Arya M. Sharma, MD

Last week, the media erupted in reports and commentaries prompted by an article by Robert Lustig and colleagues front the University of California, published in the journal NATURE, calling on governments to regulate sugar in a fashion akin to alcohol.

Although the media referred to this piece as a ‘new study’, the article did not actually provide any new data - it was merely an ‘opinion piece’ suggesting legislative approaches to the ill-effects of eating too much sugar.

Presented as a possible solution to the obesity epidemic, the jist of the arguments more or less were as follows: worldwide sugar consumption has increased, sugar is toxic and addictive and, therefore, regulating sugar like alcohol or tobacco (including taxation and limiting access to individuals below the age of 17), would reduce obesity and prevent metabolic syndrome.

In a number of media interviews, I took issue both with the proposal to tax and ban sugar as well as the rather simplistic causal linking of sugar to the obesity epidemic.

Here is why:

1) While there is no doubt that overconsumption of sugar (like consuming too much salt (not sodium!), trans-fats, alcohol, or perhaps processed foods in general) may well promote ill health, these links may be far less robust or scientifically proven than the article suggests. More importantly, there is very little evidence from high-quality intervention studies (outside of the rather artificial setting of a clinical trial) that the proposed population measures (namely attempting to restrict sugar consumption by banning or taxing it) would have the desired effect on obesity or anything else - if there are such examples, the article certainly fails to mention them.

2) As any reader of these pages will also realize, obesity is a multifactorial complex condition driven by a myriad of socioeconomic, psychological, and biological factors - some of which do indeed make many of us prone to ‘overconsume’ salt, sugar, fats, and perhaps alcohol or illicit drugs. In the case of sugar, the article unfortunately fails to seriously delve into what exactly these socioeconomic, psychological, or biological drivers to consume more sugar may be (beyond simply suggesting that sugar is cheap, omnipresent and ‘addictive’). Unfortunately, by reducing the solution to the obesity epidemic to simply a matter of banning and taxing sugar, the article not only reinforces the widely held stereotype that obese people are obese simply because they eat too much (in this case sugar) but also that obese people, because of the damage they do to themselves and society, need to be punished and policed for the benefit of all.

3) But, even if sugar was indeed a major driver of obesity (a few years ago we would have thought it was fat, others have recently suggested it is wheat or indeed all carbs, some think it is not enough protein, others point to our industrialized meat production, or is it simply having too much variety on the shelf?), calling for interventions primarily on the demand side (making sugar less accessible and more expensive) rather than the supply side (making sugar less attractive for farmers to produce) is problematic. Paradoxically, changing demand without changing supply, at least in the short term, may well have exactly the opposite effect - sugar becomes even cheaper, thus making it an even more attractive ingredient for food producers. Reductions in the price of raw materials will likely quickly neutralize any increased cost of taxation with the net effect on consumption being zero. If, in the long run, such interventions did actually reduce sugar consumption in countries where it is regulated, we would simply be diverting streams to countries where it is not (worldwide tobacco consumption is the perfect case study for this).

4) The article is also rather cavalier about how exactly such measures would be implemented and enforced. As we well know from the hopelessly lost ‘war on drugs’, if people really want something (like sugar, assuming it is indeed as addictive as the authors suggest), they’ll find ways to get it. So making something ‘illegal’ is meaningless unless government is also prepared to enforce any such legislation. For a substance as omnipresent as sugar, this would require a rather expensive bureaucracy (I can already see food and drug inspectors raiding schools, recreation facilities, and grocery stores to ensure that no candy is sold to anyone below the legal age). I would imagine that the money required to effectively police and enforce any such new legislation would more than outweigh any potential revenues from the ’sugar tax’ thereby snuffing any hope that such revenues could perhaps be used for other efforts to reduce obesity (like building bicycle lanes).

5) Finally, it is not clear to me why the authors would chose to simply focus their attention on sugar - it would have made as much sense to include all refined carbs, as it takes very little for our digestive systems to turn a slice of Wonder Bread or pizza into glucose. Will all refined carbs (and what exactly is the definition of ‘refined’ in this context? Do we include polished rice?) be next on the list of toxic substances that require a permit? And what about other natural sources of sugar - are we going to tax cane sugar, beets, honey, or perhaps even Maple syrup? Let us also not forget that biologically there is little difference (if any) between the ample sugar in fruit juice and the sugar I add to my cup of tea.

But in the end, my main criticism would be that, as so often, the authors have chosen to focus on the ‘what’ (eating to much sugar) rather than on the far more complex issue of the ‘why’ (why is this happening?). That of course would have been a very different paper requiring some very uncomfortable and complex analyses of the very core of how industrialized societies operate.

While the article is no doubt well intended, I sincerely fear that these rather simplistic and superficial ‘one-size-fits-all’ solutions to the obesity epidemic based on principles of shame, blame, tax, and ban, merely distract us from having a value-driven and non-judgemental discussion about the true drivers of the societal (e.g. industrialization and centralization of food production), psychological (e.g. stress, lack of sleep, emotional deprivation) and biological (e.g. fetal imprinting, endocrine disrupters) changes that have led to this epidemic, we will fail to even remotely begin to reverse this problem.

AMS
Ottawa, Ontario

Lustig RH, Schmidt LA, & Brindis CD (2012). Public health: The toxic truth about sugar. Nature, 482 (7383), 27-9 PMID: 22297952

..

Obesity is complex. Few health professionals are specifically trained in obesity management - few health systems have invested in managing it.

As regular readers will recall, Alberta Health Services recently launched a province-wide obesity initiative ranging from population health and community projects, across primary care, to establishing speciality centres for complex medical and surgical management of kids and adults with severe obesity.

Currently, around 100 health professionals and administrators from across the province, working on getting this initiative off the ground are meeting in Edmonton to discuss details of the plan. Many have already worked in obesity and chronic disease management and bring their own views and experience to the table. This is immensely important as sharing of best practices is one of the key mechanisms to ensure that we do more of what works and less of what doesn’t.

It is also essential that we establish common ground on the basic principles and practice of addressing this health problem - the sooner we are all on the same page, the sooner we can begin working towards consistency in obesity prevention and care across the province.

This will not happen overnight - there will be learnings, there will be things that work well and things that don’t.

But I am fully confident that in the end we will be moving in the right direction towards reducing the emotional, physical, and economic burden of obesity on all Albertans.

We may not be able to cure obesity, but we can certainly do a much better job at preventing and treating it.

AMS
Edmonton, Alberta

Yesterday, I applauded the Canadian Obesity Network for being internationally recognised as Canada’s official professional obesity association.

This is important because, although obesity now affects one in four adult Canadians, we are by no means alone with this problem.

Indeed, as noted by the Lancet in 2006,

“No health system is yet meeting the challenges of managing obesity, and no society has developed an effective strategy to prevent it.”

This is both a challenge and an opportunity for Canada. Challenge because our problem cannot be solved by simply importing successful models from elsewhere - there are none!

Opportunity, because we may well be the first to develop promising approaches that could serve as a ‘made in Canada’ solution to others.

Indeed, today I will be speaking at a Caribbean obesity conference in Bridgetown, Barbados, where obesity is rampant and diabetes is endemic. While the health care models that we are adopting in Canada to deal with our own obesity problems may not be easily transferable to Barbados, the same principles will likely hold true.

Public health measures based on the principles of shame, blame, tax, and ban, will prove as unhelpful here as they have proven unsuccessful everywhere else - not surprising as these measures fail to address the psychosocial and biological root causes of the problem.

There is also no doubt that health services approaches that do not embrace the complexity, heterogeneity, and chronicity of obesity, will be doomed to fail - obesity management has to be fully integrated into a chronic disease management framework that includes professional assessment, patient education, and lifelong self-management.

While not everyone with excess body fat needs to lose weight - many do. This will not be achieved by promoting endless cycles of yo-yo dieting with little or no professional help - there may well be far more harm in this than any potential benefit.

The causes of obesity are complex - the solutions cannot be simple.

Doing nothing is clearly not an option but let us at least stop doing things that have already been shown to fail (like simply telling people to eat less and move more).

AMS
Bridgetown, Barbados

Yesterday, the Canadian Obesity Network announced that it is now Canada’s official representative in the International Association for the Study of Obesity (IASO), the umbrella organization for 52 national obesity associations, representing 56 countries.

Click here for a brief history of IASO.

Canada was previously represented at IASO by The Obesity Society (TOS), formerly known as the North American Association for the Study of Obesity (NAASO), which continues to be the leading scientific society dedicated to the study of obesity in the USA and Mexico and will remain as the regional representative for North America within IASO.

According to IASO President Prof. Philip James,

“With a diverse and active professional community in place and a successful track record in obesity, the time was right for the Canadian Obesity Network to become a member of IASO and represent Canada.”

TOS President Dr. Patrick O’Neil adds that

“This decision has the full support of both the TOS and IASO governing councils as well as the CON-RCO board of directors. The three organizations believe this will benefit all our members, and we look forward to close collaboration as we work towards improving obesity prevention and treatment globally.”

Membership in IASO offers members of the Network a number of benefits including:

- Discounted fees for the Specialist Certification in Obesity Professional Education (SCOPE) education program
- Discounted fees to IASO events, including ICO and Hot Topic Conferences
- Substantially discounted fees for IASO journals (Pediatric Obesity, Clinical Obesity and Obesity Reviews)
- Access to an exclusive repository of obesity prevalence data

More importantly, perhaps, the many excellent obesity research programs and other initiatives happening across Canada will now gain even more international visibility and attention through this membership in IASO.

I, for one, certainly look forward to this new and expanded role for the Canadian Obesity Network on the global stage.

AMS
Dallas, TX

As regular readers will be well aware, our recent publications on the Edmonton Obesity Staging System clearly show that BMI alone is a rather poor measure of mortality risk associated with excess weight.

Thus, according to our analyses of the NHANES population, 20-30% of obese individuals (Stage 0/1) had virtually no increased mortality risk even over the almost 20 year observation period, compared to Stage 2/3 individuals, who had substantially increased risk. Conversely, even in the ‘overweight’ category (BMI 25-30), almost 50% of individuals had a mortality risk as high of that of obese Stage 2/3 individuals.

This means that indications for obesity treatment based on BMI alone will overtreat a substantial number of obese individuals, who may have little benefit in terms of mortality, and miss an even greater number of individuals, who may well benefit from such treatments.

These observations are directly relevant to yesterday’s post on the findings of the SOS study.

As readers will recall, not only was there no relationship between BMI levels and cardiovascular outcomes in the SOS population but the overall cardiovascular risk of these participants - despite the majority being ’severely’ obese - was surprisingly low. In fact, the annual risk for experiencing an adverse cardiovascular outcome for SOS participants was well under 1% per year!

This risk level is highly reminiscent of the overall risk of Stage 0 obese individuals in our NHANES analyses.

Thus, it is readily apparent why it took almost 15 years to demonstrate any cardiovascular benefit of bariatric surgery in the SOS study - clearly this was a very ‘low-risk’ obese population.

Contrast this to the almost 3% annual cardiovascular event rate for the participants in the SCOUT trial, which, by definition, consisted exclusively of Stage 2/3 individuals. In this population, it took less than 3.5 years of even very modest weight-loss (3 to 10 kg) to significantly reduce cardiovascular outcomes.

But did surgery prove more beneficial in higher-risk participants in the SOS trial? It certainly did!

In fact, the only predictor of greater benefit of having bariatric surgery in the SOS paper proved to be having an elevated plasma insulin level - a rather crude marker of insulin resistance. It is fair to assume that these participants were in fact those with higher obesity Stages (elevated fasting insulin levels alone, would already suggest at least Stage 1 obesity).

The importance of this difference is reflected in the numbers-needed-to-treat (NNT): as low as 21 in participants with baseline plasma insulin concentrations above the median (>17.0 mU/L) and as high as 173 in individuals below or at the median (≤17.0 mU/L) insulin concentration.

This essentially means that you would need to operate only 21 patients with Stage 1+ obesity to ’save’ one life (over 15 years) but 173 Stage 0 patients for the same benefit. It does not take a financial genius to figure out that from a ‘cost-per-life-saved’ perspective, operating on Stage 1+ patients is a ‘no-brainer’ whereas operating on Stage 0 patients would (and should) probably raise some eyebrows (especially in a publicly funded healthcare system).

Thus, as we have argued before (and argued by Livingstone in an editorial accompanying the SOS paper in JAMA), it is high time we fully appreciate the “inadequacy of BMI as an indication for bariatric surgery” and begin adopting more sophisticated criteria (such as those of the Edmonton Obesity Staging System) to ensure that this treatment is available to those who are likely to benefit the most.

AMS
London, UK

Padwal RS, Pajewski NM, Allison DB, & Sharma AM (2011). Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 183 (14) PMID: 21844111

Livingston EH (2012). Inadequacy of BMI as an indicator for bariatric surgery. JAMA : the journal of the American Medical Association, 307 (1), 88-9 PMID: 22215170