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The Cult of Personal Responsibility Only Extends To Obesity #COS17

Posted April 26, 2017 by Yoni Freedhoff

Yesterday saw the release of the Canadian Obesity Network’s Report Card On Access To Obesity Treatment for Adults which grades the availability of obesity treatment options in Canada.

While you’re welcome to peek at the report, its bottom line is that despite obesity’s growth and prevalence, whether it’s behavioural programs (and full disclosure, I run one), medications, or surgery, virtually nothing is covered aside from surgery, and among the report’s findings, not a single provincial drug benefit plan covers the cost of pharmacotherapy for obesity, nor do any of the Federal Public Drug Benefit Programs.

And it’s important to be clear here too as to what CON is talking about when calling for increased access to obesity treatment options. This isn’t about vanity. According to CON, obesity,

should be diagnosed by a qualified health professional using clinical tests and measures that assess health, not size

and that it matters because,

obesity is a leading cause of type 2 diabetes, high blood pressure, heart disease, stroke, arthritis, cancer and other health problems. It also affects peoples’ social and economic well-being due to the pervasive social stigma around it. Weight bias can increase morbidity and mortality, and is associated with significant employment, healthcare and education inequities.

The responses to the report (in the comment sections of various stories) are anything but surprising and can be summed up by the quotes obtained by the National Post from Senator Kelvin Ogilvie in discussing the report with him,

Obesity, to be blunt, is very largely a lifestyle issue” he said.

Translation?

It would seem that according to Senator Ogilvie people with obesity have done this to themselves, and similarly, if they just wanted to badly enough, they could fix things stating,

So, at some point people have to take some responsibility for their own management, and obesity is one of those areas around which, with some initial medical advice and guidance, people do have the opportunity, largely, to manage it on their own.

Now rather than expound on how the provision of health care should not be blame based, or discuss the fact that only ignorance and weight bias leads a person to cite personal responsibility as obesity’s answer while simultaneously discussing the appropriateness of medical attention and treatment for a myriad of other chronic non-communicable diseases (diabetes, heart disease, arthritis, many cancers, mood disorders, and many more) which are all also preventable and treatable by way of lifestyle, I want to bring your attention to a new study that just came out in JAMA that explored the use of cholesterol lowering medications in patients who had just suffered a heart attack.

You’d imagine that someone who had just survived a heart attack would be an incredibly motivated patient – one that would likely take on behaviour changes to try to prevent a recurrence. Now this study didn’t look at the far more difficult behaviour changes involving dietary overhauls and the adoption of regular exercise that would be required in the management of obesity, this study looked at whether or not post-heart attack patients took their daily recommended cholesterol lowering medication – a behaviour that no one could argue requires much effort.

Cholesterol lowering medications are recommended post-heart attack because people who have had heart attacks are at much higher risks of more heart attacks and these medications have been shown to reduce those risks.

Before getting into this study, I should point out that a prior study had found that less than 30% of Medicare beneficiaries 65 to 74 years of age who were hospitalized for heart attacks filled their prescription for statins within 90 days of discharge. That means that the vast majority of patients who’d had heart attacks didn’t even bother to try to take on the behaviour change of filling the prescription for, let alone taking, a medication shown to reduce their risk of having another.

This study wanted to explore the rest – the minority of post-heart attack patients who did fill their prescriptions for cholesterol lowering medications and it followed nearly 60,000 patients hospitalized for a heart attack who filled their prescription for a high dose of cholesterol lowering medication within 30 days of discharge and then tracked the medication’s continued usage.

6 months later 32% had stopped taking it with high adherence. 2 years later and 60% weren’t taking it as directed, and 20% had stopped taking it altogether.

Pulling the two studies together (which while not statistically fair is something I’m going to do to make a point anyways) suggests that of those patients on Medicare between the ages of 65 and 74 who had a heart attack, 2 years later only 8% were actually following through on the recommended behaviour change of taking a daily high dose statin.

I bring this up because it demonstrates that behaviour changes, even those that as effortless as taking a daily medicaitons, are challenging to sustain.

Regardless of just how tone deaf it is in the face of decades of global increases in weight, to suggest the useless truism of “eat less move more” as a practical approach to the millions of Canadians whose weights are affecting their health or quality of, the fact is that sustained changes in behaviour challenge each and every one of us regardless of how beneficial those changes might be.

Change being difficult is part of the human condition, and the provision of health care should not be dependent on a person’s success therein. Denying that only when it comes to obesity? Well that’s just ignorance, or bias, or both.

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General

A New Heart and Stroke Funded Report Calls For a “Sugary Drink” Tax

Posted March 16, 2017 by Yoni Freedhoff

Not a soda tax. And not a sugar-sweetened beverage tax. Instead Canada’s Heart and Stroke Foundation’s (HSF) latest funded report makes the case for a “sugary drink” tax which would include of course sodas, sugar-sweetened beverages (chocolate milks and drinkable yogurts for instance), but also naturally sugary drinks like 100% juice.

According to the report, Canadians purchased an average of 444ml of sugary drinks per day. And that’s a per capita average which includes people like the 5 members of my family who purchase an average of none a day – so clearly those who are drinking sugary drinks, are actually averaging more than that. Dishearteningly, things are even worse for youth with the report finding them buying 578ml per day for Canadians between 9-18 years old.

That’s a huge amount, and while some might be confused given the regular coverage of decreasing soda and juice consumption, the report explains,

Over the past 12 years (2004 to 2015), the per capita sales volume has decreased for regular soft drinks (-27%), fruit drinks (-22%), and 100% juice (-10%). In contrast, per capita sales volume increased for energy drinks (+638%), sweetened coffee (+579%), flavoured water (+527%), drinkable yogurt (+283%), sweetened tea (+36%), flavoured milk (+21%), and sports drinks (+4%). In 2004, sales of flavoured water, flavoured milk, drinkable yogurt, and energy drinks were negligible. However, by 2015, these categories accounted for approximately 18% of all sugary drink sales, and compensated for the 7% proportional reduction in sales of regular soft drinks since 2004.

Breaking it down into dollars and cents, the report estimates that sugary drink consumption will lead to over $50 billion in direct health care costs over the next 25 years coming from the costs associated with their projections of 25 years of unchecked sugary drink consumption contributing to

900,000 new cases of type 2 diabetes, 300,000 new cases of ischemic heart disease, 100,000 new cases of cancer, and 40,000 strokes. Canadians’ sugary drink consumption is estimated to account for 63,000 deaths and almost 2.2 million disability adjusted life years (DALYs), which represent premature death or poor health.

In turn, according to their modelling, a 20% sugary drink tax would generate $43.6 billion in tax revenue as well as $11.5 billion in direct health care savings from averting many of the cases, conditions and DALYs noted above.

In my opinion it’s a matter of when, not if, we’ll have some form of sugary, or sugar-sweetened beverage tax in Canada, and the sooner, the better.

[If you’re curious about the report’s methodologies and assumptions, please head over to the HSF’s media centre where they’re hosting the full report.]

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