What Do Health Professionals Need To Know About Obesity?

Achieving and maintaining competencies is an ongoing challenge for all health professionals. But in an area like obesity, where most will have received rather rudimentary training (if any), most health professionals will likely be starting from scratch. So what exactly must you expect of a health professional involved in the care of individuals living with obesity. This is the subject of a white paper on “Provider Competencies for the Prevention and Management of Obesity“, developed with support from the Robert Wood Johnson Foundation. The panel of authors led by Don Bradley (Duke) and William Dietz (George Washington) included representatives from over 20 national (US) professional organisations. The competencies expected cover the following 10 topics: Competencies for Core Obesity Knowledge 1.0 Demonstrate a working knowledge of obesity as a disease 2.0 Demonstrate a working knowledge of the epidemiology of the obesity epidemic 3.0 Describe the disparate burden of obesity and approaches to mitigate it Competencies for Interprofessional Obesity Care 4.0 Describe the benefits of working interprofessionally to address obesity to achieve results that cannot be achieved by a single health professional 5.0 Apply the skills necessary for effective interprofessional collaboration and integration of clinical and community care for obesity Competencies for Patient Interactions Related to Obesity 6.0 Use patient-centered communication when working with individuals with obesity and others 7.0 Employ strategies to minimize bias towards and discrimination against people with obesity, including weight, body habitus, and the causes of obesity 8.0 Implement a range of accommodations and safety measures specific to people with obesity 9.0 Utilize evidence-based care/services for people with obesity or at risk for obesity 10.0 Provide evidence-based care/services for people with obesity comorbidities Some of the topics include further subtopics that are deemed especially relevant. Thus, for e.g., topic 6.o, regarding communication, includes the following sub-competencies: 6.1 Discuss obesity in a non-judgmental manner using person-first language in all communications 6.2 Incorporate the environmental, social, emotional, and cultural context of obesity into conversations with people with obesity 6.3 Use person- and family-centered communication (e.g., using active listening, empathy, autonomy support/shared decision making) to engage the patient and others Similarly, topic 7.0, regarding the issue of weight bias and discrimination, includes the following sub-competencies: 7.1 Describe the ways in which weight bias and stigma impact health and wellbeing 7.2 Recognize and mitigate personal biases 7.3 Recognize and mitigate the weight biases of others This is clearly a forward-thinking outline of competencies that we will… Read More »

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How Do People With Obesity Spend Their Time?

We live in a time where most of us complain about the lack of it. Thus, I often remind myself that our “fast-food culture” is more a time than a food problem. Now a study by Viral Patel and colleagues, published in OBESITY, takes a detailed look at how US Americans spend their time according to different BMI categories. The researchers analyse data from over 28,503 observations of individuals aged 22 to 70 from the American Time Use Survey, a continuous cross-sectional survey on time use in the USA. In a statistical model that adjusted for various sociodemographic, geographic, and temporal characteristics, younger age; female sex; Asian race; higher levels of education; family income >$75 k; self-employment; and residence in the West or Northeast census regions were all associated with a lower BMI relative to reference categories whereas age 50 to 59 years; Black, Hispanic, or “other” race; and not being in the labor force were associated with a higher BMI. That said, here are the differences in time use associated with higher BMI: Although there were no substantial differences among BMI categories in time spent sleeping, overweight individuals experienced almost 20 fewer minutes of sleeplessness on weekends/holidays than individuals with normal weight. Furthermore, there was a U-shaped relationship between BMI and sleep duration such that BMI was lowest when sleep duration was approximately 8 h per day and increased as sleep duration became both shorter and longer. Less sleep on weekends and holidays (5 to 7 h) was also associated with higher BMI than 8 to 9 h or sleep. There were also no major differences between BMI categories and the odds of participating in work or in the amount of time working. However, working 3-4 h on weekends/holidays was associated with the lowest BMI. Individuals with obesity were more likely to be working between 3:30 a.m. and 7:00 a.m. on weekdays than normal-BMI individuals, again perhaps cutting into restful sleep. Individuals with obesity were less likely to participate in food and drink preparation than individuals with normal weight on weekdays but spent about the same amount of time eating or drinking as the reference category. Interestingly, individuals with obesity were more likely than individuals with normal weight to participate in health-related self-care, and overweight individuals spent over 1 h more on weekdays than individuals with normal weight on health-related self-care and also spent an additional 15 min (almost double… Read More »

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Arguments For Calling Obesity A Disease #2: It Is Driven By Biology

Continuing in my miniseries on reasons why obesity should be considered a disease, I turn to the idea that obesity is largely driven by biology (in which I include psychology, which is also ultimately biology). This is something people dealing with mental illness discovered a long time ago – depression is “molecules in your brain” – well, so is obesity! Let me explain. Humans throughout evolutionary history, like all living creatures, were faced with a dilemma, namely to deal with wide variations in food availability over time (feast vs. famine). Biologically, this means that they were driven in times of plenty to take up and store as many calories as they could in preparation for bad times – this is how our ancestors survived to this day. While finding and eating food during times of plenty does not require much work or motivation, finding food during times of famine requires us to go to almost any length and risks to find food. This risk-taking behaviour is biologically ensured by tightly linking food intake to the hedonic reward system, which provides the strong intrinsic motivator to put in the work required to find foods and consume them beyond our immediate needs. Indeed, it is this link between food and pleasure that explains why we would go to such lengths to further enhance the reward from food by converting raw ingredients into often complex dishes involving hours of toiling in the kitchen. Human culinary creativity knows no limits – all in the service of enhancing pleasure. Thus, our bodies are perfectly geared towards these activities. When we don’t eat, a complex and powerful neurohormonal response takes over (aka hunger), till the urge becomes overwhelming and forces us to still our appetites by seeking, preparing and consuming foods – the hungrier we get, the more we seek and prepare foods to deliver even greater hedonic reward (fat, sugar, salt, spices). The tight biological link between eating and the reward system also explains why we so often eat in response to emotions – anxiety, depression, boredom, happiness, fear, loneliness, stress, can all make us eat. But eating is also engrained into our social behaviour (again largely driven by biology) – as we bond to our mothers through food, we bond to others through eating. Thus, eating has been part of virtually every celebration and social gathering for as long as anyone can remember. Food is celebration, bonding, culture, and identity – all… Read More »

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Stretching The Rubber Band

I remember as a kid having a pair of pyjamas that were held up by an elastic rubber band. It must have been a pretty cheap rubber band, because every few months it would wear out and lose its stretch, so it had to be replaced it with a new band. Unfortunately, this is not what can be said about the rubber band that I used in my recent TEDx talk to demonstrate what happens when you try to lose weight. Unlike the cheap band in my pyjamas, the rubber band I used to represent our physiology trying to gain the weight back, never seems to lose its stretch. No matter how hard or how long we pull, the rubber band keeps wanting to bring our weight back to where we started. Yes, perhaps for some people, eventually the rubber band may relax (these would certainly be the exceptions) or may be the “muscles” that we use to pull on the band just grow stronger, which makes it seem easier to keep up the pull – but for all we know, in most people, this “rubber band” is of pretty good quality and seems to last forever. So, how do we take the tension out of the rubber band ? Well, we do know that people who have bariatric surgery have a much better chance of keeping the weight off in the long-term and we now understand that this has little to do with the “restriction” or the “malabsorbtion” resulting from these procedures but rather from the profound effect that this surgery has on the physiology of weight regain. Thus, we know that many of the hormonal and neurological changes that happen with bariatric surgery, seem to inhibit the body’s ability to defend its weight and perhaps even appears to trick the body into thinking that its weight is higher than it actually is. In other words, bariatric surgery helps maintain long-term weight loss by reducing the tension in the rubber band, thus making it far easier for patients to maintain the “pull”. And that is exactly how we think some of the anti-obesity medications may be working. For example, daily injections of liraglutide, a GLP-1 analogue approved for obesity treatment, appears to decrease the body’s ability to counteract weight loss by reducing hunger and increasing satiety, thus taking some of the tension out of that band. Think of it as sprinkling “magic dust” on that rubber band to reduce the… Read More »

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Are We Seeing An Upward Shift In Healthy Weights?

I don’t like the term “healthy” weights, because we have long learnt that good health is possible across a wide range of shapes and sizes. Nevertheless, epidemiologists (and folks in health promotion) appear to like the notion that there is such a weight (at least at the population level), and often define it as the weight (or rather BMI level) where people have the longest life-expectancy. Readers of this literature may have noticed that the BMI level associated with the lowest mortality has been creeping up. Case in point, a new study by Shoaib Afzal and colleagues from Denmark, published in JAMA, that looks at the relationship between BMI and mortality in three distinct populations based cohorts. The cohorts are from the same general population enrolled at different times: the Copenhagen City Heart Study in 1976-1978 (n = 13 704) and 1991-1994 (n = 9482) and the Copenhagen General Population Study in 2003-2013 (n = 97 362). All participants were followed up to November 2014, emigration, or death, whichever came first. The key finding of this study is that over the various studies, there was a 3.3 unit increase in BMI associated with the lowest mortality when comparing the 1976-1978 cohort with that recruited in 2003-2013. Thus, The BMI value that was associated with the lowest all-cause mortality was 23.7 in the 1976-1978 cohort, 24.6 in the 1991-1994 cohort, and 27.0 in the 2003-2013 cohort. Similarly, the corresponding BMI estimates for cardiovascular mortality were 23.2, 24.0, and 26.4, respectively, and for other mortality, 24.1, 26.8, and 27.8, respectively. At a population level, these shifts are anything but spectacular! After all, a 3.3 unit increase in BMI for someone who is 5’7″ (1.7 m) is just over 20 lbs (~10 Kg). In plain language, this means that to have the same life expectancy today, of someone back in the late 70s, you’d actually have to be about 20 lbs heavier. While I am sure that these data will be welcomed by those who would argue that the whole obesity epidemic thing is overrated, I think that the data are indeed interesting for another reason. Namely, they should prompt speculation about why heavier people are living longer today than before. There are two general possible explanations for this: For one these changes may be the result of a general improvement in health status of Danes related to decreased smoking, increased physical activity or changes in social determinants of health (e.g.… Read More »

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