Earlier this year I participated in a two-day workshop on weight bias hosted by researchers at the University of Calgary. The over 40 participants included researchers, clinicians, health administrators and a number of other stakeholders, who discussed all aspects of weight bias and discrimination.
A particular focus of the workshop, supported by the Canadian Institutes of Health Research (INMD) and co-hosted by the Canadian Obesity Network was to explore a research agenda towards finding effective ways to reduce weight bias and its negative consequences for the health and well-being of those living with obesity.
Indeed, there are people who consider “obesity” to be largely a “social construct” invented by the “medical establishment” to “medicalize” something that is simply a natural part of the spectrum of human shape and size.
Funnily enough, some of the most passionate opposition to calling obesity a disease, comes from that very same “medical establishment” – doctors who don’t want to see providing obesity care as part of their job, hospital administrators who think providing obesity treatments takes resources away from dealing with “real” diseases, and payers who fear having to shell out millions of dollars for expensive obesity treatments.
Indeed, if I had to point to one single factor that has in fact stopped the “medical establishment” from finding better treatments and providing access to effective and compassionate care for people struggling with excess weight, it is their refusal to consider obesity a disease.
The paradox in all this would be funny if it were not so sad – it turns out that many in the very same “medical establishment” that is being sharply criticized by social scientists and the size-acceptance crowd for “medicalizing” obesity, are in fact fighting as hard as they possibly can to NOT have obesity declared a disease.
So oddly, the people who appear so concerned that labeling obesity a disease could somehow discriminate against people of size, are widely supported by the general public, many of who would think the notion of obesity as a disease ridiculous, given that in their view, being large is simply a matter of poor choices. Sounds to me, like a rather uncanny alliance between the far left and the far right.
While I fully understand that for some people, being “labeled” as having a disease may be traumatic, I see this as no more or less traumatic than being “labeled” as having hypertension, diabetes, arthritis, sleep apnea, or for that matter, cancer.
Does this mean some people for who their excess weight poses no medical risk will get mislabeled? Sure it does. But there are also many otherwise healthy folks “labeled” as having hypertension, diabetes or even cancer, who will live to a ripe old age – good for them!
I am also the first to celebrate size and shape diversity and readers may recall that I invented the Edmonton Obesity Staging System to deal with the issue of “healthy” obesity.
However for those, struggling with the health consequences of excess weight, if calling obesity a disease gets them better access to treatments – so be it!
Case in point – the American Medical Association‘s declaration of obesity as a chronic disease has been one of the key drivers of policy decisions to include obesity treatment in various care plans across the US.
So before we accuse anyone of discriminating against larger people by calling obesity a “disease”, let’s dare ask the question – who do we harm by refusing to do so?
Yesterday, I suggested that using a cost-saving argument to justify treatments for obesity reeks of discrimination. I argued that even if obesity treatment costs the system money, it needs to be delivered in the same way that we deliver treatments for other conditions – not because they save money, but because that’s what people living with those conditions deserve.
But the “cost-saving” argument is not just used to justify treatment for obesity – it is also regularly and widely used to justify spending money on obesity prevention. The usual line of argumentation is that x dollars spent on obesity prevention will save y times x dollars in healthcare spending, which is why we need to prevent obesity.
This is nonsense. We should be preventing obesity whether or not it saves money for the healthcare system, simply because obesity (defined here as excess weight that actually causes health problems) negatively impacts health and well-being. If this costs money, so be it.
Obviously, no one is asking anyone to simply pay for everything (prevention or treatment) just because it is the right thing to do, no matter the cost.
In real life cost does matter and there is a fiscal responsibility to spend money on things that are effective and deliver real benefits – but let us not wander into weighing one disease against another in making that decision.
And most certainly the question of “fault and responsibility” leads to a very slippery slope, given that so much of what affects our health (from infections to cancer, from accidents to chronic diseases) is often avoidable.
The question really boils down to whether or not there are effective ways to prevent obesity – if there are, they need to be funded, whether they save money or not.
It turns out that this is not exactly what happens in actual clinical practice – indeed, patients with excess weight almost never go to see their doctor specifically for this reason.
Rather, patients primarily go to their doctors for help with any of the many health conditions associated with obesity – problems ranging from high blood pressure and diabetes to sleep apnea, arthritis or infertility.
In other words, obesity rarely presents as a discreet health problem – rather, it is “embedded” in other health issues.
This is the (perhaps, when you think about it, not quite so surprising, ) finding of a study by Asselin and colleagues from the University of Alberta, published in Clinical Obesity.
The 5As Team study was designed to create, implement and evaluate a flexible intervention to improve the quality and quantity of weight management visits in primary care.
To gain a better understanding of current practice, we conducted semi-structured interviews with 29 multidisciplinary team providers and field notes of intervention sessions.
A key pattern that emerged from the thematic analysis of the data was that patients do not present, nor do healthcare providers usually address obesity as a primary focus for a visit. Rather, obesity is generally “embedded” in a wide range of primary care encounters for other conditions.
This finding has important implications for clinical practice.
For one, when patients present to their health care provider with a specific problem, be it diabetes, sleep apnea, or knee pain, they want their provider to discuss their diabetes, sleep apnea or knee pain – they are not interested in hearing about their weight issues.
On the other hand, when providers see patients presenting with diabetes, sleep apnea or knee pain, it already uses up all their limited time to talk about diabetes, sleep apnea or knee pain, so tagging on a meaningful discussion of weight is simply not feasible.
These observations suggest that obesity treatment approaches and tools that assume a discreet weight management visit are doomed to fail, as they do not represent or fit into the current way of practice.
On a positive note, the embedded nature of obesity management can potentially be harnessed to leverage multiple opportunities for asking and assessing root causes of obesity, and working longitudinally towards individual health goals (as laid out in the 5As framework).
Thus, for providers it may be as simple as tactfully and non-judgementally (after first discussing the primary problem) asking if the patient has concerns or would also like to also discuss their weight issues – if yes, this should prompt the booking of a separate and discreet appointment with a focus on discussing this problem, rather than simply throwing out some advice (“eat-less-move-more”).
For people struggling with their weight reading this, the lesson is that if you want your health professional’s help in addressing your weight, then book a specific appointment for exactly that, rather than trying to have a meaningful discussion about this when you happen to be there for something else.
Dietitians play an often critical role in helping patients with obesity better manage their weight.
However, I also know that dietitians are the first to agree that obesity management is not just about diet (and exercise) but rather, that diet is just one aspect of an interdisciplinary management approach.
The two-day retreat (October 7-8, Toronto), which follows a highly intense interactive workshop format, covers all aspects of interdisciplinary obesity management including behavioural, medical and surgical treatments. There will also be a special focus on the nutritional management of bariatric patients as well as weight-sensitive behavioural modification.
Speakers at the event include Michael Vallis, Eric Doucet, Jennifer Brown-Vowles, Sean Wharton, and myself.
The course is open to all registered dietitians and anyone else interested in (not-just) nutritional aspects of obesity management.
For advanced registration (early bird registration ends Sept 15) and more information click here.