I listened to is to you don't have to but should anyway - Obesity: The Science, Impacts and Strategies webcast

In this episode of I listened to it so you don’t have to but should anyway, obesity.
I have been learning about this chronic disease recently, which is a timely learn as we in the benefits industry are navigating new entrants in the obesity pharma space. Recently I listed in on a CPBI session and a very interesting listen from the Maintenance Phase podcast. If you’re not listening to Aubrey Gordon, I highly recommend. There are my notes.
 
Part 1 –  From CPBI. Obesity: The Science, Impacts and Strategies webcast
Obesity is a prevalent, complex, progressive and relapsing chronic disease characterized by abnormal or excessive body fat, that impairs health.
Obesity is classified by the BMI – body mass index
Because BMI does not measure body fat directly, it should not be used as a diagnostic tool. It doesn’t take into consideration different body structure. Instead, BMI should be used as a measure to track weight status in populations and as a screening tool to identify potential weight problems in individuals. 
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Of note from the CDC, BMI does not distinguish between excess fat, muscle or bone mass. Nor does it provide any indication of the distribution of fat among individuals. Weight loss can lead to overall health improvements, but weight is not the only indicator of health.

• Rate of obesity has tripled in the last 30 years.
• 26.8% of adults are obese and 36.3 are overweight.

 
Is obesity only the result of not moving enough and waiting too much? NOPE! Genetics, psychological, social economical, environmental, mediations, and social impacts are all contributing factors. It’s a complex interplay of all of these components. In reality when we’re talking about sustained weight loss (assuming that is the goal) we are talking about chronic treatment.
Obesity is associated with multiple complications. It’s likely those living with obesity are also suffering with other conditions like sleep apnea, depression, anxiety, type 2 diabetes, cardiovascular disease and more.

The brain plays a large roll in controlling appetite. Reducing your weight and maintaining the loss is complex as your body will try to adjust to new norms.  From a relevant article: “Experts often talk about this idea as a metabolic "set point" that can be hard to adjust. Our genes, environment, and hormones all play a role in body size, and complex physiological factors that are still poorly understood can make it tough for many people to sustain weight loss “
 
I found this super interesting! There are a few kinds of eating –

• homeostatic eating – eating for hunger. Think about a baby. Eats when hungry. Stops when full.
• hedonic eating – eating for pleasure (where most of us live as we eat socially and enjoy taste).
• executive function – deciding to eat (this Is how we decide how much to eat)

 
There are new guidelines for treating obesity. It’s 700 pages long. I do believe this is the study that they break down in the Maintenance Phase podcast which I strongly recommend you listen so. It’s a great critical thinking piece! But here’s what the diagnosis of obesity looks like according to this document that has been widely adopted around the world:

1. Ask permission
2. Assess readiness for change (note the individual may want the outcome, but aren’t ready to put in the work)
3. Measure height, weight, bmi and waist circumference
4. Establish comprehensive history to identify root cause of weight gain. This is where I struggle with the do. I mean… what family doctor is going to do this in your 7 minute visit? In reality this is a multi visit session in conjunction with a psychologist.
5. Measure BP, fasting glucose/A1C, lipid profile, and ALT screen
6. EOSS… I didn’t take great notes on what EOSS is so I googled it. According to Obesity Canada, EOSS is the Edmonton Obesity Staging System. EOSS is a measure of the mental, metabolic, and physical impact that obesity has had on the patients’ health and uses these factors to determinative stage of obesity from 0-4. In population studies, EOSS has been shown to be a better predictor of all-cause mortality when compared to BMI or waist circumference alone. I also found that it can used for predicting risks and benefits of surgical and non surgical weight management.

 
Health care professionals are encouraged to :

• Prioritize involving the patient in the division making process
• Focus on a holistic approach to health
• Use appropriate measurements that are focused on health behaviours in all patients
• Address the root cause of obesity.

 
Ultimately the what the root cause of obesity is going to dictate what intervention should be used moving forward.

Challenges I see with this:

1. the barrier to entry is extreme in Canada due to the extreme lack of access to a family doctor and primacy care. This can’t be replaced with virtual care. Multiple doctors are needed for this process including a psychologist who are in high demand and have a long referral wait list and are expensive.
2. Documented Doctor bias against women, people of colour, not to mention fat bias
3. Several visits to a doctor may be required. You’re only allowed one issue per visit and the Average visit is 7 minutes. How on earth is a family physician supposed to do all of these tests, dig into an adults socioeconomical background and psychological issues. They are not even qualified to do so.
4. Trust – again bais. People’s past experiences with physicians could make this procees difficult for some.
5. Doctor not up to date on this 700 page report and when an individual seeks help will be told to diet and exercise. Or the doctor will skip the steps, say here’s a medication to help you lose weight, don’t worry about the side effects or lack of long term study using this drug for life.
6. Cost.

 
A note on weight bias, 40% of adults reported bias and stigma from family, colleagues,
This can increase morbidity and mortality. There is a segment that speaks to medical nutrition. Not to be confused with diet. Diet indicates short term, but medical nutrition is a life long journey. It is meant to set up a person with something that is applicable to their core values and preferences. Plus medical nutrition is culturally sensitive and promotes healthy relationships with foods, ultimately tailoring it to the patients needs.

There is also a chapter on physical activity in the report. Its important for multiple health reasons. But once someone has obesity established, we know that exercise has little impact on weight loss. Physical activity can help with other things like pain management. It’s not about weight loss. Plus, it can be used a possible preventative measure. It should not be used as the only outcomes though.
Putting it all together there is a comprehensive approach in these guidelines. So after addressing the root cause of obesity, lifestyle recommendations are introduced. They can achieve 3-5% of weight loss. But the actual pillars that are the real interventions are behaviours intervention where the patient is meeting with a therapist or engaging with a counselling. There are also pharmacotherapies – there are 4 approved meds in Canada.

Lastly there is surgical intervention which can achieve 30% weight loss.
These interventions are not independent of each other. They can be used in conjunction. It depends on the patients needs and the root cause of obesity.
 
How does a doctor determine if pharmacotherapies are right for a patent?

Healthcare providers are advised to bring up pharmacotherapies when lifestyle interventions along with tackling the root cause have been ineffective, insufficient or unsustainable.
Now here in lies the problem…. First, how often is the root cause actually being addressed and second, people don’t change their habits. This is a huge book industry on habits for a reason…
Instead it’s easy to prescribe a new drug for life. It is for life becuse once a person stops taking the drug, they are likely to regain the weight. Because obesity is a chronic disease there is evidence that weight rebounding does happen and it most common in the GLP-1 drug categoey (eg Ozempic)
4 approved drug therapies for the treatment of obesity

• The first which I did not catch the name results in a 3% weight loss
• The second which I did not catch the name results in a 6% weight loss
• Third is Injective Rimonabant which results in an 8% loss at one year. This is a GLP-1
• Fourth are the Semiglutides which result in a 15% at 1 year. Also in the GLP-1 category.

 
These should always be taken with lifestyle recommendations.
Pharmacotherapy can help target many of the comorbidities that are often present with obesity where weight loss is helpful such as cardiovascular disease and depression. There are not long-term studies yet. There is some data on people taking the drugs for 1-2 years. But not much past that.
End.