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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… Read More »
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… Read More »
Continuing in my miniseries on reasons why obesity should be considered a disease, I turn to the idea that obesity is largely driven by biology (in which I include psychology, which is also ultimately biology). This is something people dealing with mental illness discovered a long time ago – depression is “molecules in your brain” – well, so is obesity! Let me explain. Humans throughout evolutionary history, like all living creatures, were faced with a dilemma, namely to deal with wide variations in food availability over time (feast vs. famine). Biologically, this means that they were driven in times of plenty to take up and store as many calories as they could in preparation for bad times – this is how our ancestors survived to this day. While finding and eating food during times of plenty does not require much work or motivation, finding food during times of famine requires us to go to almost any length and risks to find food. This risk-taking behaviour is biologically ensured by tightly linking food intake to the hedonic reward system, which provides the strong intrinsic motivator to put in the work required to find foods and consume them beyond our immediate needs. Indeed, it is this link between food and pleasure that explains why we would go to such lengths to further enhance the reward from food by converting raw ingredients into often complex dishes involving hours of toiling in the kitchen. Human culinary creativity knows no limits – all in the service of enhancing pleasure. Thus, our bodies are perfectly geared towards these activities. When we don’t eat, a complex and powerful neurohormonal response takes over (aka hunger), till the urge becomes overwhelming and forces us to still our appetites by seeking, preparing and consuming foods – the hungrier we get, the more we seek and prepare foods to deliver even greater hedonic reward (fat, sugar, salt, spices). The tight biological link between eating and the reward system also explains why we so often eat in response to emotions – anxiety, depression, boredom, happiness, fear, loneliness, stress, can all make us eat. But eating is also engrained into our social behaviour (again largely driven by biology) – as we bond to our mothers through food, we bond to others through eating. Thus, eating has been part of virtually every celebration and social gathering for as long as anyone can remember. Food is celebration, bonding, culture, and identity – all… Read More »
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… Read More »
And finally, to end this miniseries on the arguments I often hear against calling obesity, is the objection based on the idea that there are simply too many people living with obesity to apply the label “disease” to. Doing so, would mean that over 7 million Canadians would wake up to find themselves living with a disease. Related to this argument, I also often encounter the argument, that calling obesity a disease would turn these 7,000,000 Canadians into “patients” thereby completely overwhelming our healthcare system that would now be called about to provide treatments to all these people. I hear from payers and policy makers that providing treatments for obesity as a disease is simply not practical because of the number of people who have it. As I think about it, both arguments are rubbish. Firstly, the definition of disease has nothing to do with how many people are affected. Thus, I have never heard anyone say that we need to stop calling diabetes a disease because it affects 6 million Canadians or we need to stop calling depression a disease because 2.5 million Canadians will be affected during the course of their lives. No one would ever suggest we stop calling the flu a disease just because it affects millions of Canadians leading to 12,200 hospitalizations and 3,500 deaths in Canada each year. So arguing that we must not call obesity a disease because that would be declaring far too many people as “diseased”, is simply irrelevant. Even if a disease affects 100% of the population causing important health problems and complications, we’d still be calling it a disease. As for overwhelming the healthcare system – I would say obesity is costing the health care system whether you call it a disease or not. We will still have to pay for all the health issues directly related to people having obesity – from diabetes to heart disease to joint replacements to cancers. It’s already costing billions of healthcare dollars. Except that we are now spending those dollars on the complications rather than on preventing and treating obesity itself. Again, if there was any other “disease” threatening to overwhelm the healthcare system, our response would certainly not be to simply stop calling it a “disease” – that would make no sense at all. This concludes my miniseries on arguments I often hear against calling obesity a disease (there are some I hear less often).… Read More »