When Obesity is a Sign of Good Health
Yesterday, on the first day of the 1st Caribbean Obesity Forum, I presented various talks on obesity – its economic implications, its assessment and the need for firmly anchoring obesity treatment in primary care. Interestingly, several family doctors in the audience raised the interesting issue that here on Barbados (as probably on other islands) many patients are actually quite happy with their weights. One family physician noted in his presentation the case of an overweight woman, who presented in his practice with diabetes. A few weeks after starting her on metformin, she came back considerably distressed about the fact, that she had now lost a few kilos. He noted that despite explaining out that her diabetes was now under control and her blood pressure had improved, she remained unconvinced about the benefits of being on this treatment. To her, losing weight equated directly with being unhealthy and ‘less sexy’ to her husband. This topic came up several times during the day, where the issue of how to address obesity related health problems in a culture, where excess weight is considered both physically attractive and a sign of good health – never mind that the Caribbean (as pointed out by other speakers) now has some of the highest diabetes rates in world – I have heard Jamaica referred to as the world capital of foot amputations. The notion of obesity as a sign of good health of course is not that surprising – especially in countries where malnutrition, infectious diseases, gut parasites, and other ‘wasting’ conditions, are endemic. Being skinny is a sure sign of sickness and weight loss is most alarming. One discussant reminded me of the African practice of fattening rooms, where brides-to-be would be sequestered and overfed in order to be their ‘best weight’ on their wedding day – the exact opposite of Western societies, where brides wanting to lose weight provide healthy profits for the weight-loss industry. Obviously, in such a setting, the very idea that excess weight may adversely affect pregnancy outcomes, is clearly a hard sell – as noted by the colleague speaking on the issue of epigenetic programming in utero. In the discussions, I did point out that while we certainly did not have an issue with women not wanting to lose weight (in fact our challenge is perhaps the opposite – convincing many women that the few extra pounds they would so desperately… Read More »
Obesity in Canada: Challenges and Opportunities
Yesterday, I applauded the Canadian Obesity Network for being internationally recognised as Canada’s official professional obesity association. This is important because, although obesity now affects one in four adult Canadians, we are by no means alone with this problem. Indeed, as noted by the Lancet in 2006, “No health system is yet meeting the challenges of managing obesity, and no society has developed an effective strategy to prevent it.” This is both a challenge and an opportunity for Canada. Challenge because our problem cannot be solved by simply importing successful models from elsewhere – there are none! Opportunity, because we may well be the first to develop promising approaches that could serve as a ‘made in Canada’ solution to others. Indeed, today I will be speaking at a Caribbean obesity conference in Bridgetown, Barbados, where obesity is rampant and diabetes is endemic. While the health care models that we are adopting in Canada to deal with our own obesity problems may not be easily transferable to Barbados, the same principles will likely hold true. Public health measures based on the principles of shame, blame, tax, and ban, will prove as unhelpful here as they have proven unsuccessful everywhere else – not surprising as these measures fail to address the psychosocial and biological root causes of the problem. There is also no doubt that health services approaches that do not embrace the complexity, heterogeneity, and chronicity of obesity, will be doomed to fail – obesity management has to be fully integrated into a chronic disease management framework that includes professional assessment, patient education, and lifelong self-management. While not everyone with excess body fat needs to lose weight – many do. This will not be achieved by promoting endless cycles of yo-yo dieting with little or no professional help – there may well be far more harm in this than any potential benefit. The causes of obesity are complex – the solutions cannot be simple. Doing nothing is clearly not an option but let us at least stop doing things that have already been shown to fail (like simply telling people to eat less and move more). AMS Bridgetown, Barbados
Obesity Network Now Canada’s Global Voice in Obesity
Yesterday, the Canadian Obesity Network announced that it is now Canada’s official representative in the International Association for the Study of Obesity (IASO), the umbrella organization for 52 national obesity associations, representing 56 countries. Click here for a brief history of IASO. Canada was previously represented at IASO by The Obesity Society (TOS), formerly known as the North American Association for the Study of Obesity (NAASO), which continues to be the leading scientific society dedicated to the study of obesity in the USA and Mexico and will remain as the regional representative for North America within IASO. According to IASO President Prof. Philip James, “With a diverse and active professional community in place and a successful track record in obesity, the time was right for the Canadian Obesity Network to become a member of IASO and represent Canada.” TOS President Dr. Patrick O’Neil adds that “This decision has the full support of both the TOS and IASO governing councils as well as the CON-RCO board of directors. The three organizations believe this will benefit all our members, and we look forward to close collaboration as we work towards improving obesity prevention and treatment globally.” Membership in IASO offers members of the Network a number of benefits including: – Discounted fees for the Specialist Certification in Obesity Professional Education (SCOPE) education program – Discounted fees to IASO events, including ICO and Hot Topic Conferences – Substantially discounted fees for IASO journals (Pediatric Obesity, Clinical Obesity and Obesity Reviews) – Access to an exclusive repository of obesity prevalence data More importantly, perhaps, the many excellent obesity research programs and other initiatives happening across Canada will now gain even more international visibility and attention through this membership in IASO. I, for one, certainly look forward to this new and expanded role for the Canadian Obesity Network on the global stage. AMS Dallas, TX
Childhood Predictors of Adult Obesity
There are good reasons to believe that for a significant number of people, the foundations of adult obesity may well be established in early childhood or even in utero. This topic is the focus of an extensive review by Tristin Brisbois and colleagues from the University of Alberta, just published in OBESITY REVIEWS. In their paper, the researchers screen the literature on data supporting a role for a wide range of factors in early childhood (≤5 years of age) that potentially predict the development of obesity in adulthood. Factors of interest included exposures/insults in the prenatal period, infancy and early childhood, as well as other socio-demographic variables such as socioeconomic status (SES) or birth place that could impact all three time periods. Their review of over 8,000 citations, resulted in relevant 135 studies, which reported a total of 42 variables as being associated with obesity in adulthood. Of these, however, only seven variables made the cut as potential early markers of obesity. These included maternal smoking and maternal weight gain during pregnancy, maternal body mass index, childhood growth patterns (early rapid growth and early adiposity rebound), childhood obesity and father’s employment (a proxy measure for SES in many studies). Notably, neither early childhood nutrition or physical activity were identified as possible predictors. Although such association studies alone by no means imply causality, the identified variables are nevertheless worth considering as reasonable targets in the development of health promotion programmes to reduce the risk of adult obesity. Clearly, the feasibility and effectiveness of such measures remains to be demonstrated. AMS Dallas, TX Brisbois TD, Farmer AP, & McCargar LJ (2011). Early markers of adult obesity: a review. Obesity reviews : an official journal of the International Association for the Study of Obesity PMID: 22171945 . .
When Will We Bridge The Pharmacological Treatment Gap in Obesity?
Readers will recall my recent post on how even modest sustained weight loss (in the 3-10% range) can reduce cardiovascular events in high-risk obese patients (Stage2/3). Unfortunately, in clinical practice, most patients are unable to sustain even this rather modest degree of weight loss by lifestyle interventions alone. Indeed, the typical long-term weight-loss seen with lifestyle interventions alone is in the 3-5% range, even under the rather artificial (and generally more intense) setting of a clinical trial. In contrast, patients requiring sustainable weight loss of 20% or greater, may, more often than not, need to seriously consider bariatric surgery. This leaves a wide ‘therapeutic gap’ for patients requiring sustainable weight-loss in the 5-20% range, which lies beyond what can be generally achieved with lifestyle intervention alone but well below the degree of weight loss that would suggest the need for surgery. Addressing this ‘gap’ is now widely recognised as one of the most pressing unmet needs in chronic disease management, a need that recently prompted the US Senate’s Appropriations Committee to declare itself “concerned with the absence of novel medicines to treat obesity” and call the lack of obesity drugs “a significant unmet medical need”. Unfortunately, thus far, the pharmacological options that may help bridge this gap remain sparse. One of the few options on the horizon may be Qnexa, a fixed-dose combination of phentermine and controlled-release topiramate, that recently refiled for FDA approval after being sent back to the drawing board in 2010, mainly due to lingering concerns around the potential teratogenicity of topiramate. However, despite these concerns, Qnexa may be one of the few agents that could potentially help address this therapeutic gap in obesity management. A recent publication on Qnexa by Timothy Garvey and colleagues, in the American Journal of Clinical Nutrition, certainly allows room for guarded optimism. This paper presents the results of SEQUEL, a 52-week extension of CONQUER, a previously published 56-week placebo-controlled, randomised double-blind study of placebo, 7.5 mg phentermine/46 mg controlled-release topiramate (7.5/46), or 15 mg phentermine/92 mg controlled-release topiramate (15/92)] in addition to lifestyle modification. Of 866 eligible subjects from CONQUER, 676 (76%) elected to continue for a second year SEQUEL on their assigned treatments. Overall sustained weight-loss over the extension was –1.8%, –9.3%, and –10.5% for placebo, 7.5/46, and 15/92, respectively, with almost 80% of participants in the 15/92 treatment arm achieving at least 5% weight reduction, 50% achieving 10% reduction,… Read More »
Weekend Roundup, January 6, 2012
As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts: Obesity in 2012 Intentional Weight Loss Reduces Cardiovascular Outcomes Bariatric Surgery and Cardiovascular Deaths: Does Size Matter? Is It Time to Abandon BMI Criteria For Bariatric Surgery? Formula Diet Reduces Weight, Improves Nutritional Status, and Increases Bone Mineral Density Have a great Sunday! (or what is left of it) AMS Edmonton, Alberta You can now also follow me and post your comments on Facebook
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