Obesity: The Patient Perspective

sharma-obesity-doctor-kidA key reason for the Canadian Obesity Network to roll out its public engagement strategy, is not just provide a source of credible information on obesity prevention and treatment but also to provide a forum for the prospective of those living with obesity.

That this perspective is often lost in the obesity debate, is highlighted by a thoughtful commentary published in JAMA Internal Medicine written by Fiona Clement, PhD, from the Department of Community Health Sciences, University of Calgary, and has herself struggled with excess weight for most of her adult life.

Clement, whose BMI (at 31.8 kg/m2) barely fits the “obesity criteria”, notes that,

“…this article is the first time I have told my BMI to another soul. I have never shared my BMI with my husband, my friends, nor, importantly, my physician. Given that I am an otherwise healthy 35-year-old woman, it is shocking that what is probably my only health concern has never been talked about within the privileged space of my physician-patient relationship.”

Her reasons for not talking about this are not surprising,

“Obviously, this is an awkward conversation for both the patient and physician. Weight is a tough subject, loaded with stigma, self-esteem, worthiness, and beauty issues. Despite guidelines recommending weight management counselling, the conversation is not happening regularly. Like many hard conversations, it requires compassionate listening and sympathy on the part of the physician, courage and humility from the patient.”

This problem is well recognized, which is exactly why the Canadian Obesity Network’s 5As approach to obesity management emphasizes the tact and skills needed to initiate this conversation (ASK for permission, be non-judgemental, do not make assumptions).

As to the use of appropriate obesity management strategies, Clement essentially opted for the most common “do-it-yourself” approach of “eat-less-move-more”, which as ample research shows is rarely a sustainable strategy. Not surprisingly, the weight she lost came back when, as she says, life happened.

Clement writes about the information she would want presented before she made an informed decision to pursue any of the proposed interventions.

This is exactly what the 3rd A in the 5As of Obesity Management is about – ADVISE. This is where, following the ASK and ASSESS, the health professional would offer their advice – tailored to the individual.

Given that Clement barely meets the BMI criteria for obesity and has, as she states, no weight related health issues, she would at best be considered to have Stage 0 obesity according to the Edmonton Obesity Staging system.

At this stage, the risk (not to mention the cost) of pharmacological or surgical treatments would by far outweigh any potential benefits. Indeed, the focus would be to first and foremost prevent further weight gain by addressing any underlying contributing factors while living the healthiest life she can enjoy (best weight).

This is apparently the course of action that she chose, wisely it seems.

Indeed, given that she has Stage 0 obesity, it is not clear that she would have any real health benefit from attempting to or sustaining weight loss – obesity management should never be about treating numbers on a scale.

Perhaps if Clement had a higher obesity stage, say Stage 2 with diabetes, fatty liver disease or sleep apnea, the advise may be different. In that case, given the substantial risk associated with these conditions, pharmacological or surgical options (especially if her BMI was higher that 35) may well be reasonable additions to her behavioural change.

Thus, Clement is right in noting that interventions have to be individually tailored and a frank conversation about the risks and benefits of treatment between her and a health professional who understands obesity needs to happen (unfortunately, the latter is difficult to find).

 With obesity as with other diseases, the question is always the same – at what stage of the disease does the risk of treatment outweigh the risk of not-treating (or not-treating aggressively enough). Whether the problem is diabetes, arthritis, or cancer – the question of risk-benefit ratios must always be seen in the context of the individual.

At what point, for e.g., would someone have deemed “lifestyle” management of diabetes to have failed and consider pharmacological treatment? That threshold will vary from one individual to the next (no matter what the guidelines say). Obesity is no different.
To treat or not to treat, and if yes, with what, is always a discussion that has to include the patient perspective and respect their informed decision (the key word here is “informed”).
As Clement points out, this may take more than a “10 minute interaction, where both parties would rather be elsewhere“.
Edmonton, AB