When it’s seen as a chronic condition, it can be managed in the long term

By: Bill Zolis

Obesity, or excess weight, has for a very long time been seen as a just fact of life for some people, or as a result of lifestyle choices, or perhaps as the result of a roll of the genetic dice.

Not so much anymore.

Now, increasingly, it is seen as “a complex, chronic disease in which abnormal or excess body fat… impairs health, increases the risk of long-term medical complications and reduces lifespan” – according to the latest update in the clinical practice guideline on obesity.

Of course, there has always been a serious, medical side to the treatment of obesity, and all of the related effects on health – diabetes, high blood pressure, and heart disease, to name just a few. But, as the updated clinical guideline from Obesity Canada and the Canadian Association of Bariatric Physicians and Surgeons demonstrates, both our views on obesity and our range of options are starting to change.

There are five key points covered by the guideline, which I can summarize as follows:

  1. Obesity is a “prevalent, complex, progressive and relapsing chronic disease…”. I read this quickly the first time and then realized how easy it is to miss most of the meaning. Prevalent in this case means very widespread in society. Complex means that there are a great many factors in play. Progressive means that people who have the problem tend to get worse over time. Relapsing means that people who go to great efforts to bring their weight under control face the almost inevitable prospect of watching all that weight return.
  2. “People living with obesity face substantial bias and stigma…” Well, yes, obviously. Deep down, we all know better, but it’s common to think that if a person is overweight, it’s a result of bad lifestyle choices, or a lack of willpower, or some other moral failing. (We tend to apply this negative judgement to ourselves as much as anyone else, and this is often the first hurdle that must be overcome in any successful long-term weight management plan.)
  3. The guideline “reflects substantial advances in epidemiology, determinants, pathophysiology, assessment, prevention and treatment of obesity…” and “shifts the focus toward improving health outcomes rather than weight loss alone.” In other words, medical science has come a long way, and it’s time to look at the big picture.
  4. Obesity care “should be based on the principles of chronic disease management… and move beyond the simplistic approaches of ‘eat less, move more’ and address root drivers of obesity.”
  5. People living with obesity should have access to “medical nutrition therapy, physical activity, psychological interventions, pharmacotherapy and surgery.” The last point is another one that you can read quickly – and miss the whole point. It’s pretty big. “Patients should have access” means that, according to the best current thinking of mainstream medicine in Canada, everything from medical nutrition therapy to prescription drugs to bariatric surgery – depending on individual patient needs — should be routinely on the menu for those seeking medical assistance for obesity.

Now I should mention that the guideline is intended for practising physicians, and that there is a great deal more to it than just the key points mentioned here. In fact, the recommendations and supporting evidence take up 19 chapters in the full guideline.

One more thing that I think we can quickly summarize here is what the guideline refers to as the preferred “patient arc” in the treatment process – the steps a physician should lead a patient through on the way to starting, and getting comfortable with, the concept of long-term management.

  1. “Recognition of obesity as a chronic disease by health care providers…” Wait, what? Yes, they are saying that the health care system itself has to first abandon its biases concerning obesity before, presumably, they can start to change the attitudes about it among patients and members of society in general.
  2. “Assessment… using appropriate measurements…” Again, when you read the explanatory material, this is pretty bold. Basically, the idea of using BMI, or body mass index – a formula for weight based on one’s height – as a baseline for assessing weight status is out the window. So is waist circumference. The focus is shifting toward much more contextual and individual assessments.
  3. “Discussion of treatment options…” Interestingly, the guideline defines “medical nutritional therapy” and “physical activity” as the core options. I find this oddly reassuring, and tells me that we are still on the same page. In addition to these core options, there are “adjunctive therapies that may be required, including psychological, pharmacologic and surgical interventions.” Okay, counseling, prescription drugs and bariatric surgery.
  4. “Agreement… regarding the goals of therapy, focusing mainly on the value that the person derives from health-based interventions.” There is such a thing as weight loss for the sake of weight loss, but we are talking about weight loss for the sake of being more healthy, feeling better, being able to do more things, and living longer (among other possible goals).
  5. “Engagement by health care providers and the person with obesity in continued follow-up…” I read this as referring to buy-in for the long term. This is a part of the definition of chronic care, or management of chronic conditions. It’s not a cure – we don’t have one of those yet – but it is a plan for managing the problem in the long run.

Now, as I said, the medical world has long taken obesity seriously, and many physicians have been helping their patients with weight management for many years. Benefits plans, too, have long supported things like exercise and fitness plans, and many are starting to cover the emerging range of pharmacological “adjunctive therapies,” as the guideline calls them.

That’s basically what’s changing here. We are starting to see obesity as a chronic medical condition that can be managed in the long term.

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I really appreciate comments, ideas, suggestions or just observations about the blog or any other topics in benefits management. I always look forward to hearing from readers. If there’s anything you want to share, please email me at bill@penmorebenefits.com.

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