Next, in my miniseries on arguments to support calling obesity (defined as excess or abnormal body fat that affects your health), I turn to the impact on health care providers.
Currently, most health care practitioners will happily limit their role in obesity management to warning their patients about the many health consequences of carrying excess weight and advise them to lose weight. They do not, however, see it as their job to actually provide treatment.
This is in stark contrast to diabetes or hypertension, where doctors do see helping patients control their blood glucose or blood pressure levels as an essential part of their job. Here, simply telling patients that they need to lower their blood glucose or blood pressure would not be deemed enough. Helping patients control their blood glucose or blood pressure, happens to be an important part of their job description.
One reason that health care providers have gotten away with simply telling patients to lose weight without actually helping them do so, is precisely because they have never viewed obesity as a disease. Rather, they (as much of the public) have looked at excess weight (and weight loss) as simply a matter of personal “lifestyle” – something that people with obesity should be able to manage on their own.
This, incidentally is one of the main reasons why many doctors are not happy with obesity being called a disease. I have actually heard a colleague ask me, “Why should this be my job? Why can’t they (sic) just eat less and move more – how difficult can that be?”.
That, is exactly the attitude adjustment that calling obesity a chronic disease can change. Perhaps not in the generation of doctors and other health professionals who have grown up thinking of obesity as a “lifestyle choice”. But hopefully, in the next generation of health care providers, for whom treating and helping their patients manage their obesity will be no different from treating and helping patients living with any other chronic disease.
Continuing in my miniseries on arguments in favour of calling obesity (defined as excess or abnormal fat tissue that impairs health) a disease, I turn to the perhaps most important reason of all – access to care.
Currently, few health care systems feel obliged to provide individuals presenting with obesity treatment for their condition (beyond a few words of caution and simplistic advise to simply eat less and move more).
Most health plans do not cover treatments for obesity, arguing that this is simply a lifestyle issue.
In some countries (e.g. Germany), health insurance and health benefit plans are expressly forbidden by law to cover medical treatments for obesity.
Although long established as the only evidence-based effective long-term treatment for severe obesity, many jurisdictions continue to woefully underprovide access to bariatric surgery, with currently less than 4 out of 1,000 eligible patients receiving surgery per year in Canada.
Pretty much all of this can be blamed on one issue alone – the notion that obesity is simply a matter or personal choice and can be remediated by simple lifestyle change.
Declaring obesity a disease can potentially change all of this.
As a disease in its own right, health care systems can no longer refuse to provide treatments for this condition.
In the same manner that no health system or insurance plan can refuse to cover treatments for diabetes or hypertension, no health system or insurance plan should be able to deny coverage for treatments for obesity.
As a chronic disease, obesity care must now be firmly integrated into chronic disease management programs, in the same manner that these programs provide services to patients with other chronic diseases.
How long will it take before this becomes accepted practice and funding for obesity treatments rises to the level of funding currently available for treating other chronic diseases?
That, is anyone’s guess, but no doubt, declaring obesity a disease finally puts patients living with this condition on an equal footing with patients living with any other chronic disease.
Continuing in my miniseries on why obesity (defined here, as excess or abnormal body fat that affects your health) should be considered a disease, is the simple observation that obesity responds less to lifestyle treatments than most people think.
Yes, the internet abounds with before and after pictures of people who have “conquered” obesity with diet, exercise, or both, but in reality, long-term success in “lifestyle” management of obesity is rare and far between.
Indeed, if the findings from the National Weight Control Registry have taught us anything, it is just how difficult and how much work it takes to lose weight and keep it off.
Even in the context of clinical trials conducted in highly motivated volunteers receiving more support than you would ever be able to reasonably provide in clinical practice, average weight loss at 12 – 24 months is often a modest 3-5%.
Thus, for the vast majority of people living with obesity, “lifestyle” treatment is simply not effective enough – at least not as a sustainable long-term strategy in real life.
While this may seem disappointing to many (especially, to those in the field, who have dedicated their lives to promoting “healthy” lifestyles as the solution to obesity), in reality, this is not very different from the real-life success of “lifestyle” interventions for other “lifestyle” diseases.
Thus, while there is no doubt that diet and exercise are important cornerstones for the management of diabetes or hypertension, most practitioners (and patients) will agree, that very few people with these conditions can be managed by lifestyle interventions alone.
Indeed, I would put to you that without medications, only a tiny proportion of people living with diabetes, hypertension, or dyslipidemia would be able to “control” these conditions simply by changing their lifestyles.
Not because diet and exercise are not effective for these conditions, but because diet and exercise are simply not enough.
The same is true for obesity. It is not that diet and exercise are useless – they absolutely remain a cornerstone of treatment. But, by themselves, they are simply not effective enough to control obesity in the vast majority of people who have it.
This is because, diet and exercise do not alter the biology that drives and sustains obesity. If anything, diet and exercise work against the body’s biology, which is working hard to defend body weight at all costs.
Thus, it is time we accept this reality and recognise that without pharmacological and/or surgical treatments that interfere with this innate biology, we will not be able to control obesity in the majority of patients.
Whether we like it or not, I predict that within a decade, clinical management of obesity will look no different than current management of any other chronic disease. Most patients will require both “lifestyle” and probably a combination of anti-obesity medications to control their obesity.
This does not take away from the importance of diet and exercise – as important as they are, they are simply not enough.
Despite what “lifestyle” enthusiasts will have us believe, diet and exercise are no more important (or effective) for the treatment of obesity, than they are for the treatment of hypertension, diabetes, dyslipidemia, depression, or any other condition that responds to “lifestyle” interventions.
In the end, most patients will require more effective treatments to manage their obesity and all of the comorbidities that come with it. The sooner we develop and make accessible such treatments, the sooner we can really help our patients.
Continuing in my miniseries on arguments that support calling obesity a disease, is the simple fact that, once established, it behaves like a chronic disease.
Thus, once people have accumulated excess or abnormal adipose tissue that affects their health, there is no known way of reversing the process to the point that this condition would be considered “cured”.
By “cured”, I mean that there is a treatment for obesity, which can be stopped without the problem reappearing. For e.g. we can cure an ear infection – a short course of antibiotics and the infection will resolve to perhaps never reappear. We can also cure many forms of cancer, where surgery or a bout of chemotherapy removes the tumour forever. Those conditions we can “cure” – obesity we cannot!
For all practical purposes, obesity behaves exactly like every other chronic disease – yes, we can modify the course or even ameliorate the condition with the help of behavioural, medical or surgical treatments to the point that it may no longer pose a health threat, but it is at best in “remission” – when the treatment stops, the weight comes back – sometimes with a vengeance.
And yes, behavioural treatments are treatments, because the behaviours we are talking about that lead to ‘remission’ are far more intense than the behaviours that non-obese people have to adopt to not gain weight in the first place.
This is how I explained this to someone, who recently told me that about five years ago he had lost a substantial amount of weight (over 50 pounds) simply by watching what he eats and maintaining a regular exercise program. He argued that he had “conquered” his obesity and would now consider himself “cured”.
I explained to him, that I would at best consider him in “remission”, because his biology is still that of someone living with obesity.
And this is how I would prove my point.
Imagine he and I tried to put on 50 pounds in the next 6 weeks – I would face a real upward battle and may not be able to put on that weight at all – he, in contrast, would have absolutely no problem putting the weight back on.
In fact, if he were to simply live the way I do, eating the amount of food I do, those 50 lbs would be back before he knows it.
His body is just waiting to put the weight back on whereas my biology will actually make it difficult for me simply put that weight on.
This is because his “set-point”, even 5 years after losing the weight, is still 50 lbs higher than my “set-point”, which is around my current weight (the heaviest I have ever been).
Whereas, he is currently working hard against his set-point, by doing what he is doing (watching what he eats, following a strict exercise routine), I would be working against my set-point by having to force myself to eat substantially more than my body needs or wants.
That is the difference! By virtue of having had 50 lb heavier, his biology has been permanently altered in that it now defends a weight that is substantially higher than mine.
His post-weight loss biology is very different from mine, although we are currently at about the same weight.
This is what I mean by saying he is in “remission”, thanks to his ongoing behavioural therapy.
Today, we understand much of this biology. We understand what happens when people try to lose weight and how hard the body fights to resist weight loss and to put the weight back on.
This is why, for all practical purposes, obesity behaves just like every other chronic disease and requires ongoing treatment to control – no one is ever “cured” of their obesity.
Not even people who have bariatric surgery – reverse the surgery and before you know it, the weight is back.
So, if for all practical purposes, obesity behaves like a chronic disease, why not just call a spade a spade?
For an illustration on why obesity acts like a chronic disease watch this short TEDx talk
Following my miniseries of arguments I often hear against calling obesity a disease, I now turn to reasons why I (and a number of organisations and experts) do consider obesity to be a disease.
Let us start with the most obvious reason, namely that obesity, by definition, affects health and well-being.
Remember, I am not talking about the BMI definition of obesity – I am talking about the actual WHO definition of obesity as a condition where excess or abnormal body fat affects health.
I have already discussed that there are indeed folks across a wide range of body shapes and sizes, who are perfectly healthy – by this definition they do not have obesity (no doubt, BMI and measuring tapes get this wrong).
On the other hand, even the most vehement fat acceptance enthusiasts will find it hard to argue that there are indeed many folks in whom there is indeed a direct link between excess body fat and health – be it functional limitiations or medical complications.
Thus, excess weight with sleep apnea is obesity, excess weight with type 2 diabetes is obesity, excess weight with hypertension is obesity, excess weight with reflux disease is obesity, and so on.
What some people find confusing is that fact that many of the complications of obesity can also be found in people with “normal” weight, which leads them to question the relationship between excess body fat and health.
Indeed, almost all complications of obesity can also be found in people of “normal” weight but that is because the “complications”, in turn, can have multiple causes.
Take for example fatty liver disease, the most common cause of which is alcohol, which is why in the context of obesity, we use the term – non-alcoholic fatty liver disease. But even if you exclude alcohol, there are a number of other factors that can cause fatty liver disease and these should be ruled out before jumping to conclusions that the fatty liver indeed related to the excess body fat.
The same can be said for almost any medical condition associated with excess weight – before concluding that these conditions are related to the excess weight, other possible explanations should be ruled out.
Ultimately, the test lies in observing the response to a change in body weight – does the condition get better with weight loss or worse with weight gain – if yes, it is likely related to excess weight. If it doesn’t, it probably isn’t.
When excess or abnormal body fat affects your health, it does so in the same manner as elevated blood sugars affect health in diabetes or elevated blood pressure affects health in hypertension.
Reason enough to consider it a disease.