Alternate Day Fasting Is No Better Than Any Other Fad Diet
It seems that every year someone else comes up with a diet that can supposedly conquer obesity and all others health problems of civilization. In almost every case, the diet is based on some “new” insight into how our bodies function, or how our ancestors (read – hunters gatherers (never mind that they only lived to be 35) ate, or how modern foods are killing us (never mind that the average person has never lived longer than ever before), or how (insert remote population here) lives today with no chronic disease. Throw in some scientific terms like “ketogenic”, “guten”, “anti-oxidant”, “fructose”, or “insulin”, add some level of restriction and unusual foods, and (most importantly) get celebrity endorsement and “testemonials” and you have a best-seller (and a successful speaking career) ready to go. The problem is that, no matter what the “scientific” (sounding) theories suggest, there is little evidence that the enthusiastic promises of any of these hold up under the cold light of scientific study. Therefore, I am not the least surprised that the same holds true for the much hyped “alternative-day fasting diet”, which supposedly is best for us, because it mimics how our pre-historic ancestors apparently made it to the ripe age of 35 without obesity and heart attacks. Thus, a year-long randomised controlled study by John Trepanowski and colleagues, published in JAMA Internal Medicine, shows that alternate day fasting is evidently no better in producing superior adherence, weight loss, weight maintenance, or cardioprotection compared to good old daily calorie restriction (which also produces modest long-term results at best). In fact, the alternate day fasting group had significantly more dropouts than both the daily calorie restriction and control group (38% vs. 29% and 26% respectively). Mean weight loss was virtually identical between both intervention groups (~6 Kg). Purists of course will instantly critisize that the study did not actually test alternative-day fasting, as more people dropped out and most of the participants who stayed in that group actually ate more than prescribed on fast days, and less than prescribed on feast days – but that is exactly the point of this kind of study – to test whether the proposed diet works in “real life”, because no one in “real life” can ever be expected to be perfectly compliant with any diet. In fact, again, as this study shows, the more “restrictive” the diet (and, yes, starving yourself… Read More »
GLP-1 Analogue Semaglutide Appears Promising in Phase 2 Study
Readers may by now be familiar with the GLP-1 analogue liraglutide, which has now been approved at the 3 mg dose (Saxenda(R)) for long-term obesity treatment in a growing number of countries. Now, Novo Nordisk, the maker of liraglutide, announced preliminary results from their long-acting GLP-1 analogue semaglutide, suggesting a rather remarkable ~14% weight loss in a one-year double-blind placebo controlled dose-finding study. According to the company’s press release, In the trial, 957 people with obesity were randomised to treatment with doses of semaglutide between 0.05 to 0.4 mg/day or placebo. Liraglutide 3.0 mg/day was included for comparison. Approximately 100 people were included in each active treatment arm in combination with diet and exercise. All people in the trial were treated for 52 weeks followed by a 7-week follow-up period. Furthermore, From a mean baseline weight of around 111 kg and a body mass index of approximately 39 kg/m2, a weight loss up to 17.8 kg was observed after 52 weeks of treatment with semaglutide. This corresponded to an estimated 13.8% weight loss compared to the weight loss of 2.3% achieved by diet, exercise and placebo alone, with all treatment arms adjusted for people discontinuing treatment in the study. The results from the liraglutide 3.0 mg treatment arm were broadly in line with previously reported data. Side effects were mainly reported as gastro-intestinal, as expected from this class of hormone analogues. Clearly, if borne out by the final publication and confirmed in larger and longer studies, semaglutide may well prove to be even more effective than liraglutide. It may be worth noting, that the ~14% weight loss reported in this trial comes very close to the mean ~15% weight loss seen with adjustable gastric banding, a bariatric surgical technique that is now increasingly seen as obsolete due to long-term complications and loss of effectiveness. I’m guessing it’s now on to Phase 3 for this promising anti-obesity drug. @DrSharma Edmonton, AB Disclaimer: I have received speaking and consulting honoraria from Novo Nordisk, the maker of liraglutide and semaglutide
Report Card on Access to Obesity Treatment for Adults in Canada 2017: Recommendations
Based on the failing access to obesity care for the overwhelming majority of the 6,000,000 Canadians living with obesity in our publicly funded healthcare systems, the 2017 Report Card on Access To Obesity Treatment For Adults, released the 5th Canadian Obesity Summit, has the following 7 recommendations for Canadian policy makers: Provincial and territorial governments, employers and the health insurance industry should officially adopt the position of the Canadian Medical Association that obesity is a chronic disease and orient their approach/resources accordingly. Provincial and territorial governments should recognize that weight bias and stigma are barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems and education. Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity programs and products for their employees through health benefit plans. Provincial and territorial governments should increase training for health professionals on obesity management. Provincial and territorial governments and health authorities should increase the availability of interdisciplinary teams and increase their capacity to provide evidence- based obesity management. Provincial and territorial governments should include anti-obesity medications, weight-management programs with meal replacement and other evidence-based products and programs in their provincial drug benefit plans. Existing Canadian Clinical practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of programs and policies of federal, provincial and territorial governments, employers and the health insurance industry. If and when any of the stakeholders adopt these recommendations is anyone’s guess. However, I am certain that since the release of the Report Cards, the relevant governments and other stakeholders are probably taking a closer look at what obesity management resources are currently being provided within their jurisdictions. Given that things can’t really get any worse, there is hope that eventually Canadians living with obesity will have the same access to healthcare for their chronic disease as Canadians living with any other illness. @DrSharma Edmonton, AB
Bariatric Surgery: More Is Still Not Enough
Bariatric surgery is now widely considered by far the best effective long-term treatment for severe obesity – the long-term benefits on morbidity and mortality are well-documented (not to say that there cannot be problems in individual patients, but overall, the average outcomes are pretty remarkable). That said, bariatric surgery is still not as widely available in Canada as surgical treatments for other health issues. Nevertheless, over the past decade, yearly bariatric surgery rates in the Canadian public healthcare system have increased from around 3,000 a year in 2009 to over 8,500 in 2016. However, as pointed out in the 2017 Report Card on Access To Obesity Treatment For Adults, released last week at the 5th Canadian Obesity Summit, despite this increase, only about 1 in 200 Canadians with Obesity Class II or III would have access to surgery per year (at this rate it would take 200 years to do everyone eligible today). What is also the remarkable is the variation in access to surgery from one province to the next. For e.g. while 1 in 90 eligible patients have access in Quebec, the corresponding number for Canadians living in Nova Scotia is 1 in 1,300, an almost 15-fold difference in access! I can think of no other disease or treatments that would have a 15-fold difference in access between provinces. Not quite as dramatic are the differences between Alberta (1 in 300) and its direct neighbour Saskatchewan (1 in 800). Even Newfoundland and Labrador does better with (1 in 390). With these low rates, every province (except Quebec) gets an “F” for access and waiting times that range from 18 months (Alberta) to 60 months (Nova Scotia). So, yes, while access to bariatric surgery has certainly improved in Canada in the last decade, getting it remains a rather long haul – a significant number of years of life lost, if you’re facing serious health problems from your obesity. @DrSharma Edmonton, AB
Why Would Anyone Want Access to Prescription Medications For Obesity?
Just imagine if the question in the title of this post was, “Why would anyone want access to prescription medications for diabetes?” (or heart disease? or lung disease? or arthritis? or, for that matter, cancer?) Why would anyone even ask that question? If there is one thing we know for sure about obesity, it is that it behaves just like every other chronic disease. Once you have it (no matter how or why you got it) – it pretty much becomes a life-long problem. Our bodies are so efficient in defending our body fat, that no matter what diet or exercise program you go on, ultimately, the body wins out and puts the weight back on. In those few instances where people claim to have “conquered” obesity, you can virtually bet on it, that they are still dealing with keeping the lost weight off every single day of their life – they are not cured, they are just treated! Their risk of putting the weight back on (recidivism) is virtually 100% – it’s usually just a matter of time. Funnily enough, this is no different from people trying to control any other chronic disease with diet and exercise alone. Take for e.g. diabetes. It is not that diet and exercise don’t work for diabetes, but the idea that most people can somehow control their diabetes with diet and exercise alone is simply not true. No matter what diet they go on or what exercise program they follow, sooner or later, their blood sugar levels go back up and the problems come back. You could pretty much say the same for high blood pressure or cholesterol, or pretty much any other chronic health problem (that, in fact, is the very definition of “chronic”). So why medications for obesity? Because, like every other chronic disease, medications can help patients achieve long-term treatment goals (of course only as long as they stay on treatment). Simply put, if the reason people virtually always regain their lost weight (no matter how hard they try to lose it) is simply because of their body’s ability to resist weight loss and promote weight regain, then medications that interfere with the body’s ability to resist weight loss and promote weight regain, will surely make it far more likely for them to not only lose the weight but also keep it off. Now that we increasingly understand many of the body’s mechanisms to defend… Read More »
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