I won’t apologize for my clickbait title. In a world where we are flooded with information, one needs to get creative with grabbing people’s attention. I also do have a problem with where Obesity medicine practice is headed and no one seems to be talking about it.
Proper treatment of Obesity has been a long time coming with the Canadian Medical Association (CMA) finally declaring it a chronic disease in 2015. That was 7 years ago. Isn’t that effing wild? Prior to that it was believed to be a condition of the lazy and undisciplined. Yes, there are still countless numbers of individuals and clinicians alike that still believe that is the case but we have made significant progress nonetheless. As more agents to treat Obesity such as Contrave, Saxenda, and Wegovy start coming to market to treat Obesity we are seeing clinicians becoming more comfortable with managing this disease.
Now when I first started practicing in Obesity medicine at the end of 2017 here in Canada we barely had access to any medications for weight management. There was Orlistat which I have yet to prescribe and I don’t think I ever will as I don’t want to be sued for causing a patient to experience anal leakage. Yes, you read that right. We also had Saxenda but barely any insurance companies provided coverage for it and many still don’t provide coverage for it as they are still not recognizing Obesity as a chronic disease. So when I started we really did not have much to work with.
A Clinician’s Focus
Our focus was on lifestyle interventions. In particular, digging down into the mental and emotional aspects of things; something that we all know is important but no one wants to touch because of feelings and stuff. Obesity Canada and Novo Nordisk both had collaborated and developed some fantastic materials, training modules and certifications that clinicians such as myself could utilize to start working with people in this regard! I thought it was fantastic and in my practice, many of my patients were having tremendous success. The best part was I was able to transfer these ideas and skills over to managing diabetes and other chronic diseases. I was working with people to dig down to the root of their problems and behaviours then supporting them to engage in different behaviours and habits to live a healthier lifestyle!
The Medication Cycle
The problem I am seeing now is that as new agents come to market obesity management is going in a similar direction as diabetes management. There is limited focus on actual behaviours and lifestyle interventions to the stacking of one medication after another. Now before you start thinking I’ve gone the way of Greenpeace, hippies, and naturopaths let me explain.
Medications and the technology behind them have made incredible progress over the last century. They have saved countless lives and allowed us as a species to live longer than ever before. People genuinely need medications to manage and treat their ailments. So I am pro-medication, pro-vaccine, pro-western medicine, etc. However, what occurs in diabetes management is an individual goes to their clinician and receives a diagnosis of Type 2 Diabetes.
They are provided with a script for metformin told to lose some weight and to do more blood work in 3 months. In 3 months they haven’t lost any weight, they have been taking metformin on and off as they aren’t really sure why they are taking it since they feel fine and their friend Joe says it will kill them. They do their blood work again and sh*t blood sugars are still high. They are given a prescription for an additional agent to take with the metformin and told to smarten up and get more activity in then come back after 3 months.
This cycle continues over the next few years or decades. Sometimes blood sugars look good then they deteriorate and another agent is added. All the while no lifestyle changes or modifications have been made. They perhaps are trying to be more active or reduce their carbs but nothing sustainable has been implemented as they simply don’t know where to start and they are tired of taking medications every single day.
After 4-5 medications have been added on, the clinician has the unfortunate conversation that insulin needs to be initiated. We are at the end of the line. Everything else has failed. “By the way, you are going to go chat with Dan, he is going to go over insulin and provide some education around dietary patterns and activity.” By this time it is essentially too late. Some patients can make some drastic changes and actually come off of a number of their medications but most are so fed up with so many medications and not knowing what the f*ck to do they rebel and come off medications and/or stop following up. We actually have a name for this: it is called Diabetes Distress and has been well documented to lead to worse health outcomes.
I am now in a challenging position of trying to help my patient understand how to inject themselves once or multiple times a day and what is a carbohydrate vs. a protein. They should have been seeing me a decade ago for this conversation. Once they were diagnosed it should have triggered an auto referral to me. Unfortunately, that was not the case.
The Obesity Management Cycle
We are now seeing something similar happen in obesity management. Instead of patients receiving proper education and support, they are being given medication and told to follow up. A year later, after they initially lost 40 lbs, they are now starting to gain the weight back and another agent is added on. Again the cycle continues. Now at this point, most individuals are only put on 1 or 2 agents and then referred for bariatric surgery if they qualify. In the bariatric program, they might receive more intensive education but they also might not.
Then, they have the surgery; they lose weight and end up gaining a large majority of the weight back. Now yes, both diabetes and obesity are chronic and progressive diseases. We expect them to worsen over time as that is the nature of the conditions. However, with more intensive education and behavioural changes, individuals can keep their blood sugars and weight stable for longer periods of time. Which is ultimately going to lead to better long-term health outcomes! That is the goal. Preventative over reactive medicine.
So, who’s fault is it?
By no means am I blaming the clinicians. It is not their fault. It is a broken system. A system that has been designed to be reactive vs. proactive. A system that is amazing at managing your heart attack but is terrible at preventing it from happening in the first place. So when clinicians only have 5-15 mins to spend with a patient they are going to focus on the best bang for their buck. I can tell you that prescribing a medication is a hell of a lot easier than spending 60 mins discovering why someone uses food as a coping mechanism. We know the intensive counselling and support measures work and work really well. They can also be implemented into primary care practices as highlighted by the Look AHEAD and the DPP landmark trials.
So, we have the data, we have the knowledge, and we have the agents that can provide additional support in managing an individual’s weight. Why the hell aren’t we doing a better job?
There is no single reason why. It is a systemic issue that I believe is slowly starting to shift but politicians are involved so it is going to shift at a glacial pace. Politicians also need to start doing their job for the people and not to win their next election. You see a focus on reactive medicine produces more immediate results such as reducing wait times, etc. Preventative medicine takes time to show its benefits. Much longer than a traditional election cycle. Really, the shift is going to come from the providers on the frontlines. The ones who find the loopholes, develop the clinics and programs, and build a practice that goes against the traditional models. Not an easy feat and a scary one to boot, considering most clinicians don’t have the entrepreneurial spirit. However, as the old adage goes, if you build it, they will come.
Until next time,