NIC KORMAS: When I first got into medicine at university, the prevalence of obesity would have been one in twelve Australian adults. By the time I became a specialist it was one in six, and the last census is it's now one in three, and that was a few years back. So the prevalence has quadrupled over a period of 30 years. Which is just amazing—it's the fastest growing medical problem that we face.
CAMILLE MERCEP: You're listening to Pomegranate, the Royal Australasian College of Physicians' podcast for continuing professional development.
Obesity can seem like what strategists call a “wicked problem"—a problem with so many parts that it's impossible to solve. But some things are changing. While prevalence is still high in developed countries, childhood obesity appears to be plateauing. Social movements like “Health at Any Size” promote body positive approaches. And at Dr Nic Kormas' clinics, obese patients on average are able to lose 10% of their weight.
Dr Kormas is the senior endocrinologist behind the Metabolic Rehabilitation Programs at Concord, Camden and Campbelltown Hospitals. While these programs manage some of the most complex cases of obesity in the country, Dr Kormas says there are steps every physician can take to help their obese patients.
He's joined on the program by Dr Jacqui Curran, a paediatric endocrinologist at Princess Margaret Hospital in Perth; Boyd Swinburn, Professor of Population, Nutrition and Global Health at the University of Auckland; and Dr Sophie Lewis, a public health researcher at the University of Sydney. On today's episode, they talk about strategies and pathways available for addressing this condition—from the psychological to the physical.
NIC KORMAS: My name is Dr Nic Kormas; I primarily consider myself to be an obesity physician. I became interested in obesity medicine when I was an Advance Trainee doing diabetes clinics. I very quickly learnt that if you could achieve significant weight loss in someone who was obese and who had diabetes, you outperformed any medications. And that not only applies to diabetes but that also applies to other obesity-related co-morbidities as well.
For example, in the Metabolic Rehab Diabetes Program we've had patients who were sent along who people thought they need to go on insulin treatment. Yet the patient didn’t want to go on insulin treatment. Their control was that bad that they were very high risk, and with a significant amount of weight loss, and improvement in their fitness levels, not only did they not go on insulin treatment—they were able to put their diabetes into remission.
So that’s the ultimate goal, having someone who you can turn around and say, “Well, you don’t have diabetes at the moment...your hypertension is not a problem, your dyslipidemia doesn’t need pharmacotherapy, you don’t need to be on CPAP anymore.”
JACQUI CURRAN: My name is Dr Jacqui Curran, I'm a paediatric endocrinologist. I'm working at Princess Margaret Hospital, which is the only tertiary centre here in Western Australia that manages childhood obesity and has an obesity program.
The abnormal eating patterns that children get, and the sedentary behaviour, and reduced activity levels, happens really early in life—and the earlier we can get these children in and get treatments, we're assuming the better. Because the evidence is now coming out from these early life event studies which show that some predispositions to obesity and metabolic disease can be passed down through several generations. So if you can target trying to get in during pregnancy and when that child is learning to recognise satiety and hunger and things like that, you can hopefully make the biggest difference.
It's a very difficult subject to breach if the clinician isn't that comfortable with it. Quite a lot of clinicians feel that parents must know their child is obese and at risk, but a lot of parents don’t know that. They don’t know until you plot that child on the BMI chart and show them that they're an unhealthy weight range that their child is actually at risk. It's become such commonplace to see children who are overweight and obese, with a quarter of our kids falling into that category, that parents will often just accept that in their child. And we need to dispel that, because it will have significant effect on their health long-term, particularly their psychological health.
There is a good association showing that the more obese you are the higher the chance of depression and things like that. And that's often what a lot of our adolescents will present with—the impact it's having on their schooling or their relationships. And that's why we need a multidisciplinary approach to this condition. It's not something a physician can do on their own. They have to do with a team of experts.
NIC KORMAS: The way I like to break things up so that people can understand various programs is—to simplify it in my mind is I talk about the “S's.” So for example, managing anyone with obesity, the first “S” really refers to standard advice—everyone can be given standard advice about better nutrition, more activity, and just psychological wellbeing.
And then after that you’ve got specific advice for people—where patients are seen by a clinician, they're seen by specialised allied health staff who have their role. Whether it be a dietician in regards to nutrition, a psychologist regarding any psychological barriers, a physiotherapist if there are any physical barriers, an exercise physiologist to also help with exercise prescription...I mean, it can get quite broad.
And then after that, the third “S” would be supervision. So some programs have supervised exercise classes, and others just the notion that patients have to come back to a clinic and they're accountable to someone, that's a form of supervision.
And the fourth “S” is really support. Then you’ve got the correct selection of medications, medications that don't promote weight gain, or being able to modify those mediations when people lose weight. Then you’ve got bariatric surgery.
And most importantly, selecting the right program and intensity of program for the right participant. It's a bit like not everyone who goes into a hospital has to go into intensive care. So I think it depends on the complexity of the patient and how much intervention that patient needs.
SOPHIE LEWIS: My name is Dr Sophie Lewis. I'm a public health researcher at the Faculty of Health Sciences, University of Sydney.
When we think about obesity we focus a lot on health, and the physical and emotional health consequences of obesity. But something that we often don’t think about is the social consequences, and the fact that some of these consequences of obesity are actually related to people's reactions, or societal responses, to people who are overweight or obese.
The research shows that health professionals do have negative attitudes towards their obese patients, they do see them as non-compliant, as less motivated, having less willpower than their non-obese patients. And there is evidence that care is actually affected. So health professionals report that they have less patience with their overweight and obese patients, that they have less desire to help them, and also that they have less respect towards them. And they're found to spend less time in consultations and have less discussions with their obese patients.
We also see that people with obesity report they feel more stigmatised by healthcare providers. And as a consequence people who are obese are more likely to avoid or delay medical appointments, and also to get preventative healthcare screens.
BOYD SWINBURN: My name is Boyd Swinburn, and I'm Professor of Population Nutrition and Global Health at the University of Auckland.
I started off in my career as an endocrinologist and particularly, working in diabetes. So I have “transgressed,” if you like, from a clinical space into the public health space. And I'm now trying to operate at that population level.
I think it's really important to look at this from a public health perspective and environmental, societal perspective because that is the origin of the problem. Yes, there are metabolic consequences...there are diseases that come from obesity. But the actual origins are outside the individual, not inside the individual. So this is a big question—what has happened around the world that has managed to drive obesity in almost all countries?
Whatever the driving force is it needs to be global in origin. This is not confined to any one country or any one population, and it's certainly not being driven from within the metabolism of individuals. It's being driven from outside. And the most likely candidate, by far, is the globalisation of the world food supply and everything that goes along with it.
NIC KORMAS: One of the biggest misconceptions is that obesity is due primarily to a reduction in energy expenditure. 80% of the problem is really an excess in energy intake. Patients usually have a reduction in energy expenditure as well, but most of the problem is energy intake. Whether patients do it with food or snacks or liquid calories—that's where primarily the problem is. Whereas most people, and even most clinicians, tend to focus on energy expenditure as the problem and that's not really...it contributes, but it's not the main contributor.
BOYD SWINBURN: This is a normal physiological response to a pathological, or what we call “obesogenic,” environment which is driving the weight gain. We coined the term “obesogenic environment,” Gary Eger and I, we did that in a paper in the mid-90s.
Essentially—on the food side, it is the ready availability of highly palatable, very inexpensive, heavily promoted foods. And those are the ones that you see fill the shelves of the corner stores and the dairies and the delis and the supermarkets. They're all around us, they're within reach, and we're only human—people are better equipped or less well equipped and it requires quite an effort to swim against the obesogenic environment.
NIC KORMAS: What happens a lot of the time is people will see a severely obese person and they can't see past that obesity. And one of the frustrating things I think for a lot of my colleagues is they believe that they should simply be able to tell someone that they should eat healthier, exercise more, and that should be enough. Yet we know from many other problems—as I mentioned, with alcohol excess or other behaviours—that simply telling someone to do something doesn’t mean that they'll do it.
We know that people are consuming excessive amounts of energy. It's working out how they do it, and then the most important question is “Why?”
In terms of the people that I see, the majority of people consume excess energy because they get pleasure out of it. This is part of the hedonic system, but they find it hard to stop. The second group of people that I see, primarily people who have had some trauma in their life, when they consume food or snacks or drinks they actually don’t get any satisfaction out of it. They're using food, snacks, and drinks to eliminate a painful feeling. And they're what I call a “psychological eater.”
People who have psychological reasons for why they're consuming excessive energy really they need to have psychological treatments. And I think that's the most important question, to understand why and to understand that person. Because even with bariatric surgery, 20% of people who have bariatric surgery either do not lose weight initially, or after a very modest or minimal amount of weight loss, end up putting that weight back. And the reason for that is because they're eating because of psychological reasons. And the drive to eat from our brain is much stronger than the gut restrictive or hormone effects.
SOPHIE LEWIS: Weight is a sensitive issue, and it is a challenge for healthcare providers, especially when they're discussing health issues related to weight whilst trying to remain sensitive. So I think one of the big things is actually thinking about language and thinking about sensitive and appropriate language that will make the person feel comfortable. There's been research that shows that words like “fat” and “obese” and “morbidly obese”—they're not neutral terms. They can be stigmatising for people.
So there are some suggestions that less stigmatising words such as “unhealthy weight,” or “above your most healthy weight,” or even just saying “weight” is perhaps a more sensitive way of talking to patients. And also avoiding language that might blame the patient.
I think another thing that would be useful is to self-reflect a little bit and think a little bit about what stereotypes you might have about people of different body sizes—“Do I hold certain ideas about their character about their abilities, or about their health behaviours?” And just reflecting on that. And also thinking about, “How will an obese patient feel after they’ve come to see me for a consultation?” Thinking about providing a safe and accessible space for them, so: having chairs that are appropriate and equipment that is appropriate, reading materials that are sensitive.
Obesity is a social problem and part of providing really good holistic care to people is about managing some of those social consequences.
NIC KORMAS: In someone who has obesity—and that on average means that they're carrying about 13-14 kilograms in excess weight—about 10% of people will be what we call “metabolically normal.” But I mean it depends on what stage they are. If they're very young, with time they will develop some of the metabolic problems associated with obesity. But it's not just the metabolic problems—there's the mechanical, there's also the psychological. And one of the big areas that's becoming a massive problem is the development of cancers, especially in women—endometrial cancers. Colonic cancer is increasing, oesophageal cancer, renal cancer.
Even though a very small percentage of people will be metabolically normal, with just the development of obesity, by the time people get to severe obesity if people are properly screened I think it would be very rare to find someone that does not have one of the obesity related co-morbidities.
JACQUI CURRAN: We do see a lot of parents who are obese, and I in fact in my first consultation always discuss it with them. I ask them when they developed their obesity, and quite often they're quite relieved you brought it up because their fear is that their child will develop the same things that they have. So they might have type 2 diabetes or obstructive sleep apnoea, and their fear is that their child is going to get that too.
And then we sort of open the door to say, “Well look, this program is probably going to help you too and we'll work with you, and then we will try and get as much support in the community as well.” I think you have to not tackle it on your own—as a physician we often don’t have the expertise that a dietician would have, or a physio, or a psychologist, to tackle the whole problem ourselves. So whatever resources are there, you need to use them.
The evidence is that multicomponent treatments are needed to actually get success and long term success. So use whatever is available to you. There are often community programs out there, we have some community programs here in Western Australia where we refer the less severe children.
On the flipside of that, there are some families who do not take on board what they're told, they do not make any attempt to make lifestyle changes for whatever reason. And I think clinicians need to accept that in some of these circumstances we have to consider that it can be medical neglect. Just like if you weren't feeding your child and your child had severe failure to thrive, over-feeding your child and giving them too much nutrition and not providing them with a healthy environment can also be medical neglect.
And in recent years we have, in Western Australia through our community-based Child Protection Services, got obesity and complicated obesity as part of the neglect policy so that we can refer on to external services if we feel there is a case of medical neglect in the case of the parent, or the care provider. Which is a really tricky topic for people to address—a lot of people shy away from it, but I think we have to think what is in the best interest of this child long-term, and it might be that the home environment is not sufficient to provide them with the care they need.
BOYD SWINBURN: There are populations who are at higher risk; in general the highest risk populations are Pacific populations. And that is seen not only across countries, so the Pacific countries are the countries with the highest rates of obesity, but also within a country. If you take a country like New Zealand with a high Pacific population, Pacific people will have the highest rates of obesity. Some of the Pacific Islands, for example, get up to over 90% of the adult population being overweight or obese.
There are other populations that are more susceptible to obesity—particularly Middle Eastern countries are the second fattest region after the Pacific. So people from those countries tend to have a higher risk of obesity. Southern European and a few other populations, but those are the main ones we encounter in New Zealand and Australia. And Indigenous populations in New Zealand and Australia both have high rates of obesity.
JACQUI CURRAN: In our Indigenous populations we need to just be cautious using the BMI charts, as the degree of obesity does not have to be as extreme in these children for them to get complications. So we will often screen them for diabetes and metabolic disease before they would even reach the obese category.
It is definitely more difficult to make changes as people get older, and we know that they are very likely if they're obese as adolescents to become obese adults. And well, I think there's good evidence now that life expectancy is up to 10 years less in someone who is obese compared to someone who is of a healthy BMI.
For the clinicians, the NHMRC Council Clinical Practice Guidelines that came out in 2013 are really excellent, and they're really evidence-based and give some really nice tables on how to approach families on talking about obesity, what things they should be looking for and what questions they should be asking. And I think to refer children on where they do have complicated obesity, or they have very extreme obesity, there are services in most states now for that—which is a wonderful change over the last 10 years. They can usually call the tertiary services to ask for advice as well, if they're concerned about a child.
SOPHIE LEWIS: Yale University's Rudd Centre for Food Policy and Obesity has some great resources for healthcare providers, particularly educational videos and online courses and content, about how to improve quality of care for patients with obesity—with a real emphasis on helping to reduce weight stigma in the clinical setting.
I'd also recommend Dr Rick Kausman's website “If Not Dieting.” He's a medical doctor that provides resources for health professionals about non-dieting approaches to healthy weight management. And he also runs some training courses for health professionals in different parts of Australia.
People in our study talked about how when they stopped focusing on weight and weight loss they actually found that that had a really positive impact on their lives and also the management of their weight. So when they were focusing on their health they were actually able to engage in a lot of healthy behaviours—they were more engaged in physical activity. And that may not have resulted in weight loss but it certainly made them feel healthier, and in some cases did help them to lose weight. They were certainly able to manage their weight better.
NIC KORMAS: Even though you may not be able to simply refer someone to a program next door I think there are many things that can be done. The Get Healthy Program that's been around for a number of years now is a great program as a starting program. It's a program, either internet-based or telephone coaching -based, which doesn’t cost the patient or physician any money. It is outside of business hours as well, so that's a first step that I would say.
And I think the important thing is to engage the patient and then as the patient becomes more complex to increase the level of intervention that's needed. Because at the moment I think for a lot of the medical community it’s become a bit of an all or none approach. I think it's a very powerful message if we as physicians say to a patient, “If you can achieve between 5-10% weight loss, you will lead to an improvement in these obesity-related problems. If you can achieve between 10-20% weight loss, more often than not you'll have a reduction in the number of medications you use. Or, if you can achieve more than 20% weight loss you will, in many cases, you'll reverse that condition and put it into remission.” I think that's a very strong and powerful tool that we have, just giving that simple message.
CAMILLE MERCEP: “How to Investigate Weight Gain in an Adult,” a recent article by Dr Kormas, is now available on our website, as well as links to all the resources, studies, and tools discussed by today's guests. You can find it at racp.edu.au/pomcast.
Pomegranate comes to you from College's Learning Support Unit. The program is presented by Camille Mercep, and this episode was produced by Anne Fredrickson. Thanks this month to Nic Kormas, Jacqui Curran, Boyd Swinburn, and Sophie Lewis for participating in the conversation. The views expressed are their own and may not represent those of the Royal Australasian College of Physicians.
If there's a CPD topic you'd like to see featured on the program, let us know by emailing firstname.lastname@example.org. On the next episode, we'll be discussing the gut microbiome with Dr Peter De Cruz, author of an upcoming IMJ article on inflammatory bowel disease.
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