Pain in Older Obese Adults
BEST HEALTH BLOG FINALIST: The second round of voting is on – please vote AGAIN for your favourite health blog by clicking here Last night I gave a talk to General Practitioners at the Medical School in Victoria, BC (hosted by Dr. Brad Amson, General/Bariatric Surgeon). I spoke about the importance of carefully assessing patients for contributors and barriers to weight management. As blogged yesterday, pain is one of the most common issues in patients with excess weight and can be both a contributor and barrier to weight gain and severely obese patients appear at particular risk for pain catastrophizing. But how common is pain and how great is the incident risk in overweight and obese patients? This issue was addressed in a recent study by Noor Heim and colleagues from the VU University, Amsterdam, The Netherlands, published in OBESITY. This prospective study investigated the relationship between measured BMI and waist circumference with prevalent and incident pain in 2000 participants of the Longitudinal Aging Study Amsterdam, aged 55-85 years at baseline (1992-1993) and after after 3 years (N = 1,478) and 6 years (N = 1,271) of follow-up. The overall prevalence of pain was 33% at baseline and increased significantly with higher quartiles of BM. After adjustment for age, education, depression, smoking, physical activity, and chronic diseases, both men and women in the highest quartile of BMI were around twice as likely to present with pain than individuals in the lowest BMI quartile. Of the participants without pain at baseline, those in the highest quartile of BMI had a 2-fold increased odds for incident pain after 3 years of follow-up and around 2.5-fold after 6 years. The association with BMI was independent of waist circumference, suggesting that absolute weight rather than weight distribution was important for pain. This longitudinal study also answers the question whether or not pain in obesity is the chicken or the egg – it appears that obesity increases the risk for incident pain, rather than vice-versa. But what about weight loss and its effect on pain? This issue, interestingly, has not been widely studied and results have been inconsistent. Apart from the rather dramatic improvement in pain and mobility reported in surgical obesity treatment, the effect of non-pharmacological or pharmacological weight loss on pain incidence or progression is not clear (though my guess is that weight loss can’t hurt – no pun intended). Given the tendency… Read More »
Pain Catastrophizing in Severe Obesity
BEST HEALTH BLOG FINALIST: The second round of voting is on – please vote AGAIN for your favourite health blog by clicking here Pain is one of the most common and debilitating problems in patients challenged by severe obesity. Not just a consequence of mechanical complications of obesity (osteoarthritis, back pain, plantar fasciitis, fibromyalgia, etc.), pain is often a key barrier to physical activity and thus weight management. In fact, excess pain can promote psychological (e.g. depression, anxiety) and behavioural (e.g. binge eating) factors that may further promote weight gain. This issue is of even more importance in patients who display the now well-described phenomenon of pain catastrophizing, or the maladaptive responses to pain (tendency to focus on and magnify pain sensations with an intense sense of unbearable suffering and helplessness) that plays an extremely important role in how pain is perceived and processed. Pain catastrophizing now accounts for a substantial proportion of pain-related disability. Studies in patients with fibromyalgia show that pain catastrophizing is associated with increased activity in brain areas related to anticipation of pain (medial frontal cortex, cerebellum), attention to pain (dorsal ACC, dorsolateral prefrontal cortex), emotional aspects of pain (claustrum, closely connected to amygdala) and motor control. Thus, catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain. In another recent study by Tamara Somers and colleagues from Duke University, morbidly obese patients with osteoarthritis (OA) reported higher levels of pain catastrophizing than OA patients in the overweight and obese category. The severely obese patients who engaged in a high level of pain catastrophizing reported having much more intense and unpleasant pain, higher levels of binge eating, lower self-efficacy for controlling their eating and lower weight-related quality of life. The relationship between pain catastrophizing and eating behaviour is of particular interest, as high-fat and high-sucrose foods have been shown to increase pain tolerance. Thus, binging on highly-palatable foods may be a compensatory response to emotional distress and pain. It is not difficult to see how patients can enter into a vicious cycle of pain, increased eating, weight gain, more pain, more eating, and so on. In routine practice, pain catastrophizing can be easily and reliably assessed with questionnaires like this one, which can be scored like this. Fortunately, pain catastrophizing is responsive to cognitive behavioural therapy, with clinically relevant improvements in upto 50% of individuals. I would have little doubt that failure to recognize and… Read More »
Is Asthma Overdiagnosed in Obesity?
Exertional dyspnoe, including puffing and wheezing suggestive of asthma, is not uncommon in patients with overweight and obesity. But how much of this is really asthma? This question was addressed by Shawn Aaron and other members of the Canadian Respiratory Consortium in a study published last week in CMAJ. Aaron and colleagues conducted a longitudinal study of 242 obese (BMI >30) individuals with physician-diagnosed asthma, identified by random dialing in 8 Canadian cities. A diagnosis of current asthma was excluded in those who did not have evidence of acute worsening of asthma symptoms, reversible airflow obstruction or bronchial hyperresponsiveness, despite being weaned off asthma medications. Asthma was ultimately excluded in 31.8% of obese patients, of whom 65% did not need to take asthma medications or seek health care for asthma symptoms during a 6-month follow-up period. This study shows that only 2 in 3 obese patients treated for asthma actually have asthma. Now if anyone thinks that asthma is only overdiagnosed in obese patients, it is worth pointing out that the rate of overdiagnosis of asthma was virtually identical (28.7%) in the 254 non-obese (BMI 20-25) individuals also examined in the same study. Thus, the really surprising finding of this study for me is that overdiagnosis of asthma is NOT more likely in obese patients than in non-obese patients. This is certainly unexpected, given the fact that exertional dyspnoe, which is indeed more common in obese individuals, can indeed mimic asthma. The alarming piece in this finding though, as pointed out in an accompanying editorial by Matthew Stanbrook and Alan Kaplan, is that “Asthma misdiagnosis in patients with persistent or recurrent symptoms has important and potentially serious consequences to both patients and the health care system. Symptoms assumed to be due to asthma may instead signify another medical condition that thereby goes undiagnosed and untreated. Asthma … can only be reliably distinguished with objective testing. Because asthma is a chronic disease, the consequences of misdiagnosis may extend for many years.” The bottom line is that suspected asthma should always be confirmed with spirometry – especially in obese patients, where restriction and/or simply the increased oxygen cost of breathing can cause breathlessness, which is easily misdiagnosed as asthma. AMS Edmonton, Alberta p.s. don’t forget to vote for your favourite Health Blog by clicking here!
Pregnancy and Fertility after Bariatric Surgery
Today I am presenting a talk on obesity at the 54th Annual Meeting of the Canadian Fertility and Andrology Society, being held in Calgary, Alberta. The reason that I’ve been invited, is because, as many of you know, excess weight has a significant negative effect on fertility rates. Indeed, obesity may today be by far the most frequent cause of failure to conceive. While my talk is on the general approach to obesity diagnosis and management, it is timely that in this week’s issue of JAMA, Melinda Maggard et al. from the University of California, Los Angeles, CA, publish a systematic review on pregnancy and fertility following bariatric surgery. For their review, Maggard and colleagues searched the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000 cases annually for the 3 most recent years). Matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. Rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery patients. These findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). Unfortunately, studies regarding nutrition, fertility, cesarean delivery, and contraception were limited. For e.g. on the issue of fertility, the authors identified 6 studies generally showing improved fertility, although due to lack of a denominator (the number of women actually trying to get pregnant), the impact of surgery is hard to determine. Nevertheless, data clearly shows improvements to complete disappearance of polycystic syndrome and normalization of hormonal patterns and return of normal menstrual cycles. On the issue of contraception there are isolated reports of failure of contraception following bypass surgery – systematic or controlled trial are lacking. In summary, the authors concluded that the rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared… Read More »
Obesity Epidemic Hits India
Yesterday, the Indian Ministry of Health and Family Welfare proposed new obesity guidelines, which reduce the BMI criteria for the diagnosis of overweight and obesity to 23 and 25 respectively. Likewise, the abdominal circumference cutoffs for abdominal obesity have been reduced to 90 cm for men and less than 80 cm for women, i.e. 12 cm and 8 cm, respectively, lower than the cutoff for abdominal obesity in the West. According to these guidelines, people with BMI of 25 and above will be considered for initiating drug therapy, eligibility for bariatric surgery requires a BMI of 32.5. These lower cutoff levels are fully in line with the greater metabolic risk posed by excess weight in people of South Asian origin – currently already home to the largest number of patients with diabetes anywhere in the world. The current load of diabetes in India (41 million) is expected to increase by 170% in the next 20 years. This new definition of obesity, means that currently 15% of the Indian population have obesity – not too far behind Canada, where the population prevalence of obesity is only 3% points higher. Remarkable statistics for a country, where a significant proportion of the population still performs hard manual labour and has modest access to nutritious foods. According to my good friend and colleague Dr. Anoop Misra, director and head, department of diabetes and metabolic diseases, Fortis Hospitals, New Delhi and Noida, “The guidelines – with revised statistics – will benefit the additional 15-20 per cent (60-80 million) of the Indian population who can now be clinically termed obese under the revised measurement.” How India will cope with the treatment of obesity at a population level is unclear. Knowing that so far no society has succeeded in preventing or managing the obesity epidemic (e.g. it is hard to imagine how we will actually deliver obesity treatments to the 600,000 Albertans who need it), it will be interesting to see how a country like India, with its limited health care resources, will even begin to cope. It is perhaps most timely that I have been invited to speak and chair sessions at the forthcoming 5th Asia-Oceania Obesity Conference to be held in Mumbai in February 2009 – I certainly look forward to some interesting discussions with my Indian colleagues. AMS Edmonton, Alberta p.s. don’t forget to vote for your favourite Health Blog by clicking here!
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