Junkfood Science: When is advocacy for you?

August 22, 2007

When is advocacy for you?

The Canadian Obesity Network believes 500,000 Canadians are in need of obesity treatment, specifically bariatric surgery. Years of lobbying the Ontario government to increase funding for bariatrics are paying off, in part because of a uniquely Canadian argument that CON was able to use.

A Ministry of Health press release has recently announced:

McGuinty Government Improving Access to Treatment for Severe Obesity

The McGuinty government is bolstering support for Ontarians who are fighting severe obesity by providing $700,000 to add more bariatric outpatient services at the Hamilton Health Sciences bariatric clinic, Health and Long-Term Care Minister George Smitherman announced today.... The growth of this program will improve patient accessibility for preliminary assessment, and ongoing treatment of the morbidly obese, in an outpatient clinic setting. It has been designed to provide an integrated range of services that will work in conjunction with the bariatric surgical Centre of Excellence ...

“This announcement is welcome news for Hamilton,” says Canadian Obesity Network Scientific Director and McMaster University Professor Dr. Arya M. Sharma. “Obesity is a complex and widespread disease that requires significant resources to address effectively, and I congratulate the Ministry on its decision to expand access to bariatric treatment for the many people in the region who will benefit from it.”...This is just the latest example of how, working together, Ontarians have achieved results in reducing obesity. Other initiatives include :

* Investing over $3.8 million for 225 additional bariatric surgeries and related capital expansions at Humber River Regional Hospital and creating Ontario’s first bariatric centre of excellence

* Launching EatRight Ontario telephone information service that provides healthy eating and nutrition advice to Ontarians....

* Launching a $10 million Healthy Eating and Active Living (HEAL) Action Plan designed to encourage all Ontarians especially youth to live a healthy, active lives.

As Dr. Sharma told the Edmonton Journal last week, “the Canadian Obesity Network (CON) has made great strides towards uniting Canada’s resources in the fight against obesity. This opportunity will allow us to expand its reach and open up new possibilities for our members.

For those unfamiliar with CON, it’s a coalition of weight loss, obesity and bariatric industry interests, government and policy makers, and universities. The lists of partners and supporters involve an extensive network of financial concerns. This partnership works to lobby for obesity treatment and public policies, according to its website:

The full weight of the obesity problem in Canada is only now coming into focus, and the news thus far is bleak. The crisis ...and its negative impact on our health, quality of life and economy is profound.... The Canadian Obesity Network (CON) facilitates effective partnerships that aim to remove the traditional barriers separating university research, private sector commercialization and the public use of research results. In an environment with ever-diminishing resources, economic factors play a key role in decisions about resource allocation, and so CON forges diverse partnerships designed to drive innovation forward and efficiently build Canada’s capacity to address the obesity dilemma.

CON’s influence over government spending and health policies also extends to the development of clinical practice guidelines for doctors, such as the “Canadian clinical practice guidelines on the management and prevention of obesity in adults and children” released this past April. It opens with warnings of the “alarming” problem of obesity, claiming it’s a pressing public health problem and that one in ten people die prematurely “directly attributable to overweight and obesity.” The epidemic of obesity in Canada, it says, costs Canadians $2 billion a year.

The clinical guidelines, themselves, are very similar to those recently released here in the U.S.: a focus on BMI and extensive and regular laboratory testing of fat people from the age of ten years; suggested screening for mood and psychiatric disorders and medications to be considered; a weight management program with diet and lifestyle interventions, and counseling by a clinical psychologist; prescriptions are suggested for those not able to maintain weight loss, including orlistat for adolescents; and bariatric surgery for BMIs ≥ 40 or ≥ 35 with health problems “when lifestyle intervention is inadequate to achieve healthy weight goals.”

Dr. Sharma, CON science director who was on the committee which developed the clinical guidelines, has repeatedly noted that “the track record for all commercial weight-loss programs in delivering lasting weight loss is pretty negligible, and there’s virtually no scientific evidence to back up the claim that many of the commercial weight-loss centres make.” Of course, the well-known failure of the usual lifestyle, diet and exercise interventions would lead to pharmaceutical and bariatric interventions.

Canada’s clinical practice guidelines, according to its acknowledgements, were developed with “financial assistance provided in the form of arm’s length grants-in-aid” — (Was this odd phrase an attempt to lead people to believe there were no strings attached and that the sponsors had nothing to gain?) — “from Abbott Laboratories Ltd., AstraZeneca Canada Inc., GlaxoSmithKline Inc., Merck Frosst Canada Ltd., Pfizer Canada Inc., Hoffmann–La Roche Ltd., Johnson and Johnson Medical Products, sanofi-aventis Canada Inc. and Unilever Canada Inc.”

Similarly, the competing interests declared among the Obesity Canada Clinical Practice Guidelines Expert Panel members, themselves, who developed the guidelines include extensive ties with pharmaceutical interests.**

Yet pharmaceutical ties aren’t the only interests that deserve note. Dr. Sharma, for instance, is probably unfamiliar to most readers here, but he is known in Canada not only for having been instrumental in the creation of CON, but also as the Chair of Obesity Research and Management at McMaster University and Hamilton General Hospital in Ontario. He’s visibly worked for years to promote bariatric surgery and lobby for government funding for bariatric centers, established one of Canada’s first bariatric centers and was on the planning committee for the McMaster Bariatric Conferences, sponsored by Sanofi-Aventis, Johnson & Johnson, and Abbott pharmaceutical companies.

Soon after leaving Berlin, Germany, where he was a professor of nephrology, to join McMaster University as “an obesity professor” [his emphasis], he wrote a 2004 editorial in Obesity Surgery explaining his goals and describing obesity as a deadly malignancy:

Bariatric Medicine without Surgery is like Nephrology without Dialysis

[I]t took several years of working in nephrology before I fully accepted that, despite its often devastating impact on quality of life and its rather marginal impact on survival, hemodialysis is indeed a valuable and viable treatment option for patients otherwise faced with certain death...

My arrival in Ontario as the ‘obesity expert’ was heralded by the local media. Within weeks of my arrival, referrals for patients began coming in... All had significant histories of weight loss attempts, ranging from Weight Watchers and very low- calorie diets to rather questionable ‘medically supervised’ commercial weight loss programs. Many had also failed on pharmacotherapy. None had thus far been offered surgical treatment - the few who had tried to find surgeons in Canada soon discovered that there were only six surgeons performing obesity surgery in the province (population 9,000,000), none of whom were accepting referrals....

[F]rom all that I have read and seen so far, obesity surgery for morbid (or should we call it malignant?) obesity appears far more successful in terms of improving quality of life, resolving co-morbidities, and promoting physical, mental, and socioeconomic rehabilitation than either hemodialysis or renal transplantation for patients with end-stage renal failure...

Recognition of the important role of obesity surgery in the treatment of morbid obesity by internists and family physicians, and their commitment and dedication to the long-term medical management of patients who have undergone bariatric surgery, is long overdue. For my part, I will undertake all that is necessary to establish bariatric surgery as an important and much needed surgical program at our university medical center.

One of the arguments that he and other members of CON have used for years that’s resonated with the media has been to appeal to cost savings, saying that sending patients to the United States wastes money that should stay in Ontario. Because there are so few bariatric facilities in Canada, the government is spending millions of dollars to send Canadians to the United States for bariatric surgery, Dr. Sharma said. He has recommended these funds be kept in Canada and go to bariatric facilities and surgeons in Canada because that money could be used to do twice as many surgeries in Ontario.

Last month’s story from the news bureau at CTV, Canada's largest private broadcaster, is typical. CTV reported that Ontario, like most provinces, is unable to handle the requests for bariatric surgery, so patients come to the United States. They are paying $50,000 to $80,000 apiece for the surgeries, and sometimes over $100,000 — money that bariatric interests argue are better spent in Ontario. Dr. Mehran Anvari, a bariatric surgeon seeking government funding for his facility in Hamilton said: “We estimate $40 million to $50 million a year going to the U.S for obesity surgery... for that same money, we could meet the demand for bariatric surgery for the whole of Ontario.”

While some believed that the government’s announcement this past week meant more funds were being directed for improved care for fat people — going towards better access, larger blood pressure cuffs, wheelchairs and stretchers — Dr. Sharma pointed out, the need for these major investments was to gear up for the expected obesity epidemic and expanded bariatric treatments.

As health minister George Smitherman told reporters at this past week’s announcement, the funding will shorten wait lists and help to keep bariatric surgeries in Canada. He promised additional funding in the new future, saying: “In the next several years in Ontario, I would anticipate that these services will grow by something like six, eight or tenfold,” he stated. “We're at the beginning of a very, very dramatic expansion of services for obese individuals.”

Sadly, patient advocacy isn’t always what it seems, as was recently reviewed here. Governments and health officials are readily influenced by those with the money, power and interests to push the hardest to get what they want. That does not mean the same thing as being what may help the most people or be what is best for patients.

Aren’t supplies, equipment and diagnostics, such as open MRIs, to accommodate people of larger sizes needed at all healthcare facilities and not just bariatric surgery and weight loss centers?

While an additional ten million dollars was also allocated to tell people how to eat and live “healthy,” countless parents waiting more than 7 months to get needed surgeries and tests for their sick babies and children, for instance, might have preferred the government have devoted money towards expanding pediatric services, rather than bariatrics. There is nothing here in the U.S. like the website established for desperate Canadian parents to understand the wait times they can anticipate. Ontario’s Pediatric Surgical Wait Times and assistance for parents of sick children can be viewed here. It was heartbreaking to read about the scared young mother who had to be flown 300 miles out of the country, far from the support of family and friends, to deliver her premature quadruplets in the U.S. because there was no space or staff in a single neonatal intensive care unit (NICU) in all of Canada. [We share their joy, though, that the adorable babies are all healthy and send congratulations to the new parents!] As a 2002 issue of Pediatrics reported, there are only 0.72 such units/10,000 live births in Canada, compared to 1.21 units/10,000 live births in the U.S. There are also only 3.3 neonatologists/10,000 live births in Canada, compared to 6.1 here.

For Canadian patients awaiting surgery and treatment for cancers to heart disease, many provinces are posting their wait time information on the internet on Wait List Registries.

But CON successfully ensured that waiting times were shortened for bariatric surgery.

© 2007 Sandy Szwarc


Declared competing interests of the members of the Obesity Canada Clinical Practice Guidelines Expert Panel:

David Lau owns common shares in GlaxoSmithKline and Eli Lilly. He is a consultant to Abbott Laboratories, Ltd., AstraZeneca Canada Inc., Merck Frosst Canada Inc., Bristol-Myers Squibb Canada, Eli Lilly Canada Inc., Oryx Pharmaceuticals Inc., Pfizer Canada Inc., sanofi-aventis Canada Inc., Servier Canada Inc. and Solvay Pharma Inc.; and has received speaker fees from Abbott Laboratories, Ltd., AstraZeneca Canada Inc., GlaxoSmithKline, Merck Frosst Canada Inc., Merck/Schering, Eli Lilly Canada Inc., sanofi-aventis Canada Inc. and Novo Nordisk Canada Inc.; research grants from AstraZeneca Canada Inc., Bristol Myers Squibb, Dainippon Pharmaceuticals, GlaxoSmithKline, Pfizer Canada Inc., and sanofi-aventis Canada Inc.; and travel assistance to attend international meetings from Abbott Laboratories, Ltd., AstraZeneca Canada Inc. and sanofi-aventis Canada Inc.

Irene Hramiak is a consultant to GlaxoSmithKline Inc. and is on a National Advisory Board for Abbott Laboratories Ltd., Eli Lilly, Novo Nordisk, sanofi-aventis Canada Inc. and GlaxoSmithKline Inc. She has received honoraria for speaking engagements from Merck Frosst Canada Ltd., GlaxoSmithKline Inc. and Novo Nordisk and has received a travel grant from Novo Nordisk.

Arya Sharma is a consultant to Abbott Laboratories Ltd., Boehringer Ingelheim, Novartis, sanofi-aventis Canada Inc. and Merck Frosst Canada Ltd. He has received speaker fees from Abbott Laboratories Ltd., Boehringer Ingelheim, AstraZeneca Canada Inc., Novartis and Merck Frosst Canada Ltd. and travel assistance from Abbott Laboratories Ltd., Boehringer Ingelheim, Merck Frosst Canada Ltd., Novartis and sanofi-aventis Canada Inc.

Ehud Ur has received speaker fees from sanofi-aventis Canada Inc., Abbott Laboratories, Ltd., GlaxoSmithKline and Novo Nordisk; research grants from GlaxoSmithKline and Novo Nordisk; and travel assistance from sanofi-aventis Canada Inc., Abbott Laboratories, Ltd.

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