Dr. Sharma's Obesity Notes

Earlier this week, the Canadian Diabetes Association released the newest version of the Canadian Practice Guidelines for Diabetes.

The online release includes the full text of all 38 chapters and an appendix.

Each chapter comes with a slide set and a brief video highlighting the key recommendations.

There are also accompanying tools for health care providers and  resources for patients.

The following are the main recommendations for weight management:

• An interdisciplinary weight management program (including a nutritionally balanced, calorie-restricted diet; regular physical activity; education; and counselling) for overweight and obese people with, or at risk for, diabetes should be implemented to prevent weight gain and to achieve and maintain a lower, healthy body weight [Grade A, Level 1A]
• In overweight or obese adults with type 2 diabetes, the effect of antihyperglycemic agents on body weight should be taken into account [Grade D, Consensus].
• Adults with type 2 diabetes and class II or III obesity (BMI ≥35.0 kg/m2) may be considered for bariatric surgery when lifestyle interventions are inadequate in achieving healthy weight goals [Grade B, Level 2]

While the recommendations with regard to pharmacotherapy reflect the lack of effective medications for obesity in Canada, they do highlight the role for bariatric surgery in heavier patients with type 2 diabetes.

There is also a useful checklist for weight management programs:

• The program assesses and treats comorbid conditions.
• The program provides individualized nutritional, exercise and behavioral programs and counselling.
• Nutritional advice is provided by qualified experts (e.g. registered dietitians) and diets are not less than 900 kcal/day.
• Exercise is encouraged but physical activity is promoted at a gradual pace.
• Reasonable weight loss goals are set at 1 to 2 lb/week.
• Cost is not prohibitive, and there are no financial contracts.
• There is no requirement to buy products, supplements, vitamins or injections.
• The program does not make unsubstantiated claims.
• The program has an established maintenance program.

The complete guidelines are accessible here.

AMS
Edmonton, Alberta

Obesity fact #7 in the New England Journal of Medicine paper on obesity myths, presumptions and facts, states simply that,

“Provision of meals and use of meal-replacement products promote greater weight loss.”

This “fact” is not surprising, as obviously if all you eat are the meals that are provided as part of a hypocaloric meal plan, then this is going to result in more weight loss than trying to compile those plans on your own.

Thus, as the authors rightly note,

“More structure regarding meals is associated with greater weight loss, as compared with seemingly holistic programs that are based on concepts of balance, variety, and moderation.”

While this may well be the case, the question ultimately is not just one of efficacy but also of effectiveness.

In other words, how likely, in the real world, is someone going to stick with a highly structured diet that essentially consists of meals delivered to your doorstep or even to meal replacements (rather than “real” food)?

While there are no doubt people who would fare well with such a regimen and would be willing to sacrifice variety for a plan that requires no effort in preparation and little effort in terms of decision-making, this may well be a minority of individuals.

While such strategies may well work to lose weight – the question really is whether such strategies results in long-term behaviour change that continues once you go back to eating “normal” foods in “normal” settings. Both cost and monotony could well be limitations of such approaches in the long term.

Nevertheless, I am certain that some of my readers will have their own experience with weight loss plans that either provide meals (e.g. Jenny Craig, Nutrisystem, etc.) or plans that involve replacing meals with bars or shakes (e.g. Slim-Fast).

That both strategies can be highly effective and promote weight loss is without question – they definitely work – whether such strategies are effective in the long-term (beyond the confines of a clinical trial) is perhaps less certain.

Obviously, any diet plan only works as long as you stick with it and there is probably nothing simpler or more convenient than having someone else prepare your meals for you.

AMS
Chicago, IL

Obesity Fact #6 from the New England Journal of Medicine paper on obesity myths, presumptions and facts, also states the obvious:

“For overweight children, programs that involve the parents and the home setting promote greater weight loss or maintenance.”

In contrast, Programs provided only in schools or other out-of-home structured settings, although convenient or politically expedient, are less likely to yield positive outcomes.

As regular readers may recall, I have often stressed the points that perhaps on of the most effective things we could possibly do to prevent and better manage childhood obesity is to treat the parents.

The key word in this previous statement is “treat” – this goes well beyond simply “involving” the parents in a program designed primarily to help their kids. Readers may recall the study showing that the amount of weight that parents lost was a good predictor of the “success” of their kids.

I really mean “treating” the parents as I am convinced (although this has yet to be formally proven in an RCT) that parents, who successfully manage their own weight can be much more effective in creating a home environment that could help their kids.

I do not think that it is merely a coincidence that the kids born to mothers, who have undergone bariatric surgery, are far less likely to become obese (even as adults) than kids born to obese mothers, who have not undergone surgery.

I do not believe that this is specific to surgery, but could well be common to any form of successful weight management in the mother.

My number one advise to obese parents wanting to help their overweight kids would be to themselves first seek obesity treatment (and I don’t mean join the next commercial weight loss program).

Thus, apart from rare exceptions (such as monogenic forms of obesity or obesity associated with developmental or other specific issues that affect the kid alone), I would at least propose the “presumption” that “Childhood obesity programs must also treat the parents”.

Obviously, this may not be something that childhood obesity programs are primarily designed to do – which is why I have previously suggested geographically co-locating pediatric and adult obesity programs so that everyone in the family can be treated at the same time.

This, may not be easy to accomplish but perhaps some of my readers have experience with such an combined program or at least the efforts needed to create one.

AMS
Edmonton, AB

Obesity Fact #5 in the New England Journal of Medicine paper on obesity myths, presumptions and facts, essentially boils down to the simple fact that we currently have no cure for obesity (not really news to regular readers of these pages).

Thus, as anyone, who has ever lost weight and is keeping it off, is well aware that,

“Continuation of conditions that promote weight loss promotes maintenance of lower weight”

The corollary to this is that, discontinuation of whatever treatment resulted in weight loss (and yes, behaviour change is “treatment”), will result in weight regain.

It is this basic fact about obesity that leads to the basic principle that,

“Obesity is best conceptualized as a chronic condition, requiring ongoing management to maintain long-term weight loss.”

This statement obviously has profound implications not just for people living with excess weight – who will require long-term (if not life-long) strategies to deal with their weight – but also for health systems, which have to provide obesity treatments within the framework of chronic disease management programs.

Therein lies the challenge for every health system on the planet – irrespective of whether or not these health systems eventually find effective means to prevent obesity, there are currently millions of people living with obesity, who need treatment.

Unfortunately, the treatments we have are limited and even the few treatments that we do have are not readily accessible to most.

As I often say, even running for the cure won’t cure your obesity. Unfortunately, you’ll have to keep running to keep the weight off.

AMS
Edmonton, AB

Following yesterday’s Obesity Fact #3 (exercise is good for you even if it doesn’t help you lose weight), Obesity Fact #4 from the New England Journal of Medicine paper, states that,

“Physical activity or exercise in a sufficient dose aids in long-term weight maintenance.”

This is a pretty well-established fact, however, the authors hasten to point out that the key term in this “Fact” is the term “sufficient dose”.

Thus, the authors note that,

“Physical-activity programs are important, especially for children, but for physical activity to affect weight, there must be a substantial quantity of movement, not mere participation.”

Indeed, recent studies have questioned whether in fact, the amount of physical activity that is achievable in school phys-ed programs (for example) would provide a sufficient dose to prevent weight gain (let alone maintenance of weight loss).

Thus, this “Fact” reflects the consistent body of knowledge that exercise as a way to control your weight, be it to prevent weight gain, lose weight, or prevent weight regain, requires a substantial dose of activity – more than is perhaps necessary to simply maintain good health (see Obesity Fact #3).

As I have said before, exercise is perhaps best seen as part of energy-in rather than energy-out and the right dose of exercise to help you control your weight is just the amount that it takes to RUIN your appetite. For some people that may well be the benefit you get from walking your dog.

AMS
Edmonton, AB