Today, I am attending the 8th World Congress on Trauma, Shock, Inflammation and Sepsis in Munich, Germany.

Interestingly, this conference features a whole series of seminars on the interdisciplinary management of obesity (under the rather unfortunate title ‘Fat Man – We Will Help You’ [sic]).

I have been invited to chair and speak at the session on medical therapy, but there are also sessions on adipose tissue biology, perioperative management, bariatric surgical procedures, and the emergency management of bariatric patients.

As I often say in my presentations to colleagues: it does not matter what discipline in medicine you practice – you will be seeing an increasing number of heavier patients with their own issues and complications.

The fact that a world conference on trauma should devote this much time to sessions on obesity assessment and management is clearly to be commended in the light of the global obesity epidemic.

The more all health professionals learn and understand the complexities and problems posed by heavier patients, the better we can serve this particularly vulnerable patient population.

AMS
Munich, Germany

Richard Lehner

New findings published by University of Alberta researchers in a recent issue of Cell Metabolism may point to a new pharmacological target for reducing fat and blood sugar levels in blood while also positively affecting energy expenditure (at least in mice).

The research team, led by Richard Lehner (picture), showed that genetically knocking out an enzyme called TGH (triacylglycerol hydrolase), which is normally involved in helping the liver (and other tissues) process fat, not only reduces blood fat levels but also improves insulin sensitivity and glucose tolerance.

Interestingly, the animals were also better able to utilize glucose and, despite consuming significantly more energy, they displayed increased locomotor activity and consequently did not gain weight.

As always, such studies in mice must be taken with a grain of salt in that there is usually a long way to go before (if at all) these findings pan out in new treatments for humans.

On the other hand, these studies do demonstrate the potential of TGH as a therapeutic target for lowering blood lipid levels and possibly body weight through a novel pathway.

AMS
Munich, Germany

In medical school I learnt that we have four senses of taste: sweet, sour, salty, and bitter.

Several years ago a fifth sense, umami, was officially added to this list. Umami is stimulated by glutamate (as in MSG) and apparently allows us to taste protein (as in meat, sea food, or cheese).

Now, Jessica Stewart and colleagues from Deakin University in Australia show that a sixth sense, i.e. the ability to orally “sense” the fat content of foods may explain differences in fat preferences (British Journal of Nutrition).

Indeed, previous studies in animals have suggested that oral hypersensitivity to fatty acids (the building blocks of fat) are associated with decreased fat intake and body weight.

In the current study, the investigators first examined the taste thresholds for different types of fatty acids (olate, linolate, and laurate) in 31 normal weight subjects and classified them as hypo- or hypersensitive. Subjects also completed a fat ranking task using custard containing varying amounts (0, 2, 6 and 10 %) of fat.

Hypersensitive subjects reported lower energy and fat intakes, had an increased ability to rank the custards based on fat content and also had a lower BMI levels.

These data suggest that the increased ability to detect nutritional fat may result in lower energy and fat intake, which in turn may result in lower body weights.

Obviously, the idea here is that people who are less sensitive to fat are likely to need more fat in their foods to get that same level of enjoyment as people with more sensitive fat receptors. Because of fat’s high caloric content, this means that they may in the end also end up with more calories, and thus, weight gain.

I can think of a number of interesting questions that these findings may prompt:

1) Is the increased ability to taste fat genetic or are changes in fat-sensitivity determined by habitual fat intake (gustatory plasticity)?

2) Does weight loss affect people’s ability to taste fat (resulting in them searching out fattier foods when on a diet)?

3) Does going on a low fat-diet increase fat sensitivity thereby allowing people to get the same pleasure out of low-fat foods?

4) Can we develop artificial compounds that can stimulate the fat receptors thereby mimicking a higher fat content of foods (like we do with artificial sweeteners)?

Lots of interesting questions, which may not only explain why some people derive more pleasure from fatty foods than others but also open new possibilities for the food industry to manipulate the taste of foods (hopefully to our benefit).

I’d love to hear from my readers regarding their thoughts on “tasting” fat.

AMS
Edmonton, Alberta

Over the past three days, newspapers across Canada have been publishing a three-part series on obesity by CanWest’s Sharon Kirkey.

For this mini-series, Sharon spoke to many prominent and outspoken Canadian Obesity Network members including Valerie Taylor (McMaster), Eric Doucet (Ottawa), Nikolas Christou (McGill), Robert Ross (Queens), Yoni Freedhoff (Ottawa) and researchers from the US on a wide range of subjects relevant to this topic. She also interviewed a number of people who have struggled with obesity and its many physical and psychosocial consequences.

As expected, not all experts agree on every aspect of the debate and some statements are clearly more controversial than others. Nevertheless, I would certainly view the articles as a balanced and insightful view of the true causes of the obesity epidemic and the possible solutions (or rather the barriers to solutions).

For those who missed the series, here are the links:

Part 1: The exercise myth: Physical activity plays an important role in healthy living, but it’s not enough to make you lose weight.

Part 2: The trouble with food: A look at the science and psychology of overeating.

Part 3: Fighting an epidemic: A search for the solution.

While readers may criticize that many topics relevant to the obesity discussion were not mentioned (e.g. gut bacteria, genetic programing, sleep deprivation, etc.), remember, this was a three-part not a ten-part series on this topic. 

Noticeably, the same articles appeared under different headings in different papers, in some with more controversial titles than in others (I guess the local editors wanted to add their own spin to attract readers).

Although, I believe that the articles do discuss both sides of the debate on each of the topics,  I am sure that the critics will find their pet-topic under- or mis-represented.  Indeed, I am convinced that many readers, especially those with their usual grudge and bias against obese people as well as those who have all the (simple) answers, will probably be unhappy.

I can only commend the editors of these papers (and of course Sharon) for taking on this important topic and not shying away from controversy, which I know these articles will provoke.

The more open debate we have on this subject, the better.

Appreciate views from any of my readers, who have read these articles.

AMS
Edmonton, Alberta

There is no doubt that dietitians are the health professionals most often looked to for advise on weight management.

It may therefore come as a surprise to many readers that although dietitians have vast knowledge about healthy eating and the dietary management of a wide range of diseases like diabetes, kidney disease, celiac disease and many others, most dietitians interestingly do not have specific training in treating obesity (the same can sadly be also said for the vast majority of doctors, nurses, exercise physiologists, or any other health profession you can think of).

No one is more acutely aware of this lack of expertise than the dietitians themselves, especially as they are so often called upon for dietary advise by people trying to manage their weight.

As anyone working in this field quickly recognizes (and regular readers of these pages will know this by now), eating or ingestive behaviour is only one part of the energy balance equation and even there, the many socio-psycho-biological factors that determine caloric intake are anything but simple.

I am therefore particularly pleased that the Dietitians of Canada have partnered with the Canadian Obesity Network to co-host the first pan-Canadian Learning Retreat on the Principles & Practice of Interdisciplinary Obesity Management for Dietitians, that is currently being held in Winnipeg.

The aim of the retreat is of course not to teach dietitians about counseling clients on healthy eating or even about nutritive approaches to weight losst. Rather, the retreat focusses on all of the other topics that dietitians need to know about in order to fully understand and appreciate the many factors that are essential for effective obesity management.

It is therefore not surprising that there is a lot of room on the program for the discussion of topics like weight bias, psychosocial factors, mental health, neurobiology of hunger and satiety, exercise physiology, body composition, and of course medical and surgical management of obesity.

Judging by the enthusiasm of the attendees, it appears that such a learning opportunity has been long overdue and I am certainly hopeful that events like this will help ensure that patients struggling with excess weight will have an increasing number of dietitians to turn to, who have been specifically trained in obesity management.

AMS
Winnipeg, Manitoba

Of course, obesity is associated with a wide range of health problems like high blood pressure, diabetes, arthritis, or reflux disease, all of which may all require pharmacological treatment. But this is not what this post is about.

Rather, this post is actually about the question whether or not larger patients need higher doses of medications to have an optimal treatment effect.

This topic was recently discussed by Matthew Falagas and Drosos Karageorgopoulos in a Lancet article that specifically addresses the issue of dose adjustments for antimicrobial agents in larger patients.

As the authors point out, body size is routinely considered in the optimization of drug therapy in oncology, anaesthetics and pediatrics. However, there remains a paucity of data on the optimal dosing of pharmacological agents for most of the drugs we use in clinical practice.

Thus, although regulatory agencies regularly demand special pharmacokinetic studies in children, elderly prople and patients with renal or hepatic impairment, no such studies are demanded for obese or even severely obese patients.

Requiring such studies would at least make theoretical sense as, conceivably, obesity can affect drug absorption, distribution, metabolism and clearance. Furthermore, it is obvious that body composition can particularly affect the disposition of lipophilic compounds. Obese patients are also likely to have comorbiditiesthat can affect these parameters (e.g. fatty liver disease) and are much more likely to be on multiple medications that can make drug-drug interactions problematic.

In short, as pointed out by Falgas and Karageorgopoulos the one-size-fits-all strategy for antimicrobial agents (and other drugs?) may well be outdated and require much more consideration than has been given to this issue in the past.

AMS
Winnipeg, Manitoba

Today’s post is about the problem of “helicopter parents”, who bubble wrap their kids in the hope of isolating them from all possible perils, be they physical or emotional.

It is also about how this epidemic of hyper-parenting may be directly contributing to the childhood obesity epidemic.

The post was prompted by an article written by Shannon Proudfoot (CanWest News Sevice), who writes about a new book by Gever Tulley titled 50 Dangerous Things (You Should Let Your Children Do). Shannon quotes Tulley as saying, “We create a false impression in our minds that children are in peril all the time and everywhere, when in fact, according to the most recent studies, this is the safest time in history for children. There couldn’t be a better time to be running around playing.”

In her article, Shannon mentions other efforts that are calling hyper-parents to their senses like The Dangerous Book for Boys, Why I Let My 9-Year-Old Take The Subway Alone or the Free-Range-Kids movement.

To me the real paradox is how these very same hyper-vigilant hyper-parents often don’t think twice about the very real and much more probable peril that comes from keeping their kids off the streets (and in front of TV screens). Indeed, these parents appear far more concerned about the highly improbable chances of their kids becoming drug addicts on the local play ground than worrying about the much more probable chances of their kids become junk-food and sugar-pop addicts from the foods they feed them.

Indeed, it appears that the fear of “germs” exceeds by several orders of magnitude any valid concerns about obesity, diabetes, sleep apnea, or any of the other very real dangers of inactivity and crappy diets to which they happily expose their kids everyday.

Clearly parents appear far more concerned about the chances that their kids will fall into the hands of pedophiles lurking on FaceBook than from the much more likely damage from watching 1000s of junkfood ads on TV.

I guess if we were all far less concerned about the possibility of our kids scraping their knees, breaking a limb, or falling off a fence and actually encouraged them to confidently ignore the “five second rule”, we’d probably end up with a generation of far stronger and healthier kids than the bubble-wrapped, hyper-coddled generation of over-scheduled wimpy progeny we have now.

So let those kids range free and make sure they eat their germs!

AMS
Edmonton, Alberta

This week’s edition of JAMA features a most interesting essay by Nitin Kapur, a physician associated with Yale university in New Haven, CT.

Dr. Kapur describes his interactions with a Mr C., a 5-foot 7-inch patient weighing 320 lbs (BMI=50). As Dr. Kapur points out, he himself is about the same height and carries 245 lbs (BMI=38), which led him to ponder whether he could indeed be of any help to his patient.

While Mr. C. gained his considerable stature (and continued gaining weight during his interactions with Dr. Kapur) after replacing his heroin addiction with bacon double-cheeseburgers, Dr. Kapur attibuted his weight problem to his stressful life as a medical resident and the demanding nature of physicianhood.

So here, as Dr. Kapur puts it, we have the morbidly obese drug addict and the severely obese Ivy League graduate, both struggling with their weight problem.

“So”, asks Dr. Kapur, “am I a hypocrite offering help to this patient, even though I couldn’t help myself?”

As Mr. C. continues gaining weight, Dr. Kapur begins to feel responsible and wonders it if would have been better to send Mr. C. to someone unencumbered by a 40-inch waist.

Finally, one day, Dr. Kapur asks Mr. C. whether it would indeed have been more inspirational for him to have seen someone thinner.

But Mr. C. dismisses any such concerns, responding that only Dr. Kapur could have truly understood what it felt like to be fat and that he very much enjoyed the care and had no doubt that he would eventually lose the weight.

This most insightful and touching story raises an important issue: can health professionals, who themselves struggle with excess weight, really provide help to their obese patients? Or are obese health professionals perhaps the only folks who can really understand the extent to which excess weight affects their obese patients’ lives.

What do my readers think? Does the weight of the health professionals giving weight management advice matter one way or the other?

AMS
Edmonton, Alberta

Hat Tip to Tobias Pischon for bringing this essay to my attention.

In the past years, the Canadian Obesity Network has hosted two think tanks on the importance of rehabilitation expertise in the prevention and management of severe obesity. The proceeding of the first bariatric rehabilitation workshop held in Edmonton, Alberta in 2008 was now published in the latest edition of Disability and Rehabilitation.

Participants at this think tank consisted of around 50 health professionals, administrators, researchers and even EMS professionals.

The main goal of this workshop was to identify gaps in research and professional training that need to be addressed in light of the burgeoning number of individuals with severe and extreme obesity in Canada.

According to this paper:

“Gaps in knowledge and research included the need for better understanding of the biopsychosocial causes and consequences of obesity and the role for novel and existing rehabilitation interventions to prevent and treat obesity. Research is needed to explore how existing rehabilitation interventions and technology impacts the patients with obesity, who also have physical and psychological impairments typically treated by rehabilitation practitioners.

Although the need for rehabilitation for persons with obesity is documented in the literature, the capacity in terms of human resources, funding for research and technology and the development of bariatric friendly, accessible environments is limited. Participants of this meeting reinforced the need to develop training programmes in the form of continuing education and the inclusion of topics in bariatrics in discipline specific training programmes.

Additionally, in order for patients, their families and healthcare professionals to have access to obesity prevention and treatment services, models of care and education that reach out to rural and marginalised communities must be used. These currently exist through forms of telehealth, webinars and online courses.”

Clearly a bariatric rehabilitation is a topic that deserves far more emphasis in the training of health professionals and an area where there is an urgent need for rehabilitation research regarding best practices in dealing with this rapidly growing vulnerable population.

A full report on the Canadian Obesity Network’s First Bariatric Rehabilitation Think Tank can be downloaded here.

AMS
Edmonton, Alberta

Hat tip to Mary Forhan, first author of this paper, and congratulations on the recent successful defense of her PhD thesis.

Today, I am speaking at the XII Congreso Internacional Avances en Medicina 2010 hosted by the Hospital Civil de Guadalajara (Thank you Juan Ricardo Lopez y Taylor for the kind invitation!).

There is indeed no denying that Mexico, as does everyone else in North America, has a substantial obesity problem.

As recently pointed out by Dudley Althaus, who writes for the Houston Chronicle:

“Though still afflicted by large pockets of the malnourished poor, Mexico is fat and quickly getting fatter, its children gaining weight faster than anyone else in the country.

About 70 percent of Mexican adults are now overweight, according to government estimates, more than triple the number of three decades ago. Also, about a third of the country’s schoolchildren and teenagers are overweight, making Mexicans the second-heaviest people on the planet, gaining quickly on their American neighbors.

With more people living in urban areas, and some with more money, Mexicans are eating more and exercising less. Forgoing the beans, tortillas, fruit and vegetables their grandparents ate, people flock to U.S.-style fast food.

Also, calorie-laden Mexican dishes once reserved for special occasions have become routine fare. Anything fried, packaged pastries, soft drinks and candy are widely available.”

Not surprisingly, last month, Mexican President Felipe Calderon launched a national campaign against obesity (beating the US Obama initiative by a few weeks) and called on parents, teachers and the food industry to guide people to more healthful living.

Whether or not this appeal will indeed have any noticeable impact on the obesity epidemic remains to be seen.  From my conversations with fellow delegates, at least the interest and concerns amongst health professionals seems considerable - but so does their sense of helplessness.

To read more by Dudley Althaus on the obesity problem in Mexico click here.

AMS
Guadalajara, Mexico