The short answer, for the vast majority of Canadians, would simply be, “no one”.

Last year, the Canadian Obesity Network undertook a representative survey to examine how Canadians manage their weight.

It turns out that over 65% of overweight Canadians have never talked to a licensed health professional (family doctor, dietitian, pharmacist, etc.) about losing weight. The same is true for over 40% of Canadians, who meet the clinical definition of obesity, i.e. have a BMI greater than 30.

This may probably be as well, because most health professionals are in fact ill-equipped to support individuals struggling with excess weight. Although, health professionals often cite lack of time and resources as the main reason for not broaching the topic, I suspect that the key problem is simply a lack of knowledge and training in weight management.

As I have said before, most health professionals have little more than a layman’s understanding of the complex socio-psycho-biology of energy homeostasis and have virtually no formal training in even the basics of behavioural, medical or surgical management of excess weight.

Add to this an (un)healthy dose of anti-weight prejudice and discrimination and it is probably no surprise why anyone who has ever solicited weight management advice from their health professional is more likely to receive simplistic slogans along the lines of “eat less and move more”, than a meaningful analysis of the problem with a personalized evidence-based management plan.

Indeed, weight management plans too often follow along the lines of well-meant but often ineffective diet or exercise recommendations, that virtually always fail to address the actual root of the problem (see my post - overeating is a symptom).

It should hardly come as a surprise when simply providing an impulsive overeater with a diet plan proves to be about as effective as providing a drinking plan to an alcoholic.

In contrast, teaching time-management skills to people who regularly fall back on fast food for lack of time or offering stress management classes to people who use food as a coping strategy may well be far more effective than simply educating them on healthy choices or handing them recipe books.

Of course patients can always turn to the billion-dollar weight-loss industry, that peddles everything from magical weight loss supplements to crash diets. While some of these program may well be better than others, there is no way a consumer can tell which of these many products and services are likely to be effective or just a waste of money.

Even if patients “successfully” lose weight with any of these products or services, this is rarely more than temporary “symptomatic” relief with a nineteen-in-twenty chance of weight regain within weeks or months of stopping the program.

Rarely do these products or services truly diagnose and address the root cause of the problem - that would require far more than a cursory “one-size-fits-all” business model and is unlikely to deliver the same lucrative profits.

Perhaps, it is time to promote a better public understanding of the many societal and individual level drivers of excess weight and it certainly appears high time health professionals and health care systems seriously took on the challenge of addressing the greatest health problem of our times.

When the problem is excess weight, not helping patients deal with this issue is simply palliative care.

AMS
Edmonton, Alberta

Regular readers of these pages may recall a previous post on the fact that drugs only work in people who take them.

Perhaps, not so surprisingly, the same is true for any kind of weight loss intervention.

Diets only work for people who stick to them, food journals only work for people who keep them, calorie counting only works for people who count calories, and guess what, web-based weight-loss interventions only work for people who use such programs.

The latter is pretty much the finding from a study by Kristine Funk and colleagues from Kaiser Permanente, Center for Health Research, Portland, USA published in the latest issue of the Journal of Medical Internet Research.

The researchers compared two long-term weight-maintenance interventions: a personal contact arm and an internet arm, with a no-treatment control after an initial 20-week weight loss program, during which participants lost about 9 Kg.

This paper focusses on the website use patterns and weight maintenance outcomes in the internet arm of the study (n=348). The interactive website designed to support of long-term weight maintenance, contained features that encouraged setting short-term goals, creating action plans, and reinforcing self-management habits. The website also included motivational modules, daily tips, and tailored messages.

Participants were were encouraged to log in at least weekly and enter a current weight for the 30-month study period.

After adjusting for baseline characteristics including initial BMI, variables most associated with less weight regain included: number of log-ins, minutes on the website, number of weight entries, number of exercise entries, and sessions with additional use of website features after weight entry.

In other words, the participants who used the site most ended up regaining the least weight; people who used the site less regained more weight.

Older and more educated participants were more likely to use the website consistently; higher baseline weight and less attendance at the initial group sessions was associated with minimal website use.

Because a substantial proportion of participants did not use the site consistently (40%), one may easily conclude that such internet sites are of limited use. On the other hand, the data could also be used to support the idea that such sites can be very effective in people who use them (60% of participants in this study).

Thus, as with all interventions (including pharmacotherapy or surgery), outcomes are highly dependent on the level of compliance and adherence.

In fact, come to think of it, I can’t say I am aware of any treatments that work in people who don’t use them.

AMS
Duchesnay, Quebec

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Hat tip to Sebely for pointing me to this article!

Funk KL, Stevens VJ, Appel LJ, Bauck A, Brantley PJ, Champagne CM, Coughlin J, Dalcin AT, Harvey-Berino J, Hollis JF, Jerome GJ, Kennedy BM, Lien LF, Myers VH, Samuel-Hodge C, Svetkey LP, & Vollmer WM (2010). Associations of Internet Website Use With Weight Change in a Long-term Weight Loss Maintenance Program. Journal of medical Internet research, 12 (3) PMID: 20663751

There is little doubt that changes in diet and physical activity can seriously reduce risk for cardiovascular disease (and countless other conditions from arthritis to cancer).

But changing diet and activity levels both at individual and population levels remains a major challenge. Not that these changes are not possible (they are), but rather that practitioners don’t know where to start and often default to well-meaning but useless advise (eat less - move more).

Last week, the American Heart Association (AHA) Prevention Committee of the Council on Cardiovascular Nursing released a comprehensive collation of the current evidence regarding interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults.

Although the document does not specifically address weight management, the principles and learnings from this document certainly apply as much to managing excess weight as they do to dealing with other chronic conditions like hypertension, dyslipidemia or diabetes.

The following intervention strategies and principles meet the highest levels of evidence (Level A or B):

Cognitive-behavioral strategies for promoting behavior change:

• Design interventions to target dietary and PA behaviors with specific, proximal goals/goal setting (Level of evidence: A)

• Provide feedback on progress toward goals. (Level of evidence: A)

• Provide strategies for self-monitoring. (Level of evidence: A)

• Establish a plan for frequency and duration of follow-up contacts (eg, in-person, oral, written, electronic) in accordance with individual needs to assess and reinforce progress toward goal achievement. (Level ofevidence: A)

• Utilize motivational interviewing strategies, particularly when an individual is resistant or ambivalent about dietary and PA behavior change. (Level of evidence: A)

• Provide for direct or peer-based long-term support and follow-up, such as referral to ongoing community-based programs, to offset the common occurrence of declining adherence that typically begins at 4–6 months in most behavior change programs. (Level of evidence: B)

• Incorporate strategies to build self-efficacy into the intervention. (Level of evidence: A)

• Use a combination of the above strategies (eg, goal setting, feedback, self-monitoring, follow-up, motivational interviewing, self-efficacy) in an intervention. (Level of evidence: A)

• Use incentives, modeling, and problem solving strategies. (Level of evidence: B)

Intervention processes and/or delivery strategies:

• Use individual- or group-based strategies. (Level of evidence: A)

• Use individual-oriented sessions to assess where the individual is in relation to behavior change, to jointly identify the goals for risk reduction or improved cardiovascular health, and to develop a personalized plan to achieve it. (Level of evidence: A)

• Use group sessions with cognitive-behavioral strategies to teach skills to modify the diet and develop a PA program, to provide role modeling and positive observational learning, and to maximize the benefits of peer support and group problem solving. (Level of evidence: A)

• For appropriate target populations, use Internet- and computer-based programs to target dietary and PA change; evidence is less for targeting PA alone; adding a form of E-counseling improves outcomes. (Level of evidence: B)

• Use individualized rather than nonindividualized print- or media-only delivery strategies. (Level of evidence: A)

Addressing cultural and social context variables that influence behavioral change:

• Utilize church, community, work, or clinic settings for delivery of interventions. (Level of evidence: B)

• Use a multiple-component delivery strategy that includes a group component rather than individual-only or group-only approaches. (Level of evidence: A)

• Use culturally adapted strategies, including use of peer or lay health advisors to increase trust; tailor health messages and counseling strategies to be sensitive to the cultural beliefs, values, language, literacy, and customs of the target population. (Level of evidence: A)

• Use problem solving to address barriers to PA and dietary change, such as lack of access to affordable healthier foods, lack of resources for PA, transportation barriers, and poor local safety. (Level of evidence: B)
• Nothing revolutionary here or in fact very different from the way most evidence-based weight management programs already work (scams excluded). In fact this list of recommendations provides a valuable checklist to make sure your program is hitting all the relevant buttons

Good to know that there is actually strong scientific evidence to support most of what we do at WeightWise.

AMS
Edmonton, Alberta

Hat tip to Sebely for pointing me to this article

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Artinian NT, Fletcher GF, Mozaffarian D, Kris-Etherton P, Van Horn L, Lichtenstein AH, Kumanyika S, Kraus WE, Fleg JL, Redeker NS, Meininger JC, Banks J, Stuart-Shor EM, Fletcher BJ, Miller TD, Hughes S, Braun LT, Kopin LA, Berra K, Hayman LL, Ewing LJ, Ades PA, Durstine JL, Houston-Miller N, Burke LE, & on behalf of the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing (2010). Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults. A Scientific Statement From the American Heart Association. Circulation PMID: 20625115

“The doctor wrote down “morbid obesity” in my chart. I was mortified. I looked it up. It meant I was going to die from being fat. I was 12.”

This is perhaps the most moving paragraph in Obese From the Heart, a book that everyone struggling with excess weight should read – more importantly, a book that every obesity researcher, health professional and decision maker should read.

Written by Sara L. Stein, a psychiatrist who has struggled with severe obesity all her life, the book provides profound insights into everything that I see in my own practice every day.

In just over 100 pages, divided into chapters that are often not more than a couple of pages long, Stein touches on all of the important human issues that are so often the underlying causes of uncontrolled overeating and excess weight.

From her own seminal experience as a three year old, with clear memories of the ecstatic experience of one day biting into a chocolate chip cookie, which triggered off a life long addiction, Stein writes about how emotions can profoundly influence ingestive behaviour.

With regard to food addiction, Stein notes:

“Food addiction is unique among addictions in four ways: Food is unavoidable; Food is essential for life; Food is socially acceptable, everywhere; Food can actually elevate your status if it’s good. …food is the only addicting substance where abstinence is both impossible and unacceptable.
…it’s everyone noticing that you are not eating. Especially the cook.
So begins the brutal cycle of trying to control your additcion while still using. DIEting…”

Other chapters deal with stress, depression, anxiety, anger, trauma, and grief. Regarding the later, she notes,

“I can trace my weight gains to anticipating grief, experiencing grief, and reliving grief”.

Her account of growing up as a “morbidly obese” child, teenager, and young woman are both insightful and heart wrenching.

Based on her extensive experience as a bariatric psychiatrist, she discusses the role of bariatric surgery, the problem of anti-fat bias and discrimination (especially amongst health professionals and the media), the important role of sex (or lack of it), and the self-destructive “people pleaser” attitude that reinforces the cycle of nourishing (and respecting?) everyone else but yourself.

Most importantly, Stein shares how she herself found balance – the struggle continues but, down 75 lbs from her highest weight, she has never found it easier to manage her weight since identifying her emotional eating patterns and accepting herself as a wonderful divine being. (“all of us are human with souls, and wants, and emotions, and families and friends”).

While I do not agree with everything Stein writes, such as her views on the role of nutritional supplements (for which evidence is anecdotal at best) or detoxification (whatever that means), the book is nevertheless full of important advice both for health professionals as well as anone struggling with excess weight.

Thank you Sara for sending me a copy of your book – it will definitely be recommended reading for my staff and colleagues – even my patients!

AMS
Edmonton, Alberta

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Regular readers will recall previous posts on the VBLOC device, which uses intermittent electrical signals to block the vagal nerve thereby leading to weight loss. The previous post followed Enteromedic’s announcement that the early results from the EMPOWER study failed to quite meet its primary and secondary efficacy endpoints (resulting in a 70% fall in share price).

Yesterday, however, the share price of Enteromedics more than doubled after the company announced the follow-up results of two studies, to be presented in the coming days at the American Society for Metabolic and Bariatric Surgery Meeting in Las Vegas.

After soldiering on in the randomized, double-blind, controlled pivotal EMPOWER Study, participants now at 20 months experienced an almost 20% excess weight loss, while averaging 9 hours of device use per day.

Perhaps more interestingly, in another ongoing study (VBLOC-DM2 ENABLE), obese patients with Type-2 diabetes mellitus showed an improvement in HbA1c levels of 0.8% as well as a 25% excess weight loss over 12 months while averaging about 14 hours per day of therapy with the implantable Maestro RC System.

The novelty of this second generation Maestro device lies in the rechargeability of the implanted batteries via an external mobile charger and transmitter coil that can be worn for a few hours each week, thereby allowing delivery of a far more extensive treatment that with the previous version of the device.

Although this treatment required laparoscopic implantation of electrodes and the battery pack, with the usual risks entailed in such surgery, the treatment appears to be well tolerated with few side effects.

As outlined in yesterday’s press release, the company certainly appears optimistic about the future of this treatment for obesity and diabetes - the investors clearly appear to share this enthusiasm.

AMS
Edmonton, Alberta

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