The COVID epidemic has no doubt disrupted business as usual in virtually every aspect of our lives. Some have been hit harder than others, some have struggled while others have thrived. Although perhaps not the most serious problem, the epidemic has certainly had a profound effect on clinical and academic life – most of us had to virtually overnight adapt to virtual clinics, teaching, and research.
As every major life event, the epidemic was also a chance to rethink and perhaps redirect professional (and sometime personal) life plans. In my case, this has led me to take the rather drastic step of requesting early-retirement from my tenured university position at the University of Alberta, in order to eventually move closer to my family and aging parents in Berlin (my home town).
As you may imagine, giving up a secure university position in a time of global crisis, was not an easy choice. On the other hand, this is in fact the third time that I have given up a secure tenured position as professor in favour of seeking new pastures. Oddly enough, these decisions have been far less disconcerting to me than to my friends and family, who generally responded with rather profound shock (“you must be nuts”!).
However, this time around things may be a bit different. After spending virtually all my professional life in the ivory tower of academia, deciding now to try my hand at freelancing as a consultant, strategic advisor, and all-round visionary, is going to be an interesting ride.
No doubt I am counting on my considerable experience, well-established reputation (notoriety?), and, perhaps, a few notable contributions to the field of obesity to help me manoeuvre this next stage of my professional life.
Some of you may recall that the my ruminations on the issue of weight bias, the inadequacy of BMI, the etiological framework for obesity, the importance of mental health, the need for accommodation, the Edmonton Obesity Staging System, the 4Ms of obesity assessment, the 5As of obesity management – all of these ideas originated from my postings on these very pages. You may also recall that I have long championed changing the very definition of obesity to one that aligns itself with the clinical definition of a chronic disease rather than just a matter of size. Some of you are probably also aware that the tiny organisation I founded with a few colleagues back in 2006 has now grown into Obesity Canada, one of the most recognisable and influential national obesity organisations in the world. (Incidentally, after almost 15 years of service, I also recently retired from my role as Scientific Director of this organisation, leaving it both in good hands and financially sounder than it has ever been).
Certainly my track record in research with over 450 peer-reviewed publications in areas as diverse as genetics, adipose tissue biology, human physiology, body composition, nutrition, pharmacology, surgery, epidemiology, clinical practice, health policy, stigma and discrimination speaks for itself.
Over the years I have also had the chance to develop considerable experience in public engagement and advocacy, not least to change the narrative of what obesity is and what we need to do about it.
So yes, I’m officially “retired” but far from done. In the end it all comes down to focussing on what I appreciate doing the most, i.e. exploring new ideas and opportunities, pushing boundaries, challenging conventional wisdom, thinking out aloud, and perhaps most importantly, speaking up for what’s good and right.
This career move (if you could consider it as such) would probably not have happened with out a considerable “nudge”* from SARS-Cov-2 – whether or not I will eventually owe personal gratitude to this virus remains to be seen.
If nothing else, with the extra time now on my hands, I hope to once again blog more frequently than over the past months – after all, there is certainly enough happening in the obesity world to think and write about.
Let’s have some fun with this!
*Incidentally, on Tue 29 June, 16.30-18.00 (CEST), I will be on a panel discussing the power of “nudge marketing” as a behaviour change intervention targeting HCPs at the 2021 Annual Conference of the Healthcare Communications Association (HCA)
In just a few weeks, the European Association for the Study of Obesity (EASO) and Obesity Canada (OC) will be hosting their 2021 annual conferences on-line. Both conferences will run on the same days (10-13 May) and both organisations are delighted to offer a heavily-discounted joint registration for both meetings.
For just an extra CAN$ 120 (€ 50), EASO and OC members can register for both conferences, which, thanks to the different time zones, will comfortably run with minimal overlap – thus, when the European Conference closes for the evening, delegates can join the live sessions in Canada (starting at 17:00 CET) for a few more hours of cutting-edge presentations on obesity research and practice.
Of course, registrants to both conferences will have full access to all live and on-demand content for several weeks following the conferences.
Students can attend both conference for just an extra CAN$ 40 (€ 25) – definitely a steal!
Registering for both conferences gives you access to hundreds of presentations with countless hours of CME credits – more than anyone could wish for.
For Europeans wondering why they would bother with a Canadian conference – here just a humble reminder that some of the most forward-thinking research in obesity and some of the most advanced concepts on obesity management are currently being developed in Canada (the recent Canadian Obesity Practice Guidelines are just one example).
For Canadians wondering why they would bother with a European conference – here a reminder that EASO represents the leading voices in obesity research, management and policy from 36 European countries – nothing anyone working in obesity would wish to or could afford to miss.
No matter how large or how specialised your centre, it will serve you well to establish clear standards and procedures. Topics that need to be defined and agreed upon would include not only what patients get accepted into the clinic but also treatment pathways, standards of care, sequencing of care, measuring outcomes, and ensuring on-going quality improvement.
The particulars of these topics will of course vary according to the nature, scope, and funding of the clinic, but certain aspects will be common to any kind of centre. Thus, ideally, any respectable obesity centre would likely need to adhere to the accepted obesity treatment guidelines in that country. Where there are no clear standards set up by a national professional organization, you may have to look to other countries for guidance. Obviously, some of the guidance found in such guidelines may not translate directly to the situation in your own country or region (e.g. access to medications, surgery, psychological interventions, etc.), but adhering to them as closely as possible is probably a good idea. In any case, disregarding evidence-based standards would require clear acknowledgement and justification.
Most obesity guidelines provide at least an outline of an assessment and treatment pathway or algorithm. Virtually all recommend a multi-disciplinary multi-modal approach that covers the five elements of obesity management: nutrition, physical activity, psychological intervention, medications, and surgery. Although most guidelines recommend a hierarchical approach to using these interventions (if one “fails”, move to the next), this may not be the most efficient or even most cost-effective approach.
Thus, for example, spending a lot of time and effort on trying to help someone with Class III EOSS Stage 2 obesity to try to “conquer” their obesity with diet and exercise alone, when overwhelming evidence points to the general futility of such an approach (anecdotal exceptions are just that, anecdotal exceptions!), can eat up a lot of staff time (never mind the patient’s efforts), and lead absolutely nowhere. In fact, it can make things a lot worse, as in the long run this will only lead to demotivation and learned helplessness (never mind any detrimental effects on metabolism).
In practice it may be better to think of these five approaches as complementary rather than as distinct therapeutic pathways. Patients start at different stages of motivation, knowledge, past experience, expectations, and socioeconomic circumstances. Furthermore, patients present with varying levels of complications and impairments, necessitating varying intensity and urgency of intervention. Trying to squeeze all patients into a set pathway may appear more “efficient” at first glance but also results in spending time and resources where they are either not effective or not needed. Thus, I am always wary of approaches where “all patients” have do certain things (no exceptions!) to fit into the program. Even worse, when those who drop out or are labeled as “less motivated” are quickly deemed “failures”, when it is not they who failed the program but rather the program that failed them.
It is of course one thing to recommend individualized tailored approaches, another to actually offer them to each patient, and yet another to then scale them up for efficiency and cost-effectiveness. While a small program can treat each patient as an individual and a large program can afford to divide patients into various subgroups to include more homogeneous subsets of patients, mid-size programs will likely struggle to find a workable sweet spot that does justice to all-comers. These programs will have to be particularly clear about patient selection, recognizing that they may not be the best choice for all patients.
Obviously, this will depend on the setting, the personnel, the infrastructure, the funding model (public or private) and a host of other considerations.
For example at a surgical centre, one will not only have to decide what procedures are to be performed but also just how much pre-surgical workup and management and what post-surgical follow-up will be provided. At our centre, which is a publicly funded joint medical and surgical centre staffed by family doctors, internists, dietitians, psychologists, nurses, and surgeons, we can offer extensive pre-surgical work up as well as extended post-surgical follow-up (generally up to two years). In addition, we have a robust roster of consultants, who provide a wide range of support.
It is however, also increasingly common to find surgical centres that work closely with referring physicians, who perform much of the patient selection and pre-surgical workup as well as post-surgical follow-up. In this scenario, the surgeon only sees the patient a few times prior to surgery and rarely post-surgery, unless there are specific surgical issues that may arise.
Irrespective of which model you chose, it is essential that much attention is paid to patient selection, education, work-up and preparation for surgery. The notion that patients may be chosen based on a single visit or even just a phone call is laughable, if this was indeed a laughing matter.
Similarly, I strongly feel that the surgeon is obliged to ensure that competent post-surgical management is in place and I would consider it ethically challenging to perform bariatric surgery, where there are significant doubts regarding the post-surgical long-term follow-up. Indeed, ensuring that patients fully understand and appreciate the need for long-term (lifelong) follow up is only part of the obligation. Patients may be so eager to get surgery that they do not give much consideration to the need for post-surgical care. Futhermore, in many places, there simply is no post-surgical care outside of surgical centres, so that patients who run into problems will likely find themselves left to fend for themselves.
But also the medical programs need to define their scope of practice and think about what services will be offered. Given the complexity and heterogeneity of obesity, centres that offer a limited number of treatment options (e.g. one dietary approach, such as a ketogenic or formula diet), will necessarily not be able to help all-comers. In fact, it may well be that this very treatment option is contraindicated in some patients, something the centre needs to be very clear about. Furthermore, in my opinion, any obesity centre that does not also address the common psychological or psychiatric issues present in this patient population, cannot claim to provide a holistic approach to this complex chronic disease.
Another issue related to scope, is deciding how much effort is to be put into managing comorbidities or other health issues present in the patient that may be the direct consequence of excess weight or otherwise complicate obesity treatment. A broad definition of obesity or bariatric medicine would in fact cover all areas of medicine relevant to the care of the patient with obesity (in the same way that geriatric medicine would seek to address the spectrum of care for the elderly patient). However, given the wide range of problems, it is highly unlikely that any obesity centre can provide all of these services to its patients. Rather, it is likely that the patient needs to be in the care of other physicians, especially their family doctors. In such cases, being clear about what will be managed at the obesity centre and what will need to be managed elsewhere, is of considerable importance.
Obviously, no centre can be everything to everybody – but being very clear about exactly what services will be provided and which services may need to be sought elsewhere is not only honest but in the interest of patients trying their best to live with this chronic disease.
Irrespective of what services you can integrate into your obesity clinic, there will always be issues that require consultation with other specialists or require diagnostic procedures outside your clinic. Or, as I learnt early in my medical practice, the two most important skills of being a good doctor are knowing when to consult a colleague and knowing who to consult.
Areas in which any obesity clinic will most likely need regular consult services include psychiatry, sleep medicine, gastrointestinal medicine and hepatology, thrombosis, uro-gynaecology, respiratory medicine, cardiology, orthopaedic surgery, plastic surgery and a few others. Common diagnostic requirements will include ultrasounds, cardiac testing, CTs, MRIs, etc.
In all cases, you will find colleagues who are happy to see patients with obesity and those who are not. You will also find that certain diagnostic procedures have technical or weight limitations for patients with obesity.
Ideally you would be able to identify at least one colleague in each of these disciplines who will welcome patients with obesity into their clinics and are willing to work closely with you in helping your patients deal with these issues.
Be aware that it may take time for colleagues to recognise and adapt to the special needs of this population. Not everyone is comfortable practicing bariatric psychiatry, bariatric cardiology, or bariatric plastic surgery. Over time, hopefully, these colleagues will come to appreciate the issues specific to patients with obesity.
A good source of determining whether or not your patients with obesity are welcomed and well treated are your patients themselves. Sometimes patients will complain about a specific consultant or practice and in my experience it is often worthwhile bringing this to their attention, as they may be unaware of how their attitude or statements are being received. Sometimes the complaints may not be about the colleagues themselves but rather about their clinic personnel or even just about the ambience and infrastructure. Many colleagues will thank you for this feedback and many will change their practice. In cases where patients continue to complain, you may be better off looking for a new consultant for that specific issue.
One important reason for having competent consultants at hand is, because patients presenting at an obesity centre may often have problems that need to be dealt with before you can have any hope of helping them manage their obesity. This includes patients with unmanaged or uncontrolled psychiatric issues like depression, anxiety, or ADHD, unmanaged sleep apnea, chronic pain, unmanaged reflux disease, and many more, where these conditions can be significant barriers to obesity management.
Thus, as you set up your obesity centre be prepared to proactively create and cultivate your own network of consultants, without which you will find managing obesity even more challenging than it already is.