Thursday, November 27, 2014

Would You Like Some Guilt With That Popcorn?

popcornYesterday, I blogged about the McKinsey discussion paper that calls on governments to throw everything they’ve got at the obesity epidemic – proven or unproven – anything is better than nothing.

That said, it is indeed timely that this week, the US-FDA announced sweeping regulations on putting calories on menus, not just in fastfood restaurants but also in grocery stores, vending machines, and movie theatres.

Personally, I am all for it – never mind that we have yet to show that providing this information at the point of purchase actually changes behaviour of the target population (namely the people who do need to watch their calories) – I, for one, do find this information helpful.

Thus, every time I visit a McDonalds restaurant (yes, I do), I study the nutritional information that this restaurant chain has been making available to any customer who bothers to ask for decades.

Indeed, I do admit to deriving a kind of voyeuristic pleasure in seeing those astonishingly high numbers on certain food items and cannot help myself from inwardly shaking my head at the poor schmucks who order those foods.

What I do wonder, however, is whether knowing these numbers has ever actually changed my own behaviour.

Take movie popcorn for instance – I love it! (interestingly this is a habit that I only developed since moving to Canada).

Not that I am not aware that a large popcorn can easily have all the calories I need for the rest of the weekend – yup, I know that – indeed, I am making an “informed choice”.

In the few milliseconds I spend thinking about whether or not I may wish to skip the popcorn this time, those calorie numbers do regularly flash through my mind – in the end, the popcorn always wins.

So how will having the numbers up on the menu board staring in my face change things for me?

My guess is that I’ll still buy the popcorn, except now it will come with an even larger portion of guilt than before.

Obviously, with the numbers up there for everyone to see (including the people in line behind me), there may well now be an added tinge of embarrassment on top of the guilt.

Well, I may not be the typical consumer or even the target of these measures – after all these are meant for the people who could obviously do with some nudging towards eating a healthier diet (not really sure why I am excluding myself from this list).

Yet, I don’t mind these measures, I have always considered this a good idea.

But will having these numbers staring me in the face everytime I eat out change my consumption of popcorn? Probably not.

Will they make me think thrice (I already think twice)? Perhaps.

So to sum up, funnily enough, I find myself in full support of this measure – even if I am not really sure why.

I guess anything is better than nothing.

@DrSharma
Frankfurt, Germany

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Wednesday, November 26, 2014

McKinsey on Obesity: Doing Something Beats Doing Nothing

McKinsey Overcoming ObesityLast week the McKinsey Global Institute, with much media fanfare, released a 120 page discussion paper titled, “Overcoming obesity: An initial economic analysis“, which estimates that the economic cost of the global obesity epidemic is upwards of $2 trillion, a number similar to the economic cost of tobacco consumption or armed conflicts.

The report identifies 74 interventions in 18 areas (ranging from policy and population health to health care) deemed to be cost effective, which, if implemented, could lead to annual savings of $1.2 billion in the UK National Health Services alone.

However, when it comes to the actual impact of these 74 strategies, the report is far more sobering in that it notes that many of these interventions are far from proven:

“The evidence base on the clinical and behavioral interventions to reduce obesity is far from complete, and ongoing investment in research is imperative. However, in many cases this is proving a barrier to action. It need not be so. We should experiment with solutions and try them out rather than waiting for perfect proof of what works, especially in the many areas where interventions are low risk. We have enough knowledge to be taking more action than we currently are.”

In other words, let’s not wait to find out what works – let’s just do something – anything (and keep our fingers crossed).

Thus, the report urges us to

“(1) deploy as many interventions as possible at scale and delivered effectively by the full range of sectors in society; (2) understand how to align incentives and build cooperation; and (3) do not focus unduly on prioritizing interventions because this can hamper constructive action.”

I can see why politicians would welcome these recommendations, as they are essentially a carte blanche to either doing nothing (we don’t have the evidence) or doing whatever they want (anything is better than nothing).

The fact that,

“Based on existing evidence, any single intervention is likely to have only a small overall impact on its own. A systemic, sustained portfolio of initiatives, delivered at scale, is needed to address the health burden.”

means that when any measure fails, it is not because it was the wrong measure but because there was either not enough of it or it was not complemented by additional measures.

Again, a free pass for politicians, who can pass whatever measures they want (based on their political ideologies or populistic pressure from their constituencies), without having to demonstrate that what they did, had any effect at all.

Of course, no report on obesity would be complete without also stressing the importance of “personal responsibility”, as if this was somehow more important for obesity than it is for diabetes, lung disease, heart disease, or any other disease I can think of.

Unfortunately, the report also includes rather nonsensical statements like,

“44 interventions bring 20% of overweight/obese Britons back to normal weight”

a sentence that defies the very chronic nature of obesity, where once established excess weight is vigorously “defended” by complex neuroendocrine responses that will counteract any change in energy balance to sustain excess body weight.

Thus, unfortunately, the authors fall into the common misconception about obesity simply being a matter of calories in and calories out, a balance that can be volitionally adjusted to achieve whatever body weight you wish to have.

Indeed, there is very little discussion in this “discussion paper” of the underlying biology of obesity, although it is acknowledged in passing:

“Even though there are important outstanding questions about diet composition, gut microbiome, and epigenetics, we are not walking blind with no sense of what to address. However, interventions to increase physical activity, reduce energy consumption, and address diet composition cannot just seek to reverse the historical trends that have left the population where it is today. For example, we cannot, nor would we wish to, reverse the invention of the Internet or the industrialization of agriculture. We need to assess what interventions make sense and are feasible in 2014.”

Will this report move governments to action? Or, even more importantly, will this report bring us any closer to reversing the epidemic or providing better treatments to people who already have obesity?

Readers may appreciate that I am not holding my breath quite yet.

ƒƒ@DrSharma
Edmonton, AB
ƒƒ

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Tuesday, November 25, 2014

Obesity Myth: Success Is Measured In Pounds Lost

sharma-obesity-5as-booklet-coverFinally, in this series of common misconceptions about obesity management, discussed in our article in Canadian Family Physician, we address the notion that success in obesity management is best measured in the amount of weight loss:

“Given the importance of obesity as a public health problem, there is widespread effort to encourage people with excess weight to attempt weight loss.

However, a growing body of evidence suggests that a focus on weight loss as an indicator of success is not only ineffective at producing thinner, healthier bodies, but could also be damaging, contributing to food and body preoccupation, repeated cycles of weight loss and regain, reduced self-esteem, eating disorders, and social weight stigmatization and discrimination. 

There is also concern that “anti-fat” talk in public health campaigns might further promote weight bias and discrimination. 

Therefore, it might be time to shift the focus away from body weight to health and wellness in public health interventions.

Recently, the Canadian Obesity Network launched a tool called the 5As of Obesity Management (www.obesitynetwork.ca/5As) to guide primary care practitioners in obesity counseling and management. 

Minimal intervention strategies such as the 5 As (ask, assess, advise, agree, and assist) can guide the process of counseling a patient about behaviour change and can be implemented in busy practice settings.

Obesity management should focus on promoting healthier behaviour rather than simply reducing numbers on the scale. The 5As of Obesity Management is a practical tool to improve the success of weight management within primary care.”

@DrSharma
Edmonton, AB

 

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Tuesday, November 18, 2014

Obesity Myth: Obese Individuals Are Less Active

sharma-obesity-active-livingThe second most common misconception about obesity, addressed in our article in Canadian Family Physician, is the idea that people living with overweight are any less active than people with “normal” weight:

“It is very common to hear that obese people are lazy and should get off the couch. This discriminatory bias against those with excess weight is not only widespread among the lay public but also among health professionals, even those in regular contact with patients with obesity.

Yet, the most recent data from the Canadian Health Measures Survey, a study of a nationally representative sample that used accelerometers to measure physical activity, suggest otherwise.

Based on objective measures, only 7% of Canadian children and youth8 and 15% of Canadian adults9 meet physical activity guidelines. When split by body mass index categories, obese girls average 11 159 steps per day, while normal-weight girls average 10 224 steps per day. Obese boys average fewer steps (10 256 steps per day) than their normal-weight counterparts (12 584 steps per day), but they have a larger body to carry. Translating this physical activity level into calories expended (kcal per day) would likely show that obese boys actually burn more calories on a daily basis.

Similar findings are observed for Canadian adults. Overall, the message is that there is a physical inactivity crisis in Canada—most people do not meet the recommended amount of physical activity required each day for health benefits—and every Canadian, regardless of body size, would benefit from an increase in physical activity and a decrease in sitting time.

Rather than focusing on burning calories, interventions should aim at reducing sedentary activities and increasing physical activities to improve overall health and general well-being.”

@DrSharma
Auckland, NZ

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Tuesday, October 28, 2014

Should A Political Prescription For Obesity Not Also Include Better Treatments?

sharma-obesity-policy1In the latest issue of the Canadian Medical Association Journal, the editors opine on the need for a political prescription for obesity – in short taxation and regulation of  high-calorie and nutrient-poor food products as the only viable approach to the obesity epidemic. As may be expected, they use the analogy of tobacco as a justification for this approach (given that actual data from government intervention on reducing the consumption of the said foods is so far lacking).

Be that as it may, what caught my attention in the article was the following passage:

“Treating obesity does not work well; preventing it would be better. The global failure to manage obesity, now considered by the American Medical Association to be a disease, may be considered a failure of the evidence-based medicine approach to treating disease….We know that most restrictive diets result in only short-term weight loss that frequently reverses and worsens in the long term, but dietary changes that are sustainable as a lifestyle choice may work. Physical activity is not enough to prevent or treat obesity and overweight, unless it is combined with some kind of dietary intervention. Family and community interventions may work somewhat better than interventions aimed at individuals, but their implementation is patchy. Bariatric surgery has good results in the treatment of morbid obesity, but its use is always going to be limited and a last resort. Pharmaceutical agents may work to some extent, but may have nasty adverse effects.”

The interesting thought here is that the authors parade the lack of effective treatment as a justification for prevention, when I would rather have used this state of affairs to call for greater investments in finding better treatments.

Not that I am not in favour of prevention – indeed, I am all for preventing heart disease, diabetes, cancer, depression, bone and joint disease and everything else.

But, at no point would I ever call for prevention as an alternative to finding better treatments for any of these conditions.

The fact that people still die of cancer should never justify us abandoning the search for better treatments – indeed, as far I can see, the whole Pink Ribbon Industry apparently focusses on “finding the cure” – not on “finding better ways to prevent breast cancer” (even if most experts believe that much of breast cancer is indeed preventable).

Just because  we still have no effective treatments for a host of other conditions, should we abandon the search for better treatments for these conditions?

In short, what irks me most about this article is not the call for prevention – indeed I am all for it!

But when the lack of effective (or safe) treatments is used to justify this call, I must disagree.

No matter how much we restrict and tax the food industry, there will always be people around, who despite their best efforts, will struggle with excess weight. Indeed, there is no reason to believe (at least not for anyone who understands the physiology of obesity) that any form of “prevention” will reverse the epidemic in those who already have the problem – i.e. in about 6 Mill Canadians. (even if we somehow miraculously reduced obesity in the population by 30% through “preventive measures” (well beyond even the most optimistic predictions) – we would still need treatments for 4 Mill Canadians – adults and kids!)

The longer we wait to find and implement effective treatments, the longer these individuals will struggle with a condition that should deserve the same efforts at treatment as we afford individuals with other “lifestyle” diseases (including heart disease, diabetes and cancer).

Let us not forget that treatments for other common conditions (e.g. hypertension, hypercholesterolemia and diabetes) were once lacking – today millions around the world benefit from these treatments – indeed, it is probably safe to say that these medications probably save more lives each year than any known efforts at regulating industry that I know of.

Indeed, if we wish to find more effective ways to manage obesity, we need to vastly increase our efforts at finding better treatments – not abandon them.

Prevention is never an alternative to also having effective treatments. The two go hand-in-hand.

@DrSharma
Edmonton, AB

 

 

 

 

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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