Dr. James Jung

Nearly 30 per cent of Canadian adults have obesity, yet despite its prevalence and association with serious chronic diseases like diabetes and hypertension, stigma remains a barrier to patients seeking proper treatment and care.

Dr. James Jung is a bariatric surgeon at St. Michael’s Hospital and a scientist at Li Ka Shing Knowledge Institute of St. Michael’s Hospital. He completed a clinical fellowship at the Massachusetts General Hospital, Harvard Medical School and has research interests in using machine learning for early detection of clinical deterioration in surgical patients.

We spoke with Dr. Jung about obesity, different treatment options and why he says obesity is a noun, not an adjective.

What do we know about obesity?

Obesity is a complex chronic disease in which abnormal or excess body fat impairs health, increases the risk of long-term medical complications and reduces lifespan. It’s recognized by the Canadian Medical Association as a chronic, progressive disease. Before that designation in 2015, it was not formally recognized as a disease, although many healthcare providers recognized it as such in their practices. However, without formal diagnosis of obesity as a medical disease, it was challenging for patients to get appropriate treatment. We still don’t know why some people develop obesity. We think that it’s multi-factorial and it’s a combination of genetic predisposition and behavioural or social factors.

How is obesity diagnosed?

The most popular and simplified way to measure for obesity is to measure weight and height. The index we use is called the body mass index (BMI), which is weight in kilograms over height in meters squared. There are various classes: underweight (BMI<18.5), normal (BMI 18.5-24.9), overweight (BMI 25-29.9), obesity (class 1 obesity: BMI 30-34.9), serious obesity (class 2 obesity: BMI 35-39.9) and severe obesity (class 3 obesity: BMI 40 and above). We used to use the term “morbid obesity” – we don’t use that term anymore. We call class 3 obesity “severe obesity.”

Something to note with BMI is that the range we use to classify obesity may not be robust to different races – it likely works better to estimate for the Caucasian population but less so in other races. In South Asians or the Asian population, they tend to have similar comorbidities related to obesity (such as diabetes and hypertension), even at lower BMI levels. In certain countries they actually use different cut-offs for their classes of weight and height to guide patients.

What are the barriers for patients with obesity to accessing care?

Obesity is a disease that has visible physical manifestations. There’s an increase in fatty tissue and body weight, so it’s subjective to everyone having some opinion and visually guessing or identifying someone as having this chronic disease – even if it’s true or not. The only way to actually diagnose someone with obesity is through the assessment of a physician and measuring BMI.

There’s a lot of stigma for patients with obesity, and patients can feel embarrassment and shame or experience harassment. Some do not want to come forward to have the treatment they require because of this, and it’s an area we need to really work on. The other thing is most people are very quick to judge and think patients who have this disease have it because they have a problem with overeating or living too sedentary a lifestyle or not exercising enough. While behavioural factors like eating and exercise have a role in the development of obesity, it’s not all. There are a lot of studies that have shown that there are genetic components to obesity, and a lot of studies have demonstrated obesity is regulated by hormonal changes as well.

Obesity is also a risk factor to access quality care – hospitals are designed for people with “normal” BMI, but more than half of our population is overweight or has obesity. What we call “normal” is actually the minority of the general population. It’s likely that there are shortages of ambulances or medical aircrafts suitable for transporting patients with higher BMI categories to be prepared for increasing prevalence of obesity. A lot of basic equipment like hospitals beds and chairs have specific weight-bearing statuses. For patients with a high BMI or weight class, they may need to wait for a specific bed or chair to be available. They’re likely to feel excluded from hospital setting and not feel included in the care system.

From a care and personnel perspective as well, we need more education around how we label and discuss patients with obesity or severe obesity. I like to avoid terms like “you are” obese. I don’t use obesity as an adjective because it should be used as a noun – it’s a disease. I would not say to someone “you are obese” because that’s not who they are – they’re someone’s father, mother or sister, they just happen to have this disease, and that’s very important for our healthcare workers to understand.

How big of a problem is obesity in Canada?

Prevalence of Canadians with overweight and/or obesity have been increasing for the last several decades. According to the Stats Canada self-reported data in 2018, about 10 million Canadian adults are reported to have overweight BMI and over 7 million Canadian adults are reported to have obesity. Obesity touches on almost every aspect of our health and increases the risk of developing several debilitating diseases, including diabetes, heart disease, fatty liver disease, several types of cancer, and obstructive sleep apnea.

There’s a very strong association between obesity and type 2 diabetes. Diabetes is a progressive, chronic disease and it has potential to have severe impact on your health. Type 2 diabetes can impact cardiovascular heath, kidney health, and lead to the diseases of small arteries creating issues with eye sight, ulcers in feet. These health problems are quite debilitating to many patients.

The good news is that if you have type 2 diabetes that is linked to obesity, there is an opportunity to achieve resolution of diabetes by treating obesity. If you achieve durable and significant weight loss from the treatment of obesity, you have an opportunity to be in remission from diabetes for a very long time. The same can be said for high blood pressure, fatty liver disease, high cholesterol, and obstructive sleep apnea that are due to obesity. Timely, effective, and sustained treatment of obesity can reverse many of these obesity-related diseases.

What are lifestyle modifications that can effectively treat obesity?

One is, of course, diet. This is a focus on the biochemical basis of obesity – if more energy is consumed (energy intake) than expanded (energy expenditure), the body will store that as fat and it’s a process that contributes to obesity. But we need to look at diet as not just “counting calories” but learning about food types that are more prone to generating fatty tissue per kilocalorie.

Sleep is also a very important lifestyle factor that’s associated with obesity. There’s a lot of active research in this area – studies are showing patients who have obesity tend to have lower number of hours sleeping in a continuous cycle. One reason is chronic pain because of obesity – there’s stress on the spine so they adjust more during their sleep. They’re also more prone to needing to use the bathroom during sleep so they experience chronic sleep loss. There’s a recent randomized controlled trial that showed that patients with obesity who received intervention to extend their sleep to 8.5 hours had lower energy intake, which resulted in a negative energy balance. Sleep hygiene is really an important part of a healthy lifestyle, which can be linked to weight loss.

There are also very exciting developments in medications and very encouraging studies in this area. They studies showed a few medications that are effective in using excess body weight from 5-15 per cent. That’s a great intervention. A lot of the newer medications are not yet approved by Health Canada so we’ll have to see when they become available, but medications will play a big role in managing obesity.

What about bariatric surgery?

There are three things I want people to know about bariatric surgery – it’s safe, it’s effective and that there’s a lack of awareness about it.

If a patient is at a BMI category of severe obesity (over 40 and above) or a BMI of 35 and above with one or more comorbidities, then the patient is eligible and should be encouraged to discuss bariatric surgery. It’s the most effective treatment for those patients.

Over the last 30 years, there’s been a huge improvement in the safety of bariatric surgery. There’s been also been improvements in our understanding of patients with obesity, anesthesia care improvement, and more minimally invasive options. There is such a low risk of death and of severe complications.

Bariatric surgery prolongs the lifespan and increases one’s quality of life. But there continues to be stigma towards patients who need to undergo active treatment for the disease they presume is a behavioural consequence. If you have a broken leg, you see an orthopedic surgeon. If you need braces, you go to an orthodontist. It should be the same way for patients who see professional help to treat their obesity. Yet, only 1 per cent of eligible patients based on BMI and comorbidities end up receiving bariatric surgical care, the most effective treatment for severe obesity.

What do you wish more people knew?

For patients with diagnosed obesity, I want them to know there are therapeutic options that should be explored. These options are very effective and are associated with increased life expectancy and quality of life, sustained weight loss, and resolution of diabetes, hypertension, and fatty liver disease. I also want them to know that bariatric surgery is very safe and is covered by OHIP – a lot of people don’t know that.

For people without obesity, it’s important for them to know that this is a serious disease that affects up to almost half of our population. It shouldn’t be treated as butt of a joke or a reason to harass someone. It’s a chronic, progressive disease that requires treatment. We wouldn’t make fun of anyone with high blood pressure or diabetes. We need to take obesity as seriously and be involved in the promotion of patients with obesity getting the right treatment, and be part of the movement to help educate patients.  

By: Jennifer Stranges