Setting Up An Obesity Program: Medical Expertise and Leadership

Now that we’ve looked at some of the issues around gathering administrative support for setting up an obesity program, we must turn our attention to the next key step, i.e. finding personnel to staff the program. This of course starts with finding appropriate leadership for the program – be it medical or surgical.  Today, thanks to the proliferation of bariatric surgery, finding surgical leadership for a bariatric program is in many ways far less challenging than finding medical leadership. Indeed no one would today consider hiring a bariatric surgeon who has never performed such operations to run a program. Bariatric procedures are now increasingly listed in many licensing catalogues for general abdominal surgery. There are also an increasing number of surgical bariatric centres, which regularly train residents and fellows. Thus, finding a trained bariatric surgeon to establish and lead a bariatric surgery program is rather straightforward.  In contrast, finding experienced and qualified medical leadership for an obesity centre is far more challenging. For one, while you would require a surgeon to have performed a certain number of bariatric procedures (hopefully in the hundreds) before claiming expertise in the area, no such requirements exist for other health professionals.  Thus, there is currently no accepted pathway or minimal requirement that would stop any medical professional who takes an interest in this field from setting up their own “weight-management” program.  As in my case, when I embarked on running my first obesity clinic two decades ago, I had no specific training or experience in obesity medicine – in fact the term “obesity medicine” was not even around yet. All I had was a bunch of, what I then thought were, good ideas, an interest in the field, and strong administrative support to do something in this area.  My story is by no means unusual. Most of my colleagues in this field had little, if any, formal training in obesity medicine and had little more than good intentions and a lot of hope and determination when they set out to work in this area. Many were guided by their own personal “weight-loss-success” stories, their strong interest in “preventive medicine”, or simply their fascination with healthy eating and/or exercise. Few had ever worked in an actual obesity program. Even fewer had completed a formal fellowship or had any kind of training or certification in this field.  Given that there is no accepted pathway to obesity medicine,… Read More »

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Saturday Stories: Anti-Vaxxer COVID Playbook, A Potentially Scarier Variant, And Ontario’s Abysmal Response To Date

Scott Gavura, in Science Based Medicine, on the anti-vaxx campaign to erode confidence in COVID vaccines.

Julia Belluz and Umair Irfan, in Vox, on the new South African COVID variant that may challenge current vaccines.

André Picard and Adalsteinn Brown in conversation with Matt Galloway on CBC’s The Current on Ontario’s disappointments in our fight against COVID (do give this a listen, and wow, Dr. Brown’s frustration is something to hear)

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Administration: Managing Expectations and Collegial Support

A final word on gaining administrative support for setting up an obesity program relates to the issue of managing expectations and ensuring support from colleagues in other disciplines.  As much as I have seen administrators get enthusiastic about setting up an obesity program, I have also seen them get overly optimistic about the outcomes, both in terms of health impacts and earnings (private) or savings (public). The reality is that our current obesity treatments, although much better than doing nothing, are far from “magical”. Like everyone else, administrators’ expectations have often been anchored to the rather unrealistic anecdotal before-and-after pictures touted by the commercial weight-loss industry or the overly-hyped “success” stories that are regularly celebrated in public media. This problem is even more serious, in cases, where an administrator has apparently “conquered” their own obesity and believes to have found the “cure”. Convincing them that these anecdotal outcome are not typical and can generally not be achieved in serious obesity programs can prove quite challenging. Many find it hard to believe that, based on the best evidence we have, the average more or less “sustainable” weight loss that can be achieved in lifestyle or behavioural programs focussing on diet and exercise (even with good psychological support) is roughly in the 3-5% range. Thus, a 200 lb patient who ends up at 190 lbs at 2-5 years after entering the program, is pretty much exactly where you’d expect them to be! While even this rather modest change in body weight can have important health benefits (e.g. reducing the risk for diabetes by about 75% in people with pre-diabetes), it is not very impressive when you are expecting to see people lose 50 or even 100s of pounds. Even with the addition of medications (where available), average sustainable (with continued treatment) weight loss is only in the 5-15% range (bringing your 200 lb patient down to perhaps 180 lbs). In fact, even with bariatric surgery, the average long-term weight loss is in the 20-30% range (still leaving your patient at around 150 lbs). If administrators, like most patients are hoping for a 50% weight loss, they are likely to be deeply disappointed.  This is not to pooh-pooh the benefits of an obesity program – indeed, even with just a “lifestyle” program, you may well achieve significant improvements in health despite rather modest change in body weight (if any). Indeed, even just preventing… Read More »

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Administrators: Space and Attitude

In my experience, administrators tend to often underestimate the amount of outpatient space needed to run an obesity clinic. Given the larger size of these patients, there is need for larger seating, larger scales, larger exam tables, and wider doorways (not to mention the critical importance of floor-mounted toilets!). This means larger waiting rooms, larger exam rooms, larger changing booths, larger rooms for group sessions, etc. Add to this, the additional time needs for patients to dress and undress and move between rooms, it should be no surprise that an obesity clinic will take up at least 50% more space than a regular clinic to see the same number of patients per unit time.  And while we’re on the topic of space, let us consider the physical location of the clinic in terms of accessibility including distance from parking or public transportation. Having to walk a few hundred metres, navigating ramps, long hallways, or even stairs may prove physically exhausting or almost impossible for patients with severe obesity and mobility issues.  At this point it may be appropriate to put in a plug for an exciting project on designing a bariatric-friendly hospital, championed by my colleague Mary Forhan in a partnership between Alberta Health Services and Obesity Canada at the Medicine Hat regional hospital in Alberta.  Key findings from this project, that would make an in-hospital encounter far more safe, efficient, and pleasant for both patients and staff include mandatory education of all staff on weight-bias and respectful interactions, better understanding of the unique needs of people living with obesity, access to and knowledge in the use of bariatric equipment and supplies, and the need to respectfully communicate patients’ needs to other departments (e.g. diagnostics, wards, etc.). As a learning from this project, Obesity Canada is currently working on finalizing a simple labelling system that would readily indicate the weight capacity of all hospital or clinic furniture and equipment. Finally, when it comes to naming the program, I recommend avoiding the use of the word “weight” (as in “Weight-Loss Clinic”, “Clinic for Healthy Weights”, “Weight Wise”, etc.), as a key tenet of obesity management is to improve the overall health of the patient and not just focus on changing numbers on the scale. This is why I much prefer the terms “Obesity”, “Metabolic”, or even “Bariatric”, as used in a clinical context.  These terms will also help differentiate your centre from commercial… Read More »

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Educating Administrators

While we’re on the topic of harnessing the enthusiastic support from administrators for an obesity program, it is important to consider that administrators, like most people, have little experience in thinking of obesity as a chronic disease nor fully appreciate the complexity of its causes or the need for multi-modal treatment pathways. While, given the clear unmet need,  one may well succeed in convincing administrators of the need for setting up an obesity program, they may not be thinking beyond “educational” interventions focussed on promoting “healthy lifestyles”.  In fact, their idea of an obesity program may be limited to providing dietary or exercise counselling, whether to individuals or groups, in the hope that this will be enough to help patients reduce their weight.  At the other end of the spectrum, administrators may be gung ho about bariatric surgery (perhaps hoping for a new income stream), little recognising that such a program requires far more than simply hiring surgeons and giving them sufficient OR time. They may in fact be surprised that such a program involves medical management, psychologists, dietitians, and nurses, not to mention the considerable space and infrastructure required for intake, pre-surgical assessment and management as well as extended follow-up. In addition, there is almost never consideration or plan for post-surgical abdominoplasties or body contouring surgery.  Lately, with the increasing availability of effective anti-obesity medications, the boundaries between “medical” and “surgical” programs is fast eroding, as these medications, and thus medical management, is proving to be an integral part of pre- and post-surgical care. Thus, today, obesity programs must plan to integrate both conservative medical as well as pre- and post-surgical management of patients (even if the actual surgery may be performed elsewhere). Thus, a key step in gaining administrative support for setting up an obesity program, is ensuring that they fully understand the nature of obesity and the complex needs of these patients, so that they plan for the provision of what is required. Simply hiring a dietitian and an exercise specialist does not constitute an obesity program, nor does simply performing a few bariatric surgeries on anyone willing to pay for them.  @DrSharmaBerlin, D

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Saturday Stories: The Myths Of Pandemic Fatigue, COVID Is Absolutely Controllable, And On Being A Female Expert

If you’re not already following Dr. Popescu, you should be.

Stephen Reicher and John Drury, in the BMJ, on how adherence to COVID recommendations is reliant more on resources and less on motivation or energy.

Gideon M-K, in Medium, with the plain truth – COVID is absolutely controllable through government interventions and if your government isn’t controlling it, that’s a choice they’ve made.

Jessica Gold, in Forbes, on the many layers of added nonsense that women who are COVID experts face online and in the media.

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Administrative Support: Buy-In and Enthusiasm

Now that I have discussed some of the “Big Picture” barriers that need to be considered when thinking about setting up an obesity program, it is time to take a deeper dive into the challenge of harnessing administrative enthusiasm and support. Obviously, for folks in the private sector, who are their own bosses and can pretty much do whatever they want, this topic is not of relevance. However, for those of us working in health systems, public or private, where funders, governing boards, administrators, business managers, and accountants have their say in what services are to be delivered, obesity programs are not an easy sell.  Although everyone is by now aware of the rising prevalence of obesity and its impact on health, most administrators (like most people) have little understanding of the complexity of the field. Indeed, many still don’t consider obesity a chronic disease or see the need for programs that go beyond providing some education and encouragement to eat a healthier diet and to be more physically active. Given that there is always a shortage of funding in health systems, weighing investments into this new area of medicine against investments in other, more established disease areas (all of which have their demands), is anything but straightforward.  One approach to getting interest from administrators may require making a case for obesity care that either promises a new revenue stream or cost-savings in other areas. However, in my experience, neither attractive revenue streams nor significant savings within the health system are easily demonstrable, especially over shorter time frames (e.g. 3-5 years). This is because setting up and running a high-quality and effective obesity program will require significant up-front investments in space and ongoing expenditures in personnel, with little immediate return on investment other than hopefully improving the health of patients living with obesity. Thus, trying to “sell” obesity programs to administrators using financial arguments is generally a difficult prospect.  There are of course exceptions. Thus, for example, in public systems, when governments make separate streams of targeted funding available for obesity programs, hospital administrators may sense an additional source of revenue. For e.g. a few years ago, when the Ontario Ministry of Health announced a separate funding envelope for creating bariatric surgical programs, several hospitals in Ontario (almost overnight) developed a keen interest in setting up such programs. Indeed, even in the private sector, bariatric surgery programs, in contrast to… Read More »

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Professional Barriers to Obesity Care

Put simply, one of the biggest barriers to setting up an obesity program is that most clinicians have little or no formal training in obesity assessment and management. Indeed, in most jurisdictions, there is currently no established or recognised pathway to becoming an obesity doctor (with rare exceptions for e.g. the ABOM certification), let alone any incentive to specialise in this area. Furthermore, as established centres are rare and far between, most clinicians will never have worked at such a centre or even seen one in action and will have to figure out most aspects of their programs for themselves.  Thus, although one may see the need for, have the interest in, and be enthusiastic and dedicated to creating a program for patients living with obesity, the lack of formal training and expertise in obesity medicine may be the first barrier to overcome (we’ll come back to pursuing training in this field in later posts).  Given that there is currently no universally accepted standard of expertise or criteria for an obesity clinic, pretty much anyone with an interest in this area can set up shop and claim to be running an obesity program. Indeed, we often see physicians or other health professionals from diverse backgrounds and with various motivations setting up “weight-loss” clinics based on a wide range of ideas and personal philosophies. While some may well take an evidence-based approach built on the understanding that obesity is a complex and heterogeneous chronic disease requiring multi-modal approaches to management that must include behavioural, medical and even surgical treatments, this is, by far, not the most common approach.  Rather, we often see obesity programs built around a single or dominant treatment that is offered to most (if not all) patients at that clinic. Although the programs may describe themselves as being comprehensive and holistic, they are often limited in the treatments they offer. Thus, for example, surgical obesity programs are built around surgery, formula-diet programs are built around the use of formula-diets, low-carb or keto-program are built around low-carbs and ketogenic diets, “lifestyle” programs are built around addressing “lifestyle”, psychological programs are built around psychological interventions, etc. This segmented approach to obesity care is obviously confusing to patients, who have no way of knowing whether the recommended treatment at a given centre is really the one likely to serve them best, or rather, just happens to be the one available at… Read More »

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Patient Barriers to Obesity Care

In yesterday’s post I discussed some of the policy barriers one must consider when setting up an obesity program. As important, are barriers that arise from the beliefs and misconceptions as well as the shame and internalised stigma commonly present in people living with obesity. For one, research (e.g. the ACTION Study) shows that although most people living with obesity are well aware of the potential health implications of excess weight and are largely open to the notion that obesity is a chronic disease, they generally do not seek professional help from their doctors or other health care providers, as they would for other health conditions (e.g. hypertension or diabetes). Rather, they tend to try to tackle the problem on their own, often turning to fad diets or weight-loss programs and products offered by the commercial weight-loss industry. Although most people living with obesity state that they know what to do (namely, eat-less-move-more) and believe weight to be under their control, they rarely experience long-term success in maintaining weight loss.  There are several factors that explain this behaviour. For one, the message that the root cause of obesity is simply eating too much and not moving enough is so pervasive, that trying to manage weight simply by eat less and exercising more appears to be the obvious solution. This message is of course amplified both by public health messages and by the commercial weight-loss industry that directly benefits from this simplistic notion of what causes obesity and how to manage it. The commercial weight-loss industry spends millions of marketing dollars to reinforce this message with their anecdotal “before-and-after” success stories and promises of simple and ever-lasting weight-loss whilst promoting unrealistic weight-loss expectations by anchoring the magnitude of weight loss to outliers (results not typical!) rather than the average client (never mind the lack of prospective long-term RCTs or ITT analyses).  Perhaps an even more important factor is the shame and self-blame together with internalised weight bias that prevents people with obesity from reaching out to health professionals. After all, if I am convinced that I only have myself to blame, know what to do (just eat-less-move-more), and simply seem to lack the motivation or will-power to do what is necessary, why would I expect my doctor to be of much help. Indeed, what is my health professional going to tell me that I don’t already know? So I’d much rather… Read More »

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Policy Barriers to Obesity Care

Before we get into the nuts and bolts of setting up an obesity program, it is perhaps worthwhile to look at some of the “big picture” barriers to obesity care.  These can be broadly divided into policy barriers, patient barriers, and professional barriers.  When we look at health policy barriers in general, much revolves around the failure to fully recognise and accept obesity as a chronic disease in its own right. Thus, the widely persisting notion that obesity is simply a matter of personal responsibility and that patients need to take control of their body weight and shed those excess pounds by changing their “lifestyles” and that failure to do so is simply due to lack of knowledge, motivation, or will-power, feeds into the justification for not funding or establishing obesity programs.  Thus, it would be fair to say that the main reason why obesity treatment programs are largely unavailable, under-funded, and under-valued, is that policy makers have not fully bought into the idea that obesity is a complex chronic relapsing disease that needs to be resourced as any other chronic disease (e.g. diabetes or heart disease). Indeed, by refusing to recognise obesity as a chronic disease in its own right, and by continuing to lay the blame on the people living with obesity for their excess weight, health systems can apparently get away with not addressing the needs of these patients just by declaring it “not our problem”.  Even in cases where policy makers and funders recognise obesity as a chronic disease, their reluctance to fund such programs may reflect the fact that conventional approaches to obesity management, largely based on the “eat-less-move-more” philosophy, have demonstrated only marginal long-term results, lack long-term outcome data with “hard endpoints”, and are hardly cost-effective (effective and sustained behavioural intervention is far more expensive than most people think!). Thus, as the available evidence clearly shows, weight-loss achieved with conventional approaches (eat-less-move-more) are generally modest, difficult to sustain, and not easily scalable. To be fair, other than for bariatric surgery, behavioural and medical treatments for obesity have yet to demonstrate their positive long-term impact on reducing morbidity and mortality. Thus, anyone looking for funding of an obesity program, has the onus of convincing policy makers that such a program can indeed deliver clinically meaningful outcomes, other than short-term weight loss. Obviously, there are other factors, not least the staggering size of the problem. Thus, it… Read More »

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