Adult Obesity Guidelines: What's New? An Overview | Dr. Sean Wharton

Summary

Highlights

• Obesity is recognized as a chronic disease impacting overall health 🏥
• Focus on health-centered rather than weight-centered treatment 💪
• Collaboration across healthcare providers ensures comprehensive care 👥
• The guidelines stress patient engagement in their treatment plans 🗣️
• Incorporating mental health support is key to effective obesity management 🩹

Key Takeaways

• Obesity is now defined based on health impairment, not just BMI 📏
• The guidelines propose a five-step approach focusing on patient experience and less on weight alone 🩺
• Integrating psychological interventions is crucial for long-term success 🧠
• Engaging patients in shared decision-making improves outcomes 🤝
• Regular follow-ups are vital for sustaining weight management results 🔄

Overview

Chapters

• 00:00 - 15:00: Introduction and Overview of Obesity Guidelines The chapter begins with a welcome to the Adult Obesity Guidelines webinar series, hosted by Obesity Canada and the University of Alberta's Office of Lifelong Learning. There is an acknowledgment of the traditional territories of many First Nations, Metis, and Inuit peoples across Canada. Before starting the session, the speaker mentions several housekeeping items related to technical difficulties and programming services.
• 15:00 - 24:00: Canadian Obesity Statistics and Trends The chapter 'Canadian Obesity Statistics and Trends' begins with instructions for webinar participants on how to ask questions using the chat and Q&A features. Panelists will address questions both orally and through text responses in the Q&A window. Participants are encouraged to check existing questions before submitting new ones.
• 24:00 - 40:00: Changes in Obesity Guidelines The chapter titled 'Changes in Obesity Guidelines' discusses the handling of questions during a webinar and mentions that not all queries from attendees may be addressed by the panelists. It also informs that a recording of the webinar will be accessible the following week and will be emailed to all registered participants. The chapter notes that the link to the recording is for personal use only and should not be shared or forwarded. Moreover, it adds that while the activity has not been formally reviewed by the CFPC (College of Family Physicians of Canada) or the Royal College, it is eligible for non-certified credit. Participants in the 'main pro plus' credits program may also receive credits.
• 40:00 - 65:00: Key Principles and Patient-Centered Care The chapter titled 'Key Principles and Patient-Centered Care' discusses the new clinical practice guidelines related to obesity. Denise Campbell-Sherk, an associate dean at the University of Alberta and a professor of family medicine, introduces these guidelines. The guidelines consist of 19 chapters covering various topics, including obesity diagnosis, management, and weight bias, and aim to encourage and inform healthcare professionals on patient-centered care practices.
• 65:00 - 90:00: The Five A’s Approach for Obesity Management The chapter titled 'The Five A’s Approach for Obesity Management' is centered around presenting new patient-centered clinical practice guidelines on obesity. These guidelines are the result of over two years of collaborative work among Canada's leading researchers, health practitioners, and patient advisors. Dr. Sean Wharton, who played a significant role in the executive committee for developing these guidelines, provides an overview. The guidelines emphasize a shift towards patient-centered care in obesity management, highlighting key changes to the clinical practice. Dr. Wharton holds doctorates in pharmacy and medicine, further contributing to the depth and expertise underlying these guidelines.
• 90:00 - 120:00: Medical Nutrition Therapy and Exercise Guidelines The chapter introduces Dr. Wharton, the medical director of the Wharton Medical Clinic, specializing in weight management and diabetes. He holds positions as an adjunct professor at McMaster University and York University, and works as an internist in Toronto hospitals. Additionally, Dr. Wharton is a researcher and a diplomat of the American Board of Obesity Medicine.
• 120:00 - 160:00: Pharmacotherapy and Bariatric Surgery The chapter discusses pharmacotherapy and bariatric surgery, focusing on guidelines led by an executive committee. Insights from Dr. Michael Valas, a health psychologist and associate professor at Dalhousie University, highlights his work in behavior change and lifestyle counseling for health professionals. His expertise encompasses obesity, diabetes, gastroenterology, and cardiovascular disease. The chapter emphasizes his contributions to research, teaching, and consultation in these fields, particularly in developing training programs for health care providers.
• 160:00 - 185:00: Behavioral Interventions and Psychological Support The chapter begins with a presentation on the Canadian Obesity Guidelines, highlighting the anticipation and excitement surrounding the release of this influential document. The guidelines aim to offer a fresh perspective on obesity management, emphasizing a global impact.
• 185:00 - 210:00: Final Remarks and Q&A The chapter titled 'Final Remarks and Q&A' focuses on giving a clear understanding of the new guidelines for obesity management. It covers the rationale, scope, and methodology behind these guidelines. Key changes and differences from previous guidelines are discussed. There is an emphasis on the current approach to obesity management and the evolving role of obesity medicine. The chapter transitions from an explanation of these elements to open for questions and final thoughts.

Adult Obesity Guidelines: What's New? An Overview | Dr. Sean Wharton Transcription

• 00:00 - 00:30 good morning everyone welcome to the adult obesity guidelines webinar series hosted by obesity canada and the office of lifelong learning at the university of alberta we acknowledge that we are on the traditional territories across canada of the many first nations metis and anyway whose footsteps have marked these lands for centuries just before we begin i'd like to go over a few housekeeping items if you have a question pertaining to technical difficulties or l3 and opc canada programs and services
• 00:30 - 01:00 please use the chat feature of the webinar if you have a question for our panelists please use the q a feature of the webinar our panelists will answer several questions following the oral presentation some questions will be responded to through text in the q a window you can at any point use the q a button at the bottom of your screen to submit questions we anticipate many questions please review what's already been asked and
• 01:00 - 01:30 upvote those questions you would like answered we cannot guarantee that the panelists will be able to respond to all of your questions a recording of the webinar will be available next week it will be sent via email to all those that registered the link is for your personal use and is not to be forwarded or shared this activity has not been formally reviewed by the cfpc or royal college however it is eligible for non-certified credit main pro plus participants may also earn
• 01:30 - 02:00 additional credits certified credits by completing a linking learning to a linking to learning exercise my name is denise campbell share and i'm the associate dean of the office of lifelong learning and a professor of family medicine here at the university of alberta it was my great pleasure to serve on the executive of the canadian clinical practice guidelines the new political practice guidelines are expansive 19 chapters on a wide range of topics related to obesity diagnosis and management weight bias and more all written by
• 02:00 - 02:30 canada's top researchers health practitioners and patient advisors they're truly the first patient-centered clinical practice guidelines on obesity and the results of more than two years of hard work we are very pleased that dr sean wharton will be presenting an overview of the guidelines highlighting some of the new changes dr wharton was co-lead together with dr david lau for the executive committee for the new guidelines dr wharton has his doctorate in pharmacy and medicine
• 02:30 - 03:00 he is the medical director of the wharton medical clinic a community-based internal medicine weight management and diabetes clinic in toronto he is an adjunct professor at mcmaster university in hamilton and york university in toronto he also works as an internist at women's college hospital and the hamilton health sciences dr wharton is a researcher and is qualified as a diplomat of the american board of obesity medicine we are also joined today by an additional member of the
• 03:00 - 03:30 executive committee for the guidelines who will be acting as a panelist in addition to myself dr michael valas is a health psychologist and associate professor at delhouse university halifax he has developed the behavior change institute a training program for lifestyle counseling skills for physicians nurses dietitians and other health care providers his areas of expertise are obesity diabetes gastroenterology and cardiovascular disease he is active in research teaching and consultation
• 03:30 - 04:00 now i'd like to turn it over to sean to start up our presentation thank you thank you very much denise and i'm so glad to be presenting the canadian obesity guidelines we've been waiting a long time to actually have this document in print and we're excited that not just canadians but people around the world can can also get access to this actually kind of world-changing and different viewpoint of the way that we
• 04:00 - 04:30 look at elevated weight so the objective today is to look at the rationale scope and methodology then we'll look at the key changes what have we done differently from the previous guidelines then we'll look at the approach that we're actually having for obesity management and finally the expanding role of obesity medicine so first we'll look at the rationale scope and methodology
• 04:30 - 05:00 now we know that obesity has been increasing in canada in particular from 1985 to 2016. recently over the past few years we've seen some stabilization but from an overall trend there's been a significant increase in the in the past 20 20 years and so and we know that the increase in elevated weight uh particularly if they're adipose cells
• 05:00 - 05:30 that are causing impairment health lead to a number of co-morbidity and even mortality so this is a very important time for us to look at addressing this medical disease so what has changed since 2007 so when we look at these five different panels here we see that one of the first things is that there was a declaration of obesity
• 05:30 - 06:00 as a chronic disease by the canadian medical association in 2015. that really came about because of the third panel the third panel there says advances in the science of obesity and weight regulation so what we know is that because we understand the biology and the pathophysiology and the neuroscience of elevated weight that was able to help us to understand that this is a disease process
• 06:00 - 06:30 and the cma and multiple other bodies have now recognized obesity as a chronic disease and that's important the first chapter that we have in the guidelines is on the impact of bias stigma and discrimination for people living with obesity and this is probably one of the most important things that has driven this entire process so without understanding bias and stigma we then would not be able to even understand why it's taken so long
• 06:30 - 07:00 for many organizations to declare obesity as a as a actual disease state and that was again because of bites and stigma so when we get rid of or address by some stigma things end up getting better we also have the advances in obesity treatment and therapies that's been a really big plus we've actually got things now for people to actually help them and the recognition of the patient-centered care and the outcomes beyond beyond weight loss is really important and the patient being part of
• 07:00 - 07:30 this process was a very important aspect for us so if we look at the scope of the 2020 guidelines it was to improve the standard of care and the access to care for patients living with with obesity now we know that that both of these the standard and access to care have been very poor in canada for a long time so it's time to make an actual change and the um at the target users were for primary care professionals so
• 07:30 - 08:00 we know that almost 8 million people in canada are living with obesity and if we look at overweight it's almost 26 million people so therefore we were not going to leave such a significant problem to a small number of specialists we had to put it in the hands of primary care professionals and that's what these guidelines are but also the guidelines are written in a manner wherein a patient can actually take the guidelines read it
• 08:00 - 08:30 and bring it to their health care provider and that was important so so patients can take this health care providers can take it and also policy makers and we hope that this makes some changes within policy and access and care so in terms of the methodology obesity canada and the canadian association of bariatric physicians and surgeons assembled an executive committee and steering committee with broad expertise and geographic geographic representation
• 08:30 - 09:00 so that was important for us there was engagement of a broad range of top topic experts they were in fact 64 um uh that were that were on the these got these guidelines we we also have people living with obesity and indigenous community members and and and a number of external reviewers and i believe that that's the strength of our guidelines and the fact that people with living
• 09:00 - 09:30 with obesity had a voice on these guidelines and were able to make this very practical in terms of the evidence base we used the mcmaster evidence-based reviewing and synthesis team for the literature search provision of the distiller platform and we used the agree to tool so what are some of the key changes that we see from the previous from the previous guidelines one of the first things
• 09:30 - 10:00 that we want to speak about and we changed is that the fact that we changed the definition of um change definition of obesity so obesity was previously defined by bmi which is very weight centric this mainly measures your size it doesn't measure health so we really want to move away from this weight-centric definition to one that more so focuses on health so therefore the um so obesity is defined as a prevalent complex progressive
• 10:00 - 10:30 and relapsing chronic disease characterized by abnormal or excessive body fat or adiposity that impairs health and we underline the fact that it's something that impairs health and and therefore we can now address people at different body sizes who are having impairment health particularly if it's due to these fat cells that are actually toxic so we still are going to use bmi and waste circumference as a screening tool because they can be
• 10:30 - 11:00 very useful particularly for epidemiological purposes but the diagnosis of obesity should be based on the presence of functional medical or psychological impairments related to the presence of abnormal or excessive body fat rather than on anthropometric measures alone so what are some of the key principles so one the the key principle here and what makes this guideline different than many other guidelines we've seen in the past
• 11:00 - 11:30 is that we we really wanted to emphasize the patient's lived experience and that we we had to move beyond the simplistic approaches of eat less and exercise more because this does not address really the root drivers and what we know is that when we just focus on a diet without any other interventions what it does is lowering your calories causes a cascade of neurochemicals and hormones that cause an imbalance and cause you to
• 11:30 - 12:00 have to cause you to go back up in in weight therefore we know that simply saying eat less and exercise more it does not address any of these major neurochemical and biological factors so we also felt that people living with who are living with obesity should have access to evidence-informed interventions which which would include medical nutrition therapy physical activity psychological interventions pharmacotherapy and surgical options
• 12:00 - 12:30 so in terms of recognizing and addressing weight bias which is the first chapter in in the in the guidelines and we know that people living with obesity face substantial bias and and stigma and this impairs and impacts their ability to get proper health and proper access access to care now this next slide
• 12:30 - 13:00 is going to talk a little bit about what these biases actually are so so we know that if you um see someone who is 250 3 300 um 100 pounds a common bias is going to be that this person does not have enough bill power they do not have the compliance level to control their elevated weight that means that you are biased and the thing is is we may
• 13:00 - 13:30 not be able to change a person's bias but you can you cannot act on it how do you not act on your bias by using the medical and biological principles that we know that are connected to this disease state you can then say that there are treatment options for you and i can actually help you if you act on your bias you're going to have a paternalistic type of approach which means you're acting like a parent wagging a finger and blaming and shaming a person and
• 13:30 - 14:00 saying you need to be better about your diet and use more willpower that is a biased approach and possibly why this field has sat in the dark ages in terms of treatment options for such a long period of time we're going to move away from bias into biology physiology into compassion and empathy and treating patients properly in terms of what is our approach in terms of
• 14:00 - 14:30 overall obesity management so we based this on on on the five a's so um the the five days um approach will be laid out very carefully here and uh and essentially you can use these five days approach to determine how you're going to treat a patient and this is the patient arc or the patient journey next so the first ask is clearly that we need to the first step is to ask a step
• 14:30 - 15:00 where we need to recognize that obesity is a chronic disease and that we should be asking patients permission to offer advice and to help treat the patient in an unbiased manner so this first task really talks about our biases so immediately if somebody walks into our office and they're again that elevated weight range and they have any medical condition many doctors will address it by saying that your medical
• 15:00 - 15:30 condition is due to your elevated weight and let's talk about your obesity now when in fact the patient has a bump on on on their eye or another type of medical condition that has nothing to do with their elevated weight patients um are tired of being treated in a manner wherein their weight is connected to every single medical condition and the physicians are not looking at them as a individual
• 15:30 - 16:00 again the ask is about eliminating bias that's one of the first things that patients have asked us to actually do is to have the physician actually recognize them and listen to them so that they can now start to have a dialogue in an appropriate fashion so we can move forward or else moving forward is very difficult the next step is step two the assessment assessment of the individual living with with obesity needs to look at not
• 16:00 - 16:30 just what their weight is and how they should be exercising more and eating less but identifying what are the root cause causes what are some of the challenges that they're having what are some of the complications and what are some of the barriers that they actually have and can we address some of these barriers next we have step three which is advising the patient the advising of the patient is the bulk of this this is the core it includes medical nutrition therapy there's no weight change if you're if
• 16:30 - 17:00 you're not eating healthy and if those calories are not lower so we actually know that so we have to have that and that's appropriate physical physical activity so um this of course will increase the health and that's what we're actually looking for the injunctive therapies are then added on which will include the three pillars psychological intervention pharmacological intervention and also surgical intervention the agree is is step four so you agree
• 17:00 - 17:30 with the person living with obesity that their goals should not be primarily weight based goals but should be health intervention goals or psychological goals or motivational goals these type of goals will help the patient to stay on track without focusing on on on their weight and their weight and therefore their health will get better their weight will likely end up getting better also the fifth part is the assist i like to call this the follow-up
• 17:30 - 18:00 because we know that at the beginning we talked about the definition of this disease it's a chronic lifelong disease which means that there's no cure for it so even after a certain period of time somebody's doing really well they have to continue to go back to the first steps and the second steps and continue to do an assessment because weight can come back on very easily and the health conditions can end up getting worse so that's why this is an
• 18:00 - 18:30 important aspect next so we'll go into further depth in this and so the first part that we talked about is the is the ask part um and uh and that third bullet point says don't assume all patients living with obesity are prepared to initiate obesity management this is so crucial and so different from other medical conditions as an internal medicine doctor if i'm working in a congestive heart
• 18:30 - 19:00 failure clinic the patient walking in to my practice wants treatment for congestive heart failure it's pretty clear and we start to talk about that but when i am in a practice where um the family practice if a patient walks in with another medical condition and obesity and elevated weight is part of their medical condition they may not want to initiate it at that time and if you push in a direction that the patient does not want to go in then you've ruined the um yeah
• 19:00 - 19:30 you've caused a problem with the um provider and the patient relationship and the recovery can be very challenging so asking permission is important next slide so the the assessment there's a number of recommendations here in terms of the assessment but the focus is we should look at a bmi for all patients and that is that's an important aspect it's an epidemiological factor and it also
• 19:30 - 20:00 gives us some guidance as to whether we can use a medication or whether bariatric surgery is actually is actually needed but most important is actually measuring the patient's blood pressure their blood sugar their metabolic markers and finding out whether there is a disease state or a pre the disease state so the edmonton obesity staging system actually looks at that and helps us
• 20:00 - 20:30 in in that direction next so here we have an example of the edmonton obesity staging system and i hope most of you are familiar with this this tool and if we look at stage zero and i will highlight this is this is where someone's weight is elevated but they have no signs at the time of any medical medical conditions at this stage a patient still needs to have intervention they have elevated weight
• 20:30 - 21:00 but the intervention here is to not go up further in in weight because we know that patients who have elevated weight who do not do any intervention would likely continue to have their weight go up further and further and then they're then at risk for um for uh deteriorating health consequences which is why me stage zero could be called pre-obesity so that's an important
• 21:00 - 21:30 factor next slide so in terms of looking at the treatment options this is a step three as i stated medical nutrition therapy is one of my favorite parts here and the reason why i like it so much is because we've gotten away from the word diet diet is a loaded word and every single time we think of somebody just reducing calories and not doing any other interventions we know that what they're going to do is they're going to promote a cascade
• 21:30 - 22:00 of hormones and neurochemicals that will drive their weight back up so they may be able to keep their weight down for a short period of time but certainly all those neural chemicals and hormones are going to cause a significant problem with them being able to keep the weight off over the long term so by just giving somebody a diet you may be hurting them and that's why we've moved away from that and we now discuss medical nutrition therapy and that specifically is if you have
• 22:00 - 22:30 elevated blood sugars or pre-diabetes diabetes and a lower carb diet may be a more important nutrition therapy for you if you have heart disease then a mediterranean diet may be an important aspect do not worry about the lower calories at this stage worry or or be concerned about the health consequences the lowering of the calories which allows for weight change and weight loss are afforded by the three pillars but
• 22:30 - 23:00 medical nutrition therapy should really involve eating in a healthy fashion next slide and here we have the very specific recommendations for each component of medical nutrition therapy and how it helps with many medical conditions next slide great and then the next slide so physical activity what we know about
• 23:00 - 23:30 physical activity it's probably the most important thing that a person can do to keep themselves healthy and so physical activity upwards of 30 to 60 minutes of moderate to physical vigorous intensity most days of of of the the beyond weak we know that this contributes to decreasing the risk of somebody having diabetes health consequences alzheimer's it has psychological benefit there are multiple benefits from
• 23:30 - 24:00 increasing your physical physical activity and it's documented here and it's part of the entire picture now when we're talking about significant amounts of weight loss we know that that is not what exercise does exercise keeps you healthy and as part of this this overall cornerstone picture next level great and here are the specific recommendations for that
• 24:00 - 24:30 so and these are the three pillars again the three pillars support the medical nutrition therapy and also activity and people ask at times how can these a pillar support your activity well if we look at psychological intervention the first pillar here if you're going to wake up at six o'clock in the morning to exercise on a regular basis not just for two weeks but over the long term there needs to be
• 24:30 - 25:00 a reason why you would do that a motivation that that you are we that you are that you are reminded of a value-based system and that's where psychological intervention comes it allows for the longer term healthy be behaviors so that's why we feel that psychological intervention is one of the first pillars and one of the most important pillars we can actually look at now if we look at pharmacological intervention we know that there are now
• 25:00 - 25:30 effective medications that can help to decrease weight previously we did not have these so medications have failed us in this field for many many years um so um but we have we now are in a position where we have medications that are actually effective and safe and so and i liken this to the field of breast cancer or other cancers where we failed for many years and we had toxic
• 25:30 - 26:00 medications but we didn't stop looking for an effective medication for those diseases here we have the same thing we had many medications that failed us caused problems but we didn't stop looking for effective medications that will help us and that's what we now have bariatric surgery is crucially important those with significantly elevated weight are afforded a change in their neurochemicals in their brain and their hormones by having bariatric
• 26:00 - 26:30 surgery one of the most important treatments and and it has the most evidence of any other treatment that we actually have next slide great so the behavioral interventions are are listed here and we fortunately have michael vallis on the line who is going to be able to help guide us through this and i hope that there are some questions in regards to why this intervention is such an important pillar if we look at at the um um at the guidelines around
• 26:30 - 27:00 the the beyond world in many other countries psychological interventions are not highlighted in a manner in which they've been highlighted here we now know that there's significant amount of level 1a grade a evidence telling us that that these interventions coping mechanism cognitive behavioral therapy dbp are necessary within the weight management field we're very proud to be one of the first guidelines to put this as a pillar not
• 27:00 - 27:30 just a sideline and not to include it as a behavioral modification because that's what it's been most of the time which was lumped in to diet and exercise we've we have separated it the nutrition and activity are separate psychological intervention which includes the very specific medical treatment in this area is separate and it's a very important option next slide okay and then next slide so
• 27:30 - 28:00 pharmacotherapy as stated we have we have three pharmacotherapy options um the first one from uh was and introduced to canada in 1999 and that is that is oralist at and in the actual clinical trials it was shown to be very effective but as we started to use it throughout in a clinical manner we found that it's not as effective a a medication but it's still listed
• 28:00 - 28:30 here and it has a number of actual actual benefits to it the two other medications that we have are a glp-1 analog and called called lyric glutathide 3.0 milligrams and naltrexone and bupropion and both of these work within the brain and neurochemistry and this is again getting back to what we have what we now know about the science and the biology of elevated weight
• 28:30 - 29:00 so um so these medications directly affect that neurobiological process that we have found out that cascade of hormones that push the weight weight back up we now know can be controlled to a large degree with the use of pharmacological intervention next slide and and one of the things i like about this particular slide is point number four where it says we do not suggest the use
• 29:00 - 29:30 of prescription or over-the-counter medications other than those approved for weight for for weight management and clearly this is directed towards not using uh off-label medications such as thyroid medication that were used at a time when um when we did not have interventions that were effective and safe we now have that next slide bariatric surgery
• 29:30 - 30:00 and one of the first and most important treatment options that we've ever shown to actually get the weight down and keep it down over the longer term there is no debate that bariatric surgery is the most effective treatment option we have in our armatarium and what i'm very proud of saying above with bariatric surgery is it doesn't just get the weight down it controls a number of the medical conditions particularly
• 30:00 - 30:30 type 2 diabetes next slide and one of the in one of the um the recommendations that that we've made here is that if you look at recommendation number two bariatric surgery should be considered in patients with poorly controlled type 2 diabetes with clat and class 1 obesity a bmi between 30 and 35 this is new that we have we have pushed down the
• 30:30 - 31:00 bmi to state that people with type 2 diabetes will do very well and the evidence is there it's level one grade a evidence and so when we talk about the eo staging system and is there a disease state that you have and do you qualify for bariatric surgery this is a very good and a classic example of that and this is one of the recommendations that we were very pleased to actually have here next slide
• 31:00 - 31:30 okay and then and the next slide so in the final components step four and step five agreeing with the patient that if we're going to get a sustainable long-term weight change then we need to continue to work on the behavioral goals we need to continue to work on why they are making this change how they can make it for the longer term
• 31:30 - 32:00 at times people will start with one pillar and need to move to two pillars or back and forth so the continual understanding of this is a very important aspect and the assist part tells us that the assist part is the follow-up how are things going you've had bariatric surgery i will continue to follow you up because what happens is you will regain the weight where are we when the weight starts to come back up
• 32:00 - 32:30 am i still taking care of you are we still working together because they're an intervention that we can now put into place to help with the weight regain happening after the bariatric surgery at year four at year five um so this is why necessary uh this is why the follow-up is so it's such a necessary thing next slide so when of course the this is our final slide where the fact is that there were 19
• 32:30 - 33:00 chapters so we talked briefly about how that the patient arc and the patient journey is there but what we're really proud of as well is that we have included many chapters here that are again not in guidelines on a international level we're one of the first guidelines to introduce a chapter on enabling participants and activities of daily living there are many people where obesity is going to be a factor in
• 33:00 - 33:30 their in their life over the long term learning how to live with that on a daily basis is a very important important aspect the role of mental health is crucial the psychological intervention we talked about the and the role of primary care again this is directed towards primary care not just towards specialists this has to be a primary care model or else this will not be an effective treatment for canadians the emerging technologies in virtual medicine and within the world of covid
• 33:30 - 34:00 this chapter has been probably one of the most important chapters as we now recognize that obesity medicine can be nicely managed through virtual virtual medicine weight management over over over the over the reproductive years are very important again and when they were viewers came back to us they said that this is one of our favorite chapters it's so well written and again i say uh oftentimes my
• 34:00 - 34:30 favorite chapters but the indigenous chapter is actually my favorite chapter because these as a group of people who face bias every single day when they walk into a health care provider's office they're feeling internalized bias they may face actual bias and then if you're living with obesity and you're an indigenous person their challenges are even greater so
• 34:30 - 35:00 this chapter was crucial for us because it really gives us gave us a recognition of why we were doing this entire guidelines the idea of commercial products and programs in obesity management they're everywhere we are the minority when we talk about medical intervention understanding biology understanding science most of the world when it comes to weight management or in the commercial products and programs so therefore we have a chapter here explaining which ones actually have some data have some
• 35:00 - 35:30 evidence which ones we should likely not actually look look towards so next line so thank you very much for your time and i'm giving i'm hoping i'm giving enough time in 20 minutes of our time to be able to address a number of questions and uh i hope that uh you have a good understanding of the overview of what's new in the canadian obesity guidelines
• 35:30 - 36:00 thank you so much sean uh and everyone can see there the list of upcoming webinars which will be coming over the subsequent weeks uh so it'll be really great learning journey together over the next six weeks to really explore these new guidelines and i think we'll head things off and this might be a question that's really directed towards you michael uh from evelyn
• 36:00 - 36:30 uh who's asked asking about the healthy at every size movement and sort of this this tension between what we talked about in the guidelines around the importance of focusing on health and not particular body weight um and how we reconcile that tension when the health at every size does not consider obesity as a disease yeah so thank you for that it's a really important question and i think the first thing that we would want to um offer is is really our intention is
• 36:30 - 37:00 to base our recommendations on science on ethics and on compassion um i would say that because then what we did as a team is really trying to pull together the the best um uh strategies that we could offer um i would say that we are um quite comfortable as as as a group to really make the statement that we very much believe that um
• 37:00 - 37:30 fat cells are not inert inactive cells that do not contribute to disease process that depending on where those fat cells are that they actively uh contribute to the development of disease and disability and so that that's a clear statement and therefore that's the really the reframe of obesity is not really about weight obesity is about health function and quality of life um other perspectives take different um uh perspectives from that and i think that
• 37:30 - 38:00 was the one i think that we as a as a as a group we really want to to sort of uh make claim to that if you review the evidence on how on the health impact of of adipose tissue then it seems quite quite clear and therefore we then partner um where i think the the various approaches can be so very helpful is is really to promote body diversity to promote a sense of dignity and worth and really to empower individuals to to
• 38:00 - 38:30 live well and that being said we we wouldn't and i think sean has actually mentioned this that if individuals um are actually quite comfortable with uh with their life circumstances then that's really their choice and we would respect that so i think it'll be really valuable um to look at the way in which we can um really integrate and and put the person at the center and also something that we psychologists call agency which is you know people really deserve to have
• 38:30 - 39:00 this um the sense that they can actively engage in their world in a way that improves their ability to function and so that's something that i think we would really like to promote so it's a really important question to raise um and and i think it's something that we need to really think a bit about in terms of how do we how do we move forward to to to promote really well health and and wellness over the long term yeah thanks uh thanks michael and i think it gets back to evelyn
• 39:00 - 39:30 the working definition that we had for obesity which is excess or abnormal adiposity which is causing physical or metabolic harm so just recognizing when those fat cells are sitting in the pancreas or sitting in the liver or in places where they're contributing to problem for the person or if they're you know making a osteoarthritis or spinal stenosis or something worse that that is a um but that's a problem
• 39:30 - 40:00 so um so i think that that's uh that's great michael so um now i want to make sure i don't get the pronunciation wrong zarifa has a question about bariatric surgery and reports that she'd heard from the calgary bariatric clinic that this challenge with follow-up and that perhaps patients aren't getting labs done and things within surgery and that the outcomes are potentially not worth the cost on the health care system
• 40:00 - 40:30 um sean uh do you want to take that one on and and comment a little bit about the role of bariatric surgery and the crucial importance of follow-up right terrific thank you that's a very important question thank you for for actually asking that so what um what we have seen is is that there are some instances of bariatric surgery clinics that don't do good follow-up and those were primarily with the commercial type of
• 40:30 - 41:00 bariatric surgeries i.e the lack band surgery and one of our recommendations is not to do the lap band surgery um and possibly because that came along with the fact that the follow-up was very poor there was a physician who lost his license due to a lack of follow-up not to not for doing bad surgery just not following up with his patients in an appropriate fashion so i think your point is well taken that there are
• 41:00 - 41:30 places that actually do that but what we're what that that doesn't mean but in most most of the medical centers they actually do do a good follow-up and they do actually ask their patients to come back on a regular basis um um and so so even if we had um poor follow-up at other places that doesn't exclude the actual evidence so when there is good follow-up when they're when we're looking at patients in an appropriate fashion we find that the evidence is that patients do well from a metabolic and a health
• 41:30 - 42:00 standpoint it's it's unquestionable and deniable evidence that it is the most effective treatment if someone has a bmi of 45 they have diabetes fatty liver heart d heart heart heart disease um or or obstructive sleep apnea bariatric surgery will undeniably improve the quality of life and those health parameters for that for
• 42:00 - 42:30 for that patient so i think that that's an important thing that that we shouldn't get confused with potentially um some data from one center or some proposed data from one center but the actual evidence around the world is clear that bariatric surgery is um is uh is a winner for the majority of of of patients denise if it's okay i may i make a kind of an
• 42:30 - 43:00 additional comment to this uh because the sentiment from from the question which is really an examination of the follow-up of obesity management and i would just like to to make the comment that it's it's a really strong hope that these guidelines will will shift the focus in the coming years such that if it's a chronic disease then it has to have a chronic management plan and any sort of uh uh influence that we can make and especially since and sean mentioned this
• 43:00 - 43:30 that we're we're actually hopeful that the this document will have some impact around policymakers and around health systems the uh you know health organizations like the medical association etc have certainly recognized obesity as a chronic disease and now it's time for governments to to do the same because then the governments will then allow us to uh really put that question on the table around what are those long follow-up plans that we can we can take such that
• 43:30 - 44:00 obesity management will be similar to diabetes management or to cancer management or any other chronic condition so i like the question and part of the i think from the the sentiment from the question is is it easy to priorize or the medical intervention and then then the support interventions kind of fade to the background and if that is the case the whole idea of the guideline is to try to shift that in the way that sean has described thank you denise thanks michael and i think that that's sort of a natural lead-in when we talk about
• 44:00 - 44:30 chronic disease management to scifula's question uh who states based on the new definition stage zero eos is technically excluded from the obesity diagnosis would be would be missing a precious period or opportunity to act appropriately and optionally when bargain damages have not happened uh by not considering it in the obesity diagnosis and i think as i'll take that one on um from a family medicine perspective absolutely you know so we do have a chapter and the guidelines around the importance of prevention
• 44:30 - 45:00 and um that's why i always say to my students you know every one of our patients who lives at uh with obesity who has a weight of 300 pounds was 250 pounds and they were 200 pounds and where were we um in primary care did anybody ever have a person-centered conversation with the person to try to understand what was going on in their life and health with the weight gain and so one of our hopes with this guideline is that it's going to help push the needle to empower people to be able to have conversations that are respectful
• 45:00 - 45:30 and really focus on a person's root causes to try to intervene effectively earlier and you're right so stage 0 eos is a great time to be doing that intervention i don't know michael sean if you want to weigh in on that as well or have auditions yeah yeah and i think that so aria sharma just wrote a blog on that and we've been having a lot of discussions about it over the past over the past couple of days so i've written
• 45:30 - 46:00 research articles on this is healthy obesity a actual real thing so what we do know is that if your weight is elevated so stage zero doesn't mean you don't do anything stage zero means that that you have elevated weight and as we get older we all know that weight goes up and up and we're challenged by it um um and we live in a society where where where everyone on the phone is at risk of gaining gaining weight so everyone on
• 46:00 - 46:30 this this call is at risk so we need to always be vigilant and we'll take a look at our genetic profile take a look at how fast the weight has gone up after at a certain point even if we don't have a medical condition and act and so stage zero doesn't say don't act stage stage stage zero says that you may not be the bariatric surgery patient um right away you may more so be the person who needs to work on starting off with lifestyle interventions behavioral um aspects
• 46:30 - 47:00 coping mechanisms understanding your the psychological aspects um and and uh so that's that's where i think we we need to go with with with stage zero and whether that needs to be tweaked a bit in the edmonton obesity staging system to discuss what types of options should make it clear and may need to be right and i think that that dovetails right into some more of um marie noel's questions uh so she has a few here
• 47:00 - 47:30 and um the first question that she asked is about the new definition being a step forward but how do we know that the fat is impairing the health of a client so um just to give a practical example um one of the things that's fascinating in the biology here is that we know a lot more about lipotoxicity than we used to and so we know when those cells are uh in the pancreas they're really contributing to type 2 diabetes or in the liver
• 47:30 - 48:00 really increasing our risk of non-alcoholic fatty liver disease and so we know that those are contributing to a to a cascade that can impair the health of the person or if we have a person who's suffering with severe pain chronic pain syndromes etc that excess adiposity may not be helping them so it's really about individualizing with the person uh to understand in their life and health how um and whether adiposity is contributing
• 48:00 - 48:30 and i think that dovetails there's a wonderful chapter as sean mentioned on reproductive health and one of the things we know is that at least in alberta a large proportion of women go up an entire obesity class with each pregnancy and so those are really good opportunities to try to intervene effectively to limit excess weight gain at high risk times for some women and that can really help prevent problems down the road
• 48:30 - 49:00 sean uh michael um did you have a look here at mary helen's uh questions she was talking about uh they're talking about um more regulations about the diet products industry [Music] and weight centric treatments uh the literature especially um sean around how we had a lot of literature that was still weight centric yes yes
• 49:00 - 49:30 i agree so i'll be brief and then michael can answer so i believe that we really do need to have better regulations on the diet programs diet product industry there's many countries that are ahead of canada um america is way behind everybody um but certainly other countries are doing a better job you can't say you lose 40 pounds in 40 days on the re on a radio ad so in toronto i'm sure i'm going to
• 49:30 - 50:00 hear that um as soon as i get into my car to drive anywhere but in other countries you can't and i believe that we should we really need to start regulating this you wouldn't be able you wouldn't hear you can cure prostate cancer with mustard paste being rubbed on your back and and um witch hazel um and it doesn't make any sense so they they regulate it in the disease states such as cancer and multiple other diseases why not in the obesity field and michael yeah i i i couldn't agree more and i think one of
• 50:00 - 50:30 the really important things is um you know until recently you know the sort of professionals have been sort of silent when it comes to the sort of weight-centric make all your dreams come true achieve your ideal weight and so it's really been sort of uh unfortunately this sort of unregulated field i think our hope is the guidelines will provide a kind of a a principle-based uh sort of approach that will be again
• 50:30 - 51:00 guided in science and compassion and ethics that then allows us to have these um discussions happen and and to be a bit of a lightning rod for the opportunity to introduce the full complexity of obesity as a as a as a state which is really reflected by you know the the the built environment the the social cultural context and the food production issues these are very complex issues that go way
• 51:00 - 51:30 kind of beyond the sort of medical piece of it but at the same time i think that by putting it inside of a of a compassionate medical care system we have the potential to ask some of these questions um and then to move it beyond not only the the quote-unquote treatment so get away from the weight-centric approach because remember some of your counseling of patients may be really that the that we're trying to help them to accept who they are and to um adapt to their body body diversity is
• 51:30 - 52:00 in a very important goal so when you think about you know obesity having an impact on on on mental health that's where i think even that stage zero can be really really uh and a very fruitful area for helping people promote health and promote well-being so taking it much beyond um the pure weight-centric approach and then allowing us to start to have some kind of standards because you know what sean is saying right now people seem to be able to get away with a lot and i understand that if you watch
• 52:00 - 52:30 television two things happen um these types of advertisements become more and more frequent as the hour gets later and the volume of the soundtrack of these commercials gets louder as it gets later to really kind of grab your attention so i think we need to really revise the uh the standard but having an ethical base standard that's evidence-based i think can be helpful thanks yeah and just to wind up the last of marinola's questions um marina well i was actually astonished
• 52:30 - 53:00 when we went through the evidence that there was a really substantial portion of the evidence that was actually based on non-weight uh goals um or outcome measures rather so that was really encouraging but as we acknowledge in the guideline right up front there's still a preponderance of research out there that does have those outcome measures so we're in this transition period where hopefully we're going to see researchers who are doing the studies shift their outcome measures to things that are
• 53:00 - 53:30 more representative of the condition so i think we should just pivot to a couple of these uh nutrition questions um and i think uh sean you indicated that you'd uh tackle these ones but lucia has a question about how we engage with registered dietitian colleagues and of course jennifer brown was the tremendous lead for that section of the guidelines so how we push forward on on that and evelyn has a related question about um diagnosis and who can do
• 53:30 - 54:00 diagnosis terrific so tackling both questions uh very quickly um so um we've been pushing for a diagnosis of obesity in everybody's chart so that's something that the family doctors need to do and sometimes something that the at a um certainly someone else on the team can bring to the attention of the physician or the nurse or the team and put that that the the diagnosis of obesity
• 54:00 - 54:30 on the patient's chart so it's relatively easy to actually do and it should be on the patient's chart the next important part is how will dietitians get involved in the medical nutrition therapy and so it was it was great that jennifer brown brought this to our attention during the guidelines i have to say that we learned this and during the guidelines get rid of the word diet and it was the dietitians who pushed that envelope they said that we are not going to be involved in giving somebody
• 54:30 - 55:00 a diet without any other interventions available to us so therefore you need to teach us some other treatment options one of the pillars you need to either put them on a medication to have them have surgery or at least teach a psychological intervention so that we can give somebody a medical nutrition therapy and that the weight can be appropriately managed so now the canadian bariatric um uh you can get a canadian bariatric educator
• 55:00 - 55:30 diploma from from from obesity canada and that is what dietitians have been doing to forward their knowledge base and their understanding of how they can use medical nutrition therapy and cognitive behavioral therapy and counseling to bring the patient's weight down and to make the patient healthier so that's really an exciting aspect of this guideline may i just throw a comment in there as well just to sort of embellish what you're saying so andrea when you
• 55:30 - 56:00 start to look at the individual guideline chapters with when you look at the medical nutrition therapy chapter you actually will see that you know it is indicated that dietitians specifically be referred to to address the issues associated with achieving um the appropriate medical nutrition therapy so i i do think that it it it's it's it is recognized as it is in the in the behavioral chapter we recognize that also people that have to have competency in behavior change counseling and so um the the i think the
• 56:00 - 56:30 recommendations are there i would make the statement that um we view the guidelines as a living document and what i mean by that is that it's not going to be produced as a book that's going to sit on somebody's shelf or hold up somebody's door open but it's really going to be something that we have a an ongoing relationship with so for instance the pharmacotherapy chapter will probably be updated every year because we would anticipate that there's a lot happening on the pharmacotherapy side in other chapters there will be a
• 56:30 - 57:00 lot more focus on knowledge translation types of activities so certainly i know in the behavioral chapter we're already talking about what kinds of tools can we um can we kind of develop and what kind of supports can we offer to improve the competencies um so the issue that you're describing around the role that the dietitians will play in achieving medical nutrition therapy i think is um is is actually a huge potential for going forward so thanks okay so i think i'm going to
• 57:00 - 57:30 round it up just because we're getting close to time but just the last point i would want to make on that for andrea is that there was a tension that we recognized in the guidelines these guidelines were intended for primary care providers and in many jurisdictions in the country especially in our rural settings people practice in places where they don't have the luxury of interdisciplinary team and they don't have a luxury to be able to refer to colleagues that we would like and so
• 57:30 - 58:00 we hope that these guidelines will spur governments to recognize the importance of an interdisciplinary approach but we also need to be mindful that sometimes fellow physicians are in a situation where they have to do the best they can without uh the support that they might like at the moment so um so we're just in that intermediate space and that was the line we were trying to walk when we were making these recommendations so thanks for the robust questions and discussion i just want to highlight to folks
• 58:00 - 58:30 that we would really appreciate your feedback on these webinars and we have a new kind of survey in there where we really want to also understand your experience with obesity management the purpose of that survey is going to be to try to get a snapshot of the country in terms of what's working well what are your frustrations and so if you're open to sharing and contributing to that that would be fantastic we want to use that for the continued advocacy work of obesity canada to inform learning objectives for our
• 58:30 - 59:00 courses and other offerings and some hypothesis generating about places where there might be spaces for us to work to collectively to improve and as well in the chat box don hatnaka is highlighting to everyone that if you haven't already please feel free to join the oc connect pro the link is in the chat box it's a time to write uh discussion forum for healthcare professionals to discuss uh the guidelines as well this community
• 59:00 - 59:30 is for healthcare professionals only but really encourage people uh if you're a healthcare professional on the call and to think about joining into that it's going to be a neat opportunity for all of us to stay connected um with a question about medications and insurance coverage uh and i i understand that there's a lot of national variability with regards to that and perhaps uh sue or sean uh you might want to
• 59:30 - 60:00 tackle hannah's question uh sure so um there's unfortunately very limited coverage for obesity pharmacotherapy and that's something that we really struggle with every day in clinical practice um we are our hope is that with the obesity guidelines now being available really putting shedding a light on that hey obesity is a chronic medical condition needs to be treated like that we need to have coverage just like we have
• 60:00 - 60:30 for other medical conditions like diabetes for example we're hoping that this will be an important tool to approach payers governmental organizations and so forth in order to advocate for our patients so that we do have more coverage opportunities great thanks sue absolutely and there's been people may be aware that obesity canada has been working in an advocacy role in this space and doing the report card uh which is the presentation
• 60:30 - 61:00 to the different territories and provinces and policy makers around the status of access to medications and other therapies that are evidence-based for obesity management and this is one of the reasons why we'd really love to have all of you guys contribute your expertise uh in our tool that you can see um on the browser right now because we really need to get a picture of what kind of struggles people are having with getting people evidence informed care so nadine has a question
• 61:00 - 61:30 around for those who don't have benefits would orlastat be the best choice and perhaps someone could share some of their clinical experience with using oralist at and when you might use it and and how you find it to be the most effective in those patients uh sure this is i can take this one as well so when i'm talking about obesity pharmacotherapy with my patients i talk about all three of the options so orlistat liraglutide three milligrams
• 61:30 - 62:00 naltrexone bupropion and i talk about the mechanisms of how they work we talk about the efficacy uh we talk about cost as well because i saw there was a comment there about well if my patient um you know should i recommend orlistat because it's the least expensive or if my patient doesn't have coverage and i really don't want to take that decision away from my patient a lot of people who come to us looking for help with weight management are spending extraordinary amounts of money on
• 62:00 - 62:30 programs that have or or supplements or herbal whatevers that have no evidence behind them at all and actually when we talk about the cost of the different options that they say you know i'm already spending so much on this you know herbal whatever or corner slimming clinic that has no evidence behind it i'm going to take that and put this towards this medication so i really do engage the patient in the decision-making process thanks sue so i think we can pivot now
• 62:30 - 63:00 to veronica's question and perhaps michael we can direct this one to you but veronica's asking about how to best assist patients with behavioral therapy and just considering the canadian context where in primary care we don't always have access to a behavioral health consultant or to a psychologist what are your views on how we can best support patients in this needed color thank you very much for that um question and i i really appreciate it
• 63:00 - 63:30 and i think the context to really understand is is is for us to really understand that all chronic conditions really require the active engagement of the patient to make ongoing decisions and really to manage their own conditions away from the provider so that means that that being the expert having recommendations being able to teach intel is not the way that clinical management and any form of chronic disease can can continue and so if you
• 63:30 - 64:00 think about what we really require which i consider to be the sort of common ground for all of us so the patient's acceptance of their condition their acceptance of a treatment program their readiness to engage in a program and then their ability to to adhere to the program and move forward that is actually shared territory of all of us my research in this area demonstrates that you do not have to be a psychologist to address
• 64:00 - 64:30 the many of the issues around just as sue is describing so sue just talked to you about shared decision-making around the choice of medication in which it's the patient's real decision as to how they spend their money and what's important about their money not our decision to make so we can replicate that over and over again so i would hope that people could use these guidelines as a way of really empowering themselves to be comfortable stepping into the psychosocial aspects of living with obesity
• 64:30 - 65:00 so as an example two questions that i absolutely love to ask every patient is and i would ask you as well these two questions um how did you get to be the weight you are and the answer to that question regardless of what your weight is tells you a tremendous amount about your life the struggles you've encountered and some of the causal drivers of the of the state that you are in and then the second question is what is your relationship with food and again these are open domain types of
• 65:00 - 65:30 issues so um we have written the psychological and behavioral chapters such that it will accomplish two things one is it will review the evidence and it will try to provide a comprehensive framework but the second and this is why the guidelines are we call a living document that we will supplement in the psychological behavioral chapter tools that we're hoping that providers who may be less comfortable can start to get some practice out and
• 65:30 - 66:00 and we see kind of creating really a community of practice which in many ways is what obcd canada has has done from the beginning so sorry to be a bit long-winded in my response but i would just like to suggest that that if you have access to psychology don't look at that as oh great now we can send our patients to that person think about okay who absolutely needs to see the psychologist and that's when you start to getting into some of the more severe types of issues but ask the psychologist to support
• 66:00 - 66:30 your competencies your confidence in going down this pathway because we see that that healthcare providers of all stripes can be very very motivational very supportive of behavior change and very much help patients develop the intrinsic motivation to continue to follow our recommendations thank you thanks so much and i can give a good this is sean here i can give a quick um response as well from the standpoint of a clinician working in a busy practice because that may have been part of the question as
• 66:30 - 67:00 well what we've been seeing and doing is that we have our bariatric educators and our dietitians getting trained in psychological intervention psychological treatments cognitive behavioral therapy and michael ballas has been doing a lot of this training for the people who are not a psychologist to be able to give some degree of a intervention from the psychological standpoint so you're not just giving a diet and leaving the patient without anything because there's no psychologist in your town but there's a dietitian in your town there's a bariatric educator there's a
• 67:00 - 67:30 nutritionist or someone who can spend some time and that's what we're seeing the more education they have the better so some courses and some but um but the need to be a psychologist is not absolutely needed this is not a freudian type of thing they're not lying in a couch and throwing their head back this is them um this is that relationships with food as michael has spoken about so it's been very good for us and that is what that that and that is what we are currently doing in the clinic i let patients know that
• 67:30 - 68:00 the government isn't paying for it yet and i'm paying for it um but i believe in it so much that i actually assist with it and there's also some help from some companies to help out with that as well well that's great time and just to also echo that uh obesity canada does run a course for certified bariatric educators so if this is tweaking anyone's um imagination on the call feel free to check out the ubc canada webpage for more details on how to help get team members to be certified bariatric educators
• 68:00 - 68:30 so alka has made a comment that there he's really pleased to see registered dietitians be really featured in the new guidelines absolutely i mean the approach is very much team based care and leslie has an interesting question that i want to put to the group because leslie's highlighting that she's a kinesiology instructor in british columbia and teaching people who are becoming health and fitness professionals and personal trainers and so just wondering uh from leslie's
• 68:30 - 69:00 perspective about um how perhaps this kind of information from these guidelines could be things that her industry uh could get involved in anyone have any perspectives on that one this is michael if i might just quickly say that absolutely one of the most helpful things that any health professional anybody in a supportive role can do is ask permission to educate and so in the context of the teaching that you do and in context of the
• 69:00 - 69:30 professionals that you're training then do they have a role to ask permission to educate patients about what we're learning about obcd and and how to shift the narrative away from eat less with more it's all a matter of willpower it's all under your behavioral control to the model that sean presented so i i would vote yes absolutely i could see that role being very supportive in helping people choose a pathway that will increase the likelihood of success
• 69:30 - 70:00 yeah thanks michael i think the sandra's question uh really dovetails onto that she's asking about the role of a health coach in supporting clients in daily living and i think that absolutely i mean i think anything that can help people navigate the fact that this is something which is present every day in their life this could be a really effective um helpful intervention absolutely um if i could just make a comment i'll be quite brief but um what we've learned from the
• 70:00 - 70:30 behavioral chapter has been really helpful and i was involved in writing the behavioral chapter in 2006 so we've seen the difference in the research over the time and what we can now say with quite confidence is as multi-component behavioral interventions work that we know what what behavioral interventions do work but to this point even more importantly we actually have very very good idea data that says here are the steps to success so if you think about going from not doing to sustained health behavior the steps
• 70:30 - 71:00 involve the following three first is adherence find a pathway with your patient that you could adhere to and it's more important that they can find something that they adhere to than it is to push any particular approach on them once an individual finds something that they can adhere to then they need to figure out how to overcome the barriers and the confidence to overcome the barriers is a very important psychological construct called self-efficacy and then the the sort of final step to
• 71:00 - 71:30 success is intrinsic motivation where the individual develops the internal drive so that the work associated with healthy lifestyles and the positive outcomes is something that they are internally motivated to continue with and so someone like a health coach could be supported any people in a helping position could be supported to try to support individuals to make sure that that whatever they do sticks and that they have confidence and that they have
• 71:30 - 72:00 personally meaningful reasons to change thanks thanks so much michael i think we've got a number of questions here again about medications and just to remind everybody sue will be presenting um a whole webinar as well on pharmacotherapy in a few weeks but um perhaps we can address a few of these and so mary cloud is asking the question about is there a time a limit of time to use the medication if proven proven effective so five percent weight loss after three months um and i know that there's quite a lot
• 72:00 - 72:30 of work as well sue around you know the use of the medications post surgery etc um do you want to comment on that a little bit i would love to thank you um yeah so the the um the health canada rules or guidance for obesity pharmacotherapy is very similar to what is seen in guiding documents around the world which is that if your patient hasn't achieved five percent weight loss after three months on the full dose of medication we should stop it because it doesn't work
• 72:30 - 73:00 and we really as you'll see from the pharmacotherapy chapter and the guidelines and from the talk as you mentioned that i'll be giving in a few weeks we really want to get away from that line of thinking because it doesn't take the patient's context and it doesn't take the patient's trajectory into account so if you have a patient who has come to you and said hey i just lost 20 pounds on weight watchers and i'm concerned because in the past i've done that and then i regained the weight and now i need help to keep the weight
• 73:00 - 73:30 off so we start an obesity pharmacotherapy and they come back a few months later and they're ecstatic because they have kept the same weight they haven't regained well they haven't technically satisfied that five percent weight loss rule that or or guidance from the from health canada but that doesn't make any sense because that patient is actually having success so we want to think about that trajectory the other thing is that some patients take a little longer to achieve
• 73:30 - 74:00 clinically significant weight loss on pharmacotherapy so many of the medications are uh naltrexone appropriate and there are gluten three milligrams they're both titratable medication and the idea for both of them in the standard titration is they get up to the full dose after about a month and then we see how they're doing three months later but there are some people who may struggle with some side effects and they just need a little bit more time to titrate their way up on the dose so if we have this rigorous five percent and rigorous three-month rule then we're really not
• 74:00 - 74:30 taking we're not being flexible we need to take these issues into account in order to really understand is our patient having success and we wouldn't want to stop a pharmacotherapy because they didn't meet these rigid criteria yeah and i can i can ask that and maybe these rigid criterias came out of the fact that we did so poorly with medications in the past and there were so many ones that were pulled off of the market
• 74:30 - 75:00 and things like this is a tough field it's not your typical field but we don't have these type of rigid guidelines for your high blood pressure medication the clinician makes the call and works with the patient and they decide on what they're going to do so it's it's been very strange that we've been pushed into this box of this five percent over three months time frame i think it's because of the challenges that have happened previously and um but i agree with sue i i would like to see it gone and i'd like to see us having the
• 75:00 - 75:30 capacity as a clinician to make decisions with our patient together and this actually dovetails into stephen's question uh stephen's asking about why uh laura cassarin has not come to the canadian market and um just uh to dovetail on that sean i'm not sure if that's something that you would be able to comment yeah yeah so i can comment on that briefly so so one the alert lorcan hasn't pulled off the market totally so that's a big reason but
• 75:30 - 76:00 even before it was pulled off it might just pull off the market because there were cancers that were connected to it they're not exactly sure where the cancers were there's not a lot of information it just got pulled um and i put that into the chat box um so you can read that the fda pulled it doesn't have cameron never proved it possibly because of a couple of different things one is that the weight loss is not all that and a at the impressive there's not an impressive amount of weight loss um i i
• 76:00 - 76:30 imagine the health benefits were not all that great it was okay but it really it really was just at the edge of doing doing well within these clinical trials so the company i believe didn't think they'd get a big bang for their buck their competition against the other medications are doing very very well and their cash was going to come down the bottom is not going to go very well so they made a probably economic decision at that stage not to launch it in canada and then it got pulled off the market so
• 76:30 - 77:00 yeah no that's really excellent thank you and uh perhaps just before we um uh leave the topic of pharmacotherapy there's a couple questions in the chat box um about combinations using their gluteal glutamate plus uh in combination um can either sue or sean could you guys comment on doing that in your clinical context yeah so um this is sue um so there is
• 77:00 - 77:30 very little data as far as combination pharmacotherapy at for obesity at this point in time so there's some case series uh from the united states in particular that um have just really summarized i didn't get that sorry now it's going to do it again um there are uh case series about uh combination pharmacotherapy um from the states mostly but really no
• 77:30 - 78:00 clinical trials or randomized controlled trials are the kind of data that we really want to hang our hat on we do use them together in clinical practice but i really can only just give you anecdotal commentary that we see additional weight loss when we add pharmacotherapy but we don't see additive so if we get five percent placebo subtracted with uh lira and five percent placebo subtracted with contrave we don't tend to see ten percent 10 placebo subtracted using the two together but we do see an additional
• 78:00 - 78:30 benefit of adding on in many cases remembering that every patient is different and different things work for different people in the future we expect to start seeing some combination pharmacotherapy studies coming and we hope that if we look forward you know 20 years from now that we will have a realm of choices of pharmacotherapy similar to what we have for diabetes and we use different combinations depending on what works best for our patient
• 78:30 - 79:00 fantastic food thank you yeah and there's a number of questions um about sort of off-label use of medications and of course in the clinical practice guidelines we cannot espouse the use of medications off label we're really trying to reflect the state of the current evidence about what we know works however there are ongoing studies for example there's a question here around perhaps the role of semi-glutathione in the future for weight management um sean is that something you can comment on the studies about that
• 79:00 - 79:30 uh yeah so far yeah absolutely i'd love yeah i'd love to comment on that and and david um great great question and the reason why we emphasized um in our section and the pharmacotherapy section that we don't want any off label is because we've seen too many off-labels uh thyroid medications and other types of testosterones and hormones used in the wrong way without any science and and strange things so we want to really be clear that we don't want those used now when it comes to drugs in clinical trials
• 79:30 - 80:00 like a glp-1 analog that has had a great phase 2 trial already published and a bunch of phase three trials yeah i know you're this this is a direction that a clinician would have to make a choice on and um certainly with the understanding that you know a trial is likely coming out that's going to be positive and things are looking good so that's that's what i would say we can't comment on it but certainly i think a clinician is able to make a decision on something that uh that has a lot of evidence if i could just add to that i would also just
• 80:00 - 80:30 point out that we do have a section on emerging therapies in our pharmacotherapy chapter to account for this sort of discussion because it's important you know here's where we are today but where are we going to be tomorrow and as it was pointed out as well i think by michael that this is a these are living documents so the the great thing here is that uh it's a lot of work for us as authors but the great news is that they are online documents that we can update as new information becomes available as well we don't have to wait 15 years this
• 80:30 - 81:00 time absolutely although perhaps perhaps three months given that we'll have ptsd from the first time around so i think i think we should uh i think we should go to cheryl i think this is just a fantastic question to end on uh and and cheryl's asking about regarding behavior change how do we manage um expectations and um this is such an important topic because we know that people are constantly exposed to really unrealistic
• 81:00 - 81:30 expectations for weight loss and so how do we help people deal with um that expectation gap so perhaps this is something that can go to michael again thank you yeah um i i appreciate the opportunity to answer that question and thanks cheryl i think it's critically important um we're close to being out of time but i can i can respond to this question quite quickly really and there are two things that i'd like to say first thing is it's critically important as people trying to support individuals
• 81:30 - 82:00 achieving best weights to really help the our patients understand the following weight is not a behavior and therefore you cannot control weight now this is a bitter pill to swallow as you're implying cheryl but i think if we can help people understand that what they can do is they can adhere to their medication regimen they can accumulate steps during the day they can accumulate servings of fruits and vegetables and they can alter their behaviors and then this of course has a positive effect on
• 82:00 - 82:30 weight but we have to shift the focus away from this weight centric my effort should be reflected in the outcome on the scale to to weight is not a behavior so the behavioral goals somehow have to stand for themselves now i would encourage you to know to to expect that you will have to use the following counseling strategy to gain any traction with what i've just said and the counseling strategy is repetition and relevance
• 82:30 - 83:00 in other words cheryl don't be surprised if you have to repeat this 50 60 times with your patient be very comfortable with that and each time you repeat it you ask for how that might kind of be relevant to the patient because if the patient can find the relevance there my second point is actually one that we took on in the behavioral chapter because we looked at this literature what is the what is the literature around the success of managing weight depending on your level of expectation and it's a good news bad news situation
• 83:00 - 83:30 the good the bad news is that people have extremely high expectations that are almost never achieved even surgery doesn't provide the level that many patients have in terms of their hope for our ideal goals but the evidence is crystal clear good news if you and your support of your patient can switch the experience from expectation to satisfaction with the achieved goals when you look at this issue the patient who is able to
• 83:30 - 84:00 appreciate the benefits to health function and quality of life from their efforts that it's that construct of satisfaction that is associated with really positive outcomes so i think the challenge for us is weight is not a behavior and meet them where they are don't try to challenge them on their expectations engage them but shift towards the concept of best weight and satisfaction with gains achieved thank you thank you so much michael and thank you cheryl for that question
• 84:00 - 84:30 so uh we're at time we're gonna need to wrap up uh in the chat box uh nicole from obesity canada has included a link there to the obesity times right group so if you're interested in joining the community if you have more questions uh that's a community of practice that hopefully um will continue to grow and thrive and so you're welcome to join it please uh provide us feedback um our qr code is there and within that there's also a link to our sensemaker survey where we're really
• 84:30 - 85:00 looking for your contributions about your experience with obesity management to really help us have a snapshot of what's happening in canada so once again thank you all so much thanks so much to our panelists and to sean uh and all the callings we see canada and the office of lifelong learning for your efforts in bringing this webinar uh to conclusion and we'll look forward to next week um so this will be a fun journey for the next six weeks and sarah kirk will be joining us next week
• 85:00 - 85:30 to talk about weight bias we're so pleased to have that chapter in the guidelines and really look forward to that webinar so thanks everyone and we'll look forward to seeing you next week