In a dramatic shift, new Canadian clinical guidelines for obesity — the first in almost 15 years — advocate for doctors to focus on a patient’s overall health and lived experience rather than solely on their weight.
As well, Body Mass Index (BMI) is no longer recommended as the primary tool to identify obesity, the view of “eat less and move more” for weight loss is out and the term “diet” is replaced with “medical nutrition therapy.”
The goal of the guidelines, which took more than two years to develop, is to have doctors, health agencies and patients see obesity not as a lifestyle problem but as a chronic disease that requires ongoing medical treatment.
“The big change since 2006 is we are no longer emphasizing counting calories and focusing on just having a diet,” said Dr. Sean Wharton, an internist and lead author of the guidelines, the summary of which is published Tuesday in the Canadian Medical Association Journal (CMAJ).
“Weight management is not about using willpower and just trying to find the best diet. Weight management is a chronic medical condition … and as a medical disease we need to use a medical treatment model.”
The guidelines come as obesity and weight management receive renewed attention during the global COVID-19 pandemic. Studies have shown obesity is a risk factor for serious illness or death from the coronavirus, particularly for younger patients.
Recently, the U.K. government launched its national Better Health Campaign, in part to encourage people to lose weight in a bid to lower the number of patients suffering serious illness from coronavirus and to take pressure off the country’s National Health System.
“One of the complications for COVID is elevated weight … and we need to understand that,” said Wharton, medical director of the Wharton Medical Clinic, a weight management clinic in Burlington. “I would like to see more recognition in Canada that we need to continue to focus on treating chronic diseases during (the pandemic) because the chronic diseases end up leading to more morbidity from the acute infectious disease.”
With more than 60 co-authors, including physicians, researchers, family doctors and mental health experts, the guidelines were developed in conjunction with the Canadian Association of Bariatric Physicians and Surgeons and Obesity Canada, a non-profit research and advocacy group. Those with competing interests, including Wharton as the medical director of a weight loss clinic and member of drug company advisory councils, listed them in the guidelines.
People living with obesity were also involved in creating the guidelines so they would accurately reflect a patient’s lived experience, said Lisa Schaffer, a digital marketing executive from Vancouver and chair of Obesity Canada’s Public Engagement Committee.
“We now have a common language to talk to physicians to get ourselves on the right path,” said Schaffer, adding that obesity has for too long been seen as a lifestyle choice instead of a chronic medical condition.
“We knew we needed to move the measures of success away from the scale to (things like): Can you live your life? Can you play with your kids? Can you go to the park with your grand kids? That’s what we should be measuring success by, not what you see on the scale.”
Though it will be difficult to shift away from the idea of a perfect weight and the pervasiveness of diet culture, Schaffer said the new guidelines, and the accompanying online patient portal, are a strong start. She said the recommendation for physicians to ask a patient’s permission to talk about their weight is particularly welcome.
“If I go see a physician about an ear ache but they want to talk about my weight, it can feel like I’m on the receiving end of more bias instead of care,” Schaffer said. “It can make me feel that I’m not worthy for the care I came for until I lose weight.”
Dr. Tara Kiran, a family physician and researcher at St. Michael’s Hospital, said it’s clear the new guidelines are patient-centred and that those with lived experience were involved in their creation, a focus that wasn’t apparent in the 2006 version.
Kiran, who was not involved in the guidelines, said providing advice on how to combat weight bias and stigma — also a change from 2006 — will help primary care providers in their care of people with obesity.
Get the latest in your inbox
Never miss the latest news from the Star, including up-to-date coronavirus coverage, with our email newsletters
“It’s really important for us as physicians to keep in the forefront of our minds when we are supporting people with obesity, that they are facing stigma and that we, ourselves, may have biased notions about them,” said Kiran, who is also vice chair of quality and innovation in the Department of Family and Community Medicine at the University of Toronto.
“In order to be able to have a respective, productive dialogue that helps them achieve their goals, we do need to start by asking permission about whether this is the right thing to talk about at the right time for them.”
One of the most striking changes in the 2020 guidelines is the recommendation to not use BMI — a calculation using a person’s height and weight — as the only tool to advise a patient on weight management.
The authors recommend assessing a patient’s disease severity using the Edmonton Obesity Staging System (EOSS), a five-stage method to classify obesity based on physical and psychological measures and any metabolic weight-related health problems, such as high blood pressure or obstructive sleep apnea. The patient’s own health goals should also be included when developing a weight management plan, the authors say, with the target of a positive health outcome, rather than a number on a scale.
“It’s a good reminder of the goal of health and well-being overall, and not being so focused on that one metric,” said Kiran, who would like to see health agencies and organizations help physicians easily integrate the EOSS into their practice.
And while the guidelines do address the many complexities associated with obesity, Kiran said it is critical to note the societal and structural barriers, such as poverty, and access to nutritious foods, that are both obesity risk factors and the things that hinder people’s ability to manage their weight.
Dr. Denise Campbell-Scherer, a family physician and professor of family medicine at the University of Alberta, said primary care providers will likely need training and help building new skills to integrate the new guidelines into their practice. This can start, she said, in medical schools and residency programs.
“Across the world, weight management is not well-taught to new physicians,” said Campbell-Scherer, who was a member of the executive team overseeing the guidelines. “Every single medical student knows how to assess depression … they are trained in it and know how to practise it. Thirty years ago they didn’t know how to do that.
“That’s the same place where we are with obesity now. We need to build this learning into the training programs and build awareness that this (weight management) is important.”
Wharton said the new Canadian guidelines may be among the first in the world to emphasize “medical nutrition therapy” rather than “diet” — a word that comes with potential negative connotations — to help patients lower their calorie intake. The new phrase provides clarity that obesity is a medical condition and requires an “eating regime in line with a medical condition,” he said, noting a patient with diabetes may want to use a “low carbohydrate eating pattern,” while a patient with heart disease may rely on a “Mediterranean dietary pattern.”
The guidelines, which provide specific advice for those of different ethnic backgrounds, do mention physical activity and eating patterns to lower calories. They also point to three primary methods for sustained weight loss and management — to be used on their own or together, depending on the patient — and include medications, psychological help and weight-loss surgeries.
The authors say patients and physicians must advocate for more and equitable access to obesity and weight management therapies. For example, Wharton said, weight-loss surgery is hard to access in some provinces and some private insurance companies do not cover obesity medications.
“There is clear evidence of efficacy for these treatments … they make a significant different in a patient’s life.”