The News Section of this week’s edition of the Canadian Medical Association Journal (CMAJ) features an article by Roger Collier, in which I am extensively quoted with regard to wether or not health professionals should use the term “obesity”.

Regular readers of these pages will be quite familiar with my views on this issu. Readers may also recall that there is indeed a medical definition of obesity and that this condition has long had its own code in the International Statistical Classification of Diseases (ICD 10 E66.0).

Here a few quotes from the CMAJ article:

Doctors are also aware that patients don’t like to be labelled as obese, even if the label is accurate. Dr. Arya Sharma, chair for cardiovascular obesity research and management at the University of Alberta in Edmonton, says he never refers to a patient as an obese individual, which implies they are defined by their condition. Instead, he will use phrases such as “person with obesity.” He also prefaces the word “obese” with “medically.”

“When you put the word ‘medically’ in front of it, it implies you are talking about a medical condition,” says Sharma, who is also the scientific director of the Canadian Obesity Network.

In a recent paper, Sharma explored historical approaches to classifying obesity. Some descriptive terms once used in medicine, he noted, were far from kind. “Although some earlier descriptions of obesity used less pejorative synonyms such as stout and corpulent (meaning excessively fat), other terms such as mammoth, monstrous and grotesque clearly reflect societal stigmatization against the obese individual and, although the stigma remains, these terms have long been abandoned,” he wrote.

Though he takes care not to offend patients, Sharma advocates for the use of the word “obesity” because it has a precise clinical definition. In fact, he was one of the few founding members of the Canadian Obesity Network who insisted the word be included in the organization’s name. Others, Sharma says, feared it would repel sponsors and harm funding, and suggested names along the lines of “The Healthy Network.”

Sharma also says the word “obesity” should be entered into medical records if a person’s BMI is 30 kg/m2 or higher. To just record the BMI, he says, would be akin to recording a patient’s blood pressure without noting the presence of hypertension.

Some health experts believe the stigma associated with certain conditions can have a positive effect, serving as a powerful motivator for people to improve their health. But when it comes to obesity, Sharma says, stigma does nothing but harm. It can deter people from seeking medical care and lead to depression, anxiety, poor body image and suicidal thoughts.

“These are concrete health risks,” says Sharma. “It’s not just about not being kind to people.”

But of course not everyone agrees with these views.

The article goes on to quote a Dr. Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute in Washington, DC, who has the following views with regard to stigma (at least in the context of addiction):

In an article titled “In Praise of Stigma,” she argued that stigma reflects a societal norm and can motivate people to change their behaviour. Though “stigma abolitionists” have good intentions, for the most part, Satel wrote that the fear of attributing blame for destructive behaviour can itself be destructive. There is much about addiction that is voluntary, she writes, and to dispel the concept of willpower will only deter the recovery process.

“There is nothing unethical — and everything natural and socially adaptive — about condemning the reckless and harmful behaviours that addicts commit,” she wrote. “This need not negate our sympathy for them or our duty to provide care.”

I would beg to argue that I yet to see any evidence in favour of the notion that societal stigma is an effective tool in getting people to live healthier. If this was true, given the widespread bias and discrimination that people with excess weight experience everyday, we should truly be a nation of rakes.

I wonder what my readers have to say about this.

For a link to the full article click here

AMS
Edmonton, Alberta

p.s. You can now also follow me and post your comments on Facebook

Sharma AM, & Kushner RF (2009). A proposed clinical staging system for obesity. International journal of obesity (2005), 33 (3), 289-95 PMID: 19188927

I have previously blogged about the problem of weight bias amongst health professionals and how this can possibly lead to poorer health care for people with excess weight.

A new study by Virginia Chang and colleagues from the University of Pennsylvania, just published in the Journal of the American Medical Association (JAMA) suggests that the quality of health care may not necessarily be worse for obese people compared to normal weight folks.

The reserachers examined eight different performance measures in two US national-level patient populations: (1) Medicare beneficiaries (n = 36 122) and (2) recipients of care from the Veterans Health Administration (VHA) (n = 33 550).

The performance measures included diabetes care (eye examination, glycated hemoglobin [HbA(1c)] testing, and lipid screening), pneumococcal vaccination, influenza vaccination, screening mammography, colorectal cancer screening, and cervical cancer screening.

Based on these data, the researchers found no evidence that obese or overweight patients were less likely to receive recommended care relative to normal-weight patients.

In fact, comparing obese vs normal-weight patients with diabetes, obese patients were more likely to receive recommended care on lipid screening (72% vs 65%) and HbA(1c) testing (74% vs 62%).

Obese patients were also more likely to receive pneumococcal vaccinations (53% vs. 49%).

In fact, there was no measure in which obese people were less likely to receive care compared to people with normal weight.

Of course, this study says nothing about attitudes or bias amongst health care professionals, which continues to be a concern, and it should perhaps be noted that the patients in both of these data bases tend to be older.

While the authors interpret these findings as evidence that perhaps more attention is now being paid to health in people presenting with excess weight, they also suggest that previous reports on poorer care for obesity may in part be due to self-reported recall biases in retrospective studies.

I wonder what my readers think about this issue: any personal stories or anecdotes are most welcome.

AMS
Edmonton, Alberta

p.s. Join my new Facebook page for more posts and links on obesity prevention and management

Chang VW, Asch DA, & Werner RM (2010). Quality of care among obese patients. JAMA : the journal of the American Medical Association, 303 (13), 1274-81 PMID: 20371786

Yesterday, I chaired a round table organised by the Canadian Obesity Network on behalf of the Public Health Agency of Canada on the development of tools and aids that would help Canadian primary care physicians and other health professionals improve their ability to prevent and treat obesity.

Among the many topics discussed, one of the suggestions that found the most support was to encourage physicians to actually note the diagnosis of “obesity” in their charts. As many readers may know, obesity has long been considered a disease by the World Health Organisation and in fact has its own code in the International Classification of Diseases 9 system (ICD9): 278.

(Just to confuse things, the numbers for obesity in ICD 10 are E65-E68)

The idea here is that unless physicians actually begin recording the diagnosis of ”obesity” in their notes, charts and other records, they will not address obesity with the attention it deserves.

Thus, as one attendee commented, “No doctor would ever dream of leaving out a mention of diabetes, hypertension, COPD or any other disease in their notes, but hardly any physcian ever records the diagnosis of obesity in their charts”.

Simply put, when physicians examine a patient who has obesity and fail to put down “obesity” in their medical chart, they are in fact committing an important breach in their obligations to correctly document their patient’s health status. This would in no way be different from failing to note the presence of diabetes, hypertension, or any other medical diagnosis in their records.

By failing to routinely document the medical diagnosis “obesity” in their records, the physicians are not only commiting an important error of ommission, they are, by the same token, actively ignoring one of the most important and common medical health problems in their patients.

Encouraging, or in fact, requiring physicians to actually note the diagnosis of “obesity” (ICD 278) in their medical records for all patients who meet the WHO criteria for obesity, would not only ensure a proper documentation of their patient’s medical problems, it would also (hopefully) increase the likelihood that they will address this issue with their patients.

I wonder how many of my health professional readers routinely note the diagnosis of “obesity” (ICD-9 278) in their charts when they see it in their patients and I wonder how many patients with excess weight have actually seen their physician record this diagnosis in their chart.

I am often reminded by patients when I ocassionally fail to list one of their many medical conditions in my notes or letters - interestingly, no patient has ever pointed out that I have missed the mention of their diagnosis “obesity” in my letters - I wonder why!

AMS
Edmonton, Alberta

Yesterday I had the pleasure of speaking to a group of Japanese colleagues from the Sapporo Medical University on the Edmonton Obesity Staging System (EOSS) and the recently published Etiological Framework for Obesity Assessment. The evening was chaired by Professor Kazuaki Shimamoto, who I have had the pleasure of meeting on several previous visits to Japan.

In my discussions with the participants it became immediately obvious that our proposed clinical staging of obesity can also be applied to obese patients in Japan, albeit using the lower BMI cutoff of 25 used to define obesity in this population.

Given the large number of nephrologists and cardiologists in the audience, I also found that the edema analogy, which I now often use to describe the state of excess caloric balance (or caloric “retention”), very much resonates with clinicians and provides an immediately understandable framework for approaching patients presenting with excess weight gain.

This evening I also plan to meet with a number of colleagues from Tokyo, who have previously attended the International Cardiovascular Expert Fora that I had organised during my time at McMaster University. These fora, which brought together a select group of clinical researchers from across several European and Asian countries, continues to be an interesting network of friends around the world, who always provide a sounding board for some of the issues that are relevant to cardiovascular and metabolic risk management.

As obesity rates continue to grow around the world, it is becoming painfully obvious that much needs to be done to address this issue at a global level. While we hope and wait for preventive measures to kick in, there is no doubt that the access to proper evidence-based obesity management remains a dire challenge in virtually all medical systems.

I am certainly grateful for the opportunity to share and learn from colleagues around the world on how best to approach this issue.

AMS
Tokyo, Japan

Regular readers of these pages may recall an earlier post in which I emphasized the importance of not just describing behaviours (this patient eats too much) but rather actually attempting to determine the root causes of these behaviours (why does this patient eat too much?).

I also suggested that obesity can best be conceptualized as the physical manifestation of chronic energy excess.

In fact, using the analogy of oedema, the consequence of positive fluid balance or fluid retention, I explained that obesity can be seen as the consequence of positive energy balance or calorie ‘retention’.

I further recommended that just as the assessment of oedema requires a comprehensive assessment of factors related to fluid balance, the assessment of obesity requires a systematic assessment of factors potentially affecting energy intake, metabolism and expenditure.

The full paper describing this concept has now been published as an early release on OBESITY REVIEWS.

I believe that this paper provides an aetiological framework for the systematic assessment of the socio-cultural, biomedical, psychological and iatrogenic factors that influence energy input, metabolism and expenditure.

The full paper discusses factors that affect metabolism (age, sex, genetics, neuroendocrine factors, sarcopenia, metabolically active fat, medications, prior weight loss), energy intake (socio-cultural factors, mindless eating, physical hunger, emotional eating, mental health, medications) and activity (socio-cultural factors, physical and emotional barriers, medications).

Based on my own experience of using this framework in my practice, I anticipate that clinicians will find this approach helpful in systematically assessing, identifying and thereby addressing the aetiological determinants of positive energy balance.

I very much hope that application of this framework will ultimate result in more effective obesity prevention and management.

As always, comments are most welcome.

AMS
Toronto, Ontario