Obesity, Liver Disease, and the Patient Voice: A Clinical Dialogue Podcast

00:00:00: You are listening to an ADIS Journal podcast.

00:00:05: Hello, my name is Dr.

00:00:07: Megha Podar and I'm the medical director of The Medical Weight Management Centre in Canada.

00:00:21: of someone living with obesity, highlighting the barriers of diagnosis discussing typical comorbidities experienced by people with obesity.

00:00:29: With a focus on the importance of liver health in the management of obesity.

00:00:34: Joe please tell us a little bit about yourself.

00:00:36: Hello I'm Jonah Glowski.

00:00:37: president CEO The Obesity Action Coalition have a lifelong experience with obesity and lots of experience working in patient advocacy public policy and education.

00:00:47: thanks for including me today.

00:00:48: Of course, thank you so much for talking with me.

00:00:51: You know we all kind of know obesity is a chronic disease but around a billion people worldwide live with obesity which in part was due to this definition.

00:01:00: we have around body mass index or BMI of more than thirty But We now Know that Obesity Is Really Characterized By Access Fat That Can Lead To Many Other Serious Health Conditions.

00:01:12: So Joe, I would love for you to kind of take us back when we were first diagnosed.

00:01:17: What was that experience like and who brought it up?

00:01:20: The very first time a physician spoke about my weight is when i was twenty years old so now nearly thirty five years ago And during the visit My doctor wagged his finger at me and told him he needed to lose twenty-five pounds.

00:01:33: As you can imagine It wasn't pleasant experience Not really conversation.

00:01:37: You know...I understood That I struggled with my weight most of us with obesity do, but telling me to lose weight without offering any guidance didn't feel like the best way to handle it.

00:01:48: Now I'll fast forward almost fifteen years later and i'm now in my role at The Obesity Action Coalition where I had a visit with very caring primary care physician for my annual checkup.

00:01:59: she did quick exam wrote me by blood pressure knee osteoarthritis medicine said Joe all looks good we will see you next year.

00:02:07: as she was walking out door Can we talk about my

00:02:11: weight?".

00:02:11: And she said, oh Joe don't worry about it.

00:02:13: You're within the normal range.

00:02:15: and I said, but I don't think that was the case.

00:02:18: I think you wrote me some medicines that We might be able to adjust if i wasn't overweight.

00:02:23: She then sat down and had a caring an empathetic conversation with Me.

00:02:27: That's The first time that I really felt like A doctor truly cared About My concerns With obesity?

00:02:33: She went on To share her own lived experience.

00:02:35: I Had no idea But she had also struggled with obesity So our story was very relatable.

00:02:41: Even though I had read about obesity extensively, that conversation really provided me an aha moment about my condition being a complex disease—our story resonated with my own!

00:02:51: —I felt like it could allow myself some compassion at the turning point and focus on how we can address health issues related to obesity.

00:03:03: Importantly, I realized that obesity wasn't just about magic numbers on scale.

00:03:08: In fact, her first reaction to me.

00:03:10: Don't worry about it Joe your normal took away the judgment that this was About my body size and actually got me to the point where we could Actually talk about the health side of it.

00:03:21: Telled Me better understand That This Can Impact My Risk Of Getting Type II Diabetes Cardiovascular Disease And Other Metabolic Conditions Being Treated With A Low Compassion.

00:03:30: Empathy An Understanding Really Made a Huge Difference in My Life.

00:03:34: It Started Me on The Journey To Where I am Today to make me as healthy as possible.

00:03:38: Wow, that's amazing Joe!

00:03:40: Thanks so much for sharing that.

00:03:42: you know I think the reality behind your story is.

00:03:44: it probably does reflect many other people stories and journeys.

00:03:48: It just highlights how different someone experience depending on which doctor they see but its also pretty clear.

00:03:58: The problem is really one of delayed treatment.

00:04:01: People living with obesity have had obesity for at least six years before that even discussed the problem with their doctors, so what do you think prevents people from coming to their doctors about their weight?

00:04:13: Is there something that you feel like your doctor could've done day-one that might've changed her outcome?

00:04:18: I probably think what prevents someone from going to their doctor about their way?

00:04:21: it's this societal attitude around obesity that this is something I should be able to control on my own.

00:04:28: Added of that, from experience during the very first visit where my doctor just told me to lose weight...I actually believe it was my fault and could address this on its own!

00:04:39: The best way doctors or nurses can handle this would be compassionate—to be empathetic —and ask for permission….

00:04:46: I really wish someone said hey Joe, Is okay if we talk about how your weight impacts health?

00:04:52: almost all of us struggle and we want help.

00:04:55: We just don't know how to ask for

00:04:56: it.".

00:04:58: On the other hand, if a clinician offers to have a conversation and the patient says no or they're not ready to discuss that's okay as well.

00:05:06: you simply respect those wishes when there are ready-to-have conversations with an empathetic compassionate one who is based on the science of obesity but not about self judgment.

00:05:16: Yeah I love that especially this part about bias in stigma Because as a doctor, I think it's the biggest differentiator to the experience of the patient.

00:05:26: You know people are almost expecting me to tell them that you just need to diet or exercise and they're not trying hard enough?

00:05:33: And i generally don't take that approach.

00:05:35: The minute open up by an invitation there is total shift in my patients demeanor You know, for example saying to a patient your blood pressure is high and this could be related to your weight.

00:05:49: Is weight something that you want support with?

00:05:52: That conversation is dramatically different.

00:05:55: as a doctor it actually kind of makes my job easier if I open the conversation up by reducing stigma right at.

00:06:02: You know, we all have our own biases and our own lived experience.

00:06:06: And not all of us agree or understand that obesity is a chronic disease and how we need to approach obesity in that way?

00:06:14: So from a physician's perspective I would recommend this actually the most critical first step.

00:06:20: We have to fundamentally understand why obesity is at Chronic Disease.

00:06:27: When we understand this concept, then we can appropriately address bias and stigma.

00:06:33: We can learn what real treatment is and then help our patients to undertake a successful journey to better

00:06:38: health.".

00:06:39: And one of the things that really helped me was my doctor's recognition that obesity is a disease—that it wasn't my fault!

00:06:46: It made me realize by many interventions I tried in the past were ineffective for me.

00:06:51: so i'm curious from your perspective when do you raise?

00:06:56: So, I approach this in many different ways.

00:07:23: So I asked them about their journey with weight, how long have they had difficulty losing weight and keeping it off.

00:07:29: The average patient tends to describe multiple attempts of sort-of reducing calories increasing exercise in seeking support, losing weight then regaining it... And the critical piece is summarizing back into them this way.

00:07:44: that know i've actually heard And then I'm able to explain that our body defends against weight loss by increasing our appetite and decreasing our metabolic rate.

00:07:55: This is why obesity is a chronic disease, and this is why we wait cycle despite diet and exercise?

00:08:12: So that's sort of my approach.

00:08:13: You know, it's really kind of personalizing the chronic disease piece a bit and one

00:08:17: Of those things I realized early on in my journey was that?

00:08:20: I used to primarily think about weight loss But now let's change to think more about my general health such as not being in pain Being functional being able to move not having other chronic diseases?

00:08:31: How do you talk to your patients when it comes to consider things other than the reading on the scale?

00:08:36: Yeah, I think this conversation needs to happen very early on right at diagnosis.

00:08:42: Many people are being diagnosed with obesity based off their weight and height calculation known as a BMI.

00:08:49: However, because of how it's calculated the BMI focuses overall on someone's weight.

00:08:55: But it fails to provide an understanding.

00:08:57: these kind two key things.

00:08:59: The first one is what proportion a fat that makes up someones' overall weight?

00:09:05: Is actual fat versus muscle or bone?

00:09:08: and secondly where is that fat located in your body?

00:09:12: As physicians, we need to be more concerned about the fat that's around our abdominal organs known as visceral adiposity rather than the fact kind of underneath the skin.

00:09:22: So when I'm diagnosing obesity, I talk about BMI to provide a frame of reference to help understand the disease overall.

00:09:30: but I am also doing other key things.

00:09:33: I'm also assessing waist-to-height ratio or waist circumference.

00:09:37: this gives me an indirect measure.

00:09:40: This is kind of my stepping stone to then being able to have a conversation with patients about their elevated risk of metabolic diseases like type two diabetes, heart disease and high blood pressure.

00:09:52: And then the last part of my assessment Is what we call The Edmonton Obesity Staging System?

00:09:58: this is A score that determines how much Of someone's weight is affecting Their mental health mobility and metabolic Health.

00:10:06: So you know from an Assessment perspective if You take these three parameters the BMI, The Waste to Height Ratio and Edmonton Obesity Staging System you get a very holistic view of how obesity is affecting this patient.

00:10:20: And then really can understand how best to treat it!

00:10:24: Some my patients at follow-up they're so excited to tell me about their weight since last visit but I'm always looking for other parameters like what's their waist circumference or metabolic health or mechanical mobility.

00:10:36: have those things improved?

00:10:38: And I frame it back to patients so that they can understand how I'm defining successful treatment.

00:10:44: A big challenge we know have in obesity is often the physician's definition of what successful treatments are really different from what a patient thinks, and every single visit I try to relate treatment with those health parameters of success that the patient originally described.

00:11:07: There's been so many times where I've seen patients sort of lose weight, but their disease state is not getting better.

00:11:13: Their mobility isn't getting better.

00:11:15: that's not successful treatment That's just losing weight.

00:11:18: on the other hand i've seen lots of patients who haven't lost that much weight But they're metabolic parameters actually improve significantly.

00:11:25: They're sleeping better there mood is better?

00:11:27: That's real effective treatment.

00:11:29: So we really need to be able to define successful treatment at the beginning and help patients and doctors come together so that they're on the same page?

00:11:38: You know, in the patient community a lot of what you described are called non-scale victories.

00:11:43: They're oftentimes just as or even more important.

00:11:46: I will tell you that from my own experience.

00:11:47: i finally realized that my obesity treatment was successful when i noticed that i was able to walk long distances without pain As someone who suffered from neosterearthritis and had functional issues around it.

00:11:57: It was the moment that i finally felt That we were moving forward.

00:12:01: Now, Dr.

00:12:02: Polder one of the things that always stood out to me from early on in my diagnosis was that my clinician would often trivialize My liver testing by telling me that my liver enzymes were elevated But then they would say there was nothing They could do about it and they would assess again next year.

00:12:18: So can you help me understand?

00:12:18: The impact of obesity on the liver?

00:12:21: Yeah, you know obesity is strongly associated with this condition that we call metabolic dysfunction-associated steatotic liver disease or muscle D for short.

00:12:33: About three quarters of people with obesity have muscle D so it's super strongly related but actually very underdiagnosed.

00:12:42: Some of the reason for this is because this condition doesn't necessarily show many symptoms.

00:12:48: So even in your own experience, you sort of mentioned... You didn't even know that you had a liver issue until the blood work was done.

00:12:55: And the bloodwork itself is actually not a great measure of liver health!

00:12:59: So muscle D is a manifestation of what we call metabolic syndrome.

00:13:04: This occurs when you get excess fat stored in the liver and this causes another condition called insulin resistance where the body starts to become less sensitive To this natural hormone insulin.

00:13:17: So insulin, it's released from our pancreas.

00:13:19: It helps our body use a type of sugar called glucose as a form of energy and Insulin also causes storage of fat in the liver.

00:13:28: so when the body starts to become more and more resistant to insulin it needs More insulin to be able to use that glucose for energy.

00:13:36: The more insulin the body makes the more resistance the body becomes to it And the more fat ends up getting stored in the lever.

00:13:42: Around twelve to forty percent of people with muscle D end up getting a more severe form of muscle D called metabolic dysfunction associated steatohepititis, or MASH within eight-to-thirteen years.

00:13:58: MASH is characterized by inflammation in the liver due these excess fat deposits.

00:14:03: because of insulin resistance and obesity Many patients that have inflammation in the liver are not being adequately followed up when their liver enzymes are found to be high, just like you mentioned.

00:14:18: If we leave MASH untreated... ...that inflammation can end up causing more severe issues such as liver scarring and even cancer.

00:14:28: There is a need to improve diagnosis of muscle D and MASH—as well as regular monitoring of people's liver health!

00:14:36: This is really, really important given the fact that people don't have symptoms especially at those early stages of muscle D. So it's even more important any time we're thinking about obesity assessment to be proactive.

00:14:53: Obesity treatments, especially pharmacotherapy and bariatric surgery fortunately has been shown Because we're treating that obesity, because obesity and excess fat are the underlying causes of so many of these issues.

00:15:09: So going back to my experience with my clinician many years ago not knowing what to do with my elevated liver enzymes What would better care look like today for liver health?

00:15:20: Yeah You know I think as a doctor We all kind of work within this paradigm where we have guidelines And we have algorithms And fortunately, we have very clear screening algorithm pathways for Maslidian Mesh.

00:15:33: There's an index called the Fibrosis IV Index or FIB-IV.

00:15:38: It is a really easy blood test.

00:15:40: it uses age platelet count and liver enzymes like ALT and AST.

00:15:45: Its super easy screening tests For all patients living with obesity.

00:15:50: for fibrosis We recommend using the FIB-IV Test Now, if your FIVFOR is elevated we would refer you to a diagnostic screening or high-risk screening center.

00:16:00: Or proceed with the test called a fibroscan.

00:16:03: it's a nonsurgical procedure and then allows us to look at how much fat actually in the liver And also how stiff the liver has become The liver stiffness or liver elasticity.

00:16:15: this helps us assess an amount of scarring.

00:16:18: that's actually So.

00:16:20: overall, these tests allow us to determine sort of how severe or advanced the patient's liver disease is.

00:16:27: And if a patient has a high risk of liver scarring then that's when we start to think about specialists like hepatology being involved.

00:16:35: It's true that you know while the availability of more advanced liver test it can vary from clinic-to-clinic All of us have the ability to do a fib for because it's just a simple blood test.

00:16:48: So really, you know the key learning here is that fit for screening.

00:16:52: Is The first step to opening the conversation about kind of understanding someone's liver health?

00:16:57: so on That note Joe You don't.

00:16:59: how surprised were you that obesity could affect the liver.

00:17:03: Yeah My doctors are just ignoring my liver enzyme levels.

00:17:06: It made me feel like I didn't understand what it meant and if my doctors were ignoring it probably wasn't that important.

00:17:12: I probably had the same reaction as many other patients tend to have, my only understanding of a liver is its role with alcohol.

00:17:29: Yeah, we sort of think of the liver as this organ system responsible for recycling in our body.

00:17:36: It helps metabolize glucose.

00:17:38: it's responsible for helping us absorb what we need while similarly removing any toxic substances.

00:17:45: so you can imagine if this machinery is not working as it should then you start getting toxicity buildup in the body.

00:17:52: So If you have liver disease really?

00:17:54: The problem is that it can affect other organs and the body.

00:17:58: And a lot of the time when we're doing an assessment for obesity, We find lots of different problems.

00:18:03: Elevated blood sugar elevated cholesterol pre-diabetes mash or muscle D and it leaves people quite shocked.

00:18:10: They don't feel that living with obesity is associated With all these different organs and the liver Is the biggest one because there's very little symptoms until The most severe forms of muscle D. So I really try to holistically show my patients That These are not All separate Problems.

00:18:28: The root cause of all these things is often obesity and insulin resistance.

00:18:34: Insulin resistance leads to elevated blood sugars, cholesterol you know inflammation in the liver.

00:18:39: so we need help support and treat that underlying causes so they get better but equally also proactively do monitoring.

00:18:53: This is pretty critical because we commonly associate obesity with diabetes and heart disease, cholesterol.

00:18:59: But we actually forget the liver most of the time And obesity is one of the strongest risk factors for muscle D and mash.

00:19:07: So as an endocrinologist you know We're constantly advocating for this idea that we need to look at the liver more often.

00:19:14: There's not enough hepatologists available, nor does everyone with Maslady or MASH need to see a hepatologist.

00:19:21: But in primary care and endocrinology internal medicine we all need to be more aware that the liver is part of the metabolic syndrome And We Need To Start Putting The Liver In Our Algorithms, our Clinical Pathways & Practice Guidelines.

00:19:34: What Does That Individualized Treatment Look Like For People Who Have Obesity Complications?

00:19:39: And what advice would you give to our listeners today?

00:19:41: Yeah, so where you get your treatment and ends up having a big impact on the outcome that you get.

00:19:48: Because if we're just looking at obesity as a weight problem then the goal of Obesity Treatment is going to be weight loss.

00:19:55: We end up missing all negative health outcomes and potential benefits that could actually be targeting.

00:20:02: Now also have more treatment options than ever had before.

00:20:06: So how are we gonna decide which medication best suited for which patient?

00:20:11: This is where we need to start having a really good understanding of comorbidities related to weight, how much of this weight is impacting which organ system?

00:20:21: because certain medications treat certain organ-related dysfunction better than other medications.

00:20:27: So I'm not trying to suggest that every patient living with obesity needs to lose fifteen percent.

00:20:34: I'm actually suggesting that there are certain obesity medications that better target the liver.

00:20:40: They're going to have a better outcome regardless of how much weight they lose, so when you go somebody who doesn't necessarily understand this pathophysiology or getting your medication online—they'll probably just pick the medication which provides most weight loss!

00:20:56: That's one our biggest challenges….

00:20:58: people are not being diagnosed properly, especially those with liver disease and their disease isn't being monitored or treated properly.

00:21:07: You can imagine the amount of people with liver scarring in liver cancer that have been diagnosed far later than they ever should have because their liver health was never assessed or monitored in the first place.

00:21:19: so to arc back to the start of our conversation you know I think it would be really short-sighted of us to think of obesity as a simple BMI calculation.

00:21:28: We have to do a full assessment, understand all the organ systems involved and treat those organ systems with the right obesity medication.

00:21:37: The key message I hear from this is that obesity treatment goes well beyond weight loss.

00:21:42: so what advice would you give to clinicians looking at better support their patients?

00:21:46: Yeah, I would say that understanding.

00:21:48: you know the national guidelines are important to make sure that you're doing a full assessment and then learn about the things that you can bring into your own clinic environment.

00:21:57: That are going to be helpful for your patients?

00:21:59: For example Can You Do A Fib Four Test?

00:22:02: or What About The Further Diagnostic Testing And Imaging?

00:22:05: Who Else Is Around You To Support You In That ?

00:22:07: Do You Have A Dietitian , A Psychologist Or An Exercise Physiologist?

00:22:12: If You Don't Where Are You Going To Refer Your Patient To?

00:22:16: You know, we started this conversation actually talking about bias and stigma.

00:22:20: So the worst thing I could do for my patients is refer them to a colleague.

00:22:24: who's then gonna reinforce that negative bias in stigma after I spent the entire first visit trying to address internalized weight bias.

00:22:33: so if i can't help my patient in my own clinic Then I need to make sure that the doctor I'm referring them too Is also aligned with The concept of obesity as a chronic disease?

00:22:43: And has the same ideals that I do.

00:22:46: And I would say for all doctors, you know knowing what needs to be done to properly assess and monitor your patients.

00:22:52: Then figuring out how much of this can i do myself versus How Much Of This Needs To Be Referred Out?

00:22:58: Where Are They Going To Go?

00:22:59: You'll find very quickly that you need to refer patients much less because you get more confident managing the comorbidities on yourself.

00:23:07: but if we don't talk about it at The Beginning We're Never Gonna Findout.

00:23:11: So today, I would just leave everyone with this message that holistic obesity assessment includes a full understanding of comorbidities related to excess weight.

00:23:21: It's an integral part.

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