November 22, 2022 Weight Inclusive Care with Dr. Sean Wharton
In this health-care provider webinar, Dr. Sean Wharton discusses how to identify strategies to manage patients with elevated weight without bias.
Grace Leeder: Welcome everyone to another diabetes. Canada Webinar, part of our Fall Webinar Series. I'm. Very excited for you to be joining us today for weight inclusive care strategies to manage patients with elevated weight without bias. I'm. Very excited to be joined by Dr. Shawn Wharton today, who's going to present on the topic? Uh, Dr. Warden is a as his doctorate in pharmacy and medicine at the University of Toronto. He is the medical director of the Wharton Medical Clinic, a community based internal medicine, weight, management, and Diabetes Clinic.
Grace Leeder: He's an adjunct professor at Mcmaster University, in Hamilton and York University in Toronto. He also has he also academic staff at Women's College Hospital and Clinical Staff, The Hamilton Health Sciences. Dr. Wharton's Research Focuses, on Bariatric Medicine and type, two diabetes and He's the Co-lead Author of the Canadian obesity guidelines.
Grace Leeder: Dr. Morton is involved in Uh Activism to achieve health equity. In Canada he founded the Bmsa Black Medical Students Association at the University of Toronto in two thousand, and the Bmsa is now a recognized mentorship organization across Canada without further do. Dr. Warden take it away.
Sean: Thank you very much for that wonderful introduction. Yes, um. We're going to be talking today about Wait inclusive care of the strategies to manage patients with elevated weight without
Sean: bias. So this talk is about bias and equity, and we're going to get right into it. So um! Here are my disclosures,
Sean: and there's no honorarium for this talk and no conflicts.
Sean: So the objective to identify strategies, to manage patients with elevated weights without bias, stigma and discrimination.
Sean: So first of all, a little bit about me on the personal side. I'm an internal medicine doctor, As was stated, this picture of my wife, who is a family doctor in in Toronto and Baby James, who is two years old now. So it's with the thought of baby James. I do a lot of the equity work that I do. I want this world to be a better place for him to to to to grow up and to live There's definitely some disadvantages being black in
Sean: the world. And um, and certainly Um, there's There's we'll be talking about people in with obesity, and we have the the disadvantages and discriminations there. I want this world to be a better place.
Sean: So um and uh so with that um uh for my field of research and study is in obesity medicine, but it also um connects over into equity. So we wrote the Canadian Obc guys with the focus on science. But our real goal was to focus on bias stigma and discrimination that plagues this field of people living with obesity. So once we address the bias, we can actually then focus on the science to attain the real wins within this medical.
Sean: So now, So when we talk about um uh about these, the these biases um. We know that that obviously bias and stigma and i'll explain what both of these are. Um hamper, hamper the the um field, so we can't really go very far until we deal with this, so question is, is, who has bias
Sean: the other people listening right now, who is biased Well, pretty much all of you do. Everybody has obesity. Bias is a negative thing. So how can I be so sure that all the people listening right now have? Obviously, by It's a pretty bold statement. Isn't it. Well, here are some of The reasons
Sean: studies show that obesity by starts in preschool. If you show preschoolers pictures of a child living with obesity versus child with disability, the preschooler will never choose the child elevated weight as a playmate.
Sean: They start to address negative attributes to those with obesity, including laziness, a lack of intellect, and other harmful traits.
Sean: Well, this bias continues well past past preschool. We were those kids. We watched the cartoons of of the thin dog and the bigger dog, and the thin dog was bright, and then competent, and et cetera. So we got those biases stuck in our brain, and we become adults, and we become health care providers. So we are now the ones um with bias who are treating people living with living with with obesity. So here's a great example of
Sean: by some discrimination from a family doctor in in in Canada, from subway um, and none the the last which is my home town. So here's what she writes in the medical post is right, She, she writes that losing weight is too hard because the general attitude of patients coming into her clinic is one of non accountability. Not that there's a biological or genetic reason for elevated weight, but mainly blaming and shaming them, stating that they're not accountable.
Sean: She also goes on state that when she inquires about their diet they're incensed when she tells them that Pirokis are not a good choice. She suggests that we should just paint billboards with simple common sense information to help these patients. This is a clear example of bias leading to discrimination, and this is from a doctor who who was felt strong enough to write it
Sean: in the medical post. Um! Medical post has since apologized for this. Um, but certainly it is here. So what does she represent five of doctors,
Sean: ten percent, or fifty, maybe even more. But these biases are definitely here. They're not underground.
Sean: So clearly. The biggest challenge facing a Vc. Is the lack of knowledge within the medical field. Regarding the science and the biology of obesity. This ignorance leads to recommendations such as eat less and exercise more as the only recommendation.
Sean: The simplistic message does not address the biology of Vc. As a result it does not work as a treatment,
Sean: so the science and the real driver behind understanding obesity. Medicine is understanding that there that it is a neuroscience field greater than one hundred and forty genetic folks, full full of full-site primarily in the brain hypothalamus, the mesolmic system, the frontal lobe. The intensity of these genetics is what drives elevated, weight and what drives people to not be able to keep weight off when they actually lose lose weight.
Sean: and these genes, as stated, lie within the hypothalamus, the mes limbic system, and the and within the frontal frontal lobe. Understanding these genes and understanding this biology leads us to treatment Options
Sean: rooting ourselves bias and stigma gets us nowhere close to treating this medical kind addition.
Sean: So the treatments, of course we are primarily not in man. It shouldn't say, of course, but because this is not known for many um uh doctors and health care providers. The main treatments are psychological intervention or Cbt.
Sean: Understanding the psychology there, and that's the frontal lobe, pharmacotherapy or medications and periodic surgery. These three interventions support
Sean: the healthy eating or the medical nutrition therapy, and the physical activity which are, of course, the roots of how we can treat this medical condition. Of course anyone could do a diet. Anyone can be physically active at times. Um! But maintaining those things are oftentimes impossible unless we go to understanding the biological principles. Again, our biases push us against
Sean: our understanding of the biology.
Sean: So now that we've talked about bias, Let's talk about weight, stigma, What is stigma? Um. So stigma is essentially a stereotype, and the weight stigma is what they do Is they reinforce our already set biases. So most most people are on a computer right at this very moment.
Sean: So if you stop this presentation or posit, or just go on to the computer and type in. Let's say you want to do presentation, and you want to do Want to put up a picture of somebody living with obesity. You would. Um, And he wants to be a man type in the word man
Sean: and obesity and images on your own computer. Tell me what images end up coming up.
Sean: Of course they're images of people with um their shirts uh uh, not fitting properly, their bellies showing as if they don't want to dress, and they're not competent. So
Sean: these are on your computer that are showing this significant stereotype. So your immediate thing is that this person doesn't look like they could be a a professional or a a a a doctor, an engineer, a lawyer, or a prime minister. No; they are all negative
Sean: stereotypes, negative pictures, which then informs our biases and leads us to a discrimination.
Sean: Instead of those type of images we should have these positive images in the obesity Cabinet came Canada image. Bank. There's there's positive images of people living with obesity. We're moving who are smiling or positive.
Sean: So we also know that on top of the the um uh external devices that we have against people live with. At least there's also internalized bias. So and that's because people in the obesity here all the same messages and same thing, and see the same stigmatizing pictures as um uh of themselves, and feel that they don't deserve care.
Sean: Besides the external bias that we see from um health care providers towards people live with obesity. There's also internalized bias, which means that people live with obesity here all the same messages, and see the same stigmatizing pictures, and believe the same things that all of society does, that they themselves have a character flaw, and Don't deserve care.
Sean: Research has shown strong associations between internalized weight, bias and mental health outcomes, avoidance of exercise and binge eating. So the primary solution here is for us to be um compassionate and as patient as we can with
Sean: our patients living with obesity, as they will um By having that compassion they will be able to deal with their internalized weight bias against themselves, and can be eventually treated.
Sean: So here the five a's of uh um of obesity management, the five A's is something. We set out in the Canadian obesity guidelines,
Sean: and essentially it's a roadmap as to how patients can be appropriately treated,
Sean: and the roadmap looks relatively similar to all medical conditions, such as high blood pressure diabetes. Let's look at number two to Number Five. First, you're going to assess the patient. Um! You're going to advise them on what treatments you're going to agree on what goals they should be looking at, or what values. And then you're going to system. And with the follow up. The one difference is the number. One thing that we need to do a patiently where they'll be, seeing that. Ask them permission to discuss. Wait,
Sean: and that seems a little odd right if you had had a heart attack, and you're sitting in front of a cardiologist. So cardiologists say to you, Can we discuss your heart attack and and treating your heart. Can your your your heart condition? Well, it seems obvious you're sitting in front of a cardiologist. Why would?
Sean: Why would they have to ask. Well, you know what they probably should ask. That shows compassion.
Sean: And here they definitely should ask Why? Because we've treated people in with the least so poorly for so long that they don't trust us, and by asking them permission to engage in a discussion about weight management which now has appropriate treatment options that's showing a compassionate treatment.
Sean: So here again it's when we're asking for permission. This is step. This is this is a step. Number number one, and um, and we've seen things such such as would it be all right if we discussed your weight. We know that obesity is a chronic disease the way we treated people in the past doesn't work. Would you be interested in addressing your weight at this time? So this shows compassion. We need to be better doing this
Sean: And then, if we um, we move into things such as our assessments. So how should we assess people in with? Obviously we frequently use things like Bmi or way circumference, and I have a discussion about Pmi and um, and we could use things like the eel staging tool So let's talk a little bit. Let's look deeper,
Sean: what type of assessment is appropriate and does not show bias
Sean: Well, the Edmonton, Vc. Saving system says, Um, let's not just always look at them at the patient's. Bmi um or the elevated. Wait, let's look at their co-morbidities. Do they have pre diabetes? Do they have a family history of these conditions. If they do, and if they're out of posse, is driving this, then they need treatment.
Sean: If they don't have out of posse that is driving it out of posterity is weight. Then we're in a position where we we don't need to aggressively treat it. We need to. Um uh, we need to have a greater understanding that patients can be healthy with elevator weight, and if they are,
Sean: then what they need is understanding and compassion, and and uh treatment like anyone else would, to not go up and up and up further, and wait to not go into a disease state. But they may not need treatment to go down and wait.
Sean: So um! Here again we have um more of the the the understanding of of advising the patient for management, agreeing on values and not just. And this is again a part of the um uh biases. Our biases have always been to tell a patient where their weight should be,
Sean: and we we should no longer do that. We should instead. Um, uh talk about the patient's values you value being healthy for your grandchildren. Let's work on what type of treatments can get us to, to that type of value proposition
Sean: assistant drivers, and also um making sure that um um we pay. We assess the patient on a ongoing basis. So here again are the three pillars, psychological intervention, pharmacological therapy and surgery that all support
Sean: healthy eating and activity. So let's talk a little bit about this, Bmi. We've been seeing a lot of information and article just came out of the National Post talking about the fact that we need to scrap Bmi, and that it is a flawed. It is a flawed the measure. So what do we exactly mean by this? Is this a flawed measure. So Bmi is a calculation, and essentially it's a number as a number. It doesn't. Necessarily it's not necessarily flawed, because i'll be saying things like
Sean: like our height, is flawed. It's our interpretation of it. That is the challenge or the categories. So we can see here. These are the categories that have been have um that have been established to assess health status. Once you get into the overweight category, your health is supposed to not be as good obesity class one, two, and three. Health gets even worse and worse. But
Sean: the the debate here. Does does somebody with the be it just an individual. The Bmi thirty-two Are they actually more unhealthy than than a person with the bmi of twenty-seven? If that's not the case, then where did these um categorizations end up coming from,
Sean: and so and and this may be uh. So, as we know, this is a case for criticism here that we may need to to get rid of it. So this
Sean: it initially the Bmi came from Adolf. Um Adolf. He's a he's a a physicist credited with the idea that weight increases with heights with with height squared. Quite a lot
Sean: was from Belgium. He came up with this in one thousand eight hundred and fifty. He was trying to determine the um a health status of the average man. Of course, the average man for quite a lot was a white European male in Belgium. And this is where the idea of using this this um, this quite a lot index ended up coming from what happened was in one thousand nine hundred and seventy-two, and so keys.
Sean: a uh noted physiologist in in America tried to use that quite a lot index to to um uh, and change it then, not to say, change the name, but use the name Bmi body mass index um was created to again determine how statuses again the same categories were used. But the um uh, and and so keys are not take into account the very nature of
Sean: in individuals, for instance, different bodies, different risk. So We know that African American women
Sean: carry most of their weight in their hips and in there and in their um uh um thighs they don't carry it in their central area, and as a result of that, what happens is is that they are not, as at high a risk of having it type two diabetes and medical metabol conditions, until their Bmi is significantly elevated as to where their waste circumference is also elevated, so different bodies different risk. The Bmi's
Sean: uh cut offs. Um! Were not for women. They were not for women of color, and they, as a result, can um can in for some, some, some some discriminatory practices.
Sean: And so the Edmund and Edmonton of Vc. Staging system. Again, we what what this study looked at was instead of looking at Bmi, could we look at whether you had type two diabetes or family history of it. Pre-diabetes would that predict your mortality better? And clearly it did. You can see here that that? Um, This is the Nhs data,
Sean: and it's it is a database that looks at mortality. And here we can look at um. The eel staging system from zero means that you have no risk, and and stage three means you have lots of risk, but everybody in this category. If you look at at the panel on on the um, the the right. You can see that, regardless of what category you were, that you, you, you, you, you! You were actually in be in my category.
Sean: What determined your greatest amount of risk was Um, what your eels staging system is the highest staging. You were at the higher risk. You had not your Vmi so.
Sean: And here this is. This is the classic one here. Everyone in this category gory is obese in in the obesity class three states they all have. Bmi is a greater than forty. Everyone assumes that they should be all have high, high risk, but, as you can see if you had a Bmi, a forty, two,
Sean: and no co- morbidity. That's the black line. Your risk of mortality was very low. You had one comer, baby the red line. Your risk of mortality was again very low. Once you start having more co- morbidities your risk goes up end up,
Sean: so it's the comorbidities that determine the risk, not just the elevated weight or the person's size.
Sean: So again, Bmi may not predict health in most cases. So let's look at the patient in front of us. And why this is a challenge is because many people are denied me. Surgery denied um intravenous um in vitro fertilization based on their weight if they were, If we were to look closer at what causes the mortality and morbidity in these conditions in these, in these procedures,
Sean: how getting a knee surgery done, or having Ivf. It is more so. The medical conditions as opposed to the person's weight.
Sean: So and finally, what we're going to look at here is anti-black racism
Sean: within medicine and obesity. So um we'll do a little bit on this. So we know that the drivers of our Bc. Um are primarily uh can be one of the big drivers is social economics and also race. So what what does this mean? What do we mean by this when we know that there's up, there's all the other drivers of biology that I spoke about food, consumption, individual activity. But look in at that one spot that has societal
Sean: in influences there, this one arrow that's social, economic, and race, and it definitely factors in so um so due to this driver, we see that obesity disproportionately affects marginalized people, the indigenous black people and and the beyond poor.
Sean: So i'm going to focus um the next few slides um black people within the Us. As it is a research interest of mine. And also we have data on on this to show how how this, how this uh, this. This um uh discrimination or social economic status leads to um higher rates.
Sean: So American collected race based data to account for their slaves. That is history. This accounting continued beyond slave reading from its way into hell and and and um into health based data, and has been helpful to document disparities within within care. Canada does not collect race-based data, and this is a significant promise. It makes it difficult for us to address problems. That we know that we know. Um um um
Sean: uh is challenging here within Canada. So here are the stats on obesity by race in within America overall obesity rates in America are staggering,
Sean: but it is clear that black Americans are affected more than white Americans are. There is a fifty percent obesity greater than a pmi, greater than thirty in black Americans and forty-two percent within white Americans.
Sean: And And here, if you look at black women, they're at fifty-seven percent obesity rate Bmi greater than thirty versus white women at forty. That's almost a fifty percent higher rate.
Sean: This disparity and rates of obesity and disparity in health was not by chance. It was by design and started in slavery,
Sean: and it lives on today in with when we look at structural racism. So my friend Jamie Art, an intern from North Carolina, has written a great paper on the topic of Obesity and Structural racism Here and I are one of the few black physicians working within the field, and I encourage you to read, to read this, to read um, to read this article, To understand the origins of these disparities, we need to go back to the days of slavery. Let's look at the slave rations. The objective of the slave owner was to help keep his investment
Sean: working with the bare minimum investment in food and provisions. It's often led to diets, heavy and carbs, salt excess calories from poor nutrition foods that could be burned off during the working day.
Sean: Other food was obtained by what the slaves could grow or catch. But disease and poor hygienic conditions led to multiple deficiencies and diseases.
Sean: The medical field was not concerned with with assisting um with assisting and improving health, but with but uh, instead with experimentation. Here Dr. J. Marion Sims may Um, a male gynecologist,
Sean: did experimental gynecology operations on slaves without consent or anesthesia. He did this while pre uh perfecting a surgical cure for um a secure fashionable fish to us one woman. Um, and her name is Anna Rap. Cha
Sean: required thirty procedures before a satisfactory result, and this is challenging.
Sean: Physicians attribute to disease to black people statement that those that were peculiar, the staining that that those that were peculiar to their nature, such as the quest for freedom. Physicians ignore the basic science of medicine, and that the and and that the poor conditions were leading to true medical conditions,
Sean: post, civil war conditions were even worse.
Sean: Poor nutrition and sanitation structured and designed to weaken black people. Healthy, free, black people were seen as a threat to social order.
Sean: The thought is that black people would dial out due to poor nutrition and poor constitution.
Sean: Today's food option for black people are derived from days of slavery, high starch, fat, sodium, cholesterol, and high caloric content inexpensive and often low quality. Nature of the including such a salted pork and corn meal. The collision of food insecurity in this case
Sean: is, and in this case it's the inability to choir consume an adequate dive. A. I adequate diet Quality
Sean: collided with biology, poverty, Structural racism leads to troubling aspect of obesity and black women in um with within. The United States need to remember that black women preferentially put energy into peripheral stores but up to Bmive about thirty-two, and After that the energy goes to fat stores in the visceral areas leading to metabolic diseases.
Sean: So although most of our data is from yes, I personally collected and conducted research. Um race based data. We looked at the results of weight management at a community base clinic, and over nine thousand patients. We found that overall women of color lost less weight than white women did
Sean: when we adjusted for the number of visits to the clinic there was no difference, so the issue was access to care. We could not easily reach women of color, or they could not reach us or take time off work in the middle of the day um, or find the resources for healthy, for um, for healthy eating options. The system was not built for them, but for those with privilege. We've been working on solutions to correct this by starting to do virtual care and virtual cares, and we would like to keep doing virtual care to reach these market.
Sean: Nice communities.
Sean: So what are the solutions to the disparity and care? And within medicine there's no single solution that can undo hundreds of years of racism and solutions will need to come from wide range of places, organizations, and in individuals.
Sean: So I traveled with the Black Medical Student Association twenty two years ago at the University of Toronto, and it's grown every year. I believe that a new group of physicians will make a difference by recognizing structural racism and medicine, and addressing these factors, they've already made significant strides to follow them on Twitter on a Facebook, and, as a matter of fact, just today Cmaj article was released from the Bmsa
Sean: um. So they'll also educate non racialized doctors and medical associations to recognize issues of structural racism and treat praise patients in and in an appropriate fashion.
Sean: So, in conclusion obesity rates are much higher in marginalized groups. Um, uh particularly women of color.
Sean: Um, but um, And also we see here that health care Providers are biased against people live with obesity, and we should recognize this bias and practice compassionate care.
Sean: Bmi may not be the best measure to assess health for most of the world, and may perpetuate discrimination.
Sean: Instead, we should look at the individual,
Sean: and finally, structural racism is causative in continuing to perpetuate the conditions that fuel obesity within black women.
Sean: So thank you very much for your time. This is my and my academic team and my clinical team, who significantly assist me to get um All of this work work done.
Sean: Thank you for your time, and uh and um, I hope that this will um will spur on a lot of healthy, healthy discussion. Thank you.
Grace Leeder: Um. Okay. So i'll edit this in. But but that's great. And so i'm gonna this spring the help discuss. I'm gonna i'm gonna edit in something about it being on our online community. So i'll cut to a side there and then once that's done my sort of plugs. I'm going to come back into it. Um,
Grace Leeder: Dr. Wharton, that was a fantastic Thank you so much. I think a really uh useful informative uh presentation. Um, and thank you for joining us today.
Sean: Thank you. I it's really great to be here,