Welcome to Scale Up Your Practice Podcast

– Hello and welcome to the very first episode of Scale Up Your Practice, brought to you by Obesity Canada. I’m Roshan Abraham and I’m an associate professor in the Department of Family Medicine at the University of Alberta with roles in educating medical learners of varying levels. And I’m the co-chair of the Obesity Canada Education Action Team. Most importantly though, I’m a family physician who sees on a daily basis the impact that obesity has, both at an individual and system level and what ultimately led me to be more involved with Obesity Canada and the Education Action Team.

 

– And I’m Michelle McMillan. We’re here to guide you through the evolving landscape of obesity management. Today, we’re diving into why this podcast is a must listen for healthcare professionals.

 

– Today’s episode is not sponsored. All content is supported by Obesity Canada and our expert guests based on the latest research, clinical practices and competencies. We are committed to delivering unbiased and evidence-informed information.

 

– And while this episode is not sponsored, please note that some of our episodes will be sponsored. We will always provide clear disclaimers at the beginning of those episodes to maintain transparency with our audience.

 

– Speaking of relevance, let’s talk about a fundamental concept that underscores all our discussions here. Obesity is a chronic disease that affects millions. Managing it effectively requires not only up to date knowledge, but also a compassionate understanding that it’s not just about weight, but overall health.

 

– Exactly Roshan, each episode will bring you insights from experts, practical tips, and the latest science in obesity care. Our mission is to empower you with the tools you need to enhance your practice and support your patients in a holistic way. So what are we waiting for? Let’s scale up things a notch.

 

– In today’s episode, we’ll explore what brought us into these roles and why we feel it’s important to bring a fresh perspective to the obesity space. So let’s get started, Michelle. And I’m wondering what brought you to Obesity Canada? Or how did you hear about it?

 

– Well, to be really honest, I don’t actually remember how originally I connected with Obesity Canada. What I can say is that I’m sure through these podcasts, we’ll elaborate, but I’ve been living in a larger body my whole life. My doctor first told my mom that I was overweight when I was two years old. So I’ve been living in a larger body and obesity my whole life. In my regular life, it’s very science-based, so I was looking for information about obesity that was scientifically based. And I’m sure that’s what led me to Obesity Canada. And I’m sure at some point there was a call out to people who were willing to volunteer and do some things with Obesity Canada, which I volunteered for, stepped in and discovered this amazing network of wonderful people, deeply caring people, deeply compassionate people, people who care about treating obesity as a chronic disease and not an issue about willpower, and so that’s kind of how I got involved. And once I saw these people and was involved with them, I never wanted to leave. So that’s how I got involved. How about you?

 

– It’s funny you should mention the support of that network because I definitely feel that that was a big part of why I ended up being attracted and then staying. Our producer off camera, Nicole Pierce is definitely a big reason for why I ended up staying. So I’m a family physician. I’ve been working in Edmonton now for the last seven years. I’m actually affiliated with the University of Alberta so I do have teaching roles, academic roles there. And I think I was really attracted to Obesity Canada. First of all, I was introduced to it by a colleague, Dr. Denise Campbell-Scherer, who happens to work in my clinic, has done some incredible work around obesity and very specifically the five A’s tool around how to approach discussions in obesity and primary care. And I was initially very, very interested in the work that she did. And then I slowly start to get more involved in Obesity Canada. And I think basically since taking on the role of the co-chair of the Education Action team and sort of seeing where that has taken us, I think it’s been almost impossible not to want to be more involved with Obesity Canada. As a family doctor, I see the implications of not addressing obesity, not at just at an individual level, but at a systems-based level. And it’s really hard for me not to get involved. And so I think it’s something that I hope I can continue to do, especially with my role at the university. I hope I can do fun things like this ’cause I do enjoy this type of work, and I really am excited to see who we meet along the way and what they have to say about care, because I think that’s the part that I’ve really been attracted to is meeting new people and expanding that network to find out what it is that I’m actually missing out on the world because there’s so much that I’ve learned about the world even, because of my exposure to Obesity Canada and the work that I’ve done there. So I’m really excited because I think we’re gonna get to meet a lot of cool people in the process. I think we’re gonna be interviewing a lot of people as well, who not only have professional experience, but lived experience experts and it’s intersecting conditions. I think one of the common themes that we see in obesity and obesity medicine, no matter the area’s bias. So Michelle, did you wanna give us a little bit of a lowdown on what weight bias and stigma are?

 

– I have to say, I feel like weight bias and stigma are one of those things where we think we know what they are, but we’re not, you know, it’s kind of all around us.

 

– Yeah.

 

– So if we’re gonna just kind of provide some basic definitions. So we are talking, we know we’re talking from the same points. I guess we would say that weight bias refers to negative attitudes and views about obesity and of course people living with obesity. You know, and how these negative experiences can have negative consequences on individuals. And I would say systems as well. And of course, you know, it’s complex, but you would say, you know, they cause feelings of shame and feeling blamed and that causes anxiety and that can lead to depression and, you know, poor self-esteem, definitely body dissatisfaction. And that in itself can lead to unhealthy weight control practices and, you know, unhealthy lifestyles, right?

 

– Yep.

 

– Now, if we’re talking on a bigger social level, you know, there’s a lot of weight stigma in referring to social stereotypes, misconceptions about obesity. You know, we’ve all seen the evening news where people living with obesity apparently don’t have heads. We’re only shown from the shoulders to the knees.

 

– Oh my goodness.

 

– And as far as I know, you are a physician, so you could let me know, but as far as my head is still attached to my body…

 

– You are correct.

 

– It’s not a symptom of obesity that my head disassociates.

 

– Four years of medical school definitely told me that.

 

– Yes, so you know, there’s a lot of social stereotypes and misconceptions that go with these stigmas and biases. You know, we can name them, but, you know. People living with obesity are lazy. You know, we’re awkward, we’re sloppy, we’re stupid, you know, we’re not competent. We lack self discipline, we lack self-control and these kind of things, you know, they really flow from this stigma and this weight bias. I don’t, having lived in this body in my life, having known many people with obesity both inside and outside of Obesity Canada, you know, these are just stereotypes. They’re not real, so.

 

– No.

 

– Do you want to add some more about the bias and stigma from your side?

 

– I do, because I think sort of that next stage along the spectrum, we do actually see quite frequently in healthcare. So we’ve got weight bias, we’ve got weight stigma, and then further along we see the implications of weight discrimination, because I do think we see that in our healthcare system quite a bit. So this is when we actually enact our personal biases, social stereotypes about obesity and treat people with obesity unfairly. And that happens constantly in the healthcare system, constantly. And if any of our listeners are doing, are interested in doing a deeper dive into weight bias and stigma, Obesity Canada has free courses available on their website. But I think it’s a great segue into, in a recurring segment on our podcast, because I think stigma and potentially a little bit of discrimination are actually at play in our, I guess our introductory segment of the bias break. So our bias break is something that we wanna do. It’s a bit of a break from our usual discussions with guests. We want to do this every single podcast episode, and it’s really to give our co-hosts and guests an opportunity to reflect on weight bias either that they’ve experienced, seen, or in the case of the healthcare professionals possibly even contributed to themselves. And I’m gonna be open and honest. We want this to give our co-hosts and guests the chance to be vulnerable and speak openly about weight bias and its implications on care. So I’ve got a great example from the past week about sort of a system level stigma and potentially even discrimination. I think I’d like to share it.

 

– Yes, please, absolutely.

 

– So ever since we’ve been getting a lot more traction along obesity treatment in primary care, and I’d say broader care as well, but definitely as it’s trickled down. So I have a general practice. I don’t have a specialty practice in the work that I do. I am part of an academic clinic at the University of Alberta, so I have residents, I have medical students that work that I work with. So my practice is a little bit tailored that way, but for the most part, it’s general practice. And so obesity medicine is a natural part of what I do on a regular basis, right. This isn’t some sort of specialized thing. This is primary care, right? And one of the things that has evolved over the last year, I would say, are pharmacotherapy or medications that we use to actually assist with obesity care. And one of the most frustrating things that I have found, and this just adds to the frustrations for me as a primary care physician, is the paperwork that we have to do for obesity medications and for a lot of other medications, let’s just say there’s a bit of massaging that we have to do, right, with how we write things up. But one of the challenges that I’m having right now is that I have to jump through quite a few hoops to ensure that my patients are actually getting the appropriate pharmacotherapy, or at least the ones that have the best evidence for them. So that’s one thing. We need accurate weights and very, very precise weights. We need the times of when those were done and the interval as to when we started, as well as when we next provide that weight, right? So that there’s one huge issue there. Another sort of common issue that we have with these forms is a lot of the drug companies, or sorry, the insurance companies are limiting the amount of time that people can actually get coverage for these medications. So we actually have a short window and we’re talking about like two years at the maximum with like two, one year intervals. And what was really frustrating for me this past week is that I was just talking to a patient who’s been getting extreme benefit from one of these medications, and yet we actually lapsed on the first year because just with the way that we measured that second weight and the timing of it, the insurance company denied that first year. We repeated it. I tried to advocate, I wrote a letter, I said, “Hey, you know what, there’s been an appropriate amount of weight loss in the amount of time that we usually see according to the studies that have been done on this medication. You know, please reconsider. Like, let’s not lose a year.” I didn’t get any response back. All I got was, you’re starting now at this time, it’s gonna end next year. Right, so obviously we’ve lost a year. And so having that conversation with the patient was extremely frustrating for them because it was, anyways, a process to get here and then obviously naturally for me is it pops into my head, “I don’t have to do this for any other medication, right.” And they also tag on at the bottom, by the way, are they following a caloric restriction diet as well as regular exercise, which for all the other chronic diseases, no mention of that in your special authorization forms, right? So when you think about bias, when you think about stigma, when you even think about discrimination at that larger level, you have to wonder why are we only seeing it with obesity? And one of the obvious answers is actually that all-encompassing weight bias and probably a lot of patients don’t realize that this is happening and that advocacy actually needs to incorporate potentially making some pretty big changes to this.

 

– To me, as someone living through this, you know, it just sounds insane. Like it just, and I understand that it’s the bias and the stigma that’s feeding in, right? The misunderstanding in the public in general, that it’s really about eat less, move more.

 

– If they just did that, we’d solve all the problems. But the crazy thing is that those same rules don’t seem to apply to other chronic diseases, right?

 

– Yep.

 

– So, you know, if someone had type two diabetes and had to go on insulin, and you put them on insulin and they’re doing well and it’s keeping their blood sugars down and they’re living a full life, you know, the drug company shouldn’t be coming back and saying like, or the insurance company in fairness.

 

– Yeah.

 

– Shouldn’t be coming back and saying, “Oh, two years, that’s it.” You know, and move on. The same thing I’m sure doesn’t happen with, you know, blood pressure meds. Do you have to fill out how much salt your patients are eating and track that if you give them blood pressure meds and if they don’t meet some artificial criteria, are you required to take them off the meds or the meds aren’t paid for? This just seems, to me it seems, it almost borders on insanity.

 

– Yeah.

 

– That we’re dealing with this.

 

– And we haven’t even talked about the limitations of BMI because they’re using strictly BMI basically to determine whether or not someone has reached effectiveness with the medication. When we have scales like the Edmonton Obesity staging scale, right, that serves as a compliment to BMI to actually capture a patient’s more complete story, albeit in an abridged version, but at least captures their experience with obesity in a much better way and should actually be incorporated as opposed to simply just BMI, because a lot of my patients have benefited already from these medications without a substantial drop in BMI because a lot of other areas are actually improving.

 

– Yeah, and you know, I would hope that maybe through this podcast, you know, we can kind of change some hearts and minds out there about this.

 

– Hopefully, yeah.

 

– Because, I agree with you. I think, it’s based in stigma and, you know, maybe the first hoop that we have to jump through is the fact of the general idea that obesity is a chronic disease.

 

– Precisely.

 

– It’s chronic and it’s a disease like, you know, it falls into the categories of, you know, diabetes, hypertension, all of those things which are also chronic diseases. And, you know, I think that’s maybe a starting point because clearly the bias might be feeding from that basic misunderstanding that it is actually a chronic disease and then you layer on misinformation and using wrong tools and to measure things, you know. That’s why we’re starting here, right?

 

– Yeah.

 

– We got to, start with the medical professionals who are the experts in medicine. Start from there. You know, as I say, you know, when we know better, we do better, right?

 

– Yeah, I really like that.

 

– Yeah.

 

– Yeah. Did you have an example of a bias break?

 

– I think my bias that I most find frustrating, and it’s not just me, but other people living with obesity is that quite often the bias because let’s be honest, when I walk into a room, I have a larger body. So obesity is one of those chronic conditions that you can’t really hide.

 

– Right.

 

– I’m also a type two diabetic, but if I walk into a room, no one can look at me and go, “Oh, type two diabetic, right?” So you’re dealing with that when you come into a physician’s office, and I understand that it’s right front and center, right? But what I tend to find in a lot of people living with obesity finds, is that everything is due to obesity.

 

– Right.

 

– You know, we have a running joke about, you know, you can walk in with a broken arm, maybe a broken leg is a better example, a broken leg. And the ER physician would say, you know, if you just lost some weight, that broken leg wouldn’t hurt so much, right? And so you find that regardless of what you come in for, it’s always because of the obesity and sometimes it isn’t, it has nothing to do with excess body fat, it has to do with other things. So I think that’s the biggest stigma that I find. And then that of course flows into, you know, we can’t do this for you because you have a larger body. And I think that’s a conversation for another podcast, but just that upfront bias of everything in regarding your health is positively or negatively affected by the fact that you’re living with obesity.

 

– I can tell you that during my training, we would see that all the time. All the time. Consult letters, huh? You get back and you see, and you’re like, huh. I don’t think that’s relevant. I don’t particularly think that for this particular issue that is relevant, but you decided to say that anyways. Right, and yes, there are some, you know, instances in which I would say obesity care can be optimized and improve on conditions, right? But when it’s just that line saying, and we also had a conversation about weight and that losing weight would be important. I see this in a lot of cardiology consultations. I see this in a lot of gastroenterology consultations, and it seems like they’ve just copied and pasted it. Right, and what’s interesting is that I don’t even see it like, it’s so uniformly used that sometimes they’re just copy and pasting it, even if the patient doesn’t qualify as obese, even if they don’t have obesity. Like I’ve just seen this like copy and paste that just happens because it’s a risk factor that you have to address. Well, I mean, if it’s so ubiquitous, if we’re going to copy and paste it and put it into every darn consult letter, maybe it should be more than just a copy and paste. Maybe we should actually spend a little bit more time actually hearing from the patient, just like we do with a lot of other conditions to address their concerns and address their care appropriately. And then maybe it should be more than just a copy paste, right? Like, if you’re gonna do that for everybody, I mean, you gotta spend some time just asking what is it that this is actually affecting you? Actually ask about the psychological symptoms, the physical symptoms, all of the symptoms that actually contribute the patient experience that we want to try and gather. That actually doesn’t take very long for you to just get a glimpse. Yes, obesity care takes longer than just a few minutes, but it’s just that copy paste that really bothers me. So I empathize with that because I’ve seen that throughout my career and it honestly bothers me because, and then it’s worse when the patient is actually doing something, trying their hardest, and then they still say that, oh, that gets me, oh, that gets me so bad when the patient is trying their utmost. And they say, “I don’t know why they put that in there. I told them, I told them I am doing my best, right.”

 

– Yeah, and that’s one of the frustrating things about obesity is that there is an assumption that we aren’t doing the right things.

 

– Yeah.

 

– You know, you know, there’s this is the extreme, but you know, there’s assumption that we eat McDonald’s three times a day and we never exercise, instead we sit on the couch and watch TV all the time. Well, in my experience, people living with obesity and people not living with obesity have very similar lifestyles, right? We all try to eat better. We all exercise in the ways that bring us joy to move our bodies. And I don’t think it’s that different for people living in larger bodies. The problem is that if we do the exact same things and the result people are looking for is a drop of BMI, right, or a drop on the number and the scale, which is there’s things I can control in life. I can control what I eat, what I do, work on my mental health, those kind of things. I do not have control over the scale when I step on it. I do not have control over how my body decides to allocate the calories that I eat that is on a level in my body that I don’t have control. Just like I could talk to my heart and tell it to beat faster. It’s not doing it, I just told it to do it and it’s not doing it.

 

– It’s not doing it.

 

– It’s not doing it. Yeah, so frustrating to be constantly because the implication is that you’re not doing it.

 

– Right.

 

– Right. So frustrating, yeah.

 

– I’m hoping we can draw some more similar stories over the course of our conversations with others because yes, it’s important for us to gather what brings them passion in obesity care and the work that they’re doing. But I really think it will be important for us to highlight those areas of bias and even be vulnerable and open about how we, especially as healthcare providers, actually perpetuate some of that as well.

 

– I look forward to the conversations. I know that we’re gonna have some fantastic guests both within the medical community and outside of the medical community, and yeah, to expand on these themes and expand on examples and hopefully, you know, in a perfect world, provide some simple examples of how people can apply this stuff in their practice so that, you know, tomorrow when I’m in my practice…

 

– Hmm,

 

– I heard the podcast, here’s a simple thing I can do today to move forward my treatment of my patients living with obesity.

 

– That’s beautiful.

 

– Thank you for joining us today. We hope our discussion has been enlightening and that you’re leaving with a new perspective on obesity management. Obesity Canada is a trusted global resource in obesity education. For more information and access to further resources, visit the Obesity Canada website. Help us spread the word by sharing this podcast with a colleague, a friend. Don’t forget to subscribe on your favorite podcast platform to stay updated with the latest episodes.

 

– And until next time, keep scaling up your practice. This podcast is intended for informational and educational purposes only, and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatments. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approved practices as of the time of recording. If you’re listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient client relationship.