10 years ago, I was enticed to take up an endowed “Chair” in obesity research and management at the University of Alberta with the task to develop and lead the fledgling bariatric program at the Royal Alexandra Hospital.
The decision to move to the University of Alberta from a prestigious Tier 1 Canada Research Chair in obesity at McMaster University, where my research enterprise was moving along just fine, was largely prompted by the Ontario Government’s bumbling indecision (despite all of my considerable and enthusiastic advocacy efforts on behalf of my patients) about promoting much needed bariatric services in Ontario (as a side note, only six weeks after I had signed on with the University of Alberta, the Ontario government, after much to-and-froing, finally did announce substantial funding for a province-wide bariatric program, which continues to this date as the Ontario Bariatric Network).
Despite my sadness at leaving my most wonderful and supportive colleagues at McMaster University, I have not for a moment regretted my move to Edmonton. Not only did I find another set of as supportive colleagues at the University of Alberta but also the committed and dedicated staff within Capital Health (now part of Alberta Health Services), all of which enthusiastically supported the creation of a now world-class academic bariatric program in Edmonton. With well over 100 peer-reviewed publications to show for (with a notable mention to the colleagues who helped develop the Edmonton Obesity Staging System and the 5As of Obesity Management), the academic work in obesity was only a rather small part of my activities as “Chair”.
Together with my colleagues at Alberta Health Services, we supported a total of 5 bariatric clinics across the province, all of which are now up and serving Albertans living with severe obesity – each adapted to local resources and interests. Of these, the Edmonton Adult Bariatric Specialty Program at the Royal Alexandra Hospital of course continues as the flagship program, offering a full suite of behavioural, medical, and surgical treatments for Albertans with severe obesity.
With my move to Edmonton, so did the national office of the Canadian Obesity Network (co-hosted by the University of Alberta and Alberta Health Services). As readers will be well aware, this pan-Canadian network of now well over 15,000 obesity researchers, health professionals, trainees, and now 1000s of public supporters, continues to grow and steadfastly pursue its important mission of promoting obesity research, professional education in obesity management, fighting weight bias and discrimination, and advocating for better access to obesity prevention and management for all Canadian children and adults across the continuum of care.
Now, as the 2nd (non-renewable) 5-year term of my appointment as “Obesity Chair” comes to an end, I can only humbly express my sincere thanks to all of my many colleagues and staff at the University of Alberta and Alberta Health Services for supporting all of my activities. I also send out a sincere vote of thanks to all my patients, who continue to keep me well grounded in the reality of clinical obesity practice.
While I may no longer hold the “Chair”, I will of course continue serving in my role as Professor at the University of Alberta and fully aim to further pursue all of my academic and clinical activities while continuing to advocate for better access to obesity care for Albertans (and all Canadians). I also plan to continue to in my role as Medical Co-Director of Alberta Health Services’ Obesity Strategy.
As the search now commences for a new endowed “Chair” (and I know that the University will be looking for the best possible candidates from across Canada and the world), I look forward to working closely with whoever takes on this role to continue improving care for Albertan adults and children living with obesity.
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 consider positive outcomes including but not limited to weight.• Create new standards for the portrayal of individuals with obesity in the media and shift from use of imagery and language that depict people living with obesity in a negative light. Consider the following:
- avoiding photographs that place unnecessary emphasis on excess weight or that isolate an individual’s body parts (e.g. images that dispropor onately show abdomen or lower body; images that show bare midri to emphasize excess weight);
- avoiding pictures that show individuals from the neck down (or with face blocked) for anonymity (e.g. images that show individuals with their head cut out of the image);
- avoiding photographs that perpetuate a stereotype (e.g. ea ng junk food, engaging in sedentary behaviour) and do not share context with the accompanying wri en content.
Strengthen people-centred health systems and public health:
• Adopt people-first language in health systems and public health care services, such as a “patient or person with obesity” rather than “obese patient”.
• Engage people with obesity in the development of public health and primary health care programmes and services.
• Address weight bias in primary health care services and develop health care models that support the needs of people with obesity.
• Apply integrated chronic care frameworks to improve pa ent experience and outcomes in preventing and managing obesity. In addition:
- recognize that many patients with obesity have tried to lose weight repeatedly;
- consider that patients may have had negative experiences with health professionals, and approach patients with sensitivity and empathy;
- emphasize the importance of realistic and sustainable behaviour change – focus on meaningful health gains and
- explore all possible causes of a presenting problem, and avoid assuming it is a result of an individual’s weight status.
- Acknowledge the dificulty of achieving sustainable and significant weight loss.
Create supportive communities and healthy environments:
- Consider the unintended consequences of simplistic obesity narratives and address all the factors (social, environmental) that drive obesity.
- Promote mental health resilience and body positivity among children, young people and adults with obesity.
- sensitize health professionals, educators and policy makers to the impact of weight bias and obesity stigma on health and well-being.
Hopefully, these recommendations will find their way into the work of everyone working in health promotion and clinical practice.
The whole brief is available here.
Why do doctors weigh people? Because, very early in medical school, we are taught that body weight is an important indicator of health.
While one may certainly argue about the value of a single weight measurement at any point in time (especially in adults), there is simply no denying that weight trajectories (changes in body weight – up or down) can provide important (often vital) clinical information.
Let’s begin with the easiest (and least arguable) situations of all – unintentional weight loss.
Among all clinical parameters one could possibly measure, perhaps non should be as alarming as someone losing weight without actively trying. In almost every single instance of “unintentional” weight loss, the underlying problem needs to be found, and more often than not, the diagnosis is probably serious (cancer is just one possibility).
As with any serious condition, the earlier you detect it, the sooner you can do something about it, therefore, the more often you weight someone, the more likely you will detect early “non-intentional” weight loss.
The contrary situation (un-intentional weight gain) is as important. When someone is gaining weight for no good reason, one needs to look for the underlying cause, which can include everything from an endocrine problem to heart failure.
On the other hand, weight stability, is generally a sign that things are probably “under control”, as they should be when energy homeostasis works fine and people are in energy balance.
Perhaps my own obsession with weighing people comes from my work in nephrology, where we obsess about people’s “dry weight” and use weight as a general means to monitor fluid status. The same is true for working with patients who have heart failure.
Note for all of the above, that while a single (random) weight measurement tells you very little (almost nothing) about anybody’s health status, unexplained changes in body weight are one of the most useful and important clinical signs in all of medicine. Obviously, to plot a trajectory, one has to start somewhere, which means that every patient needs to have a “baseline” body weight recorded somewhere in their chart. While this value may not provide any valuable information, the next one may.
This is why every single patient needs to be weighed at least once in a clinical setting.
As you will imagine, both the context and interpretation of serial weight measurements becomes most challenging in the setting of obesity management.
For one, there is no greater challenge than to suspect underlying “un-intentional” weight loss in someone who is actively trying to lose weight. When “suddenly” a weight loss strategy that was providing modest results “starts working” – all alarm bells should go off. Also, if weight loss is much better than “predicted” it is time to take a serious second look at what’s happening. Furthermore, you need to watch out for patients who are doing far better than expected (even after bariatric surgery) – it takes a keen clinical mind to watch out for weight loss that appears “too good to be true” (even if the patient is delighted to see the pounds drop off).
Also, in the obesity management setting, weight stability is an important clinical indicator. In someone at their maximum weight, it tells me that the patient is not actively gaining weight, which by definition means that the patient is in caloric balance – remember, the first sign of “success” in obesity management is when the patient stops gaining weight.
In someone, who has already lost weight (in the context of obesity management), weight stability means that the patient’s efforts are continuing (here weight stability is a means to monitor “control”) – weight regain means that the patient may have to re-engage in weight control efforts or (more often) that something has come up in that person’s life that is “sabotaging” their efforts and may need to be identified and addressed (e.g. lost a job, change in medication, depression, etc.). Again, the earlier you identify a “relapse”, the earlier you can intervene.
Finally, in someone attending an obesity clinic, who continues gaining weight, you can be sure that the underlying cause of weight gain has not yet been fully identified or addressed. In other words, the disease is not “controlled” and continues to “progress”.
Thus, patients must be aware, that asking not to be weighed (usually out of shame or embarrassment) derives their clinician of important and possibly “vital” information about their health status.
Again, while a single weight (or BMI) says very little about a patient’s health, changes in body weight (up or down) is a vital sign that should prompt further clinical investigation and possibly intervention.
None of this has anything to do with the fact that people can very well be healthy over a wide range of body shapes and sizes.
It also does not mean that we should take a “weight-centric” approach to obesity management – all of the usual HAES arguments remain valid, even when you regularly ask your patient to step on the scale.
Recording a weight trajectory should be no more “judgemental” than recording a fever chart in a patient with an infection – everything lies in the context and interpretation of the data.
If there is one thing we know for sure about obesity management, it is the sad fact, that no diet, exercise, medication, not even bariatric surgery, will permanently reset the body’s tendency to defend and regain its body weight to its set point – this generally being the highest weight that has been achieved and maintained for a notable length of time.
Thus, any effective long-term treatment has to offset the complex neurobiology that will eventually doom every weight-loss attempt to “failure” (no, anecdotes don’t count!).
Just how complex and overpowering this biological system that regulates body weight is, is described in a comprehensive review by the undisputed leaders in this field (Michael Schwartz, Randy Seeley, Eric Ravussin, Rudolph Leibel and colleagues) published in Endocrine Reviews. Indeed the paper is nothing less than a “Scientific Statement” from the venerable Endocrine Society, or, in other words, these folks know what they’re talking about when it comes to the science of energy balance.
As the authors remind us,
“In its third year of existence, the Endocrine Society elected Sir Harvey Cushing as President. In his presidential address, he advocated strongly in favor of adopting the scientific method and abandoning empiricism to better inform the diagnosis and treatment of endocrine disease. In doing so, Cushing helped to usher in the modern era of endocrinology and with it, the end of organo-therapy. (In an interesting historical footnote, Cushing’s Energy Homeostasis and the Physiological Control of Body-Fat Stores presidential address was given in , the same year that insulin was discovered.)”
Over 30 pages, backed by almost 350 scientific citations, the authors outline in excruciating detail just how complex the biological system that regulates, defends, and restores body weight actually is. Moreover, this system is not static but rather, is strongly influenced and modulated by environmental and societal factors.
Indeed, after reading this article, it seems that the very notion, that average Jane or Joe could somehow learn to permanently overcome this intricately fine-tuned system (or the societal drivers) with will power alone is almost laughable (hats off to the very few brave and determined individuals, who can actually do this – you have climbed to the top of Mount Everest and decided to camp out there for the foreseeable future – I wish you all the best!).
Thus, the authors are confident that,
“The identification of neuromolecular mechanisms that integrate short-term and long-term control of feeding behavior, such that calorie intake precisely matches energy expenditure over long time intervals, will almost certainly enable better preventive and therapeutic approaches to obesity.”
Sadly, despite all we have learnt about this system, we are still far from fully understanding it. Thus, the canonical molecular/ cellular signaling pathway: LEP → LEPR → POMC, AgRP → PC → MC4R is just one pathway in a complex network of multiple interacting and sometimes redundant pathways that involve virtually every part of the brain.
Also, the effect of environmental factors appears to be far more complex than most people think. Thus,
“During sensitive periods of development, ontogenic processes in both brain and peripheral organs can be modified so as to match anticipated environmental conditions. Although many exposures during development could potentially predispose to obesity in adulthood, we focus here on two that some researchers think contribute to the secular trends in obesity: parental obesity and exposure to endocrine disrupting chemicals (EDCs).”
Throw in the role of gut bugs, infections, and societal factors, and it is easy to see why no simple solution to the obesity epidemic are in sight (let alone a range of effective long-term treatments like we have for most other common chronic diseases).
As for solutions,
“To be viable, theories of obesity pathogenesis must account not only for how excess body fat is acquired, but also for how excess body fat comes to be biologically defended. To date, the preponderance of research has focused on the former. However, we must consider the possibility that some (perhaps even most) mechanisms underlying weight gain are distinct from those responsible for the biological defense of excess fat mass. A key question, therefore, is how the energy homeostasis system comes to defend an elevated level of fat mass (analogous to the defense of elevated blood pressure in patients with hypertension). Answering this question requires an improved understanding of the neuro-molecular elements that underlie a “defended” level of body fat. What are the molecular/neuroanatomic predicates that help establish and defend a “set point” for adiposity? How do these elements regulate feeding behavior and/or energy expenditure, so as to achieve long-term energy balance? By what mechanisms is an apparently higher set point established and defended in individuals who are obese?” [sic]
“Given that recovery of lost weight (the normal, physiological response to weight loss irrespective of one’s starting weight) is the largest single obstacle to effective long-term weight loss, we cannot overstate the importance of a coherent understanding of obesity-associated alterations of the energy homeostasis system.”
There is much work to be done. Whether or not, in this climate of anti- and pseudo-science, funding for such fundamental work will actually be made available, is anyone’s guess.
This morning, I am presenting a plenary talk in Berlin to about 200 colleagues involved in childhood obesity prevention.
The 1-day symposium is hosted by Plattform Ernährung und Bewegung e.V. (Platform for Nutrition and Physical Activity), a German consortium of health professionals as well as public and private stakeholders in public health.
Although, as readers are well aware, I am by no means an expert on childhood obesity, I do believe that what we have learnt about the complex socio-psycho-biology of adult obesity in many ways has important relevance for the prevention and management of childhood obesity.
Not only do important biological factors (e.g. genetics and epigenetics) act on the infant, but, infants and young children are exposed to the very same societal, emotional, and biological factors that promote and sustain adult obesity.
Thus, children do not grow up in isolation from their parents (or the adult environment), nor do other biological rules apply to their physiology.
It should thus be obvious, that any approach focussing on children without impacting or changing the adult environment will have little impact on over all obesity.
This has now been well appreciated in the management of childhood obesity, where most programs now take a “whole-family” approach to addressing the determinants of excess weight gain. In fact, some programs go as far as to focus exclusively on helping parents manage their own weights in the expectation (and there is some data to support this) that this will be the most effective way to prevent obesity in their offspring.
As important as the focus on childhood obesity may be, I would be amiss in not reminding the audience that the overwhelming proportion of adults living with obesity, were normal weight (even skinny!) kids and did not begin gaining excess weight till much later in life. Thus, even if we were somehow (magically?) to completely prevent and abolish childhood obesity, it is not at all clear that this would have a significant impact on reducing the number of adults living with obesity, at least not in the foreseeable future.
Let us also remember that treating childhood obesity is by no means any easier than managing obesity in adults – indeed, one may argue that effectively treating obesity in kids may be even more difficult, given the the most effective tools to managing this chronic disease (e.g. medications, surgery) are not available to those of us involved in pediatric obesity management.
Thus, I certainly do not envy my pediatric colleagues in their struggles to provide meaningful obesity management to their young clients.
I am not sure how my somewhat sobering talk will be received by this public health audience, but then again, I don’t think I was expected to fully toe the line when it comes to exclusively focussing on nutrition and activity (as important as these factors may be) as an effective way to prevent or even manage childhood obesity.