Thank you for joining me for this talk called Introduction to the Care for Patients Living with Obesity. I'm Dr. Sean Wharton. I'm an internal medicine physician and assistant professor at the University of Toronto here in Canada.
Here are my conflicts of interests.
And here we have a graph that goes through the years taking a look at the rate of BMI changes. So, BMI greater than 30 has been growing as a global presence. So, we can see the rate rapidly increasing over a 30-year timeframe. So, we're now in a position where we really need to know what to do about this growing rate of obesity because it comes along with complications.
Here we see some definitions because obesity has been recognized as a disease by many countries. The obesity society in 2019 looks at it as a multi-causal chronic disease. And over the long term, which leads to structural abnormalities, physiological derangements, and functional impairment, Obesity Canada defined it as a chronic progressive relapsing disease characterized by the presence of abnormal or excessive adiposity that impairs health and social wellbeing. So, we're getting to that graph on the side that shows that the visceral fat tissue can lead to an abnormal health. And the World Obesity Federation also looks at it in a similar manner. Again, chronic, relapsing, progressive, emphasizing the need for an immediate action. So here we're in a position where prevention and treatment of this condition is actually needed.
What causes this elevated weight? Well, it's complicated, very complicated as you can see. It's factors such as psychological factors, biological factors, lifestyle and behavioural factors, the environment. So, all of these things come together to make it difficult for a patient to keep their weight over the long term and also to be able to lose weight and stop the actual regain of the weight. So, understanding maybe some of these principles may put us in a position to be able to help people living with obesity.
So, what are some of the complications we end up seeing? Well, the complications start from head all the way down to toe. So, we can see up in the brain there are things like depressions and stroke that can happen. We have lung manifestations and then we have the cardio-renal complications of obesity. So, we tend to talk about those often. We have liver failure and we have down in the knees and in the joints you can develop osteoarthritis. But I'd like to draw your attention over to the side where we see even the acute conditions such as infections. So COVID was at a much higher rate in people living with obesity and a much higher complication rate and cancers are becoming one of the major things.
So, what can we do? Well, we know that a multidisciplinary approach to weight management can lead to more weight loss than just an individual trying to do it by themselves. So, we've got the obesity medicine specialist combined with other specialists such as a cardiologist or a respirologist. The interdisciplinary need, the dietitian or the nutritionist helping out, the psychologist, the pharmacist. And so, evidence shows that with this team we get greater amount of weight loss.
So, let's look at a holistic approach to the assessment of somebody living with obesity.
Here we look at what are some of the assessments we have for people living with obesity. So, we know that individuals have differences within their body that make it necessary for us to look at not just one measurement. We can look at BMI and waist circumference. We can look at the age decline in a patient because that has to do with their muscle mass. And overall are we looking at when a person is in a bigger body? Are they in a bigger body because they have a certain amount of fat mass? And where is that fat mass? Is it in the central area? Is it in the peripheral deposits? So, all of these things matter. Also, if you look on the right-hand side, what also matters is how did that patient end up getting there? What was their weight trajectory? What was their journey? And what are their individualized goals? What type of values and goals are we looking for a patient? And that may be factored in based on the person's actual journey.
So, let's look at the classic and most used definitions for obesity and that's BMI. BMI has its challenges, but from an overall population standpoint, it's used most often. Here are some of the categories. We have an overweight category, class 1, class 2, and class 3, as we go up in the BMI status, the classes end up being higher. So, what do we need? Why do we need BMI cut-offs? Because these correlate with a person's health and they also correlate with helping us to understand what type of treatment options we would be most beneficial for an individual patient.
So, we know that BMI has its limitations. It's not relevant for a lot of the world on an individual level. So, BMI of 30 may be a completely different health factor for a person living in America versus one living in a Polynesian island versus a person living in Scandinavia. So therefore, let's not just always use this simple tool, but we can still end up starting there.
So, what other parameters can we use? So, waist circumference is one that is somewhat easy to do, not as easy as the BMI. And waist circumference gives us a lot of information. So, that measurement around the abdomen tells us about visceral fat. And so, waist circumference of greater than 35 inches in women will increase the health risk and greater than 40 in men will increase your health risk.
And also, many countries are using a parameter called the waist to height ratio. Again, this is another parameter that increases risk greater than 0.5 in both men and women will give us a greater risk factor.
Here we have some other measurements of screening and of staging. So, and this gets away a little bit from just looking at the BMI. But we can initially do the BMI first. I think that's a great thing. But then if we go to the staging system that's been recommended by the American Endocrinology Society, we see here that they combine BMI with the presence and severity of an obesity-associated complication. So, we're getting into those complications. Someone's done a blood sugar, a blood pressure on a patient and individualizing it. And also, if we look at the Edmonton Obesity Staging System, what they've done here is they've taken away the BMI category totally and looked at the individual from a metabolic, a psychological and a physical impact. If obesity is impacting those specific areas and what degree it is gives you a certain staging system that severity is higher, that may tell us that our treatment options may need to be intensified.
So, let's look at some of the treatment approaches for chronic weight management.
So, for a long time, we did not do well in terms of weight management. Many, we would do interventions where there are mainly lifestyle modification, a diet, patients would lose weight for a period of time and then regain it. Why did this happen for so many years? Because we had a lack of understanding of the biological principles behind weight regulation. The essence of weight regulation is that the brain is in charge of our overall weight. It's the executive lobe, the hypothalamus and the mesolimbic system are, look at specific hormones that come from the body, the GI tract, the adipose tissue, pancreas, and stomach. They all go to the brain to tell the brain, eat more, or eat less. So, the idea here is now that we know this, and this has only been new, we've only recognized this within the past 30 years. Now that we know this information, we have no option but to use it and use it properly. And that's why we've been able to have a greater impact on treating obesity.
So, using this science, the Canadian Obesity, Obesity Canada completed a guideline that looked at three pillars of obesity management. Now these three pillars support nutrition and activity. And so, nutrition being that you need to have lower calories to lose weight. There's no way to lose weight without lower calories. There's no way to maintain weight loss without keeping those calories lower. So that is primary. And then having the activity allows a person to have better muscle mass. So what three things support lower calories and movement? So, the psychological intervention engages the executive lobe. It tells a person that they're loved that they're cared for and gives them some of the reasons as to why they need to continue to do the behavioural interventions. The pharmacological treatment again works in the brain. The neurochemicals from the majority of pharmacological interventions that have been developed recently go to the brain, allowing a person to keep on that healthy diet. And bariatric surgery does the exact same thing. Good evidence that this metabolic surgery, allowing the person's brain to be in a better position to get the weight down and to keep it down over the longer, longer timeframe.
So, and again, let's talk specifically about what these three pillars are supporting. Again, healthy eating, having a meal plan may be of help. And that's where the interdisciplinary team comes. Again, no weight loss without lower calories and no maintained weight loss without keeping it down. A good dietary, healthy intervention is necessary. The physical activity is also needed. There are recommendations here. The important thing is for patients not to be shamed and blamed. And here are the behaviouralists that can make an actual difference from a clinical psychologist or psychiatrist or a health educator reminding patients about the fact that they shouldn't be shamed and blamed, that they are loved, that they're cared for, that their interventions that work for them and how to use those interventions.
So, this is a guidance tool in terms of pharmacotherapy. So, the patient and the clinician have decided that 'I think that pharmacotherapy would help me to sustain these healthy behaviours'. So now what is the next step? The next step is to let the patient know about every pharmacological intervention that's available to them in their country. Write them down if needed, their doses, their cost aspects. So, the patient has an informed choice. Then we look at what they have access to. If they have access to no medications on the list then advocating for access is needed. If there's limited access versus there's access to all the medications, we can now consider the goals of therapy that that patient has and line it up with the pharmacological intervention. If it's type 2 diabetes care, we would look at a medication that brought the A1C down more than the other ones do and seeing if they could potentially look at that medication as an option. So, once you've started the medication, you assess it after a three-to-six-month timeframe, you look at the treatment goals, have they been met? If they have been met, continue on the medication. If they haven't been, then you have options here. You can actually switch to another medication, or you can add in one of the other medications. So, of course that is if there's no contraindication to adding in two of these meds. So, this is somewhat similar to the diabetes protocols. So how many patients are just on metformin? Well, we have these additive aspects to it. So, we feel that in the future, there'll likely be the components of more than one medication for a patient who has not reached their necessary goals. And the reassessment needs to happen on a regular basis, going back to the beginning, understanding the therapy goals, and deciding whether we're on the right treatment.
We'll now move on to the third pillar, which is bariatric surgery. And so, we know that this surgery, which is also called metabolic surgery, does good things. So, patients who fit the criteria can go on to have this surgery and they will experience significant weight loss and be able to keep that weight loss off over the long term. With the advent of more pharmacological agents, we're now seeing that some people are combining the surgery with the pharmacological interventions because there are some patients that will end up regaining weight. So, at times we see that there is this combined, the combination. So, when we look at those three pillars, the psychological, the pharmacotherapy and the bariatric surgery, they're meant to be intertwined. It's not one or the other. It can be in fact all three, but certainly we see a significant impact from this intervention of bariatric surgery.
Now let's look at the patient navigating their way through the weight management journey.
So here we know that weight stigma is probably one of the biggest barriers to a patient having an effective weight management treatment option. So, what exactly is weight stigma? Well, let's first talk about bias. So, weight bias is like prejudice. It's negative. Why do we all have a bias against people living with obesity? Because we've seen stigmatizing images and pictures and stigmatizing language about people living with obesity. And that informs our bias. And what you can do is you cannot discriminate. You cannot act on it. And that's of course the most important thing. So, ensure that your environment is at least, has the least amount of stigmatizing aspects to it and that you yourself in your conversation with your patient, you're not using stigmatizing words or language and not using discriminatory practices. Now that's easy for me to say, don't discriminate, but it's hard to actually do. We've been discriminating against people living with obesity for a long time and we have to actually change our practice. First, you have to believe that you were actually engaging in discriminatory practices and then being able to actually change those. I know that I'm biased. I am influenced by stigmatizing images and pictures and thought processes. And much of my practice previously was discriminatory and was negative towards patients living with obesity. Every day I work to have a less and less discriminatory practice and more and more compassionate and positive environment and practice setting for my patients.
And finally, I'll end with the five A's. The five A's is a treatment journey here for the patient and starts with the Ask. The Ask is asking the patient permission to discuss weight and explore their readiness for change. And why would anyone do this? Why would patients be sitting in front of you for treatment? You're going to ask them, can I treat you? It seems a little odd. Well, it's not when it comes to the fact that we've been discriminating against them for a long time. So, we're now in a position where if we ask them, we're showing that we have compassion and we understand that if they don't want treatment or what type of treatment they want, that it is a conversation. So that's what the Ask is for. The Ask is to solidify the fact that you are a clinician who understands their bias, understands the stigma, and understands that you're not going to discriminate, but instead you're going to show your compassion. Next is the Assessment. We talked a lot about that. Is it BMI? Is it your blood pressure? Is it your blood sugar? Or is it, in fact, all of those things to assess the individual patient? Advising, we've made a decision on what type of treatment options. We know that these treatment options have to support lower calories, healthy calories, and physical activity. And then the Agreement is what type of goals or values does a patient have? They may have a value such as, I want to be a healthy grandparent to my grandchildren.
Therefore, I want to focus on my health and my movement and being able to be with my grandchildren. That's their value. And you're there to help them to get to that value. The Assist is then working with the patient on a regular basis to make sure that as they age, as they move through different stages in their life, things change. You may have to assess them again. Do another blood pressure. Do another blood sugar because things have changed. Advise them differently and agree on different values, different goals, but continuing to be with them and help them all the way through their weight management journey.
So, in conclusion, we know that obesity is a chronic, complex disease. There are many contributing factors. We talked about all those. And there's multi-system complications that end up coming from it. There's still a lot of science to be worked out here. Still a lot of research. We are new in the field of understanding obesity and understanding treatment. But we do know that having a patient-centric approach, an interdisciplinary approach to weight management can yield better results than the individual trying to do it on their own. Healthy eating, and physical activity are paramount, and they're supported by psychological intervention, the caring, the compassion, pharmacotherapy, and bariatric surgery. And finally, pharmacotherapy and bariatric surgery, we know are being shown to be very beneficial within the treatment of the appropriate patient who is living with obesity. Thank you very much for your time.