Hindsight: Bariatric Medicine Without Surgery is Like Nephrology Without Dialysis
One of the first articles I wrote after arriving in Canada as Canada Research Chair (Tier 1) in Cardiovascular Obesity Research and Management at McMaster University, was an editorial published in OBESITY SURGERY, in which I expressed my frustration about not having ready access to bariatric surgery for my patients, who desperately needed it. In this article I noted that “On accepting the position, I knew that I would be required to do some pioneering work: obesity or rather bariatric medicine is not a ‘recognized’ medical speciality. Rotation in an ‘obesity unit’ is neither a requirement nor of interest to the majority of medical residents. Most doctors’ understanding of obesity, its causes, its complications, and its management is not substantially different from that of a lay person. The well-known bias and discrimination that meets obese patients is also encountered in the commonly held views on the need for and delivery of medical and surgical treatment for this condition.” “Within weeks of my arrival, referrals for patients began coming in, rapidly growing to over 20 per week. Within a few months, calls were coming in from across the province. One of the first patients I was called to see was a 41-year-old man weighing 436 kg, who had spent the last 9 months in an intensive care unit where he was being treated for intractable lymphedema and cellulitis of his lower extremities. The patient was living in his own ICU suite, while his caregivers were exploring the possibility of having him accepted for obesity surgery. It was already evident that this surgery could not be performed in Canada.” “Within the first 6 months of my practice, I saw the heaviest people I had ever seen in my life. BMIs >50 kg/m2 were the rule rather than the exception. Most were below the age of 45, virtually none were currently employed, few had drug plans, and none had coverage for antiobesity medication. The majority had a history of childhood-onset obesity, all had significant co-morbidities including diabetes, reflux disease, sleep apnea, and debilitating back and knee pains. All had significant histories of weight loss attempts, ranging from Weight Watchers and very low- calorie diets to rather questionable ‘medically supervised’ commercial weight loss programs. Many had also failed on pharmacotherapy. None had thus far been offered surgical treatment – the few who had tried to find surgeons in Canada soon discovered that there were only six surgeons performing obesity… Read More »
More Evidence Why BMI Alone Should Not Guide Medical Decision Making
Regular readers will have followed the track of studies demonstrating that BMI is but a poor measure of health. This is why we came up with the Edmonton Obesity Staging System, that defines obesity based on the actual presence of physical, mental, and/or functional problems and limitations. Readers will recall, that we have previously shown that Obesity Stage – in contrast to BMI – is a powerful predictor of CV and all-cause mortality. Now, yet another study, which looks at the relationship between BMI and mortality, again shows that ‘metabolically healthy’ obese individuals do not have an increased risk for CV mortality and in fact have a lower risk than ‘metabolically unhealthy’ non-obese individuals. This study by Mark Hamer and Emmanuel Stamatakis from University College London, UK, published in the Journal of Clinical Endocrinology and Metabolism, looks at data from an observational study with prospective linkage to mortality records in community-dwelling adults from the general population in Scotland and England. The sample includes 22,203 men and women [aged 54.1 y, 45.2% men] without known history of CVD at baseline followed for an average of about 7 years. Based on blood pressure, high-density lipoprotein-cholesterol, diabetes diagnosis, waist circumference, and low-grade inflammation (C-reactive protein ≥ 3 mg/liter), participants were classified as metabolically healthy (0 or 1 metabolic abnormality) or unhealthy (two or more metabolic abnormalities). Obesity was defined as a body mass index of 30 or greater. Compared with the metabolically healthy nonobese participants (about 20% of the obese population), their obese counterparts were not at elevated risk of CVD or all cause mortality. On the other hand, both non-obese and obese participants with two or more metabolic abnormalities were at elevated risk. Not surprisingly, metabolically unhealthy obese participants were at elevated risk of all-cause mortality compared with their metabolically healthy obese counterparts. These data fit nicely with our findings using the obesity staging system. Thus, in our studies of the NHANES and Cooper Longitudinal Fitness Study, we found that Stage 0 and 1 obese individual (i.e. those with no or pre-clinical risk factors) did not have an increase risk compared to Stage 2+ individuals (those with comorbidities and/or endorgan damage). Consistent with the present study, we also found that about 50% of non-obese individuals (in the BMI 25-30 range), would in fact fall into the Stage 2+ categories based on metabolic or other abnormalities. Thus, simply using BMI as an indication… Read More »
How Much Weight Will You Gain When You Quit Smoking?
One of the key drivers of smoking, especially amongst younger women, is to control their weight. No doubt cigarettes can reduce appetite and increase metabolic rate thus making it easier to avoid weight gain. Unfortunately, this also means that many, who try to give up smoking, will probably put on a few pounds – but just how many pounds are we talking about? This question was addressed in a paper by Henri-Jean Aubin and colleagues from the Université Paris Sud just published in the British Medical Journal. The authors identified all studies listed in the Central Register of Controlled Trials (CENTRAL) and trials listed in Cochrane reviews of smoking cessation interventions (nicotine replacement therapy, nicotinic partial agonists, antidepressants, and exercise) for randomised trials of first line treatments (nicotine replacement therapy, bupropion, and varenicline) and exercise that reported weight change. They also searched CENTRAL for trials of interventions for weight gain after cessation. A total of 62 studies were included in their analysis. In untreated quitters, mean weight gain was 1.12 , 2.26, 2.85, 4.23, and 4.67 kg at one, two, three, six, and 12 months after quitting, respectively. At 12 months after smoking cessation 13% of untreated quitters gained more than 10 Kg, 34% gained 5-10 Kg, 37% gained less than 5 Kg, and 16% actually lost weight. There was no differences in changes in body weight between those who appeared concerned about their body weight and those who were not. Treatment for smoking cessation (nicotine patch or buproprion) did not seem to have much effect in preventing weight gain. Thus, it appears that smoking cessation is associated with a mean increase of 4-5 kg in body weight after 12 months of abstinence, with most of this weight gain occurring within the first three months of quitting. However, there is a remarkable variation in weight change is large with about 16% of quitters losing weight and an almost equal number (13%) gaining more than 10 kg – a substantial weight gain by any standard. If I had to guess, I’d say that those with the strongest addiction are the ones most likely to gain more weight, as they are also the ones most likely to shift their addiction from nicotine to food. Non-dependent smokers will likely fall into the lesser weight gain or even weight loss categories. At least that is a hypothesis that I’d like to see tested. With… Read More »
Join the 5As Community of Practice
Regular readers will be well aware of the 5As of Obesity Management™ tools and resources recently launched by the Canadian Obesity Network. Since its launch, over 2,000 toolkits have been distributed to practitioners around the country – more orders are pouring in daily. Everyone interested in the 5As of Obesity Management is now invited to join the 5As Community of Practice on FaceBook. This is where you can Learn more about how to best use the 5As in your practice Ask questions about the 5As to your colleagues and experts Share your experience and feedback on the 5As Make suggestions regarding additional resources for the 5As Provide your tips and suggestions on how to use the 5As Or simply stop by to say ‘hi’ If you are a patient, who has experienced the use of the 5As, we want to hear from you too! To join the 5As of Obesity Management Community of Practice click here. To order your personal 5As Toolkit click here. AMS Edmonton, Alberta
Mental Health And Childhood Obesity: A Note to Policy Makers and Clinicians
Earlier this month, the Canadian Obesity Network, in partnership with IASO and CAMH, released the Toronto Charter on Obesity and Mental Health. Although the Charter acknowledges the importance of recognising the rather close relationship between obesity and mental health both in adults and children, the focus of this Charter (and the conference leading up to it) was largely on adults. Now, Shelley Russel-Mayhew (U of Calgary), who spoke a the Toronto Obesity and Mental Health Conference, and colleagues, publish a comprehensive overview of mental health, wellness and childhood overweight and obesity in the Journal of Obesity. The researchers performed a systematic literature search of peer-reviewed, English-language studies published between January 2000 and January 2011 on this issue. They identified 759 unique records, of which 345 full-text articles were retrieved and 131 articles included in their analyses. Based on these findings, they propose a theoretical model that reflects the current state of the literature and includes psychological factors (i.e., depression and anxiety, self-esteem, body dissatisfaction, eating disordered symptoms, and emotional problems); psychosocial mediating variables (i.e., weight-based teasing and concern about weight and shape), and wellness factors (i.e., quality of life and resiliency/protective factors). Based on their findings, they recommend a number of possible solutions to addressing the rise in childhood obesity rates without (importantly!) further marginalize overweight and obese children and youth. These include increasing mental resilience, stopping the focus on weight, recognising that many weight-related issues are socially constructed and maintained, promoting healthy body images (regardless of size or shape), and targeting positive adult role models. Thus, the authors conclude that, “…intervening for the psychosocial emotional health of overweight/obese children should be a focus in and of itself and not just an “add-on” measure to a primary outcome that is targeting weight reduction or the cessation of weight gain. Public health policy in the area of childhood obesity needs to encourage healthy body image, advocate that healthy behaviours come in every shape and size, and consider weight bias and weight and shape concerns as fundamental. In terms of mental health and wellness, this type of shift in paradigm could benefit all children and youth potentially for generations to come.” Readers will find many of these thoughts reflected in the Toronto Charter and will certainly recognise many of these principles in many of the posts throughout these pages. AMS Edmonton, Alberta Russell-Mayhew S, McVey G, Bardick A, & Ireland A (2012).… Read More »
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