TOS 2014 summary: It’s good to connect

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It’s been a week since I came back from Boston and it’s time to summarize my impressions. I would say there were fewer outstanding presentations this year compared to last year in Atlanta, but I would also say that there was a greater number of really good presentations.

My favorite this year was Richard Atkinson who gave a very honest and wide-ranging talk when he accepted his Mickey Stunkard award on where we are at the moment, and why we have largely failed to improve much on treatment and prevention outcomes. First of all, it’s good to hear when presenters are truly honest and not just telling everyone that things are great when they clearly are not. I also appreciate it when presenters go out on a limb a little more than usual and really provide some speculation about what we can do in the future to improve on those less than perfect outcomes. Even though I did not entirely agree on how to best go about doing this (more basic science and epigenetics), it is still very much appreciated when informed individuals speak their minds, so well done Dr Atkinson.

The best overall seminar was the one on obesity prevention in Mexico. Mexico has sky-high rates of childhood obesity, even higher that in the US, and a very high consumption of soda. The presenters pained a very interesting picture of how to coordinate a very thoughtful and effective campaign to reduce childhood obesity rates and taxing sugary drinks in a very challenging environment. The opposition they faced from those who wish to keep the status quo, such as Big Soda, was quite formidable, yet they were able to make considerable inroads. This serves as a positive example to us all who think that prevention of childhood obesity is a big ask. It certainly is, but by no means impossible as the team in Mexico clearly demonstrated, inspirational stuff.

But for me, the main positive was meeting up with other researchers who are pursuing similar lines of inquiry as myself, such as the influence of childhood adversity, socioeconomics, stigma and discrimination, and psychological and emotional aspects of weight control. It’s when we connect like this that I believe we take those significant leaps forward and really get somewhere. Conversely, it is when we argue and become divided that our egos get in the way of making those significant leaps forward. Regardless of our personal opinions, we can gain so much more from connecting with each other as opposed to arguing about who is right.

Were you in Boston, or did you read the updates? Please let me know what you think by leaving a comment.

Erik Hemmingsson

Obesity before the age 5 TOS seminar

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This is my last post from Boston, the meeting is winding down. Thank you to everyone who has been part of making this a really great gathering!

Dr Kirsten Davison: New avenues in the treatment of obesity before age 5 in families are being discovered. Intervening early is a key strategy for achieving long-term reductions in BMI, and there is rapidly expanding interest in this very promising area. A key strategy is the promotion of healthy lifestyles (limit added sugars, limit TV time and so on), as is parenting skills, and interventions that target broader family aspects, such as reducing stress and disharmony. The greatest intervention effects were seen in socioeconomically challenged families, for example where there is parental mental health issues and financial strain.

Dr Cynthia Ogden: epidemiology of obesity in children 2-5 year old with data from NHANES. 7-8% of US toddlers have obesity, with huge ethnic disparities (lowest in whites and highest in Hispanic children). There are no major difference between boys and girls. The increase in excess weight really increases rapidly with age. Obesity rates have levelled off since 2003-2004, and could even be declining. Extreme obesity, however, has increased from 3.6% in 2000 to 5.4% in 2012, which is reflected in the distribution histogram for BMI with a much longer right hand tail. No increase in obesity in children <24 months. Energy intake in 2-5 year olds has been stable in both boys and girls. As children grow older, their intake of added sugars increases. Strikingly, for any given day, 15% of 2-5 year old US toddlers will consume a pizza.

Food insecurity and eating disorders in obese children

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Today Dr June Tester presented the first qualitative study I have seen at Obesity Week ever, on the very interesting topic of disordered eating in children growing up with food insecurity. There is quite a marked association between food insecurity and obesity, which may seem paradoxical, but makes perfect sense to me. Subjects were 47 focus groups from a paediatric weight management clinic. Grounded theory was used to describe themes surrounding food insecurity and eating problems in the children.

There was a lot of secretive eating practices and food hiding, as one would expect. There was also a high frequency of hidden candy wrappers in the children’s rooms. Likewise, food insecure parents also hid food, i.e. fending for themselves: “Otherwise I don’t get any”. It was striking to me the low quality of food that these very poor families can afford to buy. All members of the family tend to binge eat food when there is food insecurity. Parents describe how they want to put locks on their fridges or anywhere there is food. These behaviors certainly complicate treatment of obesity.

Given the marked association between socioeconomics and obesity, we could certainly do with more of this type of studies.

Rebecca Puhl at TOS on obesity stigmatization

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Obesity stigma is a major barrier towards progress for both prevention and treatment. Dr Puhl reviewed how obese people are portrayed in the news and whether they were excessively stigmatized. Over 800 media pieces were analysed. She found that obese people were often portrayed in a very stigmatizing way (for example shown eating junk food while watching TV slumped on a couch) compared to normal weight people (eg often shown shopping for fruit and veg or exercising on a beach).

Programs that attempt to address obesity need to be informative without increasing stigma and shame, which has proven tricky in the past. Indeed, several obesity awareness campaigns have been stopped since they increased obesity stigma for the very people they wish to help, and were therefore (at least partly) counterproductive.

Interestingly, non-stigmatizing obesity awareness campaigns generated much more motivation to change than stigmatizing campaigns. Indeed, stigmatizing campaigns decreased self-efficacy for change and increased anxiety. Since campaigns want to grab peoples’ attention they often use shocking messages, which often produce stigmatizing effects. There is clearly a strong need for balanced and respectful obesity awareness campaigns that also grab peoples’ attention, a known communication challenge.

TOS session: Evolving behavioral strategies for weight control

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This was a very interesting session where all presenters gave great and informative talks and discussed various new behavioural strategies for improving obesity treatment outcomes. Clearly there has been quite significant progress in the last 5 years or so in improving behavioral treatment program, so that we can improve weight loss and quality of life. Below is a brief summary of what each presenter talked about.

Evan Forman talked about acceptance-based approaches to weight loss, for example how we are often governed by negative internal discomfort, both in terms of diet and exercise, and how this can be overcome. A low distress tolerance clearly predicts poor treatment outcomes, such as weight regain after weight loss. Cues are from both the environment and internal. Commitment and motivation erodes over time. An aversive state, both in terms of cues (hunger and cravings) and emotions (sadness, boredom, anxiety), leads to unhealthy lifestyle choices. The evidence supporting acceptance based therapy vs standard behavioural therapy is still limited, but clearly promising. Studies are now showing better outcomes than older behavioral treatment models, particularly when the intervention was delivered by experts in acceptance therapy. Patients with mood problems appear to benefit greatly from this type of intervention, and also early treatment non-responders.

Jean Kristeller talked about mindfulness-based approaches to obesity treatment. Mindfulness can work to disengage from habitual reactions. There is now a lot more evidence on a very positive role of mindfulness in food intake regulation, for example when eating is emotionally driven. Mindfulness (such as increased awareness of hunger and food cues, awareness of hedonic eating and sensations of fullness) can really help to self-regulate more or less automatic responses, such as eating comfort foods when they are freely available. Mindfulness can be a particularly useful approach for binge eaters and impulsive eaters. There is also a moderately strong association (r=-0.41) between use of mindfulness-based approaches and weight change. The evidence base for greater use of mindfulness-based approaches to weight loss is clearly increasing.

Melinda Sothern talked about the powerful role of parents and families in promoting healthy diet and exercise lifestyles in children. Poor parental role modelling, for example through unhealthy food and eating habits and lack of exercise/excessive TV time, is a major risk factor for childhood obesity. There is great potential in improving childhood obesity treatment outcomes through improving the home environment and parents are obviously critical to get on-board. More play time is recommended as is less screen time. This will also help the children to develop in many areas, not least socially and emotionally. The challenge (I presume) is how to convert these recommendations for socioeconomically disadvantaged families, where obesity is also much more common than in affluent families.

Erik Hemmingsson

Boston