Dr. Sean Wharton is working towards changing how we understand obesity, from how doctors treat patients to society’s perspectives: “African-American women carry their weight on their hips and thighs. Yet, they’re demonized when they should just be called beautiful.”
by Karen Hawthorne – first published in Healthing on March 10, 2023.
This is the second of five interviews in the “Your Health Matters Summit” series, where we spend a few moments speaking to each of the experts who shared their expertise for the summit, which was hosted by Obesity Matters. These stories will explore obesity from a medical perspective; take a look at happiness and why it’s not necessarily connected to weight; learn about food addiction; and finally get why eating less and exercising more isn’t always the answer.
Dr. Sean Wharton is the medical director of the Wharton Medical Clinic, a community-based internal medicine weight management and diabetes clinic, researcher and advocate for health equity in Canada. He’s passionate about changing the dialogue around obesity — that it’s a disease and not a lifestyle choice. Healthing spoke with Wharton about the importance of compassion in treating obesity, why ethnic diversity needs to matter more in obesity care and the role that politics plays in obesity management.
When did you realize there needed to be some serious change in the ways health-care providers looked at obesity?
Dr. Wharton: I‘m an internal medicine physician, and as I was doing my residency, I was focusing on high blood pressure, Type 2 diabetes and a number of other internal medicine conditions. It occurred to me that for people living with obesity, frequently it was their obesity that was a causative factor when it came to their medical condition. Yet there was no physician that was capable of treating it. They were very reticent to have a discussion about it because there were no treatments available that could actually keep the patient’s weight down for a long period of time and treat the medical condition. So what we would do is we would continue to give more medications, more blood pressure agents, more insulin, more diabetes treatments, as opposed to trying to manage the underlying condition. So I’m an enthusiastic resident at this stage, between 2000 and 2004, and I thought we should treat the root cause which is obesity.
Then it became clear to me that there were no effective treatment options for people living with obesity. And that was the reason why physicians were not addressing it. That, to me, was unfortunate that there were no treatment options besides telling someone to have a diet or exercise more, which is not a long-term effective treatment for somebody living with obesity. If you want to lose five to 10 pounds, do a diet at, go to the gym a little bit more. But if you’re living with obesity that’s causing a medical condition, that’s not the answer.
When you talk to your patients about quality of life, what kinds of comments do you hear, and how are you using your work to help?
Dr. W: Speaking to people about quality of life, their primary issue is that many people, particularly the health-care providers, do not treat them with compassion and do not understand their medical condition. They treat them like a child and condescendingly tell them to have a better diet, stick to it and exercise more. It’s not just embarrassing, but frustrating, saddening. And it’s discrimination. Since it continues to happen again and again from learned people, it sometimes becomes internalized where people actually believe those paternalistic, condescending messages.
So quality of life is frequently immediately improved for somebody who has a practitioner who has compassion for their medical condition and does not treat them like a child who does not know about the simplistic reductionist concepts of eating better and exercising more. And they treat them as they treat this condition, as something more important, more complex and more sophisticated, and in that sophisticated manner, sits them down and has a real discussion of the science behind obesity.
Let’s talk about treatments. Wegovy was recently made popular by TikTok. What are your thoughts on treating obesity with medication?
Dr. W.: The way I feel about treating obesity with medications is the way I feel about treating high blood pressure, cancer or any chronic disease with a medication. Medication pharmacotherapy is effective for a disease state. As an internal medicine doctor, or any other physician who understands the biology and the physiology of a chronic disease has in their toolbox pharmacotherapy to treat many of these medical conditions. So obesity is one of those medical conditions. TikTok has not made Wegovy famous for treating obesity. TikTok has made Wegovy famous for treating elevated weight. They’re two different things.
So it’s like saying that TikTok has made Botox famous for aesthetic medicine versus famous for migraine treatment. We likely wouldn’t call a neurologist and ask them how they feel about Botox being used for aesthetics. But there’s a closer parallel between somebody wanting to lose five to 10 pounds versus somebody living with obesity. For those people living with obesity, this is a breakthrough medication that frees up the brain space that takes care of their cravings and their hunger, and finally addresses one of the root neurochemical causes of obesity. Do I have an issue with the TikTok craze of people using it for aesthetic medicine? Not really. I don’t have a big opinion on it because it’s not my field.
Do you have any thoughts on how TikTok is influencing health?
Dr. W.: I don’t know that TikTok is influencing health. I have not seen any information or any data that TikTok influences health. It helps people to identify how to identify lumps in their breast for breast cancer or helps with detection of when to check for prostate cancer or for colon cancer. That to me would be an influence on health. And maybe TikTok can be a platform. Clearly, it’s influencing people’s use of aesthetic medicine and using it because Kim Kardashian uses it. But does it address actual health problems? Does it make things worse? Is it making things better or is it just fluff and everything is neutral? I don’t know the answer to that. It would require a research study.
Will TikTok information help people living with obesity? I have seen videos with people living with obesity. They had Type 2 diabetes or other metabolic condition and significant elevated weight. They, of course, took the medication. They could have been a patient at my clinic and or any other weight management appropriate clinic, and they did better and better. That’s a good video. But the video of somebody 130 pounds going down to a 125 to get into a wedding dress, that’s an aesthetic video. That’s not necessarily a bad video, but it’s aesthetic medicine.
Much of the discussion around obesity is about lifestyle. What makes a person a candidate for medication?
Dr. W.: Everyone who is admitted to my clinic has a BMI [body mass index] of greater than 27. The qualification for pharmacotherapy is a BMI between 27 to 30 with one comorbidity or a BMI greater than 30. So there’s nobody by definition that comes to my clinic that does not fit the basic criteria to have the medication. Then you discuss the next criteria that you would see in any other physician’s office. Do they have adverse side effects? If they’ve had medullary thyroid cancer, they can’t take it. If they have had idiopathic pancreatitis, then they can’t take it. There are limited other products that they could take.
Semaglutide is the real name of the medication. It comes in the form of Ozempic. Wegovy is not yet available in Canada. So, what is the difference between Ozempic and Wegovy? It would be like saying Ozempic is Coca-Cola in a 350-mL bottle, and Wegovy is Coca-Cola in a 1,000 mL bottle. They’re both the same except one is in a bigger package. And the studies for weight management were done with the ones in the bigger package.
Ozempic, which is labeled for Type 2 diabetes, is the exact same product for weight management. So the question is, am I using semaglutide in my practice for obesity management? Yes, that is the treatment. From the medical obesity world point of view, that is the treatment for obesity. Not the Keto diet or going to the gym. The medication is the treatment. Then surrounding that are all of the other treatments, cognitive behavioural therapy, the right type of diet, exercise. So for instance, someone who has a heart attack, aspirin is the treatment, but you still tell them you’ve got to eat better and follow the Mediterranean diet, maybe, do some walking, go to gym. Obesity medicine doctors are very clear that the treatment for obesity is pharmacotherapy. And then that allows the patient to eat a better diet, allows them the capacity to go and exercise. Why? Because they’re smaller, they’re seeing success, and they’re motivated to be active on a regular basis.
[The obesity medication] is altering your brain chemistry. But it’s not a permanent alteration. It’s only an alteration during the duration that you’re taking the medication. Then your brain chemistry goes back to what it was before. Because your brain chemistry is genetic. Your obesity is genetic. If you get to 350 pounds, that’s genetic. Just like your eye colour is genetic.
Are there changes that could be made on a political level to help people with obesity live healthier lives?
Dr. W.: Yes, endorsement and recognition that the world is biased, which is a negative word. They’re biased or prejudiced against people living with obesity and that the world is full of stereotypes against people living with obesity, which is stigma. If you were to google “obesity man images,” you’ll see guys wearing shirts that are too small for them as if they’re not bright enough to know that that doesn’t look good. Sure there’s one guy who will wear that, but the majority of guys that live with obesity don’t do that because they’re bright, competent people — lawyers and doctors and everything else.
We also need to enact legislations that stop the discrimination against people living with obesity. You notice how a lot of what I have to say did not have to do with let’s tax sugary food. That’s putting more of the onus on the person, like it’s their fault. The issue is, we keep blaming the person with obesity, versus actually being compassionate, appropriate and understanding science. Living with obesity is not a choice. It’s a genetic epigenetic phenomenon that’s a result of progress in society, like having cell phones, TVs, air conditioning. We need to understand that, help people to understand that and also help people living with obesity to live with a healthy, elevated weight, and then treat their elevated weight when appropriate.
What are you hoping obesity management looks like in five years?
Dr. W.: More treatment choices for people living with obesity if they have obesity and more recognition that people with elevated weight may not have obesity. African-American women may need a BMI of over 32 before they start to run into blood sugar problems because they carry their weight on their hips and their thighs, not in their stomachs. Yet they’re demonized when they should just be called beautiful. They shouldn’t be called a woman with obesity or an obese lady. If they have Type 2 diabetes or they have heart disease, then they’re living with obesity and treatment should be available for them. If you’re South Asian and your BMI is 26, which would not be defined as obesity and barely defined as overweight. But if you’re South Asian with a BMI of 26 and you have pre-diabetes, your mom has Type 2 diabetes, your auntie has it, and they all developed it at age 26 and you’re age 25, you’ve got obesity.
So a greater understanding of the ethnic diversity, as well as the difference between elevated weight and obesity. Obesity is obesity. It’s a disease. That’s where I’d like to see [obesity management] go: to the fact that it’s not a one-shoe-fits-all.
Stay connected with Obesity Matters by Getting Involved