Before, I get into the promised review of the obesity papers in the January issue of the Canadian Journal of Psychiatry, I would like to set the stage by clarifying that I certainly do not consider obesity to be a mental illness.

Thus, I very much opposed the notion (proposed by some) to include obesity as a diagnosis in the the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and was very much relieved to see this proposal being rejected.

Although the brain is the ultimate regulator of energy balance and there is a significant and relevant relationship between mental health and the propensity for weight gain (as will be discussed in forthcoming posts), obesity itself is hardly a mental illness. In fact, the vast majority of overweight and obese individuals do not have any mental health problems that would be in any form or fashion differentiate them from the non-obese population.

This situation, however, is markedly different in the ‘weight-loss-seeking’ obese population, where an increased prevalence of mental health problems has been well documented. This is why clinicians dealing with obese patients, particularly those seeking obesity treatment need to be well versed in the diagnosis and basic principles of managing mental health problems.

What is also indisputable is the fact that for patients with mental health problems, weight management can prove particularly challenging.

When we consider how difficult implementing and maintaining the often complex regimens for weight management can be for most people, it should be no surprise that adding the additional burden of mental illness can make such efforts almost impossible.

Add to this the fact that many of the psychiatric medications can further promote weight gain, and we can easily see why obesity has become such an important challenge in light of the increasing use of such medications (whether indicated or not).

Remember, that in this discussion we are talking about significant and major mental health problems like depression, bipolar disorder, psychosis, anxiety, PTSD, or addictions. We are not talking about simple ‘overeating’ associated with stress, boredom, social pressures, or other factors that have little to do with severe mental health problems and should rather be considered completely normal and natural human behaviours.

Thus, it is important that in any discussion of the clinically important relationship between obesity and mental illness, we make sure that we do not add the stigmal of the latter to the already widespread stigma of the former.

In other words, while mental health problems can undeniably contribute to or complicate obesity, let us by no means assume that everyone with excess weight must somehow have a mental health problem - the vast majority of overweight and obese individuals do not.

Nonetheless, clinicians need to be well aware of this relationship, be able to identify it where it exists, and provide or refer individual obese patients, for whom this may well be a problem, to the appropriate services.

I would certainly love to hear from any readers who have experienced that addressing their mental health issues did indeed help them better manage their weight or from readers where their mental health problems are making contributing to their weight gain.

AMS
Saskatoon, Saskatchewan

The January issue of the Canadian Journal of Psychiatry focuses on the close relationship between mental health problems and obesity.

The issue (just released online) features two review articles: One looks at the many links between obesity and chronic mental illness - as it turns out, a two-way street. The other reviews current approaches to improving obesity management in individuals with chronic mental illness.

The same issue also features an original article examining the relationship between abdominal obesity and cardiometabolic risk factors in kids with mental health problems - particularly in those who require treatment with new-generation antipsychotic medications.

In a guest editorial, I comment on the importance of understanding and addressing the links between these two co-epidemics. As regular readers are well aware, assessment for mental health problems has to be part and parcel of any assessment for obesity (the first of the 4Ms of obesity assessment).

When present, managing these mental health issues, more often than not, will be the lynchpin of successful weight management. Not addressing these issues will likely guarantee failure in weight management.

For readers, who do not have access to this journal, I will discuss these articles in more detail in upcoming posts.

AMS
Saskatoon, Saskatchewan

Dr. Sean Wharton, Burlington, Ontario

Readers may recall a recent post on a clinical trial by Wadden and colleagues on the feasibility of achieving clinically meaningful outcomes of ‘enhanced’ lifestyle counselling largely delivered by primary care practitioners with minimal training in obesity management. In that study, ‘health coaches’ (with no advanced expertise as one may expect from registered dieticians or exercise specialists), working under the guidance of a primary care physician, helped about 20-25% of patients achieve at least a 5% weight loss.

A paper by Sean Wharton and colleagues, published in the latest edition of the Canadian Family Physician, now presents ‘real-life’ data from a similar primary care approach in 2739 consenting patients attending an interdisciplinary obesity-management program in Burlington Ontario.

As described in the paper,

“The Wharton Medical Clinic (WMC) is an interdisciplinary bariatric clinic located in Hamilton and Burlington, Ont, which includes a team of physicians, behavioural therapists, dietitians, and nutritionists. The clinic operates under principles outlined in the Canadian clinical practice guidelines for the treatment of obesity, which recommend dietary, exercise, and behavioural interventions for weight loss, with meal replacement, pharmacotherapy, and surgery as adjunct therapies when indicated. Patient visits consist of services charged to the Ontario Health Insurance Plan, including physician visits, calorimetry, and diagnostic testing such as blood work and electrocardiography. Complementary services (drop-in visits in which patients weigh themselves and educational sessions) that are not charged to the Ontario Health Insurance Plan or to patients are also offered to allow for greater patient contact without increasing the cost to the health care system. As obesity is a chronic, relapsing medical condition, there is no defined program length.”

A key element of the program is the employment of ‘bariatric educators’, who have a university degree in nutrition, but no other formal training as health professionals. Under the guidance of the physicians, these bariatric educators deliver 20-minute educational sessions on nutrition and exercise to patients and monitor individualized weight-management strategies at each visit.

The paper presents the results of all 2739 patients as well as for the 1085 patients, who attended the clinic for at least 3 months, and the 389 patients, who attended for at least 6 months. The average weight loss in these groups were 2.3, 3.5, and 4.3 Kg, respectively.

Perhaps, more importantly, 17, 32, and 47% of patients achieved and maintained at least a 5% weight loss, whereas 4, 9, and 17% achieved a 10% weight loss, respectively.

Although these results may appear modest, it is important to note that these levels of adherence, retention, and ‘control’ are in fact very similar to what is seen with virtually every other chronic condition including hypertension, diabetes, or chronic respiratory disease and speaks to the general difficulties that many patients appear to have with the long-term adherence to chronic disease management programs in general, especially those requiring on-going frequent clinic visits.

Thus, as the authors note:

“As with many other chronic conditions, clinical goals and treatment outcomes for obesity management might not bring patients to “normal” levels. For example, the clinical goals for hypercholesteremia and hyperlipidemia, hypertension, and type 2 diabetes management do not return patients to levels observed in individuals without the conditions. In fact, up to two-thirds of patients are unable to meet clinical goal targets, highlighting the difficulty in managing chronic conditions. Thus, the proportion of participants achieving the targets of 5% to 10% weight loss at the WMC appears to be comparable with successes in the management of other metabolic conditions.”

This said, it is indeed notable that this ‘real-life example’ of a physician-run interdisciplinary publicly funded clinic (vs. the afore mentioned ‘clinical trial’ setting of the Wadden study) can help a substantial number of patients achieve clinically significant weight loss (almost 50% of patients who remained in the program for at least 6 months).

While this level of ’success’ may be well below what most patients normally expect (for e.g. from a commercial ‘weight-loss’ program), the health benefits of modest ‘therapeutic’ weight loss are well recognized and may perhaps be better sustainable than the much larger short-term weight-loss promised and targeted in many commercially driven ‘wehght-loss’ programs.

Obviously, as the authors note, it will be important to determine the effectiveness of this program beyond six months.

Nevertheless, this ’short-term’ real-life experience does provide some valuable insights:

For one, this paper demonstrates the potential value of bariatric educators (nutritionists), who provide education and dietary support.

As the authors note,

“The decision to engage nutritionists rather than registered dietitians in the program was based on the fact that although dietitians are highly qualified health professionals, their continuing engagement in a high-intensity program requiring ongoing follow-up visits is limited by availability and cost. In contrast, as demonstrated in this paper, bariatric educators, under the guidance of a physician, can provide an economical and effective approach to routine weight management in uncomplicated patients.”

In addition,

“Given the important relationship between frequency of follow-up visits and maintenance of weight loss, it appears prudent to offer self-directed walk-in weigh-in sessions in an unintimidating environment, which increases patient contact with the clinic and serves as a regular reinforcement of behavioural change.”

Future studies will also need to determine improvements in other relevant health outcomes including comorbidities and quality of life as well as cost-effectiveness of this approach.

Nevertheless, these initial observations certainly appear promising and may provide a model for other primary care practices considering weight-management interventions in their patients.

AMS
Toronto, Ontario

Wharton S, Vanderlelie S, Sharma AM, Sharma S, & Kuk JL (2012). Feasibility of an interdisciplinary program for obesity management in Canada. Canadian family physician Medecin de famille canadien, 58 (1) PMID: 22267637

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Regular readers will appreciate how environmental determinants can affect complex behaviours such as physical activity and eating behaviours.

New data on this topic is presented by Canadian Obesity Network Bootcamper Stephanie Prince and colleagues from the University of Ottawa in a paper just published in OBESITY.

The paper examines in considerable detail the relationships between variables from built and social environments and physical activity with excess weight across 86 Ottawa neighborhoods.

Individual-level data including self-reported leisure-time PA and other variables were analysed in a sample of 4,727 adults from four combined cycles (years 2001/03/05/07) of the Canadian Community Health Survey (CCHS) together with data on neighbourhood characteristics from the Ottawa Neighbourhood Study (ONS).

For women greater park area was associated with increased odds of leisure time physical activity as well as overweight/obesity. Also, greater neighborhood density of convenience stores and fast food outlets were associated with increased odds of females being overweight/obese.

Higher crime rates were associated with greater odds of leisure time physical activity in males, and lower odds of both male and female overweight/obesity.

Incidentally, this being Canada, it was perhaps not surprising that season was significantly associated with physical activity in men and women with the odds of leisure time physical activity in winter being half that of summer.

Based on these findings, the authors conclude that the impact of park area, crime rates, and neighborhood food outlets may has different effects on activity levels as well as the prevalence of overweight/obesity in men and women.

This may certainly be consistent with the notion that men and women interact differently with their neighbourhoods both in terms of activity as well as food choices.

AMS
Toronto, Ontario

Prince SA, Kristjansson EA, Russell K, Billette JM, Sawada MC, Ali A, Tremblay MS, & Prud’homme D (2012). Relationships Between Neighborhoods, Physical Activity, and Obesity: A Multilevel Analysis of a Large Canadian City. Obesity (Silver Spring, Md.) PMID: 22262164

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Today marks the beginning of the Chinese Lunar New Year, the year of the dragon, an event celebrated by ethnic Chinese worldwide - so Happy New Year to all my Chinese readers!

As some readers may recall, last year I was in Beijing to speak on obesity and hypertension management, problems that most non-Chinese readers may not readily associate with China. No doubt, any Western visitor to China may find it hard to spot any Chinese obese men or women, at least by applying our Western definitions of ‘obesity’.

Unfortunately, obesity and related metabolic diseases are alive and kicking across East Asia - which makes the recent rather enthusiastic announcement of Weight Watcher’s interest in growing their Chinese presence understandable.

Thus, according to Weight Watcher’s CEO David Kirchhoff in an interview to the The Wall Street Journal,

“What you see in China is that overnight, there’s this huge middle class that’s emerged: People who have all the money they could need to buy whatever food they want to buy. There are cars all over the place. People are on the Internet, doing lots of things other than being outside. They’re literally eating so much food they don’t know what to do with it. On top of that, you have the one-child policy, you have parents and two sets of grandparents spoiling one kid. Put all those things together, and it’s not surprising that China has one of the fastest growth rates in obesity of any country around.”

So while festive occasions such as New Year celebrations should perhaps not be the time to brood about the potential adverse effects of the many less-than-healthy foods served at the traditional family reunions, the rise of obesity (and related disorders) in the Chinese community may well raise concerns over the coming year.

I, for one, am quite confident that my trip to China last year to discuss obesity, will certainly not have been my last.

AMS
Toronto, Ontario

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

• Is There a Roie for Recreational Therapists in Obesity Management?
• How The Hedonic System Ratchets Up Your Weight
• Weight Based Bullying in Ontario Youth
• Establishing Common Ground in Obesity Management
• Help Teach a Computer to Recognise Obesity Websites

Have a great Sunday! (or what is left of it)

AMS

Edmonton, Alberta

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Prof. Winfried Siffert, Universität Duisburg-Essen, Germany

Continuing in my series of revisiting some of the obesity research I was involved in, here is a paper to which I contributed a fairly significant number of DNA samples from my patients.

The paper, published in the Journal of the American Society of Nephrology in 1999, examined the relationship between obesity and a common genetic variant of the gene encoding the ß3 subunit of G protein, a molecule involved in transmitting chemical signals from outside a cell to the cell inside (though G-protein-coupled receptors).

G proteins regulate metabolic enzymes, ion channels, transporters, and other parts of the cell machinery, controlling transcription, motility, contractility, and secretion, which in turn regulate systemic functions such as embryonic development, learning and memory, and homeostasis.

The lead researcher on this project, Winfried Siffert, had just shown that the 825T allele of the GNB3, associated with the occurrence of a splice variant, termed Gß3-s (which, despite a deletion of 41 amino acids, is functionally active in a reconstituted system), was more common in individuals with high blood pressure.

This study explored the possible association with obesity in young male Germans (samples that I contributed), Chinese, and black South Africans with low, intermediate, and high 825T allele frequencies, respectively.

It turned out that in each of these three distinct cohorts, the 825T allele frequency was significantly higher in overweight and obese individuals compared to those with normal weight.

Thus, the 825T allele frequencies in these three BMI groups were, respectively, 29.5, 39.3, and 47.7% in Germans, 46.8, 53.9, and 58.6% in Chinese, and 83.1, 87.7, and 90.9% in South Africans. In each of these three distinct groups, the 825T allele was significantly associated with obesity with odds ratios between 2 and 3.

The paper also presents the results of genotyping of 5254 individuals from 55 native population samples from Africa, the Americas, Europe, Asia, Australia, and New Guinea showing the highest 825T allele frequencies in black Africans (82%) and intermediate values in east Asians (47%).

This finding prompted us to suggest that “high frequencies of the 825T allele in Africans and Asians may contribute to an obesity and hypertension epidemic if Westernization of lifestyles continues”.

While in hindsight, again, the notion, that a single genetic variant (no matter how common or functionally important) could even begin to explain increased general risk of such a complex multifactorial condition like obesity, may appear naive and it is therefore perhaps no surprise that this genetic variant never turned out to the the definitive “genetic marker” of obesity, at the time, this work did stimulate a lot of interest in the potential role of genetic variants in these important signalling proteins in complex medical conditions like obesity, hypertension and even a few mental health disorders.

According to Google Scholar, this paper has been cited 317 times.

AMS
Edmonton, Alberta

Siffert W, Forster P, Jöckel KH, Mvere DA, Brinkmann B, Naber C, Crookes R, Du P Heyns A, Epplen JT, Fridey J, Freedman BI, Müller N, Stolke D, Sharma AM, Al Moutaery K, Grosse-Wilde H, Buerbaum B, Ehrlich T, Ahmad HR, Horsthemke B, Du Toit ED, Tiilikainen A, Ge J, Wang Y, & Rosskopf D (1999). Worldwide ethnic distribution of the G protein beta3 subunit 825T allele and its association with obesity in Caucasian, Chinese, and Black African individuals. Journal of the American Society of Nephrology : JASN, 10 (9), 1921-30 PMID: 10477144

At the 1st National Summit on Weight Bias and Discrimination organized by the Canadian Obesity Network in Toronto almost exactly a year ago, I learnt that weight-based bullying is one of the most common and pervasive forms of bullying experience by children and youth.

This topic is further examined by Obesity Network Bootcamper Atif Kukaswadia and colleagues from Queens University, Kingston, Ontario in a paper just published in OBESITY FACTS.

The researchers report on their findings in a longitudinal analysis of the Health Behaviour in School-Age Children Survey conducted in 2006 and then again in 2007, which included 1,738 youths from 17 Ontario high schools.

Based on self-reports, excess adiposity preceded bullying involvement and obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying over the observation period.

In addition, among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls).

These findings support previous findings on the increased risk for bullying faced by overweight and obese youth and certainly suggest that this problem, if anything, is getting worse.

Given the many deleterious (and often lasting) effects of bullying on mental and physical health, this issue is certainly something that should concern us all.

Thus, it is certainly not surprising that one of the strategic priorities identified at CON’s Weight-Bias Summit was to “address weight-bias and discrimination in education settings”.

A full report of the Summit is available here.

AMS
Edmonton, Alberta

Kukaswadia A, Craig W, Janssen I, & Pickett W (2011). Obesity as a determinant of two forms of bullying in ontario youth: a short report. Obesity facts, 4 (6), 469-72 PMID: 22248998

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Obesity is complex. Few health professionals are specifically trained in obesity management - few health systems have invested in managing it.

As regular readers will recall, Alberta Health Services recently launched a province-wide obesity initiative ranging from population health and community projects, across primary care, to establishing speciality centres for complex medical and surgical management of kids and adults with severe obesity.

Currently, around 100 health professionals and administrators from across the province, working on getting this initiative off the ground are meeting in Edmonton to discuss details of the plan. Many have already worked in obesity and chronic disease management and bring their own views and experience to the table. This is immensely important as sharing of best practices is one of the key mechanisms to ensure that we do more of what works and less of what doesn’t.

It is also essential that we establish common ground on the basic principles and practice of addressing this health problem - the sooner we are all on the same page, the sooner we can begin working towards consistency in obesity prevention and care across the province.

This will not happen overnight - there will be learnings, there will be things that work well and things that don’t.

But I am fully confident that in the end we will be moving in the right direction towards reducing the emotional, physical, and economic burden of obesity on all Albertans.

We may not be able to cure obesity, but we can certainly do a much better job at preventing and treating it.

AMS
Edmonton, Alberta

Earlier this week, Bill Colmers and I gave the inaugural Centennial Lecture for our Faculty of Medicine and Dentistry in anticipation of the upcoming 100 year anniversary of the University of Alberta medical school.

In this talk, we discussed why it is so difficult to keep weight off. I presented the clinical problem, and Colmers, the neuroscientist, presented an overview of how the brain affects eating behaviour and regulates body weight.

I was particularly impressed by how Colmers described the respective roles of the hedonic and homeostatic systems in human evolution.

While the hedonic (pleasure seeking) system evolved to help our hunter-gatherer ancestors seek out and take advantage of any highly palatable energy dense foods they happened to come upon, the homeostatic system evolved to protect from wasting away those extra calories that they did ingest.

Thus, according to Colmers, the hedonic system’s job was to make it hard to resist, in fact, make our ancestors to often go to considerable lengths to searching out those rare palatable energy dense foods and then to eat as much of them as possible, whether they were actually hungry or not. They could of course always store those extra calories as fat tissue for later use - a tremendous survival advantage.

In contrast, the job of the homeostatic system was to ‘defend’ those stored calories - in fact, it is designed to regard any accumulation of fat stores as the ‘new normal’ and from then on make sure that this increased level of fatness was maintained (or regained) ever after.

Indeed, the homeostatic system is ‘designed’ to readjust its set point of body weight - after all it has to do this starting from birth as body weight continues to increase as the baby grows into a toddler that grows into a kid and ultimately into an adult.

Unfortunately, the mechanisms that allow the set point to reset to ‘defend’ a progressively higher body weight - generally works in only one direction - after all that is all that is required by nature, where people do not naturally ’shrink’.

Colmers used the analogy of a ratchet to describe how the homeostatic system is designed to defend ever increasing body weights without having the ability to reset itself to a lower body weight even if the person now wants to lose weight.

Once set to a higher weight (e.g. resulting from ‘overindulgence’ driven by the hedonic system or other factors that may promote weight gain), the homeostatic system uses a wide range of mechanisms affecting hunger, satiety, appetite, metabolic rate, etc. to ‘defend’ this weight from then on.

A very helpful analogy I thought, nicely explaining why evolution has given us the mechanisms to gain weight but not to lose it.

AMS
Edmonton, Alberta