Is It Time To Change The Ask?
Most readers will be quite familiar with my 5As of Obesity Management (Ask, Assess, Advise, Agree, and Assist).
Until now, we have emphasized that any conversation about weight with someone in your practice should begin with a polite and non-judgmental request for permission to bring up the topic.
However, given the recent surge in popular interest in new medications for obesity, we now suddenly have patients lining up to request weight-loss prescriptions from their doctors.
So, while previously, both doctors and patients have been hesitant to bring up the topic of weight, this is now often the exact reason why people are making appointments to see their doctors.
This, of course, changes the nature of the Ask. No longer, is it about the doctor initiating the conversation by asking for permission to discuss weight. Rather it is now the patient who brings up the topic outright by asking for a prescription for an anti-obesity medication.
This obviously changes the Ask – a more appropriate response would now be, “Why do you think you need this?” and “Where did you hear and what do you know about it?”
This opens a whole new conversation.
So, yes, we still start with an Ask, but it’s a different Ask.
Obviously, we still need to then proceed with the other steps of Assessment, Advising, and Agreeing, before (if appropriate) we then Assist our patients in their treatment journey.
An interesting twist to the story is now, that we are left with figuring out how to deal with individuals seeking prescriptions, for whom anti-obesity medication may neither be indicated nor suitable.
Bing Chatbot Writes My Acceptance Speech
Last week at the 8th Canadian Obesity Summit in Whistler, BC, I was honoured to receive the innaugural Obesity Canada Founder Award for my services to the organisation.
In preparation for this event, just for kicks, I asked Bing’s Chatbot to write me an acceptance speech. The following is verbatim what Bing came up with (in under 20 seconds!) – scary!
p.s. I did not use any of it, but I probably could have without anyone noticing.
Prompt: write an acceptance speech for Dr. Arya Sharma as recipient of the Obesity Canada Founders Award
Bing Chatbot: Here is a possible thank you address for Dr. Arya Sharma:
Ladies and gentlemen,
it is my great honor and pleasure to receive the inaugural founder award from Obesity Canada, the leading obesity charity in this country. I would like to thank the board of directors, the staff, the members, and the supporters of Obesity Canada for this recognition and for their dedication to advancing obesity research, education, and advocacy.
When I founded Obesity Canada in 2006, I had a vision of creating a network of obesity stakeholders who would work together to improve the lives of Canadians living with obesity. I wanted to challenge the stigma and discrimination that people with obesity face every day. I wanted to promote obesity as a chronic disease that requires evidence-based prevention and management. I wanted to foster collaboration and innovation among researchers, health professionals, policy makers, and people with lived experience.
Fifteen years later, I am proud to say that Obesity Canada has achieved many of these goals and more. Obesity Canada has grown to become a network of over 10,000 members across Canada and beyond¹. Obesity Canada has produced the first Canadian clinical practice guidelines for obesity in adults² and children³ [sic], which have been widely adopted and endorsed by various organizations.
Obesity Canada has organized six [sic] biennial Canadian Obesity Summits, which have brought together hundreds of experts and stakeholders to share knowledge and best practices. Obesity Canada has advocated for policy changes that support obesity prevention and care, such as the inclusion of obesity in the Canadian Disability Tax Credit and the recognition of obesity as a chronic disease by several provinces. Obesity Canada has also empowered people living with obesity to share their stories and voices through initiatives such as the Public Engagement Committee, the Weight of Living project, and the EveryBODY Matters podcast.
Of course, none of these accomplishments would have been possible without the hard work and passion of many people who have contributed to Obesity Canada over the years. I would like to thank all the past and present board members, staff members, chapter chairs, committee chairs, volunteers, partners, sponsors, donors, and supporters who have made Obesity Canada what it is today. I would also like to thank my family, friends, colleagues, mentors, and mentees who have supported me throughout my career.
I am humbled and grateful for this award, but I also know that there is still much work to be done. Obesity remains a major public health challenge that affects millions of Canadians and their quality of life. We need to continue to raise awareness, generate evidence, influence policies, improve practices, and reduce stigma around obesity. We need to continue to collaborate and innovate across disciplines and sectors. We need to continue to listen and learn from people living with obesity and their needs and preferences.
I am confident that Obesity Canada will continue to lead the way in advancing obesity as a priority issue in Canada and beyond. I am honored to be part of this amazing organization and community. Thank you again for this award and for your ongoing support. Together, we can make a difference in obesity. Thank you.
Source: Conversation with Bing, 08/05/2023
(1) Home – Obesity Canada. https://obesitycanada.ca/.
(2) 2022 in review: Obesity Canada (OC) | World Obesity Federation. https://www.worldobesity.org/news/2022-in-review-obesity-canada-oc.
(3) Obesity in Canada – Opportunities for intervention – Canada.ca. https://www.canada.ca/en/public-health/services/health-promotion/healthy-living/obesity-canada/opportunities-intervention.html.
Medications Only Work When You Take Them!
Now that we have medications for managing obesity that are safer and more effective than ever before, the issue of how to get patients to actually take them deserves more attention.
Generally speaking, most people do not like taking medications, which is why the issue of adherence is not unique to patients with obesity. In fact, most people don’t take medications exactly how or for how long their doctor has prescribed them (I certainly used to belong to that club).
Thus in many ways, adherence to anti-obesity medications (AOMs) is not far worse than to medications in general, which may come as a bit of a surprise, given that the long-term use of AOMs may face more hurdles than other medications.
Thus, one of the most common reasons suggested for why people don’t stick with their AOMs is cost. While this may sound obvious, we should remember that many patients don’t stick with their prescription meds even when these are fully covered by their health plans (e.g. statins or anti-hypertensives).
Another argument often brought up in this regard, is that patients don’t look at obesity as a chronic disease requiring long-term treatment. Again, while this is certainly true, as noted above, adherence to medications for other (well-established) chronic diseases is not much better (often no more than three to six months).
It is also suggested that patients discontinue their AOMs because they are not meeting their (often unrealistic) weight loss goals. However, given that these medications take months before patients achieve their maximum weight-loss (never mind the time it takes to up-titrate to the recommended dose), this does not explain why most patients stop their meds only a couple of weeks into the treatment, i.e. long before they can expect to see the maximum effect or reach their weight-loss plateau. In fact, most patients never seek or fill a second prescription.
I also often hear the notion that patients come off their AOMs because weight is easily monitored and patients can directly see the effect (or lack of it), which is certainly different for statins or ASS. Again, we don’t see much better adherence in patients with other conditions where patients can directly experience the effect of their medications (e.g. medications for chronic pain).
The fact is that non-adherence is not unique to AOMs but of course as relevant to their use as for any other medications for chronic conditions.
This warrants that we familiarise ourselves with the rather extensive body of literature on the science of adherence, a topic that has interested me since back in the days when I worked in my hypertension clinic, trying to get my patients to take their anti-hypertensive meds.
In some ways it does seem that I may have come full circle in having to once-again revisit this topic 30 years later.
Obesity Trends To Watch For in 2023
There is no doubt that we are currently experiencing the dawn of a revolution in our ability to better treat and manage obesity. Under these circumstances, predicting the future of obesity medicine is perhaps even more difficult than when things were plodding along at a steady pace.
Nevertheless, here are some of the trends we should watch for in 2023:
- With ever more safe and effective anti-obesity medications becoming available (assuming the supply issues can keep up with the demand), patients, desperate for treatment, will be running down their doctors’ doors demanding prescriptions. At the same time, doctors, seeing the success that their patients are having, will begin feeling far more positive and optimistic about obesity management than at any time in the past.
- While the benefits for patients with clear indications for anti-obesity treatment will become more and more obvious, so will the magnitude of misuse and abuse of these medications by folks who clearly do not have a medical need to lose weight. As the misuse of these medications will largely happen without the supervision of health professionals, we should expect increased occurrence of adverse effects and complications that could well be avoided when these medications are used as intended. This development will prompt increasing critical attention by the media with warnings about these medications and calls to restrict access even for people who meet the indications and stand to benefit from these treatments.
- As medical treatments are now approaching a level of effectiveness previously only seen with bariatric surgery, one may suspect that surgery rates will decline. The opposite is likely to be true. In fact, we will probably see pre- and post-surgical use of these medications substantially enhance the safety and long-term success of surgical procedures. Thus, for many (if not most) patients with severe obesity, the question will no longer be surgery or medication – in most cases it may well be both.
- As medical treatments become more effective and available, many treatment plans that have so far relied solely on behavioural interventions (including the use of devices and formula diets), will adapt to support and embrace medical options if they hope to stay in business. The same will apply to the many behavioural apps that are now crowding the eHealth space – these will need to incorporate some form of support for patients on anti-obesity medications – and this feature may well turn out to be their most valuable function yet.
- As with other chronic diseases, the greatest challenge will be to actually get patients to use these medications as prescribed and to persist with treatment in the long-term. Thus, the issue of proper adherence (without which there will be little long-term benefit, potential harm, and a substantial economic waste) will gain increasing attention.
With my best wishes for a Happy New Year!
What Obesity Policies Do We Need?
Earlier this week, I presented at a high-level UK Health Policy Workshop on how I would shape policies to deal with the obesity issue.
My suggestions can essentially be summarised as follows:
- All relevant policies need to acknowledge that obesity management requires the same approach as any other chronic disease.
- The biological nature of the body’s defense against weight loss dictates the need for treatments that address the biology and don’t just rely on education, motivation, and willpower.
- Managing obesity needs to become first-line treatment for all patients presenting with any obesity related comorbidity.
- Obesity management can be funded by progressively diverting funds from treating obesity complication and comorbidities to treating obesity itself.
- Basic competencies in obesity management need to be a mandatory requirement in all medical licensing exams.
Whether or not these suggestions find their way into health policies in the UK or elsewehere remains to be seen, but I certainly see no alternative to implementing such policies if we are ever to make a dent in the obesity crisis that is clearly affecting every health care system around the world.
Guest Post: Racial Diversity in Obesity Research and Practice
Today’s guest post comes from my dear colleague Fatima Cody Stanford, MD, Associate Professor of Medicine and Pediatrics, Harvard Medical School.
Particularly in the aftermath of the murder of George Floyd here in the United States, there has been greater attention to racial and ethnic diversity in every domain of human life. His brutal murder during the COVID-19 pandemic set the stage for those to consider the prominence of disparities and how they contribute to differences in health, quality of life, morbidity, and mortality- just to name a few. So now, more than any time since the 1960 civil rights movement catalyzed by individuals such as Martin Luther King Jr., we recognize that racial and ethnic diversity matters.
But why does racial and ethnic diversity matter in the field of obesity? Why should we care?
The answer is quite simple. Disproportionately, individuals from racial and ethnic minority groups bear the brunt of the burden of obesity. As a Black woman obesity medicine physician-scientist, I can definitely say that the disproportionate burden of obesity in the Black community – particularly amongst those that are the descendants of the enslaved like myself here in the United States, brought me to this field. each and every day in this work I realize the importance of the focus on this issue. Yet, my daily focus on racial and ethnic diversity in the field is not genuinely shared by many of my colleagues. Hence as we seek to improve the care for persons with obesity, we fall short of being able to do so.
How is this you might ask? Let’s take a pause and look at clinical trials that are performed around the world for anti-obesity pharmacotherapy. You don’t have to do a deep dive to recognize that the subjects included in those trials disproportionately do not reflect the diverse tapestry of individuals who are impacted by the disease of obesity. As we peruse the prominent publications in the top peer reviewed journals throughout the world, you also don’t see many authors that reflect racial and ethnic diversity.
So, how are we going to treat a disease when both the patients, physicians, and other healthcare providers that care for these patients don’t reflect the diversity of the population? How can we extrapolate data and presume it will apply broadly to a population that is underrepresented? We can’t. So we continue to fail. Yet, no one really seems to care.
You might push back at me for that. I am someone who eats, lives, and breathes as a Black woman in this world. Saying that you care and speaking about the issue of racial and ethnic diversity in obesity without taking any true steps to improve the status quo means you’re complicit in the lack of progress.
So what steps can we take to make a difference?
Here are my personal thoughts of initial steps we can take to change the narrative and actually make a difference in persons from racially and ethnically diverse backgrounds in obesity.
1. Recognize the burden of obesity and racial and ethnic minority communities throughout the world and recognize that it’s prevalence stems from multiple biologic, social, economic, and other factors.
2. Empower individuals from racial and ethnic minority communities to pursue careers and work in obesity as this diversity in the workforce will lead to better quality of care for this patient population.
3. Ensure that trials of all kind: lifestyle, pharmacotherapy, surgical interventions have a diverse cohort of subjects so that the results can be extrapolated to all.
4. Be a true ally. Don’t just talk about the issue of racial and ethnic diversity in obesity. Do the work.
5. If you have no idea where to start, seek out those of us that do to assist you in this work.
The time for us to act is now. Let’s stop talking about the problem and be a part of the solution. You can start with you today.
Fatima Cody Stanford, MD
About the author: Fatima Cody Stanford MD MPH MPA MBA FAAP FACP FAHA FAMWA FTOS is an Associate Professor of Medicine and Pediatrics who practices and teaches at Massachusetts General Hospital (MGH)/ Harvard Medical School (HMS) as one of the first fellowship-trained obesity medicine physicians worldwide. She is one of the most highly cited obesity medicine physician-scientists with over 150 peer-reviewed publications.
Guest Post: Obesidades Mexico
Today’s guest post comes from my Mexican friend and colleague, Verónica Vázquez Velázquez, PhD, Co-founder and President of Obesidades.
Is obesity a single disease or are they several diseases with common clinical manifestations? Science is trying to answer this, but every one living with obesity has their personal definition.
In Mexico, more than 80 million children, teenagers and adults live with overweight or obesity (55% of children from 0 to 11 years, 44% of teenagers and 74% of adults, from a total of 126 million inhabitants). This means that most Mexican people live with abnormal or excessive body fat that may impair their health.
For some, obesity is merely living in a large body, but for others, this is a disease that leads to other diseases and has alienated us from our work, social and love lives. For many, this also means living under the critical and biased eye of physicians, relatives, friends or strangers, who think that “this is our fault”. In reality, obesity results from a series of factors, some that can be controlled/treated and others that we have not chosen (such as biology, genetics and the environment).
I remember talking with Dr Sharma in July 2020 and can´t forget his words: “What makes you angry about what is happening in Mexico with obesity? What can you do about it? Whatever it is, make it important and manageable. First, get together friends who think alike and understand obesity. Then, little by little, you will add people to spread knowledge and advocate for change. If you feel passionate about it, just do it. It does not have be perfect, it just has to be good”.
This is why we founded Obesidades (Spanish plural for obesity), to give voice to those interested in understanding and addressing obesity.
We are a non-profit organization incorporated in Mexico in 2020 by a psychologist/patient in treatment, a bariatric surgeon and a physician/patient in treatment. Our goal is to create a community that includes people living with obesity, health professionals, organizations and authorities, all joined together for changing the narrative around obesity and its treatment.
Primary prevention is important, but clearly many of us will, at some point, require access to health services offering an individualized biopsychosocial approach, incorporating early diagnosis and evidence-based treatments that includes strategies to sustain the treatment in the long term.
All of this may seem complicated. Nonetheless, we can start by changing the narrative around obesity and its treatment, as we now know how harmful weight bias, negative stereotypes, stigma, and discrimination against people living with obesity really are.
The new obesity narrative should include awareness, evidence-based education, training for health professionals based on an empathetic and compassionate approach and should place the person living with obesity right at its core.
What have we achieved?
To date, our Obesidades community includes more than 10,000 healthcare professionals, people living with obesity, family members, friends and people interested in looking at obesity from a different perspective. We work through committees, social networks, and discussion groups to put the topic on the table and offer evidence-based information in Spanish, so that we can join forces.
We began a national multi-center study in Mexico on attitudes, knowledge and stigma among the general population and healthcare professionals. We launched an awareness campaign named “Weight stories”, through which we emphasize the damage of weight stigma, and we make people aware that obesity is a disease impacting each person in a different way. Also, we created a treatment finder (with healthcare professionals, public and private hospitals and clinics) to help people living with obesity find a safe, ethical and professional place to initiate or continue treatment.
Where are we going?
Our work has begun, and we will not stop until we achieve our goals, i.e.:
1. Obesity is recognized and treated as a chronic and multi-factorial disease. Accepting this truth is not easy, but we want to be there for those in doubt, with evidence-based information, provided in a simple and compassionate way.
2. Healthcare professionals are trained for obesity management. To reduce weight stigma in the medical practice, so that every Mexican is offered adequate treatment.
3. Stigma and discrimination are recognized as harmful factors that need to be eliminated. Many people are not aware of the damage of their negative comments, jokes, and actions. If there is someone not sure about how to help, this may be a good start.
4. Verbal and visual narrative is changed. Educate the general population, authorities and associations about the use of people-first language, as well as including fair and dignified images of people living with overweight.
5. Access is offered to evidence-based and long-term treatment. If we get rid of weight and obesity treatment stigma and negative assumptions, we may reduce the time it takes before talking to a health professional about our weight and health, thereby preventing us from getting sicker every day.
Although only two years have elapsed, there is already much more to see from Obesidades. This is a good fight, a good cause, and a good team. We can be a bridge and an ally to connect different countries from Latin America, Hispanic people who are also struggling with access to more knowledge and better treatments.
We are thankful for the pathway laid out by the World Obesity Federation, Obesity Canada, ConscienHealth, Obesity Action Coalition, Global Obesity Patient Alliance, Obesity UK, European Association for the Study of Obesity, European Coalition for People living with Obesity, and Asociación Bariátrica Hispalis, all of whom have taught us to never give up, no matter how difficult the path may look.
“We with obesity live in a world that reminds us of it. We know the impact this has on our health. Many of us try to take care of it on a daily basis, but sometimes the disease is stronger than us, it defeats our strategies, our will. That is why we deserve empathy and treatment” Cristina, 47 years old.
Verónica Vázquez Velázquez, PhD
Mexico City, Mexico
About the author: Verónica Vázquez Velázquez, PhD in Psychology, is president of Obesidades. She is also a clinical psychologist at the Obesity and Eating Disorders Clinic of the National Institute of Medical Sciences and Nutrition Salvador Zubirán (INCMNSZ) in Mexico since 2000. Professor at different universities, she has published more than 45 scientific papers and book chapters and has co-edited the “Obesities Manual: An opportunity to improve the health of your patient”. She has 21 years of clinical experience with patients living with obesity and their families, in the creation of psychoeducational interventions, in the training of healthcare professionals and in clinical research. Email: firstname.lastname@example.org
Guest Post: Family Doctors and Obesity Management
Today’s Guest Post comes from my colleague Michael Crotty, MD, a family doctor in Dublin, Ireland.
I believe we are on the cusp of a new dawn where the vast majority of bariatric care will be provided in primary care with family physicians taking a leading role.
Obesity is a chronic, progressive disease that impacts every organ and system in the human body. It requires an individualised, bio-psycho-social approach which incorporates screening, early diagnosis and evidence based treatment. We must shift away from solely focusing on primary prevention to also provide treatment and support to those living with overweight and obesity. This is in addition to the ongoing management of the potential medical complications and co-morbidities. There is, undoubtably, work to be done to change the narrative around obesity in society. We must continue to reduce the weight bias and stigma that persists in healthcare and primary care is no different.
As family doctors, we are perfectly positioned to support patients who live with obesity. If we are adequately resourced, we have the capacity to see the large volumes of patients for whom excess weight may affect health. Primary care is not only a more convenient setting for our patients but it also offers significant savings from a healthcare economics perspective when compared to hospital based care. In many countries, primary care clinicians have invested heavily in healthcare informatics/IT and have been at the forefront of adopting hybrid models of care. These advancements have been realised on a day to day basis during the COVID19 pandemic. There is an opportunity to offer a blend of traditional, in-person and virtual consultations to patients living with obesity. The advantages offered are immense and can potentially remove some of the barriers to care that have existed in the past.
As GPs, we know our patients in the context of their family and their community. We treat them across their lifespan. This provides an opportunity to screen those at higher risk ( with knowledge of family history, medical history and medications etc) and to facilitate early intervention. We are skilled in managing chronic diseases and offer the continuity of care and frequent review that is needed to manage a long term, progressive medical issue like obesity. We are innovators and can be at the forefront of adopting new treatments as they become available.
We are experts in communication, behavioural support and brief intervention – the foundation of medical weight management. We are the last true generalists. We do not view our patients living in a vacuum or through the narrow lens of one disease but see them as individuals with unique experiences, skills and challenges. We spend our day managing multi-morbidity. What is best for the
heart may not suit the kidneys, what is best for mental health may not be best for weight – it is up to us to integrate these competing challenges and collaborate with our patients to find what is most appropriate and acceptable to them. Putting the person at the centre of the decision making process is vital and we do this every day in our practice. Although we are directed by guidelines and evidence, we must adjust our treatment plan based on the bespoke needs and values of our patient. We are already treating people for weight related complications and co-morbidities which will undoubtably be lessened if we can also manage the underlying cause.
In primary care we spend our day constantly shifting gears, (in my case this is assuming I have had enough coffee) and transition between discussions about psychological, functional or metabolic health. This is one of the most vital skills when managing a medical condition that can affect every facet of health. Over many years treating our patients, we develop a rapport and trust. This helps us appreciate when it may be acceptable, with permission, to start a conversation about weight. If they feel a discussion is not appropriate at that time, we know that we will certainly meet them again and have made it clear that we are available to help.
It is implausible to think of every patient with hypertension or asthma being seen by a specialist for treatment. Our hospital system does not have the capacity. The skills of my esteemed colleagues are better applied to patients living with the most complex and severe illnesses. There will always be a place for specialist multidisciplinary medical and surgical bariatric care but why must patients languish on long waiting lists developing more severe complications when we can start treatment and intervene earlier in primary care – Obesity should be treated like all other chronic diseases. With safe, effective treatments and a shift in our approach towards pharmacotherapy with an adjunct of behavioural intervention we will be less reliant on the conventional MDT approach. We are already prescribing identical treatments for other indications with great success.
With adequate funding for treatments, training and an appropriate referral pathway there is an army of healthcare practitioners in primary care who are sufficiently caffeinated, ready, willing and able to treat the chronic disease of obesity.
Michael Crotty, MD
About the author: Dr Michael Crotty is a General Practitioner who specialises in Bariatric Medicine. He is a member of the Clinical Advisory Group of the Irish National Clinical Programme for Obesity and co-chair of the Adult Weight Management Subgroup. He was awarded a SCOPE National Fellowship by the World Obesity Federation. Michael is the co-founder and clinical lead of the “My Best Weight” medical weight management clinic in Dublin, Ireland. www.mybestweight.ie