HomeMedicine By SpecialtyDiseasesWhat a bariatric surgeon wishes you knew about obesity

What a bariatric surgeon wishes you knew about obesity

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By Jennifer Stranges

Nearly 30 per cent of Canadian adults have obesity, yet despite its prevalence and association with serious chronic diseases like diabetes and hypertension, stigma remains a barrier to patients seeking proper treatment and care.

Dr. James Jung is a bariatric surgeon at St. Michael’s Hospital, a site of Unity Health Toronto, and a scientist at Li Ka Shing Knowledge Institute. He completed a clinical fellowship at the Massachusetts General Hospital, Harvard Medical School and has research interests in using machine learning for early detection of clinical deterioration in surgical patients.

We spoke with Dr. Jung about obesity, different treatment options and why he says obesity is a noun, not an adjective.

What do we know about obesity?

What are the barriers for patients with obesity to accessing care?

Obesity is a disease that has visible physical manifestations. There’s an increase in fatty tissue and body weight, so it’s subjective to everyone having some opinion and visually guessing or identifying someone as having this chronic disease – even if it’s true or not. The only way to actually diagnose someone with obesity is through the assessment of a physician and measuring BMI.

There’s a lot of stigma for patients with obesity, and patients can feel embarrassment and shame or experience harassment. Some do not want to come forward to have the treatment they require because of this, and it’s an area we need to really work on. The other thing is most people are very quick to judge and think patients who have this disease have it because they have a problem with overeating or living too sedentary a lifestyle or not exercising enough. While behavioural factors like eating and exercise have a role in the development of obesity, it’s not all. There are a lot of studies that have shown that there are genetic components to obesity, and a lot of studies have demonstrated obesity is regulated by hormonal changes as well.

Obesity is also a risk factor to access quality care – hospitals are designed for people with “normal” BMI, but more than half of our population is overweight or has obesity. What we call “normal” is actually the minority of the general population. It’s likely that there are shortages of ambulances or medical aircrafts suitable for transporting patients with higher BMI categories to be prepared for increasing prevalence of obesity. A lot of basic equipment like hospitals beds and chairs have specific weight-bearing statuses. For patients with a high BMI or weight class, they may need to wait for a specific bed or chair to be available. They’re likely to feel excluded from hospital setting and not feel included in the care system.

From a care and personnel perspective as well, we need more education around how we label and discuss patients with obesity or severe obesity. I like to avoid terms like “you are” obese. I don’t use obesity as an adjective because it should be used as a noun – it’s a disease. I would not say to someone “you are obese” because that’s not who they are – they’re someone’s father, mother or sister, they just happen to have this disease, and that’s very important for our healthcare workers to understand.

What are lifestyle modifications that can effectively treat obesity?

One is, of course, diet. This is a focus on the biochemical basis of obesity – if more energy is consumed (energy intake) than expanded (energy expenditure), the body will store that as fat and it’s a process that contributes to obesity. But we need to look at diet as not just “counting calories” but learning about food types that are more prone to generating fatty tissue per kilocalorie.

Sleep is also a very important lifestyle factor that’s associated with obesity. There’s a lot of active research in this area – studies are showing patients who have obesity tend to have lower number of hours sleeping in a continuous cycle. One reason is chronic pain because of obesity – there’s stress on the spine so they adjust more during their sleep. They’re also more prone to needing to use the bathroom during sleep so they experience chronic sleep loss. There’s a recent randomized controlled trial that showed that patients with obesity who received intervention to extend their sleep to 8.5 hours had lower energy intake, which resulted in a negative energy balance. Sleep hygiene is really an important part of a healthy lifestyle, which can be linked to weight loss.

There are also very exciting developments in medications and very encouraging studies in this area. They studies showed a few medications that are effective in using excess body weight from  five-15 per cent. That’s a great intervention. A lot of the newer medications are not yet approved by Health Canada so we’ll have to see when they become available, but medications will play a big role in managing obesity.

What about bariatric surgery?

There are three things I want people to know about bariatric surgery – it’s safe, it’s effective and that there’s a lack of awareness about it.

If a patient is at a BMI category of severe obesity (over 40 and above) or a BMI of 35 and above with one or more comorbidities, then the patient is eligible and should be encouraged to discuss bariatric surgery. It’s the most effective treatment for those patients.

Over the last 30 years, there’s been a huge improvement in the safety of bariatric surgery. There’s been also been improvements in our understanding of patients with obesity, anesthesia care improvement, and more minimally invasive options. There is such a low risk of death and of severe complications.

Bariatric surgery prolongs the lifespan and increases one’s quality of life. But there continues to be stigma towards patients who need to undergo active treatment for the disease they presume is a behavioural consequence. If you have a broken leg, you see an orthopedic surgeon. If you need braces, you go to an orthodontist. It should be the same way for patients who see professional help to treat their obesity. Yet, only 1 per cent of eligible patients based on BMI and comorbidities end up receiving bariatric surgical care, the most effective treatment for severe obesity.

Jennifer Stranges is a senior communications advisor, Unity Health Toronto.


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