Friday, June 20, 2014

Your Body Thinks Obesity Is A Disease

sharma-obesity-adipose-tissue-macrophageYesterday, the 4th National Obesity Student Summit (#COSM2014) featured a debate on the issue of whether or not obesity should be considered a disease.

Personally, I am not a friend of such “debates”, as the proponents are forced to take rather one-sided positions that may not reflect their own more balanced and nuanced opinions.

Nevertheless, the four participants in this “structured” debate, Drs. Sharon Kirkpatrick and Samantha Meyer on the “con” team and Drs. John Mielke and Russell Tupling on the “pro” team (all from the University of Waterloo) valiantly defended their assigned positions.

While the arguments on the “con” side suggested that “medicalising” obesity would detract attention from a greater focus prevention while cementing the status quo and feeding into the arms of the medical-industrial complex, the “pro” side argued for better access to treatments (which should not hinder efforts at prevention).

But a most interesting view on this was presented by Tupling, who suggested that we only have to look as far as the body’s own response to excess body fat (specifically visceral fat) to determine whether or not obesity is a disease.

As he pointed out, the body’s own immunological pro-inflammatory response to excess body fat, a generic biological response that the body uses to deal with other “diseases” (whether acute or chronic) should establish that the body clearly views this condition as a disease.

Of course, as readers are well aware, this may not always be the case – in fact, the state of “healthy obesity” is characterized by this lack of immunological response both locally within the fat tissue as well as systemically.

Obviously, it will be of interest to figure out why some bodies respond to obesity as a disease and others don’t – but from this perspective, the vast majority of people with excess weight are in a “diseased” state – at least if you asked their bodies.

While this is a very biological argument for the case – it is indeed a very insightful one: it is not the existence of excess body fat that defines the “disease” rather, how the body responds to this “excess” is what makes you sick.

As readers, are well aware, there are several other arguments (including ethical and utilitarian considerations) that favour the growing consensus on viewing obesity as a disease.

Of course,  calling obesity a disease should not detract us from prevention efforts, but, as I often point out, just because be treat diabetes or cancer as diseases, does not mean that we do not make efforts to prevent them.

If calling obesity a disease increases resources towards better dealing with this problem and helps take away some of the shame and blame – so be it.

@DrSharma
Waterloo, Ontario

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Tuesday, May 20, 2014

Mountain Living Reduces Obesity?

mountain pineLiving not too far from the Canadian Rockies, you cannot help but notice how vegetation gets short and stunted at higher elevations.

The same is apparently true for humans – while moving to higher altitudes may not make your shorter, it certainly appears to reduce your body fat and perhaps risk of obesity.

Indeed, there is ample evidence from both animal and human studies demonstrating that hypobaric hypoxia (lower oxygen levels combined with lower athmospheric pressure) may have a profound affect on body composition.

Now, a large epidemiological study by Jameson Voss and colleagues, published in PLOS|One provides strong evidence to support this hypothesis.

The researchers looked at all outpatient medical encounters for overweight active component enlisted service members in the U.S. Army or Air Force from January 2006 to December 2012 stationed in the United States and compared obesity related ICD-9 codes between those stationed at high altitudes (>1.96 kilometers above sea level) with those at low altitudes (<0.98 kilometers).

It turns out that service members stationed at higher altitudes were about 40% less likely to become obese than those stationed at lower altitudes.

Although one must always be careful to infer causality from epidemiological evidence, these findings are certainly in line with the experimental evidence on hypobaric hypoxia.

In light of these findings, I can already see the next opportunity for commercial weight loss – hypobaric hypoxic chambers at your local tan studio.

@DrSharma
Edmonton, AB

ResearchBlogging.orgVoss JD, Allison DB, Webber BJ, Otto JL, & Clark LL (2014). Lower Obesity Rate during Residence at High Altitude among a Military Population with Frequent Migration: A Quasi Experimental Model for Investigating Spatial Causation. PloS one, 9 (4) PMID: 24740173

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Wednesday, April 30, 2014

Should Governments Concern Themselves With Obesity?

sharma-obesity-policy1Yesterday, I blogged about the right-wing Fraser Institute’s report, which claims that the obesity problem is overstated and that government policies are misguided.

An interesting discussion in the report pertains to the fundamental issue of whether governments should at all concern themselves with obesity (even if the problem were really as big as is generally assumed).

The report looks at this from the perspective of whether or not obesity places an economic burden on society and whether or not it would be in the Government’s interest to intervene with the aim to reduce this burden.

Here is how the report views this:

“What is interesting here—and what is important in public policy terms—is the burden of the costs of obesity. A closer examination of the consequences of excess weight…finds that the majority of the costs of obesity are borne directly by the individual in terms of lower income, reduced employment opportunities, reduced enjoyment of life, greater illness, and a potentially shorter lifespan. The only area where these costs are not borne almost entirely and directly by the individual is the increased burden on Canada’s tax-financed health care system….From an externality perspective then (though this is not the only justification used for government intervention, as we shall discuss in the next section) the only area of the “obesity epidemic” where governments may have a legitimate role to intervene is to resolve the costs imposed by the obese [sic] on all taxpayers through the tax-funded health care system.”

However, as the report goes on to argue, the lifetime health care costs for obese individuals may not be all that much higher – in part, because of a shorter life-span.

Here the report quotes studies showing that,

“…while obese individuals incurred higher health care costs than normal-weight non-smokers during their lifetimes, over an entire lifetime normal-weight non-smokers incurred greater health care costs in total because of differences in life expectancy and the costs of care associated with additional years of life….These findings suggest that obese individuals may in fact not be a net burden to all taxpayers over their entire lifetimes, despite imposing a cost burden while they are alive. That finding is bolstered by considerations of reductions in costs associated with public pensions and other old age income supports .”

Thus, economic arguments that governments need to intervene to reduce the burden of obesity may not hold water – while being obese is sad for the folks affected (and they already pay for it dearly), there may not be all that much incentive for governments to  reduce the burden of obesity with an aim to “protecting” the economic interests of the non-obese majority.

Or, as the report puts it,

“…while there is clearly a health and economic cost associated with a high prevalence of obesity, the problem may be much smaller than many have claimed. Importantly, it may be that the serious health consequences lie at the higher end of the weight spectrum, thus affecting a relatively small proportion of the population. And many of the economic costs associated with obesity are borne privately by the individual and thus may not justify government intervention. That is the framework within which policy options should be proposed, and within which they should be considered.”

Thus, given the rather modest economic burden on tax-payers in general (most of who are not obese), it becomes even more important to look at the economic downsides of the government stepping in to impose policies that (even if effective) may not be worth the considerable impacts on taxpayers, on the economy, and on particular industries.

“Many of these interventions would require increased bureaucracy, for example an agency to determine which foods or beverages qualify for targeting or for particular food categories. Interventions may also create barriers to entry for smaller businesses or artificial constraints on growth, generate higher business costs or increase costs for consumers, increase travel times for consumers, impact business prospects, and potentially lead to job losses. Interventions may also result in a transfer of funds from one group of legal businesses to another simply because one provides a product that is disliked by interventionists.”

But irrespective of which side of the political fence you may sit on, it should be obvious that decisions about government spending have to consider more than just economic benefits.

Thus, even if there was a net cost to spending tax-money on preventing and better treating obesity, would this still not be a worthwhile investment?

Indeed, little (if anything) we do in healthcare saves money – or, as I sometimes point out, the cheapest patient is a dead patient. To me at least, healthcare is never about saving cost – it is about easing pain and suffering. Treating cancer and heart attacks does not save money – yet, they are fully worthwhile expenses.

So for obesity treatments the issue of whether or not government should get involved is rather straightforward. If we accept that obesity (at least in extreme cases) is a disease that causes pain and suffering then it is the job of healthcare systems (and in Canada this job falls to the government) to provide treatments that can ease that pain and suffering – anything else would be discrimination. As long as the treatment benefits the individual and is reasonably cost-effective (as compared to treatments for other conditions) there is no ethical argument to deny that treatment.

When it comes to prevention, the issues are less clear (as discussed in the report). Here the responsibility of governments must balance the needs of all of its citizens by broadening its view of the impact that policies would have on the entire population. Thus, the question is not just what impact certain policies would have on those who have obesity (or are at risk of getting it) but also how such policies would impact the majority of the population that neither has obesity nor is at risk of getting it.

This is where the Fraser Institute report stays true to its ideology in that any policies that limit choice or put boundaries on free enterprise are something that governments should stay out of. Rather, it may be best to leave this to the free market to sort out:

“The private sector might also be a source of solutions to concerns about the prevalence of obesity, and already provides a broad range of options for those who wish to alter their lifestyles and diets in search of a reduction in excess weight. For example, the diet and exercise industries are working to counter the prevalence of excess weight through books, videos, weight loss clinics, gyms, and exercise equipment, among other approaches. Restaurants and food producers are also involved in helping people reduce excess weight by offering lower calorie, lower fat, or other more healthful options. Many businesses also support weight loss through employer funded programs. We may also soon see medicinal solutions for excess weight and weight management.” 

The third section of the report goes on to discuss several proposed public-health policies including taxes, restricting access to certain foods and drinks, calorie and nutrient labelling, graphic health warnings, healthier school meals, advertising restrictions, and zoning  laws.

As may be expected, the report highlights the lack of effectiveness and/or the unintended consequences of these proposed policies. For anyone working in the area of public health and health promotion, these sections will make a challenging and perhaps infuriating read.

But then again, that’s exactly what political debates are about – the clash of ideologies where each side cherry picks whatever “facts” support their position.

At least we now better understand where the right stands on this issue – a first step to begin countering their arguments.

@DrSharma
Edmonton, AB

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Friday, April 25, 2014

Obesity Left, Right, and Centre

sharma-obesity-right-way-wrong-wayMuch of the obesity debate – its causes and solutions – is heavily tainted by conflicts of interest – the most important one perhaps lurking among those, who put their beliefs and ideologies before scientific fact.

An essay by Kathleen Kendall-Tackett, published in (of all places) Clinical Lactation, nicely summarizes how conventional political ideologies and belief systems colour this discourse.

Apart from commenting on the often “moralistic” nature of the obesity debate (thin = good, fat = bad), Kendall-Tackett also reflects on the racist, gender and class overtones of this discussion.

With regard to political ideologies, she notes that,

“For some on the right, the obesity epidemic merely reinforces their beliefs about the cause of the ever-widening gap between the rich and poor or between whites and minorities. After all if African Americans, Latinos, or the poor are becoming fatter than America’s predominantly white elite, it is only more proof that they lack responsibility to take care of themselves…if middle-class Americans, particularly middle-class children, are getting fat, it surely indicates the frailty of their own class status.”

“And for those on the left, the growth of obesity is further proof that large, multinational corporations are running amok, fattening a hapless public with their billion-dollar advertising campaigns and super-size value meals. The American people, particularly the poor and minorities who have the highest obesity rates, they argue, need to be protected from these corporate behemoths.”

Both positions reek of,

“…paternalistic condescension towards fatness and fat people—not only do people with this view assume that fatness is inherently bad, but they also presuppose that fat people (that is, minorities and the poor) are too ignorant to know that they should be thin.”

Or, in words of Paul Campos,

“And what is it with these skinny uptight Anglos, anyway? Who exactly deputized them to be the fat police at their local fast-food emporium?”

Indeed, it is easy to see these ideologies reflected in the political discourse around obesity.

In  prevention,  policies run the gamut from de-regulation (“consumer choice” and “free market forces”) on the right to “shame, blame, tax and ban” policies on the left.

Never mind that neither one of these approaches is supported by hard evidence – indeed, most of the evidence is so poor that it may as well be ignored when it comes to deciding who is right and who is wrong.

While the anti-sugar witch hunt is nearing its climax (the same folks were shouting for anti-fat bans just a few decades ago), those who ignore the mass of data showing the rather modest (if any) effectiveness of “lifestyle change” as a means to tackle excess body weight, continue to propagate “eat-less-move-more” solutions to this epidemic.

Caught in the centre (with nowhere to go) are those who actually bear the weight of the problem (pun intended).

While those calling for better access to and greater investments into pharmacological and surgical obesity treatments are called out by the left for “medicalizing” the issue, those on the right cry out against “coddling” people living with obesity – after all, they are only getting what they deserve given the “poor choices” they have made (you made your bed – now sleep in it!).

Again, both sides of the argument are heavily influenced by the firm belief that everyone can (and should) be a master of their own weight (after all, its just calories and calories out, right?).

No wonder I am wary of ideologies and beliefs as a source of conflict of interest – particularly as these are seldom declared or disclosed.

@DrSharma,
Edmonton

Hat tip to Noreen Willows for pointing me to this article.

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Thursday, January 16, 2014

Bariatric Care: What Can Behavioural Intervention Deliver?

sharma-obesity-exercise2Continuing 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 200 participants enrolled in the “medical” program.

This group of patients includes those patients, who at the time of entering the program were either not considering or interested in surgery. But it also includes 99 participants (50%), who changed their minds and opted for surgery after entering the program and ultimately went on to receive surgery within the 24-month follow up in APPLES. The data for these individuals was censored at the time they received surgery and was analysed as “last-observation-carried-forward”.

The Edmonton Bariatric program does not have separate entry streams for patient wanting surgery and those who don’t. Thus, all patients who enter the program, receive the same level of medical care that includes individualized intensive medical management consisting of lifestyle counseling (diet, exercise, behavioral modification), with visits every 4–8 weeks by a multidisciplinary staff (internists, endocrinologists, family physicians, psychiatrists, dietitians, nurses, physiotherapists, occupational therapists, and psychologists).

Behavioral modification focuses on teaching skills to help identify and modify eating and activity behaviors. Self-monitoring of weight, food intake and activity, stimulus control, and problem solving to help overcome barriers to weight loss are all key elements of behavioral modification.

Nurses and dieticians are the main care providers delivering intensive lifestyle counseling (diet and behavioral modification) and physiotherapists and occupational therapists provide activity counseling.

Visits with other providers are scheduled to address specific issues (ie, the internist, endocrinologist or family physician would address control of medical comorbidities, the psychologist addresses binge eating disorder, the psychiatrist assesses all patients felt to have unstable psychiatric disease).

Individualized one-on-one assessments are the norm; one exception is binge eating counseling, which is done in a group format.

Medical management is individually tailored to address root causes of excess weight and barriers to achieving weight management success. Antiobesity drug therapy (not available in Canada) and structured, very low-calorie protein-sparing diets were seldom used (< 4% of medically treated subjects received these) during the study.

Although not directly related to weight management, assessment of obesity-related comorbidities, including sleep disorders and mental health screening, is routinely performed.

Despite this rather intense and state-of-the-art “conservative” management – average weight loss over 24 months was rather modest.

While average weight loss was about 4 Kg (2.8%) – outcomes in specific individuals were more impressive. Thus, one in three (32%) patients experienced a 5% and one in six patients (17%) achieved a 10% weight loss at 24 months (LOCF).

However, even these modest changes in body weight were associated with significant improvements in cardiovascular risk factors (other health outcomes are yet to be fully analysed).

There are several important learnings from these findings:

1) Although the results may appear modest (certainly far less than the weight loss enthusiastically advertised in commercial programs), the degree of average weight loss is very much comparable to that reported at 24 months in non-pharmccological weight-loss studies in volunteers within research settings. Thus, the APPLES study demonstrates that a comparable degree of weight loss can be achieved in routine clinical practice in ‘all-comers”.

2) These findings certainly reinforce the refractory nature of severe obesity – while there is no doubt that some patients can lose a considerable amount of weight (as was the case in APPLES) – the average weight loss with behavioural modification, despite “state-of-the-art” medical care at a tertiary care centre, remains modest at best.

3) It is therefore not surprising that about 50% of severely obese patients will eventually need or opt for surgery (including those who had no interest in surgery when they entered the program).

The most important learning, however, is that overly optimistic notions that many providers (and patients) may have about how much weight the average obese individual (even with expert medical help) can hope to lose and keep off (even for just 24 months) need to be substantially recalibrated.

Clearly health providers (and policy makers), who expect that their obese clients can lose 20, 30, or even 50% of their weight by simply following their advice to “move-more and eat-less”, are kidding themselves. Evidently, this is something that even the best current medical care cannot deliver (remember treatments fail patients – patients never fail treatments).

This is not to say that the whole idea of medical bariatric care is a waste of time. For one, as regular readers will appreciate, bariatric care is far more about improving overall health and well-being than simply focussing on weight loss. Further analyses of the APPLES data to specifically examine outcomes such as improvements in quality of life, physical functioning, and specific co-morbidities including mental health are underway.

In tomorrow’s post we will look at outcomes in the surgically treated patients in the APPLES study.

@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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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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