Now a study by Crump and colleagues published in JAMA Intern Medicine suggests that some of this risk may be mitigated by increased physical fitness.
The cohort study involving over 1.5 million Swedish young men in Sweden, who underwent standardized aerobic capacity, muscular strength, and BMI measurements obtained at a military conscription examination and were followed for up to 40 years.
Almost 100,000 men went on to develop hypertension, whereby both high BMI and low aerobic capacity (but not muscular strength) were associated with increased risk of hypertension, independent of family history or socioeconomic factors.
A combination of high BMI (overweight or obese vs normal) and low aerobic capacity (lowest vs highest tertile) was associated with the highest risk of hypertension.
The association with aerobic fitness was apparent at every level of BMI.
Form this study the authors conclude that high BMI and low aerobic capacity in late adolescence are associated with higher risk of hypertension in adulthood.
Although one must also be cautious in assuming causality with regard to associations found in such studies, the observations are certainly compatible with the notion that increased cardiorespiratory fitness may well mitigate some of the impact of increased BMI on hypertension risk.
Today’s guest post comes from Jillian Avis, PhD Candidate, Department of Paediatrics, University of Alberta, Edmonton
Primary care providers (e.g., family doctor, kinesiologist, registered dietitian) play a key role in preventing childhood obesity. To assist with obesity prevention, providers use a variety of tools and resources in clinical practice to (i) assess and monitor children’s weight status (e.g., body mass index growth charts), (ii) communicate children’s weight status with families (e.g., 5As of Pediatric Obesity), (iii) educate families on healthy lifestyle behaviors (e.g., Canada’s Food Guide), and (iv) facilitate behavior change (e.g., magnetic place models).
Although such tools are regularly used by providers, little is known regarding their use and suitability in practice. Thus, in a recent publication, our team pilot‐tested a mixed methods study to preliminary assess these tools – Do they work? Do providers like them? How are they used?
We conducted one‐on‐ one interviews with multidisciplinary primary care providers (n=19) from 10 primary care clinics in Edmonton and Calgary. Following the interviews, we compiled a comprehensive list of all tools used by providers, which were subsequently evaluated using three assessment checklists (e.g., Suitability Assessment of Materials).
Our findings show that most tools score ‘average’, and criteria on the checklists (e.g., readability level, layout, graphics) overlap with providers’ perceptions of tool suitability.
However, the checklist criteria do not reflect providers’ views regarding the logistical factors that impact accessibility, such as cost, distribution, and production.
Conclusions from our research highlight that to assess the overall suitability and assist those developing tools for childhood obesity prevention, objective scoring using checklists should be considered in conjunction with contextual factors and providers’ perceptions of suitability.
If you’re interested in following Jill’s research, visit her blog
This is even more true for children with physical disabilities, who face even greater challenges when it comes to preventing or managing excessive weight gain. Unfortunately, not much is known about the extent of this problem or possible solutions.
Now a group of Canadian experts in paediatrics and rehabilitation have put out a Call to Action, published in Childhood Obesity, for a research agenda that focuses on this important sub-group of kids.
The call is the result of a Canadian multistakeholder workshop on the topic of obesity and health in children with physical disabilities that was held in October 2014.
The participants in the workshop included researchers, clinicians, parents, former clients with disabilities, community partners, and decision makers.
Given the paucity of research in this area, it is not surprising that the participants identified over 70 specific knowledge gaps that fell into 6 themes: (1) early, sustained engagement of families; (2) rethinking determinants of obesity and health; (3) maximizing impact of research; (4) inclusive integrated interventions; (5) evidence-informed measurement and outcomes; and (6) reducing weight biases.
Within each theme area, participants identified potential challenges and opportunities related to (1) clinical practice and education; (2) research (subareas: funding and methodological issues; client and family engagement issues; and targeted areas to conduct research); and (3) policy-related issues and topic positioning.
Recommendations emerging from the workshop’s multistakeholder consensus activities included:
Children’s and families’ needs must be integrated into prevention and treatment programs, taking into account the additional caring commitments and environmental challenges often experienced by families of children with physical disabilities. Guidelines need to be developed regarding how best to engage children/families meaningfully in designing both clinical interventions and health promotion research initiatives.
Research in obesity and health in children with physical disabilities should be guided by a conceptual model, determining both common and unique determinants of health and obesity compared with their typically developing peers. A conceptual model enables existing knowledge about obesity prevention and management from other populations to be integrated into approaches for children with physical disabilities where appropriate, as well as the identification of areas where disability-specific knowledge is still needed. It is critical that any such model incorporates social and environmental factors that can affect both weight and health, rather than locating responsibility within the individual by default.45 The alignment of our model with the ICF ensures that our approach remains truly biopsychosocial.
Valid, reliable, clinically appropriate, and acceptable outcome measures are urgently needed in order to monitor children’s weight and health, and identify overweight and obesity, where conventional outcomes (e.g., BMI) alone have been shown as suboptimal.
As the authors note,
“Canadian researchers are now well positioned to work toward a greater understanding of weight-related topics in children with physical disabilities, with the aim of developing evidence-based and salient obesity prevention and treatment approaches.”
Hopefully, they will now find the funding required to do the work.
A key reason for the Canadian Obesity Network to roll out its public engagement strategy, is not just provide a source of credible information on obesity prevention and treatment but also to provide a forum for the prospective of those living with obesity.
That this perspective is often lost in the obesity debate, is highlighted by a thoughtful commentary published in JAMA Internal Medicine written by Fiona Clement, PhD, from the Department of Community Health Sciences, University of Calgary, and has herself struggled with excess weight for most of her adult life.
Clement, whose BMI (at 31.8 kg/m2) barely fits the “obesity criteria”, notes that,
“…this article is the first time I have told my BMI to another soul. I have never shared my BMI with my husband, my friends, nor, importantly, my physician. Given that I am an otherwise healthy 35-year-old woman, it is shocking that what is probably my only health concern has never been talked about within the privileged space of my physician-patient relationship.”
Her reasons for not talking about this are not surprising,
“Obviously, this is an awkward conversation for both the patient and physician. Weight is a tough subject, loaded with stigma, self-esteem, worthiness, and beauty issues. Despite guidelines recommending weight management counselling, the conversation is not happening regularly. Like many hard conversations, it requires compassionate listening and sympathy on the part of the physician, courage and humility from the patient.”
This problem is well recognized, which is exactly why the Canadian Obesity Network’s 5As approach to obesity management emphasizes the tact and skills needed to initiate this conversation (ASK for permission, be non-judgemental, do not make assumptions).
As to the use of appropriate obesity management strategies, Clement essentially opted for the most common “do-it-yourself” approach of “eat-less-move-more”, which as ample research shows is rarely a sustainable strategy. Not surprisingly, the weight she lost came back when, as she says, life happened.
Clement writes about the information she would want presented before she made an informed decision to pursue any of the proposed interventions.
This is exactly what the 3rd A in the 5As of Obesity Management is about – ADVISE. This is where, following the ASK and ASSESS, the health professional would offer their advice – tailored to the individual.
Given that Clement barely meets the BMI criteria for obesity and has, as she states, no weight related health issues, she would at best be considered to have Stage 0 obesity according to the Edmonton Obesity Staging system.
At this stage, the risk (not to mention the cost) of pharmacological or surgical treatments would by far outweigh any potential benefits. Indeed, the focus would be to first and foremost prevent further weight gain by addressing any underlying contributing factors while living the healthiest life she can enjoy (best weight).
This is apparently the course of action that she chose, wisely it seems.
Indeed, given that she has Stage 0 obesity, it is not clear that she would have any real health benefit from attempting to or sustaining weight loss – obesity management should never be about treating numbers on a scale.
Perhaps if Clement had a higher obesity stage, say Stage 2 with diabetes, fatty liver disease or sleep apnea, the advise may be different. In that case, given the substantial risk associated with these conditions, pharmacological or surgical options (especially if her BMI was higher that 35) may well be reasonable additions to her behavioural change.
Thus, Clement is right in noting that interventions have to be individually tailored and a frank conversation about the risks and benefits of treatment between her and a health professional who understands obesity needs to happen (unfortunately, the latter is difficult to find).
With obesity as with other diseases, the question is always the same – at what stage of the disease does the risk of treatment outweigh the risk of not-treating (or not-treating aggressively enough). Whether the problem is diabetes, arthritis, or cancer – the question of risk-benefit ratios must always be seen in the context of the individual.
Thus, The Lancet should no doubt be commended on partnering with the World Obesity Federation to constitute an international panel of 22 experts under the leadership of Boyd Swinburn (New Zealand) and William Dietz (USA) to
“…stimulate action on obesity and strengthen accountability systems for the implementation of agreed recommendations to reduce obesity and its related inequalities and to develop new understandings of the underlying systems that are driving obesity in order to develop innovative approaches towards making those systems less obesogenic.“
While (perhaps to my surprise) I have previously heard of only one of the panelists (Shiriki Kumanyika, Emeritus Professor of Biostatistics and Epidemiology, University of Pennsylvania), I am sure that all of the panelists bring a wide range of expertise to the table.
The overall mandate of the Commission is rather ambitious, with the following declared goals:
First, the Commission will stimulate action and strengthen accountability systems for the implementation of agreed recommendations to reduce obesity and its related inequalities at global and national levels.
Second, it will develop new understandings of the underlying systems that are driving obesity and also devise innovative approaches to reorient those systems in a sustainable and scalable way to encourage healthy weight.
Third, it will also establish mechanisms for regular, independent reporting on progress towards national and global obesity targets, implementation of recommended policies and actions, and specific systems analyses of obesity drivers and solutions.
Clearly, the Commission has its work cut out for it, as their goal is to address all underlying systems that are driving obesity, including nutrition, physical activity, urban planning, food systems, agriculture, climate change, economics, governance and politics, law, business, marketing and communication, trade and investment, human rights, equity, systems science, consumer advocacy, monitoring and evaluation, Indigenous health, epidemiology, medicine, and health care.
The Commission will have its inaugural meeting in February, 2016, in Washington DC, USA, to determine its work plans.
I guess we should stay tuned to see exactly what that plan will look like.