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Arthur Kleinman’s Eight Questions

The 2020 Canadian Clinical Practice Guidelines for Adult Obesity stress the importance of patient-centred care and ensuring that we understand the patient’s story.

In this context, it may be a good idea to consider presenting the patient with Arthur Kleinman’s eight questions. These questions evolved from Kleinman’s work as a medical anthropologist working across a range of ethnic populations and are particularly helpful in approaching patients of other cultures – but nut not just those.

  • What do you call your problem? What name do you give it?
  • What do you think has caused it?
  • Why did it start when it did?
  • What does your sickness do to your body? How does it work inside you?
  • How severe is it? Will it get better soon or take longer?
  • What do you fear most about your sickness?
  • What are the chief problems your sickness has caused for you (personally, family, work, etc.)?
  • What kind of treatment do you think you should receive? What are the most important results you hope to receive from the treatment?

The answers to these questions – which the patient can formulate ahead of the clinical encounter – can provide important insights and form the basis of an explanatory model towards understanding the patient’s interpretation of their disease state and their health beliefs including their worldview, culture, social context, and spirituality.

For more on Arthur Kleinman and his Explanatory Model click here

@DrSharma
Berlin, D

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EOSS: Time To Drop Stage 0?

Readers will be well aware of the Edmonton Obesity Staging System (EOSS), which classifies the severity of obesity on a five-point ordinal scale based on presence of medical, mental, and/or functional health issues related to excess weight.

By design, EOSS considers Stage 0 in individuals, who meet the BMI criteria for obesity but do not have any apparent health issues.

However, given the recent change in definition of obesity expressed in the newly released Canadian Adult Obesity Clinical Practice Guidelines, obesity is defined as, “the presence of excess or abnormal body fat that impairs health”, BMI should no longer be used as the defining characteristic of obesity.

Thus, one would not consider someone who has no health impairments, irrespective of BMI, to have obesity.

As a result, the EOSS stage 0 no longer makes sense, as this individual, by definition, would no longer meet the key criterion for obesity, namely an impairment in health (perhaps one may consider the term “pre-obesity” in this context?).

This also means that it is now time to abandon the term “healthy obesity” – either you have obesity, meaning you have a health impairment attributable to excess body fat, or you simply do not have obesity!

In practice, you need to be able to list exactly what weight-related health impairments a given person has before labelling them as having obesity.

If you cannot specifically list the health impairments (at least possibly) attributable to excess body fat, then that individuals, irrespective of BMI, does no longer meets the diagnostic criteria for obesity.

This seismic change in how we apply the term “obesity” to a clinical diagnosis will take time to implement and be adopted. No doubt, many will long back for simpler times, where you could just step on a scale, plug the numbers into a BMI calculator, and make a diagnosis based on tables or charts.

It will be interesting to see how long it will take for this new definition to be widely adopted in policy and practice.

@DrSharma
Berlin, D

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Living With Obesity? Time To Connect!

In its continuing efforts to improve the lives of people living with obesity, Obesity Canada, has now launched OC Connect, its exclusive and private portal to engage and empower individuals living with obesity in a safe, supportive and interactive space.  

The OC Connect platform, which runs on MightyNetworks, is a place where anyone living with obesity will recognize that they are not alone in their journey and become empowered to live happy healthy lives while connecting to others who get it!

If you or someone you care about is living with obesity (or for any of your patients living with obesity), OC Connect is for you.  Through this community you will learn the latest science of obesity, what to do about it, and where to find help while building a supportive and interactive community of empowered people fighting the same fight. 

By Joining OC Connect people living with obesity will immediately be connected to others just like them, across various stages of their journey who are looking for and offering friendship and support.  They will also have access to unique and valuable content from Canadian and global experts on obesity, access to exciting live and virtual events designed to inform and empower this community and perhaps most importantly, will be given the opportunity to make a difference.  Whether that be making a difference for themselves or their loved ones, the members of this community will become and important part of something much bigger!

To join “OC-Connect” – click here.

Health professionals may wish to join “OC-Connect Pro” – by clicking here.

@DrSharma
Edmonton, AB

p.s. The “OC-Connect Pro” site works best on the the TimedRight app, which can be downloaded here

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From Blog Posts To Guidelines

Yesterday saw the release of the long-awaited Canadian Adult Obesity Clinical Practice Guidelines.

Getting to these guidelines was a long journey, that started well before the decision, about three years ago, to begin the daunting task of assembling the steering committee, the chapter authors, the literature review, the crafting of recommendations, the rating of recommendations, preparing the publication and the actual launch.

Looking back, I realise that many of the so-called “novel” concepts included in the guidelines, stem back to topics and ideas about obesity, its nature, its causes, and management that I have thought about and discussed on this blog almost a decade ago.

To illustrate this thought process, I have provided links to some of my previous posts on topics which have now found their way into the guidelines.

They certainly make for some interesting reading:

October 2007: Why I Don’t Like BMI

March 2008: Obesity Classification: Time to Move Beyond BMI?

April 2008: Recognising Barriers Key to Obesity Management?

August 2008: Obesity is a Sign, Overeating is a Symptom

February 2009: Edmonton Obesity Staging System

October 2009: Do Mental Health Problems Predict Obesity?

Novermber 2009: The M & Ms of Obesity Assessment

August 2011: Weight Loss is Not a Goal

September 2011: The 5 As Approach To Obesity Counseling

It is indeed humbling to realise just how many of these ideas, first discussed in these decade-old blog posts, are now reflected in the new CPGs.

@DrSharma
Edmonton, AB

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The Canadian Obesity Guidelines Are Here – Time To Join The Conversation!

As of this morning, the 2020 Canadian Clinical Practice Guidelines for Obesity Management in Adults are out on the CMAJ and Obesity Canada websites, respectively.

These guidelines present a departure from previous guidelines on a number of important issues.

For one, Obesity is clearly defined as “a prevalent, complex, progressive and relapsing chronic disease, characterized by abnormal or excessive body fat (adiposity), that impairs health.”

Although BMI and waist circumference can still be used for populations surveillance and screening purposes, the ultimate diagnosis should be based on the impact that adiposity has on health and not some arbitrary anthropometric cutoffs.

Other topics that receive strong consideration include the role of weight bias in clinical practice, a departure from solely weight-centric outcome with a focus on health and wellbeing, learning from the body positivity movement, recognising the importance of root causes including psychosocial factors and mental health, and much more.

Given that there will be many questions and issues around many of these topics, especially with regard to implementation in practice, Obesity Canada is also launching an online information and discussion platform OC-Connect-Pro, where health professionals can connect and share information, tap into tools and education about the guidelines.

To join OC-Connect-Pro click here.

@DrSharma
Edmonton, AB

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Early Registration For Obesity Guideline Webinars Now Open

We are now just one day from the long-anticipated release of the 2020 Canadian Obesity Clinical Practice Guidelines in the Canadian Medical Association Journal (CMAJ) and on the Obesity Canada website.

But, registration for a first series of six webinars, starting Aug 11, by some of the leading chapter authors is already open. This interactive webinar series is offered through a partnership between Obesity Canada and the University of Alberta’s Office of Lifelong Learning.

For a nominal fee of just $50 (Canadian) for all six webinars (i.e. less than $10 per webinar), participants will be able to:

  1. Provide obesity chronic disease management in a planned, proactive manner
  2. Support patients to understand how their root causes, comorbidities and personal context are related to their obesity management
  3. List, review and select therapeutic approaches (behavioural, medical, surgical) to help patients develop personalized plans to manage their obesity as a chronic disease.

Speakers include Drs. Sean Wharton (Toronto), Sara Kirk (Halifax), Michael Vallis (Halifax), Sue Pedersen (Calgary), Rita Hendersen (Calgary), and myself.

For more information visit the Obesity Canada website by clicking here.

@DrSharma
Edmonton, AB

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The 2020 Canadian Obesity Guidelines for Adults are Coming!

Finally, after about three years of hard work by a panel of over 60 authors (not to mention the incredible staff at Obesity Canada), the 2020 Canadian Clinical Practice Guidelines for Obesity Management in Adults will be released in the Canadian Medical Association Journal next week (Aug 4).

This monumental undertaking, that began with extensive literature searches (identifying over 550,000 potentially relevant articles), which was systematically whittled down to about 80 GRADEd recommendations, represents a state-of-the-art evidence and practice informed overview of managing obesity as a complex progressive chronic disease.

Without divulging too much, I can share that the guidelines will cover a broad range of topics from re-defining obesity, to the importance of recognizing weight bias in obesity medicine, to taking a patient-centred approach, where the focus is on improving health and well-being rather than just changing numbers on the scale.

Importantly these guidelines are perhaps unique in the field of obesity, as they include analyses of both quantitative and qualitative research, the latter having often being largely ignored by previous guidelines. In addition, there was ample involvement and representation of the patient voice in the discussion of findings and wording of recommendations.

Targeted at primary care practitioners, the guidelines outline what we know about obesity management but also outlines the often extensive and important gaps in our knowledge.

So please stay tuned, as more information becomes available over the next few days and weeks.

@DrSharma
Edmonton, AB

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The UK Releases a Pie-in-the Sky Plan to Tackle Obesity

Last week, the UK released a pie-in-the-sky plan to address their obesity problem.

Although, I’am sure it is well-intended, I find it impossible to fathom that anyone with even an ounce of knowledge of the complex, multifactorial, chronic, and often progressive nature of obesity should in this day and age still fail to understand that the proposed plan, which includes the usual talk of changing the food environment (largely by appealing to personal responsibility) and a 12-week weight loss plan app [sic], focussed on healthy living (read, “eat-less-move-more”), is about as likely to noticeably reduce obesity in the UK population, as taking out a full page ad in The Sunday Times stating that “Obesity is bad!”.

Let us for an instance assume that millions of UK citizen download the app and somehow manage to lose 12-pounds in 12 weeks. Why on earth would anyone expect this weight loss to be “permanent” (never mind have lasting health benefits)?

After all, if there is one single thing that decades of obesity interventions have taught us, it is that, short of bariatric surgery, there are no “permanent” weight loss solutions (and even surgery is by no means a guarantee!). This is exactly why any serious analysis of the published science on this issue today generally ignores any study of less than 12 months duration – because the results of anything shorter are entirely irrelevant in terms of informing long-term obesity management.

This is not because you cannot lose weight in 12 weeks – of course you can! But because it should be well known by now that it will take most people less than 6 weeks to put it all back on.

This is not because they are stupid, or not-motivated, or simply don’t get it, or lack will power, or are not trying hard enough – it is simply because of the fundamental biology of how bodies regulate body weight.

As I never cease to explain to my patients, “bodies like to gain weight but don’t like to lose it”. Today, we not only understand the complex and powerful biological mechanisms that defend the body against long-term weight loss but also that these very same biological mechanisms virtually guarantee weight regain (except perhaps in a handful of the most dedicated individuals).

So, as the UK embarks on a NHS-sponsored nation-wide exercise in yo-yo dieting, one must wonder about who exactly came up with this plan and why they either failed to consult with or decided to ignore the many excellent obesity experts that the UK happens to have. Hey, oddly enough, we currently even have a UK President of the World Obesity Federation, who is probably embarrassed by this plan. Why were these experts not listened to?

I cannot but notice the stark contrast of this plan to the recent declaration of obesity as a chronic disease by the German Bundestag and the call for better access to evidence based obesity treatments for Germans living with obesity. If other countries can do this, why does the UK remain stuck in the stone-ages of ineffective obesity policies.

If there are indeed subtle nuances in the UK plan addressing any of my criticisms, I must extend my sincere apologies to the authors. I probably missed them because I simply could not bear to read through the entire document for fear of popping an artery.

@DrSharma
Edmonton, AB

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