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Time To Change The Obesity Narrative

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… Read More »

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The Clinical Importance of Using People-First Language in Obesity Management

Regular readers should by now be well aware of the importance of using people-first language when referring to people living with obesity (as in “patient with obesity” not “obese patient”). As I have noted in previous posts, living with a condition is not the same as being defined by that condition – this is why we do not refer to people living with dementia or cancer as being “demented” or “cancerous”. As elegantly pointed out by Lee Kaplan in a presentation he delivered at the Harvard Medical School Center For Global Health Delivery consultation on obesity, currently being held in Dubai, there is also a pressing clinical argument for speaking of obesity as a disease rather than a descriptor of a “state”. Take for e.g. the case of a patient with hypertension, who, thanks to effective on-g0ing anti-hypertensive treatment has managed to control his blood pressure levels over the past 10 years. In fact, at no time in the past 10 years has the patient ever presented with elevated blood pressure. Any clinician would agree that this patient would still be declared to have “hypertension” despite currently not being “hypertensive”. Similarly, a patient whose depression is well-controlled with an anti-depressant is still a patient living with “depression”, although they are not currently “depressed”. Likewise, we can probably all agree that a patient who has undergone coronary bypass surgery, is still someone living with coronary artery disease, even if they have not experienced a single angina pectoris attack since their surgery. In all of these cases, hypertension, depression, and coronary artery disease would continue to appear on their medical problem list. When applied to obesity, this means that even if someone has successfully managed to lose their weight to a level that they are no longer clinically “obese”, they are still someone living with “obesity”. Even if their BMI (not a good measure of obesity) should drop to below 25, they are still someone living with obesity (albeit, as in the case of the above examples, living with “controlled” or “treated” obesity). Thus, they continue to have “obesity” even if they are currently not “obese” – ergo, the diagnosis “obesity” should remain on their problem list. Furthermore, given the high rates of recidivism, keeping obesity on the problem list serves as an important reminder to the clinician to continue supporting and reinforcing ongoing obesity treatment (even if this treatment is only… Read More »

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The Effects of Obesity on Skeletal Muscle Contractile Function

Given that obesity has profound effects on all organ systems, it is not surprising that excess body fat is also associated with a decrease in muscle function. The complex biology of the molecular, structural, and functional changes that have been associated with obesity are now extensively discussed in a review article by James Tallin and colleagues, published in the Journal of Experimental Biology. Without going into the molecular details here, suffice it to say that there is considerable evidence to show and explain why muscular function is impaired in both animal models and humans with excess body fat. (For e.g. at a cellular level, the dominant effects of obesity are disrupted calcium signalling and 5′-adenosine monophosphate-activated protein kinase (AMPK) activity. As a result, there is a shift from slow to fast muscle fibre types. There is also evidence for an impairment in myogenesis resulting from disruption of muscle satellite cell activation. Furthermore, muscle function is affected by insulin resistance and decreased adiponectin levels generally associated with obesity). Although individuals with obesity will often have a larger muscle mass and may well be stronger than “normal-weight” individuals, when corrected for the amount of extra muscle, it is evident that the muscles are less efficient. In fact, many of the biochemical and structural changes that occur in obesity are very similar to those found with aging. Not surprisingly, when aging meets obesity, things get even worse. Although the paper does not discuss the reversibility of these changes with weight loss (or obesity treatment in general), I am aware of other data showing that much of the loss of muscle contractile function associated with obesity can be reversed with weight loss. A clinical correlate of this is the fact that, following weight loss, individuals often find that it takes far more exercise to burn the same number of calories than before (this is not just because the person is now carrying less weight). Given the increased recognition that lean body mass is an important determinant of overall health and function, clearly this topic is of continuing interest. @DrSharma Edmonton, AB

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Some Limitations In Applying The Etiological Framework To Obesity Assessment

To conclude this series of citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, that guides us through a systematic assessment of factors influencing energy metabolism, ingestive behaviour, and physical activity, it is important to consider some limitations of this (and any other) etiological approach to obesity management: While we have taken efforts to provide a comprehensive and wide‐ranging list of considerations in the assessment of obesity, we fully recognize that a full work‐up of all permutations of the proposed factors may well be beyond the scope of a busy practitioner. In this regard, the old saying applies: ‘when you hear hoofs, think of horses not zebras’. Thus, consideration should be first given to the most common and obvious reasons laid out in this paper, many of which should be immediately apparent to the experienced clinician (e.g. homeostatic hyperphagia resulting from meal skipping, hedonic hyperphagia related to depression, immobility due to osteoarthritis, weight gain due to atypical antipsychotics, etc.). Also, the use of comprehensive self‐directed questionnaires such as the Weight and Lifestyle Inventory, a multiple‐page self‐report questionnaire that the patient completes before treatment visits, designed to identify the root causes of obesity and perform an environmental analysis, may be helpful in this regard. Future efforts must also aim to provide simple clinical algorithms that will guide the busy clinician through the maze of factors that can potentially precipitate and/or exacerbate positive energy balance. Nevertheless, as in a patient with oedema, despite complete recognition of the underlying factors, the clinician often has no option but to manage the patient with the judicious use of fluid restriction and diuretics. Similarly, in patients presenting with obesity, the underlying contributing factors (e.g. genetics, addiction, depression, back pain, etc.) may not be easily amenable to causal treatment. In these cases, ‘symptomatic’ treatment of obesity with caloric restriction and exercise regimens may well in many cases prove to be the only option. Nevertheless, we maintain that careful identification and management of the possible socio‐cultural, psychological and biomedical barriers will likely increase the feasibility, compliance and adherence to these measures. Recognition of the causes and barriers will also help set out realistic expectations regarding the degree of weight loss that is likely to be achievable and sustainable, an important aspect of weight management. Despite the increased time required for the comprehensive work‐up of an obese patient, we believe that this framework will… Read More »

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Applying The Etiological Framework For Obesity Assessment In Clinical Practice

Continuing with citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, that guides us through a systematic assessment of factors influencing energy metabolism, ingestive behaviour, and physical activity, we ca now apply this framework in clinical practice: This paper provides a comprehensive framework, which should enable clinicians to systematically assess and identify the socio‐cultural, biophysical, psychological and iatrogenic determinants of increased energy intake and reduced energy expenditure in patients presenting with excess weight or weight gain. Beginning with an assessment of energy requirements and metabolism, clinicians should systematically assess the role and determinants of ingestive and activity behaviour to identify the factors promoting positive energy balance. This will enable clinicians to develop management plans that address the root causes of weight gain and move beyond the simplistic and generally ineffective recommendation to ‘eat less and move more’. Thus for example, in a listless patient ‘self‐medicating’ with food, identification and treatment of depression may be the first step to reducing food intake and preventing further weight gain. In a patient with socioeconomic barriers to healthy eating or physical activity, referral to a social worker who can assist in identifying and accessing community resources may be important. Identification and effective treatment of obstructive sleep apnoea may be the key to increasing activity in someone with this disorder. Psychological counselling to manage alcohol or substance abuse or to help patients deal with binge eating resulting from past trauma, emotional neglect or grief, can put patients on a path to successful weight management. Clearly, the common notion that all forms of obesity can be addressed simply by counselling patients on diet and exercise should be considered ineffective and obsolete. To conclude this series, we will tomorrow look at some of the potential limitations of this system. @DrSharma Edmonton, AB

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