The speaker series was hosted by the principal of the college,the Right Honourable Kim Campbell, who served as Canada’s 19th prime minister in 1993.
While I spoke about the particular challenges and barriers faced by Canadians living with obesity and how these can be accommodated and supported in the workplace and society in general, other speakers spoke on the accommodation of individuals living with other challenges.
Thus, Kelly Falardeau, herself a victim and advocate for burn survivors and Deryk Beal, one of Canada’s leading clinician scientists on stuttering and other speech impediments, joined me in speaking on the importance of diversity and the need to identify obstacles to social inclusion that keep individuals from reaching their full potential.
In my presentation I did my best to portray the biological, physical, emotional and societal challenges that Canadians living with obesity face everyday.
Here is what I asked the students to think about:
“So how can we help people living with such barriers?
For one, let us educate ourselves on the real issues – if there was an easy solution that actually worked, believe me my clinic would be empty.
Secondly, let us show some respect for people who wake up with this barrier every single morning and go through their day – for the most part doing everything everyone else does.
Thirdly, let us acknowledge that once you have obesity there is no easy way back. I have patients who have lost their entire weight over on diet after diet after diet only to put the weight back again. Diet and exercise is simply not enough for most people – surgery works but is not available and not scalable – we cannot do surgery on 120,000 Albertans. So let us not pretend that there is an easy solution to the problem – we simply don’t have enough treatments that work.
Fourthly, till we do come up with more treatments that actually work or maybe even get our act together on prevention, let us not make life harder for people living with this barrier than it has to be. We can do many things to accommodate people living with obesity – we accommodate people with all kinds of “special needs” at home, in society in the workplace – just not for people living with obesity.
Fifth, let us show our support for people who struggle with their weight by the way we treat them, the way we talk about them, the way we engage with them – they are people like all of us. Just because they carry extra weight does not mean they are second class citizens or people we can simply make fun of or ignore – we are after all talking about 7 million Canadians – men, women and children.
Let us not be the barrier that makes their life even more difficult than it already is.”
Our presentations were followed by an enthusiastic ‘master class’ with students in the inaugural leadership class of the Peter Lougheed Leadership College.
I’d like to thank the organizers for giving me the opportunity to advocate on behalf of Canadians living with obesity.
Yes, there is also considerable waste in healthcare systems and not every dollar spent is necessary or provides any meaningful benefit.
Indeed, even where health benefits are achieved, these may perhaps be had at a lower cost than in our current systems.
Thus, there is no argument against reducing waste and improving cost-effectiveness of treatments (or for that matter, prevention).
However, arguing in favour of cost-effectiveness should not be confused with arguments for cost-savings, as is often put forward in discussions about obesity treatment.
Indeed, authors often bend over backwards to demonstrate the potential cost-savings that may come from treating obesity.
Case in point is a study by Oleg Borisenko and colleagues, who in a paper published in Obesity Surgery, suggest that (based on the Scandinavian Bariatric Surgery Registry), surgical treatment of severe obesity led to savings of €8408 per patient, which translates into lifetime savings savings of €66 million for the cohort, operated in 2012.
Be that as it may, I feel that savings cannot be the sole argument in favour of providing treatments for a disease. Given the tremendous impact that obesity has on the health and lives of people living with obesity, I would argue for treatments even if they increase healthcare costs.
Let us remind ourselves that we do not argue about whether or not treating people with heart attacks, osteoarthritis, kidney failure or cancer saves money for the health care system – it rarely does, and is besides the point. The reason we spend money treating these conditions is because the people presenting with these conditions deserve treatment – period!
Thus, I would argue that the primary reason that health care systems should be spending money on treating obesity is because people with obesity deserve treatment – not because it saves money for the system.
Thus, even if there was a net cost to treating obesity, people with obesity deserve treatment as much as people with diabetes, heart disease or chronic kidney disease.
If this means a greater cost to the health care system, so be it – raise taxes or increase payers contributions – don’t try to save money by simply refusing to pay for obesity treatment (or rationing it by making it difficult for patients to access).
Using cost-savings as the prime argument for treating obesity reeks of discrimination.
This is why I refuse to participate in debates about how treating obesity can save health care systems millions of dollars – while this may well be the case, it is not the argument that I am willing to make to justify providing effective medical or surgical care to people living with this condition.
As the latest HQCA report on obesity in Alberta released this week, the substantial population burden of overweight and obesity (now affecting 6 in 10 Albertans) is a significant driver of health care costs in the province. In the US, this increased health care cost for adult obesity is estimated at around $3,508 per individual with a BMI greater than 30 for a total of well over US$ 300 billion per year.
However, as highlighted in a recent article by John Cawley and colleagues in PharmacoEconomics, health care costs are not equally distributed across all people living with increased body weight – rather, obesity related health care costs rise exponentially with increasing BMI levels (i.e. at the extremes of BMI).
Thus, the greatest health care savings for individual patients can be expected in those living with severe obesity.
To illustrate this, the researchers used data from the US Medical Expenditure Panel Survey from 2000-2010 (n=41,435), to calculate the potential annual savings in health care costs (in US $ in the US health care system), for various reductions in body weight in individuals with BMI levels ranging from 30 kg/m2 to 45 kg/m2.
Thus, for e.g. the annual cost savings with a 5% reduction in body weight for someone with a BMI of 30 kg/m2 amounted to a mere $69 per year.
This figure, however, increased exponentially for people with higher BMIs, increasing to $528, $2,137, and $10,030 in an individual with a BMI of 35, 40, and 45 kg/m2, respectively (these figures were somewhat higher, when the individual also has diabetes).
Thus, while treating obesity to achieve a 5% reduction in body weight in someone with a BMI of 30 kg/m2 may never be “cost-effective”, the same amount of weight loss in someone with more extreme obesity, would likely pay for itself or even lead to significant savings.
Because the impact of obesity on mental and physical health, life-expectancy and quality of life is also greatest at higher levels of BMI, one could also make a strong ethical argument for singling out these individuals for priority treatment in the health care system.
Obviously, as readers should be aware, BMI is at best a crude measure for health – a more precise assessment would have used more sophisticated staging systems like the Edmonton Obesity Staging System to calculate individual risk and benefits. However, we should remember that at a population level BMI does function moderately well as an indicator of obesity related risk (although not in individual patients).
This analysis has important consequences both for population and individuals approaches to obesity.
Although the population burden of obesity lies in the middle of the BMI bell curve, and shifting this ever so slightly can move a substantial number of people living with overweight or obesity to a BMI that lies below the current cut-offs, such a change may have little influence on the overall health care costs of obesity, as these live in the extremes.
Thus, using the above numbers in a crude back-of-the-envelope calculation, to save $1,000,0000 per year in health care costs, one would have to lower BMI by 5% in about 14,500 people living with a BMI of 30 kg/m2 compared to only 100 people with a BMI of 45 kg/m2 – a much more manageable problem.
This is why it is harder to make a cost-savings argument for addressing obesity at a population level rather than focussing on those living with more severe obesity, unless such population measures can also substantially help lower the BMI of the latter.
Unfortunately, current population trends show that while rates of overweight and mild obesity appear to be levelling off (thank perhaps in part to population health measures), severe obesity continues to increase at alarming rates.
This is why a greater focus on finding and delivering better treatments to those living with severe obesity, including those that can only offer modest reductions in BMI, has to be the main priority of any health care system seeking to reduce obesity related health care costs.
If you are planning to attend the 4th Canadian Obesity Summit in Toronto next week (and anyone else, who is interested), you can now download the program app on your mobile, tablet, laptop, desktop, eReader, or anywhere else – the app works on all major platforms and operating systems, even works offline.
You can access and download the app here.
(To watch a brief video on how to install this app on your device click here)
You can then create an individual profile (including photo) and a personalised day-by-day schedule.
Obviously, you can also search by speakers, topics, categories, and other criteria.
Hoping to see you at the Summit next week – have a great weekend!
In last week’s 2015 Lancet series on obesity, the majority of papers focus on policy interventions to address obesity. It suggests that a reframing of the obesity discussion, that avoids dichotomies (like nature vs. nurture debates) may provide a path forward – both in prevention and management.
The policy framework presented by Christina Roberto and colleagues in The Lancet, is based on the NOURISHING framework, proposed by the World Cancer Research Fund International to categorise and describe these actions.
Together, the actions in this framework address the food environment (e.g. food availability, taxation, restrictions on advertising, etc.), food systems (e.g. incentives and subsidies for production of healthier foods) and individual behaviour change (e.g through education and counselling).
This “food-centric” view of obesity is complemented by recognising that physical activity, much of which is dictated by the built environment and captivity of the population in largely sedentary jobs, also has a role to play.
On a positive note, the Christina and colleagues suggest that there may be reasons for careful optimism – apparently 89% of governments now report having units dedicated to the reduction of non-communicable diseases (including obesity), although the size and capacity of many of these units is unknown.
On the other hand, despite an increasing number of such efforts over the past decades, no country has yet reversed its epidemice (albeit there is a flattening of obesity growth rates in the lower BMI ranges in some developed countries – with continuing rise in more severe obesity).
Despite the potential role of government policies in reducing non-communicable diseases (including obesity) by “nudging” populations towards healthier diets and more physical activity, the authors also note that,
“…the reality is that many policy efforts have little support from voters and intended programme participants, and although the passage of policies is crucial, there is also a need to mobilise policy action from the bottom up.”
Indeed, there is growing list of examples, where government policies to promote healthy eating have had to be reversed due to lack of acceptance by the public or were simply circumvented by industry and consumers.
Nevertheless, there is no doubt that policies in some form or fashion may well be required to improve population health – just how intrusive, costly and effective such measures will prove to be remains to be seen.
All of this may change little for people who already have the problem. As the article explains,
“There are also important biological barriers to losing excess weight, once gained. Changes in brain chemistry, metabolism, and hunger and satiety hormones, which occur during attempts to lose weight, make it difficult to definitively lose weight. This can prompt a vicious cycle of failed dieting attempts, perpetuated by strong biological resistance to rapid weight loss, the regaining of weight, and feelings of personal failure at the inability to sustain a weight-loss goal. This sense of failure makes people more susceptible to promises of quick results and minimally regulated claims of weight loss products.”
Not discussed in the article is the emerging science that there may well be other important drivers of obesity active at a population level that go well beyond the food or activity environment – examples would include liberal use of antibiotics and disinfectants (especially in agriculture), decreased sleep (potentially addressable through later school start times and mandatory afternoon naps in childcare settings), increasing maternal age at pregnancy (addressable by better access to childcare), time pressures (e.g. policies to address time-killing commutes), etc.
Perhaps what is really needed is a reframing of obesity as a problem where healthy eating and physical activity are seen as only two of many potential areas where policies could be implemented to reduce non-communicable diseases (including obesity).
Some of these areas may well find much greater support among politicians and consumers.