The Obesity Alphabet Soup And Its Implications

Yesterday, I gave a day-long presentation to Aboriginal nurses and other health care workers from several First Nation reserves in Southern Saskatchewan. The event was organized and hosted by the Onion Lake Health Board with support from Health Canada. It was not difficult for me to fill the almost seven hours of the meeting with a roundup of the obesity problem – everything from the societal and environmental drivers of obesity, its economic and humanitarian implications, the problem of weight bias and discrimination, to obesity definitions, classification, genetics, biology, and management. During the talk I realized that some of my work has significantly contributed to what is now turning out to be an ‘alphabet soup’ that goes well beyond just BMI, WC, or WHR. As regular readers will recall, we have added EOSS (the Edmonton Obesity Staging System), the 4Ms (Mental, Mechanical, Metabolic, and Monetary drivers, complication and barriers), and now, the 5As (Ask, Assess, Advice, Agree, Assist), to the basics of obesity assessment and management. (some may wish to add HAES to this list) Although this alphabet soup may seem mysterious and perhaps daunting to some readers, it is gradually but steadily developing into a framework, which is beginning to flesh out a lot of what needs to change and happen in obesity management. This, at least, became quite clear to me during my presentation and the rather positive response of the almost 200 attendees only served to validate that these concepts have largely been missing in our clinical approach to obesity management. Supplement this alphabet soup with the etiological framework and ‘Best Weight‘, and we have a whole different way of approaching patients affected by excess weight. As I know that many of the attendees are also avid readers of these pages, I’d certainly appreciate any feedback and thoughts on yesterday’s workshop. AMS Regina, Saskatchewan p.s. obviously the obesity alphabet soup has far more letter – I wonder how many readers can decipher and name the following (in no particular order): PCOS, NAFLD, RNY, LABG, OSA, DVT, PCOS, PYY, GLP-1, T2D, OA, LVH, a-MSH, DEXA, ADHD, PTSD, RMR, NEAT, BAT, WAT.

Obesity and Mental Health – Beyond Pharmacotherapy

Continuing my posts on the recent articles on obesity and mental health published in the January issue of the Canadian Journal of Psychiatry, I now turn my attention to a paper by Valerie Taylor and colleagues on the many links between mental health issues and obesity. Whilst in the previous post I have focussed on the relationship between psychiatric medications and weight gain, a problem that is common knowledge to the mental health community, this article highlights many of the lesser known links between mental health problems and excess weight. These include interesting neurobiological, psychological, and sociological factors, that are now increasingly understood. For e.g. “‘Atypical’ depression, a type of major depressive disorder characterized by an increase in the need for sleep and food, may actually characterize the most ‘typical’ presentation of major depression For the majority of people with depression, therefore, a diagnosis of major depression is synonymous with a phenotype that increases vulnerability towards weight problems.” In fact, “The neurobiology of depression [also] confers increased risk of obesity. The most common biological perturbation associated with depression is an increase in cortisol. This increase, and the hypothalamic pituitary adrenal axis abnormalities that accompany it, is similar to changes seen in Cushing syndrome, an endocrinological illness caused by an increase in cortisol that is characterized phenotypically by excessive visceral weight gain. While levels of cortisol found in major depression disorders are much lower than that of Cushings, the biological impact of excess cortisol is similar; a predisposition towards increased deposition of centrally located adipose tissue.” In addition mood disorders often affect sleeping behaviour, which in turn affects important regulators of appetite and metabolism like ghrelin, leptin, adiponectin, and other hormones. Moreover, chronic inflammation may play a role in both major depression and obesity. In the case of schizophrenia, primary negative symptoms like amotivation, which can be observed even in the earliest stages of the illness, may lead to reduced physical capacity and altered self-perception. Hypodopaminergic activity may in part explain increased propensity for substance use, especially cannabis, which can promote hyperphagia. There is an increasingly recognized association between obesity and attention deficit disorder, and it may well be that impulsivity may play an important role in overeating. Also, “Poor planning and an inability to delay reward, processes largely mediated by the pre-frontal cortex, may lead individuals with ADHD to over-consume highly palatable, fattening foods. A related hypothesis is that individuals… Read More »

Should We Outsource Obesity Treatment To Weight Watchers?

Yesterday, I posted on Alberta’s plan to tackle obesity by beefing up prevention and treatment efforts across the province. Today, I discuss a paper by Susan Jebb and colleagues, just published online in The Lancet, comparing weight loss in people randomised to either ‘standard’ care with their physicians or to Weight Watchers. An accompanying editorial, suggest that doctors (or health systems) should perhaps give up on obesity treatments, as commercial programs (e.g Weight Watchers, Jenny Craig, etc.) do a much better job of this and may cost less. In this parallel group, non-blinded, randomised controlled trial, 772 overweight and obese adults were recruited by primary care practices in Australia, Germany, and the UK. Participants were randomly assigned with a computer-generated simple randomisation sequence to receive either 12 months of standard care as defined by national treatment guidelines (n=377), or 12 months of free membership to Weight Watchers (n=395). While only 61% of Weight Watchers participants completed the 12-month assessment, even fewer (54%) of standard care participants showed up for their 12-month assessment. Perhaps, not surprisingly, participants in the commercial programme group lost twice as much weight as did those in the standard care group (−5·06 kg vs. −2·25 kg) at 12 months. Based on these findings, the authors enthusiastically conclude that: “Referral by a primary health-care professional to a commercial weight loss programme that provides regular weighing, advice about diet and physical activity, motivation, and group support can offer a clinically useful early intervention for weight management in overweight and obese people that can be delivered at large scale.” Sure, but the question here is, for whom (or, in other words, for which patients) and, perhaps more importantly, with what benefit? So who took part in this study: it would probably be fair to describe the participants as essentially healthy, slightly overweight, pre-menopausal women – in fact, the usual people, who show up at most commercial weight loss programs. To be exact, the participants were 85% female, in their mid-forties, mildly obese at best (BMI ~31), and had perfectly normal blood pressures (124/78 mmHg), the occasional diabetes (6%) and a metabolic profile that would hardly raise an eyebrow from most health professionals. While weight loss appeared to move some of these variables in a ‘positive’ direction, one would be hard pressed to find the odd parameter that barely reached ‘statistical’ significance (let alone ‘clinical’ significance) – most clinicians would probably… Read More »

Attention Deficit Disorder

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network. This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest. ATTENTION DEFICIT DISORDER Attention deficit disorder with or without hyperactivity (ADD or ADHD) and impulsiveness has been associated with increased risk for weight gain in both children and adults. In one study, ADHD was present in over 25% of all obese patients and 40% of patients with class III obesity. Reasons for this prevalent co-morbidity are unknown, but brain dopamine or insulin receptor activity may be involved. Patients with ADD or ADHD usually manifest a long history (since childhood) of impulsivity, lack of concentration, decreased attention, inability to complete tasks, impairment in school or work performance and social dysfunction. Being “hyperactive” in the sense of the DSM-IV diagnosis of ADHD does not prevent the development or persistence of overweight and obesity in children. Bariatric patients showing poor focus during treatment should be investigated for ADD or ADHD. Identifying the disorder is crucial as they will not be able to focus on the weight- management plan until their impulsiveness and lack of concentration are addressed. Pharmacological and behavioural therapies can often help patients improve task persistence and decrease impulsivity and distractibility, which will increase the likelihood of success with weight-control efforts. © Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved. The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network. Members of the Canadian Obesity Network can download Best Weight for free. Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network) If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Cognitive Behavioural Therapy for Attention Deficit Disorder

Regular readers will recall that almost 30% of adults with severe obesity may have signs of attention deficit hyperactivity disorder (ADHD) and, when present, this can be a major barrier to weight management. Thus, all patient in our obesity clinic are routinely screened for ADHD and often treating this condition is the first step to successful weight management. However, not all patients with ADHD are willing to undergo treatment, some do not tolerate the medications, and in others, medications are simply not effective enough. Now, a study by Steven Safren and colleagues from Harvard University, Boston, MA, published in JAMA, demonstrates the effectiveness of adding cognitive behavioural therapy (CBT) to medication for better control of ADHD. Safren and colleagues randomised 86 symptomatic adults with ADHD who were already being treated with medication to 12 individual sessions of either cognitive behavioral therapy or relaxation with educational support (controls). 79 participants completed treatment and 70 completed the 12 month follow-up assessments. CBT was delivered according to the manual, “Mastering Your Adult ADHD” and consisted of 3 core modules and 2 optional modules. The first module (4 sessions) focused on psychoeducation about ADHD and training in organizing and planning (use of calendar and task list system), including problem-solving training (generating alternatives and picking the best solution, breaking down overwhelming tasks into steps). The second module (2 sessions) involved learning skills to reduce distractibility, such as techniques to time the length of one’s attention span, and, when doing a task, write down distractions vs acting on them. The third module (3 sessions) was cognitive restructuring, which involved learning to think more adaptively in situations that cause distress. Optional modules were one session of application of skills to procrastination and one session including the patient’s family member for support. Patients for whom the optional sessions were not relevant had booster sessions on prior material. The final session was focused on review and relapse prevention. Patients in the relaxation condition received training in progressive muscle relaxation and other relaxation techniques as applied to ADHD symptoms, as well as education about ADHD and supportive psychotherapy. Participants undergoing the CBT intervention achieved lower posttreatment scores and self-reported significant improvement in symptoms. Participants in the CBT arm were about four-times more likely to respond compared to the relaxation group. Most of this response was maintained over 6 and 12 months. This study demonstrates that the use of CBT in adults with… Read More »