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Redefining Obesity Beyond Numbers

As I pointed out in yesterday’s post, there appeared to be broad acceptance for the notion that obesity is a chronic medical disease at the recent 5th Canadian Obesity Summit. In my opening address to the delegates, however, I emphasised that acceptance of obesity as a chronic medical diagnosis requires modification of the definition of obesity to ensure that people diagnosed with this condition do in fact have significant health impairments that warrant them being considered ‘sick’. This is where, the current commonly used ‘definition’ of obesity based on BMI breaks down, as it would ‘misdiagnose’ a significant proportion of Canadians with having a ‘disease’, when in fact they may be perfectly healthy. Moreover, the current BMI-based ‘definition’ of obesity would exclude an even larger group of individuals, who may stand to benefit from anti-obesity treatments as having a BMI that is too low. Let us recall that BMI is really just a measure of size and not a direct measure of actual health. As discussed in a recent editorial published in OBESITY, we have suggested that it would only take a minor (but important) modification of the current WHO definition of obesity to ensure that this label is only applied to people whose health is in fact affected by their body fat. Thus, we have suggested that the current WHO definition, “The presence of abnormal or excess body fat that may impair health.”   be modified to “The presence of abnormal or excess body fat that impairs health.”  This simple change to the wording would have significant implications in that obesity would move from simply being a term used to describe a risk factor (“may impair health“) to being an actual disease (“impairs health“), with all of its consequences for policy, regulators, healthcare systems, research, and clinical practice. Before anyone thinks that this would be far too cumbersome or impractical, let us remind ourselves that such diagnostic approaches are standard practice for a wide range of other diseases that require a clinical encounter, laboratory testing, and/or diagnostic imaging for their diagnosis. In fact, there are very few diseases that can be reliably diagnosed with just a single measure or test. Thus, “…in clinical practice, assessing whether or not abnormal or excess weight is impairing someone’s health should not pose a major diagnostic dilemma. In the vast majority of patients, a few interview questions, a brief physical exam, and a short panel of routine lab tests should readily establish (or… Read More »

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Another Canadian Obesity Summit Exceeds Expectations

Wow, what a week! Just back from the 5th Canadian Obesity Summit, there is no doubt that this summit will live long in the minds (and hearts) of the over 500 attendees from across Canada and beyond. As anyone would have appreciated, the future of obesity research, prevention and practice is alive and kicking in Canada. The over 50 plenary review lectures as well as the over 200 original presentations spanning basic cellular and animal research to health policy and obesity management displayed the gamut and extent of cutting-edge obesity research in Canada. But, the conference also saw the release of the 2017 Report Card on Access to Obesity Treatment for Adults, which paints a dire picture of treatment access for the over 6,000,000 Canadians living with this chronic disease. The Report Card highlights the virtually non-existant access to multidisciplinary obesity care, medically supervised diets, or prescription drugs for the vast majority of Canadians. Moreover, the Report Card reveals the shocking inequalities in access to bariatric surgery between provinces. Merely crossing the border from Alberta to Saskatchewan and your chances of bariatric surgery drops from 1 in 300 to 1 in 800 per year (for eligible patients). Sadly, numbers in both provinces are a far cry from access in Quebec (1 in 90), the only province to not get an F in the access to bariatric surgery category. The presence of patient champions representing the Canadian Obesity Network’s Public Engagement Committee, who bravely told their stories to a spell-bound audience (often moved to tears) at the beginning of each plenary session provided a wake up call to all involved that we are talking about the real lives of real people, who are as deserving of respectful and effective medical care for their chronic disease as Canadians living with any other chronic disease. Indeed, the clear and virtually unanimous acceptance of obesity as a chronic medical disease at the Summit likely bodes well for Canadians, who can now perhaps hope for better access to obesity care in the foreseeable future. Thanks again to the Canadian Obesity Network for hosting such a spectacular event (in spectacular settings). More on some of the topics discussed at the Summit in coming posts. For an overview of the Summit Program click here @DrSharma Edmonton, AB

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Public Engagement For Obesity

This week, the Canadian Obesity Network will host its 5th National Obesity Summit in Banff, Alberta. While the formal program begins on the evening of the 26th with the delivery of Award lectures, there are plenty of pre-conference workshops to chose from. One such workshop is the strategy meeting of the Network’s Public Engagement Committee, which will meet in person to discuss the Network’s public engagement strategy. As reader may know, this committee was formed two years ago at the last Canadian Obesity Summit in Toronto (image) and has been extremely active since in helping plan and provide direction for the Network’s activities to tie in and meet the interests and needs of the nearly 7,000,000 Canadians living with obesity. It is fair to say, that their voice has been largely ignored in the policy discussions around obesity prevention and management and there is little evidence that Canadians living up with obesity are speaking up for themselves. This is a crying shame, as who should know more about the realities and challenges that Canadians living with obesity face everyday in settings including education, workplace, and society in general? Unfortunately, the challenges also extend to health care – as will become evident from the Report Card on Access to Obesity Treatments in Canada, which will be released at the Summit later this week. With this work, the Network is following closely in the footsteps of the Obesity Action Coalition and the EASO Patient Council to provide a voice at the table for Canadians living with this chronic disease. I look forward to a most exciting and informative week. @DrSharma Banff, AB

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Arguments For Calling Obesity A Disease #9: Medical Education

Next in my miniseries on the pros and cons of calling obesity a ‘disease’, I turn to the issue of medical education. From the first day in medical school, I learnt about diseases – their signs and symptoms, their definitions and classifications, their biochemistry and physiology, their prognosis and treatments. Any medical graduate will happily recite the role and function of ADH, ATP, ANP, TSH, ACTH, AST, ALT, MCV and a host of other combinations of alphabet soup related to even the most obscure physiology and function – everything, except the alphabet soup related to ingestive behaviour, energy regulation, and caloric expenditure. Most medical students and doctors will never have heard of POMC, α-MSH, PYY, AgRP, CART, MC4R, or any of the well studied and long-known key molecules involved in appetite regulation. Many will have at best a vague understanding of RMR, TEE, TEF, or NEAT. The point is, that even today, we are graduating medical doctors, who have at best a layman’s understanding of the complex biology of appetite and energy regulation, let alone a solid grasp of the clinical management of obesity. Imagine a medical doctor, who has never heard of β-cells or insulin or glucagon or GLUT4-transporters trying to manage a patient with diabetes. Or a medical doctor, who has never heard of renin or aldosterone or angiotensinogen or angiotensin 2 trying to manage your blood pressure. How about a medical doctor, who has never heard of T3 or T4 or TSH managing your thyroid disease? Elevating obesity to a ‘disease’ means that medical schools will no longer have an excuse to not teach students about the complex sociopsychobiology of obesity, its complications, prognosis, and treatments. As I mentioned in a previous post, suddenly, managing obesity has become their job. No longer will it be acceptable for doctors to simply tell their patients to control their weight, with no stake in if and how they actually did it. Thus, if there is just one thing that calling obesity a ‘disease’ can change, it is expecting all health professionals to have as much understanding of obesity as they are currently expected to have of diabetes, heart disease, lung disease, and any other common disease they are likely to encounter in their medical practice. Apparently, simply treating obesity as a ‘lifestyle’ problem or ‘risk factor’ was not enough – hopefully, recognising obesity as a  ‘disease’ in its own right, will change the attention given to this issue in medical… Read More »

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Arguments For Calling Obesity A Disease #8: Can Reduce Stigma

Next, in this miniseries on arguments for and against calling obesity a disease, I turn to the issue of stigma. One of the biggest arguments against calling obesity, is the fear that doing so can increase stigma against people living with obesity. This is nonsense, because I do not think it is at all possible for anything to make stigma and the discrimination of people living with obesity worse than it already is. If anything, calling obesity a disease (defined as excess or abnormal body fat that impairs your health), could well serve to reduce that stigma by changing the narrative around obesity. The current narrative sees obesity largely as a matter of personal choice involving poor will power to control your diet and unwillingness to engage in even a modest amount of regular physical activity. In contrast, the term ‘disease’ conjures up the notion of complex biology including genetics, epigenetics, neurohormonal dysregulation, environmental toxins, mental health issues and other factors including social determinants of health, that many will accept are beyond the simple control of the individual. This is not to say that other diseases do not carry stigma. This has and remains the case for diseases ranging from HIV/AIDS to depression – but, the stigma surrounding these conditions has been vastly reduced by changing the narrative of these illnesses. Today, we are more likely to think of depression (and other mental illnesses) as a problem related to “chemicals in the brain”, than something that people can pull out of with sheer motivation and will power. Perhaps changing the public narrative around obesity, from simply a matter of motivation and will power, to one that invokes the complex sociopsychobiology that really underlies this disorder, will, over time, also help reduce the stigma of obesity. Once we see obesity as something that can affect anyone (it can), for which we have no easy solutions (we don’t), and which often requires medical or surgical treatment (it does) best administered by trained and regulated health professionals (like for other diseases), we can perhaps start destigmatizing this condition and change the climate of shame and blame that people with this disease face everyday. @DrSharma Edmonton, AB

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