Changing Perspectives – Let’s Talk About Obesity

This quote is not from a patient but from Dr. Fatima Cody Stanford, MD, MPH, MDH Obesity Medicine Physician at Massachusetts General Hospital on primetime US television (60 minutes 1/1/23). She found that most medical schools don’t teach that obesity is a disease — even though obesity is now the second leading cause of preventable death in many countries. This leads to worse health outcomes for patients with obesity.

To provide the best care for patients with obesity, healthcare professionals must start with the fundamental understanding that:

Obesity is a chronic, multifactorial, relapsing, progressive disease with biological, genetic, psychological, environmental and societal causes.

This year marks 25 years since the National Institute of Health declared obesity a disease, and 10 years since the American Medical Association did likewise. It would surprise many doctors to learn that origins of obesity medicine actually go back farther than that. The National Obesity Society was founded in the US in 1949 and the first International Congress on Obesity was held in 1973. Doctors then and since then were – and on occasion continue to be – actually criticised for medicalising excess weight, or insisting that weight management should be by experts. Later this spring, Dublin will host the European Obesity Meeting. And one of the focuses will be on how the rates of obesity have now reached epidemic proportions.

Over the past 20 years, the number of Irish children and adults who are above a healthy weight or have obesity have more than doubled to around 60% of the population. 25% of children and 20% of adolescent are above a healthy weight or have obesity. Because this potentially poses significant challenge to the delivery of Irish healthcare over the coming years, let’s talk about about obesity aetiology, complications, staging, and treatments.

The causes of obesity are multifactorial disease including biological, genetic, psychological, environmental and societal. The relationship among these factors is complex and still not completely understood. Let’s just highlight a few of the many factors that have been identified:

Genetics: Emerging data is suggesting that genetics play much more of an role that has been previously appreciated, specifically the genes that affect behaviours such as appetite or metabolism, such as the body’s tendency to store adipose. Studies have found genes that may regulate hunger and satiety. There is much ongoing study to better understand the complex relationship between genetics and the other factors.

Biological: Underlying conditions such as hypothyroidism, polycystic ovarian syndrome, and Cushing’s syndrome are important to highlight here. Iatrogenic can be included here, including prescribed corticosteroids and many of the medications used to treat epilepsy as well as those use d in psychiatric care and pain management.

Environmental: Among the most important environmental factors to highlight is prevalence of highly and ultra-processed foods in the Irish diet. In an outstanding recent piece in the Irish Times, “It delivers a taste bomb of pure pleasure, but ultraprocessed food is killing us” (30/1/2023) A panel of health and marketing experts lay out the stark reality that 60% of shopping trolleys in Ireland are now filled with hyperpalatable foods. These foods have a lower satiety index. One effect of food being cheaper, convenient. readily available and unnaturally tasty is over-consumption.

Societal: These factors include the increasing sedentary nature of jobs, urbanisation, changing agriculture and modalities of transportation, increasing screen time, and decreasing overall physical activity. Poverty, health literacy, education level, lack of sleep, shift work, and food distribution and marketings all been shown to be factors affecting obesity.

Psychological: Among the psychological factors contributing to obesity, one to highlight is Adverse Childhood Events (ACE). Multiple studies have demonstrated a strong relationship between recalled adverse child events and increased adult BMI.

Obesity is a chronic and progressive disease; it is associated with significant complications. Both patients and healthcare professionals should be aware of the impact of obesity on healthrelated outcomes. Let’s highlight just some of the more significant:

• Liver: NAFLD and cirrhosis
• Cardiovascular: coronary artery disease, hypertension, dyslipidaemia, congestive heart failure, stroke
• Orthopaedic: Reduced mobility, osteoarthritis, plantar fasciitis, Achilles tendonitis, foot and ankle pain, low back pain, disc degeneration, spinal stenosis, increased rate of injury with movement including meniscal tears, rotator cuff tendonitis, knee dislocations, and an increase in incidence and severity of ankle fractures
• Fertility: subfertility in both men and women
• Psychology: depression, eating disorder, body image problems, deliberate self-harm
• Respiratory: asthma, obstructive sleep apnoea, exertional dyspnoea
• Gastrointestinal: GORD, esophagitis, gallstones, diarrhoea, diverticular disease, polyps, and increased risk of cancers, including eosophageal, colorectal, gallbladder, pancreatic, and gastric cancers
• Endocrine: Type 2 diabetes and increased risk of thyroid cancers
• Renal and Urological: Chronic kidney disease, urinary incontinence, sexual dysfunction, urinary tract infections, nephrolithiasis, increased risk of renal and prostate cancers
• Neurological: Benign Intracranial Hypertension and increased risk of cognitive decline from Alzheimer’s disease and vascular dementias
• Oncological: Increased risk of additional cancers including ovarian, uterine, and thyroid cancers, myelomas, and meningiomas

While this is neither an exhaustive or in-depth exploration of the complications of obesity, it underlines that regardless of medical specialty, a better understanding of obesity as a disease is important for comprehensive patient care and better health outcomes.

Screening and identifying disease complications can also aid with stratifying risk. While BMI is commonly referred to when classifying obesity, it was never designed to be used in obesity management. It is more likely a question of when rather than if BMI will cease to be used to classify obesity. At present, obesity is both classified by BMI (WHO criteria, Figure 1) and staged by disease process. Patient decision-making is more likely to be meaningfully guided by staging the disease. Currently, the most widely researched obesity staging tool is the Edmonton Obesity Staging System (EOSS, Figure 2). Patients at 0 have no complications identified. Patients at Stage 1 have mild symptoms or subclinical risk factors. Stage 2 is established co-morbidities or moderate functional limitations. Stage 3 is established end-organ damage or significant functional limitations. Stage 4 is severe end-stage organ damage, severe psychological co-morbidities, and severe functional limitations. For example, in a patient with BMI of 32 and pre-diabetes and prehypertension, their disease can be described as Class I, Stage 1 obesity. To use another example, in a patient with BMI of 46 with liver cirrhosis, congestive heart failure, and suicidal ideation, their disease would be termed Class III, Stage 4 obesity.

“Fat-shaming is the only way to beat the Obesity Crisis” was the horrifying headline printed in The Times on 28 October 2022. This spurred appropriately intense and swift reaction from both experts as well as patient advocacy groups. It is important to note that complications from obesity are not limited to those from the weight itself, but also directly from the weight stigma. Multiple studies of shown that patients who experience weight stigma also have higher rates of depression, negative body image, reduced self-esteem and increased cardiovascular and metabolic complications. The experience of weight stigma is also associated with increased risk of disordered eating, deliberate self harm, and all-cause mortality.

Most concerning to us, as physicians, should be that these studies have shown that patients with obesity are reluctant to seek healthcare when necessary due to their negative experiences with weight bias in healthcare. Weight stigma itself – with or without the reluctance to seek healthcare when needed – can also lead to delay in diagnosis.

As health care professionals, the challenge we face is examining ourselves for unconscious weight bias or weight stigma. In this epidemic, both patients and families need us to have the skills and compassion to the necessary supportive, non-judgemental conversations.

As I discuss with my own patients: weight management is not about weight loss for sake of weight loss, it is certainly not about aesthetics – the goal of care is health gains. It is about reducing the risk from obesity-related complications and all-cause mortality. Weigh loss is unfortunately targeted by both the cosmetic/aesthetics, social media influencers, and the wellness industry, many aspects of which are unregulated. Much of what is marketed is not evidence-based or is frankly predatory, including restrictive diets, unsafe practices, expensive supplements, or unrealistic weight loss goals.

Let’s Talk about Lifestyle Medicine: It’s worth first defining a term that is used so loosely, including by non-medics and influencers. In this context of obesity prevention and treatment, we are specifically using the term to refer to a well-defined and evidence-based medical specialty, currently recognised and standardised in US and UK. Lifestyle medicine plays a key role in the evidence-based management of many chronic diseases, and in this respect, its use in the treatment of obesity should not be considered differently. Lifestyle medicine is based on the pillars of good nutrition (including a healthy relationship with food), physical activity, good mental health, stress management, restorative sleep and social connections. The role of lifestyle medicine in the management of obesity is not an iteration of the outdated “eat less, move more.” Lifestyle medicine has an essential role in the multi-disciplinary approach to the prevention of obesity as well as the management of both psychological and physical comorbidities of obesity.

Let’s Talk about Pharmaceutical Management: The most effective pharmaceutical options available to patients in Ireland currently include GLP-1 analogues liraglutide and semaglutide. Current international guidelines recommend their use in individuals who are already making lifestyle changes and have a BMI of ≥ 30 kg/m2 or ≥ 27 kg/m2 with an obesity-related comorbidity. Semaglutide has been shown to be more effective in studies than liraglutide. However, liraglutide may be more affordable for select patients; since 1/1/2023, it is now reimbursed through DPS for patients who meet defined criteria.

GLP-1 analogues mimic the effects of glucagon-like peptide 1 and can help patients feel fuller faster as it slows gastric emptying. It also stimulates the production of extra insulin in response to rising blood sugar levels after eating. The advantages of GLP-1 analogues is that there is extensive data on pharmacokinetics and drug safety as it is has been used for years in the management of diabetes. The disadvantages can include cost as many patient are not currently eligible for reimbursement. The most common side effects include nausea, belching, bloating, and change in bowel habit though for many patients this can be managed with careful prescribing, patient-led increase of dosing, and attention to diet.

It is contraindicated in certain patients including those diabetic retinopathy or ketoacidosis, chronic kidney disease, history of thyroid cancer or multiple endocrine neoplasia syndrome, type 2. Furthermore, recent negative media coverage and social media influencers about the misuse of the drug have made some patients hesitant.

Let’s Talk about Surgical Management: Bariatric surgery – specifically gastric bypass or sleeve gastrectomy – is the most effective treatment for weight loss in patients with BMI over 40 or over 35 with associated comorbidities.

However, patients in Ireland currently face significant challenges accessing timely and safe bariatric surgery, including:

1. For patients with private health insurance, the reimbursement criteria may be different than international guidelines, and commonly requires patients to have a BMI of ≥45 or ≥ 40 with weight-related co-morbidities. Not all aspect of care may be covered or reimbursed.
2. For patients depending on public services, patients can currently expect to spend up to 5 years on waiting lists for an appointment with a comprehensive, multidisciplinary weight management service that includes bariatric surgery as a potential option.
3. Travel tourism, or traveling abroad to have bariatric surgery, has risks including the recently well-publicised surgical complications. The low-risk option often presented to patients – especially those centres abroad marketing their intervention packages as cosmetic or all-incluseive – is the placement of a lap band. Globally, up to 40% of patients who have a lap band will seek to have it removed within 10 years due to side effects or complications. It is also has its limitations as a treatment for obesity as it has no metabolic effect. Treatment through these centres rarely includes access to necessary post-operative multidisciplinary care.

Obesity is a chronic disease and patients should be counselled from the outset that treatment will be lifelong, whether this involves lifestyle modifications, pharmaceuticals, or bariatric surgery. The biology is such that the patient’s body will, in short, take steps to defend its highest weight. Goals of care should include a plan for ongoing care and avoidance of weight cycling, which increases cardiometabolic risk.

The challenges facing patients with obesity are not limited just to weight-stigma in healthcare setting or difficulty accessing qualified medical care.

The Sars-CoV-2 pandemic has demonstrated that those with obesity are not only more likely to suffer from severe infections but also long term side effects. In multiple studies, women with obesity make up a disproportionate percentage of patients in long covid clinics. While the aetiology of long covid is still not understood, emerging data does that obesity is an independent risk factor for continuing symptoms including brain fog, fatigue, pain, and shortness of breath more than 12 weeks after the infection.

The continued framing of obesity as an aesthetic or cosmetic problem poses a challenge in itself. Obesity is a disease; not a cosmetic or aesthetic issue. The continued perspective of obesity as cosmetic problem only serves to perpetuate weight stigma or obstruct reforms to insurance reimbursement guidelines, support for increased public funding, and/ or patient access to properly qualified experts.

We need to, as a profession, collectively shift our perspective to one that obesity is indeed a complex and chronic disease with real, stratifiable risks, validated disease staging, and effective evidence-based based management strategies. As healthcare professionals, we will need to advocate both with patients and on behalf of patients for public health measures. As a collective profession, we will need to stay up-to-date on emerging data and options for treatment.

Let’s Talk about Obesity – with understanding. Not just because of the Oscars or to mark how many years have passed or because of sensational headlines or a day of action on the calendar. It is time for this conversation because it is an epidemic with the potential for significant impact on patient mental and physical health outcomes and on the Irish healthcare system.