Following the recent release of the Canadian Task Force on Preventive Health Care guidelines for prevention and management of adult obesity in primary care, the Task Force yesterday issued guidelines on the prevention and management of childhood obesity in the Canadian Medical Association Journal (CMAJ).
Key recommendations include:
- For children and youth of all ages the Task Force recommends growth monitoring at appropriate primary care visits using the World Health Organization Growth Charts for Canada.
- For children and youth who are overweight or obese, the Task Force recommends that primary health care practitioners offer or refer to formal, structured behavioural interventions aimed at weight loss.
- For children who are overweight or obese, the Task Force recommends that primary health care practitioners not routinely offer Orlistat or refer to surgical interventions aimed at weight loss.
The lack of enthusiasm for the prevention of childhood obesity is perhaps understandable as the authors note that,
“The quality of evidence for obesity prevention in primary care settings is weak, with interventions showing only modest benefits to BMI in studies of mixed-weight populations, with no evidence of long-term effectiveness.”
leading the Task Force to the following statement,
“We recommend that primary care practitioners not routinely offer structured interventions aimed at preventing overweight and obesity in healthy-weight children and youth aged 17 years and younger. (Weak recommendation; very low-quality evidence)”
Be that as it may, the Task Force does recommend structured behavioural interventions for kids who already carry excess weight based on the finding that,
“Behavioural interventions have shown short-term effectiveness in reducing BMI in overweight or obese children and youth, and are the preferred option, because the benefit-to-harm ratio appears more favourable than for pharmacologic interventions.”
What caught my eye however, was the statement in the accompanying press release which says that,
“Unlike pharmacological treatments that can have adverse effects, such as gastrointestinal problems, behavioural interventions carry no identifiable risks.” (emphasis mine)
While I would certainly not argue for the routine use of orlistat (the only currently available prescription drug for obesity in Canada) in children (or anyone else), I do take exception to the notion that behavioural interventions carry no identifiable risks – they very much do.
As readers may be well aware, a large proportion of the adverse effects of medications is attributable to the wrong use of these medications – problems often occur when they are taken for the wrong indication, at the wrong dose (too high or too low), the wrong frequency (too often or too seldom), and/or when patients are not regularly monitored. In a perfect world, many medications that often lead to problems would be far less problematic than they are in the real world.
Interestingly, the same applies to behavioural interventions.
Take for example diets – simply asking a patient to “eat less” can potentially lead to all kinds of health problems from patients drastically reducing protein, vitamin and mineral intake as a result of going on the next “fad” or “do-it-yourself” diet. Without ensuring that the patient actually follows a prudent diet and does not “overdo” it, which may well require ongoing monitoring, there is very real potential of patients harming themselves. There is also the real danger of promoting an eating disorder or having patients face the negative psychological consequences of yet another “failed” weight-loss diet. Exactly how many patients are harmed by well-meant dietary recommendations is unknown, as I am not aware of any studies that have actually looked at this.
The same can be said for exercise – simply asking a patient to “move more” can result in injury (both short and long-term) and coronary events (in high-risk patients). Again, ongoing guidance and monitoring can do much to reduce this potential harm.
In short when patient apply behavioural recommendations at the wrong dose (too much or too less), wrong frequency (too often or too seldom), and/or are not regularly monitored, there is indeed potential for harm – I would imagine that this potential for harm is of particular concern in kids.
This is not to say that we should not use behavioural interventions – we should – but we must always consider the potential for harm, which is never zero.
I’d certainly be interested in hearing from anyone who has seen harm resulting from a behavioural intervention.
As was pointed out, even in the best hands, 10 to 20% of patients undergoing bariatric surgery will “fail”, often prompting surgeons to reoperate.
As I write this post, I am watching live “re-do” surgery on a patient who had an open Mason vertical-banded gastroplasty in 1987 (remining us that bariatric surgery has been around far longer than many people think).
Listening to the surgeon (Dr. Bruno Dillemans, Bruges, Belgium) commenting on the operation, it is apparent (even to a non-surgeon like myself), that this kind of surgery can be most challenging.
With the vast increase in the number of patients undergoing bariatric surgery worldwide, it is easy to see that bariatric “re-do” surgery will pose a significant challenge down the road.
Over the past few months, I have been working with mdBriefCase, a major provider of free online accredited continuing medical education, to produce interactive modules for obesity management.
The modules are aimed at practitioners working in primary care and pharmacists and align closely with the Canadian Obesity Network’s 5As of Obesity Management framework.
The accredited course (Mainpro M1 and MOC Section 1 or 3 credits) is available free of charge to all Canadian Health Professionals.
To access the course for physicians and allied health practitioners on mdBriefCase – click here
To access the course for pharmacists on rxBriefCase – click here
I have long postulated that the benefits of exercise in weight management have little to do with burning calories. Rather, I am pretty sure that when people lose weight with exercise, they do so because of the impact that exercise may have on their food intake (I call it exercising to ruin your appetite!).
Thus, I am happy to acknowledge my affirmation bias in paosting about the recent study by Larissa Ledochowski and colleagues from the University of Innsbruck, Austria, published in PLOS One on the outcome of a randomised controlled trial of brisk walking on cravings for sugary snacks.
The study was conducted in 47 overweight volunteers who reported habitually consuming a fair share of sugary snacks. Following 3 days of “chocolate abstinence” subjects were randomised (using a within-subject design) to a 15-min brisk walk or passive control.
On each occasion, subjects were then stressed using the Stroop color–word interference task after which they reported their urges for sugary snacks using the State Food Craving Questionnaire [FCQ-S] adapted for sugary snacks.
Compared to the control situation, brisk walking resulted in a significant and relevant reduction in the urge for sugary snacks and attenuated the increase in sugar-cravings under trigger conditions (stress).
Although the authors are careful about not over-interpreting their findings from this acute study (that did not actually measure sugary-snack intake), they do make the following speculation regarding clinical relevance,
“This study adds to the increasing evidence that physical activity can somehow help to regulate the urge to consume snack food. It may be easy for overweight people to fit in short bouts of low-moderate intensity physical activity, instead of being sedentary, to elevate affective activation and valence and reduce high energy food cravings which may be triggered by stress and the presence of snack foods.”
While I am certain that more intense exercise may well trigger a hunger response, it appears that even a short bout of brisk walking may help dispel those cravings for sugary snacks (let me know if you have experienced this).
Readers may recall a previous post on the remarkable efficacy of beloranib, a methionine aminopeptidase 2 (MetAP2 ) inhibitor, in patients with hypothalamic obesity.
Now, a paper by Dennis Kim and colleagues present the results of a phase II study in individuals with “simple” obesity, published in Diabetes, Obesity and Metabolism.
The study included 147 participants with moderate obesity, who were randomised to 0.6, 1.2, and 2.4 mg beloranib or placebo for 12 weeks, with no specific diet or exercise recommendations.
At 12 weeks, participants had on average lost between 5.5 and 10.9 Kg in a dose-dependent fashion.
This reduction in body weight was associated with relevant improvements in waist circumference, lipids and blood pressure.
Adverse effects included dose-dependent increase in sleep latency and mild to moderate gastrointestinal symptoms.
Beloranib is an investigational weight loss therapy with a novel mechanism of action. This study assessed the efficacy, safety, and tolerability of beloranib treatment for obesity.
This is certainly a most remarkable degree of weight loss seen at 12 weeks and it will be interesting to see the results of the longer-term studies that are currently underway.
Disclaimer: I have received consulting honararia from Zafgen, the maker of belanorib.