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q and a with dr. david macklin: 'treatment for obesity is meant to be long term'

"the prevailing understanding of the obesity epidemic is that it is a consequence of a collision between our [ancestral genes] and the modern food environment," dr. macklin says.

by robin roberts

nov 14 2023
read time 8 minute read
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q+a with dr. david macklin: 'treatment for obesity is meant to be long term'
dr. david macklin is the director of medcan weight management, lecturer at the university of toronto faculty of medicine, staff at mount sinai hospital and a founding member of obesity canada. supplied

almost two in three adults and one in three children and youth are overweight or living with obesity in this country, according to the public health agency of canada . nearly all of them would have heard at one point in their lives: “eat less, move more and you won’t struggle with your weight”. they may even have heard it from their family doctor.

if only it was that simple. and for some people it is, but for others, no matter how many diet and exercise programs they’ve been on, they struggle. they also blame themselves, and see their excess weight as a personal moral failure.

but science has finally figured out that obesity is, in fact, a complex, multifactorial, chronic and relapsing disease, and the brain and genetics play a big part in who will be affected. according to obesity canada , our brain’s hypothalamus regulates calories in and calories out to maintain weight, but that system can be disrupted by biological and environmental factors, which affect our feelings of hunger and satiety.

when it comes to heredity, 70 to 80 per cent of our body mass index (bmi) is determined by genes, the majority of which are in the brain. we inherited these genes from our cave-dwelling ancestors who were motivated to hunt and gather, to eat calorie-dense foods to ensure their survival. to lose weight back then was bad news.

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but when that ancient motivation bumped up against modern menus, particularly ultra-processed foods , our bodies barely stood a chance: obesity, in fact, is a worldwide problem, having tripled since 1975, and has caused a huge burden on not only healthcare systems, but on the individuals struggling with it. complications of overweight and obesity include type 2 diabetes, high blood pressure, osteoarthritis, coronary heart disease, stroke and cancer.

for those living with obesity, there is new, effective treatment to ward off those poor health outcomes, according to dr. david macklin, director of medcan weight management and lecturer at the university of toronto faculty of medicine, as well as staff at mount sinai hospital.
macklin is also a founding member of obesity canada, an organization that supports health professionals as well as canadians living with obesity, and works with researchers and policy makers to improve knowledge around obesity prevention, treatment and policy.

here he talks about the barriers and solutions to weight loss, as well as his own  macklin method , a weight management program for patients and physicians.

can you explain more about how genetics play a role in determining a person’s weight?

we each inherit a unique appetite system, which determines our weight and how it’s regulated. the well-validated science we have is called twin studies , where identical twins and fraternal twins were raised in either the same home or elsewhere. years of data on those individuals [shows that] 70 per cent of someone’s risk of struggling with weight in their lifetime is passed down from their parents [rather than their shared environment].

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that’s why our strong messaging on obesity is that it’s not a flaw in character or lack of willpower, but a real disease.

how do our cave-dwelling ancestors factor into our weight?

the human brain was built for a time when calories were scarce and getting them took work. our ancestors woke up in the morning and were driven to hunt and gather food. if they didn’t experience a strong compelling motivation towards food they wouldn’t survive. if they lost weight, it wasn’t because it was bathing suit season, it was because of illness. the leading cause of weight loss of our ancestors were microbial illnesses and disrupted food supplies [no available prey or crops].

and now there’s abundance, and an obesity epidemic?

the prevailing understanding of the obesity epidemic is that it is a consequence of a collision between our [ancestral genes] and the modern food environment, which is filled with ultra-processed, ultra-available and ultra-portioned foods.
the main function of the human brain is to motivate us and direct our attention towards food so we survive and pass on our genes. that motivation system is powerful, and it is complicit in motivating and driving us primarily from subconscious parts of our brain to be thinking about food and to do the work to acquire food and that has collided with the modern food environment.
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i don’t really blame [food] companies for this necessarily, but in a predatory way they have been built to capitalize on this very specific subconscious motivation system through advertising and through the manufacturing of food that hits all the right buttons in the tongue, back of the throat, stomach, the receptors in the brain that create a pavlovian conditioning so we become conditioned over time to be driven and motivated to find these foods. why wouldn’t they capitalize? if they make this food like this, twice as many people will buy it.

what are some effective treatments for people living with obesity?

canada leads the world in many areas of obesity recognition treatment. many countries, including the u.s., spain and chile, have adopted [our] clinical practice guidelines for obesity , which we update regularly. we have three effective pillars of treatment: cognitive behavioural therapy (cbt), medication and surgery.

a mechanism of cbt is cognitive restructuring, which is another name for changing one’s thinking. an example is, if someone is struggling with their weight, they’ll be subjected to an automatic barrage of thinking that speaks poorly about themselves and their capacity to manage their weight, thoughts they’ve learned by being the target of stigma and bias and discrimination from hearing messages that it’s their fault.

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one of the roles of cbt — and i’m the co-author of the behavioural chapter in the clinical practice guidelines — is helping individuals who live with obesity to recognize these automatic thoughts and ultimately challenge them by learning that their past is inadmissible evidence as to whether they can succeed.
one of the reasons we understand obesity to be a real disease is because, as an individual loses fat, their appetite will increase, they’ll have more interest in food, they’ll be full less soon, they’ll be motivated and driven to food. that’s what the brain’s [done] for the last 200,000 years. and the only reason anti-obesity medications exist is to defend against the increased appetite response, which is a consequence of weight loss.

what are some of those medications?

we now have one, soon to be two [with mounjaro expected to be approved in the u.s. by the end of the year and canada to follow soon after], remarkably effective and safe medications in canada. ozempic is a diabetes medication and wegovy is the weight loss version of ozempic. it’s branded as an anti-obesity medication, not a weight loss drug, that’s an important distinction.

and by the way, financial disclosure here: i have for 10 years been a member of the national obesity advisory board for the manufacturer of ozempic. [i receive] consulting fees for talks i do, and licensing fees for material and content i’ve created.

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the treatment for obesity is meant to be long term, just like any other disease state, from ulcerative colitis to diabetes. this class of medications is remarkably well-tolerated, [but] it is not a diy project. if you do, there can be complications. otherwise, they’re easily managed by a health care team.

both mounjaro and wegovy have as a key central component the ability to activate glp-1 receptors . when we eat, we release from our gut a molecule, hormone, called glp-1 [which] will travel to our brain and create a signal of i’ve had enough. that’s how we stop the eating process, we’re no longer interested. medications dampen appetite, [and make it] less sensitive to cues.

access to that kind of health care is, unfortunately, not common [a one-month supply of ozempic, for example, costs about $300], although there has been a trend in employee benefit plans in covering these medications, reaching around 30 per cent.
at obesity canada, we created a report card on access to specialists, programs and medications for those living with obesity in each province, and it’s very low. of those eligible . . . currently about 1.3 per cent are prescribed an anti-obesity medication. that leaves a lot of others who don’t have access.

will there be a reduction in bariatric surgery with the availability of these anti-obesity medications?

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ironically, we may see increased gastric bypass surgery and sleeve gastrectomy procedures [because] as obesity becomes more recognized as a real disease, and an understanding that effective treatment exists, there will inevitably be individuals who are non-responders to behavioural therapy and medication. as the effectiveness of anti-obesity medications continue to increase, more individuals living with obesity will be receiving a trial of medical treatment before being considered for surgery.

how schooled in obesity management is the average family physician?

a significant part of my career is educating physicians regarding obesity — recognizing the disease, treating it, understanding it and communicating that to patients. out of 50 doctors, maybe five will be a bit interested, 10 will come to one of my talks. it’s a slow process. there’s a [study] called action [awareness, care and treatment in obesity management] which described the relationship between those living with obesity and physicians and other health care practitioners as dysfunctional, where neither group understands the other.

a very common refrain, still in 2023, amongst primary care docs — and i don’t blame them, this has never been part of their education — directed at someone struggling with weight is to eat less, move more. we call it the nightmare on elmm street. i don’t mean to be unkind to physicians or other health care practitioners but we consider it to be a discriminating statement. it’s not too different from telling someone with depression to cheer up, or someone with asthma to just breathe deeper and cough less.

obesity is a disease, but isn’t lifestyle still an important component of weight loss?

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what you didn’t hear in the three pillars is diet and exercise. what we now communicate is that changes in eating and exercise are a consequence, or the effect of, treatment. if behavioural therapy and medical therapy are [offered in an] effective, ethical and evidence-based way to a patient, then the outcome is that they’re able to make sustained changes in their eating and exercise.
that’s a really important point: the changes in eating and exercise weren’t the prescription, they’re the outcome. that helps us counter the eat less, move more messaging that is still so common.

what do you foresee – or hope – will be the outcome of fewer people living with obesity?

it’s quite likely that on a global level we will see health care systems come out of crisis [mode] and into well-managed models. and that will be just because we’ve effectively treated the leading preventable cause of death and disability. we’re already seeing fast-food company shares going down, knee surgeries will be [reduced].
i think we’ll see [in the workforce] over the next five years increased productivity, decreased absenteeism, decreased other medication costs. health care systems will see a reduction in treatments for weight-related conditions like sleep apnea, fatty liver disease, high blood pressure or high cholesterol. we’ll start to finally see reductions in rates of type 2 diabetes — all because of this class of medications and effective treatment.
robin roberts
robin roberts
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