In March, I had the privilege of being invited by the organisers of TEDx UAlberta to present a talk on obesity.
This talk is now online – please take a look and join the discussion on facebook
If clicking on the image does not work for you, click on this link for YouTube
Please support European Obesity Day
European Obesity Day (EOD) takes place this coming Saturday, 21 May, and is aimed at raising awareness and increasing knowledge about obesity and the many other diseases on which it impacts.
EOD is a major annual initiative for the European Association for the Study of Obesity (EASO) and so would like to ask you to support the activities by joining in the conversation on social media. It will help us to reach more of the policymakers, politicians, healthcare professionals, patients and the media who we are targeting with important messages about the need to take obesity more seriously.
There are several ways you can show your support:
Like the European Obesity Facebook Page
Follow EOD on Twitter @EOD2016
Join the conversations on twitter using the hashtag #EOD2016
Pledge your support on the European Obesity Day website
Visit the EOD website to see what we have been doing
Encourage your friends and colleagues to support us too
In line with the Action for a Healthier Future theme for EOD 2016, we hope we can count on your support.
Last year, the Canadian Obesity Network and the Werklund School of Education and departments of Psychology and Community Health Sciences at the University of Calgary co-hosted the 2nd Canadian Summit on Weight Bias and Discrimination in Calgary, AB.
The proceedings of this two-day summit, which was attended by 40 invitees representing education, healthcare, and public policy sectors in Alberta, British Columbia, and Ontario are now published in OBESITY.
The 40 attendees included 14 researchers, 11 practitioners, and 15 policy makers, although some participants represented multiple perspectives.
On the first day, speakers from across Canada presented their research on the prevalence and consequences of weight bias, as well as on interventions to reduce weight bias in the education, healthcare, and public policy arenas.
These daytime sessions concluded with an evening public outreach event in the form of an expert round table titled “Fear of Fat: Promoting health in a fat phobic culture” at a local community center with 100 attendees.
The second day consisted of a round table of facilitated discussions to identify what research question(s), if answered, would make the greatest impact on weight bias reduction efforts in Canada.
The key outcome from these deliberations include the identification of six research areas that warrant further investigation in weight bias: costs, causes, measurement, qualitative research and lived experience, interventions, and learning from other models of discrimination.
It also became evident that progress in this field requires attention to three key issues: language matters, the voices of people living with obesity should be incorporated, and interdisciplinary stakeholders should be included.
A 3rd Summit on Weight Bias and Discrimination that will build on the learning form the previous workshop will be held in Edmonton, May 26-27, 2016.
It will be interesting to see what progress has been made in field since the last meeting in 2015.
Nevertheless, epidemiologists (and folks in health promotion) appear to like the notion that there is such a weight (at least at the population level), and often define it as the weight (or rather BMI level) where people have the longest life-expectancy.
Readers of this literature may have noticed that the BMI level associated with the lowest mortality has been creeping up.
Case in point, a new study by Shoaib Afzal and colleagues from Denmark, published in JAMA, that looks at the relationship between BMI and mortality in three distinct populations based cohorts.
The cohorts are from the same general population enrolled at different times: the Copenhagen City Heart Study in 1976-1978 (n = 13 704) and 1991-1994 (n = 9482) and the Copenhagen General Population Study in 2003-2013 (n = 97 362). All participants were followed up to November 2014, emigration, or death, whichever came first.
The key finding of this study is that over the various studies, there was a 3.3 unit increase in BMI associated with the lowest mortality when comparing the 1976-1978 cohort with that recruited in 2003-2013.
Thus, The BMI value that was associated with the lowest all-cause mortality was 23.7 in the 1976-1978 cohort, 24.6 in the 1991-1994 cohort, and 27.0 in the 2003-2013 cohort.
Similarly, the corresponding BMI estimates for cardiovascular mortality were 23.2, 24.0, and 26.4, respectively, and for other mortality, 24.1, 26.8, and 27.8, respectively.
At a population level, these shifts are anything but spectacular!
After all, a 3.3 unit increase in BMI for someone who is 5’7″ (1.7 m) is just over 20 lbs (~10 Kg).
In plain language, this means that to have the same life expectancy today, of someone back in the late 70s, you’d actually have to be about 20 lbs heavier.
While I am sure that these data will be welcomed by those who would argue that the whole obesity epidemic thing is overrated, I think that the data are indeed interesting for another reason.
Namely, they should prompt speculation about why heavier people are living longer today than before.
There are two general possible explanations for this:
For one these changes may be the result of a general improvement in health status of Danes related to decreased smoking, increased physical activity or changes in social determinants of health (e.g. work hours).
On the other hand, as the authors argue, this secular trend may be that improved treatment for cardiovascular risk factors or complicating diseases, which has indeed reduced mortality in all weight classes, may have had even greater beneficial effects in people with a higher BMI. Thus, obese individuals may have had a higher selective decrease in mortality.
There is in fact no doubt that medical management of problems directly linked to obesity including diabetes, hypertension and dyslipidemia have dramatically improved over the past decades.
Thus, it appears that the notion of “healthy” weight is a shifting target and that changes in lifestyle and medical management may have more than compensated for an almost 20 lb weight increase in the population.
This is all the more reason that the current BMI cutoffs and weight-centric management of obesity both at a population and individual level may need to be revisited or at least tempered with measures of health that go beyond just numbers on the scale.
While the debate about whether or not obesity merits being called a disease may still be discussed in lay circles (and, unfortunately, even amongst some so-called “experts”), there have been some remarkably forward-thinking policy decisions in the US, that should have long helped lay this “debate” to rest.
Here are just some of the policies supporting the idea of obesity as a disease passed by US legislators in recent past, as outlined in the article by Scott Kahan and Tracy Zvenyach published in Current Obesity Reports.
In 2002, the US Internal Revenue Service (IRS) explicitly stated obesity is a disease and codified the right to deduct medical treatment for obesity.
In 2004, the US Centers for Medicare and Medicaid Services (CMS) revised longstanding national coverage determination (NCD) policy that explicitly stated obesity was not an illness, to state that it was.
In 2006, CMS instituted coverage for certain bariatric surgical treatments for Medicare beneficiaries with BMI >35 and at least one obesity comorbid condition. However, the determination clearly states that surgery is only covered as part of treatment for obesity comorbid conditions, but treatment for obesity per se is not covered (that is, patients must have acceptable comorbid conditions, regardless of the extent of their excess weight).
In 2011, CMS declared intensive behavioral therapy, consisting of screening, nutrition assessment, and frequent behavioral counseling (as defined by 14 face-to-face interactions with a primary care provider over 6 months and up to 22 sessions over a year), as a covered service for Medicare beneficiaries with BMI >30.
The Affordable Care Act (ACA) included several provisions with implications for obesity-related care, most notably that USPSTF grade A and B recommended services must be covered, including intensive behavioral counseling for obesity—a grade B recommended service. Although this benefit is categorized as a preventive service, rather than disease treatment, this designation nonetheless benefits patients, as ACA designates USPSTF recommended services to be covered without cost or cost sharing (co-payments, co-insurance, or deductibles).
Between 2012 and 2015, the US Food and Drug Administration (FDA) Center for Drug Evaluation and Research (CDER) approved four medications for the chronic treatment of obesity. These were the first medications to achieve approval in more than a decade, and came on the heels of several disapprovals. Also notable, these medications were approved for long-term use, consistent with the concept of chronic disease management.
Additionally, in 2015 FDA Center for Devices and Radiological Health (CDRH) approved three minimally invasive medical devices for obesity treatment.
In March 2014, the US Office of Personnel Management (OPM) issued official guidance to the Federal Employees Health Benefits (FEHB) Program health insurance carriers to clarify its policy for obesity pharmacotherapy coverage. OPM specified that “excluding weight loss drugs from FEHB coverage on the basis that obesity is a ‘lifestyle’ condition and not a medical one or that obesity treatment is ‘cosmetic’- is not permissible.” Among other clarifications made in this guidance, this explicitly chastises attempts to circumvent addressing obesity as a medical condition requiring clinical treatment as indicated.
In addition to these policies, both the American Medical Association as well as the US National Institutes of Health have explicitly recognized obesity as a chronic disease.
Although the full impact of these policies on prevention and access to care for people living with obesity remains to be determined (I believe they will prove to be substantial), they do herald a change in thinking about the nature of obesity and the need for providing better behavioural, medical and surgical treatments to individuals living with this chronic disease.