Italian Parliament Recognises Obesity As A Chronic Disease

“On November 13th the Camera dei Deputati of the Italian Parliament voted unanimously to approve a motion that recognises obesity as a chronic disease and asks the Government to implement specific actions to promote and improve obesity prevention and management.“ Luca Busetto, co-chair of the EASO Obesity Management Task Force. Why is this important? Because only through the unequivocal recognition of obesity as a chronic disease can governments mobilise the immense resources need to prevent and manage it in people living with this chronic disease. To be clear, not everyone living in a larger body has obesity – as I have written countless times before, health cannot be measured with scales or measuring tapes. The disease “obesity” only exists when abnormal or excess adiposity affects health. Thus, the term “healthy” obesity is in fact a misnomer – there is no such thing. By definition the clinical term “obesity” should refer only to people who have a clear health impairment as a direct result of their adiposity. That said, the Italian Governments all-party declaration of obesity as a chronic disease, will hopefully mean that Italians living with this chronic disease now have better access to preventive and therapeutic interventions. I am thus happy to see that among the various commitments made towards a national plan, the Italian government also emphasizes full access to diagnostic procedures for comorbidities, to dietary interventions, as well as psychological, pharmacological and surgical approaches as indicated. Hopefully other European countries, and in fact, countries the world over will follow this example and ensure that people living with obesity are no longer treated as second-class citizens when it comes to access to treatment for their chronic disease. @DrSharmaEdmonton, AB

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The Corollary To If You Serve It We Will Eat It (If You Don’t, We Won’t)

I’ve written before how as human beings, if you serve it to us, we will eat it, with examples from medical conferences, medical resident events, and dietetic conferences, and published recently in JAMA Internal Medicine is it’s corollary, if you don’t serve it, we won’t eat it, or at least we’ll eat it less.

The paper, Association of a Workplace Sales Ban on Sugar-Sweetened Beverages With Employee Consumption of Sugar-Sweetened Beverages and Health explores what happened to sugar-sweetened beverage (SSB) consumption in the 10 months after the University of California at San Francisco banned their sale from campus and medical centre venues (including in their cafeterias, vending machines and retail outlets). People were of course still free to bring whatever beverages they wanted to work or school. Specifically researchers were interested in the impact the sales ban would have on those with heavy SSB intake (defined as a pre-intervention consumption of more than 12 fl oz daily for the prior 3 months).

For two months prior to the intervention, they canvassed for heavy intake participants, and once the SSB sales ban was enacted, half were randomly assigned to receive a 15 minute motivational intervention targeting SSB reduction, half were not, and 10 months later, all of their intakes were again explored.

The findings weren’t particularly surprising. When SSBs aren’t sold, fewer are consumed.

How much fewer?

Half as much overall, with those receiving the brief motivational intervention seeing their consumption decrease by roughly 75%, and those who didn’t by 25% (though it should be noted, especially among those who received the motivational intervention, social desirability bias may have influenced their self-reported consumption reductions).

Bottom line though, it certainly stands to reason that if you don’t serve or sell it, we won’t eat or drink it, or at the very least, we’ll eat or drink much less of it, and so as far as public health interventions go, likely wiser to reduce access to hyperpalatable and indulgent fare rather than simply encouraging people to just eat less of them.

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Saturday Stories: Campus Antisemitism, Campus Conservatism, Bernie Sanders’ and The Left’s Antisemitism

Blake Flayton, in The New York Times, on his experiences being a young, gay, left-wing Jew, and how University’s progressive spaces are for non-Jews only.

Jane Coaston, in Vox, on the “Groyper Army” and the war over college campus conservatism

Yair Rosenberg, in Tablet, on whether Bernie Sanders is the man to fix antisemitism and the left?

Photo By Lorie Shaull – https://www.flickr.com/photos/number7cloud/30924024642/, CC BY-SA 2.0, Link

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The History of “Essential” Hypertension Has Much To Teach Us About Obesity

I spent the first 10 years of my professional life studying and treating hypertension. As a bit of a history buff, I dug out old books on hypertension and went back to reading papers on blood pressure that were written in the 20s and 30s. I also had numerous mentors, who were around well before the advent of modern diagnostics or pharmacotherapy. In retrospect, I believe that there is much we can learn from the history of hypertension. In the early part of last century, as we learnt more about the physiology of blood pressure regulation, numerous forms of “secondary” hypertension were identified (e.g. renal artery stenosis, Conn’s Syndrome, pheochromocytoma, etc.). Although these were rare conditions, they taught us much about pathophysiology – but (to this day), most case of elevated blood pressure are still considered “essential”, meaning that they do not appear to have a defined cause (genetics and environment both play a big role but the details remain rather murky). Although the link between elevated blood pressure, stroke, heart disease, and kidney failure were well-recognised, there were no good treatments. In fact, the history of medical and surgical treatment of hypertension during the first part of the 1900s was so dismal, that many were opposed to treating hypertension with anything other than a highly restricted low-salt diet. Prior to the 1950s, pharmacotherapy included drugs like sodium thiocyanate, barbiturates, bismuth, bromides, hexamethonium, hydralazine, or reserpine – drugs that were poorly tolerated and for which there was little evidence that they lowered mortality. In desperate cases, surgeons performed sympathectomies – a drastic and complex operation. Given the dismal landscape of medication for hypertension, there were loud voices that challenged the whole concept of hypertension. After all, if there were no good treatments, would it not be best to leave the patients alone and perhaps just support them in other ways? There were prominent doctors who warned about the possible damage that lowering blood pressure could do (particularly to the elderly). Even those who supported treatment, suggested modest targets – 170/110 mmHh was deemed “not so bad”. Then came the 50s. The first modern drug to be introduced was the oral-diuretic chlorothiazide. Then came, beta-blockers, ca-antagonists, ACE-inhibitors, ARBs, and renin blockers. Now that effective medications were available, researchers could conduct long-term studies to prove that these medications were not only safe and effective in lowering blood pressure, but could actually drastically… Read More »

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Is There A Role For Dietitians In Obesity Management?

Over the past 30 years, I have actively been involved in nutrition research – conducting numerous carefully controlled dietary studies ranging from the impact of electrolytes on blood pressure and renal function, to the impact of micro and macronutrients on insulin resistance and metabolism, to the role of genetic factors in response to nutrient intake. In all of this, dietitians have always been key players in my research team helping with the design and execution of these studies. In my clinical work, I have regularly depended on the tremendous expertise of dietitians in the care of my patients with hypertension, chronic kidney disease, dyslipidemia, and type 2 diabetes – in virtually all of these conditions, dietitians have helped my patients on a wide range of treatments ranging from medications to chronic hemodialysis improve their diets, thereby significantly improving control of their underlying diseases or averting complications. I have practiced medicine long enough to remember the days of prescribing low-salt diets before the modern era of anti-hypertensive medications, dietary lipid management before the introduction of statins, and worrying about glycosuria well-before most people considered type 2 diabetes to be an actual “disease” and not just a “risk factor” of questionable significance that happens to old people. Thus, it is with a bit of wonder that I sense an increasing reluctance of some dietitians (at least in Canada) to fully embrace the important role that they could play in obesity management. At times, in recent conversations, I was surprised (and concerned) that more than a few (younger?) dietitians are not only uncomfortable with addressing obesity in their clients, they are in fact ambivilant (if not frankly hostile) to the very idea that obesity is a disease or that dietary interventions to support weight loss have a role to play in obesity management. This, of course does not apply to the many excellent and skilled dietitians working in the many bariatric centres and obesity clinics, without who many of the successful outcomes in medical and surgical treatment of this chronic disease would hardly be possible. Rather, ambivalence towards nutritional obesity management appears to emanate from folks who clearly do not (yet) have a sound understanding of the complex psycho-neurobiology of obesity or the mode of action and effectiveness of evidence-based obesity treatments that include medications and surgery. Indeed, I cannot but wonder about these dietitians’ qualifications to actually contribute to the care of… Read More »

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New Systematic Review Concludes No One Will Ever Successfully Maintain Their Lost Weight. Or Does It?

From the Journal I Can’t Believe This Ever Got Published (ok, in this case from Obesity Reviews) comes The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments.

The paper apparently is meant to be a counterpoint to other systematic reviews of long term weight loss where,

conclusions are generally positive and give the impression that weight loss interventions work and that weight loss can be maintained

Well we can’t have that now can we?

It appears these authors sure couldn’t because here are the criteria they used in selecting papers for their systematic review that concluded long term weight loss is impossible:

  1. Studies must have follow up periods of at least 3 years
  2. Patients must not have had any continued interventions during the follow up period
  3. Medications approved for weight management aren’t allowed

So what they ended up with were 8 studies of varied protocols being administered temporarily for a chronic medical condition where half provided what by definition were only temporary interventions (3 with very low energy diets, and one with hospital provided food). But guess what, chronic medical conditions require ongoing treatment, and what happens when you actually provide it? Well you get studies that would spoil the impossible narrative as noted by the authors of this paper,

“several of the non-included studies report a majority of participants achieving satisfactory weight loss and little regain, especially among studies with continued interventions during the follow-up period.”

Imagine that! Appropriately treating a chronic medical condition with continued interventions works!

And this notwithstanding the fact that many (most? all?) of those studies that provided ongoing interventions likely did not include the appropriate prescription of medications to either help with losses or to prevent regain (just as we would with any other chronic condition) because weight loss medications are almost always excluded from use in weight loss diet studies. Which is odd by the way. Consider hypertension for instance. Sure some people might be able to resolve theirs by way of such things as lower sodium diets, increased exercise, and weight loss, but there’s zero doubt that patients with hypertension will receive regular ongoing follow up visits with their physicians, and where appropriate, will be prescribed medications to help. Why? Because that’s how chronic condition are managed! Which is why we’ll never see a systematic review of hypertension treatments demonstrating that brief lifestyle counselling and the explicit exclusion of medications didn’t lead to lower blood pressure 3 years later.

Leaving me to wonder, why publish a paper with the literal conclusion,

that the majority of high-quality follow-up treatment studies of individuals with obesity are not successful in maintaining weight loss over time

when really all your systematic review (of just 8 papers all with different dietary/lifestyle interventions) has proven is that delimited, lifestyle counselling doesn’t miraculously cure a chronic medical problem, and where you admit in your paper that the appropriate provision of ongoing care might well in fact lead to sustained treatment benefits?

But I don’t really need to wonder. Because the only reason that this paper was conceived and published is because of weight bias, whereby obesity has different rules applied to it, in this case, the notion that unlike so many other chronic medical conditions that are impacted strongly by lifestyle changes (eg. hypertension, type 2 diabetes, GERD, heart disease, COPD, gout, osteoarthritis, osteoporosis, kidney stones, and many more) people believe that for obesity some brief counselling should be enough to do the job, because that in turn plays into the trope of obesity being a disease of willpower and a deficiency of personal responsibility.

(Thanks to Dr. Andrew Dickson for sending my way)

Thanks to your generosity I’m over 2/3s of the way to my $3,000 Movember fundraising goal. While I’ll never monetize this blog, this is my annual fundraiser and if you find value here, consider a donation! Remember, every dollar counts, it’s tax deductible, and you can give anonymously! To donate, simply click here

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Saturday Stories: Mary Cain, Fatal Powerpoint, And Echo Chambers

Mary Cain, in the New York Times, tells her story of the intersection of abuse and elite sport.

Jamie, in McDreeamie Musings, on the Powerpoint slide that killed 7 people.

C Thi Nguyen, in Aeon, on the dangers of echo chambers

And if you haven’t had a chance to donate yet to my lipterpillar, and you find some value or enjoyment from this blog, please consider and remember, every dollar counts. So far this year the generosity of friends and family have helped to raise $1,640. Movember is a tax deductible charity and you can give anonymously if you’d prefer. And of course, as I’ve mentioned, Movember funds multiple men’s health initiatives including mental health, suicide, body image, eating disorders, substance use disorders, & testicular cancer. To donate, simply click here

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Are You Living With Obesity? Time To Speak Up

Yesterday, at Obesity Week, I co-chaired a symposium on how stigma and weight-bias directly affects the health and health care of people living with obesity. As several of the speakers pointed out, the prevailing false narrative that obesity is simply a matter of lifestyle “choices” that people make and that there are easy solutions (just eat-less move-more) is so dominant, that it has even been internalized by people living with obesity – they also believe that they have “done this to themselves” and “know what to do” (just eat less and move more), which is why they generally don’t reach out to health professionals and “demand” the standard of care and support that they would expect if they were living with a less stigmatized condition. Indeed, in any other health area, people (and their family members) would hardly accept the almost complete lack of support or access to care (as for e.g. the grotesquely long wait-times for bariatric surgery) as people living with obesity are apparently willing to put up with. Unfortunately, not speaking up and demanding the same level of health care as people living with other chronic diseases, is by far the #1 barrier to getting policy makers to move on this issue – as long as people living with obesity continue to blame themselves, feel “undeserving” of care, and are too ashamed to stand up for themselves, not much is going to change. At Obesity Week, I also attended a full-day workshop of the international OPEN coalition, where I listened to experts on advocacy explain that the only way to ever effectively change policy is to speak up and speak out – not something most people living with obesity are comfortable with. Unfortunately, there is no alternative – as long as people living with obesity are “OK” with being treated as “second-class” citizens and are “OK” with not having better access to proven and evidence-based obesity treatments, nothing will change. If you are someone living with obesity who feels strongly that you should have the same right to supportive health care and treatments as people living with other chronic diseases, seek out and engage with organisations, who are there to help (e.g. Obesity Canada). Fortunately, you are not alone – there are millions of people living with obesity – if only a fraction of them stood up for themselves and demanded action – no politician seeking re-election… Read More »

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“Severe” Energy Restriction Better For Weight Loss Than “Moderate” Energy Restriction?

Well according to this new RCT it is – in it they found that patients randomly assigned to 4 months of severe energy restriction (65-75% restriction of energy by way of total meal replacement/all liquid diet) followed by 8 months of moderate energy restriction (25-35%), at 12 months, lost significantly more weight than those assigned from the get go to the same degree of moderate energy restriction.

Hurrah?

So first off it’s not remotely surprising that putting two groups on the exact same diet (25-35% energy restriction) but starting one group off with 4 months of extreme energy restriction sees those who had the extreme jump start lose more in total.

Secondly, it would appear that the extreme folks have a weight gain trajectory that may well erase the differences over time.

And thirdly, this got me thinking. Behavioural weight loss programs, because they don’t involve products (unless medications are being tested, and here they were not), have outcomes that are likely significantly dependent on both material, and perhaps more importantly, on the service providers. Consequently I do wonder about the ability of any of these sorts of studies to be applicable to other offices or programs. Meaning here at least, it would appear the extreme folks did better, and the moderate folks dropped out more often (perhaps consequent to slower than desired initial losses), but would the same necessarily be true at a different site, with the same restrictions but with different service providers, collateral materials, attention and support?

I’d venture those things matter a great deal more than is generally ever mentioned in the medical literature.

And a Movember update! If you enjoy these posts (or even if you don’t but you hate read them for something to rage about thereby adding some extra meaning or identity to your life) would love your tax deductible donation to my lipterpillar’s growth (and remember, you can give anonymously too). And though I have a family history of prostate cancer (hi Dad!) I think it’s important to note that beyond prostate cancer Movember funds multiple men’s health initiatives including mental health, suicide, body image, eating disorders, substance use disorders, and testicular cancer. And while I will never charge a penny or host an advertisement on this site, I will, on an annual basis, ask for your donation to this cause. To donate, simply click here

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ABOM Master of Obesity Medicine

Yesterday, at the 2019 Obesity Week in Las Vegas, I had the honour of receiving the 2019 American Board of Obesity Medicine “Master of Obesity Medicine” award. This is indeed a remarkable privilege, given that many of the previous distinguished award winners were folks that I have always looked up to, who have always offered their friendship and advice, and without whose mentorship, I would certainly not have developed the ideas or had the influence in obesity medicine that regular readers of these pages will be familiar with. It was particularly humbling to see so many of my Canadian colleagues in the audience, who have always supported my endeavours and, in true Canadian fashion, have welcomed me to the Canadian research and practice community since I moved to Canada in 2002. Finally, I owe this award to the many patients who have taught me much of what I know about obesity over the years. If nothing else, this award will serve as a constant reminder that we continue to do what we can as researchers, clinicians, and advocates to make a difference in the lives of the millions of children and adults living with this complex chronic disease. @DrSharmaLas Vegas, USA

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