I thought I’d share with you just some of the highlights of Day One of European Congress on Obesity 2023, which is here in Dublin this week.  First part of this post breaks down the science.  My thoughts on both the conference and some of last night’s media coverage follows at the end…

If you’ve been to a large conference of any type before, you know that there’s lots going on at the same time in different room.  So, this is limited to what I managed to attend:

   Are you ready? – let’s science!

The central – and oft-repeated –  message – if anyone didn’t already know it  – is that Obesity is a Disease.  Prof. Carel le Roux optimistically remarked at one point that he hoped what he was saying wasn’t new to anyone in the audience.

“Obesity is a progressive and relapsing chronic diseases characterized by excess or abnormal body fat that impairs health and wellbeing, requiring prevention and treatment strategies.”

So, some random take-away messages from experts:

5. Lots of talk about who lack of access to qualified care for patients with obesity harms patients, including patients resorting to Turkey.

   Safe Bariatric Surgery

   Since we are here, let’s just highlight safety: Do not go to Turkey. Not only because of the safety issue, but also because obesity treatment requires comprehensive expert pre-care and post-op care – airport transfers do not count.   Post-op complications in bariatrics surgery aren’t limited to post-op infections, and can include intense psychological complications that can occur months later.  Just because you stay in Ireland doesn’t mean it’s automatically a safe choice. Do not go to any clinic advertising aesthetic surgery and lap bands. Lap Bands are no longer considered a treatment for obesity. They do not work. They are not standard of care. They have high rates of complications.    Set on Surgery? Ask your GP for a referral to a qualified Upper GI and Bariatric Surgeon who works in either an established and comprehensive private hospital or public university hospital.s here

6. There was some coverage about the detrimental effects that slimming clubs can have on patients with obesity. Slimming clubs are fine and often helpful for peoples who need to lose some weight.  But for patients with established disease of obesity with complications, it is unlikely to be enough.  The recurrent nature of the disease of obesity means that patients have “weight cycling”.  That is, they keep losing and regaining the same couple of stone. For slimming clubs, it’s a great business model.  For patients, it can be an independent risk factor for some further obesity complications.

7. In one session, lots of talk about involving the family and partner in the discussion and approach to everything from meals to lifestyle. I love the approach (disclaimer: I’m biased because I have that approach.)  The session on childhood obesity had some great speakers (paediatric people, in general, are just the happiest people).  Interesting research shows that most children attend appointments with the mother. However, research found that fathers were more likely to use food as a reward,and when it comes to parent modeling (children do what parents do, not what they say), the father’s intake of fruits, vegetables, fish directly impacted the child’s. They advocated more whole-family approaches — and getting dad involved!

8. The role in recognizing, preventing, and treating iatrogenic obesity. That is, patients who have obesity as a complication from medications that are treating another disease.

9. Lots of great biochemical talk about the metabolic signaling pathways. Lots of new research on the genetics involved, the signalling pathways involved, and what that means for potential treatments in the future (Did you know? My post-doc work was in molecular biology; I am a true nerd and sought out that session.)

Session that was most intriguing included Dr. Acosta from the Mayo Clinic – probably my favourite part of the day! He’s been working on “phenotyping” obesity. “phenotype” means the interaction of our genes with our environment.   He has been researching exactly how/why one person’s obesity is not like another person’s obesity.  No only cause.  But also how it impacts their health – and treatment/prevention.  That means that while surgery is right for one but drugs are right for another while psychology/lifestyle is right for another – what’s the difference?  How can best figure out what will work for the patient? Obesity is a complex and heterogenous (means looks different in differnt disease with multiple phenotypes. How complex is it?  Well, in Dr. Acosta’s work, he found that 16% of patients had a “hungry brain” (their brain didn’t get satiety signal) 12% “slow burn” -had slow metabolism factors (low basal metabolic rate combined with activity level lower than they needed) , and 12% had emotional eating (disordered eating, trauma). However, if you do the math, you will realise that that leaves 27% that were various combinations!

Dr. Acosta’s take-away message:  “One-treatment-fits-all” is not working (but most of us already knew that – it’s why we work in multi-disciplinary teams!)  I’ll be reading more if his work this week when I get a chance.

More things that were really interesting?

• It’s not new idea but it’s always important to have a new discussion with latest research: The role of ACE (adverse childhood events) or trauma on obesity. This research has been ongoing since 1985!  Did you know??  At least 60% of patients attending for obesity services need – and deserve – qualified psychology support.

• Lack of access to treatment highlighted repeated. Major barrier was patients experience weight bias and weight stigma. 9 out of 10 patients in one study had not asked for help for treatment for their obesity.

So, before we leave the fact-based part of this post, let’s go to the big topic:  Yes, some sessions did cover pharmaceuticals. It’s important  to talk about these medications because bariatric surgery was discovered in 1955 (!) and lifestyle modification and psychology for eating disorders/trauma  has been around along time – and we all know there are many patients that none of these treatments have been working for.    While the drugs available and under development aren’t for everyone, they are the right treatment choice for some patients.

While we are here, let’s clear up some misconceptions:

• the drugs are for treating the disease of obesity and the reducing/reversing complications. The drugs are not weight loss, and mischaracterizing them as such is unhelpful – and too often comes from a place of weight bias.

• The drugs are not designed to replace the necessary whole-patient care — such psychotherapy and lifestyle modifications where indicated.  They are an adjuvant.

So, where are we at? Lots of data presented that can be summed up like this:  New drug on the market (not Ireland) Mountjaro is superior to the current obesity drug available on the Irish market, Saxenda. True, sponsored by Lilly But, honestly, we already knew that before the conference (so why Lilly paid all that money to tell us something we already know…?)   Saxenda is not nearly the best drug (also not the cheapest!) anywhere, and there has been appropriate questions raised as to why the HSE has chosen to reimburse that one.

That’s the science.  Yes, I’ve got thoughts.  Reactions?  Read on:

So much is right about #ECO2023.  The science is wonderful.  The speakers ar passionate.  There is so much space given for patients living with obesity to share their lived experience.  So much research has been done in this area!

What was really right?  From the start – and repeated nearly every session – experts in metabolism, obesity medicine, endocrinology, nutrition, psychology, primary care, and patient lived experience – got up and stated what is now accepted as fact:

Obesity is a complex, chronic, progressive, and recurring disease.

The complexity refers to 2 things:

• Causes: There is not one cause of obesity in most cases.  With exception of some rare monogenetic syndromes, even genetic causes of obesity account for only around 40-70%.   Other causes include thing such  trauma, disordered eating, environmental, socio-economics, and other metabolic conditions.

• Complications: Obesity as a disease is important.  It is not about body image or shape. It’s about the health impacts.  And the impact that the disease has on the body has complex mechanisms, whether it is metabolic (high cholesterol or diabetes, for example) or biomechanic (back pain, poor mobility, joint arthritis) or difficult to treat such as NASH, a form of liver disease.

But, not everything was great.

In addition to give platforms to experts (both patient and medical professionals), platforms were also given to for-profit companies.   I know you immediately thought: Ozempic.  Would you believe that  NovoNordisk was nowhere to be seen, nor was the word Ozempic/Wegovy anywhere?  And why would that be?  It would be because the major sponsor of the ECO is a company called Eli Lilly.  Eli Lilly is launching a drug that is more effective than semaglutide, which goes by trade name of Mountjaro. No, you can’t get it in Ireland yet.  And the prominent marketing of pharmaceuticals – which I am against anyway for many reasons – in this case fed the anti-drug backlash.

But to break it down:  Are these drugs “bad” or “Good”? Actually, neither.  For the some patients, this is the right treatment.  For other patients, bariatric surgery is the right path. For other patients, psychology and lifestyle modifications are the right path. For all at-risk patients, lifestyle prevention is important to maintain health and reduce complications.

The reality remains that obesity is a complex, chronic, progressive, and recurring disease.  What that means is that the patient will have obesity for their entire lives. Even after weight loss, weight recurrence is part of the disease process due to the complex mechanisms that do things such as alter the body’s metabolism to return to the set point.

Patients deserve expert, multi-discplinary care to access the right treatment – or prevention –  at the right time for their obesity.  

For some patients, that might look like starting their journey with lifestyle modifications and psychology, and then surgery.For some patients, that might look like the surgeon recommending a few months of medication to reduce weight to reduce surgical complications before surgery.For some patients, it may be they need therapy for disordered eating or trauma.  It’s really neither drugs or surgery.For some patients, drugs might be necessary short term. For some patients, drugs might be necessary long term. Many patients will need lifestyle assessments and modifications to address complications of obesity from sleep to body image to nutrition to exercise tolerance to biokinetics (joints and function).

What patients deserve is access to ongoing and unbiased expert care.  That is, the team advising you has no financial or commercial interest in which treatment you receive, just that the patient has access to safe and appropriate care that meets the patient’s health goals.

While experts agree that the drugs aren’t for everyone, but they are the right treatment choice for some.  And make no mistake:  misuse of any drug is a problem. 

Let’s flip this for a moment and realise how much conscious/unconscious weight bias is present in some of the arguments against pharmaceuticals:  What if we said that all patients with high blood pressure shouldn’t be offered medication for their blood pressure without trying diet and exercise first? Or they can’t have it before psychology reviews how they cope with stress?  Or not start it if they might be on it for life?  Or not start it because there is a percentage chance they won’t get heart attack or stroke?  While Big Pharma has it’s evils, denying or restricting patient medications – including by shaming patients for drugs they need – is not how we solve the inherent problems.

And what was really disappointing was, after all that, yesterday the Irish television media found – out of a Congress of hundreds of international experts who hailed from UK, Rotterdam, Canada, Brazil, Massachusetts, Mayo Clinic who are publishing new and exciting obesity research …. – they instead chose to feature a rather outdated voice who had contributed nothing to the research or panel discussions, but much to the culture of public patient-shaming.

While that should have been a low point, I then saw one speaker ranting on social media about the “wrongness” of every session that was about an approach to obesity treatment that wasn’t hers.  While she may be an expert in her area and well-intentioned,  she is missing the fundamental point that not all patients with obesity fit the model of obesity she treats.   Even worse, rather than expand her view of what other obesity experts are sharing, she proudly states that she walked out of the session.  The meaning of science is to question and debate with an open mind – quite the opposite of  belief. And if you think an approach or data is wrong, stand up at the microphone and share the counterpoint where you can also be challenged and engaged (that’s the good stuff in conference anyway!)– that is the point of these scientific conferences.  Storming out and ranting to followers and echo chambers is not how science works.

Our understanding of obesity as a disease, from causes (genetics, metabolism, psychology, socio-economic factors) to complications (heart disease, NASH/liver disease/cirrohosis) to treatments has come a long way in last 10 years from patient-shaming and “eat less, move more.”  Everyone needs to catch up.   The oft-repeated messages about ending weight bias and that  “One-treatment-fits-all is not working” were really important.  Which is why I think a session by Dr. Acosta yesterday was so important.  It seems obvious, but it is crucial that those who work with patients with obesity – whether as physician, dietitian, psychologist, or surgeon —  to realise that no two patients with obesity are the same.  Not the same causes.  Not the same experience. Not the same complications. And not the same approach – or response – to treatment.

For more disease of obesity, Try On World Obesity Day and Let’s Talk: World Obesity Day

Conflict of interest:  It’s fair if I’m talking commercial interest, I declare mine. I receive no funding or any compensation or any perks of any kind from any pharmaceutical or supplement industry.   I work with patients who have been prescribed Saxenda/Ozempic; all of my patients who are on those medications are under joint care of a Consultant Endocrinologist or the GP primary care reimbursement scheme.  I do not have any financial interest in any aspect of bariatric surgery. I have patients who are preparing for bariatric surgery (pre-hab) and in post-surgery rehabilitation, as part of shared care of a multi-disciplinary team. Lifestyle medicine has a role to play in prevention and treatment of obesity, and I am SCOPE-certified in obesity medicine. However, my practice is not at all exclusively obesity medicine and I support patient who are at-risk or who have been diagnosed with a range of conditions, including subfertility, heart disease, PCOS, hypertension, and diabetes.