Obese Canadians find effective medical help elusive
Anne Marie Owens
National Post
Saturday, April 29, 2006
CREDIT: CanWest News Service File Photo
Obesity is on the rise in Canada but medically, there is little help available.
HAMILTON - By the time Luis Couto was turned away from the U.S. border on his way to an appointment to discuss gastric bypass surgery, he had already spent seven hours on a bus, staring at an openly hostile bus driver, and he had already watched as the entire bus was emptied and the passengers rearranged so he could take the two seats his body fills.
"When I finally got there and they told me they weren't going to let me go across, I just lost it," he says.
"There's a five- to six-year wait for this surgery in Canada; in the U.S., it's six months to a year. I don't have a lot of time. Look at me."
When you look at Mr. Couto -- and it is impossible not to look at him -- you cannot help but think, "How does someone get this way?"
There has been a great deal of talk about the rising level of obesity in Canada. But amid all the discussion about getting people off the couch, about banning junk foods and sugar-laden drinks from schools, and about instituting a fast-food tax, there is nothing in the panicked rhetoric that applies to such people as Luis Couto.
None of these obesity-fighting initiatives is aimed at helping him -- although maybe they would have back when he was 10 and weighed 200 pounds, even though his mother was steaming his vegetables and chicken and serving him separate meals from the rest of the family.
But not now that he is 22 and carries 450 pounds on his five-foot-5 frame. On the standard measurement used to calculate body mass in relation to height, he has a BMI of 75. Anything over 30 is considered obese. Anything over 40 is morbidly obese.
It is going to take more than a walk around the block or a prohibition on junk food to keep Mr. Couto from becoming a costly lifelong drain on the system. He knows it. His doctor knows it.
Even though the number of people considered morbidly obese is growing more rapidly than other categories of obesity, with potential health care and social services costs that are staggering, it is where the least amount of medical resources and attention are being directed in this war on obesity.
Dr. Arya Sharma, a world-renowned expert in obesity research and Mr. Couto's doctor, says most of his patients weight more than 300 pounds and it is not unusual for him to see someone who is 600 to 700 pounds.
But there is something even more disturbing about his client profile -- they're getting younger: "I'm not treating 65-year-old obese people. They're 20, 30 years old. They're not working. They're not buying homes. They're not having families."
He says the economic argument alone should compel Canada's medical system to attend to the problem. But it isn't.
"Treat obese people -- and the fact that they have obesity -- the same way you treat people with any other disease," he argues. "The way the system is now, it's as if doing cancer surgery on a 70-year-old is more important than doing obesity surgery on a 20-year-old.
"Hospitals are always happy to announce the opening of a new cancer centre, but there's nothing sexy about a new obesity centre ... I'm not saying the cancer centre isn't important, but we have an awful lot of them.
"The money always goes to people who make the most noise. Obese people don't make noise."
A case in point is bariatric surgery. Regarded as the most effective way for the morbidly obese to keep off the weight and begin tackling health problems, it is offered by only a handful of Canadian clinics despite a burgeoning waiting list.
The ratio of potential candidates to the actual rate of surgeries means it would take 30 years to meet the current need, Dr. Sharma says. That's why many patients get Canada to pay the hefty price tag for them to have the surgery in the United States, where the number of these surgeries has risen five-fold in a four-year period.
The man who has just been named to lead the Canadian Obesity Network insists that the system regards those with the most to lose, literally and figuratively, with the same kind of discomfort and disdain as the rest of society.
"Look around this waiting room and what do you see?" says Dr. Sharma, gesturing to where he runs his clinic in Hamilton General Hospital. It looks like every other hospital waiting room, except a closer inspection reveals a few armchairs that are considerably wider than the standard chair.
"It took me 2 1/2 years to get them. We only just got a bariatric wheelchair [which accommodates heavier weights]."
There is a heavy-duty scale that exceeds the normal weight allowance, but there is only room for it within the waiting room, so patients must stand on the scale in front of a crowd, a cringe-inducing manoeuvre even for those of healthy weight.
He tells me about patients so large they cannot be scanned on regular medical equipment, so they have been sent to the University of Guelph in Guelph, where large animals such as horses receive MRI scans. But when I ask for more details, he demurs.
He says even the clinic's location illustrates the systemic misunderstanding about obesity. For a healthy person, it is a 20-minute walk -- down stairs, along a ramp and through winding corridors -- from the parking garage to the clinic. For one of Dr. Sharma's patients, it is an arduous journey, usually requiring a wheelchair.
"People will say, 'Oh well, it's good for them to walk.' But that's just not helpful. They're going to feel exhausted, demoralized, worn down by the time they get here. And a walk like that, though exhausting, isn't about to make a dent in their weight."
Someone is considered morbidly obese when they weigh 100 pounds or more over ideal body weight, or have a BMI of 40 or higher. Obesity becomes morbid when it significantly increases the risk of one or more obesity-related health conditions or disease (such as diabetes and heart disease).
About 18 million Canadians, more than half of the population, are considered fat, with the majority classified as overweight, in the pre-obesity range. A study on the prevalence of various levels of obesity in Canada found a relatively minor increase in the number of people considered overweight, but a significant hike in obesity: Between 1985 and 2003, the number of people considered obese doubled, while the number of morbidly obese almost quadrupled.
The numbers, of course, are much smaller at the more extreme levels -- 33.9% of Canadians are overweight, compared to 4.3% who are at the highest levels of obesity -- but the trend is alarming.
A downside to the increased focus on obesity is that everyone thinks they have a solution, even the medical community. And while "Just lose weight," or "Go on a diet" may be helpful advice for those hoping to stave off obesity, it does not do anything for those requiring treatment.
Obesity prevention is a low-calorie diet and moderate exercise; obesity treatment is adhering to an extreme calorie-restricted diet typically achieved by consuming only meal-replacement substances or by invasive surgery, such as the gastric bypass procedure or stomach stapling.
Both procedures, which essentially cut off part of the stomach so as to dramatically and permanently reduce food intake, are done so rarely in Canada that the long waiting lists propel a steady flow of patients into the United States for the $18,000 surgery.
Mr. Couto was on his way to Detroit for a long-awaited consultation for the surgery when he was turned away at the border over paperwork.
His journey to that crushing rejection is a sad story of an endless one-step-forward-two-steps-back loop of weight loss and weight gain.
When he was just a boy, he got a placement in an innovative children's hospital weight-reduction program but his mother -- a Portuguese immigrant single-handedly raising four children -- could not find any neighbourhood pharmacy to fill some of the unusual prescriptions.
Throughout his teens, he shed and gained dozens of pounds through a succession of fad diets, exercise regimes and herbal remedies. In high school, he weighed 325 pounds before dropping out.
Even as recently as a couple of years ago, he went through an extreme fitness phase where he swam for hours at a time each day at his local YMCA, but then his unemployment benefits ran out and he could no longer afford the costs or the time on welfare benefits.
He lives alone, suffers bouts of depression and is so desperate for the gastric bypass surgery he sees as the only way to turn his life around that he is eager to share his personal story and even pose for photographs. It is obvious he is painfully aware his life is passing him by.
Getting on a bus is difficult because he cannot "just squeeze by" other passengers or strollers to find a seat. Hopping into a friend's car is dodgy because most seatbelts will not extend far enough to wrap around his stomach. Local restaurants may not have seats big enough to accommodate him and he is wary about just plopping down on a friend's couch for fear of breaking the furniture.
Cheryl Harvey, another one of Dr. Sharma's patients, consumed nothing but meal replacement shakes for an entire year in an effort to lose some weight. At 51 and 5-foot-3, her ideal weight is 128 pounds; she weighed 421 pounds when she joined the clinic more than a year ago and at 340 pounds now, still has a BMI of 60.
We are about the same height, but her legs are as thick as the trunk of my body. After the weight loss, she has so much excess skin that her stomach drops almost to her knees.
She is seeing a plastic surgeon about removing the excess skin but what she is desperate for is a gastric bypass, for which she is on a long waiting list.
To bolster her case, she has letters from friends and physicians talking about her lifelong struggle with obesity.
"When we look back, even our parents were overweight," her sister writes in a letter. "My mother cooked good and healthy food but we all seemed to be on the overweight side."
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