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Do Anti-Depressants Promote Weight Gain?

There is no doubt that some people gain weight when started on anti-depressant medications. However, it is also true that the increased appetite and listlessness that accompanies “atypical” depression can contribute to weight gain. Finally, there is evidence that weight-gain in turn may decrease mood, which in turn may further exacerbate weight gain.

Trying to cut through all of this is a study by Rafael Gafoor and colleagues from King’s College London, in a paper published in BMJ.

They examined data from the  UK Clinical Practice Research Datalink, 2004-14, which included data on 136,762 men and 157,957 women with three or more records for body mass index (BMI).

In the year of study entry, 17,803 (13.0%) men and 35,307 (22.4%) women with a mean age of 51.5 years were prescribed anti-depressants.

While during 1, 836,452 person years of follow-up, the incidence of new episodes of ≥5 weight gain in participants not prescribed anti-depressants was 8.1 per 100 person years, it was slightly higher at 11.2 per 100 person years in those prescribed an anti-depressant.

In the second year of treatment the number of participants treated with antidepressants for one year for one additional episode of ≥5% weight gain was 27.

Thus, there appears to be a slight but discernible increased risk of weight gain associated with the prescription of anti-depressants, which may persist over time and appears highest during the second and third year of treatment.

However, as the authors caution, these associations may not be causal, and residual confounding might contribute to overestimation of associations.

Nevertheless, the notion that there may be a distinct weight-promoting pharmacological effect of some anti-depressants is supported by the finding that certain anti-depressants (e.g. mirtazapine) carry a far greater risk of weight gain than others (e.g. paroxetine).

Given the frequency with which anti-depressants are prescribed, it could be argued that the contribution of anti-depressants to the overall obesity  epidemic (particularly in adults) may be greater than previously appreciated.

If nothing else, patients prescribed anti-depressants should be carefully monitored for weight gain and preventive measures may need to be instituted early if weight gain becomes noticeable.

@DrSharma
Edmonton, AB

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Are Bariatric Centres of Excellence Meeting The Standards of Care?

Anyone familiar with the issue, would readily agree that the actual surgery involved in bariatric surgery is only a small (but undeniably important) technical piece in what is a rather complex treatment for a rather complex chronic disease.

Clearly, this is not exactly how all bariatric surgeons approach or treat their bariatric patients.

Since 2012, the US has a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program that designates bariatric surgery centers as Centres of Excellence if they meet specified requirements in 7 core standards that include case volume, commitment to quality, appropriate use of equipment and instruments, critical care support, continuum of care, data collection, and continuous quality improvement.

However, as a recent paper by Andrew Ibrahim and colleagues, published in JAMA Surgery, elaborates, despite these quality criteria, there remains a substantial variability in outcomes across designated Bariatric Centres of Excellence.

Based on their retrospective analysis of claims data from 145 527 patients who underwent bariatric procedures, there was a 17-fold variation (ranging from 0.6% to 10.3%) in rates of serious 30-day complications across accredited bariatric centers nationally and up to 9.5-fold variation across individual states.

As the authors note,

“this finding suggests that participation alone in the Center of Excellence Program did not ensure uniform high-quality care….Given that most bariatric procedures are now performed at accredited centers, wide variation among these centers suggests that accreditation alone does not discriminate enough to guide patients to the best centers for care.”

Moreover, they found that poor performing centres were often located close to better performing centres (regression to the mean?). Interestingly, in contrast to what one may suspect, outcomes overall were not related to case volume (perhaps because in order to be a designated Centre of Excellence, all centres needed to have a minimum number of cases per year).

Rather, the authors discuss that poorer outcomes may be largely attributable to varying technical skills of the surgeons as well as inconsistent adherence to accepted bariatric care pathways.

Finally, the authors argue that there is  need to make performance data available to the public, as simply trusting in the “Centre of Excellence” designation by no means guarantees excellent outcomes.

As important as these data may be, it is also important to note that this paper only looked at complications within a 30-day time period following surgery.

As anyone dealing with bariatric patients is well aware, successful outcomes of bariatric surgery(as well as its complications) should be measured in years (if not decades). This is where much of bariatric surgery falls down, as one of the key criteria mentioned above, i.e. “continuum of care” seldom extends beyond the rather brief period of post-surgical discharge. Indeed, in most cases, bariatric patients continue to be prematurely discharged into “the wild” with little ongoing support from health professionals competent in looking after the psychological and medical needs of this population.

None of this takes away from the fact that bariatric surgery is still the most effective long-term treatment for severe obesity – however, clearly there remains substantial room for improvement.

@DrSharma
Edmonton, AB

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Liraglutide Effects on Upper Gastrointestinal Investigations: Implications Prior to Bariatric Surgery

With the considerable waits that patients in Canada often face prior to bariatric surgery, we generally recommend that patients, who have access to them, try anti-obesity medications while waiting. This not only prevents further wait gain, but also often helps them shed a significant amount of weight prior to surgery.

The GLP-1 analogue liraglutide is now approved for long-term obesity treatment and is generally well tolerated. Nevertheless, we now present a series of patients in Obesity Surgery, who were treated with liraglutide 3.0 mg whilst waiting for bariatric surgery, and showed significant upper GI dismotility that was reversible on discontinuation of liraglutide.

Although, investigations of upper GI motility are by no means part of routine assessment for bariatric surgery, tests may be ordered in patients who present with unclear upper GI symptoms, as the findings may guide the choice of surgical intervention.

In this paper, we present six cases in which patients treated with liraglutie 3.0 mg presented with varying degrees of esophageal and/or gastric dysmotility demonstrated using a variety of investigative procedures including formal gastric emptying scintiography as well as less specific  esophageal manometry, and upper endoscopy.

In all cases normal motility was restored on discontinuation of liraglutide and all patients subsequently underwent or are continuing to wait for bariatric surgery.

Based on our observations we discuss that,

“Liraglutide is associated with decreased esophageal peristalsis and gastric emptying. These effects can result in abnormal upper GI investigations, leading to delays, increased testing, and questions of patient candidacy for surgery. If patients on liraglutide are noted to have abnormal esophageal manometry or gastric emptying studies, medication should be discontinued, with repeat studies done to look for reversibility. If this abnormal result is due to drug effect, this should not preclude patients from having bariatric surgery.”

Just how long liraglutide needs to be stopped prior to performing upper GI investigations remains unclear. Furthermore, as the dysmotility often appears to be symptomless and well-tolerated, we do not recommend routine ordering of motility tests in patients treated with liraglutide.

@DrSharms
Edmonton, AB

Disclaimer: I have served as a consultant and speaker for Novo Nordisk, the makers of liraglutide.

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Why Weight-Loss Challenges Send the Wrong Message

I was recently, once again asked about my opinion on weight-loss challenges. So here is a repost of an article I wrote back in 2008 on this topic – apparently, it is still as relevant today, as it was almost a decade ago.

There appears to be a rather widespread notion out there that introducing a bit of competition into the affair may spurn people on to try and lose those “extra” pounds.

In fact, a quick google search on the term “weight-loss challenge” reveals an amazing array of challenges from voyeuristic and sadistic TV shows like the “Biggest Loser” to well-meant workplace wellness initiatives or fund raisers. I am sorry to admit that I recently even became aware of a weight-loss challenge within my own hospital – well intended, but useless in the fight against obesity.

So what’s wrong with this idea? Isn’t competition a great motivator?

Sure it is – and people will do anything to win a competition – including crazy stuff like starve themselves, exercise till they drop, or even (God forbid) pop diet pills, diuretics or laxatives just to win.

All of this is in direct contradiction to a fundamental principle of obesity management: you do not do things to lose weight that you are unlikely to continue doing to keep the weight off.

Most people seem to think that if only they could lose some weight, they will somehow be able maintain that lower body weight in the long-term with less effort.

The reality unfortunately is (and most dieters have experienced this over and over again) that no matter what diet or exercise routine you chose, no matter how slow or fast you lose the weight, no matter how long you keep the weight off – the minute you relax your efforts, the weight simply comes back.

As I have blogged before: obesity is a chronic disease for which we have no cure – only treatments! When you stop the treatment the weight (and any related problem) simply comes back.

By now you will already have figured out the problem with these challenges – unless you are very modest and reasonable about your weight-loss target and are carefully making changes that you can reasonably sustain forever, you are simply setting yourself up for failure.

If you are indeed modest and reasonable – you’ve already lost the competition to all the crazy folks who’ll do anything just to win.

My advise to anyone with a weight problem – the next time you see an invitation to a weight-loss challenge – simply ignore it!

If you really think you will benefit from obesity treatment – seek help from a trained and accredited health professional with experience in weight management – let’s put an end to weight cycling!

@DrSharma
Berlin, Germany

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We Need To Change The Public-Health Narrative On Obesity

While at the level of the individual, clinicians are beginning to acknowledge the vast body of research now showing that “lifestyle” approaches to managing obesity (“eat-less move more”) result in minimal outcomes (3-5% sustainable weight loss at best), public health attempts to address the obesity epidemic continue to perpetuate the myth that obesity (and its prevention) is simply about getting people to eat better and move more (with very little  evidence to show that such measures can be implemented at a population level to effect any noticeable change in obesity rates).

In an article I co-authored with Ximena Ramos-Salas, published in Current Obesity Reports, we provide an in-depth overview of current public health policies to address obesity in Canada and argue that the “narrative” underlying these policies is an important driver of weight-bias and discrimination and significantly hindering efforts to provide Canadians living with obesity better access to obesity prevention and treatment efforts.

As we state in the article (based on original research by Ramos-Salas and others),

“A critical review of Canadian obesity prevention policies and strategies revealed five prevailing narratives about obesity: “(1) childhood obesity threatens the health of future generations and must be prevented; (2) obesity can be prevented through healthy eating and physical activity; (3) obesity is an individual behavior problem; (4) achieving a healthy body weight should be a population health target; and (5) obesity is a risk factor for other chronic diseases not a disease in itself”. These narratives create the opportunity for Canadian obesity policy recommendations to focus mainly on individual-based healthy eating and physical activity interventions. By simplifying the causes of obesity as unhealthy eating and lack of physical activity, these policies may be contributing to the belief that obesity can be solely controlled through individual behaviors. This belief is a fundamental driver of weight bias.”

This “world-view” of obesity at the level of policy makers has a significant impact on the willingness and capacity of health systems to provide access to evidence-based obesity treatments to the nearly 7 million Canadian adults and children living with this chronic disease – in fact, the unwillingness to even consider obesity a chronic disease is a big part of the problem.

“..the conceptualization of obesity as a risk factor in public health policies has implications for government action, by prioritizing prevention over treatment strategies and potentially alienating Canadians who already have obesity. The review concludes that existing Canadian public health policies and strategies (a) are not sufficiently comprehensive (i.e., solely focused on prevention and mainly focused on children; exclude evidence-based management approaches; are not person-centered); (b) are based on reductionist obesity models (i.e., models that cast shame and blame on individuals by focusing on individuals’ responsibility for their weight); and (c) do not account for individual heterogeneity in body size and weight (i.e., generalize weight and health outcomes at the population level).”

In contrast we suggest that,

“Adopting a chronic disease framework for obesity would imply that both prevention and management strategies need to be implemented. Within this chronic disease context, public health should ensure that strategies do not have unintended consequences for individuals and populations, such as perpetuating weight bias. There is now sufficient evidence demonstrating that weight bias and obesity stigma are fundamental drivers of health inequalities. Public health has an opportunity to leverage existing health promotion frameworks such as the health for all policy framework and the global plan of action on social determinants of health to address weight bias and obesity stigma”.

Based on the analyses presented in this paper, we make the following recommendations:

  • Canadian provincial and territorial governments, employers, and the health insurance industry should officially adopt the position of the Canadian Medical Association and the World Health Organization that obesity is a chronic disease and orient their approach/resources accordingly.

  • Canadian provincial and territorial governments should recognize that weight bias and obesity stigma are significant barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems, and education policies.

  • In an era of people-centered health care, public health and health system decision makers should engage people with obesity in the development of policies and strategies. Having active participation of individuals with obesity can help change negative attitudes and beliefs about obesity and facilitate the development of compassionate and equitable health promotion strategies.

  • Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity treatments for their employees through health benefit plans.

  • Provincial and territorial governments should increase training for health professionals on obesity prevention and management.

  • Existing Canadian Clinical Practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of evidence-based programs and strategies by health systems, employers and health insurance companies.

@DrSharma
Athens, Greece

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