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Tuesday, November 4, 2014

On a serious note.

I believe obesity is a disease. I have spent more than a decade studying this disease in the literature and at the bedside.

In fact as I write this piece I am in Boston attending the Obesity Week 2014- national conference of The Obesity Society

What I have learned in my 20 years in medicine is that nothing is absolute.

The human body is a complex system that operates based on shifting parameters and adaptations more than a set of golden rules.

The old explanation of obesity rested in the principle of physics of “Calories in, Calories out.” Years of study have since shown that obesity is less about the laws of physics and more about the laws of chemistry and biology.

Matching energy stores with energy needs is an essential part of life.

If there is indeed a flaw in this, when the system gets broken for whatever reason, obesity is the result. This is not a linear process.

Diseases are the result of genetic predisposition, physiological mechanisms and environmental triggers and promoters.

Obesity is no exception to this. Some people are more genetically predisposed, others more environmentally influenced.

Like all diseases- there is no single cause for all people.

The key to understanding this disease like many others is to understand that obesity is not one disease.

I would argue that obesity is likely a spectrum of diseases. Like any spectrum of disease there is a spectrum of causes and a spectrum of treatment.

Think about cancer for a moment. To pool all cancers into one group and see them as all caused by one entity is not only simplistic but dangerous.

How would we function as a medical community if everyone with cancer got the same treatment for all cancers regardless of cause and organ affected?

What if I treated my patients with lung cancer, colon cancer and breast cancer all with the exact same chemotherapy?

Certainly I’d get some responders, (especially if the chemotherapy I chose was targeted to their specific cancer).

But inevitably if I took this “blanket approach” to a diverse disease I would only effectively treat a specific group of people.

As a medical community we need to strive to understand the biology of obesity as a disease.

This is not the just the complex environmental and socio-cultural global epidemic that is obesity- but the complex biology of the patient sitting in front of me who indeed has a disease that is multifactorial and born in genetics, and body chemistry.

The push here is that just because we don’t have the answer does not mean we should tell patients that treatment is not possible.

I agree that we need to advance the science further.

When we study one disease- indeed it may enlighten us as to the nature of another.

I must believe that are on the cusp of a significant discovery that will indeed dramatically change the epidemic of obesity at a population level.

But I’m not a population scientist. I am an individual physician that treats one patient at a time.

I know what many of my colleagues say:
“Obesity can not be cured- permanent weight loss is impossible.”

Indeed I attended a review course yesterday at this very meeting where a colleague from the Mayo clinic (no less) insisted that if a patient is not losing weight on calorie restriction:
“They are lying, don’t waste your time making them think they are special”.

When I stopped swearing (under my breath of course), I realized that medicine is indeed a reflection of the society at large. The world has yet to achieve true empathy for the Obese population and so medicine merely reflects this.

But I sit here in a lobby hotel in Boston an Obesity Doctor and an Obesity survivor with this thought….

In medicine, when we can not FIX the problem, we feel powerless. When we are powerless we lash out.

Are not people more than just a FIX?
Is there not something in the process?

Can we not as a profession and a culture learn from this current crisis of future and faith?

Patients are more than just numbers. When we focus purely on pounds lost we lose the intricacies of prevention benefit.

We practice “what’s the point” medicine. Many of my colleagues have fallen prey to this.

Patients gain the weight back — what’s the point? Patients are not going to change their lifestyle — what’s the point? The disease is too big — what’s the point?

The five-year survival of patients with Stage 4 heart failure is about five per cent. Shall we close down cardiology units now?

The issue here is that we are currently in a public health crisis and the current therapies are not meeting the needs of patients.

When you tell a patient that permanent weight loss is impossible, based on population studies, you encourage them to stop trying.

The bigger message here is that our treatment needs to be advanced and improved upon.

We need to improve patient education and remove internal bias to enlighten people on the physiology of their disease.

Doctors and scientists need to advance our own understanding and that of our patients into the complex process at work in their own bodies.

We need to rally our government for better treatments, better food sources and better quality of care when it comes to this disease.

We as a population must change the way we look at the biology and culture of obesity and work towards a solution.

When I tell patients to keep trying to eat better and exercise more, I am doing it because they indeed are more than a number on a scale. Small weight changes prevent disease and my patients deserve this benefit.

The current problem we face in obesity medicine today is not that our therapies don’t work. Our therapies work for the right patient. Instead we blanket the therapy for all obese patients. The landscape of this disease is not so simple.

Like any complex disease we need to tailor our therapy for the individual. I would argue that we have not done that. We’ve blanketed our approach to lifestyle modification on a population level.

Moreover, we’ve asked patients to diet in a world where dieting is nearly impossible.

We’ve insisted that they adhere to certain dietary constraints in a world, which is conspiring against them at every turn.

In short we ask them to exercise the dietary equivalent of swimming upstream at all times.

Obesity is the greatest public health crisis this country has ever seen. Yes, the current dieting paradigm is not working for most people. But instead of telling patients to walk away let’s encourage them to find the right treatment.

Let’s establish a better understanding for who responds best to certain dietary changes.

Let’s study the five per cent responders and learn what it is that makes them succeed. Let’s see if we can indeed push the conversation forward. Let’s insist upon better treatments for all.

Studies do show that the greatest weight loss success was in populations who had the greatest adherence.

Studies also show that patients with the most realistic expectations stay with behavioural chance longest and have the most significant and long-term success.

How do we make it easier for patients to adhere to lifestyle change?

How do we give people realistic expectations that help them improve their health?

As a doctor that sits in front of 20 obese men and women every day I think we need to empower patients to fight the good fight.

I think we need to accelerate our efforts into understanding the science behind the heterogeneity of this disease. I think we need to insist on a better level of care for our patients.

Permanent weight loss is brutal. It requires an understanding on an individual level that you are indeed fighting physiology.

It requires and unrelenting and constant attention to lifestyle change. And it doesn’t work for a majority of patients under the current treatments available.

The field of obesity treatment is evolving daily to try and meet the needs of a growing epidemic.

My colleagues and I are on the front lines of this. We explain to our patients the complexity of their disease and the treatment options available.

I am honest with the data and the science that exists and I am forthcoming with the patient sitting in front of me.

I’m not about to start practicing “what’s the point medicine.” My patients deserve honesty yes, but hopelessness? Never.



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