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Guest Post: Australian GPs Recognise Obesity As A Disease

The following is a guest post from my Australian colleague Dr. Georgia Rigas, who reports on the recent recognition of obesity as a disease by the Royal Australian College of General Practice (RACGP). Last week, the Royal Australian College of General Practice (RACGP) President, Dr Seidel recognised obesity as a disease. The RACGP is the first medical college in Australia to do so. This was exciting news given that we have just observed World Obesity Day a few days ago. According to the Australian Bureau of Statistics1, over 60% of Australian adults are classified as having overweight or obesity, and more than 25% of these have obesity [defined as a Body Mass Index (BMI) ≥30] (ABS2012). Similarly in 2007, around 25% of children aged 2–16 were identified as having overweight or obesity, with 6% classified as having obesity (DoHA 2008). These are alarming statistics. The recent published BEACH data for 2015-162, showed that the proportion of Australian adults aged 45-64yo presenting to GPs has almost doubled in the last 15+ years. Worryingly the numbers are predicted to continue rising, with 70% of Australians predicted to have overweight or obesity by 2025. Embarrassingly, the BEACH data also indicated that <1% of GP consultations centred around obesity management. So obviously what we, as GPs have been doing..,or rather not doing…isn’t working! The RACGP’s General Practice: Health of the Nation 2017 3report found Australian GPs identified obesity and complications from obesity as one of the most significant health problems Australia faces today and will continue to face in coming years as the incidence of obesity continues to rise. But what are we doing about it?…. I think the answer is evident… clearly not enough! Thus, we can only hope that this announcement by the RACGP will have a ripple effect, with other medical colleges in Australia and then the Australian Medical Association following suit. So what does this mean in practical terms? For those individuals with obesity (BMI ≥30) with no “apparent” comorbidities or complications from their excess weight…[though you could argue they will develop (if not already) premature osteoarthritis of the weight bearing joints…..] would be eligible for a chronic care plan [government subsidized access to a limited number of consultations with allied health services] given the chronic and progressive nature of the disease. It also highlights the need for GPs to start screening ALL patients in their practice-young and old; for… Read More »

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World Health Organisation Warns About The Health Consequences Of Obesity Stigma

Yesterday (World Obesity Day), the European Regional Office of the World Health Organisation released a brief on the importance of weight bias and obesity stigma on the health of individuals living with this condition. The brief particularly emphasises the detrimental effects of obesity stigma on children: “Research shows that 47% of girls and 34% of boys with overweight report being victimized by family members. When children and young people are bullied or victimized because of their weight by peers, family and friends, it can trigger feelings of shame and lead to depression, low self-esteem, poor body image and even suicide. Shame and depression can lead children to avoid exercising or eatng in public for fear of public humiliation. Children and young people with obesity can experience teasing, verbal threats and physical assaults (for instance, being spat on, having property stolen or damaged, or being humiliated in public). They can also experience social isolation by being excluded from school and social activities or being ignored by classmates. Weight-biased attitudes on the part of teachers can lead them to form lower expectations of students, which can lead to lower educa onal outcomes for children and young people with obesity. This, in turn, can affect children’s life chances and opportunities, and ultimately lead to social and health inequities. It is important to be aware of our own weight-biased attitudes and cautious when talking to children and young people about their weight. Parents can also advocate for their children with teachers and principals by expressing concerns and promo ng awareness of weight bias in schools. Policies are needed to prevent weight-victimization in schools.” The WHO Brief has important messages for anyone working in public health promotion and policy: Take a life-course approach and empower people: Monitor and respond to the impact of weight-based bullying among children and young people (e.g. through an -bullying programmes and training for educa on professionals). • Assess some of the unintended consequences of current health-promo on strategies on the lives and experiences of people with obesity. For example: Do programmes and services simplify obesity? Do programmes and services use stigmatizing language? Is there an opportunity to promote body positivity/confidence in children and young people in health promotion while also promoting healthier diets and physical activity?• Give a voice to children and young people with obesity and work with families to create family-centred school health approaches that strengthen children’s resilience and… Read More »

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Residential Schools And Indigenous Obesity – More Than Just Hunger?

A recent CMAJ article, by Ian Mosby and Tracey Galloway from the University of Toronto argues that one of the key reasons why we see obesity and diabetes so rampant in Canada’s indigenous populations, is the fact that widespread and persistent exposure to hunger during the notorious residential school system may have metabolically “programmed” who generations toward a greater propensity for obesity and type 2 diabetes. There is indeed a very plausible biological hypothesis for this, “Hunger itself has profound consequences for childhood development. Children experiencing hunger have an activated hypothalamic–pituitary–adrenal stress response. This causes increased cortisol secretion which, over the long term, blunts insulin response, inhibits the function of insulin-like growth factor and produces long-term changes in lipid metabolism. Through this process, the child’s physiology is essentially “programmed” by hunger to continue the cycle of worsening effects, with their bodies displaying a rapid tendency for fat-mass accumulation when nutritional resources become available.” While the impact of hunger may well have been one of the key drivers or metabolic changes, the authors failed to acknowledge another (even more?) important consequence of residential schools – the impact on mental health. Oddly enough, in a blog post I wrote back in 2008, I discussed the notion that the significant (and widespread) physical, emotional, and sexual abuse experienced by the generations of indigenous kids exposed to the residential school system would readily explain much of the rampant psychological problems (addictions, depression, PTSD, etc.) present in the indigenous populations across Canada today. The following is an excerpt from this previous post: This disastrous and cruel [residential school] policy resulted in much pain and despair in the First Nations’, Inuit and Metis people that lasts to this day (known as the “generational effect”). Sexual, physical and mental abuse was widespread; students were broken in heart and spirit; culture and identities were destroyed. Much (if not all) of what ails the Aboriginal peoples of Canada can be traced back to this policy – including possibly issues that affect Aboriginal health to this day. It is no secret that obesity and its consequences (e.g. diabetes) are rampant amongst the Aboriginal peoples of Canada. While poverty, breakdown of traditional lifestyle and culture and even genetic factors (thrifty genotype) have all been implicated in this, I wonder how much the misery caused by the residential school program had to contribute. Early traumatic life experiences including sexual, mental and physical… Read More »

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Balancing Benefits And Harms From Redefining Obesity

The final and eight item on the disease definition modification checklist developed by the Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group published in JAMA Internal Medicine,  deals with issue of determining the benefit/harm ratio of the proposed new definition. With terms to redefining obesity as the presence of abnormal or excess body fat that impairs health, I have discussed the potential benefits and harms in previous posts. The question is, whether or not the overall balance comes down on the benefit or harm side of the equation. Here, the authors of the checklist have the following to offer, “Modifying a disease definition should be guided by a balanced assessment of the anticipated benefits and harms, using the best evidence available. The definition should reflect the values and preferences of patients and the wider community and include the impact on resource usage….In general, we recommend that panels consider both an individual and societal approach to assessing the overall benefits and harms of changing disease definitions. We recommend introducing a new disease definition where there is an expected positive balance of harms and benefit for individuals, and in aggregate at the societal level.” In addition, the authors note, “Different definitions may be required for research purposes, for example more stringent standardization, than for clinical purposes where more stringent definitions may deny access to care for patients who would benefit.” Thus, as we have seen, changing disease definitions is not just a matter of opinion but rather, the pros and cons must be considered both at an individual and societal (resource) level. That said, disease definitions are in constant flux as new knowledge and treatments emerge – obesity, should be no exception. Indeed, guidelines would be amiss in not reconsidering the validity of current definitions and exploring potential changes as part of the guidelines process. The published checklist can certainly serve as a guide for this process. @DrSharma Edmonton, AB

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Are There Any Harms Of Redefining Obesity?

The seventh item on the disease definition modification checklist developed by the Guidelines International Network (G-I-N) Preventing Overdiagnosis Working Group published in JAMA Internal Medicine,  deals with issue of potential harms to patients. Given the obvious benefits of redefining obesity as the presence of abnormal or excess body fat that impairs health outlined in the previous post, it is nevertheless prudent to explore the possibility of unintentional harms. Obviously, expanding the term obesity to include millions of people, who currently fall under the BMI threshold but may well have health impairments attributable to their body fat, may not sit well with these folks. In fact, they may find themselves shocked to learn that they would now be considered to have obesity (more a reflection of the stigma attached to this term, than its non-judgemental medical meaning). Thus, the authors of checklist remind us that, “The potential harms from diagnosis include the physical harms of diagnosis and treatment; psychological effects, such as anxiety; social effects, such as stigma and discrimination; and financial consequences, such as effects on employment….Potential harms also include the misapplication and misinterpretation of the disease definition when taken from a confined research application to more widespread clinical use.” A, perhaps more concerning issue, is the impact that redefining obesity may have on limited resources for obesity management in the healthcare system. “Changes in resource usage can result in harm by reducing access to care for some patients and by diversion and distraction of clinical care. This can happen at both the societal level, with resources taken from areas more important to health, and at the individual level, by distracting individuals from activities more important to their well-being. Modifications of disease definitions can have considerable impacts on costs, including the costs of testing, and the resources needed for treatment and follow-up for those diagnosed using the new criteria. There may also be resources needed for training and implementation regarding the change, and to minimise misdiagnosis. Costs are particularly important in low- and middle-income countries where inappropriate disease definitions can result in considerable diversion of limited health care resources.” These concerns are far from trivial. Not only are current resources for managing obesity in our healthcare systems limited (to non-existant), but one of the main reasons that employers and payers balk at providing access to obesity treatments, is the sheer number of individuals that already qualify for such treatments. Significantly expanding the pool of eligible patients, is therefore. unlikely to be met with much enthusiasm from these stakeholders. Not only would one need to demonstrate… Read More »

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