Every two years the Canadian Obesity Network holds its National Obesity Summit – the only national obesity meeting in Canada covering all aspects of obesity – from basic and population science to prevention and health promotion to clinical management and health policy.
Anyone who has been to one of the past four Summits has experienced the cross-disciplinary networking and breaking down of silos (the Network takes networking very seriously).
Of all the scientific meetings I go to around the world, none has quite the informal and personal feel of the Canadian Obesity Summit – despite all differences in interests and backgrounds, everyone who attends is part of the same community – working on different pieces of the puzzle that only makes sense when it all fits together in the end.
The 5th Canadian Obesity Summit will be held at the Banff Springs Hotel in Banff National Park, a UNESCO World Heritage Site, located in the heart of the Canadian Rockies (which in itself should make it worth attending the summit), April 25-29, 2017.
Yesterday, the call went out for abstracts and workshops – the latter an opportunity for a wide range of special interest groups to meet and discuss their findings (the last Summit featured over 20 separate workshops – perhaps a tad too many, which is why the program committee will be far more selective this time around).
So here is what the program committee is looking for:
- Basic science – cellular, molecular, physiological or neuronal related aspects of obesity
- Epidemiology – epidemiological techniques/methods to address obesity related questions in populations studies
- Prevention of obesity and health promotion interventions – research targeting different populations, settings, and intervention levels (e.g. community-based, school, workplace, health systems, and policy)
- Weight bias and weight-based discrimination – including prevalence studies as well as interventions to reduce weight bias and weight-based discrimination; both qualitative and quantitative studies
- Pregnancy and maternal health – studies across clinical, health services and population health themes
- Childhood and adolescent obesity – research conducted with children and or adolescents and reports on the correlates, causes and consequences of pediatric obesity as well as interventions for treatment and prevention.
- Obesity in adults and older adults – prevalence studies and interventions to address obesity in these populations
- Health services and policy research – reaserch addressing issues related to obesity management services which idenitfy the most effective ways to organize, manage, finance, and deliver high quality are, reduce medical errors or improve patient safety
- Bariatric surgery – issues that are relevant to metabolic or weight loss surgery
- Clinical management – clinical management of overweight and obesity across the life span (infants through to older adults) including interventions for prevention and treatment of obesity and weight-related comorbidities
- Rehabilitation – investigations that explore opportunities for engagement in meaningful and health-building occupations for people with obesity
- Diversity – studies that are relevant to diverse or underrepresented populations
- eHealth/mHealth – research that incorporates social media, internet and/or mobile devices in prevention and treatment
- Cancer – research relevant to obesity and cancer
…..and of course anything else related to obesity.
Deadline for submission is October 24, 2016
To submit an abstract or workshop – click here
For more information on the 5th Canadian Obesity Summit – click here
For sponsorship opportunities – click here
Looking forward to seeing you in Banff next year!
To conclude my miniseries on the recent “Clinical Discussion” on obesity, published in the New England Journal of Medicine, I now turn to the final question – does this relatively healthy 29 year-old woman with a BMI of 32 warrant treatment?
And if yes, what treatment would you recommend.
This question cannot be answered without considering the following:
Often, we tend to focus on potential benefits of treatment, and so most of us would probably approach this question by comparing the potential benefits of treatment vs. the potential risks of not treating this patient – this is often referred to as the benefit-risk ratio.
When this ratio exceeds 1 (i.e. the potential benefits of treatment outweigh the potential risks of treatment), we would recommend treatment.
One could, however, also turn this into a risk-risk ratio.
Both, the decision to treat and the decision to not-treat bear risks.
Given that the woman in this case has Edmonton Obesity Stage 1 at best (borderline hypertension?), her mortality risk over 20 years is rather low.
For one, this means that treating her obesity would likely also have rather modest benefits (if any). In fact, there is currently no proven health benefit of even just modest weight loss in a patient like her.
Thus, we would certainly want to rule out treatments that carry any potential risk.
Clearly, obesity surgery,would not even remotely enter the picture.
Even the risk of medication, although much safer than anything we may have had before, is probably too high. Although the statistical risk for severe side effects (ranging from teratogenicity to pancreatitis – depending on the chosen medication) is rather low, it may still be substantially higher than doing nothing.
This leaves us with behavioural modifications, which would pose the lowest treatment risk (although it is important to remember that the risk of behavioural treatments is not zero: exercise can result in injury, a too restrictive diet could result in nutritional problems or, as some folks fear, trigger an eating disorder).
The most conservative approach would be to reassure her that her mortality risk is indeed rather low (certainly not warranting the risk of medication).
However, treatment decisions are not only guided by mortality risk – we also need to consider quality of life.
Despite being at low medical risk, it may well be that our patient is unhappy with her weight (although we have no information in this regard other than that she has made previous attempts at weight loss).
Exploring this further would certainly require a much deeper dive into how she feels about herself – her weight may not even be the real problem here.
Can she eat better and be more active? Sure, most of us can!
Would I want to see her again, perhaps in a year or so to see how she is doing – sure, even if just to confirm that she still has EOSS 1.
Beyond that, I would be guided by the principle of “first-do-no-harm” and probably leave it at that (at least for now).
Continuing in my miniseries on the recent “Clinical Discussion” on obesity, published in the New England Journal of Medicine, I now turn to the second question that we need to answer before jumping into giving our patient any advice about managing her weight.
The first question, as discussed in yesterday’s post, is to understand the possible “root-causes” of her weight gain, as these may not only have to be targeted during treatment but can also pose important barriers to management (e.g. emotional eating, depression, lack of time, stress, etc.).
Unfortunately, as I noted yesterday, the case presentation did not provide much in terms of helping us understand, why this patient has a BMI of 32 in the first place.
Not only did we not get any information regarding her weight trajectory, we were also only told that she eats out often and is largely sedentary – not really much to go on, given that the same could be said about the vast majority of people living in the US (or in Canada), irrespective of their size or weight.
As for the second question that we now need to answer, before giving any advice, is whether or not she even has a health issue that needs to be addressed.
Thus, while we may be led to believe that her BMI of 32 in itself justifies the diagnosis of “obesity”, we must remember that BMI is a essentially a measure of body size, in fact, not much better than a dress size.
Although statistical risk for certain health problems (e.g. diabetes, hypertension, joint problems, sleep apnea, etc.) may rise with increasing BMI, this relationship is far weaker than most people think.
Indeed, as we have previously noted, as many as 25-30% of individuals in the BMI 30-35 range may have no clinically significant health impairments whatsoever. This is particularly true for younger individuals and for women – out patient just happens to be a 29 year-old female.
Thus, it is in fact not all that surprising, that the case report goes on to note that Ms Chatham has neither a history of coronary artery disease nor diabetes (which would indeed be rather unusual if did), and, apart from a marginally elevated blood-pressure, her health status is largely “unremarkable”. Although not mentioned in the case vignette, we can perhaps also assume that all her lab values are normal.
Thus, even if we assume that the blood pressure reading is reliable, this information would at best put her at an Edmonton Obesity Stage 1, a stage where her long-term mortality risk would be almost indistinguishable from “normal”.
And, if we apply the actual WHO definition of obesity (the presence of excess or abnormal body fat that impairs health), we may in fact have to bend over backwards to diagnose this woman as having obesity at all.
So if there is no relevant health impairment from her BMI of 32, why is she even concerned about her weight?
Because, as we learn from the case study, she has been told indirectly, by her friends and family, that she is “overweight.”
Which brings me back to our question at hand: does this woman even have a health problem that needs to be addressed?
My answer would be a rather enthusiastic, “not really”.
We could of course leave it at that, and simply reassure her that she is pretty healthy (although she may perhaps want to have her blood pressure rechecked in the near future).
If however, she does persist in her intention to lose weight, and continues to insist that we advise her on what she can do to improve her health (which are really two very different questions), we may need to have a much longer discussion with her.
This is something we will look at tomorrow, when we address the third question:
What would be the best management plan for this patient?
Yesterday, I posted about the “Clinical Discussion” of obesity management, presented to us by the venerable New England Journal of Medicine.
I wrote about how the ignorant and moralizing “opinion” of one of the discussants, devoid of even the smallest insight in to the complex sociopsychobiology of this chronic disease, is exactly the kind of “thinking” that is holding back the field (and has been for decades).
But these are not the only problems with the “Clinical Discussion”.
Rather, the problems start with the very choice and description of the “case”.
Indeed, the case warrants a careful line-by-line analysis, to reveal just how the use of the “stereotypical” depiction paints a picture of what (as we will see in a later post), could well turn out to be a much more complicated case than either of the discussants acknowledge.
As we are told,
Ms. Chatham is a 29-year-old woman who recently joined your practice; this is her second visit to your clinic.
In other words, this is a young woman, whose life you know virtually nothing about, not that this should ever stop you from stating your sound medical opinion.
She made today’s appointment to discuss how she can lose weight and whether there are medications that she can take to aid in weight loss.
In other words, a typical “fat” patient looking for a “quick fix” via “diet pills”?
She is relatively healthy, except for a history of childhood asthma.
Did the asthma play any role in her weight gain? Did it limit her physical activity as a kid? Was she on anti-allergic drugs or even systemic steroids that may have led to weight gain? Your guess is as good as mine.
She says that she has been told indirectly, by her friends and family, that she is “overweight.”
Because, obviously, she does not own a mirror, never shops for clothes, and has probably never given her shape or size a second thought, and therefore, needs to be “told” by the good people around her (and perhaps on occasion by perfect strangers she may just happen to meet on the street), that she has a serious health problem and needs to urgently see a doctor.
She has tried several popular diets without success; each time, she has lost 4.5 to 6.8 kg (10 to 15 lb) but has been unable to maintain the weight loss for more than a few months.
Which, I’m guessing, simply goes to prove her lack of motivation and effort. Obviously, like most “fat” people, she is just too weak-willed to maintain weight loss and apparently always gives up far too soon. Never mind, that this is exactly what happens to 95% of people (skinny or fat) who lose weight and never mind, that (as some of us now realise) there is in fact a complex neurohormonal physiology, which tightly regulates body weight and is there solely for the purpose of effectively “defending” against weight loss.
She does not have a history of coronary artery disease or diabetes.
Which would in fact be surprising, given that she is a 29 year-old woman!
She has a regular menstrual cycle.
Which means what exactly? Are we supposed to rule out PCOS or fertility issues based on this clinical “pearl”?
She does not take any medications or nonprescription supplements.
So at least we know that she cannot simply blame her weight gain on any current medications.
She does not smoke but does drink alcohol, occasionally as many as 4 or 5 drinks in a week, when she is out with friends.
Which you could also say about millions of other people (including myself), irrespective of their BMI or health status – it’s what people do!
She tells you that she “watches what she puts in her mouth”…
Which, of course we should have a hard time believing, because as we all know, “fat” people are habitual liars when it comes to what they “tell” us about their diets.
…and reads the nutritional labels on food packaging.
or, at least that’s what she “tells” us – you’re welcome to believe her or not.
However, she enjoys eating out and orders take-out meals 8 to 12 times a week.
Wow! Here we have a “fat” person who actually “enjoys” eating out – as many times as (hold your breath) once or twice a day – and that, despite claiming to read food labels! Never mind that this is exactly how 99.9% of the US population happens to eat (no matter what their size or health status) – clearly, this irresponsible behaviour must change if there is to be any hope for her!
She works as a computer programmer and spends most of her day sitting in an office.
There we have it – typical “sedentariness” a well-known “cause” of obesity (or so we are told), because (as should be obvious to anyone who understands the complexity of energy homeostasis), all people who sit in offices (not to mention the now immortalised 400 lb “hacker”), struggle with their weight.
She belongs to a fitness club and tries to go there about once a week but notes that her attendance is inconsistent.
Because, of course, it’s typically the fat people with gym memberships, who never show up for training. Also relevant, because most of us continue to believe that exercise is the best way to lose weight.
On physical examination, her vital signs are unremarkable except for a blood-pressure measurement of 144/81 mm Hg.
Which we must obviously assume to be reliable, as the docs have certainly ruled out the presence of “White-Coat” hypertension and bothered to ensure that they are indeed using an appropriate cuff size.
She is 1.7 m (5 ft 7 in.) tall and weighs 92 kg (203 lb), and her body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) is 32.
Which contains about as much clinically valuable information as telling us that she is a size 16.
Her waist circumference is 94 cm (37 in.).
Another piece of useless information, especially in an otherwise healthy woman.
There is no peripheral edema.
Which, I guess, clearly tells us that she can forget about using “fluid retention” as an “excuse” for her weight.
The rest of the examination is unremarkable.
There you have it – with this information in hand, we are now clearly poised to give her meaningful clinical advice to help her better manage her weight.
What surprises me about this (apparently “typical”) case history, is that the editors of the New England Journal of Medicine, otherwise so concerned with brevity, did not simply decide to shorten the “case” to the following:
“Ms. Chatham is a pretty healthy 29-year-old working woman, who happens to live in the USA.”
That one line would in fact contain about all of the information we now have about Ms. Chatham, the difference being, that this statement is actually better, in that it is elegantly crafted to avoid the use of “stereotypical” fat-shaming language and imagery.
Furthermore, this sentence, quite like the “case”, is also void of any indication of the actual complexity that even “simple obesity” can present in clinical practice (which, I perhaps mistakenly, assumed would have been the whole point of the Clinical Discussion in the first place).
Is anyone curious as to the information that I would really liked to have about Ms. Chatham to come up with advice that would actual help her?
Then, please stay tuned for tomorrow’s post.
The biguanide metformin is widely used for the treatment of type 2 diabetes. Metformin has also been shown to slow the progression from pre to full-blown type 2 diabetes. Moreover, metformin can reduce weight gain associated with psychotropic medications and polycystic ovary syndrome.
Now, a randomised controlled trial by M P van der Aa and colleagues from the Netherlands, published in Nutrition & Diabetes suggests that long-term treatment with metformin may stabilize body weight and improve body composition in adolescents with obesity and insulin resistance.
The randomised placebo-controlled double-blinded trial included 62 adolescents with obesity aged 10–16 years old with insulin resistance, who received 2000 mg of metformin or placebo daily and physical training twice weekly over 18 months.
Of the 42 participants (mean age 13, mean BMI 30), BMI was stabilised in the metformin group (+0.2 BMI unit), whereas the control group continued to gain weight (+1.2 BMI units).
While there was no significant difference in HOMA-IR, mean fat percentage reduced by 3% compared to no change in the control group.
Thus, the researcher conclude that long-term treatment with metformin in adolescents with obesity and insulin resistance can result in stabilization of BMI and improved body composition compared with placebo.
Given the rather limited effective options for addressing childhood obesity, this rather safe, simple, and inexpensive treatment may at least provide some relief for adolescents struggling with excess weight gain.