A new Canadian clinical practice guideline for treating adults with obesity emphasizes improving health rather than simply losing weight, among other things.
A summary of the guideline, which was developed by Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons, was published online August 4 in the Canadian Medical Association Journal.
This patient-centered update to the 2006 guidelines is “provocative,” starting with its definition of obesity, co–lead author Sean Wharton, MD, adjunct professor at McMaster University, Hamilton, Ontario, Canada, told Medscape Medical News.
The guideline was authored by more than 60 healthcare professionals and researchers who assessed more than 500,000 peer-reviewed articles and made 80 key recommendations.
These reflect substantial recent advances in the understanding of obesity. Individuals with obesity (from a patient committee of the Obesity Society) helped to shape the key messages.
“People who live with obesity have been shut out of receiving quality healthcare because of the biased, deeply flawed misconceptions about what drives obesity and how we can improve health,” Lisa Schaffer, chair of Obesity Canada’s Public Engagement Committee, said in a press release.
“Obesity is widely seen as the result of poor personal decisions, but research tells us it is far more complicated than that. Our hope with the [new] clinical practice guideline is that more healthcare professionals, health policy makers, benefits providers and people living with obesity will have a better understanding of it, so we can help more of those who need it.”
“Obesity management should be about compassion and empathy, and then everything falls into place,” Wharton told Medscape.
“Think of obesity like breast cancer,” he advised.
Address the Root Causes of Obesity
The guideline defines obesity as “a prevalent, complex, progressive and relapsing chronic disease, characterized by abnormal or excessive body fat (adiposity) that impairs health.”
Aimed at primary care providers, the document stresses that clinicians need to “move beyond simplistic approaches of ‘eat less, move more,’ and address the root drivers of obesity.”
As a first step, doctors should ask a patient for permission to discuss weight (eg, they can ask, “Would it be all right if we discussed your weight?”) — which demonstrates empathy and can help build patient-provider trust.
Clinicians can still measure body mass index as part of a routine physical examination, but they should also obtain a comprehensive patient history to identify the root causes of any weight gain (which could include genetics or psychological factors such as depression and anxiety), as well as any barriers to managing obesity.
“Eat Less, Move More” Is Too Simple: Employ Three Pillars
Advice to “eat less and move more is dangerously simplistic,” coauthor Arya M. Sharma, MD, from the University of Alberta, Edmonton, Canada, and scientific director of Obesity Canada, told Medscape Medical News, explaining that “the body fights to put back any lost weight.”
Patients with obesity need “medical nutrition therapy.” For patients at risk for heart disease, that may mean following a Mediterranean diet, Wharton said.
“Physical activity and medical nutrition therapy are absolutely necessary” to manage obesity, he clarified.
As a person loses weight, Wharton continued, their body “releases a cascade of neurochemicals and hormones that try to push the weight back up” to the original weight or even higher.
Therefore, to maintain weight loss, people need support from one or more of what he calls the “three pillars” of effective long-term weight loss — pharmacotherapy, bariatric surgery, and cognitive-behavioral therapy — which tempers this cascade of neurochemicals.
Cognitive-behavioral therapy could be given by various healthcare professionals, he noted. A behavioral strategy to stop snacking, for example, is to wait 5 minutes before eating a desired snack to make sure you still want it, he explained.
Similarly, Sharma noted, “The reason obesity is a chronic disease is that once you’ve gained the weight, your body is not going to want to lose it.
“That is what I tell all my patients: ‘Your body doesn’t care why you put on the weight, but it does care about keeping it there, and it’s going to fight you” when you try to maintain weight loss.
“Clinicians should feel very comfortable” treating obesity as a chronic disease, he added, because they are already treating chronic diseases such as heart, lung, and kidney disease.
Don’t Play the Blame Game: “Think of Obesity Like Breast Cancer”
Clinicians also need to avoid “shaming and blaming patients with obesity,” said Sharma.
He noted that many patients have internalized weight bias and blame their excess weight on their lack of willpower. They may not want to talk about weight-loss medications or bariatric surgery because they feel that’s “cheating,” he said.
By thinking of obesity in a similar way to cancer, doctors can help themselves respond to patients in a kinder way, says Wharton.
“What would we do with somebody who has breast cancer?
“We would have compassion. We would talk about surgery to get the lump out and medication to keep the cancer from coming back, and we would engage them in psychological treatment or counseling for some of the challenges they have to face,” he told Medscape.
“The right answer is to treat [obesity] like a disease — with surgery, medication, and psychological intervention,” depending on the individual patient.
The complete guideline is available on the Obesity Canada website.
The study was funded by Obesity Canada, the Canadian Association of Bariatric Physicians and Surgeons, and the Canadian Institutes of Health Research. Wharton has received honoraria and travel expenses and has participated in academic advisory boards for Novo Nordisk, Bausch Health, Eli Lilly, and Janssen. He is the medical director of a medical clinic specializing in weight management and diabetes. Sharma has received speaker’s bureau and consulting fees from Novo Nordisk, Bausch Pharmaceuticals, and AstraZeneca.
CMAJ. Published online August 12, 2020. Full text