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Does Maternal Obesity Promote ADHD?

Regular readers of my blog know about the risk of increased pre-pregnancy weight and pregnancy-induced weight gain for mother and child. Readers may also recall my posting on the potential importance of recognizing attention deficit disorder (ADD) as a common and important barrier to obesity treatment. This month, a new study by Alina Rodriguez and colleagues from the University of Upsalla, Sweden, published in the International Journal of Obesity, may help bring it all together. Rodriguez and colleagues examined whether pregnancy weight (pre-pregnancy body mass index (BMI) and/or weight gain) is related to core symptoms of attention deficit hyperactivity disorder (ADHD) in school-age offspring. They analyzed data from three separate prospective pregnancy cohorts from Sweden, Denmark and Finland within the Nordic Network on ADHD. Maternal pregnancy and delivery data were collected prospectively. Teachers rated inattention and hyperactivity symptoms 12 556 school-aged offspring in relationship to maternal weight measures. While gestational weight gain was unrelated to ADHD rate, the researchers found significant associations between pre-pregnancy overweight or obesity and a high ADHD symptom score in offspring, ORs ranged between 1.4 and 1.9 fold higher despite adjustment for gestational age, birth weight, weight gain, pregnancy smoking, maternal age, maternal education, child gender, family structure and cohort country of origin. Children of women who were both overweight and gained a large amount of weight during gestation had a 2-fold risk of ADHD symptoms compared to normal-weight women. Although the authors carefully note that associations do not prove causality, they do point out that if future studies prove causality, then we may need to add ADHD to the list of deleterious outcomes related to maternal overweight and obesity in the prenatal period. It would certainly explain why ADHD is so common in patients battling overweight and obesity. AMSEdmonton, Alberta

Setting Up an Obesity Program: Importance of Having a Diagnostic and Consultant Network

Irrespective of what services you can integrate into your obesity clinic, there will always be issues that require consultation with other specialists or require diagnostic procedures outside your clinic. Or, as I learnt early in my medical practice, the two most important skills of being a good doctor are knowing when to consult a colleague and knowing who to consult.  Areas in which any obesity clinic will most likely need regular consult services include psychiatry, sleep medicine, gastrointestinal medicine and hepatology, thrombosis, uro-gynaecology, respiratory medicine, cardiology, orthopaedic surgery, plastic surgery and a few others. Common diagnostic requirements will include ultrasounds, cardiac testing, CTs, MRIs, etc.  In all cases, you will find colleagues who are happy to see patients with obesity and those who are not. You will also find that certain diagnostic procedures have technical or weight limitations for patients with obesity. Ideally you would be able to identify at least one colleague in each of these disciplines who will welcome patients with obesity into their clinics and are willing to work closely with you in helping your patients deal with these issues.  Be aware that it may take time for colleagues to recognise and adapt to the special needs of this population. Not everyone is comfortable practicing bariatric psychiatry, bariatric cardiology, or bariatric plastic surgery. Over time, hopefully, these colleagues will come to appreciate the issues specific to patients with obesity.  A good source of determining whether or not your patients with obesity are welcomed and well treated are your patients themselves. Sometimes patients will complain about a specific consultant or practice and in my experience it is often worthwhile bringing this to their attention, as they may be unaware of how their attitude or statements are being received. Sometimes the complaints may not be about the colleagues themselves but rather about their clinic personnel or even just about the ambience and infrastructure.  Many colleagues will thank you for this feedback and many will change their practice. In cases where patients continue to complain, you may be better off looking for a new consultant for that specific issue.  One important reason for having competent consultants at hand is, because patients presenting at an obesity centre may often have problems that need to be dealt with before you can have any hope of helping them manage their obesity. This includes patients with unmanaged or uncontrolled psychiatric issues like depression, anxiety, or… Read More »

Setting Up An Obesity Program: Medical Expertise and Leadership

Now that we’ve looked at some of the issues around gathering administrative support for setting up an obesity program, we must turn our attention to the next key step, i.e. finding personnel to staff the program. This of course starts with finding appropriate leadership for the program – be it medical or surgical.  Today, thanks to the proliferation of bariatric surgery, finding surgical leadership for a bariatric program is in many ways far less challenging than finding medical leadership. Indeed no one would today consider hiring a bariatric surgeon who has never performed such operations to run a program. Bariatric procedures are now increasingly listed in many licensing catalogues for general abdominal surgery. There are also an increasing number of surgical bariatric centres, which regularly train residents and fellows. Thus, finding a trained bariatric surgeon to establish and lead a bariatric surgery program is rather straightforward.  In contrast, finding experienced and qualified medical leadership for an obesity centre is far more challenging. For one, while you would require a surgeon to have performed a certain number of bariatric procedures (hopefully in the hundreds) before claiming expertise in the area, no such requirements exist for other health professionals.  Thus, there is currently no accepted pathway or minimal requirement that would stop any medical professional who takes an interest in this field from setting up their own “weight-management” program.  As in my case, when I embarked on running my first obesity clinic two decades ago, I had no specific training or experience in obesity medicine – in fact the term “obesity medicine” was not even around yet. All I had was a bunch of, what I then thought were, good ideas, an interest in the field, and strong administrative support to do something in this area.  My story is by no means unusual. Most of my colleagues in this field had little, if any, formal training in obesity medicine and had little more than good intentions and a lot of hope and determination when they set out to work in this area. Many were guided by their own personal “weight-loss-success” stories, their strong interest in “preventive medicine”, or simply their fascination with healthy eating and/or exercise. Few had ever worked in an actual obesity program. Even fewer had completed a formal fellowship or had any kind of training or certification in this field.  Given that there is no accepted pathway to obesity medicine,… Read More »

Arguments Against Obesity As A Disease #1: BMI Is Not A Good Measure Of Health

Over the past months, I have been involved in countless discussions and debates about whether or not obesity should be considered a chronic disease (as it has by the American and Canadian Medical Associations and a number of other organisations). I therefore thought it perhaps helpful if I discussed each of the common pros and cons on this issue in a series of blog posts. To begin this short series, I’d like to discuss perhaps the most common argument against calling obesity a disease, namely, the well-known shortcomings of BMI. As regular readers will know, I have long railed against the use of BMI as a clinical definition of obesity as it is neither a direct measure of body fatness nor does it directly measure health. In fact, its specificity and sensitivity to pick up health problems commonly associated with obesity (such as type 2 diabetes or hypertension) is so limited, that it would not even remotely meet the criteria commonly applied to other diseases for diagnostic testing. Thus, especially around the BMI cut off of 30 (widely used to “define” obesity in Caucasians), anywhere from 5-25% of individuals would be considered pretty healthy by almost any clinical measure. Even at higher BMI cut offs, it is not all that difficult to find individuals with very mild to non-existent health problems related to their size (as in EOSS 0-1). While some of these individuals may well go on to develop health problems over time, “risk for” a disease is generally not considered a “diagnosis” of that disease. Thus, even if an elevated BMI may indicate increased risk of obesity, it cannot be used to “define” an individual as having the “disease of obesity”. This shortcoming of BMI has been widely (albeit perhaps not widely enough) recognised, which is exactly why, for e.g. the Canadian Medical Association, in their declaration of obesity specifically states that, “BMI is a useful operational definition for obesity but should not be used as the defining characteristic of the disease….in the case of individuals who are very obese, issues of definition and measurement are not relevant.” (emphasis mine) Similarly the WHO in its definition of obesity states that, “BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness… Read More »

Obesity & Energetic Offerings

For several months now, my colleagues at the University of Alabama have been compiling a weekly list of selected obesity related articles in a list they call Obesity and Energetic Offerings. The list is compiled by David B. Allison, Michelle Bohan-Brown, Emily Dhurandhar, Kathryn Kaiser, and Andrew Brown. The following is this week’s list – the selection are theirs, not mine: Findings Contrary to Hypotheses or Common Beliefs RCT: Calorie menu labeling had no effect on total calories ordered. Click Here The density of healthy food outlets did not predict consumption of fruits or vegetables in NYC. Click Here Densities of supermarkets and other retail outlets are not associated with fruit and vegetable purchases. Click Here Non-monotonic relation of dietary energy density to body composition and growth in pigs. Click Here Are plant-based diets environmentally friendly? Click Here Compared with infants fed formulas, infants fed breast milk had higher fat mass at age 3 months, and lower fat-free mass at age 6-12 months. Click Here Policy-Related Unambiguous Identification of Obesity Trials. Click Here Substitution Patterns Can Limit the Effects of Sugar-Sweetened Beverage Taxes on Obesity. Click Here Sugar-Related RCT: Effects of Caloric and Non-caloric Beverages Consumed Freely at Meal-time on Ad libitum intake. Click Here RCT: Neither HFCS nor table sugar increases liver fat under ‘real world’ conditions. Click Here RCT: Four hypocaloric diets containing different levels of sucrose or high fructose corn syrup do not produce different weight losses.Click Here Basic Science X and Y Chromosome Complement Influence Adiposity and Metabolism in Mice. Click Here The immune system’s involvement in obesity-driven type 2 diabetes. Click Here Accelerated fat cell aging links oxidative stress and insulin resistance in adipocytes. Click Here Asthma drug amlexanox reverses obesity and diabetes in mice. Click Here Children with obese fathers show epigenetic changes that may affect their health. Click Here Chronic treatment with a melanocortin-4 receptor agonist causes weight loss, reduces insulin resistance, and improves cardiovascular function in obese rhesus macaques. Click Here Cycles of protein restriction improved memory and slowed advance of the Alzheimer’s-like disease in mice. Click Here Early Life Nutritional Programming of Obesity: Mother-Child Cohort Studies. Click Here Evidence of Brown Fat Activity in Constitutional Leanness. Click Here Gut Microbiota Helicobacter pylori colonization suppressed weight gain in mice. Click Here RCT: A Mixture of trans-Galactooligosaccharides Reduces Markers of Metabolic Syndrome and Modulates Fecal Microbiota and Immune Function of Overweight Adults. Click… Read More »