Arya M. Sharma, MD

Although many initiatives on preventing obesity aim to change individual behaviour, the reasons driving these behaviours (insofar that these are not directly attributable to biological or psychological issues) can no doubt be found in the ‘obesogenic’ environment that surounds us.

How this obesogenic environment is, in part, attributable to ‘globalization’ and how approaches that go well beyond educating or targeting individuals will need to be considered to improve population health (rather than just obesity), is the topic of an editorial by Kim Raine, University of Alberta (and Chair of the Canadian Obesity Network’s Science Committee), published in the International Journal of Public Health.

Given the rising obesity rates in emerging economies around the globe, Raine asks,

“Are emerging epidemics inevitable, or have we learned lessons that may help prevent developing countries from suffering our fate?“

As Raine points out, the determinants of obesity include individual behavioral determinants (diet and physical inactivity), environmental determinants (e.g., economic access to healthy food and physical activity opportunities) as the context for behavior and social determinants (cultural, economic and political) that function at societal levels.

Yet, the first line of defense in public health often emphasizes educating individuals on the importance of maintaining a health lifestyle, when in fact the experience for from industrialized nations actually suggests that a focus on individual behavior change is insufficient to stem the rising tide of obesity. Rather, it appears essential to address the “upstream” environmental and social determinants of diet and activity behaviours.

Thus, instead of focusing on changing peoples behaviours through education, it is perhaps important to note that (as stated by Swinburn)

“Obesity is the result of people responding normally to the obesogenic environments they find themselves in. Support for individuals to counteract obesogenic environments will continue to be important, but the priority should be for policies to reverse the obesogenic nature of these environments”.

Thus, an ‘ecological perspective’ on the obesity crisis suggests that efforts must influence policy to create opportunities for social and cultural change and address the social, economic and cultural determinants of obesity.

As Raine writes:

“The urgency of shifting the intervention focus upstream to reverse the obesity epidemic poses a significant public health challenge to local, national and global organizations. Addressing the root causes, or drivers, of obesity means confronting and regulating a globalized economic system that promotes growth and consumption, including a food system that profits from expanding markets and promoting energy-dense products.”

Unfortunately, as I have noted before, changing such social and environmental drivers of obesity at a policy level may have to go well beyond simply making this a matter of ‘diet and exercise’.

Thus, simply calling for populistic ‘quick-fix’ policies, which focus on making us “eat less and move more”, an approach that has proven so ineffective at the individual level, is likely to remain as ineffective at the population level, unless we address the key societal values and norms that lead to such policies.

As I have previously declared, ’shame, blame, ban and tax’ approaches, that may have worked well for tobacco, are very unlikely to work for obesity (how exactly would you tax someone into feeling better about themselves, getting more restorative sleep or lowering their emotional stress levels?).

Indeed, such a policy discussion would likely need to be prefaced by a fundamental societal discourse on what we value as individuals and as social beings - everything from how we make and spend our money, raise our kids, build and nurture relationships, and find spiritual meaning, purpose and balance in our lives would likely have to be ‘open game’ for discussion.

Are we really ready for that?

AMS
Toronto, Ontario

Raine KD (2011). Obesity epidemics: inevitable outcome of globalization or preventable public health challenge? International journal of public health PMID: 22075687

This morning, I am presenting a plenary talk on obesity at the 2011 Canadian Military and Veteran Health Research Forum, here in Kingston, Ontario.

In preparation for my talk, i took an in-depth look at the 2008/09 results from the Health and Lifestyle Information Survey of Canadian Forces (CF) Personnel.

According to this report, obesity rates in CF personnel increased from 20.5% in 2004 to 23.5 in 2008/2009 - a rate not remarkably different from Canada’s overall population. In fact, based on BMI, over 70% of CF personnel were either overweight or obese. Obesity rates were higher among males (25%) than females (17%).

Obese CF personnel reported significantly poorer health, were more likely to have one or more chronic co-morbid condition were about 50% less likely to be able to deploy than non-obese personnel.

While obese CF personnel reported eating fewer servings of vegetables and fruit, energy expenditure through physical activity was surprisingly similar for non-obese and obese personnel.

The top 3 actions which CF personnel believed would improve their health and well being were to exercise more or start to exercise, improve their diet, and lose weight. Intent to make that change for all 3 actions was over 90%. Surprisingly perhaps, less than 20% thought that access to additional nutrition information would increase their ability to lose/gain weight.

In my talk I highlight the need for a better understanding of the underlying reasons for weight gain in AF personnel - although it is likely that high-stress levels, mental health problems, and other root drivers of weight gain or barriers to weight management are probably as (if not more) prevalent amongst AF personnel, these relationships were by no means clear from the report.

At least it would probably be fair to believe that simplistic ‘Eat-Less-Move-More’ (ELMM) approaches to weight management will likely be as ineffective for AF-personnel as for anyone else.

Rather, the solutions will likely be as complex and require the same dedicated resources as for non AF personnel.

AMS
Kingston, Ontario

It’s Thanksgiving weekend in Canada, a festive time of feasting with friends and family. Since food takes centre stage during this holiday, I thought this would be a good time to bring up a whole other turkey of a discussion that’s been simmering on my back burner for a while. Warning: I am serving this with a large smattering of sarcasm on the side.

As readers may be aware, in my ample spare time I volunteer as the Scientific Director of the Canadian Obesity Network – to my knowledge, the largest NGO of obesity professionals in the world – dedicated to fighting weight bias and promoting evidence-based solutions to obesity prevention and management.

Wearing this hat sometimes puts me in situations where I have to face important questions like whether or not the Network could possibly partner with or accept money from corporations – especially those deemed ‘part of the problem’.

Food corporations, like all corporations, exist to make money for their shareholders. They do so by selling food and beverages – as much as possible, to as many customers as possible, with the greatest profit margin possible.  Unhealthy foods are cheap to make and distribute, while healthy foods are expensive to make and distribute. Therefore, the more unhealthy foods ‘Big Food’ can make and sell, the greater their profits.

So are food and beverage companies to blame for the obesity epidemic? Are they tainted in the same way that ‘Big Tobacco’ is tainted for promoting and selling cigarettes?

Tobacco causes cancer and heart disease – tobacco companies sell tobacco – so taking money from tobacco companies to fight cancer and heart disease is probably not a good idea. This is especially true if giving a small share of their profits to fight cancer and heart disease actually helps them sell a lot more tobacco (perhaps even to little children slaving away in sweat shops in developing countries). In fact, you could argue that if tobacco companies were at all serious about preventing cancer and heart disease, they could simply fire their employees and quietly go out of business.

If only things were that straightforward when it comes to linking Big Food to obesity.

First of all, most major food corporations also makes some foods that are healthy (or can, in moderate amounts, be part of a ‘balanced’ diet).  In contrast, although some tobacco products may be less harmful than others, no tobacco company makes a truly ‘healthy’ tobacco product.

Secondly, no one needs to smoke – but everyone needs to eat. So while we will all happily survive even it the last tobacco company went out of business – most of us would likely go hungry if even just a few of the major food corporations stopped making food.

But neither one of these arguments is really the topic of today’s post. Rather, this post is about addressing the concerns of purists and health-evangelists, who point out that, since all major food corporations make and sell at least some products that may well ‘promote’ obesity, for an obesity NGO to accept ANY support from Big Food (even if there are ‘no strings attached’) can only be completely and utterly unacceptable. Doing so, they argue, would amount to nothing less than helping Big Food sell even more of their ‘obesogenic’ foods. Essentially, the argument goes, taking money from Big Food – even if only to fund a worthwhile project, like addressing weight bias or supporting professional education – is merely ‘putting lipstick on the pig.’

So if the argument is that an obesity NGO simply cannot partner with any food (or beverage) company that makes ANY ‘unhealthy’ food products because by doing so would only help the corporation sell even more of their unhealthy foods, then I would happily argue that the same logic should apply to any business or industry that makes money by enabling or promoting ‘obesogenic’ foods (or other obesity-promoting products).

To me this would imply that an obesity NGO would also have to say ‘no’ to funding from the folks who happen to make any of the unhealthy ingredients that go into these unhealthy foods and drinks – food processors, chemical manufacturers and so on.

But why just them? Isn’t the production of these unhealthy ingredients also promoted by the irresponsible corporations that produce the (genetically modified) seeds, fertilizer, pesticides, hormones and antibiotics required to grow or raise these unhealthy ‘ingredients’?

And why stop there? How about the retail and restaurant industry and the evil marketing and advertising companies that unscrupulously continue to make handsome profits from helping Big Food ‘push’ these unhealthy foods onto gullible consumers?

What about the media corporations that make billions by publishing and broadcasting advertisements for unhealthy ‘obesogenic’ products to our children? What about the nefarious designers and software companies that make the programs that make these advertisements and commercials so appealing, or the institutions that teach people the skills that can be misused for such purposes? What about the many scoundrels who make the very equipment that allows mass publishing of these ‘obesity-promoting’ ads?

And let us not forget the dastardly entertainment industry that unethically makes billions each year by cleverly littering their movies, video games and live events with product placements for unhealthy foods and drinks.  And don’t even get me started on the obscene billions that Hollywood makes from irresponsibly licensing cartoon characters to boost sales of even more junk to kids. And aren’t these the same folks, who also produce those addictive TV shows that keep us in front of screens late into the night instead of allowing us all to go to sleep at sunset so that we can get enough sleep and not have to crave those unhealthy foods in the first place? And wouldn’t banning television past 8:00 pm encourage us to sleep, so we can wake up bright and early with enough time to eat a healthy leisurely breakfast?

Indeed, I simply cannot see how any obesity NGO could ever partner with or even consider accepting free ‘air-time’ from an industry that puts on a “Hockey Night in Canada” only to keep people glued to their TV sets (which incidentally allows them to happily sell even more ads for unhealthy foods and drinks)?

Indeed, why even stop at unhealthy foods?

Isn’t sedentariness as much part of the obesity problem? Isn’t the automobile industry and the personal computer industry and those irresponsible and unethical companies that make industrial robots and elevators and escalators or garage door openers also to blame?

How about the IT and electronics industry that will not cease and desist till every one of us carries at least three portable (time-saving?) ‘personal’ devices and will not rest before there is at least one LCD or plasma screen in every room of our homes?

And how about those scoundrel land developers who put us all at risk for obesity by continuing to build unwalkable communities? And how, exactly, are we punishing the fiendish architects who cunningly hide the entrance to stairwells deep in the bowels of their buildings?

Which reminds me, isn’t there also a problem with the air-conditioning industry that allows us to control our environment to temperatures that destroy brown fat, thereby preserving bazillion calories worth of non-shivering thermogenesis?

And why would anyone even consider taking money from the banks that finance these evil industries?

Which makes me really wonder about the folks who shamelessly make good money working for these industries and then impudently seek to ease their troubled conscience by ‘generously’ donating a minute fraction of their annual income to health charities, all the while actively contributing to the childhood obesity problem by failing to ban unhealthy foods and TV screens from their homes and irresponsibly continue dishing up obscene Turkey dinners for their family and friends.

And let us not forget the many self-righteous ‘white-hat’ researcher/activist-types, these incorrigible do-gooders, who make a rather respectable living by unrelentingly waving their fingers (in New York Times bestsellers and box-office-busting award-winning ‘documentaries’) at the evil dark forces that promote the very conditions (cancer, heart disease, obesity) that they are funded to study.

And last but not least, how can we even trust the health care industry or those parasitic health ‘charities’. After all, isn’t their only raison d’etre the very fact that people get unhealthy by doing unhealthy things (like trying to live forever)? Just imagine the catastrophic scenario that would completely devastate the ‘pink ribbon’ industry if someone somewhere actually did suddenly find ‘The Cure’! (Imagine all the people who would be left with no reason to run!).

So why just go for the easy targets – the ‘Big Foods’ and ‘Big Drinks’ of the world? Why not go after anyone and everyone, who is in any form or fashion is part of the problem or ruthlessly profits from it.

So please, if you work for or even just happen to own any shares of the above-mentioned industries in your retirement funds, please do not offend obesity NGO’s by offering them your money.

Also, if your company has ever taken money from any of these industries thereby enabling their ‘evil deeds’, and most certainly, if any of your employees have ever supported any of these industries by consuming any of these companies’ products (even just the ‘healthy’ ones), then please DO NOT CALL US.

And, taking this line of reasoning to its ultimately absurd conclusion, if you have ever paid taxes to support any government that has ever passed any laws to support ‘obesogenic’ industries - or that simply refuses to pass laws to ensure that we are only and at all times surrounded by ‘healthy’ products – please do not block our telephone lines with your offers of support.

In fact, I’d much rather see organizations like the Canadian Obesity Network turn off the lights forever than even remotely have to consider accepting donations that are the fruit of ill-begotten gains and will only serve to make the problem even bigger.

Perhaps simply shutting down the Network is indeed the surest way to ensure that no one (corporate, non-corporate, or private citizen) will ever misuse their contribution to the Network (however big or small) to make the obesity problem worse than it already is.

I could simply not imagine myself waking up to a front-page headline that screams:

“Big Food Funding for Obesity Network Helps Canadians Pack on the Pounds.”

I sincerely doubt I could live with myself if that were ever to happen.

How about we simply accept that all of us are more or less part of the global obesity problem and that all of us need to be part of finding solutions. Only large corporations and governments (and perhaps a handful of philantropists) have the necessary clout to support the activities of an organization like the Obesity Network, which I hope most people will agree, is trying hard to find and promote solutions based on the best scientific evidence and reasoning.

Pointing fingers, politicizing and demonizing is not helpful. ‘Unconstructive’ criticism will take us nowhere.

And believe me, I am not proposing or seeking an ‘appeasement’ strategy - I am also not talking of blankly endorsing or implicitly white-washing any industry or all of their practices.

But to close the door to funding and partnerships that could help the Network accomplish its declared strategic goals and objectives, simply based on a matter of ‘principle’, would ultimately mean giving up.

Yes, there need to be clear rules, policies, transparence, accountability, governance and oversight - the more the better - fortunately, the Canadian Obesity Network has all of that and more.

I, for one, would like to thank all of the many partners and members of the Network for their unwavering and enthusiastic support. I invite all who consider themselves part of the problem to step up to the plate and become even a small part of the solution!

Happy Thanksgiving to All.

AMS
Edmonton, Alberta

Yesterday, at the 47th EASD meeting, I spent most of my time in sessions dealing with the improvement of insulin.

While there was a lot of fascinating basic and clinical science and, certainly, newer insulin analogues appear less obesogenic than their older cousins, this entire line of treatment at least for type 2 diabetes, by definition, cannot be considered anything other than palliative (even if diabetologists would argue that insulin treatment helps prevent many of the complications of diabetes).

Indeed, if we consider obesity as one of the main ‘modifiable’ risk factors for type 2 diabetes (some would prefer the term ‘root cause’), then treating diabetes without also treating obesity, is hardly a solution.

Unfortunately, our ability to treat obesity ranges from the notoriously limited “Eat-Less-Move-More” (ELMM) approaches to the rather drastic surgical treatments, with little in terms of conservative medical treatment in between.

This, as I have often discussed in the past, is in part due to the rather ultra-conservative approach that regulators have taken towards approving obesity drugs - a situation that has considerably stifled enthusiasm of pharmaceutical companies to forge ahead with the necessary investments in this area.

It is therefore perhaps occasion for guarded optimism to note that in a report accompanying the 2012 US appropriations bill for agriculture, rural development and FDA, the US Senate Committee on Appropriations has now directed the FDA to provide a report by March 30, 2012, regarding steps the agency will take to support the development of new treatments for obesity.

The committee was apparently “concerned with the absence of novel medicines to treat obesity” and called the lack of obesity drugs “a significant unmet medical need,” noting that obesity is “a disease linked to cancer, high blood pressure, heart disease, diabetes, and stroke” and is the second leading cause of preventable deaths in the US.

The committee’s directive for FDA to look at risk mitigation recognizes that safety issues have been a major stumbling block for developers of weight-loss drugs.

Such steps, the report says, include the use of Risk Evaluation and Mitigation Strategies and other post-market authorities “to mitigate risk and ensure rigorous post-market scrutiny while increasing access to novel medications.”

On a side note, the FY12 bill, as part of the Transforming Food Safety and Nutrition Initiative, states that

“the FDA will also begin an $8.8 million program to improve nutrition labeling on restaurant menus and vending machines so that consumers can adopt healthier diets….the investments in this initiative will empower consumers to make better nutritional choices and will motivate food producers to develop healthier foods.”

While I am not sure, what influence the infusion of a paltry $9 Million into food labelling and similar (’educational’) approaches will have, I do believe that the strongly worded ‘warning’ to the FDA regarding taking a more ’supportive’ attitude towards finding ways to hasten the development and launch of new anti-obesity drugs, may prove promising.

I know for one that despite a rather large number of molecules in early pipelines (and a few that are further along) as well as the substantial number of druggable targets, many large pharmaceutical companies appear to have taken a rather unenthusiastic ‘wait-and-see’ attitude towards developing competitive anti-obesity portfolios.

At least from what I see here at the EASD, there appears far greater enthusiasm for playing it safe, even if only with another ‘me-too’ launch in the already ‘overloaded’ anti-diabetes market.

The FDA will now need to report back in six-months - I (as many others) will be watching closely to see what they come up with.

From my perspective, risk mitigation strategies must include development programs and approval pathways that target ‘complicated obesity’ (Edmonton Obesity Stages 1-4) rather than simply weight loss, and take the rather heterogenous nature and etiological heterogeneity of obesity into account (there is absolutely no reason why any obesity drug should work for all - rendering average weight loss or even response rates meaningless).

It is perhaps time for companies and researchers to begin ‘pigeon holing’ obesity drug development into categories that better reflect risk and aetiology in a manner that would essentially make BMI-based definitions and approaches obsolete.

AMS
Lisbon, Portugal

Today, as I attend the 47th European Association for the Study of Diabetes (EASD) Annual Meeting here in Lisbon, I cannot help but discuss an article by Kenneth E. Thorpe and Zhou Yang, Emory University, Atlanta, Georgia, published in the latest issue of Health Affairs.

Based on their analysis of the significant impact of even modest sustained weight reduction on the incidence of type 2 diabetes, these authors suggest that enrolling overweight and obese pre-diabetic US adults aged 60–64 into a proven, community-based weight loss program nationwide could save Medicare $1.8–$2.3 billion over the following ten years.

Estimated savings would be even higher ($3.0–$3.7 billion) if equally overweight people at risk for cardiovascular disease were also enrolled.

Thus, lifetime Medicare savings could range from approximately $7 billion to $15 billion, depending on how broadly program eligibility was defined and actual levels of program participation, for a single “wave” of eligible people.

A key assumption in their proposal, is that a fully funded sixteen-twenty week community program (perhaps delivered by the YMCA), would deliver about 4% weight loss and replicate the almost 50-70% reduction in progression to diabetes seen in some diabetes prevention studies.

Using our Edmonton Obesity Staging System definitions - this program would target Stage 1 patients (pre-diabetes) or Stage 2 patients (with hypertension or dyslipidemia).

There is no doubt that community based ‘lifestyle’ interventions are the only plausible way in which any program can be delivered to millions of eligible individuals. There is also little doubt that in randomised controlled trials, considerable benefits have been demonstrated.

The question remains, however, whether enough eligible participants will in fact participate and persist with these ‘lifestyle’ changes without continuing and ongoing support (which is generally what the clinical trials have delivered). The notion that an intervention of limited duration (even twenty weeks) will lead to sustainable effects, may be a bit over optimistic, even if 10 year follow-up data from some diabetes preventions studies suggest long-term benefits even after the end of the trials.

It is also worth discussing whether or not success is actually dependent on losing weight (not a behaviour) rather than simply increasing physical activity and eating better (which are behaviours).

Whether or not there is indeed a realistic chance that millions of people can be enrolled in community based interventions programs will remain to be seen, but it is certain that, if feasible, savings would indeed be substantial.

This is why, in the recently announced Alberta Health Services Obesity Initiative, there is a significant emphasis on the importance of community based programs (such as Thr!ve on Wellness, a joint initiative from Alberta Health Services and the Alberta Cancer Foundation, which will soon be expanded to over 100 Alberta communities).

If successfully adopted, these programs should have benefits far beyond diabetes prevention and reduce rates of heart disease, cancers, musculoskeletal problems and hopefully also improve mental health and well being.

Perhaps this is when we can truly claim to be moving towards a ‘health care’ rather than a ’sickness care’ system.

AMS
Lisbon, Portugal

Thorpe KE, & Yang Z (2011). Enrolling people with prediabetes ages 60-64 in a proven weight loss program could save medicare $7 billion or more. Health affairs (Project Hope), 30 (9), 1673-9 PMID: 21900657