AACE and ACE Changing Name for Obesity

Kenny Lin who blogs at Common SenseFamily Doctor has a great blog about what the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) are proposing to replace the word obesity. I appreciate that he spoke out and discussed his thoughts about this.

The AACE and ACE want the words "adiposity-based chronic disease," (ABCD) which does not define accurately the one word “obesity.” The authors argued that this new term emphasizes that most persons with obesity will struggle with weight gain for their entire lives; encourages a complications-centric as opposed to body mass index-based management approach; and "avoids the stigmata [sic] and confusion" associated with obesity in popular culture. They also asserted that ABCD is more amenable to interventions based on the Chronic Care Model, which explicitly recognizes that screening and office-based management need to be adapted to the patient's unique environment.

None of these concepts should surprise family physicians, though, and after reading through the AACE/ACE statement, I was not sold on the benefits of the new term. Some patients with body mass indexes above 30 don't like the obesity label, but would they respond any more positively to the disease acronym ABCD? There are potential harms to consider, too. One of my American Family Physician colleagues felt that the new term was "intimidating" and "not at all patient centered," while another thought that it "only hides the issue [of obesity] instead of confronting it."

This discussion brought to mind another medical term often associated with overweight and obese patients: prediabetes. On one hand, being classified as "prediabetic" or at risk for this exceptionally common diagnosis may motivate obese patients to lose weight through improved diet and physical activity. On the other, the term prediabetes is misleading: many of these patients will not develop diabetes, and the diagnostic accuracy of the most common screening tests (hemoglobin A1c and fasting glucose levels) is poor, according to a systematic review published in the BMJ. Due to the tests' low sensitivity and specificity, some persons are incorrectly diagnosed with prediabetes, and others who might actually benefit from interventions to prevent diabetes are falsely reassured. Therefore, the review authors concluded, "'screen and treat' policies alone are unlikely to have substantial impact on the worsening epidemic of type 2 diabetes."

For all its limitations, obesity is a diagnosis with well-established clinical utility. It is less clear how many patients have been helped (or harmed) by being diagnosed with prediabetes. With more study, adiposity-based chronic disease might someday become a useful term, but the current case for more widespread use is unconvincing.

Then on January 18. 2017, Endocrinology Advisor published this article praising the new term and how it may end the stigma obesity has with it. They also believe that the BMI should no longer be associated with the term ABCD. To me this is doing nothing more that obscuring the meaning for patients and using terms, even some doctors may find confusing.

Stigma Keeps Obese Elders Away from Medical Care

Older adults with obesity may avoid health care due to the stigma associated with excess weight. This explains a lot of what happens by the elderly. I am different and being overweight hasn't stopped me, even with needing to put up with snide comments from a few doctors. I no longer see one doctor, but because of the way I turn some of the snide remarks back on the doctors, I have also had one doctor refuse to see me.

I admit that I ask the doctors if that comment was really necessary and if they felt that this was the unprofessional way they treated all patients. Sometimes there are a few more comments made by both the doctor and myself, but this is seldom.

Previous studies suggest that obesity is associated with weight stigma and lower rates of some preventive care. However, the effect of BMI on care and health-seeking behaviors among older adults has not been thoroughly investigated. Now, a new study looking at adults aged 65 years and older has found that obesity itself may be significantly associated with the predilection to avoid medical care. The findings, which were presented at Obesity Week 2016, also suggest that this predilection is not explained by functional impairments.

“The study found that people with a higher BMI (greater than 30) have an increased association with having an adverse perception of their physician's interpersonal manner and reporting the predilection to avoid care,” said study investigator Janet Ho, MD, Beth Israel Deaconess Medical Center in Boston.

Dr. Ho, who presented the study findings, said given the prevalence of older adults with obesity in the United States, this adverse perception or predilection to avoid care may translate into significant clinical effects. The study focused on patient perceptions of primary care providers because they traditionally have longitudinal relationships with patients.

“The findings could pertain to endocrinologists, who also often times become the primary health care provider for their patients,” Dr. Ho told Endocrinology Advisor. “Endocrinologists should care about the study findings, because patients with higher BMI who report a predilection to avoid care are the very ones who may need additional specialist support.”

Dr. Ho reports that prior research has shown that being overweight or obese may be a barrier to health care access, utilization, and quality. For example, patients with obesity have been shown to have lower rates of health care maintenance, diabetes screening, and recommended cancer screenings. She also shares that prior research has also found that provider attitudes and interactions with stigmatized groups can contribute to health care access disparities, and that said health care professionals may sometimes hold strong negative opinions about people with obesity.

Dr. Ho noted that stigma may not just affect quality of care, but also affect appropriate and timely care. To better understand the association among adults aged 65 and older who are overweight or obese, and in whom the effect of this stigma is less known, Dr. Ho and her colleagues Long Ngo, Wenxiao Zhou, and Christina Wee looked at surveys of a nationally representative sample of Medicare recipients between 2002 and2012. For this investigation, Dr. Ho and her team accounted for various demographic and clinical factors.

“The most important take-home message is that medical stigma can be implicit and insidious, and that patients with higher BMI may perceive such stigma in their interactions with health care providers, environments, and systems. As providers, especially endocrinologists who may interact frequently with patients with higher BMI, becoming aware of these biases and actively combating its effects in ourselves, colleagues, and interactions with patients is the first step towards improving care for these patients,” said Dr. Ho.

She said while it is possible to conceptually appreciate downstream effects of avoidance of care on health outcomes and costs, it is too early to report on those effects. However, examining the association between this self-reported predilection to avoid care or adverse perceptions of physicians and downstream consequences on health will be the next step in the team's research efforts. Dr. Ho said further studies may help elucidate what the best approaches for addressing this issue are.

Soybean Oil Causes Obesity

If you don't believe in rodent studies, you may want to skip this blog. I don't either, but felt that this study needs to be reproduced in humans – highly unlikely. It does raise some interesting ideas and even Tom Naughton covers this in his blog here.

Scientists at the University of California, Riverside have found that mice on a high soybean oil diet showed increased levels of weight gain and diabetes compared to mice on a high fructose or high coconut oil diet. The scientists fed male mice a series of four diets that contained 40 percent fat, similar to what Americans currently consume.

1. In one diet, the researchers used coconut oil, which consists primarily of saturated fat.
2. In the second diet about half of the coconut oil was replaced with soybean oil, which contains primarily polyunsaturated fats and is a main ingredient in vegetable oil.
3. The other two diets had added fructose, comparable to the amount consumed by many Americans.
4. All four diets contained the same number of calories and there was no significant difference in the amount of food eaten by the mice on the diets.

Yes, the study is on rodents. Will it give the same results in homo sapiens? While the statistics are interesting, something says it will not be the same in humans.

In the U.S. the consumption of soybean oil has increased greatly in the last four decades due to a number of factors, including results from studies in the 1960s that found a positive correlation between saturated fatty acids and the risk of cardiovascular disease. As a result of these studies, nutritional guidelines were created that encouraged people to reduce their intake of saturated fats, commonly found in meat and dairy products, and increase their intake of polyunsaturated fatty acids found in plant oils, such as soybean oil.

Implementation of those new guidelines, as well as an increase in the cultivation of soybeans in the United States, has led to a remarkable increase in the consumption of soybean oil, which is found in processed foods, margarines, salad dressings and snack foods. Soybean oil now accounts for 60 percent of edible oil consumed in the United States. That increase in soybean oil consumption mirrors the rise in obesity rates in the United States in recent decades.

During the same time, fructose consumption in the United States significantly increased, from about 37 grams per day in 1977 to about 49 grams per day in 2004.

The study also includes extensive analysis of changes in gene expression and metabolite levels in the livers of mice fed these diets. The most interesting results were those showing that soybean oil significantly affects the expression of many genes that metabolize drugs and other foreign compounds that enter the body. This suggests that a soybean oil-enriched diet could affect one's response to drugs and environmental toxicants, if humans show the same response as mice.

The UC Riverside researchers also did a study with corn oil, which induced more obesity than coconut oil but not quite as much as soybean oil. They are currently doing tests with lard and olive oil. They have not tested canola oil or palm oil.

Is Fructose Off the Hook for Overweight and Obesity?

According to the online site WebMD, more controversy is coming. In my reading lately, fructose and gluten-free are the latest to enter the controversy. We have seen sodium and fat at the head of the line, but the latest two entries are interesting. I feel that research agendas are driving all the controversies and not pure scientific research.

As a person with diabetes, high-fructose corn syrup is on the list of “do not eat items.” Therefore, it is with more than a passing interest that I read these articlse. I do have to wonder why there is no listing of the people who are quoted in the WebMD article and who they work for. Yes, in the WebMD article they are all associated with Canadian or US universities, but are they truly independent from the grain industry?

I have in the past, not been too kind to the corn industry and have had several nonproductive conversations with people in the industry. They always spouted the mantra of “sugar is sugar” and quoted industry experts that proclaimed there was no difference. They have well rehearsed answers.  This is most unsatisfying and leaves the discussion without any conclusion.

Most studies are too small and thus not very reliable. Quite possibly, they were done to obtain the results of the agenda of the researchers. This is disturbing at best. Plus, most studies or done using healthy people and not people with diabetes.

By reading a blog by Tom Ross here, and following his link, you may read about a study on fructose reported in the Annals of Internal Medicine (page down to find the abstract). Their review states that most trials had methodological limitations and were of poor quality. They do conclude that fructose does seem to cause weight gain when substituted on the same caloric level as the carbohydrate replaced.

Therefore, with the caloric intake being equal, fructose does not automatically mean weight gain. Now I have to question whether most people can reduce the caloric intake when they are unaware of the number of calories that have been added to their soft drinks and other processed foods. This is where better labeling requirements need to be placed on foods with added fructose, regardless of the type of fructose. The control group did have weight increase when the fructose calories were in addition to the carbohydrate calories already present.

These studies do make some sense of the fructose issue, but there are still many unanswered questions about the effect of fructose on the body, especially the lipid levels produced by fructose.

Now we have another study saying the opposite of these studies. “These studies may provide important insights into the cause of the prediabetic condition known as "metabolic syndrome," which currently affects more than one-quarter of adults in the United States.” Whether this is true, or is just another agenda driven study remains to be seen. Obviously there will be more studies.

Inactivity Linked to Risk for Type 2 Diabetes

I wish I could comprehend some items with the ability of Tom Ross. He has a sense of humor and skepticism that make reading him blog very enjoyable for me. He can rant and vent with the best of them and you will not even know it by the way he writes. That is another reason to read his blog.

Since his blog is not one that you can link to for a specific post, I will just tell you that you need to read his post from Thursday, August 25, 2011. I like the way he boiled done the relationship between obesity and diabetes and then took us to the study which is the topic of this blog – inactivity. You will need to scroll down the page to find the blog, and I think you will enjoy his presentation. He packs a lot of good sense into his discussion and at the same time makes excellent points.

Quote I doubt very much that we are ever going to narrow this down to a simple cause-and-effect relationship between a single issue and diabetes; it is far more likely to be a tangled interaction between multiple factors.

But one factor which could be as important as obesity tends to be mentioned far less often than obesity is, as a possible cause of diabetes: physical inactivity. Unquote.

That is one of the best ways to describe much of the discussion from many articles about diabetes and obesity.

So rather that cover the topic again, it is well worth your time to read Tom's blog and then read two articles covering the topic – here from Science Daily and Medical News Today here.

Why Are You Missing Work?

While I had not really thought about it this way, it does answer some questions I was asked by some employers recently, specifically the human resource departments. I attended because the speaker wanted someone with diabetes he could call on. We had prepared for the meeting, but were hit with a few questions that took all of us by surprise. There were four of us on a panel (representing different non-contagious diseases) to answer questions plus the speaker.

This article goes a long way to answer one of the questions and another blogger did a good blog that covered another question. One of the questions was how liberal an employer should be in allowing absences by people with chronic diseases. Most of us had covered absences for doctor visits and other possible related absences. None of us was ready for one question. What about the times when an employee is unable to work a full day, but has no doctor appointment.

We all fumbled with this one. I mentioned depression as one possibility and hypoglycemia as another, but did not realize how much time was being lost. So this survey results article has been sent to the speaker to forward to the employers in attendance.

This survey was recorded from four countries – U.S., UK, Germany, and France and involved 1404 people with Type 1 and Type 2 diabetes that had reported a hypoglycemic event in the preceding month.

The average loss of workplace productivity on a per person, per month basis from a night-time hypoglycemic event was 14.7 missed hours of work or estimated dollar value of $2,294 per person, per year. It is noteworthy that 22.7 percent arrived late or missed a full day and events occurring during work hours showed 18.3 percent needing to leave work early or miss a full day.

Another piece of information also forwarded to the speaker and then to the employers is this from Diabetes Care via a BD Newsletter. This covers work loss and employees leaving work because of disability after age 55. Rather shocking and large numbers.  I had been alerted to this a few days ago by a fellow blogger.

The one recommendation the entire panel agreed should be considered by every employer was having a health screening at least annually for all employees. This would be a preventive measure and could be conducted during the workday and might help catch health issues before they became serious and then with follow-up would encourage people to take the steps to maintain good health. Emphasis was on stopping obesity, hypertension, diabetes, and related health issues.

These studies and the growing numbers of new diabetes every year is creating concern for employers. Some employers are taking positive actions and some are not handling the situation.