Conduit Magazine Summer 09

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					CONDUIT
Summer 2009 Volume 3 • Number 2 • $4.95

PHARMACISTS
The Front Line Of Obesity Management?

CHILDHOOD OBESITY
On The MEND

COALITION
Takes Aim At Incontinence

OBESITY, THE BRAIN AND MENTAL HEALTH
What Really Drives Gaining And Losing Weight? SEE PAGE 6

CONTENTS
SPECIAL REPORT: OBESITY, THE BRAIN AND MENTAL HEALTH

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IS OBESITY PART OF THE MENTAL HEALTH EPIDEMIC?

APPETITE’S ON AND OFF SWITCHES By studying women’s hormonal cycles, current research seeks to understand how neural circuitry regulates appetite and how it is linked to the reward centre of the brain.

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GUEST EDITORIAL The Honourable Wilbert Keon, O.C., O.Ont., B.Sc., M.D., M.Sc., F.R.C.S.

MENDING CHILDHOOD OBESITY Evidence-based and reproducible program promotes healthier, happier kids.

PATIENTS NEED ACCESS TO TREATMENT: PANEL Pharmacists play a key role in advising patients on weight management.

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COMPELLING EVIDENCE Understanding biobehaviourial differences among obese people.

SALT LICK STRIKES AGAIN The second annual national “Salt Lick Award” goes to the country’s pizza producers for loading the popular fast-food with bloodpressure raising sodium.

STRESS AND THE EMOTIONAL EATER Researchers at Carleton University are studying the relationship between stress, ‘unsupport’ and emotional eating.

COALITION TAKES AIM AT INCONTINENCE Obesity affects virtually every organ in the body, and the bladder is no exception.

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CON-RCO PARTNERS

BRAIN, MIND BODY: MAKING THE CONNECTIONS Research supported by the Institute of Neurosciences, Mental Health and Addiction (INMHA) attempts to add to the understanding of the mind-brain’s role in obesity, its causes, prevention and treatment.

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GUEST EDITORIAL

CONDUIT
SUMMER 2009 Volume 3 • Number 2
The official publication of the Canadian Obesity Network (CON-RCO) © 2009 Canadian Obesity Network EXECUTIVE EDITOR Dr. Arya M. Sharma, CON-RCO Scientific Director EDITOR Brad Hussey ASSOCIATE EDITORS Ximena Ramos-Salas Dawn Hatanaka CONTRIBUTORS Elizabeth Garel Lisa Willemse Brad Hussey DESIGN Mark Tzerelshtein | Markintoshdesign.com Printed at McCallum Printing Group Inc.

Focusing on CHILDHOOD OBESITY
Obesity is affecting a significant portion of Canada’s population, with serious consequences for our public health care system. What is most disturbing is the startling rise in obesity among Canadian children: they are heavier than those of past generations and of their cohorts in other countries. This trend is a very poor indicator for the future health of our nation. A person’s overall wellness is dependent upon much more than simply winning the genetic lottery and exercising daily, although these certainly help. It arises from a vast array of factors and conditions, collectively known as the social determinants of health or population health. Of these determinants, early childhood development is possibly the most important. Prenatal and early childhood development establish the foundation for one’s subsequent health and general well-being. Exposure to prolonged and intensive stress during prenatal and early childhood can disrupt brain development and compromise the nervous and immune systems. By the time children reach the ages nine through 12, their already firmly entrenched lifestyle habits could put them on the fast track for developing cardiovascular, type II diabetes and other chronic diseases by the time they are in their thirties. Children brought up under adverse conditions are predisposed to a range of health problems, including obesity. Children who are obese are at high risk of becoming adults who are obese. This, of course, puts pressure on our already over-burdened health care system which must deal with all the conditions associated with obesity—including diabetes, cardiovascular disease and cancer. Tackling obesity in children is critical. The question is how to do it. We know that from a metabolic perspective, obesity is generally related to too much food intake and too little energy expenditure. We also know that, from a population health perspective, obesity is caused by a range of vectors, namely the underlying issues that shape eating habits and social-economic factors. In order to deal with childhood obesity adequately, we need to take into account both these perspectives and work towards treating and preventing obesity. Such a strategy requires better and more detailed research than what we now have, with a focus on four areas: • The basic science of the biology and genetics of obesity; • Clinical work on prevention, treatment and rehabilitation; • Environmental issues; and • Health economics and policies. The solutions that emerge from this research must be shaped to respond to the needs of the child as a whole—mental and social, as well as physical. Unless the underlying currents and issues that precipitate the original eating and lifestyle habits are addressed directly, the obesity will not be appropriately treated and efforts at prevention will almost surely fail. The good news is that we are increasingly seeing such holistic approaches to obesity. Better news would be to see it applied more vigorously to children. Helping families to ensure that children lead their lives in the healthiest way possible is the best way ensure that they will grow into healthy adults. This requires an overall determinants of health or population health approach. We need an all-of-government approach to develop communities of health, well being and productivity throughout the life course. The Hon. Wilbert Keon, O.C., O.Ont., B.Sc., M.D., M.Sc., F.R.C.S.

Address correspondence to: Canadian Obesity Network Royal Alexandra Hospital Room 102 Materials Management Centre 10240 Kingsway Avenue, Edmonton, AB T5H 3V9 E-mail: conduit@obesitynetwork.ca For address changes, contact: Canadian Obesity Network Royal Alexandra Hospital Room 102 Materials Management Centre 10240 Kingsway Avenue, Edmonton, AB T5H 3V9

CONDUIT is a publication designed to promote dialogue and understanding about obesity research and networking activities across Canada. The opinions expressed in the articles do not necessarily reflect those of CON-RCO, its members, its partners or its supporters. CON-RCO does not endorse any products, services, methods or research results contained herein. CON-RCO is funded by the federal Networks of Centres of Excellence program (www.nce.gc.ca), a joint initiative of the Natural Sciences and Engineering Research Council, the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council and Industry Canada. The network is hosted by the University of Alberta and Alberta Health Services. Visit the CON-RCO website: www.obesitynetwork.ca Publications Mail Agreement Number 41467026

Please return undeliverable Canadian addresses to: Canadian Obesity Network Royal Alexandra Hospital MMC Room 102 10240 Kingsway Avenue, Edmonton, AB T5H 3V9

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OBESITY, THE BRAIN AND MENTAL HEALTH

IS OBESITY
R
eaders of my blog (www.drsharma.ca) are probably well aware of the emphasis I place on identifying mental health factors that either promote weight gain or pose significant barriers to weight management. Indeed, I have previously proposed that the rise in obesity is more closely related to the mental health epidemic (in kids and adults) than to any other aspect of health status. Thus, although the public and political focus remains on improving nutrition and promoting physical activity, I maintain that failure to acknowledge the importance of mental health as a major determinant of ingestive and activity behaviours ignores a significant part of the problem. Certainly anyone involved in an obesity clinic is keenly aware of the importance of having psychologists and psychiatrists on the interdisciplinary bariatric care team. Anyone who still doubts the close relationship between obesity and mental health may be interested in the latest study on this issue just out in the April, 2009 issue of the Journal of Psychosomatic Research. In this paper, Amber Mather and colleagues from the University of Manitoba examined the relationship between obesity

PART OF THE MENTAL HEALTH EPIDEMIC?
“Certainly anyone involved in an obesity clinic is keenly aware of the importance of having psychologists and psychiatrists on the interdisciplinary bariatric care team.”
and mental health in more than 36,000 participants in the nationally representative Canadian Community Health Survey. Even after adjusting for sociodemographic factors and physical illness, obesity was associated with a 25% to 50% increased risk of lifetime psychiatric disorders (depression, mania, panic attacks, social phobia, agoraphobia), any lifetime mood or anxiety disorder, suicidal ideation and suicide attempts. The only negative association was with past-year drug dependence (50% reduced risk). Most of these associations were specific to women, although some were also present in men. In an earlier study, published in Psychosomatic Medicine, the same Canadian investiga-

By Dr. Arya M. Sharma
tors reported a two-fold higher risk of paranoid, antisocial or avoidant personality disorders in overweight and obese women. It is clearly time to fully acknowledge the close link between obesity and psychiatric disorders. Although it is not clear from this work which comes first, I have no doubt that a full assessment for obesity (particularly in women) must routinely include a comprehensive assessment of mental health status. In many cases, targeting weight management without also addressing underlying or comorbid mental health problems is unlikely to prove effective. All health professionals dealing with obese clients require at least a minimum competency in recognizing mental health problems and should familiarize themselves with the adequate management and/or referral of these clients for appropriate interventions. Mental health was a key theme of the First National Obesity Summit, hosted by the Canadian Obesity Network in May, 2009 (see page 17). Videos of the plenary presentations are available at www.obesitynetwork.ca. Originally published at www.drsharma.ca.

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APPETITE’S ON AND OFF SWITCHES
ithin the brain, the hypothalamus is considered the primary brain region where a variety of hormones and peptides control appetite. Recent studies show that the same appetite-regulating hormones and peptides are also active in the cognitive, emotional and reward centres of the brain outside the hypothalamus. But how they control appetite and what affect an imbalance has on a person’s ability to manage food intake need to be better understood in order to determine their implications for obesity. These are some of the questions a team of researchers at Queen’s University is seeking to answer. Using Magnetic Resonance Imaging (MRI) technology, the team, led by Dr. Dean Van Vugt, is looking specifically at the roles of estrogen and progesterone in appetite regulation in women, and more broadly, at how neural circuits differ or overlap in men and women, and how these neural circuits are disregulated in overweight and obese individuals. Their findings could lead to new drug development and changes to current hormone-replacement therapies. “Eating is a complex behavior that is regulated by hormones and nerve signals, but also by brain regions involved in processing pleasure, emotion and reward,” says Dr. Van Vugt, a professor in the departments of Obstetrics & Gynecology and Physiology at Queen’s. The first of Dr. Van Vugt’s studies is looking at energy balance and female reproduction. It has been well documented that large cyclic changes in food intake occur during the menstrual cycle in synchrony with changes in estrogen and progesterone secretion. “Prior to ovulation, women have as much as a 40 per cent

OBESITY, THE BRAIN AND MENTAL HEALTH

By studying women’s hormonal cycles, current research seeks to understand how neural circuitry regulates appetite and how it is linked to the reward centre of the brain

W

Effect of the menstrual cycle phase on brain activity. Women viewed pictures of food while undergoing real time brain activity recording with functional MRI during pre-ovulatory (late follicular) and post-ovulatory (luteal) phases of the menstrual cycle. Food pictures elicited greater activation in the follicular phase. Activation of the left orbitofrontal cortex (L. OFC), amygdala, and hippocampus (not shown) in the follicular phase but not luteal phase may influence reward perception of food cues and effect ingestive behavior.

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OBESITY, THE BRAIN AND MENTAL HEALTH

reduction in food intake, whereas in the luteal phase there is an increase in food consumption,” says Dr. Van Vugt, “We’re looking at brain activity during these phases of the menstrual cycle to try to identify why these changes occur.” Subjects in the study fall into a range of weight categories from thin to obese and are tested in various stages of their menstrual cycle. A subject’s brain activity is measured in response to food and nonfood cues. The MRI scans thus far have shown activation in expected areas such as reward centres, the amygdala, hippocampus, insula and orbitofrontal

HUNGER, APPETITE AND SATIETY
People often think about hunger and appetite in the same way, as though the words were interchangeable. But the drivers within the body are quite different: • Hunger is the body’s cue of a physiological need for food. It occurs when blood glucose levels decline and hormones such as ghrelin rise. The body’s response to these fluctuations is symptoms such as a growling stomach and a drive to eat in order to restore the body’s homeostatic levels. Once these levels are attained, satiety — hunger’s opposite — is reached. • Appetite is a psychological desire to eat, based more upon eating experiences, such as memories of good food, or other sensory cues such as taste, smell or texture of food. While hunger occurs only when the body needs food, appetite can occur at any time, irrespective of the body’s need for energy. Appetite is why many still reach for dessert after a full meal, and can be correlated with the hedonic centres of the brain. In such cases, the physiological cues of satiety — stomach distention, elevated glucose levels and changes in hormone levels — are overridden.

cortex, all of which have been implicated in the control of appetite. “We know the hormones estrogen and progesterone have an influence on food intake,” says Tamar Frank, a Physiology Master’s candidate who is running the tests at Queen’s University. “Some hypotheses are that more food energy, minerals and vitamins may be required following ovulation if pregnancy were to occur, but this has not yet been substantiated.” “Findings from this study will have implications for hormone-replacement therapy,” says Dr. Van Vugt. “For instance, if we can show a clear-cut effect of estrogen on brain activity responsible for appetite regulation, this could be an important benefit of hormone replacement therapy in the menopause that could tip the balance in favour of its use. In addition, if we understood more fully the areas of the brain that promote or inhibit food intake, then you could design drugs or behavioural therapies that influence this activity and ingestive behaviour.” The second and third phases of the Queen’s study will look more closely at the biology of appetite regulation. There are over 30 peptides currently identified that tell the brain whether we’re in a positive or negative energy balance. These factors either stimulate or inhibit appetite, but that’s where our current understanding ends. “What we do know is that the regulatory function of the peptides is not doing a very good job in obese people,” says Dr. Van Vugt. “Something is overriding this complex appetite regulatory system, likely involving activation of hedonic brain regions that leads to consumption based on desire and not on the body’s need for food.”

The overlap between addiction and overeating has been a subject of intense study in Canada and abroad. Many of the same brain regions that promote addictive behaviour also promote overeating. Animal studies have demonstrated a significant relation between the reward regions of the brain (those activated by stimulants such as nicotine, alcohol or cocaine) and those activated by food. But while it has been argued that the western diet is addictive, Dr. Van Vugt is uncomfortable with this notion. “I think it’s too simplistic to use addiction as the sole explanation. While there is overlap in these areas of the brain, there is much we have yet to learn about the biology behind overeating.” For example, hormonal peptides such as ghrelin (an appetite stimulant — see sidebar) and leptin (an appetite suppressor), which are active in the hypothalamus, are also active in other regions of the brain. It suggests that more than one area of the brain is responsible for regulating the circuits which regulate food intake and metabolism. “The beauty of this MRI methodology is that once you identify the neural circuits and how they regulate appetite, this can be used as an early outcome measure of treatment’s potential and make modifications if needed, and in this way individualize treatments,” says Dr. Van Vugt. While the costs of installing the MRI technology needed to assess each patient are prohibitive, Dr. Van Vugt projects that the basic knowledge resulting from MRI studies could form a basis from which to develop surrogate tests. Such tests would assist in the prevention and treatment of obesity and its related health issues.

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OBESITY, THE BRAIN AND MENTAL HEALTH

BRAIN IMAGING OFFERS NEW CLUES TO OBESITY

B

rain imaging has played an important role in expanding our understanding of diseases such as Alzheimer’s disease, multiple sclerosis and cancer. Now advanced brain imaging technology may offer new clues about obesity and why some people overeat while others do not. Functional brain imaging goes beyond traditional Magnetic Resonance Imaging (MRI) and CT scans, as it provides images of brain function, not just structure. “With functional brain imaging, we can measure changes in blood flow in particular areas of the brain,” explains Alain Dagher, a neurologist at the Montreal Neurological Institute of McGill University. “Since we know that different parts of the brain do different things, if you can map these various brain regions in action you can tell a lot about brain function.” Although the primary focus of Dr. Dagher’s studies is in Parkinson’s disease and addiction, his work also has implications for obesity. He has developed a method to measure the release of dopamine by neurons in the living human brain. Dopamine is a key neurotransmitter involved in addiction as well as motivation, feeding behaviours,

reward, learning and risk taking. “One link we’re exploring is the connection between addiction and obesity,” he says. “If you define addiction as the pathological desire for something harmful to the individual, then the overweight person who continues to overeat can, to a certain extent, be viewed in the same light as the addict.” Using positron emission tomography (PET) and an injected radioactive tracer, Dr. Dagher is able to measure dopamine levels in the brain and study its normal and abnormal function and how it interacts with other brain systems. Other research has suggested that obese individuals — like drug addicts — have fewer brain receptors for dopamine; as a result, people may overeat to stimulate these deficient reward centres. Dr. Dagher’s research will build on this body of knowledge and add important insights into excessive eating and obesity. In another study, Dr. Dagher uses functional MRI to understand how factors like stress act on the brain and influence food intake. Participants are exposed to various food-related stimuli, such as food images, odours or tastes, while brain scans are taken. “This method allows us

When an individual is exposed to various stimuli — images of food or scenery — a functional MRI captures the brain’s response. Here, the brightly coloured areas indicate regions of the brain activated in response to images of food.

to map the appetite centres in the brain — a group of regions that control hunger, motivation to eat, the perceived desirability of food, etc. — and study how these regions are affected by factors such as stress or hunger,” he explains. Dr. Dagher is particularly interested in the impact on the brain of ghrelin, a peptide that is associated with increased hunger. His research shows that when ghrelin is present, individuals are more receptive to food-related stimuli. “When you have increased ghrelin activity, there is an increased tendency to eat,” he says. This finding supports other research that suggests obesity is a brain disease; that is, people eat because of messages from the brain. These messages, in themselves, are not abnormal, says Dr. Dagher, as they were a survival mechanism for our ancestors. “But in today’s environment, where food is cheap and plentiful, they lead people to eat more than necessary.”

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OBESITY, THE BRAIN AND MENTAL HEALTH

COMPELLING
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UNDERSTANDING BIOBEHAVIOURAL DIFFERENCES AMONG OBESE PEOPLE

EVIDENCE

OBESITY, THE BRAIN AND MENTAL HEALTH

A

t its most basic level, the cause of obesity is often the result of an energy imbalance — an intake of calories that is greater than an individual’s output. But that simple equation doesn’t accurately describe what in reality is a heterogeneous condition underscored by varied and complex causes. A 65-year-old woman whose BMI has gradually climbed to 30 over the past decade and a 30-yearold man with a BMI of 50 are both considered obese, but the root causes of their condition are likely quite different. Nevertheless, when researchers study obesity, they typically compare normal-weight individuals to those classified under the umbrella grouping of “obesity” (usually defined as a BMI of 30 or greater). Caroline Davis, psychology professor with the School of Kinesiology and Health Science at Toronto’s York University, is attempting to correct this paradigm of ‘overinclusion’ in obesity research by studying biobehavioural differences in various subgroups. In a recent study (Obesity, 2009), Dr. Davis and her team examined genetic and psychological indicators of hedonic eating in obese adults with and without binge eating disorder (BED). According to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), BED is defined as recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of bulimia nervosa, such as vomiting, fasting or the use of laxatives or diuretics. “While some people become overweight passively — they eat overly large portions or snack liberally on high-fat high-sugar foods — binge eaters are compulsively driven to overeat,” Dr. Davis explains. “Binge eating isn’t just about the amount of food consumed but also the feeling of loss of control.” Individuals with BED typically eat normally most of the time but are compelled by a craving at least once a week or more to eat excessively, which they later regret or feel disgusted by. After examining dopamine and opioid genetic markers, which are jointly associated with the functioning of brain reward mechanisms, Dr. Davis’ and her colleagues found that individuals with BED were more likely to have a specific genotype related to hedonic eating (i.e. motivated by the appealing look and taste of

“BINGE EATING ISN’T JUST ABOUT THE AMOUNT OF FOOD CONSUMED BUT ALSO THE FEELING OF LOSS OF CONTROL.”
food to eat in the absence of hunger). In addition, BED subjects were more likely to self-report a stronger response to the hedonic properties of food. Dr. Davis believes that her study is unique, not only because it is the first to look at genetic variation in the opiate system regarding eating patterns in humans, but also because other researchers have concluded from their studies that obese individuals have a reward deficiency. “I have always hesitated to agree,” she says. “In both genetic and psychological indicators, the binge eaters [in this study] were more sensitive to reward.” The team’s findings suggest that BED is a biologically based subtype of obesity and that the proneness to binge eating may be influenced by a hyper-reactivity to the hedonic properties of food, she concludes. “This study shows there are different routes to the same outcome, and that should have an impact on how we treat obese people,” she says. “Recognizing that all obese people are not the same and identifying subgroups will help improve our understanding of the causes of the condition and improve our ability to treat it,” she says.

OBESITY AS AN ADDICTION
In another York University study of binge eating, PhD candidate Claire Curtis examined whether obese individuals with BED differed from non-binge-eating obese individuals and normal-weight controls. The goal of the study was to determine whether these groups differ in addictive personality traits, food cravings, response to the food environment and engagement in other addictive behaviours. Previous research has suggested that compulsive overeating shares many simi-

larities with other addictions, such as substance abuse and pathological gambling, as both addictive drugs and highly palatable foods activate the brain’s Common Reward Pathways. Less clear is whether other forms of overeating/obesity deserve the same diagnostic designation. Curtis found that obese participants in her study were more likely to score higher on ratings for food cravings, addictive personality traits and the rewarding power of food than normal-weight controls. Obese participants with BED scored even higher on these measures than those without BED. In addition, the BED group engaged in more addictive behaviours — including gambling, caffeine use and compulsive shopping — than the other two groups. The finding that binge-eaters had much stronger cravings for food than obese nonbinge-eaters supports the view that BED can be an addiction disorder; a key characteristic of all addictions is cue-elicited craving. Although this was a small study, with about 90 participants in each group, Curtis believes the results hold important implications. “In addicts, cravings can potentiate disorder and cause relapse. If an individual has a high response to food cravings, our environment — which bombards us with cues to eat — is not conducive to treatment,” she says. “Abstinence clearly isn’t an option for this population as it is for other types of addicts, so an effective treatment needs to look beyond the individual and look at how the environment needs to be modified.” Like Dr. Davis, Curtis concludes that the heterogeneous nature of obesity warrants diversity in treatment strategies that are subgroup specific. “You can’t lump everyone with a BMI over 30 together in one group. To be successful in treating obesity, we need to identify what is motivating an individual to overeat and then tailor the treatment accordingly,” she says. Curtis’ next research project builds on her interest in food addictions. She recently began a study of addictive behaviours in bariatric surgery patients, examining how individuals who feel ‘addicted to food’ fare after surgery. Among other questions, her research will examine whether compulsive eaters — when forced by surgery to give up binge eating — transfer their addictions to another compulsive behaviour.

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OBESITY, THE BRAIN AND MENTAL HEALTH

nder stressful conditions, our body gives us the signal to eat. It’s a natural response, and if we traced its physiological history, we’d go all the way back to our human origins, when stress generally meant physical danger, either in defense or while on the attack. Such stressors required energy expenditure. While today’s sedentary lifestyles do not create the same need for energy replacement, our body has not yet evolved to recognize the difference. For those whose eating behaviours are more commonly driven by emotional stimuli, high or frequent stress events can lead to overeating and weight problems. As recent research demonstrates, one reason emotional eaters are more likely to reach for the fridge and are more likely to eat more when coping with stress may be due to hormonal or adrenal imbalances. Emotional eating is negative coping. “Binge eaters seem to be sensitive to negative social interactions — ‘unsupport’ — but less is known about sub-clinical emotional eaters. It’s suspected that unsupport may play a role in this behaviour as well,” says Kate Raspopow, a PhD candidate at Carleton University. Unsupport is not necessarily a lack of support, but a negative response from

U

TRIER SOCIAL STRESS TEST (TSST)
This standard test was developed in 1993 by a team of researchers, at the University of Trier, Germany to measure the impacts of moderate psychosocial stress in laboratory settings. The test induces significant changes in the endocrine and cardiovascular systems of most subjects, and has thus been used to investigate a wide range of outcomes such as subjective-verbal stress responses and objective behavioral and biological stress responses. The TSST is a performance task consisting of a brief preparation period (3 minutes) followed by a test period in which the subject has to deliver a free speech (5 minutes) and perform mental arithmetic (5 minutes) in front of an audience.

STRESS and the
RESEARCHERS AT CARLETON UNIVERSITY ARE STUDYING THE RELATION BETWEEN STRESS, “UNSUPPORT” AND EMOTIONAL EATING
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EMOTIONAL EATER

OBESITY, THE BRAIN AND MENTAL HEALTH

“Instead of going to the fridge, possible alternatives are listening to music or going for a walk.”

others to the need for support. For example, unsupport could be a circle of friends who are also emotional eaters and who would not be able to provide alternative coping strategies to a person who is under stress. Other instances of unsupport investigated within the study included distancing from a person who requires support, minimizing or blaming a person for what’s happening to them, and bumbling — not knowing how to act around the person, or providing a mismatched type of support. Raspopow is leading the Carleton study, which is looking at the effects of stressful events on eating, and on emotional eating as a way of coping. Subjects were undergraduate women of all body weights who had their blood levels of cortisol and ghrelin measured over a set duration. Some of the participants were given stressors, such as having to give a public speech and completing a math test (see sidebar). Following each of the tests, the participants were offered food. Cortisol is the primary hormone released as a stress response and ghrelin is a hormone associated with appetite stimulation. Under normal conditions, ghrelin levels rise to stimulate eating, but then fall once a person begins a meal. The study found that those subjects who experience unsupport showed increased emotional eating. Emotional eaters then displayed ghrelin levels which

were maintained for a longer duration as compared to normal eaters. The emotional eaters also showed higher levels of cortisol after the stressor task and did not show a decrease in the level of ghrelin after the food was consumed. There was

no correlation between stress and increased levels of ghrelin. “What we can surmise is that negative support leads to emotion-focused and avoidant coping strategies,” says Raspopow. “This may trigger the development of emotional eating.” “Our results also show that emotional eaters have more prolonged levels of ghrelin, suggesting that emotional eaters may have an extended ‘start to eat’ signal, even after they’ve begun to eat when we expect this hormone to decrease.” Raspopow recommends preventive strategies for emotional eaters, which includes alternate activities when in a stressful or negative support situation. “Instead of going to the fridge, possible alternatives are listening to music or going for a walk.” “Another strategy is to keep daily diary logs to try to identify the triggers to emotional eating,” says Raspopow. “And finally, identify those people who are giving negative support so that a strategy can be employed to avoid those people when stressful situations arise, or to match the type of support needed at the time.”

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PRE-OBESITY+
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obesitynetwork.ca
In collaboration with

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OBESITY, THE BRAIN AND MENTAL HEALTH

MAKING THE CONNECTIONS
Federal institute keeps mental health top of mind
“People think of the regulation of food intake as a physiological process, but the factors that determine the initiation and cessation of eating go beyond taking in calories when you need them and stopping when you have enough. How and what we eat is largely determined by cephalic factors; it’s very psychological.”
While obesity is not classified as a mental illness, there are many connections between mental health, the brain and excessive body weight. Some of these connections are well documented — the increased risk of depression among obese individuals, for example — but far more is yet to be explored. Research supported by the Institute of Neurosciences, Mental Health and Addiction (INMHA) attempts to add to the understanding of the mindbrain’s role in obesity, its causes, prevention and treatment. INMHA is one of 13 “virtual” institutes that comprise the Canadian Institutes of Health Research (CIHR). Bringing together researchers, health professionals and policymakers from voluntary health organizations, provincial government agencies, international research organizations and industry and patient groups from across the country, each institute focuses on a specific health issue. INMHA supports more than 5,000 Canadian senior scientists covering mental health, neurological health, vision, hearing, cognitive functioning and related disorders. Research ranges from fundamental bio-medical and clinical research, to research on health systems, health services, population health, societal and cultural dimensions of health and environmental influences on health.

BRAIN MIND BODY

Dr. Anthony Phillips.

“We have a very large portfolio at INMHA,’ says the Institute’s Scientific Director, Anthony Phillips. “INMHA champions research in three distinct but related areas: the brain, mental illness and addiction.” Putting its massive scope of research into perspective, Dr. Phillips notes that the areas covered by INMHA in Canada are divided among six separate institutes under the National Institutes of Health in the U.S. There are advantages to bringing diverse strains of brain science under one umbrella, says Dr. Phillips. “Learning about the brain in all its complexity helps us to better understand the very powerful biological and environmental influences at play in mental illness and addiction.”

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“Now, you have basic science tied into mental health and addiction, which can then build on and translate to other important areas of health research, including obesity…”
Some of that information is useful in obesity studies. Just one example that Dr. Phillips offers is in the area of orexin research. Orexin is a neuropeptide released in the hypothalamus (the neuroendocrine control centre of the brain) that has been linked to sleep-wake cycles, motivation and appetite regulation. “There is a great deal of interest in these neurons,” he says. While some INMHA scientists are researching the neurobiology of orexin, others are working with animal modes to investigate its connection to addiction. “So now, you have basic science tied into mental health and addiction, which can then build on and translate to other important areas of health research, including obesity,” he says. Dr. Phillips has a long-standing interest in understanding the neural basis of mental illness and addiction. In addition to his April 2009 appointment as INMHA’s Scientific Director, he is also the Founding Director of University of British Columbia’s Institute of Mental Health, Professor of Psychiatry and Senior Scientist in the UBC/Vancouver Coastal Health Brain Research Centre. His research interests are in the neurochemistry of the brain and how drugs affect it to bring about change in behaviour and the effective management and prevention of mental illness. He is particularly known for his work in the role of dopamine in motivation and memory, and its implications for understanding addiction. Some of his findings — and those of his fellow researchers at INMHA — may eventually aid obesity treatment. “INMHA encourages the translation of scientific knowledge into health improvements. It takes time, but our researchers are determined to have an impact on the health of Canadians,” he says. For more information about the Institute of Neurosciences, Mental Health and Addiction, visit www.cihr.gc.ca

UNTANGLING THE BRAIN’S COMPLEX (OBESITY?) WEB

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ometimes, trying to decipher neural connections in the brain is like trying to decode messages between espionage agents: even if you don’t understand exactly what’s being said, you can gain a lot of information just by knowing the parties that are talking. That’s the analogy Dr. William Colmers, professor in the Department of Pharmacology at the University of Alberta in Edmonton, offers in explaining his research into activity of neuropeptide Y in the hypothalamic ventromedial nucleus (VMN). Ongoing activity of neurons in the VMN is known to control hunger and satiety, and this effect is enhanced by leptin, an appetite suppressant. But the VMN is also one of the most sensitive sites for neuropeptide Y, whose actions increase hunger. In a recent study, Dr. Colmers and fellow researchers sought to identify the mechanisms underlying neuropeptide Y’s actions in the VMN and determine if neuropeptide Y signals converge with others implicated in energy balance regulation. “Both eating and overeating are behaviours. As a consequence, everything that is related to obesity is related to the fact that people don’t stop eating when they have enough energy,” says Dr. Colmers. “We have a highly sophisticated switch in the brain that tells us when we have had enough to eat. But when we are exposed to a highly caloric, highly tasty diet, something goes wrong.” In his research, Dr. Colmers is trying to determine where that “switch” in the brain is located and how it malfunctions in obesity. Dr. Colmers’ team used electrical recordings from mouse brain cells to do the experiments. Using a fluorescence microscope, researchers examined brain samples containing the VMN from mice that had a gene inserted to make a green fluorescent protein in nerve cells where the receptor for leptin is also made. Neurons in the VMN that made the leptin receptor could be identified by their distinct fluorescence; these neurons were then specifically targeted for patchclamp recordings. The patch clamp is an electrophysiological lab technique used to study the effects of various interventions (e.g. a drug) on ion channels in cells such as muscle fibres and neurons. Dr. Colmers’ team found that neuropeptide Y signals converged onto VMN neurons that are sensitive to leptin and glucose signalling. As a result, the VMN’s hunger-suppressing actions were overridden by neuropeptide Y’s actions to increase eating. “This research is another step in trying to understand the mechanism that regulates body weight and the patterns of how the brain is organized to regulate hunger and satiety. In the long term, we may then have targets for drug therapy,” says Dr. Colmers.

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MENDing CHILDHOOD OBESITY
o one disputes the troubling trend of increasing rates of childhood obesity. Over the past 25 years, the prevalence of overweight and obese children and youth has risen to an estimated 155 million worldwide, with the most substantial increases observed in economically developed countries. In Canada, 26% of children and adolescents aged 2 to 17 are overweight or obese, according to a 2004 Statistics Canada report. Clearly, interventions are required in order to slow — or ideally reverse — this trend. While many jurisdictions have taken steps to develop programs that target various solutions — from nutrition education for parents to physical fitness in primary schools — there is no standardized program that can be easily reproduced in communities across the country. A British organization known as MEND (Mind, Exercise, Nutrition... Do it!) is looking to fill that gap with an effective and research-based obesity prevention and treatment program that can be replicated and costeffectively delivered in any community in any country. Developed in 2005 at Great Ormond Street Hospital for Children and the University College London Institute of Child Health, the MEND program is a 10-week course for overweight children age 7 to 13 (two other programs target younger children: MEND 5 -7 is for overweight early-school-aged children, while Mini-MEND is an early prevention program for preschoolers of any weight).

EVIDENCE-BASED AND REPRODUCIBLE PROGRAM PROMOTES HEALTHIER, HAPPIER KIDS

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also observed for secondary outcomes, including reduced BMI and improved self esteem and cardiovascular fitness, and increased physical activity. Longitudinal follow-up indicated that these benefits were sustained at 12 months. The Institute of Child Health is now conducting a second, larger trial to follow families up to 10 years after their participation in a MEND program.

done in close collaboration with local experts,” says Sacher. Randomized control trials in Australia and Texas will add to the body of research that allows the program to continually improve. “The program is like a growing organism that evolves as everyone’s experience and feedback is captured,” says Sacher. “We are now in our sixth major version, each one an improvement on the last.”

COMING TO CANADA?
Canada may be the next country to benefit from MEND. Sacher presented research from MEND to attendees at the recent National Obesity Summit in Kananaskis, Alberta, which triggered discussions with Alberta Health Services about potential for MEND to become part of that province’s service delivery. Dr. Geoff Ball, Director of the Pediatric Centre for Weight and Health at the Stollery Children's Hospital in Edmonton, was at the Summit, and he is particularly interested in the prospect of a Canadian MEND program. “There are more than 150,000 overweight or obese kids in Alberta alone, and the programs we have just don’t meet the need,” says Dr. Ball, noting the geographic and cultural challenges inherent in any program delivery in Canada. Once tailored to a particular community, MEND becomes a turnkey operation. Because program leaders are supported with a standardized, comprehensive training package, a healthcare professional is not required to deliver the course. “A program like MEND could be delivered as easily in a hospital in Edmonton as in a community centre or school in a remote area of the North,” says Dr. Ball. “If MEND can be customized to the Canadian context, it would be a lot easier than reinventing the wheel.” The fundamental question is whether the program works in the real world. “It appears that it does,” says Dr. Ball. “And it’s an evidence-based program. That gives us more confidence about what we can expect if we implement it in Canada.” For more information, including the results of the MEND study, visit www.mendprogramme.org.

Children and their parents meet twice a week to learn how manage their weight and health through balanced eating and increased activity. “We give the children and their parents information in an accessible, nonthreatening way,” explains Paul Sacher, MEND’s Chief Research and Development Officer. For example, in addition to learning how to read food labels, families are given a tour of their local market and encouraged to try new foods. While the children are taught basic balance and agility skills, parents are given ideas to help motivate the whole family to be more active. Sacher admits that MEND’s content is not particularly novel. “It’s not rocket science to teach kids how to lose weight,” he says. “What makes our program unique is that we’ve put research into action and standardized the program so that it can be scaled up, replicated and made cost effective.”

EVIDENCE-BASED PROGRAM
Unlike most community-based childhood obesity intervention programs, MEND is supported by ongoing research and evaluation that demonstrate the program’s effectiveness. A randomized control trial followed 104 obese children who participated in the nine-week MEND pilot. After six months, the waist circumference of children in the MEND group was significantly reduced compared to children in the control group. Positive results were

“A lot of good research stops at the research stage. MEND is successful because right from the beginning, we designed the program so that we could standardize it and implement it in a largescale way,” says Sacher. Thanks to support from partners from the private, public and not-for-profit sectors, free MEND programs are now offered in some 350 community locations in the United Kingdom. In just four years, more than 10,000 families have participated in MEND programs in the UK. MEND also adapts its programs for other countries and is now offered in Australia, Denmark, New Zealand and the United States. The program undergoes significant adjustments to account for local foods, culture, restaurants, and dietary and physical activity guidelines. “It’s quite a detailed process, which is

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PATIENTS NEED ACCESS TO TREATMENT: PANEL
Pharmacists play a key role in advising patients on weight management
besity is increasing at epidemic rates in Canada, yet far too often it is viewed as a lifestyle problem and not as the chronic disease that it is. That was a key conclusion reached by a panel of Canadian experts in obesity, primary care, pharmacy, nutrition and consumer wellness. The panel convened to discuss the public health crisis of obesity, and recently issued a consensus statement on access to obesity treatment in Canada. In examining the current landscape of weight management in this country, the panel found that although one in 10 premature deaths of Canadian adults is directly attributable to obesity, most overweight and obese patients do not seek or receive any weight loss advice from their physicians. “Unfortunately, many people — including healthcare professionals — fail to recognize that overweight and obesity is the primary cause of many health issues, including diabetes, heart disease and many cancers,” says panel chair Dr. Richard Tytus, Associate Clinical Professor at McMaster University in Hamilton, Ontario. When obesity is addressed, patients and healthcare professionals continue to think in terms of cosmetic or “Hollywood” weight loss (>20%), believing that acquiring an ideal body shape or BMI is key.

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In publishing its findings in a consensus paper, the panel hopes to create a paradigm shift that supports what Dr. Tytus calls a ‘therapeutic weight loss’.” Clinical evidence has shown that even a modest weight loss of 5% to 10%, if sustained, can have significant health and quality-of-life benefits,” he says. “We need to get away from the idea of extreme, short-term Oprah-like results and instead focus on achieving and maintaining small, sustained weight loss.” One of the obstacles facing patients in their weight loss goals is the lack of access to effective, safe and proven pharmacotherapies, says pharmacist and panel member Tom Smiley of Pharmavision Health Consulting Inc, in Paris, Ontario. “Most Canadians are currently self-managing their weight with the products and programs that are available to them. The panel would like to see more evidence-based therapies made available over-the-counter to Canadian consumers so that they don’t turn to so-called dietary supplements that have no evidence of safety or efficacy.” He notes that more proven OTC weight loss products are available in the United States and Europe, with many users achieving good outcomes. “People need to access as many effective tools and resources as possible,” Smiley adds. In addition to pharmacotherapies, these resources include a full range of healthcare professionals such as pharmacists, dietitians and counsellors. Pharmacists in particular are highly accessible to patients and can have an important role to play in educating consumers on evidence-based treatments and providing behaviour support for weight management; more than 1,000 pharmacists across Canada have recently received speciality training in obesity management. “As with any chronic disease, weight management requires education, improved access to evidence-based therapies and behavioural support,” concludes Dr. Tytus. “There is no magic bullet, but these efforts can improve our prevention and management of obesity.”

CONSENSUS PANEL MEMBERS
Richard Tytus, MD; McMaster University, Hamilton, Ontario Carol Clarke, RD; Diabetes, Obesity and Cardiovascular Network Executive, Burlington, Ontario Karen Duffy, RYT; President Wellness Direct Inc. Iris Krawchenko, BScPhm; Dell Pharmacy Ltd., Hamilton, Ontario David C.W. Lau, MD; University of Calgary Tom Smiley, PharmD; Pharmavision Health Consulting Inc., Paris, Ontario Arya Sharma, MD; Canadian Obesity Network, University of Alberta, Edmonton

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CON-RCO thanks you for making the First National Obesity Summit a roaring success!

The First National Obesity Summit (May, 2009) was a smash hit, thanks to our many speakers, presenters, sponsors and exhibitors. More than 400 delegates attended the conference, and the buzz around the Delta Lodge in picturesque Kananaskis, AB was electric. An online satisfaction survey conducted in the days following the Summit revealed: 100% of respondents indicated that information presented at the Summit will bring about changes in their practice 95% said the conference met or exceeded their personal objectives 93% indicate they will attend the 2011 National Obesity Summit in Montreal, PQ Don’t take our word for it – check out what attendees had to say: “What an excellent conference. The variety of the subjects supported the fact that obesity is a complex disease. Kudos to the organizers.” “I really appreciated this conference – (it was) high quality and it made a big impact on my attitudes and practice. Lots of good networking.” “It was a fantastic event. I learned tons, and the conference helped to pull together my understanding of obesity in a very broad yet specific clinical way. The CON organizers and staff were very helpful and you could tell they really wanted us to enjoy ourselves!” “As an overall comment, I wanted to add that this is the best conference I have attended (in terms of content of presentations, quality and diversity of speakers, friendly attendees and collegial atmosphere). Thank you!” Videos of First National Obesity Summit plenary sessions will be available soon at www.obesitynetwork.ca.

MARK YOUR CALENDARS:

Second National Obesity Summit
April 28th — May 1st, 2011 Montréal, PQ

SALT LICK
strikes again
T
hree of Canada’s Networks of Centres of Excellence — the Canadian Stroke Network, the Canadian Obesity Network and the Advanced Foods and Materials Network — awarded the second annual national “Salt Lick Award” to the country’s pizza producers for loading the popular fastfood with blood-pressure raising sodium. The level of sodium in a couple of pieces of pizza can far exceed the recommended daily intake for adults of 1,500 mg as well as the Upper Tolerable Limit (UTL) of 2,300 mg. of sodium. Consider these examples, based on a scan of nutritional information posted on pizza makers’ own websites: • Two slices (292 grams total) of a Pepperoni Lover’s large stuffed crust pizza at Pizza Hut contain 3,000 mg of sodium — double the recommended intake for a full day. • Two slices (284 grams total) of a large Rustic Italian pizza at Boston Pizza contain 2,580 mg of sodium. • One large slice (339 grams) of Meat Supreme from a walk-in Pizza Pizza restaurant contains 2,400 mg of sodium. According to Statistics Canada (Health Reports, Vol. 18, No. 2), processed foods are the main source of sodium in the diets of Canadians, accounting for 77% of our average daily sodium intake. The same report says that pizza, submarines, hamburgers and hotdogs account for a large percentage of daily intakes. “The onus is on the food processing industry to cut back on sodium in processed meats and cheese used to make pizza,” says Dr. Kevin Willis, a Canadian Stroke Network director and spokesman on the issue. “Action is urgently needed.” In the meantime, pizza should only be consumed as an occasional treat. When ordering pizza, consumers should avoid processed meats, ask for little or no cheese, and limit the number of slices they consume. A high-sodium diet increases blood pressure and high blood pressure is a major risk factor for stroke, heart disease, kidney disease and dementia. High sodium consumption has also been linked to osteoporosis, asthma, stomach cancer and obesity. “High levels of sodium in fast and prepared foods often go hand-in-hand with higher calories and fat content, adding significant health risks to the equation,” explains Dr. Arya M. Sharma, Scientific Director of the Canadian Obesity Network. “Overweight and obese people have

DUBIOUS DISTINCTION TARGETS EGREGIOUS SODIUM IN FAST FOODS
heightened sensitivity to the effects of sodium, and will experience higher increases in blood pressure in response to sodium intake than normal-weight individuals. It is therefore extremely important for people above a healthy weight to limit salt intake in the diet.” Excessive sodium intake is responsible for the premature death of more than 30 Canadians a day, according to research published in the Canadian Journal of Cardiology. “The message is clear — Canadians are asking for healthier alternatives,” notes the Advanced Foods and Materials Network’s Chief Research Officer Dr. Rickey Yada. “Our researchers are responding by not only using food to find cures for diseases such as hypertension and kidney disease but also by looking at foods’ potential to prevent disease and making these power foods available to consumers. Restaurants need to follow suit, providing healthy options and removing toxic ones.” The “Salt Lick” award annually coincides with World Salt Awareness Week — an effort by some 20 countries around the world to highlight the excessive amounts of sodium in fast-food and restaurant fare.

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COALITION takes
besity affects virtually every organ in the body, and the bladder is no exception. Excess weight not only increases an individual’s risk for urinary incontinence — the involuntary leakage of urine — but also makes it worse in those who have it for other reasons (for example, after childbirth). Incontinence affects more than three million Canadians, predominantly women. “It can impact all parts of a person’s life: their social interactions, their sex life, their ability to work, travel, play sports and participate in community life,” says Jacqueline Cahill, Executive Director of the Canadian Continence Foundation. Yet, because of the huge social stigma attached to the condition, it is rarely discussed, even between patients and physicians. As a result, incontinence can be emotionally devastating, causing social isolation, low self-esteem, depression and a fear of intimacy, Cahill adds. A Harvard study published in Obesity (April 2008) highlighted the connection between incontinence and obesity. Analyzing data about women aged 54 to 79 in the Nurses’ Health Study, researchers found that women with a BMI greater than 35 kg/m2 were about 70% more likely to have incontinence than women with a BMI of 21 to 22.9. The good news is that obesity treatment can significantly benefit urinary incontinence. Results from the PRIDE

aim at incontinence
OBESITY INCREASES RISK OF EMBARRASSING AND DEBILITATING CONDITION

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THE INCONTINENCE COALITION
• • • • • • • Canadian Continence Foundation Canadian Obesity Network Canadian Paraplegic Association Canadian Prostate Cancer Network CARP, A New Vision for Aging in Canada Easter Seals Canada Spina Bifida and Hydrocephalus Association of Ontario

study (Program to Reduce Incontinence by Diet and Exercise) published in the New England Journal of Medicine (January 2009), found episodes of incontinence decreased by 47% in women who lost about 8 kg over six months compared to a 28% reduction in episodes in women who lost about 1.5 kg in the same period. “These findings suggest that urinary incontinence should be added to the long list of health problems that improve with moderate weight loss,” says Dr. Arya Sharma, Professor of Medicine and Chair for Obesity Research and Management at the University of Alberta, Edmonton, and Scientific Director of the Canadian Obesity Network. To promote efforts to increase the recognition of chronic incontinence as a serious and debilitating medical condition,

the Canadian Obesity Network recently joined forces with a number of respected and well-known organizations that represent the voice of many Canadians affected by the condition. In April, the newly founded Incontinence Coalition endorsed a letter to federal and provincial Ministers of Health urging steps to help de-stigmatize the condition and improve access to care. In particular, the Coalition encourages the government to publicly acknowledge the prevalence of incontinence and the need for treatment, and to take a proactive role in promoting public education and awareness, in order to help normalize and de-stigmatize the condition. The Coalition also calls for better treatment and care for people living with incontinence. This includes better access to and/or financial assistance for absorbent products, surgical treatments, medications and catheters for both those living in the community and in long-term care facilities. Also vital is increased education for healthcare providers, including general practitioners, nurses and caregivers. “All health providers must become more knowledgeable and proactively raise the subject of incontinence with their obese patients,” says Dr. Sharma. “Because the distress of having obesity-related urinary incontinence can far outweigh the “inconvenience” of having silent conditions such as high blood pressure or dyslipidemia, these patients may be more receptive to obesity treatments.”

CONDUIT | 21

PARTNERSHIPS
The full weight of the obesity problem in Canada is only now coming into focus, and the news so far is bleak. The crisis is rooted in a complex web of economic, psychosocial, behavioural, biological and other contributing factors, and its negative impact on our health, quality of life and economy is profound. There will be no simple solution to the problem. Significant improvements in the understanding, prevention and treatment of obesity that result in tangible humanistic and economic benefits for Canadians can be made only through a collaborative effort across many sectors and disciplines. The Canadian Obesity Network is pleased to work with the following partners: Universities (Canada)
Dalhousie University Lakehead University McGill University McMaster University Memorial University Queen’s University Ryerson University Simon Fraser University Université de Sherbrooke University of Alberta University of British Columbia University of Calgary University of Guelph Université Laval University of Manitoba Université de Montréal University of New Brunswick University of Ottawa University of Prince Edward Island University of Saskatchewan University of Toronto University of Victoria University of Waterloo University of Western Ontario York University Communications Research Centre Canada Health Canada, Office of Nutrition Policy and Promotion National Research Council Canada Institute for Information Technology Ontario Ministry of Agriculture, Food and Rural Affairs Ontario Ministry of Education and Training Ontario Ministry of Health Promotion Public Health Agency of Canada Public Health and Community Services, Hamilton, Ont. Heart and Stroke Foundation of Canada Mathematics of Information Technology and Complex Systems (MITACS) Obesity Canada Society of Obstetricians and Gynaecologists of Canada The Arthritis Society Atlantic Health Promotion Research Centre, Halifax, N.S. Canadian Health Services Research Foundation Centre for the Advancement of Minimally Invasive Surgery, Alta. Connex Health Child and Family Research Institute, Vancouver, B.C. Dairy Farmers of Canada De dwa da dehs nye>s Aboriginal Health Centre, Hamilton, Ont. Drug Information and Research Centre Food and Consumer Products of Canada Firestone Institute for Respiratory Health, Hamilton, Ont. Golden Horseshoe Bioscience Network, Hamilton, Ont. Institute of Health Economics Obesity Surgery Ontario Science Centre, Toronto, Ont. Ontario Training Centre in Health Services and Policy Research, Hamilton, Ont. MaRS Discovery District, Toronto, Ont. Metabolic Modulators Research Ltd., Edmonton, Alta. PATH, McMaster University, Hamilton, Ont. Population Health Research Institute, Hamilton, Ont. Refreshments Canada Society of Rural Physicians of Canada, Shawville, Que. Technical Standards and Safety Authority, Toronto, Ont.

Non-Government Organizations (International)
European Association for the Study of Obesity International Association for the Study of Obesity International Obesity Task Force The Obesity Society

Hospitals/Health-Care Networks
Alberta Health Services Hamilton Health Sciences Corporation, Hamilton, Ont. Hôpital Laval Research Centre, Sainte-Foy, Que. Ottawa Hospital, Ottawa, Ont. St. Boniface General, Winnipeg, Man. St. Joseph’s Healthcare, Hamilton, Ont.

Industry
Abbott Laboratories Ltd. Boehringer Ingelheim Ltd. Ethicon Endo-Surgery Inc. GeneOb Inc. GlaxoSmithKline Consumer Healthcare Canada Global Diagnostics Glycemic Index Laboratories Inc. Hill-Rom Innovus Research Inc. Isotechnika Diagnostics Johnson & Johnson Medical Devices Division JSS Medical Research Eli Lilly Medtronics Inc. Merck Frosst Canada Ltd. Natural Factors New Era Nutrition Nestlé Nutrition OPTIFAST Novartis Pharmaceuticals Pfizer Sanofi-Aventis TM Bioscience University Technologies International Wyeth

Universities/Institutes (International)
Karolinska Institutet, Sweden Max-Delbrück-Centrum für Molekulare Medizin, Germany Mayo Clinic Department of Medicine, Rochester, Minn. Medical University of Gdansk, Poland Pennington Biomedical Research Center, Baton Rouge, La. Rockefeller University, New York, N.Y. The Royal Veterinary and Agricultural University, Denmark University of Cincinnati, Cincinnati, Ohio University of Colorado, Denver, Colo. University of Kansas, Lawrence, Kan.

Non-Government Organizations (Canada)
Active Healthy Kids Canada Canadian Association of Bariatric Physicians and Surgeons Canadian Association of Cardiac Rehabilitation Canadian Association of Gastroenterology Canadian Association of Occupational Therapists Canadian Council for Food and Nutrition Canadian Diabetes Association Canadian Hypertension Society Ontario Pharmacists Association Canadian Physiotherapy Association Canadian Public Health Association Canadian Society for Exercise Physiology Canadian Society for Clinical Nutrition Canadian Urological Association Conference Board of Canada Dietitians of Canada

Government
Canadian Institute for Health Information- Canadian Population Health Initiative Canadian Institutes of Health Research — INMD

OTHER
Active Living Alliance Advanced Foods and Materials Network, Guelph, Ont.

If you’d like to know more about how to partner with the Canadian Obesity network or if you have suggestions for possible partnering opportunities, contact: Ximena Ramos-Salas, Manager Canadian Obesity Network Royal Alexandra Hospital MMC Room 102 10240 Kingsway Avenue Edmonton, AB T5H 3V9 Website: www.obesitynetwork.ca

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Can’t remember the last Coca-Cola ad targeted at children? There’s a reason.

Parents tell us they prefer to be the ones teaching their children about beverage choices. That’s why for over 50 years, we’ve had a company policy that prohibits advertising soft drinks to children. And as a founding member of the Canadian Children’s Food and Beverage Advertising Initiative, we’ve recently extended this policy to include all forms of media, including broadcast, print, the web and beyond. To learn more about our commitments, visit coca-cola.ca

www.coca-cola.ca
TM/® trademarks of Coca-Cola Ltd., used under license, except: ® Simply Orange, Minute Maid, Dasani, Fruitopia and Five Alive, which are trademarks of The Coca-Cola Company, used under license. ® Evian is a registered trademark of Société Anonyme des Eaux Minérales d’Evian, used under license.

is on the move…
…and we want to meet you! Join representatives from the Canadian Obesity Network at these and other North American venues related to the fight against obesity. Stop by our booth to learn more about how to partner with Canada’s only national organization dedicated to reducing the impact of excess weight on the hearts, minds and bodies of people worldwide.    

CON-RCO

october ’09

18–22

International Diabetes Foundation 20th World Diabetes Congress
October 18-22, 2009 Montreal, QC       www.worlddiabetescongress.org

24–28

The Obesity Society:  2009 Obesity Society Annual Scientific Meeting
October 24-28, 2009 Washington, DC www.obesity.org Join us for a ‘Meet the Canadians Reception’ at the Embassy of Canada in Washington on October 26th – details coming soon at www.obesitynetwork.ca!

24–28

Canadian Cardiovascular Congress, Edmonton, AB 
October 24-28, 2009 www.cardiocongress.org

…
www.obesitynetwork.ca


				
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Description: Conduit Magazine Summer 2009 - Canadian Obesity Magazine