Ep. 32: Rethinking Obesity with Dr. Arya Sharma
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Dr. David Macklin, left, with Dr. Arya Sharma at a medical conference in Buenos Aires.
Leading the fight against the professional weight loss industry is Dr. Arya Sharma, a crusader for a new, medical approach to treating obesity that recognizes the patient’s lived experience and takes into account just how difficult it can be for a person to lose weight and keep it off. But hope is on the horizon, Dr. Sharma says. Here, Dr. David Macklin, Medcan’s director of weight management, interviews his mentor, Dr. Arya Sharma, the founder and scientific director of Obesity Canada.
LINKS AND HIGHLIGHTS
Dr. Arya Sharma is on Twitter @drsharma. Dr. David Macklin is on Twitter @DavidMacklinMD.
Dr. Sharma’s website is drsharma.ca. His post about the new clinical practice guidelines provides numerous links to past articles he’s authored that will provide context on the new approach. That’s here.
A Globe and Mail article by Wency Leung about the new clinical practice guidelines for obesity.
Obesity Canada posted the new clinical practice guidelines for obesity in full.
Here’s the article on the new guidelines in the Canadian Medical Association Journal.
A link to the weight management program Dr. Macklin leads at Medcan.
Please subscribe and rate us on your favourite podcast platform. Eat Move Think host Shaun Francis is Medcan’s CEO and chair. Follow him on Twitter @shauncfrancis. Connect with him on LinkedIn. And follow him on Instagram @shauncfrancis. Eat Move Think is produced by Ghost Bureau. Executive producer is Chris Shulgan. Senior producer is Russell Gragg.
Rethinking Obesity with Dr. Arya Sharma final web transcript
CHRISTOPHER SHULGAN
Hi, I’m Christopher Shulgan, executive producer of Eat Move Think. For some years in this country, a group of maverick MDs have felt frustrated with the way the medical profession treats obesity. The traditional approach didn’t work. If you were defined as clinically obese, you found it difficult to lose weight and keep it off. In one study, most people who lost the weight gained it back within five years. So a group of doctors has led a revolution in obesity treatment in Canada. Their culminating achievement came recently when they published—in the Canadian Medical Association Journal—new clinical practice guidelines for obesity.
CHRIS
Clinical practice guidelines are the directions that all other doctors use to guide the treatment of various medical conditions. That these doctors wrote the guidelines, well that was revolutionary, too. The outsiders had become the insiders. And these guidelines were the biggest ever overhaul of the way obesity is treated in this country—and perhaps the rest of the world as well.
CHRIS
The new guidelines changed the definition of obesity. Rather than talking about body mass index, the new definition is based on health. If excess body fat is affecting your health, you’re obese. It’s that simple. The new guidelines also describe obesity as a chronic disease. They incorporate patients’ lived experience, and the substantial bias and stigma that they face. The guidelines also shift the focus of treatment away from weight loss and to the improvement of patient health.
CHRIS
Which brings us to this episode. One of the people who authored the new instructions is Medcan director of weight management Dr. David Macklin. In this episode, Dr. Macklin takes over the microphone to interviews one of his mentors, Dr. Arya Sharma, a professor at the University of Alberta. Dr. Sharma is the founder and scientific director of Obesity Canada, and a leader behind this new approach to obesity. It’s the rare opportunity that sees two weight-management pioneers in conversation about a fast-changing medical discipline. Here’s Dr. Macklin’s conversation with Dr. Arya Sharma.
DR. DAVID MACKLIN
Hi, I'm David Macklin. I'm the medical director of the Medcan weight management program. Joining me today is Arya Sharma, one of the co-authors of our new and groundbreaking Canadian clinical practice guidelines for the recognition and treatment of those living with obesity. It's a real honour to speak to you. We've spent a lot of time together in our lives. But what many people don't know is the extremely substantial role that you have personally played. And I've seen your humility, but I'll say it anyway, that you've played in the establishment of Canada as really a leading country globally, in the health care practitioners that we have in our country, recognizing those who struggle with weight, recognizing obesity, and supporting them. You've had a real significant role in establishing our country in that position, I actually wouldn't mind hearing a little bit about how it is that you came to Canada, and how did you lead our country to become a world leader in the recognition and treatment of obesity? How does that happen?
DR. ARYA SHARMA
Well, it's a bit of a story. I was born in Berlin, I grew up in India, I went to medical school in Germany. I graduated back in '86 and trained as a general internist. And then I specialized in nephrology. And it was really as a nephrologist, my interest was largely hypertension. And so when I started out my academic research career, my focus was really on hypertension. And my main focus there was really lifestyle and hypertension. So this idea that, you know, if you're eating a diet that's high in salt, your blood pressure goes up, you reduce the salt, the blood pressure goes down, and we didn't really understand the mechanism. So I was involved in, you know, trying to understand how that whole thing works. So I got to be known as sort of the guy who does hypertension in our hospital.
DR. SHARMA
And I remember that one day we were doing rounds on a patient and, you know, we had this professor, and we just admitted a patient who was probably about 140 kilos or something, was a very large patient. He'd come in, he had very high blood pressure. And while we were rounding on this patient, you know, my professor he turned to me and said, "Hey, Arya, you're the hypertension guy. So why don't you explain to us what it is about being large that makes your blood pressure go up? And why does blood pressure go down when people lose weight? And I just stood there, because, I mean, I knew that that's what happens. You know, gaining weight makes blood pressure go up, losing weight makes it go down. But with all the reading I'd done about hypertension, with all this research I'd done around high blood pressure, I really didn't know the answer to that question. And so I kind of probably mumbled something. And I remember that right after that round, I ran off to the library, and I started trying to figure this out. There must be an explanation why when people gain weight, the blood pressure goes up.
DR. SHARMA
It turns out that nobody knew. So this was very well described, and there wasn't a lot of information on what actually happens. And so I said, you know, this is actually an interesting area. I should probably look into this, and maybe I can come up with some kind of research project that's going to explore this. So I got interested in this, and I started thinking about what are the possible mechanisms, and that took me into my first beginnings of obesity research. But I'd already been doing hypertension research for 10 years. I was already well established as someone who was studying blood pressure. And as I started studying about obesity and what happens to the body and what's the physiology and, you know, I got more and more interested in this. And that then took me to my first obesity meeting. And I noticed that this was not a very big meeting, I was going to hypertension meetings where you'd have thousands of people in the room, and you'd have these huge industry exhibits. And these were major massive meetings. And I went to my first obesity meeting, and I don't think there was even 100 people in the room. And I think, you know, 90 of the hundred people were probably dietitians or exercise people. And there might have been the odd psychologist, but I remember quite clearly that I was probably the only medical doctor in that entire room.
DR. SHARMA
And I looked at this and I said, "Well, you know what? If this is a medical problem, we need doctors involved in this, and we need researchers involved in this." And so I said, "Maybe that's what I need to be doing." And so that's where, you know, I kind of switched my career to having more interest in obesity and said, "You know what? I need to look at obesity and see if we can work on this and try to understand what's going on. So this was back in the early '90s. This was before the discovery of leptin. This was before the discovery of everything we know about obesity today.
DR. SHARMA
Now the problem with Germany—and this is getting to the answer of your question, "How did I end up in Canada?" So the problem with Germany is that Germany, you know, if you think of medical systems as being siloed, Germany is probably the best example for that. So, you know, if you're a cardiologist then you worry about the heart, if you're a diabetologist, then your organ is the pancreas, and if you are a nephrologist, your organ is the kidney. And so in the German system for someone to come out and say, "You know what? I want to do obesity," well, unless you can show me that the kidney is the main organ that's involved in obesity, really you shouldn't be touching this area. So I knew that there was not going to be any future for me in obesity research or obesity management as a nephrologist in Germany. And so when I started getting offers from Canada, and the offers were actually coming because of my work in hypertension and genetics, I looked at those offers and I said, "You know what? I'll come to Canada, but you're going to have to let me work on obesity." And they said, "That's fine. You know, just come and you can work on whatever you want to work on."
DR. SHARMA
And that's basically what took me to Canada. And when I came to Canada, you know, ever since I haven't looked back because since coming to Canada back in 2002, so that's 20 years ago, my entire clinical and research career has totally shifted to obesity. And I've had the opportunity of doing quite a bit in obesity, certainly a lot of things that I would never have been able to do as a nephrologist, practising back in Germany.
DR. MACKLIN
And so fast forward to today, three weeks ago or so is published our national guidelines. So the Canadian national guidelines for the treatment of obesity in the Canadian Medical Association Journal, the highest impact medical journal in Canada. 60 specialists, all who probably came into obesity through you, I would include myself in that, here putting together what is decidedly the most comprehensive in breadth, well thought through, and well-researched obesity guidelines that have ever been published. I'd love to hear a little bit more about some of the key points of these guidelines, and be able to communicate to our listeners some of the really important or salient points of this new document, and how it's going to be a call to action for all of us physicians and healthcare practitioners to support those who are struggling with obesity.
DR. SHARMA
Well, let's start with the diagnostic criteria. So traditionally, obesity it's been defined by size. So, you know, a lot of your listeners will probably have heard of body mass index, which is really just a number that you calculate based on someone's height and weight. So there's a formula, you plop it in, and then you get this number, and then you look it up on a chart. And if your body mass index is above this number, well then you have obesity, and if it's below that number, well then you don't. That never made sense to me, because in real life, we know that people come in all shapes and sizes, and size or weight is not really a direct measure of really anything. I mean, you know, you can have people who are large, who are high performance athletes, their BMI comes in at a number that's off the charts if you want, you know? And then there's a lot of people who have health problems that would probably get better if they lost few pounds, but those guys don't consider themselves as having obesity or would not be considered to have obesity simply because their body mass index happens to live below that number on the chart.
DR. SHARMA
So this made no sense to me right from the start. I mean, the minute I started thinking about this, I said, you know, this is the worst possible criteria for any diagnostic disease, because if you're going to call it a disease, you know, we have to worry about labels. So when you say somebody has a medical condition, then you better make sure that person actually has that medical condition. And you don't want to be mislabelling people and you don't want to be missing people. So we talk about sensitivity and specificity for making a diagnosis. And body mass index is terrible at that, because it really doesn't tell you anything about anybody's health. And so right from the start, from the get go, I said we've got to do something about this. If you want to be taken seriously as a doctor diagnosing a medical condition, well then we'd better make sure that our definition of this disease really identifies people who are sick and does not mislabel people who are healthy.
DR. SHARMA
At the same time, you know, we want to make sure we're capturing everybody who's sick and not missing half the guys just because their body mass index happens to fall below this magic cutoff. And so one of the major advances in the current guidelines is that we're moving—actually, in fact, we've completely moved away from this body mass index definition of obesity. And as you just mentioned, our definition of obesity today is really based on whether or not your body fat is affecting your health. If it is, you've got obesity. If it's not, you just happen to be a big person with a lot of body fat.
DR. MACKLIN
A key point of our guidelines describes that people living with obesity face substantial bias and stigma. And that itself contributes to illness and even death independent of weight or body mass index, just living as a target of bias and stigma can have significant consequences. I'm wondering if you might comment on that key point.
DR. SHARMA
Sure. And I can give you again, the story. So this was—I think I was in Canada two days, or I just arrived in Canada. I was barely there two days, and I was just watching Canadian television. And there's an evening program called The National. There's a commentator there was very well known across Canada, you know, a guy called Rex Murphy. And what had happened in that week—and this was actually in the news, that the Canadian Institutes of Health Research, which is one of the major funders, it's a major government funder of health research in Canada, had actually just made an announcement that day that there was a new program and there was going to be $15 million that are going to go towards supporting obesity research. That was the news item. And then this Rex Murphy guy comes on, and basically he spends three minutes ranting about why this is a complete waste of taxpayers' money, because we already know what causes obesity. You know, it's people eating hamburgers and not moving enough and making poor choices. And he does not understand what the need is for research. He also doesn't understand why we would have to spend any research any money on trying to find solutions because there is a solution: stop eating hamburgers and get off the couch and then you'll be fine. So I listened to him ranting for about two minutes, and it became clear to me instantly that if that is the prevailing attitude, then it's very easy to understand that there's never going to be enough funding for obesity research, and there's never going to be access to care. And if you're going to be stuck in that paradigm, and if this is what people think about obesity, then we're not going to, you know, we're never going to make any progress.
DR. SHARMA
So I think on my second day in Canada, I decided that if we were going to do anything in obesity, we are going to have to have this huge task of getting people, decision makers, people in power, obviously health professionals, but also the general public to understand that obesity is a lot more complex than this, and that this is not just, you know, people eating hamburgers and sitting on their couch, that this is a much, much more complex problem that has to be faced. And so right then and there, I decided that weight bias and discrimination was going to be one of my top agenda items that needed to be addressed.
DR. MACKLIN
It's really interesting for me as a physician working in this area is that there's this concept of internalized weight bias. So the concept there is that the messaging has been around this person so long that they've internalized these ideas. And so in a moment of setback or struggle, there'll be automatic thoughts in someone's mind of "I'm no good, and I don't have enough willpower, and I'm not strong enough," leading to emotions of frustration or disappointment and ultimately, de-motivation. And so much of my clinical practice early on, early stages of a clinical treatment of someone struggling with weight is to help them understand their internalization of this bias, and understanding how that's a significant obstacle in their path going forward. By learning that first point you mentioned today that this is actually a real medical condition, which we know is centred in the brain and much is conferred genetically, we can start the unpacking of the messages that were previously internalized. And I hope these guidelines helps practitioners and patients alike start to shift that paradigm to understanding this is a real condition and not a flaw in character, or a lack of willpower. There's a point in our new guidelines that describes that rather than having weight loss alone as a focus of management, that there's this shift that's described in the guidelines, more towards patient-centred health outcomes. I'm wondering if you might comment on that.
DR. SHARMA
Well and again, that takes me back to my old days when I was doing high blood pressure and where I pretty much in every talk that I ever gave about hypertension management or managing high blood pressure, where I had to remind the audience that the whole point of managing hypertension is not to lower blood pressure, it's to prevent people from having heart attacks and strokes. And in fact, you know, in those days, there were actually medications where if you lowered the people's blood pressure, their risk for having heart attacks and strokes actually went up. So you were lowering blood pressure, but you weren't actually achieving the objective. And so if you apply that same logic to obesity management, well then of course obesity management is not just about lowering body weight, because, you know, I can lower body weight in anybody by starving them. Well, that doesn't mean they're getting healthier, that just means that their body weight is going down. In fact, they might be getting a lot sicker.
DR. SHARMA
So making that clear distinction and saying that, you know, the whole goal of obesity management is not about—this is not about getting someone to lose weight, this is about ending up improving the health and improving the well-being of people living with obesity. And if weight loss is part of that program, that's okay. But we've got to do this in a way that's healthy, that improves the health of the patient and not makes their health worse. You know, the reality is also that you can actually get a lot of improvement in the health of a patient with very, very little weight loss or no weight loss. If I have a patient who eats better, gets more physically active, sleeps better, feels better about themselves, is in a better mood, that's going to be a healthier, happier person, whether they lose weight or not.
DR. SHARMA
In all of the previous guidelines that I've seen, the focus has always been on, you know, which treatment can get you the most weight loss, and whatever treatment gets you the most weight loss is probably the best treatment. But that may not be true. And in fact actually, I don't think it's true. So moving away from thinking about management of obesity simply in terms of how do I change or reduce numbers on the scale, but actually looking at what is the health problem here that I'm trying to fix, and making sure that it's that health problem that actually gets better as your principal outcome, you know, I think is a huge shift in obesity management, and certainly that's what we have in the new guidelines.
DR. MACKLIN
I love that idea of a patient-centred focus, because if I think of Obesity Canada, the organization to which you’re the scientific director of, and the conferences that we have every couple of years, and then think about our guidelines, there's a very interesting place that we find for the patient and for their story. I remember at conferences only within Obesity Canada where it would be very common that someone who's been living with obesity will start a conference or start a talk describing their lived experience. In the guidelines, there's a chapter written by individuals living with obesity and dedicated to describing their lived experience. I'm wondering if you might comment on that really interesting shift in focus.
DR. SHARMA
Well, so let's start with the organization Obesity Canada, which is the organization that's produced the guideline together with the Canadian Association of Bariatric Physicians and Surgeons. So let's focus on Obesity Canada. So Obesity Canada was an organization that I started a couple of years after ending up in Canada when I realized that there were quite a few people actually doing obesity research across Canada, but what I really very quickly realized when I was talking to these various people who were doing obesity research in Canada, I quickly realized that a lot of these people don't even know each other because they work in silos. So if you're someone who works on diet, well then you go to diet conferences and you talk about diet and you talk to all your colleagues who worry about diet and you're kind of in this diet silo. And then if you're somebody who works on exercise, well then you go to exercise conferences and your research buddies are all exercise people. And so you do your exercise stuff. And if you're someone who works on appetite, well then you do appetite research.
DR. SHARMA
So all these guys were working in silos. And so I said the first thing you want to do is you want to create some kind of organization that brings all of these people together. Now at the time, there weren't a lot of clinicians doing obesity, right? I mean, there was almost no doctors in Canada doing obesity management. So these were all basic researchers or people who really were academic people, you know, they have laboratories, and they work—if they work with humans at all, a lot of these guys were doing animal studies. But if you worked with humans at all, you're usually working with more or less healthy volunteers. So this was not clinical practice. And so when they started organizing these meetings, we would bring all these people together, and they would get to know each other and you'd talk about the research. But what I quickly realized that a lot of these people didn't really know what the lives of people living with obesity was like, because they were not clinicians. They weren't working in a doctor's office where you would see people with obesity come in and who have problems.
DR. SHARMA
And so they didn't really know what the life story was. And so, you know, after a couple of these meetings, I realized that all these guys who are not—they all look at themselves as obesity researchers, but nobody's ever spoken to anybody who actually has obesity. And that makes no sense to me. So I said, "You know, we've got to bring the voice of patients living with obesity into this conference." And so I remember in Toronto, it was probably six or eight years ago, when we had our first meeting there, where we brought in patients. And we just said, "Get up there on stage. And, you know, in 10 minutes tell us what your life looks like, and what your take on the problem is." And I could just watch the audience, because I think every assumption they ever had about obesity based on their research kind of flew out the window, because here they were actually hearing a life story about someone who had had, you know, sexual trauma when they were five years old. And then they had depression, and they had binge-eating disorder and PTSD. And here you had all these researchers worrying about healthy eating, who'd never heard the story and had no idea that this was the real problem.
DR. SHARMA
And so that has now become routine in all of our conferences. Every single session that you would go to at an Obesity Canada conference is opened by a patient presenting their story. And what I found was that this is not just helpful for people who are non-clinicians, but even a lot of the clinicians actually when they listened to those stories are surprised, because in clinical practice patients don't get 10 minutes uninterrupted to tell you their life story. You know, in clinical practice, we ask questions and they give us answers and then we move on. So even for a lot of clinicians, being able to listen to some of these life stories, I think was very revealing. And that has now become part and parcel of our program. So for me, it was clear right from the start that if you are going to write guidelines, we have to bring the patient voice into those guidelines. Because traditionally again, when you do guidelines, you know, you look at all the randomized control trials, and again you've got the researchers and you know, you're basically looking at scientific data, and then you kind of count outcomes. It's what you describe as being quantitative. There's a lot of numbers there.
DR. SHARMA
But what's missing there is the qualitative aspect. You know, the "Okay, how do you feel about this, and how does this actually affect your life? And let's look at shame and let's look at blame and look at self-efficacy. And how do you feel about your body? And what's your body image, and how do you feel as a person when you lose weight, and then you just end up putting all the weight back on? How does that really affect your life?" So when you start looking at those things and actually start incorporating the patient voice, then of course, you end up with guidelines that are going to be very, very different than if you were just looking at numbers on the scale. And the fact that we've actually managed to take that qualitative research and incorporate the learnings from the qualitative research and combine it with the quantitative research which is the traditional numbers, we've actually ended up with a guideline, which if you read as a patient, you actually find your voice in those guidelines. And I think that's really the big difference. And I think that's when a lot of people read these guidelines and say, "Well, now I understand what these patients are going through and what these patients need." And I think that's why we ended up with guidelines that are very, very different from anything that's been there previously in obesity.
DR. MACKLIN
So Arya, I'm really lucky. For the last 16 years I've been able to run a clinical practice where I support individuals living with obesity with treatment with a multidisciplinary team. I bill OHIP, the billing processes within my province here. But you've discovered in work that you've done with Obesity Canada that that's really an abnormal state, that someone living with obesity has access to ethical, evidence-based effective treatment. In fact, you went pretty far to examine really to what level—and this is a key point in our national guidelines, which is describing that individuals living with obesity should have access to effective interventions that include behavioural interventions, food and exercise elements, psychological interventions, pharmical therapy, surgery. And you've spoken in the past and examined the current state of access in Canada to those effective and ethical treatments. I was wondering if you could speak to that as well.
DR. SHARMA
Well, I think obesity as a problem is unique in the sense that while we do have a few medical treatments that we can offer people living with obesity, most people are not looking to the medical system for help. So all the patients find that yes, of course I have obesity, and of course it's affecting my life. They're not reaching out to doctors for help. The people that they reach out to is the commercial weight loss industry. And that is quite unique. We don't have a commercial cancer industry. We don't have a commercial industry that's out there where people with diabetes can go to get their blood sugar lowered. You know, we don't have for people who have heart failure and they end up having edema, we don't have a water loss clinic or a edema management centre that's run by some guy where you sign up and then they have some kind of plan that they sell you. And then you walk in there every week and then they put you on a scale and then they say, "Oh, see? Now you've got less edema." And that's what you're paying for.
DR. SHARMA
So in a lot of areas of medicine, we don't have that private industry that's taking your money and offering something that at the end of the day, we all know does not work, right? Because I have yet to meet the person who's lost weight in any one of those programs and, you know, two, three, four, five, six, ten years later is still keeping the weight off, because we know that's not how bodies work. So I think one of the main challenges we have in obesity is that we are competing more or less with this commercial weight loss industry, which is basically everybody. I mean, every fitness studio that you sign up for was going to promise you weight loss. You know, every second week there's a new diet book that's going to sell you the secret code to obesity, or the secret something or the other about obesity, the secrets your doctor does not want you to know. You know, that kind of nonsense. You know, every 10 years, we've got the resurgence of the low-carb keto diet, which has been around for about 100 years. But every 10 years, a new guy comes along and it's just like he's reinventing the wheel, you know, and he writes the best seller and sells you the same old nonsense that's been around for 100 years that we have learned in 100 years does not actually work. But there's a lot of money to be made here. And that's, of course, where people go.
DR. SHARMA
So this has two effects. The first one is, when patients think about, "I need to really do something about my obesity," they're not thinking, "I need to go to my doctor and talk about obesity." No, they're thinking, "Which of all of these commercial programs do I sign up for? Well, I'm going to sign up for the one that either my friend has gone to, or the ones who have the fanciest ads, or the guys who can promise the most weight loss, or the one that I haven't tried yet, because there's so many of them. So I've tried 20 of those programs, they haven't worked. But, you know, there's now program number 21 that I can try." And so you're kind of competing with that commercial weight loss industry that, by the way, is completely unregulated. I mean, I can open a weight loss centre tomorrow, nobody's going to ask me my credentials, I can promise whatever I want. Nobody's controlling me, nobody's policing me. I can do whatever I want. Now if I tried opening that kind of a centre, I'm going to call this the breast cancer cure centre. And I'm going to set up shop at your local mall, and anybody who's got breast cancer come to my office, I've got this new program. It's all that stuff your doctor does not want you to know. There's mysterious vitamin injections and there's ozone therapy and there's you know, otter infusion and all the nonsense I can think of, well they'll shut me down in 24 hours.
DR. SHARMA
But for obesity, you know, it's a free for all. Do whatever you want. You know, sell any nonsense you can sell, you know, whether there's any data supporting or not. I mean, whatever scam you can come up with, you're welcome to do it, right? So we've got this huge industry that's earned billions and billions of dollars, who has absolutely no interest in us calling this a disease, because the minute we actually say it's a disease, suddenly all those guys have to shut down their shops, right? I mean, if you say obesity is a disease like cancer, well that means all my weight loss nonsense has to go away because suddenly that becomes a regulated industry. Well, that's the last thing any of these guys want. That's their living.
DR. SHARMA
So we've got that problem. Now part of why they can get clients and clients will have a hard time finding you is because they're not regulated, which means they can have billboard ads, they can have TV ads, they can do all whatever they want. You can't do any of that. Why? Because you're a regulated health professional. I mean, there are clear strict rules about what you can advertise. You can't even call yourself an "obesity expert" on your own website, because the college will instantly shut you down. Okay, so it's completely unfair. So that's one of the problems. The second problem there is that if that's what you're competing with, then the things that we can offer as evidence-based treatments, even if you take bariatric surgery as the most effective evidence-based treatment for obesity, you know, the average outcome there is what? 20 percent weight loss, 25 percent on average. So now you started at 400 pounds and you've had bariatric surgery and you've done extremely well and you're actually doing better than the average, well you're still 300 pounds. Now people look at that and say, "Well then, why bother?" Now you and I know that 100 pounds of weight loss makes a huge difference, and that your chances of keeping the weight off after you have surgery is, I don't know, a thousand times more than anybody who loses 100 pounds with any kind of crazy diet and exercise program. Now you and I know that. But we're not even allowed to say that because that would be like we're advertising our programs and we would get shut down by the college. But if you're some entrepreneur-type guy setting up shop, well you can say, you know, get 150 pounds weight loss guaranteed. You know, money back guarantee, all that kind of nonsense.
DR. SHARMA
So we're not fighting with similar weapons here if you want, and I think that is a big huge part of why patients are not reaching out for ethical programs, because they get sucked into this commercial weight loss industry. Now the existence of that industry also makes it very easy for policy people to then say, "Well, why should we be funding obesity treatments out of taxpayer dollars? We already have a weight loss industry that people can go to for treatment." Because the people who make those decisions don't understand well, that's not actually treatment. Those are scams. Yes, you lose the weight but you put it back on, guaranteed. That's the only thing a weight loss program can guarantee is that when you lose the weight, I can guarantee you're going to put it back on. That's the only guarantee they can actually give you. But they're a great excuse for anybody saying, "Well, you know what? We don't have enough money in the system, so let's print the system on other things because, you know, weight loss anybody can—you know, you got a weight loss centre at every corner, so people living with obesity don't really need our help." So that's a great excuse for not providing obesity treatments in the healthcare system.
DR. SHARMA
And it's all based on this idea that obesity is simple. You know, obesity is energy in energy out. You know, just eat fewer hamburgers, get off the couch, and you cure the problem. So we are back to weight bias and discrimination. And so that's a huge problem that we have in obesity, which we simply do not have in a lot of other medical conditions. In fact, I can't think of any other medical condition where you've got this billion-dollar scam industry that's out there offering stuff that we all know is nonsense and doesn't work, but they can do it and we can't. So that's a huge problem in obesity.
DR. MACKLIN
So I love your summary of the problem. And yet, I find solace and a more than mild level of excitement, knowing really what's coming down the pipe. I have a sense that not only have I seen effective behavioural interventions, which the sophistication has grown and using technology can support that, using remote visits can support them, but there really seems to be—I'm wondering if you might comment about this—a real recent progression and development of effective medications that can support a behavioural intervention, and when combined with a behavioural intervention can be quite effective. Are we going to see medication soon that can support someone living with obesity, almost to the level of the results that they can get in quality of life and health from gastric bypass surgery? Are we moving in that direction?
DR. SHARMA
So let's start with the basic concept of why do you even need—why would you even consider medication? Or why would you even consider bariatric surgery as a treatment? Why does simply following a diet and reducing my calories and doing my exercise program and losing weight, why does that not solve the problem? Like, why would anybody even argue that no, you need a medication or you need a surgery to do this? And this has to do with the fundamental way that bodies work. And when I see patients, one of the first things I tell them, "You know what, here's what you're up against. Bodies like to gain weight. They don't like to lose it." In fact, there's a very complex biology that will actually make it easier for your body to gain weight, but then when you try to lose the weight, your body's going to respond by not letting you do it. It's going to fight you, and it's going to fight you for every single pound that you're trying to lose. And now there's all these tricks that you can do to trick to your body into losing weight, but sooner or later, your body's actually going to notice that you're losing weight, and it's going to fight you. And this is where I say, you know, anytime you try to lose weight, it's always like you're pulling on a rubber band, and that rubber band, the more weight you lose, the tighter the rubber band gets. So, you know, the first three, four pounds are easy, but then the next four or five pounds are going to be a little bit more difficult. And then by the time you get to 10 and 15 pounds, it's going to get even harder. And then at some point, your body is going to say, "Enough of this nonsense. Enough is enough." And no matter what you try to do, your weight is not going to go down anymore.
DR. SHARMA
And that's the famous weight loss plateau, which everybody's experienced, right? So first two weeks into your diet, you think you're doing great, and then you come to the point where you say, "Well, this diet is no longer working because I'm still doing everything but I'm not losing weight." And then you start coming off your diet and boom, you know, in half the time it took you to lose the weight the weight's back. That is normal biology; that happens to everybody. That's what happened to me. If I tried to lose five pounds, my body's not going to like it. It's going to fight me. And sooner or later that weight is going to come back. Now what has changed in obesity management is that we've kind of largely, I think, solved the puzzle of how the body defends its body weight and what the body does to limit weight loss when you try to lose weight, and how the body sets you up for failure, or weight regain if you want to put it that way. Because your body's got all these tricks, it's got a whole bag of tricks. It's a complex biology there that is actually going to make it much easier for you to put the weight back on than somebody else. If you took somebody who has never been 250 pounds. I take someone who's 200 pounds, never been 250 and I try to get them to 250 pounds, that will actually take a lot of effort to get them up there, and I might not even be able to get them up there. But for someone who was 250 pounds who lost 50 pounds and is now 200 pounds, they can put 50 pounds what, in four weeks, right? Because there's a different biology there.
DR. SHARMA
Now that we've understood the biology, we can take the next step. Because now we understand that that's the biology you're going to be up against. Now you can try to fight the biology with willpower. But we know that willpower is only very limited. You know, some people can do it, but you pretty much got to dedicate your lifestyle to lifestyle change, and maybe you can do it, or you've got to have a mild form of OCD, well then maybe you can get away with it. But for most normal people who have normal lives, who have got other stuff in their life to worry about, they don't have enough willpower to keep doing this for the rest of their lives.
DR. SHARMA
Okay, so what else can we do? Well, now let's go to surgery. Why does surgery even work? Well, because surgery fundamentally changes the biology. Because of the operation, your body is in a poorer position to defend its body weight than it was before surgery, because half the tricks that your body is going to use to try to defend its body weight now no longer work. Why? Because you've had the surgery. So what you've actually done is you've made it possible, you know, with that willpower that you have to now actually do something that's possible. There's no guarantee, but because of the surgery, a fight that was virtually very, very, very hard is now, because you've had the surgery and the surgery has changed the biology, now you have a fighting chance. So now that we've understood why surgery actually works, we can say, well then what does surgery actually do to all of those hormones and all of those signals that are making this so difficult for you to keep the weight off?
DR. SHARMA
And now that we know the hormones and we know the molecules and we know the receptors, we say, "Well, you know what? Maybe we can actually target those receptors and those systems with pharmacology. And so now we have medication that will actually specifically target those molecules that are getting you to not lose weight or regain the weight. And so now the medication actually kind of does what the surgery does, except that, you know, because it's a medication that you can take, that's obviously most people would probably much rather take a tablet or have an injection once a week or something like that, rather than major surgery. You know, major surgery, even the best surgeon still has the risk. And the biggest problem with surgery is well, if you don't like it, there's no way back because, you know, you can't try surgery. You know, you're either you're going to have it or you're not going to have it. But medication, you know, there's a chance you can try it and it works for you, that's great. If it doesn't work for you, well then you can stop it, right? So now that we've said these are all biological processes that we can target, we are actually now in a position where we can work with—the pharmacologist can actually develop medications that very specifically address and target those molecules which are making it so hard for people to lose weight and keep it off, that when these people are on those medications—and that's when all the data shows—they have a much higher chance of actually keeping the weight off than if they were trying this with willpower alone.
DR. SHARMA
And at the end of the day, you know, that's exactly what we do for people who have hypertension, or that's what we do for people who have high cholesterol, or that's what we do for people who have diabetes. I mean, what do we do for all of these people? We treat with medication that target the specific molecules and specific processes that are causing the underlying problem. And that's where we're going to be moving towards in obesity. The more we understand about the science of obesity, the more we can actually start targeting those molecules and those receptors and those enzymes that are causing people to regain the weight. Because that's how biology works. And that's why I'm very optimistic. Because I think now that we are starting to take obesity seriously, and where we are understanding why it is that people who lose weight but, you know, with the diet and exercise always tend to put the weight back on, not because of any fault of theirs, but because that's how bodies work, we can actually now change the biology through those medications and through the surgery. And that's why I'm very optimistic that we are going to be having treatments for people that are going to give them long term success, which they're not going to find by simply relying on their willpower. Which is what we see. Because, you know, the vast majority of people who, no matter what diets they're on, no matter how they do it slow, fast, high protein, low protein, high fat, low fat, whatever the diet is, most of these people are going to put their weight back on.
DR. SHARMA
Now we know that people who are on medication, if they keep taking those medications, have a much better chance of keeping the weight off. We know that people who have bariatric surgery, most of those people actually do keep the weight off. And we've got long-term data, 35 years. Well, show me somebody who's lost weight with diet and exercise and has been keeping it off for 35 years with no effort. That's what surgery can do for thousands of people.
DR. SHARMA
Now, surgery unfortunately, of course as I've said, you know, it's not an easy treatment. And you can't do surgery on, you know, half a million people or a million people. So we have to ultimately have medical treatments which you can use for lots of people, in the same way that we use medical treatments for diabetes, we use medical treatments for heart disease, we use medical treatments for all kinds of diseases, and that's what medicine does. But you need to make sure those medications work, they're safe, they're efficacious, they don't have side effects that cause problems. So there's still a lot of research to be done, but I think we're moving in the right direction here. And I think we're going to see a lot of changes happening in obesity management.
DR. MACKLIN
So Arya, those are exciting principles. I'm wondering if you might share your vision. I'm sure the listeners are kind of curious where's this going? What would be your vision of, you know, five years from now or 10 years from now someone living with obesity? What would their relationship be with their physician? And what kind of support and treatment will they receive? What kind of outcomes might they expect in the near future?
DR. SHARMA
Well, I think where we need to head with obesity is in a direction that we've already headed, you know, that already exists for a lot of other chronic conditions. If you think of someone who is diagnosed with diabetes, where do you go for help? Well, you go to see your doctor. And what's your doctor going to do? They're going to try to find out what kind of diabetes it is, what do you need as a treatment, they'll send you to the diabetes educator, you're going to learn all about diabetes, they're going to put you on different medications. You know, this could be tablets, this could be—you know, this might be insulin injections. They'll set you up for coming back in a few weeks. You know, they're going to get you probably to measure your own blood sugar so that you can stay control. And they'll actually help you manage your diabetes. And if you look at all of the resources that are out there for people who are living with diabetes and all the support that they have at the doctor's office, from the nurses, from the dietitians from the community resources, there's a whole infrastructure that's there to support people living with diabetes.
DR. SHARMA
Now in obesity, we don't have any of that. But I think that's what we need in obesity, and I think that's what we're going to see in obesity. And we're already starting to see it, you know? And I can imagine, you know, when a patient comes to see you for their obesity, well then you're going to take time to figure out what the problem is, you want to make sure you got the right diagnosis. And once you've got the right diagnosis, you're probably going to have a conversation with what you think the right treatment is. And then, you know, you come to some kind of agreement with your patient. Okay, so this is what we're going to do. And then you're going to help the patient. And if there's community resources that you think are going to be helpful, then you're going to direct the patient there. You're certainly going to educate your patient. So you're saying, "You know, you've got obesity. You're going to live with this for the rest of your life, you better learn about it." And so there'll be courses and there'll be resources. And at the end the day, you know that you're going to be seeing this patient pretty much for the rest of their lives, they're always going to come back, they're never going to get discharged as cured because I've been doing this for 30 years, I've never cured anybody's obesity. Which is fine. I also have never cured anybody's diabetes, you know? I've also never cured anybody's hypertension. And yet I think I do a good job of managing diabetes and hypertension. And we can do a good job of managing somebody's, or helping someone manage their obesity. You know, it's not going to be a cure. And it has to happen in the same way that we manage other chronic diseases.
DR. SHARMA
So what I envision as the future is that when a patient feels that somehow this weight thing, you know, I need to do something about it, they go to see their doctor, and the doctor hopefully then not only has the right attitude, but also has the right knowledge about obesity. Knowing that this is a chronic condition, knows what questions to ask, knows what the diagnostic criteria are, knows what tests to perform and knows what the treatment options are that actually work. And then works with the patient and says, "Okay, here's what you need to do. Here's what we can try." I mean, we never know whether anything works for anybody, you got to try these things sometimes. But you know what? It's a therapeutic relationship in the same way that you have a relationship to your family doctor for depression or for hypertension or for type two diabetes or heart disease or Crohn's disease, or you name it. You know, who's your partner in all of that? That's your family doctor. Well, your family doctor also needs to be a partner in obesity.
DR. SHARMA
I think that's where we need to get to. And I think that's what the guidelines are for. And hopefully these guidelines are going to be read by a lot of family doctors, who even if they don't get all the information they need from those guidelines, at least know where the bar is. The bar is that you should be able to get from your family doctor the exact same level of attention and professional help that you would get from your doctor if you went there with any other medical condition. If you went there with your diabetes or your hypertension or your heart disease or your lung disease or whatever disease it is, you want that same level of care. And in fact, you have a right to that same level of care. You know, we have a public health care system. It's your tax dollars. Why should your tax dollars pay for everything that the guys with diabetes are getting and the people with arthritis are getting, and then you show up with your disease, and so sorry, you know, we don't do obesity. That's your fault. You're on your own. We need to move away from that. And I hope the guidelines are really going to help us do that.
DR. MACKLIN
You’ve really closed out with a positive vision, Arya. Listen, it's such a pleasure listening to you. You've done remarkable things for Canada. You've helped the physician and medical community advance, I think, above any other country in our recognition and support. I think our most recent guidelines, which I had the honour of being a co-author on as well, will go as far as we take them. So I like your vision, and let's all get to work and make sure that happens sooner rather than later. Arya Sharma it's been a real pleasure. Thank you so much for taking your time today, and I look forward to working together with you as we embark on the challenges that we face and supporting those who struggle with this real medical condition. All the best, Arya. Thanks again.
DR. SHARMA
Well, thanks for all the work that you do in your practice. And thank you very much for having me.
DR. MACKLIN
My pleasure, Arya. All the best.
CHRIS
That’s a wrap for this episode of Eat Move Think. Check out the podcast website for highlights and full episode transcripts at Eatmovethinkpodcast.com. Eat Move Think is produced by Ghost Bureau. Senior producer is Russell Gragg. Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow host Shaun Francis on Twitter and Instagram @Shauncfrancis—that's Shaun with a "U"—and our sponsor Medcan @medcanlivewell. We'll be back soon with a new episode examining the latest in health and wellness.