Obesity: A chronic disease and risk factor for type 2 diabetes

Dr. Yoni Freedhoff and Dr. Sue Pedersen discuss the stigma around living with overweight or obesity 

Living with obesity is a risk factor for a number of conditions, including type 2 diabetes, high blood pressure and some cancers, according to the Heart and Stroke Foundation of Canada’s position statement on Overweight, Obesity, and Heart Disease and Stroke. In 2017, 36.1% of Canadians were living with overweight while 23.1% were living with obesity.

In 2015, the Canadian Medical Association (CMA) recognized obesity as a chronic disease, so that preventative measures could be taken in health-care practices, and misconceptions about obesity as a lifestyle choice could be dispelled. Three years after that move was made, other bodies, including the federal government and provincial governments, have not yet followed the CMA’s lead.  

We spoke with two of Canada’s foremost experts on overweight and obesity about the classification of obesity as a chronic disease, and asked for their advice on ways to improve care from health practitioners. 

Dr. Sue Pedersen is a medical doctor, Specialist in Endocrinology & Metabolism, and Diplomate of the American Board of Obesity Medicine, and has a clinical practice at C-ENDO Diabetes and Endocrinology Clinic in Calgary. She is a member of the Expert Committee for the 2018 Diabetes Canada Guidelines, and an author on the upcoming Canadian Obesity Guidelines. 

Dr. Yoni Freedhoff is the Medical Director of the Bariatric Medical Institute in Ottawa and has dedicated his life to treating and managing overweight and obesity. He served as the Inaugural Family Medicine Chair of the Canadian Obesity Network, and is a frequent speaker in Canadian and international press on obesity and nutrition policy.

Note to readers: You’ll see us using terms throughout this article such as “living with overweight and obesity” which may appear awkward, but are patient-first terms designed to remove the stigma related to the use of “overweight” and “obese” as a descriptive term, as opposed to a condition that someone has. This patient-first terminology was recommended by both Dr. Freedhoff and Dr. Pedersen. 

In your experience, how does the double stigma as a person living with both obesity and type 2 diabetes affect health outcomes in general?

Dr. Sue Pedersen:

There is stigma associated with both conditions, and 90 per cent of people with type 2 diabetes have overweight or obesity. The stigma is worse amongst medical professionals; there is often a perceived association of metabolic syndrome and diabetes with being lazy and not exercising enough. This stigma affects the ability of patients to access care, which leads to worse outcomes. 

 For some people, stigmatization can be a stimulus to eat for comfort, and this becomes a vicious cycle. While lifestyle issues can contribute, there are other factors such as the genetics behind obesity and type 2 diabetes, the bacteria in our intestines, medications that a person is taking, and so many more. It is so much more than a lifestyle issue.   

Dr. Yoni Freedhoff:

Any chronic disease is challenging for patients. From studies, patients with obesity are treated differently. Patients with obesity may get substandard care and may not get screened as frequently. Really, people with obesity struggle by themselves. Then, you tack on a disease such as diabetes that can lead to medical issues over time. If that person is not seeking care due to stigma, I think they run additional risks, compared with someone without diabetes with obesity. 

How would you describe the role of mental health care in the treatment of obesity and type 2 diabetes? 

Dr. Sue Pedersen:

Mental health care is something that is lacking, particularly in the obesity realm. Diabetes centres may have free access to psychologists in some major centres, such as Calgary, but there is very little to nothing free of charge for people with obesity without diabetes. Dealing with mental health issues and quality of life is paramount for both obesity and diabetes. 

Dr. Yoni Freedhoff:

If a patient’s mental health is challenged, if their mood is impaired, the likelihood of behaviour change is low. Mental health challenges can get in the way of intentional behaviour change, and some physicians don’t respect that. It’s depressing to be stigmatized by your medical care team. Mood must be taken care of before any other measures are taken to treat obesity, and diabetes can be managed with medication. 

 

How has the Canadian Medical Association’s classification of obesity as a chronic disease influenced action from Health Canada? 

Dr. Sue Pedersen:

The Canadian Medical Association does recognize obesity as a chronic disease, but the federal and provincial governments do not. Having the CMA recognize it was an important first step. There are further steps required in order to improve management of obesity, including better education and availability of treatment options. The vast majority of health-care providers agree that it is a chronic condition, yet only half of people with obesity are having that diagnosis actually established by their health-care provider. The most important next step is to have government bodies recognize obesity as a chronic disease.

Dr. Yoni Freedhoff:

I have hopes that over time we may see improvements. One of the challenges is remuneration. There isn’t much incentive for physicians to do preventative care and counselling in regard to obesity in their practices. Obesity being designated as a chronic disease may have an impact on teaching in residency schools and programs. But until it is examined on its own as a medical condition, it is easy for schools to not teach obesity treatment because curriculum time is precious. If it is not part of the examination it’s hard to convince schools to get it on the curriculum. Obesity and related diseases are the largest cause of death in Canada, but medical students will spend more time on (other) diseases they will never see. 

 
People with obesity often report feeling judged and shamed by medical practitioners. In your view, how does this affect outcomes? 

Dr. Sue Pedersen:

We have addressed this with the ACTION Canada Study, which we are currently working on publishing.  Our research showed that people with obesity generally feel that their struggles with weight are their own responsibility; they don’t feel like they should reach out to health-care providers for help.  This becomes an obstacle to accessing evidence-based treatment strategies. 

Dr. Yoni Freedhoff:

People with obesity avoid interacting with the health-care system for fear of being judged and treated poorly. If you don’t access care, you don’t get care. That is one of the biggest problems by far that exists – patient stories are heartbreaking and common. Focusing on that in medical schools can be done fairly quickly. I don’t know if they are providing training in reducing weight bias, but it is definitely required. 

 

What are some ways medical practitioners can reduce prejudice towards people living with obesity? 

Dr. Sue Pedersen:

Patient-first language is important to adopt.  Avoid the word “obese”, as this is an adjective that defines a person. You would never say “Mark is cancerous” if he has cancer. You would say “Mark has cancer.” Instead of saying a person is obese, say that the person has obesity or is living with obesity. Personally, I’d like to see the word “obese” eliminated from the English language. 

There also can be implicit bias in clinical practice. A patient with obesity may not be able to sit in their doctor’s waiting room because the chairs have arm rests and are not large enough. Clinicians can take care to have chairs or benches without arm rests, blood pressure cuffs in large sizes, scales and exam tables that are large enough to accommodate a person living with obesity. 

Dr. Yoni Freedhoff:

There isn’t a simple answer to this, but The Rudd Center for Food Policy and Obesity has a free online course for health-care practitioners to improve quality of care for patients with obesity that I would recommend. 

 

How do the new Diabetes Canada Clinical Practice Guidelines address obesity and diabetes treatment differently from before? 

Dr. Sue Pedersen:

 One thing we made a point of in the Guidelines was to use patient-first language. We now also have key messages for people living with diabetes.Previously, the key messages were only directed to health-care professionals. There are now key messages for people living with diabetes in all chapters of the Guidelines,including the Weight Management Chapter for which I am one of the authors. We are now writing the Canadian Obesity Guidelines with Obesity Canada, and they are coming out in 2019 with an extensive update to the 2006 edition. 

 

What are some recommendations you would offer to a patient living with both obesity and diabetes? 

Dr. Yoni Freedhoff:
If there was a short statement I could make, we wouldn’t be having this discussion. When we see pieces in the media, giving “Three easy things you can do,” or something like that, [those articles] suggest it is easy, and everyone can do it. That attitude is not helpful. There is no quick fix, and making people think there is one can lead people to believe they are failures. 

Compiling a good team to help you is important. Team members can include doctors, dietitians, social workers, psychologists – resources you can get in your community. However, there is quackery in this area as well. When building your team, ask physicians, friends and family for recommendations. Skeptically approach various programs to see what’s involved. Programs are only as good as their providers. Ideally, I would like to see a certification program where you have to meet certain criteria in order to put a sign in your window that you are certified to provide the kind of advice that you are giving, and only because there are unhelpful people out there selling hope. 
Are you a Canadian living with diabetes and obesity? Visit the Diabetes Canada website for more information on what you can do to manage both diabetes and obesity. 

 
 Dr. Sue Pedersen

Dr. Sue Pedersen


 The 5As of obesity management

Obesity Canada offers guidelines for health-care teams to better treat patients living with obesity. These “5As” give health-care practitioners a framework for a patient-centric approach to obesity management, designed to lead to more positive patient outcomes. 

  • Ask – permission to talk about the patient’s weight struggle, rather than telling them what they need to do.  

  • Assess – risks and root causes of the obesity. 

  • Agree – on health risks and treatments. 

  • Advise – on health outcomes and options. 

  • Assist – in getting the patient the right resources for success. 

Find out more about the 5 As of Obesity on Obesity Canada’s website