This week, I once again presented on the need for recognising obesity as a chronic disease at the annual European Society for the Study of Obesity Collaborating Centres for Obesity (EASO-COMs) in Leipzig, Germany.
Coincidently, The Lancet this week also published a commentary (of which I am a co-author) on the urgent need to change the obesity “narrative”.
So far, the prevailing obesity “narrative” is that this is a condition largely caused by people’s lifestyle “choices” primarily pertaining to eating too much and not moving enough, and that this condition can therefore be prevented and reversed simply by getting people to make better choices, or in other words, eating less and moving more.
As pointed out in the commentary, this “narrative” flies in the face of the overwhelming evidence that obesity is a rather complex multi-factorial heterogenous disorder, where long-term success of individual or population-based “lifestyle” interventions can be characterised as rather modest (and that is being rather generous).
This is not to say that public health measures targeting food intake and activity are not important – but these measures go well beyond “personal responsibility”
” The established narrative on obesity relies on a simplistic causal model with language that generally places blame on individuals who bear sole responsibility for their obesity. This approach disregards the complex interplay between factors not within individuals’ control (eg, epigenetic, biological, psychosocial) and powerful wider environmental factors and activity by industry (eg, food availability and price, the built environment, manufacturers’ marketing, policies, culture) that underpin obesity. A siloed focus on individual responsibility leads to a failure to address these wider factors for which government policy can and should take a leading role. Potential health-systems solutions are also held back by insufficient understanding of obesity as a chronic disease and of the necessary integration across specialties.“
It is also important to recognise that the prevailing “lifestyle” narrative plays a major role in the issue of weight-bias and discrimination:
“Behind every obesity statistic are real people living with obesity. The prevailing narrative wrongly portrays people with obesity in negative terms as “guilty” of obesity through “weakness” and “lack of willpower”, succumbing to the siren call of fast and other poor food choices. This narrative leads to stigmatisation, discrimination—including in health services, employment, and education—and undermines individual agency.“
Thus, it is time to change this narrative:
“If the narrative is instead reframed around individuals at risk of or living with obesity as protagonists with agency who operate within physiological limitations and a much larger obesogenic environment over which their control is limited, then a better, more accurate story can be told.“
This new narrative must incorporate four dimensions.
“First, recognise that obesity requires multiple discrete actors and sectors to work together simultaneously through many entry points. Second, change the words and images used to portray obesity to shift blame away from individuals and towards upstream drivers. For example, photographs of anonymous or faceless people with obesity must be substituted with images of real people that foster respect and identification. Third, prioritise childhood obesity and the growing burden of obesity in low-income settings. Rights-based policy approaches that address inequalities and social and physical determinants of obesity are particularly relevant. Finally, appreciate that obesity is a chronic disease within the health system, with both its prevention and management embedded within calls for effective and comprehensive universal health coverage globally.“
Following this line of reasoning we argue that,
“Shifting to a human-focused narrative that encompasses this vulnerability and complexity will require effort and commitment across many sectors. We call on all affected by or concerned with obesity to come together with a common sense of purpose and shared accountability for building this new narrative and a more comprehensive response to obesity.“
Not discussed in this paper (largely due to space limitation), is my pet peeve, that we also need a new non-anthropometric definition of obesity – one that relies on actual health measures rather than just scales and measuring tapes. As we move to a “disease” definition of obesity, we need to ensure that we are not mis-labeling healthy individuals as “diseased” just because they happen to exceed a certain body weight, as well as the corollary, mis-labeling individuals who may stand to benefit from obesity treatments as not having obesity just because they fall below an arbitrary BMI cutoff.
Regular readers should by now be well aware of the importance of using people-first language when referring to people living with obesity (as in “patient with obesity” not “obese patient”).
As I have noted in previous posts, living with a condition is not the same as being defined by that condition – this is why we do not refer to people living with dementia or cancer as being “demented” or “cancerous”.
As elegantly pointed out by Lee Kaplan in a presentation he delivered at the Harvard Medical School Center For Global Health Delivery consultation on obesity, currently being held in Dubai, there is also a pressing clinical argument for speaking of obesity as a disease rather than a descriptor of a “state”.
Take for e.g. the case of a patient with hypertension, who, thanks to effective on-g0ing anti-hypertensive treatment has managed to control his blood pressure levels over the past 10 years. In fact, at no time in the past 10 years has the patient ever presented with elevated blood pressure. Any clinician would agree that this patient would still be declared to have “hypertension” despite currently not being “hypertensive”.
Similarly, a patient whose depression is well-controlled with an anti-depressant is still a patient living with “depression”, although they are not currently “depressed”.
Likewise, we can probably all agree that a patient who has undergone coronary bypass surgery, is still someone living with coronary artery disease, even if they have not experienced a single angina pectoris attack since their surgery.
In all of these cases, hypertension, depression, and coronary artery disease would continue to appear on their medical problem list.
When applied to obesity, this means that even if someone has successfully managed to lose their weight to a level that they are no longer clinically “obese”, they are still someone living with “obesity”. Even if their BMI (not a good measure of obesity) should drop to below 25, they are still someone living with obesity (albeit, as in the case of the above examples, living with “controlled” or “treated” obesity).
Thus, they continue to have “obesity” even if they are currently not “obese” – ergo, the diagnosis “obesity” should remain on their problem list.
Furthermore, given the high rates of recidivism, keeping obesity on the problem list serves as an important reminder to the clinician to continue supporting and reinforcing ongoing obesity treatment (even if this treatment is only behavioural).
It should be evident from this analogy that although the use of people-first language may seem like semantics, it does have very real consequences for long-term clinical management.
Over a decade ago, together with over 120 colleagues from across Canada, representing over 30 Canadian Universities and Institutions, I helped found the Canadian Obesity Network with the support of funding from the Canadian National Centres of Excellence Program.
Since then the Canadian Obesity Network has grown into a large and influential organisation, with well over 20,000 professional members and public supporters, with a significant range across Canada and beyond.
During the course of its existence, the Network has organised countless educational events for health professionals, provided training and networking opportunities to a host of young researchers and trainees, developed a suite of obesity management tools (e.g. the 5As of obesity management for adults, kids and during pregnancy), held National Obesity Summits and National Student Meetings. raised funds for obesity research, the list of achievements goes on and on.
Most importantly, the Network has taken on important new roles in public engagement, voicing the needs and concerns of Canadians living with obesity, and advocating for better access to evidence-based prevention and treatments for children and adults across Canada.
To better reflect this expanded mission and vision, the Board of Directors has decided to convert the Canadian Obesity Network into a registered health charity under the new name – Obesity Canada – Obésité Canada.
So with one sad eye, I look back and hope that the Canadian Obesity Network rests in peace – Long Live Obesity Canada!
Several years ago, my colleague Raj Padwal and I published a paper in Obesity Reviews, where we outline a rational approach to an aetiological assessment of obesity.
As many readers may not have seen this paper, I will repost several of the key elements we discussed in it. Although some of our thinking has evolved since then, I believe the overall reasoning remain as relevant today, as when we first wrote the paper back in 2010:
Obesity is characterized by the accumulation of excess body fat and can be conceptualized as the physical manifestation of chronic energy excess. Using the analogy of oedema, which is the consequence of positive fluid balance or fluid retention, obesity can be seen as the consequence of positive energy balance or caloric retention. Just as the positive fluid balance of oedema can result from a host of underlying aetiologies including cardiac, hepatic, renal, endocrine, infectious, venous, lymphatic or drug‐related causes, obesity can result from a wide range of aetiologies that promote positive energy balance.
As with oedema, assessment and management of obesity requires an exploration of the root causes and underlying pathologies. To extend the obesity–oedema analogy, addressing all forms of obesity simply with caloric restriction and exercise (‘eat less and move more’) would be akin to addressing all forms of oedema simply with fluid restriction and diuretics. As this narrowly focused approach is not considered standard‐of‐care in managing patients with oedema, why should it be considered as the preferred method of treating obesity?
The classical treatment of obesity, based on increased physical activity and decreased calorie intake, has not been successful. Approximately two‐thirds of the people who lose weight will regain it within 1 year, and almost all of them within 5 years. In our opinion, the lack of efficiency in these therapeutic approaches is likely due to an incomplete understanding of the precise aetiology or aetiologies of obesity and, consequently a failure to address the root causes of energy imbalance.
In this paper, we present a theoretical diagnostic paradigm that provides an aetiological framework for the systematic assessment of obesity and discuss how this framework can enhance our ability to diagnose and manage obesity in clinical practice. The framework considers socio‐cultural, physiological, biomedical, psychological and iatrogenic factors that can determine energy input, metabolism and expenditure.
Comment: In hindsight, I would note that apart from failure to address the underlying pathology and drivers of weight gain, the “failure’ of conventional “eat-less – move-more” approaches to obesity management, relying largely on willpower, primarily fail because these efforts are counteracted by powerful neuroendocrine factors that both defend against continuing weight loss and promote weight regain. At the time we wrote this paper, we had perhaps not given the powerful nature of these effects full consideration. Nevertheless, I still believe that trying to understand exactly why a given person has gained excess weight is a good start to any obesity management endeavour.
More to follow…
Anyone familiar with the issue, would readily agree that the actual surgery involved in bariatric surgery is only a small (but undeniably important) technical piece in what is a rather complex treatment for a rather complex chronic disease.
Clearly, this is not exactly how all bariatric surgeons approach or treat their bariatric patients.
Since 2012, the US has a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program that designates bariatric surgery centers as Centres of Excellence if they meet specified requirements in 7 core standards that include case volume, commitment to quality, appropriate use of equipment and instruments, critical care support, continuum of care, data collection, and continuous quality improvement.
However, as a recent paper by Andrew Ibrahim and colleagues, published in JAMA Surgery, elaborates, despite these quality criteria, there remains a substantial variability in outcomes across designated Bariatric Centres of Excellence.
Based on their retrospective analysis of claims data from 145 527 patients who underwent bariatric procedures, there was a 17-fold variation (ranging from 0.6% to 10.3%) in rates of serious 30-day complications across accredited bariatric centers nationally and up to 9.5-fold variation across individual states.
As the authors note,
“this finding suggests that participation alone in the Center of Excellence Program did not ensure uniform high-quality care….Given that most bariatric procedures are now performed at accredited centers, wide variation among these centers suggests that accreditation alone does not discriminate enough to guide patients to the best centers for care.”
Moreover, they found that poor performing centres were often located close to better performing centres (regression to the mean?). Interestingly, in contrast to what one may suspect, outcomes overall were not related to case volume (perhaps because in order to be a designated Centre of Excellence, all centres needed to have a minimum number of cases per year).
Rather, the authors discuss that poorer outcomes may be largely attributable to varying technical skills of the surgeons as well as inconsistent adherence to accepted bariatric care pathways.
Finally, the authors argue that there is need to make performance data available to the public, as simply trusting in the “Centre of Excellence” designation by no means guarantees excellent outcomes.
As important as these data may be, it is also important to note that this paper only looked at complications within a 30-day time period following surgery.
As anyone dealing with bariatric patients is well aware, successful outcomes of bariatric surgery(as well as its complications) should be measured in years (if not decades). This is where much of bariatric surgery falls down, as one of the key criteria mentioned above, i.e. “continuum of care” seldom extends beyond the rather brief period of post-surgical discharge. Indeed, in most cases, bariatric patients continue to be prematurely discharged into “the wild” with little ongoing support from health professionals competent in looking after the psychological and medical needs of this population.
None of this takes away from the fact that bariatric surgery is still the most effective long-term treatment for severe obesity – however, clearly there remains substantial room for improvement.