Follow me on

The Canadian Obesity Network Is No More – Long Live Obesity Canada!

Over a decade ago, together with over 120 colleagues from across Canada, representing over 30 Canadian Universities and Institutions, I helped found the Canadian Obesity Network with the support of funding from the Canadian National Centres of Excellence Program. Since then the Canadian Obesity Network has grown into a large and influential organisation, with well over 20,000 professional members and public supporters, with a significant range across Canada and beyond. During the course of its existence, the Network has organised countless educational events for health professionals, provided training and networking opportunities to a host of young researchers and trainees, developed a suite of obesity management tools (e.g. the 5As of obesity management for adults, kids and during pregnancy), held National Obesity Summits and National Student Meetings. raised funds for obesity research, the list of achievements goes on and on. Most importantly, the Network has taken on important new roles in public engagement, voicing the needs and concerns of Canadians living with obesity, and advocating for better access to evidence-based prevention and treatments for children and adults across Canada. To better reflect this expanded mission and vision, the Board of Directors has decided to convert the Canadian Obesity Network into a registered health charity under the new name – Obesity Canada – Obésité Canada. So with one sad eye, I look back and hope that the Canadian Obesity Network rests in peace – Long Live Obesity Canada! @DrSharma Edmonton, AB

Full Post

Etiological Assessment of Obesity: Factors Affecting Ingestive Behaviour

Continuing with citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, we now turn to the some of the factors that can affect ingestive behaviour. Once you have quickly established that weight gain is not primarily driven by a change (decrease) in metabolic requirements, you turn to the most likely cause of weight gain – eating more calories than your body actually needs: Ingestive behaviour, which includes both eating and drinking, accounts for 100% of total energy intake. In contrast to total energy expenditure, caloric intake (on a daily basis) can vary from zero (fasting) to several times that of total energy requirements (e.g. during a binge eating episode). Given the ease with which it is possible for energy intake to exceed caloric expenditure, it is therefore not surprising that caloric hyperalimentation is a major determinant of weight gain. Any assessment of obesity or increase in body weight thus requires a careful assessment of ingestive behaviour. Evidence for caloric hyperalimentation or hyperphagia should in turn prompt systematic exploration of the determinants of this behaviour. In this context, it helps to view over‐eating as a symptom of an underlying perturbation of ingestive behaviour rather than simply a wilful behavioural choice. While the socio‐psycho‐neurobiological determinants of ingestive behaviour are exceedingly complex, in clinical practice, it is possible to divide them into four domains: socio‐cultural factors, biomedical or physiological (homeostatic) factors, psychological (hedonic) factors and medications. In a given individual, these domains are intimately connected and show considerable variation and overlap. Nevertheless, in practice it is often possible to determine the primary domain that explains the excess caloric intake in a given individual and can thus provide the key to developing a treatment plan that addresses the root cause of this behaviour. More on the various factors affecting ingestive behaviour  in coming posts. @DrSharma Edmonton, AB

Full Post

Do Anti-Depressants Promote Weight Gain?

There is no doubt that some people gain weight when started on anti-depressant medications. However, it is also true that the increased appetite and listlessness that accompanies “atypical” depression can contribute to weight gain. Finally, there is evidence that weight-gain in turn may decrease mood, which in turn may further exacerbate weight gain. Trying to cut through all of this is a study by Rafael Gafoor and colleagues from King’s College London, in a paper published in BMJ. They examined data from the  UK Clinical Practice Research Datalink, 2004-14, which included data on 136,762 men and 157,957 women with three or more records for body mass index (BMI). In the year of study entry, 17,803 (13.0%) men and 35,307 (22.4%) women with a mean age of 51.5 years were prescribed anti-depressants. While during 1, 836,452 person years of follow-up, the incidence of new episodes of ≥5 weight gain in participants not prescribed anti-depressants was 8.1 per 100 person years, it was slightly higher at 11.2 per 100 person years in those prescribed an anti-depressant. In the second year of treatment the number of participants treated with antidepressants for one year for one additional episode of ≥5% weight gain was 27. Thus, there appears to be a slight but discernible increased risk of weight gain associated with the prescription of anti-depressants, which may persist over time and appears highest during the second and third year of treatment. However, as the authors caution, these associations may not be causal, and residual confounding might contribute to overestimation of associations. Nevertheless, the notion that there may be a distinct weight-promoting pharmacological effect of some anti-depressants is supported by the finding that certain anti-depressants (e.g. mirtazapine) carry a far greater risk of weight gain than others (e.g. paroxetine). Given the frequency with which anti-depressants are prescribed, it could be argued that the contribution of anti-depressants to the overall obesity  epidemic (particularly in adults) may be greater than previously appreciated. If nothing else, patients prescribed anti-depressants should be carefully monitored for weight gain and preventive measures may need to be instituted early if weight gain becomes noticeable. @DrSharma Edmonton, AB

Full Post

Are Bariatric Centres of Excellence Meeting The Standards of Care?

Anyone familiar with the issue, would readily agree that the actual surgery involved in bariatric surgery is only a small (but undeniably important) technical piece in what is a rather complex treatment for a rather complex chronic disease. Clearly, this is not exactly how all bariatric surgeons approach or treat their bariatric patients. Since 2012, the US has a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program that designates bariatric surgery centers as Centres of Excellence if they meet specified requirements in 7 core standards that include case volume, commitment to quality, appropriate use of equipment and instruments, critical care support, continuum of care, data collection, and continuous quality improvement. However, as a recent paper by Andrew Ibrahim and colleagues, published in JAMA Surgery, elaborates, despite these quality criteria, there remains a substantial variability in outcomes across designated Bariatric Centres of Excellence. Based on their retrospective analysis of claims data from 145 527 patients who underwent bariatric procedures, there was a 17-fold variation (ranging from 0.6% to 10.3%) in rates of serious 30-day complications across accredited bariatric centers nationally and up to 9.5-fold variation across individual states. As the authors note, “this finding suggests that participation alone in the Center of Excellence Program did not ensure uniform high-quality care….Given that most bariatric procedures are now performed at accredited centers, wide variation among these centers suggests that accreditation alone does not discriminate enough to guide patients to the best centers for care.” Moreover, they found that poor performing centres were often located close to better performing centres (regression to the mean?). Interestingly, in contrast to what one may suspect, outcomes overall were not related to case volume (perhaps because in order to be a designated Centre of Excellence, all centres needed to have a minimum number of cases per year). Rather, the authors discuss that poorer outcomes may be largely attributable to varying technical skills of the surgeons as well as inconsistent adherence to accepted bariatric care pathways. Finally, the authors argue that there is  need to make performance data available to the public, as simply trusting in the “Centre of Excellence” designation by no means guarantees excellent outcomes. As important as these data may be, it is also important to note that this paper only looked at complications within a 30-day time period following surgery. As anyone dealing with bariatric patients is well aware, successful outcomes of bariatric surgery(as well as its… Read More »

Full Post

Liraglutide Effects on Upper Gastrointestinal Investigations: Implications Prior to Bariatric Surgery

With the considerable waits that patients in Canada often face prior to bariatric surgery, we generally recommend that patients, who have access to them, try anti-obesity medications while waiting. This not only prevents further wait gain, but also often helps them shed a significant amount of weight prior to surgery. The GLP-1 analogue liraglutide is now approved for long-term obesity treatment and is generally well tolerated. Nevertheless, we now present a series of patients in Obesity Surgery, who were treated with liraglutide 3.0 mg whilst waiting for bariatric surgery, and showed significant upper GI dismotility that was reversible on discontinuation of liraglutide. Although, investigations of upper GI motility are by no means part of routine assessment for bariatric surgery, tests may be ordered in patients who present with unclear upper GI symptoms, as the findings may guide the choice of surgical intervention. In this paper, we present six cases in which patients treated with liraglutie 3.0 mg presented with varying degrees of esophageal and/or gastric dysmotility demonstrated using a variety of investigative procedures including formal gastric emptying scintiography as well as less specific  esophageal manometry, and upper endoscopy. In all cases normal motility was restored on discontinuation of liraglutide and all patients subsequently underwent or are continuing to wait for bariatric surgery. Based on our observations we discuss that, “Liraglutide is associated with decreased esophageal peristalsis and gastric emptying. These effects can result in abnormal upper GI investigations, leading to delays, increased testing, and questions of patient candidacy for surgery. If patients on liraglutide are noted to have abnormal esophageal manometry or gastric emptying studies, medication should be discontinued, with repeat studies done to look for reversibility. If this abnormal result is due to drug effect, this should not preclude patients from having bariatric surgery.” Just how long liraglutide needs to be stopped prior to performing upper GI investigations remains unclear. Furthermore, as the dysmotility often appears to be symptomless and well-tolerated, we do not recommend routine ordering of motility tests in patients treated with liraglutide. @DrSharms Edmonton, AB Disclaimer: I have served as a consultant and speaker for Novo Nordisk, the makers of liraglutide.

Full Post