Following in the footsteps of other organisations like the American and Canadian Medical Associations, the Obesity Society, the Obesity Medical Association, and the Canadian Obesity Network, this month, the World Obesity Federation put out an official position statement on recognising obesity as a chronic relapsing progressive disease.
The position statement, published in Obesity Reviews, outlines the rationale for recognising obesity as a chronic disease and is very much in line with the thinking of the other organisations that have long supported this notion.
In an accompanying commentary, Tim Lobstein, the Director of Policy at the World Obesity Federation notes, that recognising obesity as a disease can have the following important benefits for people living with this disease:
1) A medical diagnosis can act to help people to cope with their weight concerns by reducing their internalized stigma or the belief that their problems are self-inflicted and shameful.
2) A classification of obesity as a disease, or disease process, may help to change both the public and professional discourse about blame for the condition, the latter hopefully encouraging greater empathy with patients and raising the patient’s expectations of unbiased care.
3) Recognition of obesity as a disease may have benefits in countries where health service costs are funded from insurance schemes that limit payments for non-disease conditions or risk factors.
While all of this is great, and I am truly delighted to see the World Obesity Federation come around to this statement, I do feel that the policy statement seems rather tightly locked into the notion that obesity (or at least most of it) is a disease “caused” primarily by eating too much, with the blame placed squarely on the “toxic obesogenic environment”.
Personally, I would rather see obesity as a far more etiologically heterogenous condition, where a wide range of mental, biological and societal factors (e.g. genetics, epigenetics, stress, trauma, lack of sleep, chronic pain, medications, to name a few) can promote weight gain in a given individual.
Although these factors may well operate through an overall increase in caloric consumption (or rather, a net increase in energy balance), they, and not the act of overeating per se must be seen as the underlying “root causes” of obesity.
Thus, I tend to see “overeating” (even if promoted by an obesogenic food environment) as a symptom of the underlying drivers rather than the “root cause”.
Thus, saying that obesity is primarily caused by “overeating” is perhaps similar to saying that depression is primarily caused by “unhappiness”. Readers would probably agree that such a statement regarding the etiology of depression would make little sense, as “unhappiness” is perhaps a symptom but hardly the “cause” of depression, which can be promoted by a wide range of biological, environmental and societal factors, all resulting in the underlying biology that results in the mood disorder.
Similarly, I would say that there are indeed a number of complex socio-psycho-biological factors that underly the biology that ultimately results in overeating and excess weight gain (the food environment clearly being one of these factors).
While this may seem like semantics, I do think that a more differentiated look at the underlying etiology of obesity at the individual level (rather than simply blaming it all on “overeating”), is essential for promoting a more sophisticated view of this complex chronic disease both at the level of the individual and the population.
Thus, for e.g. every plenary session was opened by a brief presentation from a representative of the Canadian Obesity Network’s Public Engagement Committee, which not only illustrated the remarkable diversity of individual “obesity stories” but also set the stage for the scientific and clinical presentations that followed.
Indeed, one of the recurring themes at the Canadian Obesity Summit was, “nothing about us, without us”.
Thus, I was happy to see that the “patient voice” is also gaining increasing attention at the European Congress on Obesity, currently taking place in Porto, Portugal.
In fact, the conference was kicked off by a workshop on weight bias, discrimination, and other issues relevant to people living with obesity, organised by representatives of the EASO patient council, with representatives from across Europe.
How much impact these presentations and role of people living with obesity will have on the overall conference will remain to be seen, but clearly, as in other areas of medicine, the patient voice is certainly become more important as a driver of knowledge and policy – as it should.
Based on the failing access to obesity care for the overwhelming majority of the 6,000,000 Canadians living with obesity in our publicly funded healthcare systems, the 2017 Report Card on Access To Obesity Treatment For Adults, released the 5th Canadian Obesity Summit, has the following 7 recommendations for Canadian policy makers:
- Provincial and territorial governments, employers and the health insurance industry should officially adopt the position of the Canadian Medical Association that obesity is a chronic disease and orient their approach/resources accordingly.
- Provincial and territorial governments should recognize that weight bias and stigma are barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems and education.
- Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity programs and products for their employees through health benefit plans.
- Provincial and territorial governments should increase training for health professionals on obesity management.
- Provincial and territorial governments and health authorities should increase the availability of interdisciplinary teams and increase their capacity to provide evidence- based obesity management.
- Provincial and territorial governments should include anti-obesity medications, weight-management programs with meal replacement and other evidence-based products and programs in their provincial drug benefit plans.
- Existing Canadian Clinical practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of programs and policies of federal, provincial and territorial governments, employers and the health insurance industry.
If and when any of the stakeholders adopt these recommendations is anyone’s guess. However, I am certain that since the release of the Report Cards, the relevant governments and other stakeholders are probably taking a closer look at what obesity management resources are currently being provided within their jurisdictions.
Given that things can’t really get any worse, there is hope that eventually Canadians living with obesity will have the same access to healthcare for their chronic disease as Canadians living with any other illness.
Every single guideline on obesity management emphasises the importance of interdisciplinary obesity management by a team that not only consists of a physician and a dietitian but also includes psychologists, exercise specialists, social workers, and other health professionals as deemed necessary.
As is evident from the evident from the 2017 Report Card on Access To Obesity Treatment For Adults, released last week at the 5th Canadian Obesity Summit, the overwhelming majority of Canadians living with obesity have no access to anything that even comes close.
Thus, the report finds that
Among the health services provided at the primary care level for obesity management, dietitian services are most commonly available.
Access to exercise professionals, such as exercise physiologists and kinesiologists, at the primary care level is limited throughout Canada.
Access to mental health support and cognitive behavioural therapy for obesity management at the primary care level is also limited throughout Canada. bariatric surgery programs often have a psychologist or a social worker that offers mental health support and cognitive behavioural therapy to patients on the bariatric surgery route, but the availability of these supports outside of these programs is scarce.
Centres where bariatric surgery is conducted also have inter- disciplinary teams that work within the bariatric surgical programs and provide support for patients on the surgical route.
Alberta and ontario have provincial programs with dedicated bariatric specialty clinics that offer physician-supervised medical programs with interdisciplinary teams for obesity management.
Interdisciplinary teams for obesity management outside of the bariatric surgical programs are available in one out of five regional health authorities (RHa) in british Columbia, one out of 18 RHas in Québec, one out of two RHas in new brunswick and one out of four RHas in newfoundland and labrador.
Among the territories, only yukon has a program with an interdisciplinary team focusing on obesity management in adults.
I hardly need to remind readers, that this is in stark contrast to the resources and teams available to patients with diabetes, heart disease, lung disease, or any other common chronic disease, that are regularly available in virtually every health jurisdiction across the country (not to say that they are perfect or sufficient – but at least there is some level of service available).
I understand that our current obesity treatments are extremely limited (at least when effectiveness is measured in terms of weight loss). But even if access to these resources could simply help stabilise and prevent further weight gain (progression) and perhaps improve overall health and well-being, surely Canadians living with obesity should deserve no less that people living with any other chronic disease.
There is simply no excuse for treating Canadians living with obesity as second-class citizens in our publicly funded healthcare system.
It has now been almost two years since the Canadian Medical Association declared obesity to be a chronic medical disease.
This declaration was widely praised by people living with obesity as well as healthcare and academic professionals (not least myself), who supported the notion that recognition of obesity as a disease would help precipitate a shift in thinking of obesity as just a lifestyle choice to a medical disease with an obligation to prevent and treat it as other chronic diseases.
Not much has happened since then – at least not as far as Canadian policy makers are concerned.
Thus, it is evident from the 2017 Report Card on Access To Obesity Treatment For Adults, released last week at the 5th Canadian Obesity Summit, that so far, neither the federal government nor any of the provincial/territorial governments in Canada have recognized obesity as a chronic disease. As discussed in the report, this has a significant negative trickle-down effect on access to obesity treatment for the over 6,000,000 Canadians living with this chronic disease, not to mention the millions of Canadians at high risk of developing this disease in the near future.
As a reminder, in preparing the Report Card, the Canadian Obesity Network extensively reviewed all publicly accessible resources and documents for evidence of policies, guidelines and services for obesity treatment and management in each province and territory. In addition, the Canadian Obesity Network tried to identify and speak directly to government officials in each province and territory regarding their take on obesity as a chronic disease.
This was by no means an easy task,
“The search for information on the recognition of obesity as a chronic disease and treatment guidelines or recommendations by provincial/territorial governments and identifying appropriate policy makers in each province/ territory required significant effort. many provinces and territories do not have a person or department dedicated to the bariatric or obesity-treatment portfolio.”
As the Report Card highlights,
“Since the declaration, none of the provincial or territorial governments have officially recognized obesity as a chronic disease.”
“Health Canada has also not officially recognized obesity as a chronic disease and has continued to consider obesity as a lifestyle risk factor. There is no directive from Health Canada on the treatment and management of obesity in adults.”
It also notes that the 2016 report of the senate standing Committee on social affairs, science and technology titled Obesity in Canada, referred to obesity as a risk factor for several chronic conditions, but that not one of the 21 recommendations calls for better access to obesity management or bariatric care. Moreover, there was no mention of the existing Canadian Clinical Practice Guidelines, which clearly outline both preventive and treatment measures for Canadians.
This has important negative consequences for the millions of Canadians living with this disease. Thus,
“Canadians living with obesity are largely left to navigate a complex landscape of weight-loss products and services, many of which lack scientific rationale and openly promote unrealistic and unsustainable weight-loss goals. Failure rates of over 95% perpetuate a vicious cycle of “yo-yo dieting,” resulting in frustration, depression, poor self-esteem and further weight gain.”
This is not to mention the substantial humanitarian, physical, emotional, and societal costs that are directly related to not managing this chronic disease.
If and when Canadian governments and healthcare systems will step up to the plate and take responsibility for providing access to evidence-based obesity treatments to Canadians living with obesity is anyone’s guess.
Two years after the declaration, the vast majority of Canadians living with obesity are still waiting for respect and services from their publicly funded health services.
Sadly, not much to write home about.