Podcast: Obesity: shifting to a patient-centred approach to management
Transcript
Diane Kelsall: In recent years, we've gained understanding about the complex interplay of factors that can lead to obesity. These include genetic, metabolic, behavioral, psychological and environmental factors, but also stigma, which we now know contributes to morbidity and mortality independently of other factors. I'm Dr. Diane Kelsall, consulting editor for CMAJ. Today I'm speaking with Dr. Sean Wharton and Dr. David Lau, the authors of the clinical practice guideline on obesity published in CMAJ. Also joining us is Lisa Shaffer who is chair of Obesity Canada's Public Engagement Committee. Lisa was part of a group of people living with obesity who contributed to the development of the guideline. This guideline is an update to the 2006 clinical practice guideline that incorporates increased knowledge of the disease, and better approaches to assess and manage obesity. Thank you all so much for joining me today. Welcome.
Sean Wharton: Thank you. And hello.
Lisa Schaffer: Thank you for having us.
Diane Kelsall: Let's start with telling listeners a bit about who you are. Perhaps we can start with you, Sean.
Sean Wharton: Hi, I'm Dr. Sean Wharton, and I'm an internal medicine doctor. I do clinical and, and research that focuses primarily on obesity medicine, and also type two diabetes. Now I run a community-based medical clinic that is in southern Ontario, and I'm also adjunct professor working out of McMaster University, and also York. And that's where we do a lot of the clinical research.
Diane Kelsall: Thanks, Sean. So maybe I can turn it over to you, David.
David Lau: My name is David Lau. I'm an academic endocrinologist who started out with bench lab doing adipose cell biology and research. And over the years, I really have become an obesity clinician. And I must say that my biggest duality of interest is that I'm an obesity and diabetes advocate, hoping to see a world with fewer people affected by both conditions. And I started way back in 2003, with the first you know, world's first evidence based clinical practice guidelines on the management, and prevention of obesity, and that was published in in CMAJ in 2007. So I'm very pleased to be involved with the current update, because a lot has changed over the years.
Diane Kelsall: It certainly has. Thanks so much, David. And and over to you, Lisa.
Lisa Schaffer: Thank you, I'm Lisa Schaffer. As you mentioned, I am the Chair of the public engagement committee with Obesity Canada. I'm a very passionate patient advocate. I live in Vancouver. Professionally, I'm a marketer, but I am also just one of the millions of Canadians that live with obesity. So I use my personal experience of educating myself about obesity, to really try and help influence change and really change the conversation people are having about obesity. So I was thrilled to be able to be part of the development of the guideline.
Diane Kelsall: Now we know that, you know, we all watch the news, we know that the prevalence of obesity has been increasing steadily. You talk about some of the recent numbers in Canada. Have the rates of increase slowed at all? Are we doing any better? Are things getting worse?
Sean Wharton: Thanks, Diane, this is a terrific place to start. So when we start looking at the rates of obesity across the country, we're going to look at to the patient's BMI body mass index, but we don't, like, we've tried to move away from being weight centric or just focusing on weight as the definition of the challenges that we have here. But when we look at the epidemiology, we do have to look at the person's weight and the height. So we do have a definition here that we use. So when we look at a BMI greater than 30, and that is defined as as obesity, we have 26.4% or 8.3 million Canadians affected with this elevated weight. Back in earlier years, it was about 23%. So we've moved from 23% up to 26%. But more concerning is this severe obesity, severe obesity is a BMI greater than 35. So we're getting into those bigger ranges now. And what we've seen in the past 15 years, is that there's been an increase of 455%. So we now are seeing about 2 million Canadians living in that severe range, and we also have another section and that's the overweight section overweight is a BMI between 25 and 30. And so it's not that severe obesity range. It's looking at the harder bellies and the thinner legs of people that people have. And that's a concerning fact because men in Canada are the ones who have more of that problem. We have 10.6 million Canadians living in that overweight range. And we know that that range often gives us a risk of cardiac conditions and multiple other problems. And the final issue is that we're seeing that children are now affected, they're having a lot of challenges, we used to have one in four children by around 1980, that were in the overweight range. Now, it is one in three. So it's continuing to be a greater problem and adolescent boys tend to be one of the major, major challenges here.
Diane Kelsall: So this guideline is coming at a really good time. What has changed in recent years in our understanding of obesity and approaches to diagnosis and assessment?
David Lau: Well, I think the most important aspect is really to focus on obesity as a chronic complex disease, where excess body fat can impair health. To the extent that it's associated, as Sean mentioned, with a number of medical conditions that can shorten the person's lifespan. But importantly, it decreases health for years. So what has evolved over the last several years is the fact that we have a much better understanding of the drivers for obesity. And it's simplistic to think that obesity is just a matter of not being physically active and overeating. In fact, obesity is actually caused by a very complex interplay of genetic, metabolic and behavioral as well as obesogenic environmental factors. The latter would be thought to be the proximate cause for the rising prevalence of obesity globally. But I think it's important to understand that over the years, we now have a better insight in terms of the regulation of energy balance, and importantly, appetite. And clearly, the brain plays a very central role in terms of energy balance, and appetite regulation, of course, bodyweight, and it receives input from the fat organ from the gut. And it also has a lot of interaction with other parts of the brain. So it's important to understand now that regulating appetite is really centrally located in the brain, but it also receives input so that we can look at body weight regulation in terms of consisting of three parts. One is what we call the homeostatic control, and that is the body somehow knows whether we're getting enough energy or not. But in addition to that, there's also the hedonic component of eating, which means that if the food is appealing, we tend to crave for food, even though we may be completely satisfied or satiated with eating. And then finally, there's the executive control, which means that the brain can decide whether or not we should eat, even though we know that we crave for the food and so on. So all this really tells us that the integration of the various input in the brain coming from signals from the gut, from the fat organ, as well as from other organs in the body, totally integrate how our body responds to energy intake, energy expenditure, and overall balance in terms of body weight. And we also know that when a person loses weight, the body starts to adapt to tell the person to regain the weight. And for the longest time, we blame our patients. We blame people living with obesity, for the lack of willpower, in terms of overeating, in terms of not being physically active. And really over the years, we now know that really, this is a totally misperceived conception. And I think one of the major changes over the years, is the fact that we now understand why people have difficulty losing weight. And even if they're successful in losing the weight, they can quickly regain the weight because of the hormonal and other adaptation in the body to tell the individual to regain the weight. So I think all of this leads to new, more insights, which is very important because a stigma against body weight, against obesity is a huge problem that can actually impair or affect how we deliver care to people living with overweight and obesity. So perhaps I'll stop here and I'll elaborate a little further in terms of what has changed. So to sum up, there have been a lot of changes over the years, we have better understanding of what regulates appetite. We also have a better understanding of the complex, behavioral, genetic and other interplay that you know leads to excess body fat.
Diane Kelsall: Thanks, Dave. One of the things that we're seeing in in medicine these days in the health professions is an increase involvement of patients in the generation of knowledge, whether it is on steering committees in research, but also we're seeing increased involvement of patients in guideline development. And in on this particular guideline, there was a large group of authors who worked on it, and patients were included as well. So Lisa, perhaps you can tell us a little bit about what was the role of patients in the development of this guideline.
Lisa Schaffer: It was recognized very early on that the patient perspective needed to be built right into the development and update of these guidelines, which is, I think, an amazing process to have had, it can definitely look different ways. I know there are other applications where it can be, you know, we're a tick box at the end, let's have some patients review this and make sure that they're on board. And this was definitely not the case in the development of these guidelines. So Dr. Ian Patten, another patient advocate with Obesity Canada was a member that was involved in the steering committee, and he actively engaged public members of obesity Canada, to take part in the review process as well. So we wanted real life experiences to really inform these updates. As Dr. Lau was just mentioning, there have been a lot of changes. And another change that's on the forefront is a lot of patients are more educated and being more empowered when they go into see their physicians. So we needed to make sure that this information was disseminated to both patients as well as physicians, and that the guidelines really served both audiences very well. And it's really a testament to how invested the patient voice is and how much we want to see change happen.
Diane Kelsall: What are some common experiences that patients with obesity encounter in healthcare?
Lisa Schaffer: It's frustrating. The reality is for all, many of us living with obesity, healthcare is a really negative space. And it can be honestly scary and terrifying. I know for myself, my experience was that from a very young age that the doctor was a scary thing, and or that my weight would become the focus of any appointment. And that was really frustrating as well. I can also remember being repeatedly tested for things like diabetes and PCOS, and the conversation being around the lines of, we need to find the reason why you're having this issue with your weight. And then those would all come back negative leaving me with the messaging that I was the cause. And I was also the person that needed to figure it out. And until I figured that out, I really wasn't worthy of care and attention for any health concern. At least that was the slightly twisted messaging that I got infused in my brain along the way, because that's that's the way life is. So that was, you know, a lot of what we hear from people, we also know that there are a lot of cases of people who have legitimate health concerns, who are on the receiving end a far more bias than they are care when they go see a doctor. And that is not acceptable. And that really needs to change. And that is a big part of why we advocate the way that we do. You know, it was really important that the guidelines spoke to our reality, and not just the clinical reality, because they can be very, very divergent.
Diane Kelsall: So you talked about the guidelines reflecting your reality. How were these kinds of issues considered when the guideline was created?
Lisa Schaffer: We definitely spoke about real life experiences and, you know, optimal experiences as well, because for as many negative experiences, maybe not for as many negative experiences, but there are a lot of people doing it right as well. So we needed to talk about those things that can go from as small as what does your clinic look like to legitimately how to have these conversations in appropriate ways. Because often they can come with the best of intentions. But if I'm there to see you about something else, and you move the appointment to speaking solely about my weight, I don't feel heard, it doesn't feel as democratic and we continue the cycle of making healthcare not approachable.
Diane Kelsall: Some of those points we're going to get into later, as we move through this podcast, the recommended clinical management approach was developed for the guideline is broken down into five steps, some of which you've talked about already. Can you outline for us what they are Sean? And then we can discuss each one.
Sean Wharton: Terrific. Yeah, absolutely. I'm really pleased to say that we incorporated this patient arc. So as Lisa was talking about, we really looked at where the patient is and what they're looking for. So we tried to make the treatment process a little bit simple and clear. It's all complicated, but if we break it down, it can be a little bit easier within the steps. And the first step is the ask, and that ask step is what Lisa was talking about. You're asking the patient or engaging with the patient, you're developing a healthy relationship where you can now start to talk about all the different treatment options. The second step is the assessment of the elevated weight and we have a number of advances here within assessment, David's going to talk about, that's going to be great. The third step is one of the most in-depth steps. And that's the adviser step where we're looking at the treatment, what treatment options do we actually have in there anchored in healthy eating activity. And those two things are supported by psychological interventions, medication, and surgery. Then we go to the fourth step, which is the agree step. And this is again, going back to the relationship with the patient agreeing with the patient to look at different treatment options, and not to look at weight as the goal. But to address the behavioral accomplishments, what have you accomplished, how are things going. And the final step is the assist step, which really means assisting the patient when they fallen off track, and we visiting all the previous aids to get the patient back. And within these five steps, we believe that it really helps the clinician to know where they're going. And the patient knows, also, so they understand that these steps are going to be taken. And so everyone is on the same page.
Diane Kelsall: So the first step is for the healthcare provider to recognize disease and ask permission to discuss and offer advice. This is obviously incredibly important. Can you tell us more about this recommendation, Sean?
Sean Wharton: Yeah, and I like going into this, this to me is one of my favorite steps. And the reason why this is likely the most important step is because it addresses bias and stigma. If we can't get past bias and stigma, the other steps don't really work. So the ask is to work on the elimination of this. So the healthcare provider, if a healthcare provider believes that people living with obesity have less willpower, or less intelligence than people at lower weights, or have ever said, get your act to gather or this isn't rocket science, they are biased. And many of us have biases in all kinds of different fields. And there is bias in weight management. And those statements would clearly indicate that somebody has bias. Now bias can turn into stigma, when you're acting on the bias, and you're implementing just a diet and say here, here's a good diet, you know, an exercise a little bit more, and then just be a little more motivated. And everything will work out, I'm going to work with you on this diet. So that's wrong. That's a wrong approach for a doctor to take. But it's the most common ones. That's that's bad medicine. So it's not easy to do an elimination of bias, we easily eliminate it from our brain totally. But we can put mechanisms in place. So we don't act on our biases. And that asking, is the first mechanism that we put in place to not act on our internal bias. So you asked the patient and you don't assume and you ask, can we talk about weight management, we imagine it's maybe something you may want to look at, there's some some health complications that could be connected with it, would that be something you'd like to talk about, and it's a good time to talk about it, because we have actual treatments, if you ready for that, that would be terrific. And the next thing that I would recommend that healthcare providers do with the Ask is once a patient says, you know, what I'd like to talk about weight management and what it means and how I can look at it. Then to go to the next ask, before you even go to all the other things is, is can I ask you, whether we can discuss more than just diet and exercise, which you already know. But discuss treatment options that can help to sustain lower calories and healthy activity, namely, the psychological interventions, medications and surgery. So those are two asks, but they're really important in this entire step.
Diane Kelsall: What does this first step look like when someone living with obesity is seeking medical treatment for an unrelated issue, like a rash or something like that? Lisa, you talked a little bit about your experiences, how should clinicians approach these types of scenarios?
Lisa Schaffer: That's a really important part about it. And I think it's important for clinicians and healthcare practitioners to remember that negative experience is a big driver for a lot of patients that are seeking care for anything. And in, in all honesty, we probably come in, pretty amped up, we come in conditioned to expect the worst and to know that I might be coming in to talk to you about a rash, but I know I'm going to get shamed and blamed. So I put my shield up right away. It's important for everyone to keep that in mind. And I and I love the way that this approach has been set up and and how Dr. Wharton just unpacked it there. Because it really is an opportunity to help deflate the room a little bit and make it an equitable space where everybody can just have an honest conversation, even if that means the answer to the first question is no, we can't talk about that today. It may require planting a couple of seeds, it's all about communication, checking our bias and you know, really helping everyone connect these dots. We need to give the healthcare practitioners the tools to have the right conversations. And equally we need to make it okay for patients to realize these are good conversations to be having. And there are more solutions than just eat less and move more. It's a very important moment with patients and clinicians and an opportunity to create a great relationship. Even if you don't have the big conversation that day, you're making it an approachable conversation.
Diane Kelsall: Now, as you said, Lisa, if a patient says, No, I'm not going to give you permission to discuss my weight during the visit, what should clinicians be aware of during the rest of the encounter and subsequent ones? How can a clinician be respectful of a patient's wishes honoring them while also communicating factors that might be relevant to their recovery or or a diagnosis that might be affected by their weight?
Sean Wharton: This is a really good question. Because as an internal medicine physician, and most physicians out there, we're accustomed to patients sitting across the table from us who need help, and we tell them what to do. And that's why they're sitting there, that's what's in our head. A lot of the times, we have a paternalistic approach to health care or to sick care. And that's a challenge here, because this is a different modality that we're working with. And I believe that we could probably use what I'm going to talk about in multiple other fields as well. It's easy to teach the docs that work with me at my clinic, about what the medical challenges are, and how to do the medicine side of things, the medication, the surgical preparation, etc. But what's hard to teach them is compassion and empathy. They really need to listen to the patient. And when the patient is saying, Listen to me, don't just push in a direction that just says do this and do that, you need to hear the sounds of I am struggling and i i'm looking for help or I need help, I need compassion. And you don't need to tell the patient that whatever medical condition they have, they may have two or 10 medical conditions, you have to tell them anytime that those are related to elevated weight, they know that they walk in knowing that almost everything that they that has happening to them is related to their elevated weight. And many of those things aren't actually related to their elevated weight, but they think everything is. So we don't ever need to state that to them. And that's where physicians make a mistake over and over again. Are you aware that your diabetes is related to elevated weight? We were really aware that your osteoarthritis and your bad knees, your weight is a major factor there? Yeah, yeah, they know that. So what they need is to hear your compassion and your empathy, to hear that you know what, there are treatments available for elevated weight. We spoke about them before, if you'd ever like to talk about them, I'm right here for you. I will listen to you. And I'll help you to get engaged with proper treatment.
Diane Kelsall: So if a patient has given permission to discuss this, this the next step, step two is assessment. David, perhaps you can tell us a little bit about what are the components of the assessment step?
David Lau: First, I think let me emphasize that obesity is a chronic relapsing disease caused by excess body fat that can impair health. And when we're talking about impairing health, we're talking about not just the physical health, but also mental health. So primary care clinicians should promote a holistic approach to health, with a focus on health behaviors in all the patients by addressing some of the root causes of weight gain, but with care to avoid stigmatizing and overly simplistic narratives. So what we would recommend to primary care practitioners is to measure the height, weight and waist circumference and calculate the body mass index. And of course, before we do this, we really have to, again, as Sean mentioned, we need to engage the five A framework in terms of asking for permission before we even measure the height and weight and the waist circumference and calculate a Body Body Mass Index. Now, even though body mass index has limitations it's by far still a fairly useful operational definition of obesity, and helps us to identify what are some of the health conditions that may be associated with excess body fat. And of course, we still have to focus mainly on a quality of life issues. So we recommend a comprehensive history to identify what are the root causes of weight gain as well as what are some of the medical complications associated with excess body fat. So we recommend in addition to the weight, height, calculating the waist circumference and calculating the BMI. We also recommend blood pressure measurement as well as where appropriate laboratory investigations to identify as an example whether or not the person is at risk for developing type two diabetes, other cardiometabolic risk, such as non alcoholic fatty liver disease, and I should put in the plug to recommend to primary care physicians not to measure TSH because it's an expensive test to identify hypothyroidism, and yet hypothyroidism only adds on a few pounds, and yet it's not a major cause of obesity. And we have to think of choosing wisely to avoid using TSH as part of the routine measurement, but rather, where appropriate, fasting glucose, a1c, lipid profile, and individuals in whom we expect non alcoholic fatty liver disease liver enzymes such as ALT. And of course, we'd like to find out to what extent the health is affected by these complications. And accordingly to do appropriate investigations along the lines of the various conditions that we may be suspecting the patient may suffer from.
Diane Kelsall: In step three, we get to core treatment options, which address the various factors leading to obesity, perhaps Sean, you can start us off, if we can start discussing a bit of what some of these treatment options are.
Sean Wharton: This is the bulk part of the of the five As. So we start off with the medical nutrition therapy. So instead of using the word diet, which is a loaded term, I'm going to put you on this diet, we are getting away from that and we're talking about healthy eating and nutrition. So medical nutrition therapy is clearly about nutrition that helps that assist with medical complications. So if you have heart disease, then the Mediterranean diet is a medical nutrition therapy (MNT), you if you have type two diabetes, then a lower carb eating behavior is actually better. And so once we start to discuss things like lower calories, like diets and lower calories, what we know is that the lower calories for weight loss will trigger neurochemical adaptations that drive us to gain the weight back, it drives a disappointment at times, of depression, because people feel that they are always failing. So we're really trying to get away from this discussion of diets and lower calories, whereas MNT for weight management is really going to be to focus on healthy eating, and to leave the ability to decrease the calories to the pillars, the medication, the surgery, David's going to be talking a lot about that, and the psychological intervention. So those things help us to pull the calories down while we are eating in a healthy fashion. Now for physical activity, we know that it's the best medicine for most medical problems, because activity is great. So it has a minimal effect on actual weight changes. But it has a great effect on every other health problem. So 30 to 60 minutes, a day of activity is a optimal amount. But any amount in a safe manner is a good step. So doing more than you did yesterday. If you do it safely, that's actually positive. So now we know how do we maintain our lower calories or MNT, any kind of nutritional health eating? How do we maintain the physical activity, the way that we maintain these two pillars there these these two cornerstones is to look at the three pillars. The three pillars are psychological intervention, medication, and surgery. I'll talk about the psychological intervention. And David will talk about the other two terms. Psychological treatment, it's not mental health intervention. Instead, it's understanding what motivates a person to continue to do behaviors that are not easy. Values, such as self esteem, understanding who cares about the the person about the patient? And who do they care about? Are they trying to stay healthy for their grandchildren for a child for a partner, how to handle stress, and how those how permissive thoughts about engaging in unhealthy behaviors happen with with stress. So understanding how to deal with these type of intervention, that psychological treatment, and that can be done by a counselor or a psychologist, even dieticians have learned cognitive behavioral therapy and can do that. So I believe that that psychological intervention CBT treatments and other types of treatments are critical, if we're going to maintain any degree of lower calories when we're eating healthy, or maintain our activity levels, which are challenging to actually do. And now I'll let David talk about some of the medication and surgery.
David Lau: Well, I think it's important to again, emphasize this, Sean mentioned that healthy behavior changes are the cornerstone management of excess body fat. That said, unfortunately, there's a limited success in terms of the degree of weight loss that we can achieve through healthy behavioral intervention. Meta analyses have shown time and time again, that the best form of diet and exercise program or healthy behavior changes would bring about at best about three to 5% body weight loss. And for some, of course, there are some super-responders. But by and large, we're talking about very modest weight loss. And that is not to dismiss the benefit of modest weight loss because for the majority of people, even 3% body weight, also one to 3% body weight loss, can lead to meaningful improvement in the health, decreasing the risk for developing diabetes and improving blood pressure and lipid profiles and so on. Now, that said, for those people who need a little bit more extra body weight loss, then we have to consider in addition to healthy behavior changes, pharmacotherapy and in selected individuals bariatric or sometimes referred to as metabolic surgery. So let me perhaps say a few more words about pharmacotherapy. Because for the longest time, pharmacotherapy was not considered as a useful health for people with weight loss, partly because of the tainted history of some of the weight loss medications that have serious medical complications. But we now have two newer medications to help people to lose weight, and has been approved in Canada for long term chronic weight management. The first one is liraglutide, which is a glucagon like peptide, one receptor agonist that has been approved for the management of diabetes. But we also know that GLP-1 receptor agonist also has a tremendous effect on appetite regulation. So when the dosage of liraglutide is increased, we now know that as actually a very successful way to help people to lose weight. And this has been developed as a new medication called Saxenda or liraglutide three milligrams. In addition, there's also the naltrexone bupropion combination pill available that also targets appetite regulation, as well as food craving. So the bottom line is, we now have two useful medications to help people to lose more weight if needed, in addition to the healthy behavioral changes, and it's important to focus on the fact that some individuals may need to lose more weight. For instance, in patients who have non alcoholic fatty liver disease, they need to lose more than five or even 10% body weight. And we now have data to suggest to us that for people with type two diabetes, if they want to achieve remission, they need to lose up to 15% body weight and minimum of 15 kilograms in order to see that benefit. So it highlights for us that we need more than three to 5% body weight loss in some individuals. So pharmacotherapy certainly helps to augment the success of healthy behavior intervention, but it also helps the individual to achieve better health and better quality of life. Now for some individuals who are super overweight, bariatric surgery certainly can be very helpful. And increasingly, we now know that bariatric surgery is particularly helpful in people who have type two diabetes, or newly diagnosed diabetes or diabetes with recent onset. Because bariatric surgery can certainly help people to lose weight. And even before the weight loss, they can see dramatic improvement in terms of the blood sugar control to the extent that they can achieve diabetes remission, so baratric surgery in some individuals can be seen as a means to induce diabetes remission. Now, that said, bariatric surgery is now available in literally all the provinces but unfortunately, the two territories still do not have bariatric surgery available partly because of lack of experienced bariatric surgeons. So, bariatric surgery should be performed by experienced bariatric surgeons, along with a team of health professionals to make sure that after the surgery the patients who have undergone bariatric surgery receive long term management to make sure they don't develop any complications such as nutritional deficiencies and so on. So let me sum up that pharmacotherapy is and should be considered as a very important option. And let me perhaps use an analogy that, that we often refer to, say, for instance, people with diabetes, if they have poor glycemic control, we start them on healthy behavior intervention. And very quickly, we then consider medical therapy. And if they achieve a desirable glycemic control based on, for instance, the hemoglobin A1c levels, we don't stop the medication, we continue the medication while emphasizing the importance of continuing the healthy behavior changes. So we should adopt a paradigm for the management of obesity because obesity is a chronic disease. So stopping medication is really a stopgap measure, we should consider pharmacotherapy as part of a long term chronic management. And similarly, bariatric surgery, which provides a much more sustained and long term option to help people to lose weight.
Diane Kelsall: David, you've mentioned the importance of follow up and steps four and five of the guideline are about agreeing on an action plan incorporating some or all or most of the factors that you and Sean have talked about, but also the importance of follow up. What's important for healthcare providers to keep in mind here?
David Lau: Well, I think the most important aspect is to remind ourselves that as healthcare professionals, we're very much like coaches, for professional athletes, we're there to help them to provide them with, you know, recommendations in a respectful, non judgmental manner. So I think it's important to emphasize that whatever guidance we provide to people living with overweight and obesity, it has to be worked out in a manner that is respectful, that helps the individual so that means a better understanding of what are some of the barriers that prevent the individual from adopting healthy behavior changes, or what are some of the circumstances that may prevent the person from engaging in pharmacotherapy and in selected individual bariatric surgeries. So I think it's important to understand that. But also, let me emphasize that we now know that people who have lost weight often regained weight not because they failed to follow the recommendation, but because of the hormonal and physiological adaptation to drive the body to regain the weight. So let's stop the blame game, let's reinforce the importance of healthy behavior intervention. And in those individuals in whom were unable to achieve the desirable goal, which is not just focused on weight, but focus on the complications associated with excess weight, I think we have to consider pharmacotherapy and bariatric surgery accordingly. But all along, we need to respect people living with overweight and obesity.
Diane Kelsall: You know, as we've been talking, it's really come out how important this is, you know, given that obesity is a chronic long term condition that a partnership really needs to be developed in the patient health care provider. And one of the keys to that is communication. Lisa, what are some tips for ensuring good ongoing communication, once an action plan has been agreed upon?
Lisa Schaffer: I'm a firm believer that with enough kindness and communication, I think we can heal a lot of the world. So I love all of the things that Dr. Lau just laid out as well. And I think that really is as simple as it is. Empathy and openness will be critical for success. We're talking about a cohort of people that have often been burned by asking for help in the past. So this needs to not feel like any of those other commercial diet moments or false promises, which can mean that as Dr. Lau was saying, you need to act a bit more like a coach. And that includes setting realistic expectations. We have a society that is bombarding us with messaging that you know, weight loss needs to be extreme or that body diversity is not a good thing. And those are just not true statements. The reality is that I am not 100% in control of what my body looks like. And what my body looks like is not a result of me being a failure on fronts, but that's new information. So that's going to be a repeated message. We also as Dr. Lau was saying, need to make sure that we leave room for life to happen. This is by no means going to be a linear path. I also don't enjoy the word journey. Because this isn't a journey, there is no end. This is a chronic complex disease and it needs to be treated like one, which is why the patient voice is so important. We deserve equitable care and treatment options. So it's important to have those honest conversations. Life is going to happen. If 2020 has taught us anything, you know, unpredictable stressors are going to happen. And we need to make sure that people understand that's okay. And if you've asked for help once, I'm still gonna help you if you ask again. And just because we tried a treatment option it might not have worked for you, doesn't mean you're not worthy of other treatment options and more conversations. So those are the really important things. And really, it boils down to just be human and have that conversation, help us understand that some is better than none. And that the scale isn't the be all end all measure of what we're working towards.
Diane Kelsall: Thanks so much, Lisa, for that. The guideline also includes recommendations for discussing obesity with Indigenous peoples, Sean, perhaps can you tell us how those recommendations were developed? What should clinicians know when meeting an Indigenous patient living with obesity?
Sean Wharton: Right, thanks a lot, Diane, this was a great chapter. So I'm very proud of this chapter. And I'm pleased with a lot of the messaging. It taught me a lot, actually. And it will teach a lot of people a lot about how similar the position as being an Indigenous person in Canada, and how challenging it is to live with, with elevated weight and obesity, and how those two things intersect. So, so if you're an Indigenous person, and you're living with overweight, or obesity, you have a double challenge within the healthcare system. So, so we know that Indigenous people have higher rates of obesity and other chronic diseases, such as type two diabetes, than any other groups within the Canadian system. So socioeconomic, social, cultural factors, are all really paramount. And what health care providers have to do to understand again, their biases and their stigma towards indigenous people, and similar to the way that they have to do it with elevated weight, and they should expect patient mistrust in the healthcare system. Because that's what's happened in the in the past hundreds of years, is there's there's been challenges and a mistrust. So your patients walking in with their own internal challenges, our own internal biases, and we have to reposition ourselves as not just the expert that's going to be paternalistic, and tell them what to do. But to moreso be a helper and as we're a helper will stop this during up of the resistance that normally happens, that can be a barrier to us getting any type of a conversation going. Again, the medical part is easy. The medicine is easy. The relationships, and compassion and empathy and getting rid of the bias Those are our real, real challenges. So it was this chapter was was put together by a number of Indigenous health care practitioners, and also people living in the Indigenous community to sit around and talk about what are the things that affect them when it comes to overall health care and chronic disease management and obesity being one of them? What things can we do as healthcare providers to actually help them and understanding things like it's hard pressed to sometimes get like, what does this factor have to do with the with elevated weight management, but we need to understand to build relationships that incorporate healing from the multi generational trauma from the residential schools and the child welfare systems, understanding the multi generational trauma and the welfare systems, residential schools helps us to do obesity management. Without it, we won't be able to do effective obesity management in the Indigenous groups. And that's why this was one of my most favorite chapters, and I thought it was very well written.
Diane Kelsall: Lisa, is there a part of the guideline that you feel particularly benefits through the involvement of yourself and others living with obesity? Which issues did your group feel strongly about when discussing what needed to be included in this in this guideline?
Lisa Schaffer: I feel like the guidelines overall absolutely benefited from the participation of patients. I think that's evident by the conversation that we've had here today. But I think what excites me even more about the patient voice and the involvement in the guidelines, is what comes next. Because we've created this amazing set of guidelines that are set to be released, we're going to ensure that it's a living document ongoing for healthcare practitioners. But more importantly, we're going to disseminate this information to patients themselves. And that's really what we're proud of is that we've created a document that we know can be translated and will make sense that we can help put in the hands of the millions of Canadians that are living with obesity who need help and deserve this help and are going to demand access to care. The guidelines provide a great constant for both audiences. You know, it gives us this common language between patients and healthcare practitioners. I know myself I've had great success in actually educating my GP and taking information and doing it in a way where she was very receptive to it. So we can join together and create a plan. But this really is just one piece of the puzzle, as we've discussed around obesity, we're kind of fighting a battle on many fronts. So it's important for us to, first and foremost, invest in the education and empowerment of patients for what this can really mean for them. You know, we need to invest in the healthcare practitioners as well to make sure that they are having the right conversations, but are also getting the right kind of tools that they need to be able to disseminate this information. Even translating to a patient that this is a disease can take more than one conversation. So that's really important. So at Obesity Canada, we're investing a lot in what comes next, we're going to be creating a suite of tools of infographics, white papers, we want to hear from clinicians, what do they need to be able to have these kinds of conversations and create these kinds of dynamics. We're also in the final beta testing of a really great online community that we're developing, that's going to be called OC Connect. And we're really building this with physicians in mind as well. We know that physicians and healthcare practitioners are overstretched that this is a really complicated topic. So we want to create a space online where patients can gather, share information, where Obesity Canada can disseminate evidence based information and empower people to have the right conversations with their healthcare providers, with their families, with their employees, with employers, as well as our policymakers and the government. We want this guideline to really be the root of systemic change. And that's why we're excited about what comes next. And making sure that this information that has been developed in this beautiful holistic way, becomes a reality for everyone.
Diane Kelsall: And that's really critical, because it's one thing to go through. And I know guidelines take an incredible amount of work and input and research and everything to get it to this point. But that's for nothing if it's not implemented. And I think it's great that Obesity Canada is supporting the guideline with all these measures. And that's going to be very critical for it to be used for improving the health of Canadians. So we've had a really good discussion today. I think I think I have a better understanding of the guideline and, and I hope our listeners will as well. So thank you all for joining me today.
Lisa Schaffer: Thank you. This was fantastic.
David Lau: Thank you. It's been great.
Sean Wharton: Thank you.
Diane Kelsall: I've been speaking with Lisa Schaffer, Dr. Sean Wharton and Dr. David Lau. To read the clinical practice guideline on obesity management, visit cmaj.ca. Also, don't forget to subscribe to CMAJ Podcasts on Soundcloud or a podcast app and let us know how we're doing by leaving a rating. I'm Dr. Diane Kelsall, consulting editor for CMAJ. Thank you for listening.