It is now widely recommended that addressing childhood obesity requires a whole-family approach with a focus on educating and helping parents provide a healthier environment for their children. This has sometimes resulted in the slogan, “treat the parents”.
But just how effective is this approach?
Now a study by Gisela Nyberg and colleagues from the Karolinska Institute in Stockholm, Sweden, published in the International Journal of Behaviour, Nutrition and Physical Activity, suggests that even this strategy may not be quite as effective as one would hope.
The study was designed to study the effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas in Stockholm.
The cluster-randomised controlled trial involved 31 school classes with 378 six-year-old children. The 6 month interventions were 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children.
Overall, while there was some effect of the intervention on eating behaviour, there was no overall impact on physical activity levels.
There was also no change in BMI for the whole group, although there was small drop in BMI in kids at the higher range of the BMI spectrum, which disappeared at 5-months post-intervention.
The authors grasp at the fact that the effects of the intervention were short-lived to recommend that the programme needs to be prolonged and/or intensified in order to obtain stronger and sustainable effects.
Just how much longer or how much more intense the intervention would need to be is unclear.
These findings certainly reflect the real-life problem that we currently have no universally effective approach to dealing with childhood obesity (with parents or without).
Sadly, no one has yet demonstrated that any type of intervention for childhood obesity, whether individual, family, shool or community based, despite occasional short-term improvements in health behaviours and body weight, ultimately translates into fewer adults with obesity.
Perhaps, the best time to intervene to prevent childhood obesity is even before the kids are born.
One factor accounting for this may well be the lack of timely access to sleep testing.
Now, a study by Hirsch Allen and colleagues from the University of British Columbia Hospital Sleep Clinic, published in the Annals of the American Thoracic Society, examined the relationship between severity of sleep apnea and travel times to the clinic in 1275 patients referred for suspected sleep apnea.
After controlling for a number of confounders including gender, age, obesity and education, travel time was a significant predictor of OSA severity with each 10 minute increase in travel time associated with an apnea-hypopnea-index increase of 1.4 events per hour.
The most likely explanation for these findings is probably related to the fact that the more severe the symptoms, the more likely patients are to travel longer distances to undergo a sleep study.
Thus, travel distance may well be a significant barrier for many patients accounting for a large proportion of undiagnosed sleep apnea – at least for milder forms.
Given the often vast distances in Canada one can only wonder about just how much sleep apnea goes under diagnosed because of this issue.
One of the key barriers to accessing obesity treatments in many countries (besides lack of training and common weight-bias of health professionals) is the lack of coverage for obesity treatments in public and private plans.
Thus, for example in the US, under the Medicare Modernization Act of 2003, Medicare is in fact prohibited from covering prescription obesity medicines.
Now, a US survey conducted by the Gerontology Society of America among 1,000 US Adults using online interviews shows a strong majority in favour of Medicare coverage for obesity medications.
Here is a summary of the main findings:
- 87 percent of Americans believe obesity is a problem in their state.
- 69 percent of Americans believe Medicare should expand coverage to include prescription obesity medicines.
- 77 percent were unaware that federal law specifically prohibits Medicare from covering patient costs for prescription obesity medicines.
- 69 percent of Americans were unaware that the FDA has found that current prescription obesity medicines are safe and effective in treating obesity. (In the last 5 years multiple medicines have been approved as safe and effective by the FDA)
To me these results are surprising as I would have expected that most Americans (like most everybody else) still believes that people with obesity need to overcome this by simply eating less and moving more rather than taking the “easy way out” by simply “popping a pill”.
Perhaps, the notion that obesity is a chronic disease and that people who have it deserve treatment the same as anyone else with any other chronic disease is starting to trickle through.
Then again of course, this survey (as so often with polls) may simply be completely off the mark.
Although bariatric surgery is by far the most effective treatment for severe obesity, most health professionals will have learnt little about it during their training. For those who did, much of what they learnt is probably obsolete, given the remarkable advances both in surgical technique as well as patient management.
Given that the family doctor may often be the key person to suggest or counsel patients about the pros and cons of bariatric surgery, refer appropriate patients for surgery and manage them long-term in the years following surgery, it is essential that they have a sound understanding of the indications, risk and benefits of surgery.
Now, a survey of Ontario family docs, published in Obesity Surgery by Mark Auspitz and colleagues from the University of Toronto, reveals important knowledge gaps and misconceptions about bariatric surgery.
The 28-item questionnaire, sent to 1328 physicians in Ontario resulted in 165 responses.
Overall experience was limited: around 70% of responding family physicians had less than five surgical patients in their practice, almost 10% had none.
The vast majority of responders (70 %) stated that they at best referred about 5 % of their patients with severe obesity for surgery.
Not surprisingly, compared to physicians who had previously referred patients for surgery, physicians who had never referred a patient for surgery were less likely to discuss bariatric surgery with their patients (30 vs. 79 %), less likely to feel comfortable explaining procedure options (6 vs. 34 %) or providing postoperative care (27 vs. 64 %).
Virtually all (92%) of family physicians stated that they would like to receive more education about bariatric surgery.
To the question as to whether or not they would consider referring a family member for surgery, only 56% of docs who had never referred a patient would consider it, compared to 85% of physicians with previous referrals.
As a side note, only 30% of responders felt that they had the appropriate equipment and resources to manage patients with obesity.
Unless one assumes that the docs who responded to this survey are somehow very different from the docs who didn’t, one must conclude that there are indeed considerable knowledge gaps about bariatric surgery among family docs in Ontario (and I have no reason to believe that this situation would be much better anywhere else in Canada).
On a positive note, it appears that the vast majority of docs are keenly aware of this deficit and would appreciate more education on bariatric surgery.
How much does your doctor know about it?
Now, an analysis of how this distribution of centres affected rates of surgery in various geographic parts of Ontario has been published in the Annals of surgery.
The authors mapped all adult patients who received bariatric surgery from April 2009 to March 2012 to their geographic neighbourhoods to determine those with significantly higher (hot spots) or lower (cold spots) rates of surgery.
As one may expect, rates of surgery declined in proportion to distance from the centre – rates decreased by about 10% per 100 km distance from the nearest COE.
In contrast, odds of for having surgery in a COE within the same administrative health region as the neighbourhood were about 75% higher than for people living outside the health region.
Interestingly however, the analysis also identified 40 cold spot neighbourhoods, within a relatively small geographic area that happens to contains 3 of the 4 COEs.
Why this would be is anyones guess, but may well have to do with issues related to patient or provider attitudes to surgery for obesity than availability of the service.
Since 2012, two more COEs have been established in Ontario (complemented by several non-surgical “assessment centres”). How much of an impact this has had on access will remain to be seen.
In the meantime, it should be acknowledged that access to bariatric surgery in Ontario has substantially increased since the establishment of the COEs (surgery rates are currently only higher in Quebec).
How the province deal with non-surgical obesity management, a task that will largely fall to primary care, remains to be seen.