Health Canada Approves New Obesity Treatment

Hot on the heels of the FDA's recent approval, Health Canada has now also approved the use of a diabetes medication called liraglutide as a weight loss medication for people with or without diabetes.

  

Liraglutide is a medication that has been in use in Canada to treat type 2 diabetes for several years (called Victoza).  As an obesity treatment, it will have a different name, Saxenda; the medication is the same, but the dose to treat obesity is a little higher (based on clinical trials, which you can read more about here).  

Liraglutide can now be used as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of:

-      30 kg/m2 or greater (obesity), or;

-      27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, or high cholesterol);

and who have failed a previous weight management intervention.

Liraglutide is a derivative of a human hormone called GLP-1, which is released in response to meals.  It works to tell the pancreas to release insulin, and suppresses another hormone involved in blood sugar regulation, called glucagon.  It helps with weight loss by sending a message to the satiety (fullness) centre of your brain, and it has an effect, particularly in the early weeks of treatment, to slow down the stomach.

As for any medication, there are potential risks with using liraglutide.  Common side effects include stomach upset, particularly nausea as the stomach is slowed initially, but this usually improves in the first weeks on the medication.  As for more severe side effects, the question has been raised as to whether this class of medications could cause inflammation of the pancreas (called pancreatitis), but to date, a causative connection has not been established (see more from the FDA and European Medicines Agency on this here).  Liraglutide has been shown to cause a rare form of thyroid cancer in rodents; this has not been seen in humans but is being monitored.  (For further discussion of side effects, see the FDA press release on Saxenda). 

My take on this? The approval of liraglutide for obesity is a landmark, in that this is the first time that a human gut hormone has been approved for obesity treatment.  There are many gut hormones involved in the feeling of fullness, many of which are being actively studied; combinations of these hormones look promising as well.   This is also a landmark decision for Health Canada, in that it has been almost twenty years since a medication was approved for the treatment of obesity in Canada.    

Please refer to my blog post on the FDA's approval last month for my further thoughts on this topic.  

Disclaimer: I was involved in the research trials of liraglutide as an obesity treatment.  I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk). I am involved in research of medications similar to liraglutide for the treatment of type 2 diabetes. 

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Canadian Obesity Guidelines - What's Missing

Last week, new clinical practice guidelines for the prevention and management of obesity in Canada were published by the Canadian Task Force on Preventive Health Care in the Canadian Medical Association Journal.

Unfortunately, it is not exactly a 'solutions based' document.   The main recommendations are as follows:

1.  Body mass index (BMI) should be calculated by family doctors to help prevent and manage obesity.

2.  Structured programs should not be offered to adults of normal weight, to prevent weight gain.

3.  For adults with overweight or obesity, structured programs should be offered to help with weight loss.

4.  Medications should not be used to treat obesity.


While I could pick apart their focus on BMI, or that not offering preventive programs was (in their words) a weak recommendation based on very low quality evidence, I want to focus on their recommendation not to use medications to treat obesity.

Advising us against using medications to treat obesity may be short sighted.  While Canada currently has very little in terms of medications to treat obesity, several medications have been approved in the last three years by the FDA in the United States to treat obesity, some of which may become approved for use by Health Canada as well.  Will the guidelines be hastily rewritten if/when these medications become available to us? Advising against medications to treat obesity leaves us with lifestyle measures on one end of the spectrum, and bariatric surgery on the other end.  While the US and Europe move forward in accepting obesity as a medical problem with medication options to treat it, is Canada going to stay in the dark ages on this?  Note that while our Task Force is telling us not to use medications to treat obesity, that the Endocrine Society in USA simultaneously released their Clinical Practice Guideline about how to treat obesity with medications.  While I agree that the current singular medication available to treat obesity in Canada (orlistat) is not very useful, a note that options may change in the near future may have given this section a little more balance.

Another concern I have with these guidelines: Discussion of bariatric surgery was conspicuous in its complete absence.  While bariatric surgery is an extreme treatment measure for obesity, it is a valuable one, and of great benefit for some patients.  It is stated that these guidelines are not intended for patients with a BMI over 40 (bariatric surgery is considered an option if BMI is >40, or >35 with complications of obesity), but I feel that at least a head nod to the existence of bariatric surgery should have been given in this document.

And - how does one exclude people with BMI >40 from the guidelines, when one in eight Canadian adults who struggle with obesity fall into this category?

The procedure that leads to creation of guidelines is a rigorous review of evidence, and I get that this is why these guidelines look the way they do - lifestyle intervention studies and evidence are poor, medication options in Canada are currently limited, and availability of bariatric surgery is minimal compared to the number of people who could benefit from these procedures.

However, as an advocate (warrior?) for my patients who struggle with excess weight, I will continue to remain optimistic that more options and accessibility will ultimately become available to Canadians to treat this condition.

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Dr Oz Fails The True Test Of Research

There are a lot of conflicting opinions about Dr Oz out there.  Some people feel that he is the guru of modern medicine, whereas others, including many health care professionals, are very critical of his claims.  I'm thrilled to report that researchers at the University of Alberta have put this debate to the true test of research.

In the study, which was published in the British Medical Journal, researchers analyzed 40 episodes each of The Dr Oz Show and The Doctors, and objectively analyzed medical claims made in each show.

They found that only one out of three Dr Oz recommendations had believable evidence behind it, and one out of two for The Doctors. They found that overall, insufficient information was provided for medical claims made, and therefore it was not possible for viewers to make informed decisions about what they were hearing.  Their conclusion was that recommendations taken by patients watching these shows ends up being based on trust of the TV host rather than on the actual information provided.

As quoted by one of the authors of the study on the University of Alberta website: “Our bottom-line conclusion is to be skeptical of what you hear on these shows.”  Amen!

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Do iWant the iWatch?

Big news in the technology world - the Apple Watch was unveiled for the first time, and it's expected to arrive on shelves in 2015.  Of the multitude of fascinating features, one aspect that is getting a lot of attention is the iWatch's ability to track physical activity and provide integrated fitness/activity apps to help guide your progress.   You may find yourself asking - is this something that iWant? that iNeed? Will iBenefit?? Can iTrust it??

While there are many fitness apps out there, here's what catches my attention: the iWatch can measure your heart rate, and your total body movements (via an accelerometer).  It also uses the GPS and wifi in your iPhone to track how far you've moved.  There's a little circular icon that fills up each day as you move - even letting you know how many minutes you have stood during the day.

Pretty nifty that you can now track your activity, heart rate, and personal info all together in one internet-linked system.  I also really like the encouraging nature of the movement icons filling up, with Apple's stated goal to be 'Sit less, move more, and get some exercise by completing each ring each day.'

There are rumblings as well that the iWatch will someday be able to check blood sugar without poking the skin.   (Currently, the closest a diabetic can get to this is with a continuous glucose monitor, which still requires that a sensor is worn under the skin, and it has to be calibrated against the standard finger-poke twice a day.  There is also a brand new technology just approved in Europe early this month, whereby a small round sensor is placed on the skin with a small filament that is inserted just under the skin; a reader is scanned over the sensor to get a glucose result. More on this on drsue.ca soon - stay tuned.)      As testing blood sugars can be painful and frustrating for my diabetic patients, this news not only got me sitting up, but also spiked my own heart rate to well over 100.

With real time, painless monitoring of these parameters, I get carried away into a dream land where patients could be monitored in second-to-second real time with internet data transmission to their family members, caregivers, or health care professionals anywhere in the world... do I dare to dream?? (editorial note: there are a number of established glucose monitor companies working on this for blood glucose monitoring, in various stages of development)

Before we get carried away, though, we need a lot of questions answered.  How have they validated their technology?  How accurate is their accelerometer? How accurate is the heart rate monitor?  Can the heart rate monitor pick up irregularities and notify the patient or caregiver?  If they are going to incorporate a blood glucose monitor, how will this be tested and validated for precision and accuracy?  I suspect these details and information will become available as the iWatch unfolds into the marketplace, but if we as people, patients, and health care professionals are going to trust the data, we need to know that the studies have been done to prove that it is worthy of our trust.

Definitely exciting, though - my eyes will be focussed on these interesting developments in health technology.

Thanks to Glenn for the heads' up, and to Anita Dobson for her input.

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Dr Oz Swallows A Bitter Pill at the US Senate

It's about time that the crackdown on Dr Oz rises to the next level.  Following publications by several medical journals speaking out against Dr Oz's false health claims, the US Senate is now taking Dr Oz to task on his 'miracle' weight loss solutions that he touts on his TV show.

At a Senate hearing addressing over the counter diet supplements and products which Dr Oz attended as a panel member, he was openly and harshly confronted by Senator Claire McCaskill, a strong advocate for consumer protection.

She says to Dr Oz (and the entire video is well worth watching):

"I am concerned that you are melding medical advice, news, and entertainment, in a way that harms consumers.... I get that you do a lot of good on your show, but I don't get why you need to say this stuff, because you know it's not true."

The 'Dr Oz' effect is known as the most powerful sales pitch in the diet industry - the problem is that most of the products he touts do not have scientific evidence to back them up.  Some, such as the HCG diet, are dangerous.

Dr Oz's shameless promotion of products without scientific evidence of benefit (and some with potential harm) is completely opposite to the appropriate behavior of a medical doctor.  Our job as physicians is to critically assess scientific evidence, and only to recommend a treatment if there is evidence to prove that it is effective, and that the benefits outweigh the risks.

We take the Oath of Hippocrates on the day we become doctors, with two of the primary tenets being to prescribe medicines for the good of our patients, and never to do harm.  Oz needs to take a long, hard look at himself in the mirror, and reflect on this oath that he committed to upholding years ago.

You can read about my thoughts about Dr Oz's 'superfoods' here,  and Dr Oz's claims about Garcinia cambogia here.

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Help Stop Fat Bullying - Start With Children!

Bullying and stigmatization of people with obesity happens, sadly, at all ages.  One of the most impactful things we can do is teach our children about the harms of bullying, so that this generation grows up understanding that stigmatization of any kind is hurtful and wrong.  
Today's post is dedicated to the children's book project, Pom Pom - A Flightless Bully Tale, by Linnie Von Sky (daughter of Dr Arya Sharma and a key member of the Canadian Obesity Network family).  It's about a slightly rotund penguin called Pomeroy Paulus Jr III.

Like any boy his age he's busy trying to impress 'the birds', namely one bird: Pia. Pomeroy dreams of a pair of orange swim trunks; the ones that Pete, Pucker and Piper own. The same ones Pia said she loved. There's just one little hiccup. The antAmart doesn't carry his size. 

Stay tuned to learn how mom helps Pomeroy get his orange swim trunks, see that Macaroni penguins are not made of mac'n'cheese, and watch Pia save the day when she puts bullies in their place. 

By supporting Linnie's publication dream, Linnie writes:

♥  You'll help us stand up against bullies and lend your voice to someone so big that his voice has become small: Fat jokes are not funny and they hurt!

♥  You'll allow us to produce (illustrate, edit, scan, post produce, book design & print in Canada) every part of Pom Pom - A Flightless Bully Tale 

♥ You'll own a copy of the book you helped us publish (and maybe even your own custom antarctic character)

♥  You'll help fund Rebecca's 2nd year of Art School. By paying Rebecca (21) real market value for her art work we were able to fund her first year of Art School with Our Canadian Love Story (Linnie's 1st book) without her having to bag groceries. How cool is that?

Click here to join Linnie's campaign against fat bullying - she's already a third of the way to her goal!

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Lose It Right - Book Review!

I've had the great pleasure of reading James Fell's new book, Lose It Right, and let me tell you, it's a great read!

The book is written by James Fell, a Calgarian fitness journalist, MBA, columnist for Chatelaine and the LA Times, amongst a long list of achievements.  He has written a very pragmatic, well researched, and entertaining approach to weight management and leading a healthy life.  He truly walks the walk, enjoying a permanent (and impressive!) healthy lifestyle after struggling with his weight in the past.

The book goes through three Stages:

Stage I: Learning why we as a society, and as individuals, struggle with our weight.  From portion sizes, stress, and external food cues, to understanding the dopamine reward pathway in our brain that reinforces rewarding behaviors, James runs the gamut to help us explore the diverse elements that may be contributing to each individual's weight struggle.


Stage II: Preparation for changing your lifestyle, from changing how you view food, to goal setting, and how to manage practical aspects of lifestyle change.


Stage III is the Doing part of the book - James' actual how-to's of morphing your lifestyle into a healthy one.

You can read an excerpt from his book here.

What I really love is that this book is all about not just doing a lifestyle plan, but becoming that lifestyle.    James' plan has an emphasis on exercise - while exercise is important, it's not for everyone, or at least it is more for some people than for others.  Also, it's important to speak with your doctor before you embark on a new exercise routine, to ensure it is safe for you to do so.

But regardless of the details of how you embark on a healthier lifestyle:

"Losing It Right is about changing who you are.  It is not a list of actions, but rather someone you become."

And finally, my very favorite quote:   "Don't just do this.  BE this."

Follow me on twitter: @drsuepedersen

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