Q&A with Dr. Sean Wharton: Obesity through the Eyes of an Expert

As a leading expert in the field of obesity and a Canadian Obesity Network (CON) member, Dr. Sean Wharton MD, FRCPC, PharmD has significantly contributed to the field of obesity in terms of research, treatment, education and patient advocacy over the course of his amazing career.

I had the pleasure of interviewing Dr. Wharton to learn about his career focusing on obesity and his thoughts on the various aspects surrounding this chronic disease. He also discusses what we can do as healthcare professionals to better help our patients living with obesity.

The excerpts below are a summary of my interview with him. I hope this interview provides some food for thought on how we currently manage obesity and what changes can be done to improve management for our patients.

Why did you choose to focus on obesity when there are so many other conditions to manage?

As a general internist, I chose to practice obesity medicine as it had a niche for internists that was unfilled by other subspecialties and there was very little focus on it. I felt that a lot of different chronic diseases being managed including diabetes and hypertension were frequently a result of a person's weight, so if you can manage obesity you can manage a lot of the other health conditions that are associated with it. It’s [obesity] a very interesting, new and exciting field to actually tackle.

What is the most frustrating aspect when dealing with patients or other healthcare professionals?

The most frustrating [aspect] in both patients and healthcare providers is a lack of understanding of the biology of weight change as well as the belief that it is [obesity] primarily a lifestyle issue and not a biological medical condition. I encounter this misunderstanding often and I think clinicians and patients want to believe that obesity is a lifestyle issue and they dismiss the fact that it’s a medical condition despite presented with evidence because it doesn't fit with their thought process.

Most of my patients have little understanding of the biological processes and feel that willpower and/or lifestyle changes are all that is needed to be able to keep weight off over the long term.

Are these biases that you mentioned affecting healthcare professionals’ ability to help patients?

Absolutely, these biases affect the clinicians ability to help patients to lose weight because they lack the true understanding of the biology of obesity. It [these biases] ends up impacting their relationship with patients, their ability to be sensitive to a patient's challenges and ability to offer other aspects of healthcare to their patients in a timely fashion.

Comments like “If you just lose some weight then we can do your pap-smear better because how can I do it if you don't lose weight” results in patients feeling embarrassed and unwilling to return. People who struggle with obesity do not visit their doctor as often [as those without] because of the embarrassment and stigma leading to significant decrease level of care which increases their risk of developing further problems. When they [healthcare professionals] tell patients “You can lose weight with just diet and exercise”, the patient becomes discouraged because they know that they can't and they feel that they’re disappointing their physicians, so they don't come back and see them.

How does commercial diets that guarantee weight loss impact practicing evidence based obesity management?

The short term willpower capacity [that these diets promote] is what ends up confusing people because they really believe that short term weight loss equals the ability to continue [losing weight] in the long term if they just keep on fighting. The analogy I like to paint is playing the slot machines in Vegas; you play it over and over again – winning once in a while, which tends to keep you going and thinking that maybe you’ll win big but in the end everybody loses money at the slot machine eventually. Of course there’s a small percentage of people that have won big and they’re held up as examples of what everyone else can achieve. It’s unfortunate because people want to believe in success and they want to believe in the dream but it’s misleading.    

What is the biggest achievement and setback that has occurred in obesity management?

I think the biggest achievement is the introduction of GLP-1 analogues [for obesity treatment] because for the first time the neurological and biological aspects [of obesity] were highlighted by a medication backed by a big pharmaceutical company. This facilitated the education of obesity to a large number of people whereas prior to that, the medications on the market didn't really highlight how much obesity is a biological and neurological process.

The biggest setback I think has been the commercialization of weight loss shows which continue to perpetuate that this [obesity] can be managed through lifestyle modification alone. People only see the initial weight loss success but not the regaining of weight after due to the biology [of obesity].

In your opinion, what are some of the most useful resources for obesity management for both healthcare professionals and patients?

In terms of physician and researcher resources, I found that the Canadian Obesity Network (CON) has been very good. For patient resources I have not found very many that are actually helpful but there are multiple websites that do not provide useful information about the biological aspect of obesity and do nothing to help a patient.

The few [patient resources] that are helpful include Dr. Yoni Freedhoff’s blog and Dr. Sue Pederson’s blog as well as Dr. Freedhoff’s book “The Diet Fix” which is pretty good but it’s a little wordy and not as patient friendly.

When should a general practitioner refer their patients to an obesity specialist?

I think any time a patient expresses that they are feeling lost, having difficulty managing weight and expressing the need to see somebody with greater knowledge. It shouldn’t be based on the patient’s health or weight. Although a patient might not fit the BMI criteria for referral to a weight management clinic, the degree of stress that is associated with weight gain and the need for greater understanding of their bodies is an important consideration. Of course if they have other health conditions associated with elevated weight (e.g. fatty liver, osteoarthritis, diabetes, hypertension and dyslipidemia) they should definitely find their way to an obesity specialist.

What is it the single best thing, as healthcare professionals we can do to reduce the stigma patients experience?

I think the best thing we can do is explain the biology [of obesity] to patients. I believe that not only the physician community but the patient community needs to be aware of it too. This goes a long way in accepting obesity as a medical condition and therefore provides the ability to actually treat it. By explaining to patients the biological process that dictates the weight gained once weight has been lost, it helps them understand their struggle and reduce the self-blame which can significantly affect their goals. With the appropriate goals, patients have a greater ability to be happy and self-efficacious.

Post Reflection

After speaking with Dr. Wharton, I could feel the immense passion he has for the field of obesity and it is exciting to see how the future of obesity management and treatment will change as more research is being conducted in different areas from pharmacotherapy, surgery to psychology.

For more information on topics discussed in the interview, here are some links:

• Canadian Obesity Network Resources for Healthcare Professionals
• Dr. Yoni Freedhoff’s blog
• Dr. Sue Pederson’s blog
• Madsbad, S. (2014), The role of glucagon-like peptide-1 impairment in obesity and potential therapeutic implications. Diabetes Obes Metab, 16: 9–21. doi:10.1111/dom.12119

Cheers, 

Aveline 

Q&A with Dawn Hatanaka: Exploring the Canadian Obesity Network

Although it is Canada's largest obesity association, made up of healthcare professionals, researchers, policy makers and people with an interest in obesity, I had not heard of the Canadian Obesity Network (CON) prior to my rotation at mdBriefCase.

In the excerpts below, I’ve summarized my interview with Dawn Hatanaka, the Director of Education for CON, who is responsible for the organization’s educational initiatives. Dawn explains the association’s origins, goals, achievements as well as what we can expect from the future of CON. I’m hoping that after sharing this excerpt, more healthcare professionals will be aware of CON as both an organization and its offerings.

What is the Canadian Obesity Network and why was it created? 
The Canadian Obesity Network - Réseau canadien en obésité, or CON-RCO, is our official acronym and I like to think we’re Canada’s authority on evidence-based approaches for obesity prevention, treatment and policy. CON-RCO was started in 2006 to create a coordinated response to obesity care; from prevention, treatment to policy across the board. 

When we launched, everything was siloed and piecemealed across the country, so the thought was the network would join obesity research and funding along with prevention and treatment strategies. As of January 2018, the network has about 15,000 professional members and we just opened to the public in 2015 with around 2,000 public supporters.   

You mentioned CON started targeting a scientific community but later opened to the public for membership. Why the change? 

Our mission has always been to improve the lives of Canadians affected by obesity but to do so, we needed to reach out to them. At a 2015 CON workshop – which brought together people living with obesity, healthcare professionals, researchers, policy makers and collaborators - everyone agreed that Canadians living with obesity needed a credible source of resources about their health and how to advocate for themselves. So in June of 2015, the Public Engagement Committee was established, where all members are people living with obesity in Canada and managing their obesity in different ways. They’re our spokespeople across the country for the public and have actively participated in activities to help raise the voice of Canadians affected with obesity, through social media, media interviews, speaker bureaus, education activities and practice and policy committees around the country. 

What would you say are CON’s current goals right now? 
Our official goals are addressing social stigma associated with obesity, changing the way policy makers and health professionals approach obesity and improving access to evidence-based prevention and treatment resources. While we continue with what one could say are lofty goals, the things we do to reach them change yearly. We continue to deliver education programs for healthcare professionals, we’ve partnered with government agencies and others working in population health policies because there has been a lot of unintentional consequences of population health messaging which deter people from seeking out treatment due to that stigma. We’re also supporting obesity research, through collaboration with the Canadian Institute of Health Research (CIHR) and leveraging 1.5 billion dollars in funding for obesity research. 

Many of the myths and messages in the public are very patient centric. What are the major initiatives CON has spearheaded recently to combat these myths? 
Last year we started a “Bust The Bias” campaign over social media only. These short videos [on CON’s YouTube channel] talk about all these myths and why they’re wrong. We placed them in the public eye and shared them with our partner associations to increase people’s exposure to the content. For example, the bariatric clinic in Ottawa have all of them rolling on their TVs in the waiting room all the time. 

What would you say is the biggest challenge the network faces as an organization? 

Getting obesity recognized as a chronic disease across the board is our biggest challenge so far. Despite CON-RCO, Canadian Medical Association, American Medical Association and the WHO declaring obesity to be a chronic disease, the provinces and territories don’t recognize it as a chronic disease nor do they treat it that way. They still categorize obesity as a result of poor lifestyle choices.

Obesity is not on their radar and I think it’s one of the things that CON-RCO needs to do; mobilize that advocacy side and the public to ask because you’re never going to get something if you don’t ask. 

What would you say are the key milestones CON has made since its inception? 
There are a couple of key things. The number of Canadian physicians taking the American Board of Obesity Management (ABOM) exam almost doubled between 2016 and 2017. We also launched the Certified Bariatric Educator program in 2016, which started out with very small numbers but continues to grow with interest in Canada as well as internationally.

I also think with the CMA declaring obesity as a chronic medical disease in October 2015 was a big thing. We had champions within the CMA that had been pushing this agenda forward for years. Of course, the report card that was released last year was huge because you can finally put some numbers and grades to show people [the issues surrounding access to obesity treatments]. 

Where would you like to see CON in the next 5-10 years and what steps must be taken to get there? 

Provincial and territorial governments need to recognize the position that CMA and CON have taken - that obesity is a chronic disease and they need to put resources towards it and change their approach accordingly. I’d also like to see employers & health insurers do the same – that would be amazing.

That’s where I think we should go - getting obesity recognized as a chronic disease across the board, which will have a trickle-down effect to increase access to care. We still have a lot more work in the weight bias and stigma space to get people to recognize weight bias and stigma as barriers preventing people from accessing treatment for their chronic disease.

I’ll also mention that we’ve just started writing new Canadian clinical practice guidelines for the management and treatment of obesity in adults which should be released in early 2019. This one is going to be quite different, as the target audience is family physicians and it will be patient-centered. We also have people living with obesity as part of the committee. One of the things the patient group is suggesting is that we have a patient tool kit included so they can talk to their physician and help promote the uptake as well. 

Post Reflection 
After speaking to Dawn, I realized how much CON has to offer to healthcare professionals and to patients as well. It’s also free for healthcare professionals to join and access the various resources available from the Network regarding obesity management. For more information on topics discussed in the interview, please see below for some links:

• Canadian Obesity Network 
• 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children 
• Report Card On Access To Obesity Treatment For Adults In Canada 2017
• Advanced Obesity Management Program 
• Certified Bariatric Educator Exam on Advancing Practice 
• Diffusing Obesity Myths by X. Ramos Salas, M. Forhan, A.M. Sharm

Cheers,
Aveline

5 Misconceptions Every Pharmacy Student Probably Has About Obesity

Obesity is in some ways like trying to fix a pipe leak – we think we know how to do it, yet 5 minutes into an overflowing washroom, we’re calling the plumber.  

That is exactly how I felt when I was completing the Advanced Obesity Management Program (AOMP) on Advancing Practice, I thought I understood obesity but in fact I had a lot to learn. As a 4^th year pharmacy student on the cusp of becoming a licensed pharmacist, I was shocked at how little I knew about obesity as a disease and its management. Even though the prevalence of obesity is widespread, there is still a large knowledge gap among many healthcare professionals; especially pharmacists in my opinion.

Here are the 5 greatest misconceptions I feel pharmacy students have on obesity, which I have also experienced:

Misconception #1: Obesity is solely caused by excessive eating and/or lack of physical activity

From the AOMP, I have learned that obesity is much more complex than just “energy in” versus “energy out”. Important contributors such as genetic pre-disposition, insufficient sleep, psychological stress, hormonal imbalance and medications, have compelling supporting evidence in the development of obesity.¹

Misconception #2: Obesity is a risk factor for disease, it is not a chronic disease itself

Obesity is in fact both a risk factor and chronic disease itself, similarly to hypertension. Although pharmacists are well aware that obesity can increase the risk of other diseases (e.g. type 2 diabetes, obstructive sleep apnea, hypertension etc.), it is also important to acknowledge obesity as a chronic disease. This would allow us to change how we manage obesity as well as help reduce the stigma surrounding it.²

Misconception #3: Patients’ willpower and self-control determines their ability to lose weight and keep it off

A patient may be successful in losing weight but the maintenance of weight loss is hard. Despite putting in more effort into a weight loss program, it does not always result in additional weight loss. When I learned that our bodies had an inherent compensatory to maintain our “highest weight”, I had a deeper appreciation for the fight patients had to go through.¹ This explains the difficulty of maintaining and further achieving weight loss.

Misconception #4: Body Mass Index (BMI) can be used to define obesity 

For a very long time, I believed BMI was a number that determined if a patient had obesity or not. However, the Canadian Medical Association recommends using clinical measures of health rather than diagnosing obesity with BMI values as it measures body size.^2-3 Although BMI can be a useful tool to glean insight into a patient’s health status, it should not be the sole measure of obesity.

Misconception #5: Pharmacists do not have a role in obesity management 

I have been guilty of providing the oversimplified “Eat less, move more” response to patients seeking weight loss advice in the pharmacy and often, would redirect patients to dieticians or family physicians. However, as frontline healthcare workers, we are in the perfect position to initiate conversations about obesity, arrange follow-up monitoring, and provide patient support and encouragement. Most pertinent to our practice is preventing weight gain caused by certain medications dispensed regularly by providing weight management strategies beforehand.

It is definitely a difficult feat to manage obesity, especially when the individuals that patients turn to for help already have misconceptions about the disease and/or patient. Hopefully, as healthcare professionals, we can further educate ourselves on obesity and try to move away from our own biases to help make a significant impact on this disease. To learn more about obesity, click below to discover Advancing Practice’s continuing education program and become certified as a Bariatric Educator:

• Advanced Obesity Management Program (CAD$ 495)
• Canadian Obesity Network: Certified Bariatric Educator Final Exam (CAD$ 295)

If you are itching to delve into the obesity conversation, look out for my 3-part interview series where various experts weigh in on the subject of obesity, no pun intended!

Cheerio,

Aveline

References:

1.  Chaput, J.-P., Ferraro, Z. M., Prud’homme, D., & Sharma, A. M. (2014). Widespread misconceptions about obesity. Canadian Family Physician, 60(11), 973–975.
2.  An Obesity Manifesto: Debunking the Myths - Medscape - Feb 23, 2017. Retrieved from https://www.medscape.com/viewarticle/875964#vp_1
3. Rich P. CMA recognizes obesity as a disease. Oct 9, 2015. Retrieved from www.cma.ca/En/Pages/cmarecognizes-obesity-as-a-disease.aspx2015.