Today’s guest post comes from Kristy Wittmeier, PhD (and CON Bootcamper), a physiotherapist at the Winnipeg Health Sciences Centre and Director of Knowledge Translation at the Manitoba Centre for Healthcare Innovation. She has a special interest in physical activity as a tool to prevent and manage obesity-related conditions in youth. Her current positions and affiliation with the Children’s Hospital Research Institute of Manitoba allow her to combine research and practice to improve patient outcomes. Twitter: @KristyWittmeier
If you were trying to build a coordinated provincial strategy to promote healthy weight in children and youth, where would you start? This has been a question on the minds of a team of healthcare providers and researchers in Manitoba for some time now.
Manitoba has the highest rate of type 2 diabetes in children in Canada, a condition that is in part related to obesity. In Manitoba, youth are diagnosed with type 2 diabetes at a rate 20 times higher than in any other province.
There are well-established, multidisciplinary clinical programs in our province that work with youth living with type 2 diabetes. For example, the Diabetes Education Resource for Children and Adolescents, which has existed since 1985, runs two weekly clinics and an outreach program for youth affected by type 2 diabetes.
Recently, the diabetes care team joined forces with pediatric kidney specialists in the province to provide a combined clinic for youth affected by both type 2 diabetes and kidney complications.
Manitoba is also home to the Maestro Project, which helps teens living with type 2 diabetes navigate what could otherwise be a difficult transition from pediatric to adult health care services and teams.
Similarly, research teams that include community advisors and families are tackling important questions related to the origins of type 2 diabetes and exploring innovative interventions to improve the health and quality of life for kids with this diagnosis.
Members of the DREAM (Diabetes Research Envisioned and Accomplished in Manitoba) Theme at the Children’s Hospital Research Institute of Manitoba are studying important biological, social and psychological factors linked with early kidney disease in youth with type 2 diabetes in a study called iCARE (Improving renal Complications in Adolescents with type 2 diabetes through REsearch).
While we have made significant progress in the area of type 2 diabetes care and research, we have made less progress in the areas of prevention and treatment of obesity in children and youth. We are one of the few provinces in Canada without a specialized clinical team dedicated to pediatric obesity. We lack a comprehensive provincial strategy that can link health care providers to each other, or to existing community programs that might help families. Gaps in services can leave families without access to care that could help their children. This is the issue that we have decided to tackle in a study that was recently funded by the Children’s Hospital Research Institute of Manitoba.
Our study is called “Mapping the state of pediatric weight management programs in Manitoba.” We will start with a survey within Manitoba, to identify existing programs that are available to families affected by obesity in our province. We want to know what is currently available. Where can health care providers refer families? And importantly, what resources are missing in our province to be able to provide an evidence-based approach to pediatric weight management?
While the title suggests we are solely focused on Manitoba, we are in fact looking to shape our provinces’ approach by learning from others across Canada and the United States.
To do this, the second part of the study will involve updating a 2010 study that mapped Canadian pediatric weight management programs to understand what has changed on the national landscape. What new programs exist and where? What programs are no longer offered and why?
Then we will move on to more in-depth conversations with members of the eight clinics involved in the Canadian Pediatric Weight Management Registry (CANPWR), and an additional eight clinics in the United States to better understand how their approaches evolved, barriers and successes that they have experienced and other key learnings that they can share to help inform a Manitoba approach.
Once we have brought the information from these activities together, we will hold a meeting for families, community members, clinicians, researchers, healthy living organizations and policy makers in the province. We will look at the data together and prioritize the next important steps on this journey.
We all need to work together to build healthier families, healthier communities and healthier populations. This novel approach that integrates the experiences and priorities of others will ensure that when we launch a new direction for pediatric obesity management in Manitoba, it will be relevant and targeted to everyone’s needs.
Last week I posted on the importance of non-acoholic fatty liver disease as one of the most common yet insidious consequences of obesity.
Now, a paper by Bower and colleagues from Imperial College London, published in Obesity Surgery, provides a systematic review of the impact of bariatric surgery on liver biochemistry and histology.
The review clearly shows that bariatric surgery is associated with a significant reduction in the steatosis, fibrosis, hepatocyte ballooning and lobular inflammation. Surgery is also associated with a reduction in liver enzyme levels, with statistically significant reductions in ALT, AST, ALP and gamma-GT.
However, there is considerable variability in these outcomes and between different types of interventions – clearly suggesting that more research on this issue is needed.
Nevertheless, at this time it appears that bariatric surgery may well be the most effective treatment for fatty liver disease.
As regular readers are well aware, obesity is a chronic disease which simply means that any treatment you decide to pursue needs to be one you can stick with in the long-term (this applies as much to your diet as it does to taking an anti-obesity drug or, for that matter having surgery – when the treatment stops the weight comes back!).
That said, it would be easy to assume that if you chose (or otherwise have a say) in the kind of diet you think will help you manage your weight, you’d a) lose more weight and b) be more likely to keep it off.
As a randomised controlled study by Annals of Internal Medicine, neither of these assumptions may be true.Duke University Medical Center, Durham, North Carolina, published in the
The researchers randomised 207 participants to two groups – a choice group in which participants had the choice of going either on a low-carbohydrate (less than 20 g/day) or low-fat diet (less than 30% energy from fat).
The non-choice group was not given this choice but were randomly assigned to either of these diets. Both groups were provided with group and telephone counseling for 48 weeks.
Of the 105 choice participants, 58% chose low-carb and 44% chose low-fat – 83% completed the study – and lost on average 5.7Kg.
Of the 102 non-choice participants, 52 % were assigned to low-carb and 48% to low-fat – 86% completed the study – and lost on average 6.7 Kg.
Of note, the actual reported intake of carb in the low-carb groups ranged between 45-80 g of carbs per day (down from about 200 g/day) while fat intake in this group increased from about 40 to 55% of total energy); In the low-fat group, actual fat intake, fell from about 40% at baseline to about 35% on the diet.
There were no difference in dietary adherence, physical activity or quality of life.
This study illustrates that whether or not you get to chose your preferred diet or not doesn’t matter – what does is that you stick with it.
Or as the authors put it,
“The double-randomized preference design of our study allowed us to determine that preference did not meaningfully affect weight loss. Moreover, the range of estimated weight differences between groups in the 95% CIs does not contain a clinically meaningful difference in favor of the choice group.”
Both findings may not be exactly what one may have predicted – which is exactly why we need these types of studies.
Of all of the common complications of obesity, fatty liver disease is perhaps the most insidious. Often starting without clinical symptoms and little more than a mild increase in liver enzymes, it can progress to inflammation, fibrosis, cirrhosis and ultimate liver failure. It can also markedly increase the risk for hepatocellular cancer even in patients who do not progress to cirrhosis.
Now, a paper by Mary Rinella from Northwestern University, Chicago, published in JAMA provides a comprehensive overview of what we know and do not know about early detection and management of this condition.
The findings are based on a review of 16 randomized clinical trials, 44 cohort or case-control studies, 6 population-based studies, and 7 meta-analyses.
Overall between 75 million and 100 million individuals in the US are estimated to have nonalcoholic fatty liver disease with 66% of individuals older than 50 years with diabetes or obesity having nonalcoholic steatohepatitis with advanced fibrosis.
Although the diagnosis and staging of fatty liver disease requires a liver biopsy, biomarkers (e.g. cytokeratin 18) may eventually help in the detection of advanced fibrosis.
In addition, non-invasive imaging techniques including vibration-controlled transient elastography, ultrasound with acoustic radiation force impulse or even magnetic resonance elastography are fairly accurate in the detection of hepatic fibrosis and are the most reliable modalities for the diagnosis of advanced fibrosis (cirrhosis or precirrhosis).
Currently, weight loss is the only proven treatment for fatty liver disease. Pharmacotherapy including treatment with vitamin E, pioglitazone, and obeticholic acid may also provide some benefit (none of these treatments currently are approved for this indication by the UD FDA). Futhermore, the potential benefits of existing and emerging anti-obesity treatments on the incidence and progression of fatty liver remains to be established.
As Rinella points out,
“It is important that primary care physicians, endocrinologists, and other specialists be aware of the scope and long-term effects of the disease.”
Clearly, screening for fatty liver disease needs to be part of every routine work up of individuals presenting with excess weight.
This is why the recent paper by Nia Mitchell and colleagues from the University of Colorado, published in the American Journal of Preventive Medicine is of considerable interest.
The study looks at long-term weight loss of participants who joined Take Off Pounds Sensibly (TOPS), a US nonprofit, low-cost, peer-led weight-loss program between 2005-2011 (207,469 individuals) and consecutively renewed their annual membership at least once 74,629 (35.9%).
Mean weight loss for those who renewed their membership at least once was 6% and 8% for the 2,289 participants with 7 years of consecutive annual renewal.
Three points are probably worth emphasizing: for one, as with most weight loss programs, only a small proportion of individuals stick with it even for just a year (in this case about 35% which is still probably better than for most programs that I am aware of). Long-term members (in this case about 10%, who manage to stick with the program for at least 7 years) are even a greater minority.
Secondly, those who stick with the program in the long-term are able to sustain their benefit – of course it is hard to prove that this long-term benefit is actually causally related to the program – after all, the kind of people who make long-term commitments to a weight management program may well differ from the general public in other ways that may be important for their success.
Thirdly, the study illustrates that the average weight loss even for those who stick with the program over 7 years manage to keep off only about half of what is generally seen in long-term studies with bariatric surgery (about 20% weight loss over 15-20 years).
None of this takes away from the success of the TOPS approach to long-term weight management – it does however illustrate that even one of the best and longest running “lifestyle” management approaches to weight management, faces the usual challenges of attrition and plateauing weight loss at a level that may be less than what many living with severe obesity would consider a satisfactory outcome.
Kudos to TOPS for allowing this public analysis of their data – few other weight loss programs would dare to do the same.