Obesity: Where we've come from and where we're headed

There’s still a gap in medical education when it comes to obesity.

Vanessa Hrvatin 6 minute read November 25, 2020
World Obesity

Our understanding of obesity has changed over the last few decades. PHOTO SUPPLIED BY THE WORLD OBESITY FEDERATION World Obesity Federation

It was 2002 when Dr. Arya Sharma moved to Hamilton to start a research program on obesity. At the time, there was very little in the way of obesity medicine in Canada—most physicians were simply telling larger patients to eat less and exercise more. Others ignored the issue altogether.

One of the biggest shifts over the last 15 years is that a lot more people have realized that obesity is a chronic disease,” says Sharma, who founded Obesity Canada in 2006. “The reality is it’s a medical problem and we have to manage it just like we would manage every other medical problem.”

But the path towards this realization hasn’t been clear cut and the field of obesity medicine has undergone many changes—not to mention challenges and opposition—over the last couple of decades.  

Understanding the science behind the disease

One of the most significant advances over the last 20 years according to Sharma is a greater understanding of just how complex the biology behind obesity is. Research now shows countless reasons why someone might gain weight, many of which are rooted in genetics. It’s also become clear that the body will actually defend itself against weight loss, which makes weight frustratingly difficult to lose but easy to gain.

As the science behind obesity started to crystalize, the Canadian Medical Association declared obesity a chronic disease in 2015, which Sharma and others in the field saw as a major milestone.

“Labelling obesity as a chronic disease helps people understand that the cause of obesity is not singular in nature, it’s not just people being lazy and eating too much, there are so many other complex factors involved,” says Dr. Sasha High, Medical Director of the High Metabolic Clinic. “I find this actually empowers my patients because it takes the blame and shame away and by removing that we can focus on how we to move forward with confidence.”

Treatment and education

Today, bariatric surgery is seen as one of the few treatment options for people living with obesity. But back in the early 2000s, Sharma says there were very few centres in Canada that performed this surgery, forcing many patients to travel to the United States instead.

Lack of bariatric surgery options was probably tied to the fact that Canadian physicians weren’t receiving much education on obesity at all. The first Canadian obesity guidelines were released in 2006 but later research showed that not many physicians were actually referring to them in their practice. There was also no formal obesity training being offered in medical schools or other health professions.

There has been a forward-marching movement over the last decade when it comes to bariatric surgery. In 2009, Ontario alone committed $75 million dollars to increase bariatric surgery capacity six-fold. Today, bariatric surgery is more widely available (although long wait lists can be prohibitive) and there are dozens of multidisciplinary bariatric clinics nationwide.

But there’s still a gap in medical education. High, who graduated from medical school in 2012, says she received essentially no training on how to address obesity.

“We don’t learn obesity medicine and we don’t learn anything about what changes behaviour,” says High. “I honestly feel like 90 per cent of what I do I learned on my own through experience and research after I completed medical training.”

High is certified through the American Board of Obesity Medicine, along with nearly 150 other Canadians (this in stark contrast to the one Canadian physician who held this certification in 2006). The truth is, says High, there just is no Canadian equivalency, so anyone wanting to make obesity a focus of their practice has limited options.

Other professions aren’t immune to a lack of obesity training. According to registered dietitian Jennifer Brown, historically, the emphasis from food and nutrition experts has been on dieting.

“When I started out 13 years ago, most of our training was based around obesity being a crisis and the messaging was very much around calorie restriction,” she says. “Unfortunately, I think this, coupled with public health messaging, really created a focus on healthy eating and exercise as the way to lose weight and we know now it isn’t that simple.”

Fighting stigma

Perhaps one of the biggest shifts — with maybe the longest road ahead — has been confronting the stigma that engulfs obesity.

In August, Canada published a new version of obesity guidelines with an entire chapter focused on reducing weight bias. The definition of obesity also changed, now defined as abnormal or excessive body fat that impairs health. The intention, says Sharma, is to move away from recognizing obesity as a disease that relates to weight and instead seeing it as a disease that impacts health.

“It doesn’t matter how much body fat you have; obesity is about whether or not that body fat is impairing your health, which has a lot to do with the type of body fat and where it’s located on your body,” says Sharma. “If it isn’t [impairing your health] then you don’t have obesity, regardless of your body size. This means a person living in a thin body could be living with obesity if their existing body fat is impacting their health.”

The guidelines encourage doctors not to use the infamous body mass index (BMI) measurement, which has long been criticized for being a poor indicator of health. Brown also stresses that weight loss shouldn’t be the goal when addressing obesity; instead, the focus should be on improving quality of life and health conditions.

While the field tries to steer towards uncoupling health from weight loss, there are polarizing opinions on how this can be achieved. Several health movements have sprung up over the last decade fighting for size acceptance, such as the health at every size approach. Many who practice under this model challenge the term obesity and its classification as a chronic disease.

“If we were to truly uncouple weight from health, then there would be no need for the obesity guidelines to even exist,” says registered dietitian Jillian Walsh. “We can treat everything the obesity guidelines talk about in terms of other health conditions like type 2 diabetes and gallbladder disease without ever speaking about weight.”

Walsh points to the fact that many diseases associated with obesity are not exclusive to weight—after all, a thin person can also have type 2 diabetes.

And while research suggests that clinicians themselves are less likely to stigmatize a condition if it’s considered a disease, some argue that labelling a person as living with obesity can do more harm than good.

“We know that there have been anti-stigma campaigns that have adopted a medicalized approach and they haven’t always produced the outcomes that were intended, which we can see when we look historically at things like mental health and addiction,” says Dr. Andrea Bombak, a researcher at the University of New Brunswick. “What it might end up doing instead is reconstituting stigma; in other words, it’s a different kind of stigma but that stigma still exists by labelling someone as different. It might not be beneficial from a social justice standpoint (to label obesity as a chronic disease) when people would argue that weight is a natural part of human diversity.”

Despite opposing views, most seem to agree that everyone—from physicians to sociologists to registered dietitians to people living with obesity—needs to be involved in conversations around obesity in order to move the field forward.

“The amount of change I’ve seen in the last 10 years makes me so hopeful for the next decade,” says Brown.

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