Q&A with Dr. Yoni Freedhoff, Part 1: Taking the burden of obesity, and blame, off patients
Dr. Yoni Freedhoff has some great perspectives for people concerned about obesity, the state of health care and health journalism. He is the founder and director of the Bariatric Medicine Institute (BMI, get it?) in Ottawa. He calls it "a multi-disciplinary, ethical, evidence-based nutrition and weight management centre."
He is best known, though, as the every-day-of-the-week blogger on Weighty Matters, where he opines on everything from the Canadian government's nutrition guidelines to the latest fast food menu items. His work on obesity has prompted the Canadian House of Commons to invite him to testify and has helped spur a whole movement in the country to better manage patients who are overweight and obese.
Antidote reached him at his office in Ottawa. The interview has been edited for space and clarity. The first part appears below. The second part will appear on Friday.
Q: When did you make the decision to focus on weight loss medicine, and what prompted that choice?
A: I started off as a traditional family doctor for the first few years of my practice. I had a lot of people asking me for advice on what they should do with their weight and I had nothing to offer them because we are not taught those things in medical school or in residency at all. Also, a relative of mine was doing something to lose weigh that, at least to me, seemed superficial and ridiculous. I thought that I needed to learn a lot more about weight management to be able to have an informed opinion about these things. In 2002, I went to a conference on obesity and found it fascinating. It snowballed from there.
I tried at first to be a one man gang, being a doctor, a dietician, a counselor, a trainer and coach and a motivator. It was very challenging. The Canadian health care system is unique and universal coverage is wonderful. But the system has its warts as well. One of the warts is that we are understaffed in terms of doctors. That means you don't get a lot of time with each patient, and so there just wasn't enough time for me to be all of those things. So in 2004, I raised some money and opened up my office where I am now. We have doctors, trainers, dieticians and a psychologist so we can approach all of the factors that contribute to being overweight.
Q: Was your practice unique to that area?
A: Prior to that, there were the obvious options: Weight Watchers, Jenny Craig. And that was pretty much it at the time.
Q: Have others opened as a result of the success of your practice?
A: One did. But it later closed. Having onsite fitness and dieticians made us unique to the country, to be perfectly honest. Maybe somebody else is doing this out there that I'm not aware of.
Q: What was it about what you were doing or how you were branding yourself that brought your name to prominence as an obesity expert?
A: That came from the blog more than anything else. A friend said to me, "You have lots to say about obesity," and so in 2005 I started saying it on my blog. I didn't really have any idea what was going to come of it. I was an English major before I went into medicine, and that obviously has helped with the writing part.
Q: That doesn't surprise me. There obviously are many, many smart and articulate physicians out there who are able to explain the science of medicine quite well, but you are doing something beyond that. You are speaking to multiple audiences at once, both to your fellow clinicians and to the guy who just bought a cheeseburger.
A: I started being critical of things that are sacred cows. Like Canada's Food Guide, which is awful. That got the attention of some of our parliamentarians, and I got invited to the House of Commons in 2006. I talked about the Food Guide there, and met some people as a result who cared about the same issues. Over time, I became someone who the media looks to for opinions. Within the Canadian obesity research and treatment community, I became friends with some of the folks who are the more prominent researchers in Canada. We coauthored a text book that we offered as a free download to all the members of the Canadian Obesity Network. That brought more attention to some of the ideas I have been putting out there on the blog.
Q: Where did the Canadian Obesity Network come from?
A: The network started not long after I opened my practice here. I got involved fairly quickly and then they put me on their list of Canadian obesity experts. Now I'm their family medicine chair. The network is basically a group of like-minded individuals. It's not there to take stands. It's not there to issue guidelines or edicts. It's there to bring people together. And that is actually one of the shortcomings of the organization. We need a group that will make noise. I've founded, along with a number of other like-minded individuals, something called Reality Coalition Canada. You have that in the states, too. That will be a group of people who are going to make noise. We have written our first white paper that we hope to have published in April or May about the realities of being obese and obesity treatment in Canada. It will talk about the problems in terms of treatment availability, surgery, the lack of training in medical schools, the economic consequences and what this all means for the future.
Q: On your blog, you call yourself "a certifiably cynical realist." What does that mean both in terms of your approach to medicine and your approach to writing about medicine and health?
A: I think idealism runs rampant, especially when it comes to weight management. Unfortunately, the ideal does not reflect reality particularly well. When it comes to the other stuff I talk about in terms of the media and advertising and policies that are backward, I don't mean to be rude or grating on the blog but its difficult not to be when you look at what's being put out there. There would be many people out there who point to my blog and say that I'm angry and all I want to do is criticize. You can see this in some of the comments people make on the blog. But that's just not true. None of it is personal. People need to open their eyes to what actually is going on around them in terms of the food industry and the government and what they are and are not doing. We spend tens if not hundreds of millions on West Nile Virus. And yet the virus killed nobody and infected 25 people last year. By the most conservative estimates, obesity is killing tens of thousands of Canadians every year and impacts tremendously on people's quality of life and the economy and yet we spend nothing on it as a country.
Q: What do you think it would take for people to start changing the way they think about some of these issues?
A: It makes me very cynical about whether people want to open their eyes to weight management and obesity. I hope that in time people will, but I suspect it will only be as a consequence of the economics of the single payer health system. There will have to be a lot more knee replacements and gastric bypass surgeries before people start to see that obesity is actually costing us a lot of money.
Q: Those with the dimmest view of American health habits tend to think of the US as full of overweight people gorging on fast food with a broken health care system that can't pay for all the resulting heart attacks and strokes. While in Canada, though, healthy people enjoy universal health coverage and longer lives. You obviously don't believe that. What are the differences between the two countries in your view?
A: In Canada, if you are acutely dying you are going to receive world class health care for free, where as in the US you may not. If you have something that can wait, you are going to wait a lot longer than in your country. Universal coverage is a wonderful thing, but there should also be a way for people to access the health care system more quickly if they have the means to do so. They shouldn't have to wait a year for knee replacement surgery or weight-loss surgery. I purchased critical illness insurance for myself because if I am diagnosed with an aggressive cancer or another disease I want to be able to go tomorrow to the states to get it treated rather than wait two months to get it treated. In terms of obesity, we are a few years behind you guys, but we are following the same pace. I wouldn't be bragging about Canada's obesity rates. We are climbing just as quickly as the US is climbing. We just started the trend later.
Q: The fact that too many Canadians are actually overweight prompted the Ottawa Sun to call you out saying that you had "critical things to say about the revised Canada Food Guide, but none of them were about how you psychologically get the nation's fatsos-through-junk-food to stop eating junk food and getting fat." You responded on your blog and took the Sun to task for calling people "fatsos." What is your sense of how well the media cover weight issues?
A: The media are not great at it. There are some great reporters, don't get me wrong. But overall, the media are still stuck in this idea that obesity is a problem of lack of willpower and lack of exercise and so all of the reporting is spun with that viewpoint. This works with their readers, because most of society believes that to be true.
Q: They do, don't they. They think that people are overweight because they are lazy.
A: Right, and reporters approach the issue with the idea that we should just be able to push away from the table. These people are so lazy that they can't be bothered to do anything to help themselves. From an evidence-based perspective that is ridiculous. People don't want to have this problem, especially people who are morbidly obese. This is an awful condition. It's tough to live your life when you have an extreme amount of weight to lose. It is not a disease of choice.
Q: If you had to cite the single biggest reason people are overweight, what would it be?
A: It's definitely an environmental issue. I don't think our genetic backgrounds have changed over the past 60 years. Our energy expenditure hasn't changed over the past 40 to 60 years. When you compare us to people in rural Nigeria, we burn the same number of calories despite the fact that most of us think we have a more comfortable lifestyle. We have an environment that makes calories almost unavoidable and exercise difficult to obtain. We need to store energy for the future, and it's only been the past few 100 years that we have been living in this rich food environment and only in the last 50 years where food became something that was everywhere. Crop subsidies for corn are one problem, because of how they encourage the use of so much high-fructose corn syrup in foods. Schools now have school lunch programs offering chocolate and other flavored milk.
When I went to school there was only water available, let alone chocolate milk. We are feeding our children garbage. Just because you eat and know that vegetables are good for you, doesn't mean that you are eating the right diet for you. The food industry has created this cornucopia of garbage that makes you feel like you are cooking, but just because you are stirring ingredients doesn't mean you are cooking. Add to that the increase in eating outside or your home and the perpetual snack involved in every event our children do. People are eating more, but it's not because of gluttony. It's because we are completely behind the eight ball in an environment that is completely unfair to the average person. The amount of energy and resourcefulness it takes to navigate this environment is very large. You in the US have your food pyramid, and we have our food guide. None of it helps. Most of the interventions tend to center around exercise, but the literature comes down on food as the culprit. We still focus on exercise because that is what people want to hear and believe.