Why Does The Food Addiction Model of Obesity Management Lack Good Science?
Yesterday’s guest post on the issue of food addiction (as expected) garnered a lively response from readers who come down on either side of the discussion – those, who vehemently oppose the idea and those, who report success. Fact is, that we can discuss the pros and cons of this till the cows come home, because the simple truth is that the whole notion lacks what my evidence-based colleagues would consider “strong evidence”. Indeed, I did try to find at least one high-quality randomized controlled study on using an addictions approach to obesity vs. “usual” care (or for that matter anything else) and must admit that I came up short. The best evidence I could find comes from a few case series – no controls, one observer, nothing that would compel anyone to believe that this approach has more than anecdotal merit. Yet, the biology (and perhaps even the psychology) of the idea is appealing. Self-proclaimed “food addicts” that I have spoken to readily identify with the addiction model and describe their relationship to “trigger foods” as an uncontrollable factor in their lives that calls for complete abstinence. Animal studies confirm that foods do indeed stimulate the same parts of the brain that are sensitive to other hedonic pleasures and substances. So why the lack of good data? After all, the idea is hardly new – intervention programs for “food addicts” using the 12 steps or other approaches have been around for decades. Can it be simply the lack of academic interest in this issue? I find that hard to imagine – but nothing would surprise me. Is it perhaps because addiction researchers do not take obesity seriously and obesity researchers don’t like the addiction model? I certainly don’t buy the argument that there is no commercial interest in such an approach – if there were strong and irrefutable evidence, I’m sure someone would figure out how to monetize it. So again, I wonder, why the lack of good data? Honestly, I don’t know. I’m open to any views on this (especially if substantiated by actual evidence). @DrSharma Berlin, Germany
If Oprah Can’t Why Do You Think You Can?
There are no doubt long-term “success stories” out there – people who just by making (often radical) changes in their diet and activity behaviours have lost a substantial amount of weight AND are keeping it off. However, there is also no doubt that these people are rare and far between – which is exactly what makes each one of them so exceptional. I am not speaking of all the people we hear or read about who have lost tons of weight – we hear about their spectacular weight loss – cutting carbs, cutting gluten, going vegan, going paleo, alternate day fasting, running marathons, training for iron man competitions, going on the Biggest Loser or eating at Subway. What we don’t hear about is the same people, when they put the weight back on – which, in real life is exactly what happens to the absolutely vast majority of “losers”. We hear of their “success” and then we never hear from them again – ever. Oprah is different! Different because, we have had the opportunity to follow her ups and downs over decades. When Oprah “succeeds” in losing weight, she does not disappear into the night – no – she puts the weight back right in front of our eyes, again and again and again and again. Now, comedy writer Caissie St.Onge, in a comment posted on facebook, pretty much summarizes what it is we can all learn (and should probably have learnt a long time ago) from Oprah: “Oprah is arguably the most accomplished, admired, able person in the world. She creates magic for other people and herself on the regular. So, if Oprah can’t do permanent lifelong weight loss, maybe it can’t be done. Oprah is also crazy rich. If Oprah can’t buy permanent lifelong weight loss, maybe it can’t be bought.” “I’m not saying you should give up on your dreams of having the body you want. I’m just asking, if you never get that waist, will your life have been a waste? (I see what I did there.) Every day we are bombarded with media, content and products. Special foods and drinks. Programs and plans. None of this shit has ever worked for Oprah and it probably isn’t gonna work for me or you.” “I know the reason isn’t because you’re weak. If you’re carrying around 10 or 20, or 50 or 150 pounds more than the tiny… Read More »
A Call To Action: Obesity In Children With Physical Disabilities
There is no doubt that children growing up in today’s obesogenic environment are at greater risk of developing obesity than previous generations. This is even more true for children with physical disabilities, who face even greater challenges when it comes to preventing or managing excessive weight gain. Unfortunately, not much is known about the extent of this problem or possible solutions. Now a group of Canadian experts in paediatrics and rehabilitation have put out a Call to Action, published in Childhood Obesity, for a research agenda that focuses on this important sub-group of kids. The call is the result of a Canadian multistakeholder workshop on the topic of obesity and health in children with physical disabilities that was held in October 2014. The participants in the workshop included researchers, clinicians, parents, former clients with disabilities, community partners, and decision makers. Given the paucity of research in this area, it is not surprising that the participants identified over 70 specific knowledge gaps that fell into 6 themes: (1) early, sustained engagement of families; (2) rethinking determinants of obesity and health; (3) maximizing impact of research; (4) inclusive integrated interventions; (5) evidence-informed measurement and outcomes; and (6) reducing weight biases. Within each theme area, participants identified potential challenges and opportunities related to (1) clinical practice and education; (2) research (subareas: funding and methodological issues; client and family engagement issues; and targeted areas to conduct research); and (3) policy-related issues and topic positioning. Recommendations emerging from the workshop’s multistakeholder consensus activities included: Children’s and families’ needs must be integrated into prevention and treatment programs, taking into account the additional caring commitments and environmental challenges often experienced by families of children with physical disabilities. Guidelines need to be developed regarding how best to engage children/families meaningfully in designing both clinical interventions and health promotion research initiatives. Research in obesity and health in children with physical disabilities should be guided by a conceptual model, determining both common and unique determinants of health and obesity compared with their typically developing peers. A conceptual model enables existing knowledge about obesity prevention and management from other populations to be integrated into approaches for children with physical disabilities where appropriate, as well as the identification of areas where disability-specific knowledge is still needed. It is critical that any such model incorporates social and environmental factors that can affect both weight and health, rather than locating responsibility within the individual by default.45 The alignment of our model with the ICF ensures… Read More »
Obesity: The Patient Perspective
A key reason for the Canadian Obesity Network to roll out its public engagement strategy, is not just provide a source of credible information on obesity prevention and treatment but also to provide a forum for the prospective of those living with obesity. That this perspective is often lost in the obesity debate, is highlighted by a thoughtful commentary published in JAMA Internal Medicine written by Fiona Clement, PhD, from the Department of Community Health Sciences, University of Calgary, and has herself struggled with excess weight for most of her adult life. Clement, whose BMI (at 31.8 kg/m2) barely fits the “obesity criteria”, notes that, “…this article is the first time I have told my BMI to another soul. I have never shared my BMI with my husband, my friends, nor, importantly, my physician. Given that I am an otherwise healthy 35-year-old woman, it is shocking that what is probably my only health concern has never been talked about within the privileged space of my physician-patient relationship.” Her reasons for not talking about this are not surprising, “Obviously, this is an awkward conversation for both the patient and physician. Weight is a tough subject, loaded with stigma, self-esteem, worthiness, and beauty issues. Despite guidelines recommending weight management counselling, the conversation is not happening regularly. Like many hard conversations, it requires compassionate listening and sympathy on the part of the physician, courage and humility from the patient.” This problem is well recognized, which is exactly why the Canadian Obesity Network’s 5As approach to obesity management emphasizes the tact and skills needed to initiate this conversation (ASK for permission, be non-judgemental, do not make assumptions). As to the use of appropriate obesity management strategies, Clement essentially opted for the most common “do-it-yourself” approach of “eat-less-move-more”, which as ample research shows is rarely a sustainable strategy. Not surprisingly, the weight she lost came back when, as she says, life happened. Clement writes about the information she would want presented before she made an informed decision to pursue any of the proposed interventions. This is exactly what the 3rd A in the 5As of Obesity Management is about – ADVISE. This is where, following the ASK and ASSESS, the health professional would offer their advice – tailored to the individual. Given that Clement barely meets the BMI criteria for obesity and has, as she states, no weight related health issues, she would at best be considered to have Stage… Read More »
It Is Time Canadian Benefits Plans Begin Considering Obesity A Disease
The recent declaration by the Canadian Medical Association that obesity is a chronic disease not only sends a strong signal to medical doctors to take this issue seriously but also has important consequences for Canadian benefits plans. As international readers may not be aware, while the Canadian publicly funded health care system covers all in-hospital costs and visits to doctors, it does not generally cover cost for medications or consultations with dietitians, psychologists or other allied health professionals in the community. These healthcare costs can be covered by private benefits plans, often paid or co-payed for by employers (plan sponsors). Thus, while consultations in hospital based clinics or primary care units are generally covered, whether or not patients have coverage for medications and other treatments depends on whether or not they have benefit plans. Unfortunately, when it comes to obesity, Canadian drug benefits plans generally do not cover treatments, as these plans consider obesity a “lifestyle” problem rather than a disease (e.g. unlike type 2 diabetes, which although as much a “lifestyle” issue, is covered as a disease). Thus, it will be interesting to see how the declaration of obesity as a chronic disease by the Canadian Medical Association, will change how obesity treatments are covered by Canadian benefits plans. Now a white paper sponsored by Novo Nordisk, the maker of Saxenda, a GLP-1 analogue recently approved for obesity treatment in Canada, outlines why reclassifying obesity as a disease would be of advantage to Canadian employers (who usually decide what is covered in the plans they buy for their employees). The paper summarizes finding from a series of meetings with obesity experts, patients, plan sponsors, benefits providers and advisors, and calls for a rethinking of obesity as a medical condition that can benefit from individualised and ongoing management. While it is obvious why Novo Nordisk would have an interest in better coverage for its anti-obesity drug, it is important to note that the white paper outlines the benefits of treating obesity like every other chronic disease that go well beyond just coverage for obesity drugs – rather it argues how this shift in thinking will benefit all Canadians affected by obesity irrespective of what treatment they chose. The full white paper is available on the Benefits Canada website and can be downloaded here. @DrSharma Edmonton, AB
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