Wednesday, June 18, 2014

4th Canadian Obesity student Meeting (COSM 2014)

Uwaterloo_sealOver the next three days, I will be in Waterloo, Ontario, attending the 4th biennial Canadian Obesity Student Meeting (COSM 2014), a rather unique capacity building event organised by the Canadian Obesity Network’s Students and New Professionals (CON-SNP).

CON-SNP consist of an extensive network within CON, comprising of over 1000 trainees organised in about 30 chapters at universities and colleges across Canada.

Students and trainees in this network come from a wide range of backgrounds and span faculties and research interests as diverse as molecular genetics and public health, kinesiology and bariatric surgery, education and marketing, or energy metabolism and ingestive behaviour.

Over the past eight years, since the 1st COSM was hosted by laval university in Quebec, these meetings have been attended by over 600 students, most presenting their original research work, often for the first time to an audience of peers.

Indeed, it is the peer-led nature of this meeting that makes it so unique. COSM is entirely organised by CON-SNP – the students select the site, book the venues, review the abstracts, design the program, chair the sessions, and lead the discussions.

Although a few senior faculty are invited, they are largely observers, at best participating in discussions and giving the odd plenary lecture. But 85% of the program is delivered by the trainees themselves.

Apart from the sheer pleasure of sharing in the excitement of the participants, it has been particularly rewarding to follow the careers of many of the trainees who attended the first COSMs – many now themselves hold faculty positions and have trainees of their own.

As my readers are well aware, I regularly attend professional meetings around the world – none match the excitement and intensity of COSM.

I look forward to another succesful meeting as we continue to build the next generation of Canadian obesity researchers, health professionals and policy makers.

You can follow live tweets from this meeting at #COSM2014

@DrSharma
Waterloo, Ontario

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Thursday, May 1, 2014

Can Private Solutions Tackle Obesity?

weight scale helpIn my final instalment of commentaries on the right-wing Fraser Institute’s report claiming that obesity is overstated and that Governments may best stay out of trying to tackle this problem (except perhaps to provide treatments to those with more severe obesity), here are the arguments that the report puts forward favouring private solutions.

“First, there is a market test for private solutions where products and services that fail to meet their promises or customer expectations will cease to be provided. This is quite different from government interventions that do not need to meet such a test and thus may continue even if they have failed to produce the desired results in practice. Government interventions may in fact become more stringent and interventionist over time in response to their failings.”

“Second, private companies will continue to innovate and experiment in an effort to best meet the needs and desires of consumers in a cost-effective way. This is very much unlike government interventions, which are often precsriptive and constrain innovation. The result is that private organizations are more likely to find effective and less costly solutions for individuals, and are better able to adjust to changing information and knowledge, and changing consumer preferences over time.”

“Third, private initiatives do not impose a cost on the non-obese generally. This is very much unlike government initiatives that impact both the obese and the non-obese, for example through reduced options/choices, increased travel time, increased costs from taxation, increased costs of goods and services as a result of regulation, or taxpayer-funding of programs.”

While each of the above may carry some merit or are at least worth discussing, the final paragraph in this section reeks of considerable and unacceptable weight bias:

“Finally, and perhaps most critically, it is likely that most obese individuals realize they are heavy and that they may be making diet and lifestyle choices that keep them obese. They also have strong reasons to drop their excess weight including social stigma, reduced incomes, and the health risks associated with the excess weight. As Marlow and Abdukadirov note, “[the obese] hardly need the government to give them additional incentives to lose weight. People aware of their mistakes also have strong incentives to correct them.”

This rather abhorrently worded paragraph reflect all that is wrong with most public discussions on obesity – irrespective of political ideology – namely the notion that obesity is largely a matter of choice and that excess weight is something people can simply chose to drop if only they so chose by giving up their “mistakes”.

It is in this single paragraph that essentially makes the entire report largely irrelevant, as it is evident that the authors themselves struggle with fully understanding  the actual nature of the problem they are trying to address.

Indeed, the whole tenor of individual “responsibility” interwoven with the language of “shame and blame” shows virtually no understanding of the real causes of the obesity epidemic or of the complex biology that people challenged by this problem face in trying to control their weight.

So, while we may quibble about whether or not the government is the best institution to tackle obesity or not, no meaningful discussion of solutions to the problem are possible unless we go beyond blaming the individuals struggling with this condition.

And certainly, while private enterprise may in some cases provide solutions, given the number of money printing weight-loss scams out there, much of this can certainly be construed as simple exploitation of a vulnerable and desperate population.

If this is what private enterprise is about – count me out.

@DrSharma
Edmonton, AB

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Friday, January 17, 2014

Bariatric Care: What Surgery Delivers

sharma-obesity-bariatric-surgery21Continuing in my discussion of the weight and health outcomes of the APPLES study, reported by Padwal and colleagues in Medical Care, we now turn our attention to the 150 participants who underwent bariatric surgery in a publicly funded bariatric program.

As noted in yesterday’s post, all surgical patients underwent intensive medical assessment and behavioural interventions prior to undergoing surgery. Thus, the outcomes reported in this group of participants is on top of any weight loss or benefits that patients may have experienced as a result of this intervention prior to surgery. It is thus, not surprising that at the time of enrolment to the APPLES study, surgical participants were approximately 4 Kg lighter than the “medical” participants (this being the average weight loss seen in the “medically” managed group).

Of the 150 surgical participants, 129 (86%) completed their 24 month visit. Data for the “drop-outs” was analysed as “last-observation-carried-forward”.

Overall weight loss at 24 months for the surgical group was 22 Kg (16.3%) with 75% achieving more than 5% weight loss, and 63% achieving more than 10% weight loss.

There were distinct differences in weight-loss outcomes between the different surgical procedures (all of which were performed in approximately equal proportions).

While the average weight-loss at 24 months for patients undergoing adjustable gastric banding was a paltry 7 Kg (5.8%), sleeve gastrectomy patients lost 21 Kg (16%), whereas bypass patients lost 37 Kg (26%) of their initial body weight.

All of these weight-losses were associated with marked improvements in cardiovascular risk factors.

There are several important learnings from this data.

1) Surgical treatments were markedly more effective than behavioural intervention (no surprise here).

2) There are significant differences in the amount of weight lost with the different surgical procedures, with bypass patients losing almost five times more weight that those undergoing gastric banding (rather unexpected).

3) Even with the greater weight loss achieved through surgical treatment, the average weight loss is still well under 30% of initial weight – again speaking to the refractoriness of severe obesity even with surgery.

Thus, despite its greater efficacy, even bariatric surgery will still leave many patients obese (based on BMI).

For clinicians (and patients) this means that many patients undergoing bariatric surgery, despite significant weight loss and considerable improvements in health and quality of life, may still be disappointed to not achieve their “ideal” or “dream” weight.

In the next post, I will summarize the overall learnings from this study and what they mean for the current status of bariatric care.

@DrSharma
Banff, AB

ResearchBlogging.orgPadwal RS, Rueda-Clausen CF, Sharma AM, Agborsangaya CB, Klarenbach S, Birch DW, Karmali S, McCargar L, & Majumdar SR (2013). Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program: Prospective Cohort Study. Medical care PMID: 24374423

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Thursday, January 9, 2014

Results Not Typical: FTC Clamps Down on Fraudulent Weight-Loss Claims

sharma-obesity-weight-loss-supplementsOnce of the big news items this week was the announcement of a $34 million settlement with four marketers of weight-loss products that made misleading claims (L’Occitane, which claimed that its skin cream would slim users’ bodies but had no science to back up that claim, and HCG Diet Direct, which marketed an unproven human hormone that has been touted by hucksters for more than half a century as a weight-loss treatment, LeanSpa, LLC, an operation that allegedly deceptively promoted acai berry and “colon cleanse” weight-loss supplements through fake news websites).

According to the US Federal Trade Commission, this is part of its “Operation Failed Resolution” to stop misleading claims for products promoting easy weight loss and slimmer bodies. The FTC will make these funds available for refunds to consumers who bought these allegedly fraudulent products (although it appears that some of these companies may not have enough funds to pay up).

The agency also announced that additional charges have been made against the marketers of two other products.

The FTC is also calling upon broadcasters and other media outlets to stop promoting weight-loss products that promise results that defy science (and common sense) and has release a new guidance document to help spot such fraudulent weight-loss claims.

In a letter to be sent to US publishers and broadcasters, the FTC states that,

“Every time a con artist is able to place an ad for a bogus weight loss product on a television or radio station, in a newspaper or magazine, or on a legitimate website, it undermines the credibility of advertising and does incalculable damage to the reputation for accuracy that broadcasters and publishers work hard to earn.”

Here is the “business” rationale that the FTC has to offer to publishers and broadcasters for refusing to running such ads:

  • No legitimate media outlet wants to be associated with fraud. Accuracy is your company’s stock in trade. Why sully your good name by being known as a publication or station that promotes rip-offs?
  • If scammers are willing to cheat consumers, there’s a good chance they’ll cheat you by not paying their bills. By the time fly-by-nighters have made a quick killing, they’ve disappeared – and left you holding a stack of worthless receivables.
  • You want to protect loyal readers, listeners, and viewers from bogus products that can’t possibly work as advertised.
  • Reputable advertisers don’t want to associate their brands with media outlets used by con artists.

The FTC advises publishers to run a “Gut Check” and to think twice before running any ad that says a product:

  • Causes weight loss of two pounds or more a week for a month or more without dieting or exercise;
  • Causes substantial weight loss no matter what or how much the consumer eats;
  • Causes permanent weight loss even after the consumer stops using product;
  • Blocks the absorption of fat or calories to enable consumers to lose substantial weight;
  • Safely enables consumers to lose more than three pounds per week for more than four weeks;
  • Causes substantial weight loss for all users; 
  • Causes substantial weight loss by wearing a product on the body or rubbing it into the skin.

Furthermore, all weight-loss ads should include “clear and conspicious” disclosure of how much weight consumers typically can expect to lose. (emphasis mine)

Whether or not publishers and broadcasters will actually heed such advice remains to be seen. My guess is that running such ads may be far too lucrative a business for these agencies to simply give up.

To educate broadcasters and the public, the FTC has released an online “Gut Check” test, where you can check your own ability to spot false weight loss claims – to take the test click here

While the FTC is to be commended for taking these steps, we have yet to see similar punitive action against irrational and unscientific weight-loss claims here in Canada – I wonder why.

If you would like to see more regulation or have had your own experience with such products, I’d love to hear from you.

@DrSharma
Edmonton, AB

Hat tip to the many readers who sent in links to news articles about this announcement.

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Monday, October 7, 2013

Weight Loss is Not a Behaviour!

Football-penalty-kickLast week, I gave the plenary key note talk at the 2013 Obesity Help Conference in Anaheim. I also held a standing-room-only workshop in which I discussed behaviour change.

One of the points I made at the workshop, was to remind the audience that weight loss is not a behaviour.

Let me explain: when I tell patients to stop smoking – they know exactly what to do, namely to stop putting a cigarette in their mouth and inhaling its smoke. That’s a behaviour they can change. When they stop smoking they have “successfully” changed a behaviour – that’s behaviour change – end of story.

But, when I tell a patient to go and lose weight, I haven’t actually told them what BEHAVIOUR to change.

Rather – to use the smoking analogy – it is as though I had simply told my smoking patients to go out and reduce their cardiovascular risk, leaving it up to them to figure out how exactly to go about doing that.

Some of my patients may perhaps realize that quitting smoking is by far the most effective way to lower their risk – others may not and merely try to reduce their salt intake or start exercising – neither of which is likely to reduce their cardiovascular risk to the extent that smoking cessation would.

This is exactly why I would be very specific as to exactly what behaviour I want my smoker to change – namely to STOP smoking.

If I wanted them to eat less salt or start exercising – then that is exactly what I would tell them to do.

Those are BEHAVIOURS that they can change.

Contrast this to a doctor telling his patient to lose 20 pounds.

This may seem like a specific and achievable goal – but it is not a BEHAVIOURAL goal because the doctor has not “prescribed” a BEHAVIOUR – he have simply “prescribed” an outcome.

To use a sports analogy – kicking the ball at the goal is a BEHAVIOUR – scoring a goal is not!

In fact, with no further instructions, the doctor is leaving it up to his patient to figure out exactly what BEHAVIOUR they would perhaps need to change. Start eating breakfast? Eat more fruits and vegetables? Keep a food journal? Join an exercise program? Take a stress management course?

Of course, his patientss could “successfully” change their BEHAVIOUR and do all of the above only to find that not much happens to their weight.

Would they have “failed” at behaviour change? Of course not! After all they have “succeeded” in changing their behaviour.

But have they also “succeeded” in weight loss? Maybe – maybe not.

To be clear:

“I want to cut my daily caloric intake by 500 calories”, is a behavioural goal; “I want to lose one pound a week”, is not!

(indeed, you may well find yourself “successfully” cutting your daily intake by 500 calories without coming anywhere close to losing one pound a week – let alone 20 pounds any time soon).

Thus, we must remember that BEHAVIOURAL interventions can only aim to change behaviours (this is where SMART goals come in – more on this here).

The only real measure of “success” of a BEHAVIOURAL intervention is whether or not your patients have “successfully” changed their BEHAVIOUR.

There are many BEHAVIOURS that will make them healthier – but there is simply no BEHAVIOUR that GUARANTEES sustainable weight loss.

This is why weight loss is not a BEHAVIOURAL goal.

@DrSharma
Edmonton, AB

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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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