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Breaking News - Canada's Report Card On Access To Obesity Treatment

>> Tuesday, April 25, 2017

Obesity is a treatable chronic medical condition that affects over 25% of Canadian adults.  But how well are we doing at treating obesity in Canada?

Today, the Canadian Obesity Network has released the Report Card On Access To Obesity Treatment For Adults In Canada. This is the first rigorous assessment of the degree to which Canadians with obesity can access publicly funded treatments such as dieticians, psychological counselling/support,  medically supervised weight management programs, medications for obesity, and bariatric surgery.

The Report, not unexpectedly, showed that access to care for obesity in Canada is extremely limited.

  • There is very little publicly funded access to dietary counselling, mental health support, cognitive behavioural therapy, or exercise professionals. 
  • There is no public coverage for anti-obesity medication, and only about 20% of private medical plans offer coverage. 
  • Bariatric surgery is available to only 1 out of every 183 adult Canadians per year who may be eligible for it (this varies widely by province, with the best availability of 1/90 in Ontario, and the lowest availability of 1/1,312 in Nova Scotia).  

So why is access to obesity care in Canada so poor?

1.  Despite the Canadian Medical Association declaring that obesity is a chronic medical condition (and not a lifestyle issue) in 2015, neither Health Canada, nor the federal government, nor any provincial governments have followed suit. This results in a lack of policies that support obesity care.

2.  Medical schools have little to no formal obesity training, and very few Canadian doctors pursue additional obesity training of their own accord.   Only 40 out of 80,544 doctors in Canada have completed certification through the American Board of Obesity Medicine. (there is no formal obesity training equivalent in Canada)

3.  There remains a powerful and pervasive obesity stigma in Canada, which has been shown to be even worse in the medical community than in the general population.  Person-first language is often not used in government resources nor in medical literature - meaning that obesity is used as a description of a person rather than as a diagnosis. (The correct terminology is a 'person with obesity', not an 'obese person'.)

4.  Government programs tend to focus on health promotion and obesity prevention, which is important, yes, but with a lack of attention to helping people who have obesity and need treatment for it.

So, where does this leave us?  The Report recommends:

  • Government, employers and the insurance industry need to adopt the position that obesity is a chronic medical condition and orient their approach and resources accordingly;
  • Government needs to recognize and help break down weight bias and stigma;
  • Obesity training for health care professionals needs to increase;
  • Governments need to increase funding and access to interdisciplinary care, weight management programs, anti-obesity medications, and bariatric surgery; 
  • The Canadian Clinical Practice Guidelines, last published in 2006, need to be updated (and we are starting work on this!)

It seems we have a lot of work to do. 

Follow me on twitter! @drsuepedersen © 2017


Dangers of Green Tea Extract

>> Monday, April 17, 2017

Unfortunately, in today's society and times, more people are reaching out than ever before for anything to help manage their weight, including naturopathic remedies.  On this list is green tea extract. Sounds like it must be safe, right?  It comes from something natural, after all....

CBC's Marketplace launched an investigation into green tea extract, featuring my colleague in obesity medicine,  Dr Sean Wharton.   They discovered more than 60 documented cases worldwide of liver failure associated with green tea supplements, with at least 2 deaths that may have been related to taking these pills.

Take 20 minutes and have a listen.

The bottom line is this:  Because it's natural does not mean it is safe.

Follow me on twitter! @drsuepedersen © 2017


Could Yo-Yo-Ing Weight Increase Risk Of Heart Attack?

>> Monday, April 10, 2017

In the effort to manage excess body weight, many people have experienced the 'yo-yo' effect: start a diet, weight goes down... end the diet, weight goes back up (and then some, in many cases).  We already know that this fluctuation in weight is damaging to metabolism, in that our bodies essentially remember the highest weight we have ever had, making powerful hormonal and metabolic changes to drive us back up to our highest weight.  Now, a study in the New England Journal of Medicine demonstrates that fluctuation in body weight is associated with a higher rate of heart attack and death in people who have coronary artery disease.

The study evaluated fluctuations in body weight amongst 9,509 people with heart disease, who were enrolled in the TnT trial of cholesterol medication atorvastatin, taking the opportunity to evaluate whether fluctuations in weight made a difference in terms of risk of having a cardiovascular event.  In a post hoc analysis, they found that the greater the weight fluctuation, the higher the risk.  Specifically, for every 1 Standard Deviation (SD) in weight, there was a 4% increase in risk for any cardiovascular event, and a 9% increase in risk of death, independent of other cardiovascular risk factors.  Among patients in the top 20% for fluctuations in body weight, there was an 85% higher risk of a cardiovascular event and over a double increased risk of death, compared to those in the lowest 20% for fluctuations in body weight.  The risk associated with weight fluctuation was higher in those with obesity or overweight, compared to those of normal body weight. Also, a greater body weight fluctuation was also associated with a higher risk of developing type 2 diabetes.

One wonders whether these findings could simply reflect that people who had wide fluctuations in weight were sicker in general (eg big weight loss with illness), though this clinical trial did exclude people with a poor prognosis. The study also did not assess whether the weight fluctuations were intentional (eg dieting) vs unintentional (eg illness).  

We cannot infer causality from this study - in other words, we can't be sure that the weight fluctuations were the cause of the increased cardiovascular events - but the association between weight fluctuation and cardiovascular events was nevertheless strong.  Given these findings, it seems more important than ever to avoid yo-yo weight changes by making permanent lifestyle changes rather than engaging in temporary solutions/programs to optimally manage weight.

Follow me on twitter! @drsuepedersen © 2017


After Bariatric Surgery - Patients' Perspectives

>> Monday, April 3, 2017

There is no doubt that bariatric surgery is a hot topic of research these days.  Most of this research focuses on the medical benefits that can be enjoyed after bariatric surgery, such as improvements in diabetes control, high blood pressure, sleep apnea, and so forth.  Much less qualitative research has been done - the kind of research that looks at things that are hard to measure with numbers, such as psychological effects and changes in quality of life. Most of the qualitative information that has been published is on small groups of individuals, and it is challenging for patients or clinicians to synthesize this smattering of data as a whole.

Coulman and colleagues recently collected information on this topic in the first systematic review of qualitative research in the bariatric surgery field.  Published in Obesity Reviews (and free to download!), they included 33 studies reporting on the patient perspective on living with the outcomes of bariatric surgery.

Three themes were identified:

1.  Control.  Patients reported making the decision to undergo bariatric surgery to gain control over eating, weight, and health.  In general, a feeling of improved control was experienced in the first year after surgery, but after a year, there was less of a sense of physical control (described as 'stomach control'), and it became more about relying on their own 'head control' to manage food intake.

2. Normality.  A sense of 'normality' was something that many patients were striving for after bariatric surgery - lives less burdened by physical and psychological ill health, ability to participate in normal everyday activities, and what patients described as a more 'socially acceptable' appearance.  While many people felt more 'normal' after surgery, there were also several issues identified that challenged patients' desire to feel 'normal'.  This included a change in their own or others' perceptions of their bodies, unpleasant gastrointestinal side effects (eg vomiting or diarrhoea), not being able to eat like others, and loose hanging skin.

3.  Ambivalence. Patients reported that while some things changed for the better, other changes were difficult to cope with or adapt to. This included physical pros (improvement in metabolic health) and cons (gastrointestinal and nutritional side effects of surgery).  This also included psychological pros (improvement in depression, self esteem, control) and cons (eg continued depression and self esteem issues with a realization by some that bariatric surgery was not going to fix these issues; challenges of finding ways other than food to cope with emotions; feeling a loss of protection from the outside world and a feeling of vulnerability with weight loss).

This review is a treasure trove of information, including quotes from patients, and is a great read in its entirety.   These findings highlight that while bariatric surgery is an excellent treatment strategy for some people, for others it may not be the best choice.  These findings certainly speak to the need for long term follow up for patients who have had bariatric surgery, including long term psychological and nutritional support.

As the authors write: Surgery was not the end of their journey with obesity, but rather the beginning of a new and sometimes challenging path.

Follow me on twitter! @drsuepedersen © 2017





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