Jordan: Canada has an obesity problem. You probably didn’t need me to tell you that. But you might need me to tell you this: The cause of, and solution to our struggles with obesity might be nothing like what you’re picturing when I say the words, obesity problem. Anyone who worries about their weight or struggles with medical conditions that impact it can tell you all about the bias that most people have towards obesity. But if I told you that most people definitely included a lot of doctors, if I told you that not only are fad diets not a solution to obesity, neither are normal ones, that our obesity problem is likely a matter of hormones and science, would that change your mind? Canada has a new set of guidelines for health professionals on treating obesity, and they are basically throwing the old recommendations out the window. So what replaces them? We’ll find out. I’m Jordan Heath Rawlings. This is The Big Story. Dr. Sean Wharton is an obesity medicine clinician and a researcher. He is one of the lead authors on those new guidelines that I mentioned. Hi, Dr. Wharton.
Dr. Sean: Hello. How are you?
Jordan: I’m doing well. Thanks. Can you maybe start by giving us a sense of the scale of the problem in Canada? How many of us are obese?
Dr. Sean: Right, so the number of people living with obesity in Canada is between the 25 to 30% range. So we’re talking about 8 million people in Canada living with the obesity. And if we look at the overweight problem, how many people have a BMI of over 25, so that’s the overweight zone and obesity is a BMI greater than 30, with overweight we’re talking about 26 million people in Canada. So it’s a really big challenge.
Jordan: And what has typically been the difficulty with treating obesity in the past? Why did we need new guidelines?
Dr. Sean: That’s a great question. So the reason why new guidelines are needed is because what we’ve been doing before wasn’t working. Everybody knows this. Everyone knows that dealing with obesity is a real challenge. Dealing with your weight’s a real challenge. You can, people can lose a little bit of weight, but they can’t seem to keep it off over the long run. They always regain the weight and likely go even higher than they were before. So that’s the reason why we needed new guidelines or new treatment options, cause nothing was working. So where we are now is that we have really figured out that we can’t use the same shovel to try to dig through this problem. What is our new approach? And the new approach is really getting rid of the word diet out of our lexicon. So stop dieting, stop focusing on the numbers, and start focusing on yourself. The person, the individual, what are the concerns? What are the issues? And what’s the pathophysiology, the science behind obesity and elevated weight? And if we can attack those neurochemicals, those hormones, those scientific, biological markers, we actually have a chance of doing that well in an area where we’ve had very poor treatment in the past.
Jordan: One of the things I’ve seen you discuss, and heard discussed by other medical professionals are biases, particularly when it comes to treating people who struggle with obesity. What kinds of biases are in play here and how do we work around them?
Dr. Sean: Excellent, and then I think that that’s the reason why we’ve done so poorly in the past is because we’re all so extremely biased. And so you’re biased. I’m biased. Everyone who’s listening to this podcast has a bias against people living with obesity. That’s a fact, even people living with obesity have a bias against themselves. So what does this even mean? What am I talking about? Really, what it is is that if you see somebody who’s 300 pounds, you instantly think, why are they going into that Tim Horton’s? Or why can’t they just get it together? Or they must not have enough willpower, not enough compliance. They’re not compliant with regimens, clearly, cause they’d be able to stay on the diet. That is a bias. Instead of possibly thinking, you know, that person’s 300 pounds, was 350 pounds previously, and they’re keeping 50 pounds off. Or they have extreme amounts of at willpower compared to somebody who’s 170 pounds, because they could go up to 350, 375 easily, yet they’ve been able to try to maintain some weight off, when in fact they have a disease state. So we really need to understand that this is a disease, and that we should not have the biases that we previously had or else we’ll go down the same road that we did before with the bias. What we think about for treatment is stick to the diet. Just work harder. Use more willpower. Get serious about this. That’s the paternalistic approach to dealing with treatment when you have the bias and can’t shake it. Now, when you understand that you have the bias, and you think what can I do? I’m going to use science and biology to treat this the same way I would do with breast cancer. I’m going to think about a surgical option, a medication option and a psychological intervention, because it’s a disease. So again, surgery, medication, psychological interventions, real disease treatment options for a real disease. Not soft things like use more willpower, get it together. And so that is the real change that we have here.
Jordan: I can understand where biases against obese people come in in the general population. Like it’s obvious that that exists. But were you seeing biases among clinicians and doctors working with people who struggle with obesity?
Dr. Sean: Absolutely. But the reason being is because when I stated that everyone listening to the podcast and us on the podcast are biased against people with obesity, it’s because we live in this world and it’s impossible for us really not to be. It’s a very visual type of circumstance where we see somebody living with obesity and we automatically have those thoughts in our head. Hard to get rid of it. And so we see people having those biases every day, the doctor has it, the nurse has it, the guidelines, the way they’re written also had them. And that’s what we need to get rid of, regardless of the fact that we have them when we see somebody, the guidelines should not have them. The guidelines should be devoid of that. So somebody can say, I know I have the bias. I can’t shake it completely, but what I can do, is I can pick up this document that doesn’t have biases and actually has an appropriate treatment approach that I can use so that I don’t have to act on my bias. And it’s the same thing like prejudice and racism. People can have prejudices and stereotypes. And as long as you don’t act on them, acting on them turns into racism. And this is the same thing here. Acting on your bias in terms of dealing and living and seeing people with obesity turns into stigmatizing, and is essentially a form of racism or a bias against people living with obesity, which is a real challenge.
Jordan: Before we get into the science and the research in these guidelines, where does that bias come from? And why is it so hard to shake?
Dr. Sean: Yeah, that’s a really good question, isn’t it? And I’m not sure we actually know. But I think that it continues to be one of the last things that we can make fun of in terms of, there’s a lot of comedy still about people with elevated weight. And we’ve been seeing that from many, many years, from a hundred years ago, where the comedy is there. So I think that maybe it’s something that society has grown up with for a long period of time. And now that it’s turned into a disease state more so, that these toxic fat cells can turn themselves into causing problems, such as people with COVID-19 are at higher risk of morbidity and disease illness, when those toxic fat cells cause an actual problem. So we now know that we’ve got to get rid of this comical and inappropriate viewpoint of people living with obesity, and treat it in a very scientific and biological way. Those who have impairment of how the due to the obesity need help, need assistance, need true treatment options. And those who don’t have impairment of health, should not be treated in a unfair manner, should not be looked upon in an unfair manner, but should be celebrated and treated like everybody else.
Jordan: Tell me about how these guidelines came about. What’s the driving science behind them? And where did that begin?
Dr. Sean: Yeah, so I think two things came about at the same time for us to be able to write the guidelines. Over the past 20 years, and that’s a short period of time within the medical field, we’ve learned a lot more about a number of hormones that are peripheral hormones, coming from the gut and coming from the pancreas and the liver, that then go up into the brain, and give us a signal as to whether we should eat more, whether we should have hunger, whether we should decrease eating. So we didn’t understand those signals previously, and we didn’t understand where those signals went, what part of the brain they were actually interacting in. So we now know what those hormones are, and we know which neurochemicals they generate within the brain and how the brain then gives us a message of either hunger, craving or decreased hunger and use your fat cells for energy, your storage. How do we get those messages to either eat more or to use storage energy? And that’s a very interesting interplay of understanding weight changes. And then at the same time, we actually got a lot of inference from patients. Patients actually drove this process to say that whatever you people are doing within the medical field, it’s not helping us. It’s causing harm when you tell us to diet all the time. So something is wrong and we’re here to let you know that. We don’t know what all the right answers are, but certainly we know you can do a better job. So I think those two things coming together, us listening to patients and understanding that there’s an absolute need here and we weren’t servicing it. And then the scientific field getting much better in terms of our understanding of the neurobiology and the neuroscience of weight change. Those two things came together to help us to write this guideline.
Jordan: And the coverage these guidelines have gotten so far, you know, the biggest headline seems to be around, no dieting, which is, you know, a pretty big recommendation in the weight loss world. Can you tell me a little bit about the science behind that and what happens when people attempt to lose weight by dieting?
Dr. Sean: Right. Excellent. And yeah, so this is what kind of drove us, the idea that diets have caused such a big problem over so many years. So the word diet is now, we’re going to consider it a bad word, because it’s so loaded. Now, just the word diet just means the type of food you are actually eating. So it’s not a negative word, but it’s been turned into a negative word, cause we really only think about it as decreasing calories and not doing much else, but using willpower and decreasing calories. So we know that whenever somebody decreases calories, what they do is they release a cascade of neurochemicals that say, I don’t like you decreasing calories. I don’t like this lower weight. I’m going to drive as many hormones as I can to get you to have hunger cravings, less of your activity, so be less motivated to move, so that I can get that weight back to its previous level, if not even higher, because why did you try to lose weight in the first place? So I’m going to give myself some extra pounds for some insurance. So we know what those hormones are now. They’re GLP-1, adiponectin, leptin, ghrelin. And some of them are good chemicals that get lowered when you start to eat less calories. And some of them are bad neurochemicals that get higher when you start to eat less calories. And all those hormones go into the brain and trigger neurochemical processes within the hypothalamus and the mesolimbic system, the two areas of our brain that drive extra eating. And there is no way for the majority of the world to actually prevent the weight regain. That’s why 99% of people who go on a diet, regain all the weight they have previously lost, and some extra weight. There’s only a very, very small percentage that are able to keep that weight off in an effective manner if they’re not using the appropriate interventions. So that’s why, just simply going on a diet is a bad idea.
Jordan: How wide is the gap between what we know about the science of what causes obesity and our ability to actually do something about it, whether that’s through hormones or surgery or other medical procedures to get a handle on it without blaming the person or forcing them to diet or any of these things that don’t seem to work?
Dr. Sean: So that is a good question. This is an evolving science. And when we look at the hormones that we’ve discovered, we discovered leptin, which is one of the most important hormones within this field. And we discovered that in 1994. So that is less than 30 years ago. And as you can imagine, that in the medical world is a relatively short, short period of time. So how do we– where does leptin go? How does it work? How do we– and leptin is a positive hormone– how do we make that hormone stronger? How do we make the resistance decrease, et cetera? We’re still working on all of these principles. So the fact is, is that what this did was, understanding leptin, it opened us to the fact that, wow, there’s a pathological process here, the same way I think about diabetes and it’s connected to insulin, I can now think about obesity being connected to leptin and CCK and GLP-1. This is great. We now have markers and tools that we can research and try to have a understanding of. Do we have all the right treatment, monikers as of yet? No, we don’t. So think of obesity, the same way you would think of diabetes back in the 1930s. So obesity in the 2000s is like diabetes in the 1930s. It’s like breast cancer in the 1970s, where we didn’t understand all of the different aspects. And now we have a much greater understanding. So we are going to be much better in the next 20 years. So what we know now, though, is that if we leave the aspect of lowering the calories to three main treatment options, we have a much better chance of getting the weight down and keeping it down. And those main treatment options are surgery, medication, and psychological intervention. So those three things are the quote unquote diet, because they are the things that help to keep the weight down over the longer term, because the only way to actually lose weight is having less calories than previous and keeping those less calories than previous. And the way to do that is medication, surgery, and psychological effects.
Jordan: When you say surgeries there, what surgeries are you talking about?
Dr. Sean: So for surgery, we have bariatric surgery. Bariatric surgery, the main two types of surgeries that we do here in Canada, one’s called the gastric sleeve and the other one is called the gastric bypass. And what happens is the rewiring of the gastrointestinal track through the surgeries, allow different hormones to be released. And these different hormones can then go up to the brain and give the brain a positive signal. So after you do the gastric bypass surgery, there is a release of a hormone called GLP-1. GLP-1 is a positive hormone and it tells the brain to stop eating. So in the face of eating lower calories, the GLP-1 tells their brain stop eating, you don’t need more calories, use the fat cells, which have the storage of energy, and that will work out well. And the other one, the gastric sleeve surgery, that takes off the top part of the stomach, which is called the fundus. The fundus of the stomach releases a hormone called ghrelin. Ghrelin is a bad hormone and it makes you hungry. So when you take that fundus off, the grelin goes down and therefore the person can have a brain signal that says I am not hungry any longer. And I can use, again, my extra storage of fat cells for my energy and not eat extra food and keep the weight going up and up. The weight can now go down and it can stay down. And so, what we really need to know here is that bariatric surgery does not decrease your weight because you have a smaller stomach and you’re forced to eat less food. It does it because it changes the neurochemicals within the brain to allow your brain to say, I don’t need as much food as I previously did.
Jordan: I’m glad that you explained that because I really do think that there’s something of a stigma around having, you know, what is quote unquote called weight loss surgery.
Dr. Sean: Yeah, I think you’re right. There is a stigma around it, but there’s no stigma around cutting out a breast lump that is cancerous, which is a surgery. So it all comes back to the bias. So there’s no bias against breast cancer as a disease. So you cut out the lump and you have the medication and things work out. Well, no one gets on you because of that. But when you, so when you know that this is a disease, obesity is a disease, you’d do this surgery, which changes the neurochemical processes. And you may also then need a medication as well to treat the disease. So, all of our stigmas come from the initial bias. And that’s why in our guidelines, the first chapter is understanding that bias. Cause you can’t get to the surgery chapter if you don’t recognize and understand the actual bias.
Jordan: My last question then is, you know, if I’m someone that struggles with obesity and I’ve listened to this conversation and these guidelines and they feel different to me, how can I start that positive conversation with a doctor, I guess, or even, you know, my GP who, I may have felt in the past was subjected to the same biases we just talked about.
Dr. Sean: Right, and so we wrote these guidelines for the primary care physician and the primary care team to be able to know that there are appropriate treatment options to understand their own biases and to be able to use science and biology, to not act on their bias. So that’s why we wrote it for it as the primary target. And then the secondary target we wrote it for was for the patient. So, the patients were involved from the very start, and we also made sure that it was written in a really nice patient friendly way so that they can grab this document and then bring it over to their doctor and say, it says here in this document, that there’s good treatment options for me. And I’d really be interested in looking at these treatment options. And this isn’t a document that I found on Google and just a soft document. This is a scientifically based guideline process by a bunch of academics in Canada who are telling us that there’s really good treatment options. Can you look at this? Can we have a discussion about it? Can we move forward with one of the three pillars, or maybe more of the three pillars? It says here surgery is helpful, it says medications are very helpful for me, it says psychological interventions are going to help me. And then I should not focus on the diet, focus on eating healthy, medical nutrition therapy, healthy eating, and then activity whenever I can, but that one of these three pillars will help me to get things down in an inappropriate fashion. Can you, doctor, help me with this process? So that’s what we want to see happening.
Jordan: Well, Dr. Wharton, thank you for walking us through that today. And I hope some people take a look at these guidelines and take them to their doctor.
Dr. Sean: Absolutely. Thank you very much.
Jordan: Dr. Sean Wharton, obesity medicine clinician and researcher. That was The Big Story. For more, you can head to thebigstorypodcast.ca. You can find us on Twitter at @thebigstoryFPN. You can look us up and your favourite podcast player. We’re an Apple and Google and Stitcher and Spotify and every single other one of them. And please do write to us, the email address is firstname.lastname@example.org. Thanks for listening. I’m Jordan Heath Rawlings. We’ll talk tomorrow.
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