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
In my TEDx talk “How to Lose 50 Pounds and Keep Them Off” released earlier this week, I recommend that people struggling with obesity seek help from a health care professional trained in chronic disease management.
Given that most of what we deal with in medicine is chronic disease, one would imagine that almost any health professional can give competent advice on living with a chronic disease.
Unfortunately, while this may be true for diabetes or hypertension or most of the other common chronic diseases that virtually all health professionals at some time in their careers will have learnt to manage, very few will have any experience at all in treating obesity – let alone even thinking of obesity as a chronic disease.
It is therefore not surprising that when it comes to weight management people often turn to lay “experts” who proclaim themselves as “experts” simply because they have somehow managed to lose weight and are (at least for now) managing to keep it off.
Often, these “experts” (not seldom with the help of a savvy publicist) will launch a lucrative speaking business including authoring self-help books, offering diet/exercise plans, appearing on TV talk shows, endorsing supplements or promoting whatever it is they believe helped them lose their weight.
Unfortunately, as I hear over and over from my patients, these self-proclaimed “experts” who, having “conquered” their obesity, have now embarked on a mission to help you “conquer” yours, are about as effective as any other commercial fad diet.
This is because, we have long known that in obesity, what works for one person may be entirely ineffective in the next.
Just because you lost weight by following (insert your approach here), does not mean that you have found the Holy Grail of weight management and are now somehow professionally qualified to offer your help to everyone else.
Living with heart disease does not make you cardiologist!
Surviving cancer does not make you an oncologist!
Losing weight does not make you an obesity specialist!
This is not to say that the “patient” experience is not important or that “peer support” cannot be a valuable tool in chronic disease management.
Indeed many successful weight management programs including Taking Off Pounds Sensibly or Weight Watchers rely heavily on “peer support”, in that groups are generally run by lay people who are themselves “affected”.
While this makes a lot of sense, it does not replace the need for a professionally qualified health professional to ensure that all goes well.
Just because you are a member of the local diabetes support group does not mean you no longer need to meet with your diabetes educator or family doctor.
Just because your dearest friend survived a heart attack and is willing to share her experience and support, doesn’t mean you no longer need to see a cardiologist for your own heart problems.
This is an important distinction and should be a warning to not rely too heavily on people peddling their “success stories”.
While it may well of interest to listen and perhaps even examine their suggestions, hoping that what worked for them will work for you, is both shortsighted and can potentially do more harm than good.
Do I wish that all health professionals had a sound understanding of obesity management and are there to support people living with obesity – of course I do.
But I know we are not there yet and it will take time before health professionals begin seeing their role change from simply “recommending weight loss” t0 actually having the expertise and experience required to help patients better manage their weight and health.
It must have been a pretty cheap rubber band, because every few months it would wear out and lose its stretch, so it had to be replaced it with a new band.
Unfortunately, this is not what can be said about the rubber band that I used in my recent TEDx talk to demonstrate what happens when you try to lose weight.
Unlike the cheap band in my pyjamas, the rubber band I used to represent our physiology trying to gain the weight back, never seems to lose its stretch.
No matter how hard or how long we pull, the rubber band keeps wanting to bring our weight back to where we started.
Yes, perhaps for some people, eventually the rubber band may relax (these would certainly be the exceptions) or may be the “muscles” that we use to pull on the band just grow stronger, which makes it seem easier to keep up the pull – but for all we know, in most people, this “rubber band” is of pretty good quality and seems to last forever.
So, how do we take the tension out of the rubber band ?
Well, we do know that people who have bariatric surgery have a much better chance of keeping the weight off in the long-term and we now understand that this has little to do with the “restriction” or the “malabsorbtion” resulting from these procedures but rather from the profound effect that this surgery has on the physiology of weight regain.
Thus, we know that many of the hormonal and neurological changes that happen with bariatric surgery, seem to inhibit the body’s ability to defend its weight and perhaps even appears to trick the body into thinking that its weight is higher than it actually is.
In other words, bariatric surgery helps maintain long-term weight loss by reducing the tension in the rubber band, thus making it far easier for patients to maintain the “pull”.
And that is exactly how we think some of the anti-obesity medications may be working.
For example, daily injections of liraglutide, a GLP-1 analogue approved for obesity treatment, appears to decrease the body’s ability to counteract weight loss by reducing hunger and increasing satiety, thus taking some of the tension out of that band.
Think of it as sprinkling “magic dust” on that rubber band to reduce the tension, which makes it easier for patients to maintain that pull thereby helping them keep the weight off.
Of course, both surgery and liraglutide only reduce the tension as long as you continue using them.
Undo the surgery or come off your anti-obesity meds and the tension in that band comes back as strong as ever.
For readers, who have no idea what I’m talking about, hopefully things will become clearer after you watch my talk by clicking here.
The last time I checked, my TEDx talk “How To Lose 50 Pounds And Keep Them Off“, had over 3,500 views on its first day!
While that is far from going “viral”, I do admit that it’s a lot more than I expected.
Although the overwhelming response and comments were positive, some viewers appeared frankly disappointed, not to say frustrated by the notion that obesity, once established, behaves like a chronic disease.
This may in part be due to the fact that, despite all evidence to the contrary, many people continue to believe (as suggested by the diet, fitness and weight-loss industry) that “permanent” weight loss is within anyone’s reach (it isn’t) and reaching your “dream weight” means winning the battle (it doesn’t).
But, I also believe that some of the frustration that comes with seeing obesity as a chronic disease for which we have no cure (which happens to be the definition of “chronic disease”), stems from the notion that living with a “disease” is terrifying and hopeless (it isn’t!).
In fact, most of what we deal with in our health care systems are “chronic diseases” – the exceptions being largely limited to accidents, acute infections and some cancers – these we can “cure”, by which I mean that we treat them for a given period of time after which they ceases to exist and the patient can be considered “cured”.
Unfortunately, as important as these “cures” may be, they constitute a rather small proportion of what goes on in the health care system. It is fair to say that for the vast majority of medical conditions, we may have treatments, but most certainly no “cures”.
However, this is not as depressing as it may seem. Indeed, it is one of the great achievements of modern medicine that we have turned diseases that would have been fatal in the not too-distant past (e.g. type 1 diabetes, coronary artery disease, HIV/AIDs, breast cancer), into conditions where, with proper treatments, most patients can enjoy decades of meaningful and productive life, despite living with their “chronic” disease.
Not that the treatments are always easy or cheap or well tolerated – but, when applied and adhered to properly, they generally do their job of allowing patients to go about their lives in a fairly acceptable manner.
So the idea that living with a chronic disease is all doom and gloom is certainly not true – ask anyone living with well-controlled diabetes, hypertension, coronary artery disease or even cancer.
Compared to a lot of these conditions, people living with obesity may well be a lot better off.
For one, while even with the best treatment many chronic diseases tend to get worse over time (take for e.g. chronic kidney disease with progressive loss of kidney function), stopping obesity form progressing (i.e. stopping further weight gain) is actually very achievable. In fact, as shown by the “placebo” groups in most obesity trials, even minimal intervention can help stabilize weight and prevent further weight gain – thus, while you may continue living with obesity, at least we can do a fairly good job of preventing it from getting worse.
Secondly, we have ample evidence that many of the health consequences associated with excess weight will improve with very little or even no weight loss through appropriate interventions that focus on improving mood, self-esteem, sleep, diet and physical activity. We know that with these interventions many people living with obesity will feel a lot healthier and better about themselves – which in the end should really be the principal goal of treating obesity in the first place.
Thirdly, there is hope on the horizon as both medical and surgical treatments for obesity are steadily getting better. Take for example bariatric surgery, which has gone from not too long being a highly invasive procedure ridden with often catastrophic complications in the days of open surgery, to a minimally invasive procedure with surprisingly minor risks and complications (in appropriate hands) with well-documented and often remarkable long-term benefits for health and well-being (not to say that there isn’t further room for improvement).
On the medical front, the last few years have seen the approval of several new obesity drugs, which have been rigorously tested for safety and efficacy in thousands of volunteers in randomised controlled trials. While these drugs may not be for everyone and come with a price tag (that varies from drug-to-drug and country-to-country), they do raise optimism that one day, medical treatment of obesity will be no more (or less) routine than treating diabetes, hypertension or any of the other many chronic diseases where long-term medical treatment is well established.
So, the notion that just because obesity is a chronic disease somehow means that all hope is lost, is simply nonsense.
Yes, the idea of thinking of of obesity as a “disease” may not sit well with everyone, especially with the minority of people, who happen to meet the BMI criteria for obesity but appear in perfect health – I do understand that for this minority, we do need a better definition of obesity that is not based on BMI and the Edmonton Obesity Staging System is certainly a start.
But for the vast majority of people with obesity (Stage 1-4), who do experience (or will experience) the health consequences of obesity, we can certainly do a better job of serving them, by looking at their obesity as a chronic disease rather than a “problem” that can be easily “fixed” by simply telling them to “eat less and move more”.
We know a lot about managing chronic diseases – we do this all the time.
It is now time to apply that knowledge to the benefit our patients living with obesity.
They deserve no less.
In March, I had the privilege of being invited by the organisers of TEDx UAlberta to present a talk on obesity.
This talk is now online – please take a look and join the discussion on facebook
If clicking on the image does not work for you, click on this link for YouTube