This commentary piece written in the Lancet Psychiatary, reviews Stanley J Ulijaszek’s new book, Models of Obesity. It argues that the field of mental health could learn a lot from the challenges of obesity and the approaches used to tackle it. It first argues that the obesity debate has been reframed in a way that presents it as a chronic relapsing-remitting condition. This has shifted the approach to the treatment of obesity and would be a useful if implemented in mental health.
Next, it highlights the standard unit of measurement that exists in obesity; BMI. Despite its faults, this practice has meant that it’s far easier to make sense of population obesity through epidemiological studies. Mental health researchers often use confused terminology, meaning that it is difficult to perform population studies and so to grasp the scale and nature of the issue.
Third, the field of obesity considers the complex systems that create public health problems better than that of mental health. This means that considerations for environmental factors and psychopathogenic factors are much better integrated into obesity care than in mental health.
Fourth, there is a polyrational approach in obesity that frames obesity public health in a field of competing interests and behaviours, such as between corporations and governments. This means that there is a better understanding of the rationalities and their relationship to each other.
Finally, “viable clumsy solutions” are used to address obesity; these are “a combination of single rational policies towards a particular problem”. This follows from the polyrational approach of understanding obesogenic environments. It involves bringing individual stakeholders together to find solutions, which combine to advise policy.Read More
The obesity paradox refers to the paradoxical relationship between obesity and instances of better long-term survival in cancer, given the huge body of evidence for obesity’s carcinogenic effects. This article, published in Eating and weight disorders- studies on anorexia, bulimia and Obesity, seeks to explore the available studies concerning cancer incidence, survival and obesity in order to offer possible explanations for the paradox and a methodological framework.
The potential mechanisms highlighted for the ‘obesity paradox’ are that obesity provides a nutritional reserve, helping the patient survive surgical interventions and anti-cancer treatments. Also, that obesity is associated with a lower-stage of disease, smaller tumour size and less aggressive subtypes. Finally, that obese patients are likely to be frequent users of healthcare, therefore cancer may be diagnosed sooner.
There are however, methodological issues with these explanations. The issue of BMI, which is a proportional score based on weight and height, gives no information regarding body composition which is important in cancer care. Furthermore, the overall literature that supports this relationship, uses mainly retrospective studies and often fails to include confounding variables such as age and smoking. Rigorous prospective studies need to be conducted to define the impact of obesity in the oncology setting.Read More
This paper, published in Revista de Saúde Pública, aimed to determine the relationship between socioeconomic status (SS) in childhood and obesity in adult life. It conducted a cross-sectional analysis of a population of 1,222 adults in Florianópolis, Southern Brazil. Socioeconomic status was determined using the participant’s parents level of education as a proxy. Adult obesity was determined as a combination of BMI and waist circumference (WC).
The results showed a difference between genders. It was found that women with lower SS in childhood had a higher mean BMI and WC in adulthood. While in men, higher SS in childhood was found to be associated with increased BMI and WC in adulthood. It is suggested that this pattern is related to the income of the country, meaning countries of a similar income share this pattern. Although inconclusive, it raises the interesting point that patterns of obesity and socioeconomic status vary in different countries, so researchers must be careful when making assumptions about these two factors.Read More
This review published in Current obesity reports looks at how our increased understanding of energy regulation and neurohormonal pathways in energy homeostasis (the body’s mechanism for controlling caloric intake and energy expenditure) are being utilised to find pharmacological solutions to obesity. The review looks at centrally acting agents, gut hormones & incretin targets and other novel targets which include anti-obesity vaccines.
Centrally acting agents are drugs which work by altering brain neuronal circuits, by simulating or blocking the effects of other brain neurotransmitters, leading to changes in metabolism and behavior. This paper discusses four of these drugs, which can increase resting energy expenditure- leading to weight-loss- and can also change feelings of hunger/satiety, which then leads to decreased food intake.
Gut hormones and incretin targets are drugs that utilise the complex neurohormonal system of the gut and pancreas to alter feelings of hunger and fullness, with some also improving glucose control. The seven drugs discussed are at varying stages of clinical trials, some only being tested in animals while others are in phase-II. The promise in the phase-II trials is high though, meaning that this new class of anti-obesity drug could soon enter clinical practice.
Five other novel targets were also discussed. Firstly, a drug that reduces production of new fatty acids by the liver and converts stored fats into useful energy; leading to increased energy expenditure. Second, an enzyme inhibitor which leads to reduced absorption of fats in the gut; meaning fewer calories are extracted from food. Third, a triple monoamine reuptake inhibitor of neurotransmitters in the brain, which has proven effective and entered phase-II trials, despite some safety concerns. Fourth is a growth hormone that turns white fat into brown fat; this leads to increased energy expenditure. Alongside this it also provides added benefits such as anti-inflammatory properties. The final drugs discussed are anti-obesity vaccines; these involve targeting molecules that lead to obesity (e.g. ghrelin) or a vaccine to an adenovirus that has been shown to cause significant obesity in mice and may also do so in humans.Read More
In this review article published by the Mayo Clinic, Dr Scott Kahan discusses the best strategies for engaging patients in obesity management, as well as looking at the barriers to good clinical practice. His findings are based on PubMed searches as well as his own clinical experience.
The two strategies identified as being practiced sub-optimally are screening and referral for counselling. Screening for obesity has been shown to be effective as it can lead to better perception of weight status, increased likelihood of trying to lose weight and of starting an obesity management programme. Patients with obesity who receive counselling have been shown to have a four-fold increased chance of losing weight.
The reason for suboptimal implementation of these strategies has been attributed to lack of training in obesity at medical school, with only 25% offering a dedicated nutrition course. Other reasons given by healthcare professionals are insufficient time, training, confidence in the method and resources. From the patient perspectives, stigma, inappropriate facilities (e.g. small waiting room furniture), previous negative care experience and a belief in moral failure in seeking help were found as barriers to care.
The practical guidance for improvement, aims at small changes to many aspects of care. It highlights the importance of people-first language and motivating terminology that encourages the patient rather than demeans them. In addition, improvements to the clinical environment so the patient doesn’t feel embarrassed, for example putting the weighing scales in a private place. Integration of digital technology was highlighted, such as reminders to measure BMI, as this would help with sub-optimal screening. In addition, using available online teaching resources and the multi-disciplinary team to minimize the burden of obesity management, as well improve the effectiveness of counselling technique. Finally, taking a long-term view of the support required, with extended duration weight-loss counselling and monitoring of progress.Read More