Why are fewer men being treated for this disease of obesity?
Obesity was historically viewed as the fault of the person because of their poor lifestyle choices, while being linked to lower social and economic strata in wealthy societies. Previously, clinicians thought that risk factors for obesity included dietary habits, physical inactivity, environmental influences, psychosocial aspects, and genetic predispositions. Most diseases thought to cause obesity are considered neurobiological.i While specific genetic diseases cause syndromes like Prader-Willi or Bardett Biedl, most other obesity diseases result from complex polygenic interactions influenced by environmental factors.ii, iii Thus, the latest science has changed our perspective on obesity as experts now recognize obesity as a chronic, complex biological disease.
Obesity remains a global health concern, with prevalence still increasing in all socioeconomic groups and regions. The World Health Organisation’s definition of excessive adipose tissue resulting in a deterioration of health moves the focus away from the widely held idea that an imbalance between caloric intake and energy expenditure is the cause of the disease. Obesity has a specific pathophysiology, and most current research is focused on the links between the brain, gut, and adipose tissue. Genetic, environmental, and behavioral factors contribute to obesity.ii iii A step change is expected after the latest studies suggesting that obesity is not one disease but most likely the result of multiple diseases. This will allow us to understand our clinical observations regarding the heterogeneity of risk of obesity complications, and response to obesity treatment.iv
Obesity is associated with more than 220 complications; thus, medical students are now taught: “if you know obesity, you know medicine.” There are very few medical specialties not impacted by obesity-related complications such as cardiovascular disease, type 2 diabetes, dyslipidemia, gastroesophageal reflux disease, metabolic dysfunctional associated steatohepatitis, gallbladder diseases, musculoskeletal disorders like low back pain, obstructive sleep apnea, and increased risk for certain cancers. Furthermore, obesity can have profound psychological effects, thought to be in part related to stigma suffered by patients, leading to higher rates of depression and anxiety. Reproductive health issues are also more common, with increased incidences of infertility, polycystic ovarian syndrome, and complicated pregnancies such as gestational diabetes and preeclampsia.
Despite experts recognising obesity as a disease, most clinical services and research centers are treating or recruiting vastly fewer males. Recognising that men are undertreated may be the first step to ensure fair healthcare strategies. Men and women respond similarly to various obesity treatments, including lifestyle modifications and bariatric surgery. The response to pharmacotherapy is also similar when weight loss is corrected for plasma levels of the drug.v Weight loss outcomes and improvements in metabolic health after treatment are comparable between males and females, suggesting that treatment protocols should be adjusted to the individual rather than being sex-specific. However, men constitute only about 25% of participants in clinical studies, limiting the generalisability of research findings and the development of universally effective treatments.iii, vi
Reasons for fewer men benefiting from obesity treatment may include societal stigma, lack of awareness, and differences in health-seeking behaviors. Men are generally less aware of health risks, and traditional views of masculinity often emphasize self-reliance. Society may also place less emphasis on the appearance of men. Visits to doctors are less regular compared to women. Thus, missing routine check-ups may reduce obesity being identified, and interventions suggested. Finally, men might perceive weight loss programs as being tailored primarily for women, which discourages them to seek help. Addressing these barriers is crucial to ensuring equitable access to obesity treatment.iii, v, vii
To address these imbalances, funding bodies and ethical review boards must emphasise guidelines for equitable representation in clinical studies, mandating minimum male participation thresholds. Healthcare providers must be trained to recognise and treat obesity with a patient-centered approach that considers individual circumstances rather than the sex of the person. Public health campaigns aimed explicitly at men should be developed to raise awareness about obesity as a chronic disease, reduce stigma, and promote early intervention. Additionally, policy interventions should promote equality in healthcare access and research funding, facilitating the inclusion of men in obesity clinical trials and clinical treatment programs.viii
* Underrepresented groups: older participants, those with class 3 obesity (BMI ≥ 40.0 kg/m2), non-White, and male participants.
Written by Faisal Almohaileb and Carel Le Roux, Diabetes Complications Research Centre, University College Dublin, Ireland
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