This week, I once again presented on the need for recognising obesity as a chronic disease at the annual European Society for the Study of Obesity Collaborating Centres for Obesity (EASO-COMs) in Leipzig, Germany.
Coincidently, The Lancet this week also published a commentary (of which I am a co-author) on the urgent need to change the obesity “narrative”.
So far, the prevailing obesity “narrative” is that this is a condition largely caused by people’s lifestyle “choices” primarily pertaining to eating too much and not moving enough, and that this condition can therefore be prevented and reversed simply by getting people to make better choices, or in other words, eating less and moving more.
As pointed out in the commentary, this “narrative” flies in the face of the overwhelming evidence that obesity is a rather complex multi-factorial heterogenous disorder, where long-term success of individual or population-based “lifestyle” interventions can be characterised as rather modest (and that is being rather generous).
This is not to say that public health measures targeting food intake and activity are not important – but these measures go well beyond “personal responsibility”
” The established narrative on obesity relies on a simplistic causal model with language that generally places blame on individuals who bear sole responsibility for their obesity. This approach disregards the complex interplay between factors not within individuals’ control (eg, epigenetic, biological, psychosocial) and powerful wider environmental factors and activity by industry (eg, food availability and price, the built environment, manufacturers’ marketing, policies, culture) that underpin obesity. A siloed focus on individual responsibility leads to a failure to address these wider factors for which government policy can and should take a leading role. Potential health-systems solutions are also held back by insufficient understanding of obesity as a chronic disease and of the necessary integration across specialties.“
It is also important to recognise that the prevailing “lifestyle” narrative plays a major role in the issue of weight-bias and discrimination:
“Behind every obesity statistic are real people living with obesity. The prevailing narrative wrongly portrays people with obesity in negative terms as “guilty” of obesity through “weakness” and “lack of willpower”, succumbing to the siren call of fast and other poor food choices. This narrative leads to stigmatisation, discrimination—including in health services, employment, and education—and undermines individual agency.“
Thus, it is time to change this narrative:
“If the narrative is instead reframed around individuals at risk of or living with obesity as protagonists with agency who operate within physiological limitations and a much larger obesogenic environment over which their control is limited, then a better, more accurate story can be told.“
This new narrative must incorporate four dimensions.
“First, recognise that obesity requires multiple discrete actors and sectors to work together simultaneously through many entry points. Second, change the words and images used to portray obesity to shift blame away from individuals and towards upstream drivers. For example, photographs of anonymous or faceless people with obesity must be substituted with images of real people that foster respect and identification. Third, prioritise childhood obesity and the growing burden of obesity in low-income settings. Rights-based policy approaches that address inequalities and social and physical determinants of obesity are particularly relevant. Finally, appreciate that obesity is a chronic disease within the health system, with both its prevention and management embedded within calls for effective and comprehensive universal health coverage globally.“
Following this line of reasoning we argue that,
“Shifting to a human-focused narrative that encompasses this vulnerability and complexity will require effort and commitment across many sectors. We call on all affected by or concerned with obesity to come together with a common sense of purpose and shared accountability for building this new narrative and a more comprehensive response to obesity.“
Not discussed in this paper (largely due to space limitation), is my pet peeve, that we also need a new non-anthropometric definition of obesity – one that relies on actual health measures rather than just scales and measuring tapes. As we move to a “disease” definition of obesity, we need to ensure that we are not mis-labeling healthy individuals as “diseased” just because they happen to exceed a certain body weight, as well as the corollary, mis-labeling individuals who may stand to benefit from obesity treatments as not having obesity just because they fall below an arbitrary BMI cutoff.
Over a decade ago, together with over 120 colleagues from across Canada, representing over 30 Canadian Universities and Institutions, I helped found the Canadian Obesity Network with the support of funding from the Canadian National Centres of Excellence Program.
Since then the Canadian Obesity Network has grown into a large and influential organisation, with well over 20,000 professional members and public supporters, with a significant range across Canada and beyond.
During the course of its existence, the Network has organised countless educational events for health professionals, provided training and networking opportunities to a host of young researchers and trainees, developed a suite of obesity management tools (e.g. the 5As of obesity management for adults, kids and during pregnancy), held National Obesity Summits and National Student Meetings. raised funds for obesity research, the list of achievements goes on and on.
Most importantly, the Network has taken on important new roles in public engagement, voicing the needs and concerns of Canadians living with obesity, and advocating for better access to evidence-based prevention and treatments for children and adults across Canada.
To better reflect this expanded mission and vision, the Board of Directors has decided to convert the Canadian Obesity Network into a registered health charity under the new name – Obesity Canada – Obésité Canada.
So with one sad eye, I look back and hope that the Canadian Obesity Network rests in peace – Long Live Obesity Canada!
A wide range of socio‐cultural and environmental factors can determine changes in ingestive behaviour. Thus, traditions or habitual patterns, belief systems, peer pressure, availability of foods, and the context in which these are presented and consumed can all significantly predispose to or prompt increased caloric consumption. Moving to a neighbourhood with more fast food outlets, exposure to food advertising, decreasing affordability of healthy foods, or increased professional or social pressure can all influence eating behaviour. Thus, for example, taking up a job that requires extensive wining and dining of clients is likely to increase caloric consumption. Similarly, regularly partaking in social activities that revolve around eating and drinking can promote caloric excess. Not surprisingly, the frequency of eating out is an important determinant of food quality. As many of the factors that influence overconsumption are subtle (e.g. plate size, food variety, ambient distractions, etc.) and do not generally involve conscious decision‐making, exposure to an environment that promotes ‘mindless’ overeating will promote weight gain. For individuals in lower socioeconomic class, affordability and availability may limit access to a healthy nutritious diet. Lack of knowledge about healthy eating may also contribute. When present, identifying, recognizing and acknowledging the possible role of the socio‐cultural factors that promote overconsumption or pose important barriers to eating a healthy, calorically balanced diet is the first step to devising strategies to mitigate these influences or overcome these barriers. In addition to nutritional counselling patients in whom strong socio‐cultural determinants of obesity are identified may benefit from counselling by a social or public health worker.
Commentary: as important as socio-cultural factors may be, they are by far not the only factors affecting ingestive behaviour – more on this in coming posts.
Most healthy women, who live long enough, will eventually become unhealthy.
So it should not at all come as a surprise to anyone, that the vast majority of women with “healthy” obesity (a misnomer, as in my view, the medical term “obesity” should only apply to people who already have health problems attributable to abnormal or excess body fat), eventually end up with “unhealthy” obesity.
This, essentially, is the gist of a paper by Nathalie Eckel and colleagues, published in The Lancet.
In their study of 90,257 participants of the Nurses Health Study, who were followed-up from 1980 to 2010 for incident cardiovascular disease (representing over 2 million person-years of follow-up), they found that around 80% of metabolically healthy women with obesity converted to metabolically unhealthy obesity over the course of follow-up.
But one might say that this was only marginally higher that the 70% of metabolically healthy “normal weight” women, who also converted to metabolically unhealthy over the 20 years of observation. In fact, the population-attributable risk of the latter group was much higher, as it consisted of almost 10 times the number of women than in the former.
While the risk of cardiovascular disease was statistically elevated (by about 40%) in the metabolically healthy women with obesity, this risk was 243% higher in metabolically unhealthy women with normal weight, 260% higher in metabolically unhealthy women with overweight and 315% higher in metabolically unhealthy women with obesity, all compared to metabolically healthy women with normal weight.
So, yes, women with metabolically “healthy obesity” have a high risk of becoming metabolically unhealty and developing cardiovascular disease, so are metabolically healthy normal-weight women.
Overall, I believe it is safe to say that the vast majority of metabolically healthy women (regardless of body weight) will eventually become metabolically unhealthy, at which time their risk for cardiovascular disease increases.
Bottom line, everyone (not just women with obesity) will benefit from efforts to stay as metabolically healthy as possible for as long as possible – fortunately, we know that healthy diets and regular physical activity (while not necessarily preventing weight gain) can help maintain metabolic health, irrespective of current body weight.
Clearly, living as healthy as possible is not just good advice for women with obesity – who would have guessed?
p.s. although this was a study in women, I have no doubt whatsoever that the findings also apply to men – most metabolically healthy men will eventually become metabolically unhealthy over the course of their lifetime.
While at the level of the individual, clinicians are beginning to acknowledge the vast body of research now showing that “lifestyle” approaches to managing obesity (“eat-less move more”) result in minimal outcomes (3-5% sustainable weight loss at best), public health attempts to address the obesity epidemic continue to perpetuate the myth that obesity (and its prevention) is simply about getting people to eat better and move more (with very little evidence to show that such measures can be implemented at a population level to effect any noticeable change in obesity rates).
In an article I co-authored with Ximena Ramos-Salas, published in Current Obesity Reports, we provide an in-depth overview of current public health policies to address obesity in Canada and argue that the “narrative” underlying these policies is an important driver of weight-bias and discrimination and significantly hindering efforts to provide Canadians living with obesity better access to obesity prevention and treatment efforts.
As we state in the article (based on original research by Ramos-Salas and others),
“A critical review of Canadian obesity prevention policies and strategies revealed five prevailing narratives about obesity: “(1) childhood obesity threatens the health of future generations and must be prevented; (2) obesity can be prevented through healthy eating and physical activity; (3) obesity is an individual behavior problem; (4) achieving a healthy body weight should be a population health target; and (5) obesity is a risk factor for other chronic diseases not a disease in itself”. These narratives create the opportunity for Canadian obesity policy recommendations to focus mainly on individual-based healthy eating and physical activity interventions. By simplifying the causes of obesity as unhealthy eating and lack of physical activity, these policies may be contributing to the belief that obesity can be solely controlled through individual behaviors. This belief is a fundamental driver of weight bias.”
This “world-view” of obesity at the level of policy makers has a significant impact on the willingness and capacity of health systems to provide access to evidence-based obesity treatments to the nearly 7 million Canadian adults and children living with this chronic disease – in fact, the unwillingness to even consider obesity a chronic disease is a big part of the problem.
“..the conceptualization of obesity as a risk factor in public health policies has implications for government action, by prioritizing prevention over treatment strategies and potentially alienating Canadians who already have obesity. The review concludes that existing Canadian public health policies and strategies (a) are not sufficiently comprehensive (i.e., solely focused on prevention and mainly focused on children; exclude evidence-based management approaches; are not person-centered); (b) are based on reductionist obesity models (i.e., models that cast shame and blame on individuals by focusing on individuals’ responsibility for their weight); and (c) do not account for individual heterogeneity in body size and weight (i.e., generalize weight and health outcomes at the population level).”
In contrast we suggest that,
“Adopting a chronic disease framework for obesity would imply that both prevention and management strategies need to be implemented. Within this chronic disease context, public health should ensure that strategies do not have unintended consequences for individuals and populations, such as perpetuating weight bias. There is now sufficient evidence demonstrating that weight bias and obesity stigma are fundamental drivers of health inequalities. Public health has an opportunity to leverage existing health promotion frameworks such as the health for all policy framework and the global plan of action on social determinants of health to address weight bias and obesity stigma”.
Based on the analyses presented in this paper, we make the following recommendations:
Canadian provincial and territorial governments, employers, and the health insurance industry should officially adopt the position of the Canadian Medical Association and the World Health Organization that obesity is a chronic disease and orient their approach/resources accordingly.
Canadian provincial and territorial governments should recognize that weight bias and obesity stigma are significant barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems, and education policies.
In an era of people-centered health care, public health and health system decision makers should engage people with obesity in the development of policies and strategies. Having active participation of individuals with obesity can help change negative attitudes and beliefs about obesity and facilitate the development of compassionate and equitable health promotion strategies.
Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity treatments for their employees through health benefit plans.
Provincial and territorial governments should increase training for health professionals on obesity prevention and management.
Existing Canadian Clinical Practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of evidence-based programs and strategies by health systems, employers and health insurance companies.