Tuesday, March 25, 2014

Challenges in Pediatric Obesity Management

sharma-obesity-kids-scale2If treating obesity in adults is challenging, managing obesity in kids is even more daunting.

Now, a seminal paper by Jill Avis and colleagues (representing a virtual who-is-who of pediatric obesity management in Canada), published in Expert Reviews in Diabetes and Metabolism, with the fitting title, “It’s like rocket science…only more complex“, explores the many challenges in pediatric obesity management in Canada.

The thoughts and analyses presented in this narrative review are largely based on the responses to a national survey of folks providing pediatric “weight-management” services across Canada. Responses were sought to a range of questions, including:

In regards to managing pediatric obesity in Canada, what lessons have you learned related to: Caring for children?; Collaborating with clinicians and/or researchers?; and Working within the health care system? In addition, what do you consider to be important future directions for clinical care and research in Canada?

Apart from noting the importance and challenges of adopting a family centred approach, the paper highlights the importance of factors that go well beyond “eat-less-move-more” platitudes.

Thus, the authors note that,

“Internalizing (e.g., anxiety, depression) and externalizing (e.g., hyperactivity, aggression) disorders are common in children and adolescents with obesity, which can make management strategies more difficult to implement…..these realities highlight the need for mental health professionals to assume active roles in pediatric obesity management to explore, identify and manage families’ unique mental health concerns.”

With regard to the importance of weight bias, the authors state,

“Many parents in our care have experienced shame and blame from other family members, friends, coworkers and health professionals regarding the weight status of their children….The underlying assumption in this instance is that individuals with obesity just need to eat less and move more….a sentiment that demonstrates a lack of understanding and empathy.”

Thus,

” There is a clear need to shift from a singular focus on physical weight status to define the health of individuals with obesity to a nonjudgmental and unbiased appreciation of the complex causes and consequences
of obesity.”

Despite all efforts, the authors describe the outcomes of childhood obesity interventions as “modest”.

This has prompted a number of collaborative research initiatives including the Canadian Pediatric Weight Management Registry (CANPWR), the Should I Stay or Should I Go study and (in partnership with the Canadian Obesity Network) the development of a national network called Treatment and Research of Obesity in Pediatrics in Canada (TROPIC), whose purpose is to promote knowledge translation and dissemination of issues related to pediatric obesity management in Canada.

All of these activities demonstrate a high degree of collaboration and coordination among the pediatric obesity management community in Canada.

The paper also addresses the challenges of providing childhood obesity management services within the health care systems (which vary across provinces).

“…there is substantial heterogeneity across the multidisciplinary clinics we lead and work within; some are well-resourced (i.e., physical space, clinical, and administrative personnel), while others struggle with limited budgets to provide comprehensive and long-term care for families.”

“…relatively small numbers of patients (compared with other outpatient pediatric clinics [e.g.,general pediatrics]) and a lack of substantial weight loss for most children and adolescents with obesity…necessitate education, contextualization and justification to colleagues and administrators within the health care system so that obesity is viewed not as a simple problem that requires a quick fix in order to achieve weight loss, but as a chronic disease that requires ongoing support and management.”

Important work to aid clinicians include the adaptation of the Edmonton Obesity Staging System for pediatric populations (EOSS-P), the family centred adaptation of the 5As of Obesity Management for managing pediatric obesity in primary care, and CONversation cards, a tool to facilitate discussions between clinicians, parents and kids on issues related to healthy lifestyle changes.

Finally, the paper discusses the many barriers to accessing timely obesity management including costs (travel, parking, time off work), geography (distances) and wait times.

Clearly, despite all progress, significant challenges remain to be addressed – “it’s like rocket science…only more complex.”

@DrSharma
Edmonton, AB

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Tuesday, January 21, 2014

Quality of Life in Obesity is Determined by Health, Not Size

weight scale helpOver the past few days, I have been posting on the results of the APPLES study – a prospective 24-month assessment of patients wait-listed for or undergoing treatment at a publicly funded bariatric centre in Alberta, Canada.

In a separate analysis, just released in OBESITY, Lindsey Warkentin and colleagues present the baseline quality of life (QoL) data for the 500 patients enrolled in this study.

As noted previously, the average BMI of participants in this study was 47.9, 90% were female with an average age of 43.

Quality of life was assessed at the time of enrolment in the study using several standardized and validated instruments (Short-Form (SF)-12 [Physical (PCS) and Mental (MCS) component summary scores], EuroQol (EQ)-5D [Index and Visual Analog Scale (VAS)], and Impact of Weight on Quality of Life (IWQOL)-Lite).

As may be expected, the overall QoL of these patients was substantially lower than the general population in Alberta.

Thus, the mean physical and mental component summary scores in the SF-12, were both substantially lower (by about 10 points) than general population scores in Albertan adults. Similar reductions in QoL were found with the other instruments.

Key predictors of poor QoL included fibromyalgia, pain, depression, sleep apnea, coronary artery disease and stroke (among others).

Interestingly, however, despite a wide range of body weights in this study, BMI itself had almost no predictive value in terms of health status or quality of life.

This is perhaps not surprising, as we have previously shown that BMI alone is not a reliable or even sensitive measure of health (which is why we developed the Edmonton Obesity Staging System to better characterize the health status of individuals with obesity).

Thus, it is the actual presence of related illnesses that determine the quality of life – not simply the amount of excess body fat.

This finding has important implications for treatment and prioritization.

For one, as noted previously, BMI or other measures of size alone are a poor guide as to how sick your patient is – determining the health impact of excess weight actually requires assessing the presence of physical and mental comorbidities (of which there are many).

Conversely, as QoL is largely dependent on the presence of related illnesses – it may well be that treating and controlling these illnesses may have a great impact (and perhaps be far more effective and practical) than simply focussing on weight loss.

Thus, for example, it may be far more cost effective and practical to treat the symptoms of severe osteoarthritis (by replacing a knee or hip) or the symptoms of sleep apnea (with CPAP) than simply focussing all attention on dropping the numbers on the scale.

As much as losing weight may be the preferred option (if we had better treatments), better management of relevant comorbidities could perhaps result in substantial greater improvements in health-related quality of life than struggling to lose a few pounds.

Thus, an important tenet of bariatric care has to focus on better managing the health problems that obese patients present with even if significant and persistent weight loss remains elusive in most patients.

Bariatric care is so more than just running a weight-loss clinic.

@DrSharma
Edmonton, AB

ResearchBlogging.orgWarkentin LM, Majumdar SR, Johnson JA, Agborsangaya CB, Rueda-Clausen C, Sharma AM, Klarenbach SW, Birch DW, Karmali S, McCargar L, Fassbender K, & Padwal RS (2014). Predictors of health-related quality of life in 500 severely obese patients: An assessment using three validated instruments. Obesity (Silver Spring, Md.) PMID: 24415405

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Wednesday, April 24, 2013

Roads to Obesity: Social Environment

sharma-obesity-money1Continuing my discussion of the paper by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, on what causes some people to gain weight, we turn to what the authors describe as, “Gradual Processes”.

Thus, in their extensive interviews with individuals seeking bariatric surgery, although most interviewees focused on explanations with a considerable sense of self-blame, many did report social structural factors as playing an important role in their weight gain, without using these as “excuses”.

“Zoë pointed out that outdoor exercise was too difficult for her in winter conditions, and indoor exercise in a gym was out of her reach financially, and gave specific policy recommendations: “They’re always telling people to lose weight, that we’re an overweight province. Well, help out a bit. Make gym memberships a little more cheaper, make it a little more accessible to people.”

Other barriers included occupational and domestic work schedules:

“When you’re sitting at a desk 40, 45, or 50 hours a week, you’re trying to establish yourself so that people are looking to you, so you get promotions as opposed to someone else, so you’re putting in those extra hours and you’re coming home tired. You’re sitting down for supper, and then it’s 7:00 at night.Okay, when do I do anything now?”

“Wanda explained, “I got the two kids. I have a gym membership, a family gym membership; it’s just that we never get there. I work all day. When I get home I’m tired. … Just finding the time is hard.”

As the authors note, leisure time distribution is a social inequality that particularly affects those with less income as well as mothers of young children.

Furthermore, social inequality related to the risk for occupational injuries with subsequent weight gain are likewise often not seen as related to the social determinants of health.

Finally, built environments and the cost of weight-loss programs were seen as contributing factors that made weight management efforts difficult or unsustainable.

I am sure that readers will have their own social determinants to contribute to this list.

AMS
Berlin, Germany

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Thursday, August 16, 2012

Obesity Surgery is not Just About Surgery

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Feb 2, 2008:

With the “sensational” results of obesity surgery being publicized in the media, it is not surprising that expansion of bariatric surgery is receiving increasing support. In every province, health plans are carefully looking at expanding access for their populations.

In light of these development it may be time for a word of caution.

Obesity surgery is not just about surgery. In fact, even the most enterprising bariatric surgeons will readily agree that the actual surgery is just a small (but important) technical piece in the overall treatment plan.

No doubt, good surgical outcomes require well-trained experienced surgical teams but we know that much of the long-term outcome depends on what happens before and after surgery.

Done in the wrong patients with no or little long-term follow up, what could be a life saving operation can become a disaster – and weight regain is perhaps the least that can go wrong. Much more severe and potentially devastating are the nutritional deficiencies and the psychological and social consequences that are not seldom after surgery.

For surgery to produce good long-term results it is absolutely essential that as access to surgery expands, so does the pre-surgical selection and education process as well as the access to life-long post-surgical monitoring.

Expansion of surgical programs does not just need more surgeons and OR time – it needs dietitians, psychologists, physicians, occupational therapists, social workers and other health professionals who are trained and qualified to prepare and follow-up surgical patients.

In the end it will be family doctors who have to look after the 1000s of patients who will be asking for and undergoing surgery. Given the numbers of eligible patients and the geographic distances in Canada, this task of preparing and following patients for life cannot be performed by a handful of Centres of Excellence. This is particularly true for the adjustable gastric band, which while offering a simpler and safer surgical procedure, does require regular and ongoing adjustments to be fully effective.

If we hope to see the spectacular results from the published studies on bariatric surgery replicated in daily practice, we must start bringing primary care providers up to speed on counseling, preparing and following their patients.

Ignoring this task will leave 1000s of Canadians stranded post-surgery with nowhere to go when things go wrong.

Obesity surgery is NOT just about surgery.

AMS

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Friday, January 20, 2012

Weight-Based Bullying in Ontario Youth

At the 1st National Summit on Weight Bias and Discrimination organized by the Canadian Obesity Network in Toronto almost exactly a year ago, I learnt that weight-based bullying is one of the most common and pervasive forms of bullying experience by children and youth.

This topic is further examined by Obesity Network Bootcamper Atif Kukaswadia and colleagues from Queens University, Kingston, Ontario in a paper just published in OBESITY FACTS.

The researchers report on their findings in a longitudinal analysis of the Health Behaviour in School-Age Children Survey conducted in 2006 and then again in 2007, which included 1,738 youths from 17 Ontario high schools.

Based on self-reports, excess adiposity preceded bullying involvement and obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying over the observation period.

In addition, among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls).

These findings support previous findings on the increased risk for bullying faced by overweight and obese youth and certainly suggest that this problem, if anything, is getting worse.

Given the many deleterious (and often lasting) effects of bullying on mental and physical health, this issue is certainly something that should concern us all.

Thus, it is certainly not surprising that one of the strategic priorities identified at CON’s Weight-Bias Summit was to “address weight-bias and discrimination in education settings”.

A full report of the Summit is available here.

AMS
Edmonton, Alberta

ResearchBlogging.orgKukaswadia A, Craig W, Janssen I, & Pickett W (2011). Obesity as a determinant of two forms of bullying in ontario youth: a short report. Obesity facts, 4 (6), 469-72 PMID: 22248998

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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