Drivers of medicalization in the Canadian Adult Obesity Clinical Practice Guidelines

Abstract

The new Canadian Adult Obesity Clinical Practice Guidelines frame higher body weight as a chronic, relapsing disease requiring comprehensive medical treatment pathways. In this commentary, we will demonstrate how a process called pharmaceuticalization is informing the new guidelines. We join those questioning the normalization of industry and medical collaboration and interrogate whether the new guidelines meaningfully address stigma.

Introduction

Medicalization is “defining a problem in medical terms, usually as an illness or disorder, or using a medical intervention to treat it” (Conrad 2005, pg. 3, italics in original). Medical professionals and organizations are not the only actors in this process. Conrad (2005) and others (Blech 2006, Moynihan 2002, Moynihan & Henry 2006) have described a shift by pharmaceutical companies from marketing drugs to creating and marketing diseases themselves. An offshoot and sometimes complement of medicalization, pharmaceuticalization is defined by Williams et al. (2011) as “the translation or transformation of human conditions, capabilities and capacities into opportunities for pharmaceutical intervention” (p. 711). Industries use research funding to influence entire fields, prioritizing topics that support their desired messages, distracting from potentially unfavourable research in a way that appears scientifically credible, and spreading these agendas through collaborating researchers and institutions (Fabbri et al. 2018). Williams et al. (2011) argue that the benefits and harms of this process are not known in advance, but instead, should be explored for each case.

We aim to initiate the conversation about the pharmaceuticalization of fatness in this commentary. Using the case of the recent Canadian Adult Obesity Clinical Practice Guidelines (Obesity CPG) (Obesity Canada 2020a; summarized in Wharton et al. 2020) developed by Obesity Canada (OC) and the Canadian Association of Bariatric Physicians, we examine how pharmaceuticalization is a driver in the work of OC, an organization that seeks to further medicalize fatness. We join those questioning how the co-occurrence of mutually reinforcing pharmaceuticalization and medicalization entrenches a medical framing of body size, and we interrogate whether guidelines steeped in such an approach can meaningfully address stigma. To do so, we must consider who may benefit from “treating” “new” diseases and how industry influence may operate (Lexchin and Fugh-Berman 2021).

Pharmaceuticalization can involve multiple strategies or dynamics (Williams et al. 2011). Those most relevant to the particular case we explore below include the following: first, growing pharmaceutical markets, sometimes by expanding diagnostic categories—even with limited scientific evidence; second, generating investment by promoting particular pharmaceutically inclined visions of the future, which can close down other possibilities.

The entanglements of Obesity Canada and pharmaceutical companies

OC promotes itself as the largest organization of “obesity” professionals in the world (OC 2019a), which may illuminate why pharmaceutical involvement has been so pronounced. In 2019, pharmaceutical company Novo Nordisk was the sole corporate sponsor of OC in the $100,000 or more category (OC 2019a). Bausch Canada, another pharmaceutical company, contributed between $50,000 and $99,999. At least two other weight-loss companies, WW and TOPS, are also listed as OC corporate sponsors (OC 2019a; 2021a).

Novo Nordisk (2019) is “committed to expanding access to obesity care... and [they] fight for better recognition of obesity as a treatable disease” (p. 12). Partnering with “professional associations and other stakeholders” is one strategy Novo Nordisk employs to realize their targets (Novo Nordisk 2019, p. 12). OC’s “Report Card on Access to Obesity Treatment for Adults in Canada 2019” shares that frame; the report laments the lack of recognition of “obesity” as a disease and poor uptake of “obesity” drug and bariatric treatment in Canada (OC 2019b). The report mentioned a “Knowledge Translation Advisory Committee”, comprised of pharmaceutical company employees. After releasing this report card, Novo Nordisk paid a strategy company to lobby politicians and “educate” them about “obesity” being a disease (OC 2019a, p. 9).

The Obesity CPG illustrate the extent of industry entanglement: all 6 executive committee members disclose multiple industry relationships. In general terms, conflicts of interest among clinical practice guidelines authors have been linked to pharmaceutically disposed recommendations (Cosgrove et al. 2017; Tibau et al. 2015) and more favourable perspectives concerning pharmaceutical safety (Wang et al. 2010). Hunt et al. (2021) described these issues within the American Diabetes Association (ADA). Their Consensus Statement on type 2 diabetes management (Garber et al. 2020), which featured increasingly industry-aligned recommendations, included 15 of 19 authors with industry ties. The authors of the Obesity CPG maintained the executive committee developed and managed a conflict of interest policy. However, nearly half of the broader list of Obesity CPG authors declared industry links. That each executive committee member had multiple financial relationships with industry, notably with Novo Nordisk (Wharton et al. 2020), violates standards for managing conflict of interest (Institute of Medicine 2011; Schünemann et al. 2015).

How the Obesity CPG can grow pharmaceutical markets by expanding diagnostic categories

As the health conditions correlated with “obesity”1 (for example, diabetes) are already recognized diseases with established risk reduction and treatment pathways, the value of further medicalization of a correlated risk marker (“obesity”) must be demonstrated. The Obesity CPG distinguish between someone with “obesity” [which they define as a “complex, progressive and relapsing chronic disease characterized by abnormal and/or excessive body fat (adiposity) that impairs health” (OC 2020b, p. 3)] and someone living in a larger body without health impairment. This distinction is then contradicted, with claims that “so-called metabolically healthy patients with obesity should not be considered to be fully medically healthy” (Rueda-Clausen et al. 2020, p. 5), and pharmacotherapy and bariatric surgery recommendations are made for metabolically-healthy individuals based on body mass index (BMI) alone (Biertho et al. 2020; Pedersen et al. 2020).

In the Obesity CPG, clinicians are encouraged to, “Acknowledge that obesity is a complex, heterogeneous chronic disease that requires individualized treatment and long-term support” (OC 2020b, p. 4). Regarding treatment, “medical nutrition therapy” will not suffice to effectively treat “obesity” due to “compensatory mechanisms” stimulating weight regain (OC 2020b, p. 5). “Instead, medical nutrition therapy, in combination with other interventions (psychological, pharmacologic, surgical), should be tailored to meet an individual’s health-related or weight-related outcomes” (OC 2020b, p. 5, italics added). This phrasing suggests weight outcomes may be divorced from health outcomes in clinical practice.

As the Obesity CPG authors note, weight-loss dieting is generally ineffective in the long term (Bacon and Aphramor 2011). Furthermore, it is associated with risks such as loss of bone mass, disordered eating, diminished dietary quality, and elevated stress (Aphramor 2005; Bacon and Aphramor 2011). However, biotechnological therapies may not be low-risk solutions. The Obesity CPG chapter on Pharmacotherapy in Obesity Management was authored by three industry-funded researchers (Pedersen et al. 2020) and recommends medicating people with quite low BMIs, including “individuals with BMI ≥ 30 kg/m² or BMI ≥ 27 kg/m² with adiposity-related complications”, and also for those trying to maintain weight reductions (Pedersen et al. 2020, p. 1). The Obesity CPG focus on the three pharmaceuticals indicated for chronic “obesity” management in Canada; however, emerging and international pharmaceuticals are discussed as potentially beneficial in the future (Pedersen et al. 2020). Given the broad range of Canadians identified as possible users, the history of “antiobesity” pharmaceuticals must be considered.

When “obesity” is viewed as a disease and pressure is exerted from various interest groups, drug efficacy and safety standards could be altered (Cheung et al. 2013). Pharmaceutical studies may be biased by high attrition rates (Khera et al. 2016; Robison 2015), may not report long-term outcomes, and may not produce relevant cardiovascular outcomes (Fujioka 2015; Kang and Park 2012). “Antiobesity” medications are frequently withdrawn from the market for safety reasons and have produced serious effects, including fatality (Aagaard et al. 2016; Cheung et al. 2013; Fujioka 2015; Kang and Park 2012). In a European database, over 90% of “antiobesity” medicine-related adverse events were serious, including cardiac and psychiatric disorders and death (Aagaard et al. 2016). Recently, Novo Nordisk paid a $58.65 million settlement to the United States federal government and state Medicaid programs for creating a false or misleading impression that their type 2 diabetes medication, Victoza, was not associated with cancer or that this association was irrelevant, or encouraging its use for those without type 2 diabetes mellitus (United States Department of Justice 2017). Victoza has the same active ingredient (liraglutide) as Saxenda, another Novo Nordisk medication prescribed for weight loss, and recommended in the Obesity CPG (Pedersen et al. 2020; Saxenda n.d.). Saxenda also carries a warning for causing thyroid tumours in rats and mice. Wegovy, Novo Nordisk’s new weight-loss drug, recently approved by the United States Federal Drug Administration, also carries a warning for thyroid tumours (Commissioner of the FDA 2021).

In addition, the Obesity CPG prominently feature bariatric surgery. Of note, there is considerable inconsistency in reporting bariatric surgery outcomes and no agreed-upon definition of “failure”, despite the need for repeated surgeries due to insufficient weight loss, weight regain, or complications (Mann et al. 2015). Risks associated with bariatric surgery include bowel obstructions, gastrointestinal or intra-abdominal bleeding, venous thromboembolism, malabsorption, hernias, wound infections, gastrogastric fistula, suicidality, alcohol abuse, and depression (Arterburn et al. 2020; Backman et al. 2016).

In addition to the risks associated with potentially widespread use of pharmaceuticals and surgery, medicalization in general may drive mental health problems, such as eating disorders. In a retrospective study of people receiving intensive treatment for an eating disorder, almost one in five patients attributed the onset of their illness to anti-“obesity” messaging (Mensinger et al. 2021). Focusing on expensive, industry-aligned “treatments” for individuals will obscure the need for structural and societal changes such as addressing poverty, racism, and other social determinants of health.

The Obesity CPG’s impact could be both intensive within Canada and widespread. Novo Nordisk and OC are directly marketing an “obesity management program” to Canadian healthcare professionals, offering instruction on how to “integrate the 2020 Canadian Adult Obesity Clinical Practice Guidelines into practice” (OC 2021b). Obesity is currently not recognized as a disease by the Canadian government. Lobbying governments to grant obesity a “disease” status is an explicit aim of the pharmaceutical industry (Novo Nordisk 2019, p. 19). The Obesity CPG state that “this guideline will be used to assist in advocacy efforts to federal and provincial governments to improve the care of individuals with obesity” (Wharton et al. 2020, p. E887).

OC are also planning to roll out the Obesity CPG to other countries, overseeing a pilot program to “create a process for adapting and implementing the CPG”. The pilot program has been funded by an unrestricted grant from Novo Nordisk (OC 2021c). Thus, the Obesity CPG are poised to provide a template for the further geographical expansion of pharmaceuticalization.

How the Obesity CPG may generate pharmaceutical investment and limit alternate visions of the future

The Obesity CPG promote a medical and pharmaceutical “pathway” of “treatment” for higher-weight people. But we want to interrogate the claim that this vision for the present and future meaningfully undermines weight stigma. Pharmaceuticalization, like medicalization, works in part by cutting off other possible frames for the improvement of existing problems (Thille 2018).

In reality, there is little consensus on the medicalization of “obesity” (Lupton 2018). Proponents of weight-neutral, health-promoting strategies or targeting social determinants of health are outside of the Obesity CPG frame (Bacon and Aphramor 2011; Medvedyuk et al. 2018), and thus hidden from consideration. The lack of consensus is clear also around Novo Nordisk and OC’s claim that medicalizing “obesity” goes hand in hand with meaningfully addressing weight stigma (Kirk et al. 2020; Novo Nordisk 2019, p. 12). Such a claim takes an ahistorical approach to understanding stigma and thus misconstrues how stigma is best undermined (Brady and Beausoleil 2018; Medvedyuk et al. 2018). Medicalization and focusing on body size as a “crisis” may magnify the “otherness” of higher-weight people, elevate sizeism, and counteract activism and interventions led by individuals with lived experience of stigma and/or advocating for acceptance of bodily diversity (Cain et al. 2022; Corrigan 2019; Frederick et al. 2016). Such approaches may exclude the knowledge of higher-weight people who do not perceive their bodies as diseased/requiring “treatment” (Brady and Beausoleil 2018; Kanagasingam et al. 2021; Warin and Moore 2020). These individuals are unlikely to have joined OC’s Public Engagement Committee (seven of whom were consulted as “lived experience” representatives for the Obesity CPG), trained advocates with the industry-aligned aim of establishing “obesity” as a disease (Canadian Obesity Network 2017; OC 2019c).

In the Obesity CPG chapter on Reducing Weight Bias in Obesity Management, Practice and Policy, Kirk et al. (2020) argue, citing a previous policy analysis conducted by several of the Obesity CPG authors (Ramos Salas et al. 2017), that constructing “obesity” as a risk factor (not a chronic disease) contributes to stigma by funnelling funding from treatment to prevention and pitting professionals against one another. Previously, these arguments were challenged given the lack of effective “obesity” treatments; the crucial need to address the social determinants of health, irrespective of any effects on body size; and the persistently stigmatized conditions that are widely considered “diseases” (Brady and Beausoleil 2018).

Even if “obesity” is rendered more palatable to doctors through medicalization, this may not make the public more tolerant or self-accepting. Indeed, exposure to media emphasizing fat rights reduced anti-fat prejudice while exposure to articles emphasizing “obesity” as a public health crisis elevated sizeism (Frederick et al. 2016). A biomedical perspective on “obesity” and reliance on biomedical therapies such as surgery do not interrupt belief in behavioural models (i.e. individuals control their size through consumption and exercise); rather, patients are blamed for behavioural “failures” when intended results are not achieved or do not persist (Boero 2012; Throsby 2012). A message such as this, rooted in medicalized discourse, is unlikely to disrupt weight-based stigma. However, it may sell more pharmaceuticals, while de-emphasizing approaches that encourage self-acceptance and health optimization through self-care or ones that champion rectifying social inequities (Bryant et al. 2011).

Conclusion

It is not in public health’s interest to have to contend with conflicts of interest fueled by an industry attempting to create an illusion of certainty. Transparency of conflicts of interest is crucial but not sufficient to mitigate industry-related bias (Lexchin and Fugh-Berman 2021). Canada has a major problem with the production of national clinical practice guidelines by professional societies that receive funding from pharmaceutical companies (Elder et al. 2020). Urgent reforms are called for, including more government-produced clinical practice guidelines, independent oversight of industry-supported ones, and improved monitoring from scientific journals publishing the resulting guidelines (Elder et al. 2020). The Obesity CPG may be considered a good example of the problem we are trying to overcome. Rather than accepting ubiquitous entanglement with industry as “normal”, we argue we need to address the potential cost of consigning so much influence over health care and medicine to industry, including going beyond simple declarations of conflicts of interest to meaningfully curtail the influence of industry on scientific knowledge.

Author contributions

All authors contributed to conceptualization, writing—original draft preparation, and writing—review and editing.

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Conflict of interest

The authors declare no competing interests.