Now a paper by Argyro Syngelaki and colleagues from the UK, published in the New England Journal of Medicine, suggests that the anti-diabetes drug metformin may limit weight gain in pregnant non-diabetic women with obesity and also reduce the incidence of pre-eclampsia.
The researchers randomised 450 pregnant women with a BMI greater than 35 and no diabetes to either metformin (3 g/day) or placebo from weeks 12-18 weeks of gestation till delivery in a double-blind fashion.
Among the 400 women who completed the study, those on metformin gained about 2 Kg less weight than the placebo group.
There was also an almost 75% decrease in the risk of developing preeclampsia.
Despite these effects, metformin did not significantly reduce the incidence of large-for-gestational-age babies or other adverse neonatal outcomes.
While these findings may be somewhat disappointing with regard to outcomes in the offspring, the reduction in pre-eclampsia is impressive and, if confirmed, could well be an interesting use of this compound in high-risk pregnancies.
It is now widely recommended that addressing childhood obesity requires a whole-family approach with a focus on educating and helping parents provide a healthier environment for their children. This has sometimes resulted in the slogan, “treat the parents”.
But just how effective is this approach?
Now a study by Gisela Nyberg and colleagues from the Karolinska Institute in Stockholm, Sweden, published in the International Journal of Behaviour, Nutrition and Physical Activity, suggests that even this strategy may not be quite as effective as one would hope.
The study was designed to study the effectiveness of a universal parental support programme to promote health behaviours and prevent overweight and obesity in 6-year-old children in disadvantaged areas in Stockholm.
The cluster-randomised controlled trial involved 31 school classes with 378 six-year-old children. The 6 month interventions were 1) Health information for parents, 2) Motivational Interviewing with parents and 3) Teacher-led classroom activities with children.
Overall, while there was some effect of the intervention on eating behaviour, there was no overall impact on physical activity levels.
There was also no change in BMI for the whole group, although there was small drop in BMI in kids at the higher range of the BMI spectrum, which disappeared at 5-months post-intervention.
The authors grasp at the fact that the effects of the intervention were short-lived to recommend that the programme needs to be prolonged and/or intensified in order to obtain stronger and sustainable effects.
Just how much longer or how much more intense the intervention would need to be is unclear.
These findings certainly reflect the real-life problem that we currently have no universally effective approach to dealing with childhood obesity (with parents or without).
Sadly, no one has yet demonstrated that any type of intervention for childhood obesity, whether individual, family, shool or community based, despite occasional short-term improvements in health behaviours and body weight, ultimately translates into fewer adults with obesity.
Perhaps, the best time to intervene to prevent childhood obesity is even before the kids are born.
There is no doubt that bariatric surgery is currently the most effective long-term treatment for severe obesity, however, there is also some evidence to suggest that patients seeking bariatric surgery (or for that matter any kind of weight loss) are more likely to have accompanying mental issues that individuals with obesity who don’t and that such issues may affect the outcomes of surgery.
Now, a paper by Aaron Dawes and colleagues from Los Angeles, CA, published in JAMA presents a meta-analysis of mental health conditions among patients seeking and undergoing bariatric surgery.
They identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65,363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50,182 patients).
Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, each affecting about one-in-five patients were depression and binge eating disorder.
However, neither condition was consistently associated with differences in post-surgical weight outcomes. Nor was there a consistent relationship between other mental health conditions including PTSD or bipolar disease and post-surgical outcomes.
Interestingly, bariatric surgery was consistently associated with a significant decrease in the prevalence and/or severity of depressive symptoms.
So what do these findings mean for clinical practice?
As the authors note,
“Guidelines from the American Society for Metabolic and Bariatric Surgery and the Department of Veterans Affairs/Department of Defense recommend routine preoperative health assessments, including a review of patients’ mental health conditions. Other groups advocate for a more comprehensive, preoperative mental health examination in addition to the general evaluation currently performed by medical and surgical teams. The results of our study do not defend or rebut such a recommendation.”
So why are these data not clearer than they should be? Here is what the authors have to offer:
“Much of the difficulty in determining the effectiveness of preoperative mental health screening is due to the limitations of current screening strategies, which use a variety of scales and focus on mental health diagnoses rather than psychosocial factors. Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks, and socioeconomic stability play major roles in determining outcomes after bariatric surgery. Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the optimal strategy for evaluating patients’ mental health prior to bariatric surgery.”
At this time, perhaps to err on the side of caution, our centre (like many others) continues to screen for and address any relevant mental health issues in patients wishing to undergo bariatric surgery.
Obesity, like most other chronic diseases, requires interdisciplinary approaches that involves a wide range of clinicians from different disciplines (e.g. physician, nurse, psychologist, dietitian, exercise physiologist, social worker, physiotherapist, occupational therapist, etc.).
But exactly how to get these teams to function efficiently and deliver timely and ongoing obesity management remains largely understudied.
In a paper by Jodi Asselin and colleagues, published in Clinical Obesity, we explore the challenges faced by members of multidisciplinary teams working in the setting of a large primary care network.
Participants (n = 29) included in this analysis are healthcare providers supporting chronic disease management in 12 family practice clinics randomized to the intervention arm of the 5As Team trial including mental healthcare workers (n = 7), registered dietitians (n = 7), registered nurses or nurse practitioners (n = 15). Participants were part of a 6-month intervention consisting of 12 biweekly learning sessions aimed at increasing provider knowledge and confidence in addressing patient weight management.
Qualitative methods included interviews, structured field notes and logs.
Four common themes of importance in the ability of healthcare providers to address weight with patients within an interdisciplinary care team emerged, (i) Availability; (ii) Referrals; (iii) Role perception and (iv) Messaging.
Availability (i) refers to the ability of two or more people to meet and communicate as needed within a reasonable amount of time. This included the interdisciplinary team members knowing and meeting each other, being able to consistently communicate during the work-day, or deliberately asynchronously, and having work schedules that allowed collaboration.
Availability was often affected by scheduling that limited face-to-face time between providers and subsequently limited the potential for collaboration or discussion. Another issue was lack of in-clinic time to speak to providers who were physically present but otherwise unavailable.
Referrals (ii) points to the need for weight management referrals to take place, for those referrals to be appropriate to provider ability and for the patient to be knowledgeable about, or in agreement with the reason for referral. Many practitioners felt they were not receiving the weight management referrals they could, or that the referrals often left the patient and provider unclear as to where to begin the conversation.
Role perception (iii) concerns the way a provider’s role is understood by other interdisciplinary team members. Issues pertaining to role perception were fairly consistent and strongly linked to concerns with referrals. Common examples included concern that they were not receiving the type of referrals they could, that other providers did not understand their role in weight management, or that they as providers did not understand the role of others.
Messaging (iv) refers to the overall approach to weight management that providers within the same clinic were using, as well as the key information being shared between providers and patients. Inconsistent messaging among providers within clinics, as well as with specialists seen by the patient, was a common concern raised during interviews. In such cases there was feeling that advice was not patient-centred, that efforts had not been taken to consider patient history and that as a consequence, the patient might suffer a setback, reduced interest, or reduced personal confidence. In these cases the message a patient had received from another provider was counter to the message or approach the interviewee was giving.
However, we find that what was key to our participants was not that these issues be uniformly agreed upon by all team members, but rather that communication and clinic relationships support their continued negotiation.
Our study shows that firm clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care in weight management.
Furthermore, there is a clear need for shared messaging concerning obesity and its treatment between members of interdisciplinary teams.
From the project it is evident that broad training in the various contributors to obesity enables providers to not only see their own role in treatment, but to better understand the role of others and therefore begin addressing problems in referrals, messaging and role perception.
One of the key barriers to accessing obesity treatments in many countries (besides lack of training and common weight-bias of health professionals) is the lack of coverage for obesity treatments in public and private plans.
Thus, for example in the US, under the Medicare Modernization Act of 2003, Medicare is in fact prohibited from covering prescription obesity medicines.
Now, a US survey conducted by the Gerontology Society of America among 1,000 US Adults using online interviews shows a strong majority in favour of Medicare coverage for obesity medications.
Here is a summary of the main findings:
- 87 percent of Americans believe obesity is a problem in their state.
- 69 percent of Americans believe Medicare should expand coverage to include prescription obesity medicines.
- 77 percent were unaware that federal law specifically prohibits Medicare from covering patient costs for prescription obesity medicines.
- 69 percent of Americans were unaware that the FDA has found that current prescription obesity medicines are safe and effective in treating obesity. (In the last 5 years multiple medicines have been approved as safe and effective by the FDA)
To me these results are surprising as I would have expected that most Americans (like most everybody else) still believes that people with obesity need to overcome this by simply eating less and moving more rather than taking the “easy way out” by simply “popping a pill”.
Perhaps, the notion that obesity is a chronic disease and that people who have it deserve treatment the same as anyone else with any other chronic disease is starting to trickle through.
Then again of course, this survey (as so often with polls) may simply be completely off the mark.