Clinical FeaturesEndocrine/MetabolicMen’s Health

Let’s Talk Weight Management

As we roll into November, there will be multiple media campaigns reminding men to get themselves checked. It is very likely that as part of those health checks, the patient will be asked to get on the scale. How many men will be told that they should take steps to reduce their weight? And more importantly, how many men will be offered supports to lose the weight? Statistically, probably not as many that need it.

It is important to talk about weight during Men’s Health Awareness Month. In Ireland, men are more likely to be above a healthy weight or obese compared to women. 43% of men versus 31% of women are above a healthy weight. 25% of men versus 22% of women are obese. If we break this down by age, 65% of those aged 15-24 are a healthy weight, but this dramatically decreases to only 35% by age 24, and then only fewer than 20% of men are a healthy weight by age 64. Obesity in 51- 64 year old Irish men has risen 42%. . A NIHR study found that the likelihood of men returning to healthy weight was only 1: 210 compared to 1:124 in women. Studies also show that not only are men more likely to be above a healthy weight, but that men are more likely than women to need the supports to lost weight.

In the current climate, it is simply impossible to discuss obesity and weight management without talking about pharmaceutical treatment options. In this context, though, what has the option of GLP-1a medications (liraglutide, semaglutide), meant for men?

I’m not sure enough people are asking that very good question. In September, there was a UK documentary about “skinny jabs.” There were many criticisms that could be – and should be – levelled at that particular programme, but let’s just focus on that the show only featured women’s experience with obesity and treatment. Now, I will be the first to argue that women’s voices need to be heard. But in this case, the documentary subtly perpetuated many unhelpful biases, including that not only the myth that weight is predominantly a body image problem but that weight is more of a problem for women. Like the ads for weight loss programmes that feature images of women, it is based on solid market research: women more consistently report that they are actively trying to lose weight than men. We should be discussing treatment options equally with our male patients.

It is challenging the outdated ideas surrounding obesity – for example, that treatment is just a matter of the outdated mantra “Eat Less, Move More”. We know now that obesity is a complex, chronic, recurring, and progressive disease. While evidence-based lifestyle intervention is an essential part in both obesity prevention and management, patients may need far more. Evidence-based lifestyle interventions should consider the patient’s goals, and target sustainable, long-term changes. It may require input from dietitians, physiotherapists, and psychologists. Patients who have metabolic or hormonal factorsincluding hypothyroidism, PCOS, hypotestosteronism – may also need that addressed with expert endocrinology input. Options such as GLP-1 analogues or referral to tertiary level, multi-disciplinary bariatric services should also be discussed where indicated. Patients deserve these informed conversations about their evidence-based and safe options. And if patients are not offered these conversations from their doctor, with knowledge and empathy, then the information and offers of help will come from elsewhere. While GLP-1a medications sourced from online virtual consultation services may be effective at moving numbers on the scale, that is not the end in itself. We need to treat obesity as the complex disease it is that deserves whole patient care. Guidance on incorporating physical activity to maintain bone health, mental health, and reduce blood pressure is important — independent to any effect on weight loss. Addressing any unhealthy drinking or any underlying trauma that has led to comfort eating patterns is important. Addressing potential obstructive sleep apnoea is essential to reduce cardiovascular risk factors and improve mental health. Nutrition input is key: reducing risk of complications from obesity requires not just eating less, but eating a diet that will reduce risk of complications from obesity, such as heart disease, stroke, and colon cancer.

These obesity-related complications should be highlighted in relation to men’s health. In Europe, about 11% of colorectal cancers are associated with being above a healthy weight or obesity; this data suggests that obesity is associated with between 30%-70% increased risk of colon cancer in men, an association that is not seen in women. In regards to fertility, up to 50% of couples who present with subfertility will have a contributing male factor. Obesity in men is associated with erectile dysfunction, hypotestosteronism, secondary hypogonadism, and low sperm count. In regards to cardiovascular disease, metaanalyses have demonstrated that for each 10 kg increase in body weight, there is an associated 12% increase in the risk of coronary artery disease. For each 1kg/ m2 increase in BMI, the risk of ischaemic stroke increases 4% and the risk of haemorrhagic stroke increases by 6%. For men, an increased waist circumference is associated with a five-fold risk of diabetes, compared to a three-fold risk of diabetes in women with an increased waist circumference.

Reducing these risks is why we need to have discussions with our patients about the disease of obesity and treatment. Based on multiple studies, HIQA has recommended that surgery is safe and the most effective treatment for type 2 diabetes; not only do patients go into remission but surgery also reduces the risks of diabetic complications, including kidney disease. The results of the SELECT trial were published this past August. This trial was important because it measured the impact of semaglutide not on weight but on reducing the incidence of myocardial infarction, heart failure, peripheral vascular disease, and stroke over a 5 year period in a predominantly male cohort. While the ability to prescribe and dispense these drugs is currently impacted by a long waiting lists for bariatric services, limited access to necessary multidisciplinary supports, restrictive reimbursement schemes, prohibitive drug prices, and a global drug shortage, it is still worth considering and having the discussion about treatment options with patients.

We need to talk about the options with patients because the consequence of all of this, coupled with weight stigma and environmental factors that contribute to the perpetuation of our current obesity crisis –including urbanisation, sedentary lifestyle, socio-economic factors, diets high in ultra-processed foods — has created situations in which many patients feel pushed into unsafe or desperate choices. Top of the list of unsafe options for patients include medical tourism for bariatric procedures. Too many health professionals, unfortunately, who will read this article will already have come across a patient with complications from an ill-advised surgery abroad. Problems with surgery abroad include out-of-date procedures, such as the fitting of a gastric band or balloon, which is not a recommended treatment for obesity (Up to 40% of patients will have to have these removed.) For those who have had gastric sleeve or gastric bypass done abroad, complications include not just peri-operative risks such as complications from anaesthesia, VTE, or infection, but long term complications due to lack of standard pre-operative and post-operative care, including addiction, self-harm, malnutrition, vitamin deficiencies, and dumping syndrome. Conversely, we also should be having conversations with patients who are excellent candidates for medications or surgery but a reluctant to be referred to safe, expert bariatric programmes due to the misinformation about side-effects, the procedures, or fears of complications.

Throughout this article, the term “men” has been used inclusively, but I think that most healthcare professionals will read it as referring to cisgender men. It is important to highlight that there are groups of men with increased risk. There is an overall increased risk of obesity among transgender men. Men who identify as gay are less likely to be above a healthy weight or have obesity, but seven times more likely to report binge eating, and in a UK study, 42% of men with eating disorders identify as gay. In regards to MSM (men who have sex with men) who are living with HIV, complications from some of the anti-retroviral agents may include lipodystrophy and insulin resistance.

Overall, as we roll into November, it is helpful to remember that we are advocating for men to schedule their health checks because men are around 32% less likely than women to seek a healthcare appointment when needed. In this context, when we do see men in in our clinical practice, it is a good time to Make Every Contact Count and, where appropriate, have supportive, compassionate, and informed conversations around maintaining a healthy weight and obesity as a complex disease with safe treatment options.

Written by Dr Kate McCann, Lifestyle Medicine Physician

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