Arya M. Sharma, MD

OK, we know stress, lack of time, low socioeconomic status, poor locus of control and poor sleep promote obesity - but here is a new one (at least for me): Vital Exhaustion.

The term Vital Exhaustion (VE) has three defining characteristics: (1) feelings of excessive fatigue and lack of energy, (2) increasing irritability, and (3) feelings of demoralization.

People often attribute these feelings to overwork, or to problems at work or in other important life areas that the person has not been able to solve, or to a real or symbolic loss. Therefore, it has been suggested that VE is a mental state at which people arrive when their resources for adapting to stress are broken down.

Now Maria Bryant and colleagues from the University of Leeds, UK in a paper just out in OBESITY, examined the relationship between VE and BMI cross-sectionally and after 3 and 6 years of follow-up among the 13,727 participants in the Atherosclerosis Risk in Communities (ARIC) study.

BMI was significantly higher among both white and African-American men and women in the highest VE quartile compared to those with no VE. Similarly, high VE at baseline was associated with higher BMI 3 and 6 years later. Baseline VE predicted future excess weight gain in white men and women, but not in African Americans.

Clearly, if this relationship is causal, identifying the factors contributing to VE and addressing them may help prevent and reduce the burden of obesity - certainly easier said than done.

Anyone who thinks we will solve the obesity crisis by handing out diet plans and chasing people around the block are kidding themselves.

AMS
Edmonton, Alberta

So to finish this week on men’s health let me pose a question:

According to the new numbers from the Canadian Community Health Survey released last week, men aged 25 to 44 were considerably more likely than their female counterparts to be obese. Even in the age group 45 to 64, men were slightly more obese than women.

So clearly, at least as many men as women should be worried about their weight and seeking help - especially since men, due to their greater likelihood to gain abdominal fat, are at much higher risk for weight-related diabetes and heart disease.

But when you look at any obesity program (including ours), the women seeking help by far outnumber the guys (probably by 4 to 1, if not more).

So the question is - how do you get the guys to realize that their increased weight is putting them at risk and that it is they rather than the women, who should be seeking help.

Any suggestions from my readers out there on how to increase “obesity-risk-awareness” amongst men would be most welcome.

I look forward to your thoughts on this,

AMS
Edmonton, Alberta

Humans are omnivores and apparently our hunter-gatherer ancestors ate an extraordinary range of plant and animal foods.

The advent of culinary skills and use of spices and seasonings further enhanced the variety, taste, flavour, appearance, texture and consistency of foods.

Today, the apparently limitless choice of foods in our supermarkets, restaurants and homes is a sure sign of the importance we place on variety and variation when it comes to eating.

When trying to manage your weight, however, variety may be your downfall.

This at least is the gist of a recent study by Ramona Guerrieri and colleagues from the Department of Experimental Psychology, Maastricht University, in The Netherlands, who examined the interaction between impulsivity and a varied food environment and its influence on on food intake and overweight, published in the International Journal of Obesity.

The study is based on two observations:

1) Our current food environment offers a large variety of cheap and easily available sweet and fatty foods

and

2) Impulsive people may be reward sensitive and are generally less successful at inhibiting prepotent responses (i.e. a response that is or has been previously associated with positive reinforcement)

Using a rather complicated experimental design masquerading as a taste test, Guerrieri and colleagues studied 78 healthy primary school children (age: 8-10 years) regarding two aspects of impulsivity: reward sensitivity and deficient response inhibition.

The kids were studied in two groups: one was offered rather monotonous foods; the other was offered foods varied in colour, form, taste and texture.

As expected, reward sensitivity interacted with variety. In the “monotony group” there was no difference in food intake between the less and more reward-sensitive children (183 kcal+/-23 s.d. versus 180 kcal+/-21 s.d.).

However, in the “variety group” the more reward-sensitive children ate almost 70% more calories than the less reward-sensitive children (237 kcal+/-30 s.d. versus 141 kcal+/-19 s.d.).

While reward sensitivity in itself was not linked to overweight, deficient response inhibition (a measure of impulsivity) was.

Clearly, the kids with poor impulse control were handicapped when it came to dealing with variety.

Why is this important?

What the data suggest is that kids (and adults?) who have poor impulse control are more likely to overeat when faced with variety. Therefore, the incredible variety and choices of food that we have available to us, may indeed be a major factor in the problem of overeating.

As blogged previously, attention deficit disorders (ADD) are surprisingly common in obese children and adults - in our currently environment, this increased impulsivity may be an important factor contributing to their weight gain.

If your problem is impulse control - the less choices you give yourself the better.

AMS
Edmonton, Alberta

Most people fail to keep off any weight they lose.

This may in part be attributable to the substantial barriers that undermine long-term obesity management strategies.

In a paper I wrote with my colleagues Marina Mauro, Valerie Taylor and Sean Whartan just out in the European Journal of Internal Medicine, we highlight the importance of recognizing and addressing these barriers before embarking on obesity treatments.

Common barriers include lack of recognition of obesity as a chronic condition, low socioeconomic status, time constraints, intimate saboteurs, and a wide range of comorbidities including mental health, sleep, chronic pain, musculoskeletal, cardiovascular, respiratory, digestive and endocrine disorders.

Furthermore, medications used to treat some of these disorders may further undermine weight-loss efforts and promote weight regain.

Unfortunately, lack of specific obesity training of health professionals, attitudes and beliefs as well as coverage and availability of obesity treatments can likewise pose important barriers.

Health professionals need to take care to identify, acknowledge and, if possible, address these barriers in order to increase patient success as well as compliance and adherence with treatments.

Failure to do so may further promote the sense of failure, low self esteem and low self efficacy already common among individuals struggling with excess weight.

I have little doubt that addressing treatment barriers can save resources and increase the prospect of long-term success.

Identifying and discussing barriers with patients has to be a routine part of obesity care.

AMS
Edmonton, Alberta

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