to improve prevention and care
• Support ongoing collaboration among stakeholders, government, other chronic disease groups

Obviously, all of this is of great interest to many overweight and obese individuals living with arthritis – irrespective of whether or not their weight is the root cause or simply a contributor to their joint pain.

For clinicians, as was pointed out in yesterday’s meeting, at least a cursory knowledge of assessing clients for joint problems should be part of a standard assessment – certainly a must for all patients presenting with excess weight. (Assessment for Osteoarthritis and joint pain are part of the 5As of Obesity Management ‘Assess’).

Reason enough for the Canadian Obesity Network to partner with and strongly support the goals of the Alliance.

AMS
Toronto, ON

One of the most common misconceptions about obesity management is that identifying and addressing a potential contributor to weight gain should automatically translate into weight loss – it does not!

As I pointed out in a recent post, when you identify and address the cause of weight gain – weight gain stops, and that’s usually it!

That many of us fail to recognize this rather simple principle, is again illustrated by a paper by Penner and colleagues published in the Journal of Joint and Bone Surgery, which found that successful ankle reconstruction surgery does not decrease BMI in overweight and obese patients.

According to their findings, the 145 patients with excess weight who underwent successful ankle replacement or ankle fusion, despite significant improvements in Ankle Osteoarthritis Scale (AOS) scores and increased physical activity scores, pretty much maintained their preoperative BMI levels at six months and one, two, and five years.

Based on these findings, the authors conclude that:

“Pain and disability are significantly reduced in overweight and obese patients after successful ankle replacement or fusion. Despite this, the mean BMI remains unchanged after the surgery, indicating that weight loss does not commonly occur following successful ankle reconstruction in this patient population. Obesity is likely attributable to factors other than limited mobility caused by ankle arthritis.”

Obviously, the authors assumed that if limited mobility caused weight gain, then increasing mobility should reduce it – that, however, is not what happens.

Rather, what they found, is exactly what I would expect – with regain of their mobility, patients stopped gaining weight – and that’s all.

Without a targeted obesity treatment strategy, there is indeed no reason to expect that these patients would now begin losing weight simply because their activity levels may now be somewhat higher than before. The few extra calories that they may perhaps now burn as a result of being more physically active would easily be compensated by an increased intake or other biological mechanisms that are there to ‘defend’ their current weight.

Thus, the observation that successful ankle surgery did not result in ‘spontaneous’ weight loss neither disproves nor proves that pain or disability may have contributed to weight gain in the first place – it probably did in some and probably did not in others.

Interestingly enough, I believe that this study also bears an important lesson for those attempting to address obesity at a societal level – even if we did know what exactly is driving the obesity epidemic – removing this cause does not necessarily mean everyone gets thinner – it just means that things may hopefully not get worse.

AMS
Berlin, Germany

Penner MJ, Pakzad H, Younger A, & Wing KJ (2012). Mean BMI of Overweight and Obese Patients Does Not Decrease After Successful Ankle Reconstruction. The Journal of bone and joint surgery. American volume, 94 (9) PMID: 22552679

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Yesterday, the Arthritis Alliance of Canada together with the Canadian Arthritis Network released The Impact of Arthritis in Canada: Today and Over the Next 30 Years, a 50-page report that provides a detailed look at the impact of arthritis in Canada and offers solutions on how to mitigate and manage the situation.

According to this report, there are currently more than 4.4 million people living with osteoarthritis (OA) in Canada. In 30 years, more than 10 million or one in four Canadians is expected to have OA. Within a generation (in 30 years), there will be a new diagnosis of OA every 60 seconds.

Currently OA drives about $10 billion in direct health care costs and about $17 billion in indirect costs (lost wages, lost taxes, etc.) – together with other forms of arthritis (especially rheumatoid arthritis) the total cost of arthritis amounts to an estimated $33 billion annually. These numbers will on only grow.

Recognising that excess weight is one of the prime (modifiable) drivers of the OA epidemic, the report suggests that targeting obesity should be a priority (along with better access to joint replacements and adequate pain management) in reducing the burden of arthritis on Canadians.

As the report points out:

If a prevention program was available to reduce obesity rates by 50% in the Canadian population over the next 10 years:

• 45,000 new cases of OA could be avoided over 10 years and over 200,000 cases of OA could be avoided over 30 years;

• 25,000 workers could avoid OA over 10 years and over 136,000 cases of OA in the labour force could be avoided over 30 years;

• $3.8 billion could be saved in cumulative direct health care costs over 10 years and $48.3 billion over 30 years (2010 dollars); and

• $14.0 billion could be saved in cumulative productivity losses over 10 years and $163.7 billion saved over 30 years (2010 dollars).

(Limitation: Costs attributable to obesity-reduction interventions were unavailable and, therefore, not considered in the model.)

While this conclusion stresses the importance of obesity as a key driver of arthritis costs, this assumption of course is rather optimistic.

To my knowledge, there is no known prevention strategy that comes even close to reducing obesity prevalence by 50% in 10 years. Indeed, for those at the highest risk of OA, namely, those who are already obese, ‘prevention’ strategies come too late – you would actually have to look at ‘treatment’ strategies.

The authors are certainly aware of this as they concede that:

“Further research is needed to improve on current strategies for preventing and treating obesity.”

Fortunately, we’re already on it.

AMS
Edmonton, Alberta

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

• Should We Outsource Obesity Treatments To Weight Watchers?
• Alberta’s Obesity Initiative: Not Just Diet and Exercise
• Is There Any Path For Approval of Anti-Obesity Drugs?
• GLP-1 Receptor Agonists, Obesity and Psoriasis
• Bariatric Surgery For Osteoarthritis of Hips and Knees?

Have a great Sunday! (or what’s left of it)

AMS
London, UK

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