Doctors Told To Watch Your Weight

The trend line on Canada's obesity rate remains decidedly upward. The Canadian Public Health Agency says more than one in four Canadians is considered obese.There's hope that a new set of guidelines published today in the Canadian Medical Association Journal will help doctors stem the tide.

Obesity rates are up dramatically in Canada. Primary care professionals as being asked to do something to reverse the trend.

The recommendation come from a group called the Canadian Task Force on Preventative Health Care. The task force says primary care professionals (family doctors, GPs & nurse practitioners) and specialists need to be much more vigilant about weight gain instead of ignoring it.  They're being asked to calculate the patient's body mass index or BMI at every visit.  If you don't like pen and paper, here' s a handy calculator.  Measuring BMI at each visit means checking height and weight at every visit because you need both to calculate BMI.  That's because the BMI is the measure that most closely tracks with your long-term survival. Although the evidence for measuring BMI is limited, it's easy to calculate and requires no special training, and can be used to measure changes over time.  The other reason why BMI is recommended is that patients tend to underestimate their weight and overestimate their height and therefore underestimate their BMI. Better to calculate it than to guess.  

Why the change in the guidelines? Since 1978, obesity rates have nearly doubled - from fourteen percent back then to twenty-six percent today.  Obesity increases the risk for heart disease, diabetes, cancer, arthritis, hip and knee replacement surgery and back pain.  The thing is, most Canadians don't start off overweight or obese.  Around two-thirds of overweight and obese adults were of healthy weight during adolescence but gained weight as they got older.  On average, Canadians gain up to a kilogram every two years which in ten years can really add up.  If primary care professionals measure BMI all the time, they'll be in a much better position to prevent further weight gain and thus avoid the associated risks and complications.

The new guidelines also say doctors should offer weight loss programs to all adult patients who are overweight (BMI 25-30) or obese (BMI 30-40), and especially those at risk of type 2 diabetes.  In those cases, they recommend a referral to what's called a structured behaviour modification program with several sessions spread out over weeks or months.  These involve teaching on diet, food choices, increasing exercise and other lifestyle interventions.  These may be offered by the doctor, nurse, health coach or registered dietitian who is part of the team, or by a credible commercially available weight loss program.  Although medications are considered the Holy Grail of weight loss, the task force concluded that the two medications in wide use - Orlistat and Metformin - aren't that effective and have the potential to do more harm than good.

Interestingly the new guidelines say little about weight loss or bariatric surgery. There are three types of bariatric surgery covered by some but not all provinces and health care plans.  Gastric banding involves placing a flexible band around the upper part of the stomach.  The band can be tightened or loosened externally to permit more or less food to be eaten.  Sleeve gastrectomy involves the removal of eighty to eighty-five percent of the stomach.  With gastric bypass, the size of the stomach is reduced and part of the small intestine is bypassed.  Most patients lose a lot of weight, and some find their diabetes and high blood pressure are improved.  Complications include ulcers, bowel blockages caused by scar tissue and gallstones.  A 2014 report by the Canadian Institute for Health Information said weight loss surgery has jumped nearly four-fold in Canada - from sixteen hundred operations performed in 2006-2007 to six thousand six years later.  But that's a drop in the bucket compared to the number of Canadians that could benefit. The demand for surgery is outstripping its availability - especially in Atlantic Canada.  There just aren't enough surgeons and not enough OR time - and so wait times are often measured in years.

To think these guidelines are the answer is to be quite naive. Doctors aren't that great at motivating patients to live healthier lives.  Perhaps a health coach (a peer coach who has successfully lost weight) working alongside the doctor or nurse practitioner might have more success.  Neither do I believe that labelling obesity a disease - something adopted back in 2013 by the American Medical Association - will make much difference either.  It's a myth that medicalizing obesity helps defeat it right up there with other myths that having sex burns off a lot of calories or that being breast fed protects against obesity or that childhood Phys-Ed programs prevent or reduce childhood obesity.   All of those are myths - each unproven by scientific evidence.

Prevention through early childhood education plus making it easier for families to make healthy food choices - are the tactics that offer the most promise.


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