This month, if you are a healthcare professional, you can read my full piece on Obesity in Healthcare Professional News. If you aren’t a healthcare professional, you can read a few excerpts from the piece below that I really want to share with patients and families
4 March is World Obesity Day, and this year’s theme is “Changing Perspectives: Let’s talk about Obesity.” And, more than ever, in the past year, we are talking about obesity — from reactions to the shocking The Times editorial last october calling for an increase in Fat-shaming to the polarised conversations sparked by the recent oscar-nominated film The Whale – but are these the conversations we need to be having?
Obesity is a chronic, multifactorial, relapsing, progressive disease with biological, genetic, psychological, environmental and societal causes.
The National Obesity Society was founded in the US in 1949… Doctors then and since then were – and on occasion continue to be – actually criticised for medicalising excess weight, or insisting that weight management should be by experts. Later this spring, Dublin will host the European Obesity Meeting…. Over the past 20 years, the number of Irish children and adults who are above a healthy weight or have obesity have more than doubled to around 60% of the population. 25% of children and 20% of adolescent are above a healthy weight or have obesity.
Complications from Obesity
- Liver: NAFLD and cirrhosis
- Cardiovascular: heart disease and stroke
- Orthopaedic: joint disease and back pain
- Fertility: subfertility in both men and women
- Psychology: depression, eating disorder, body image problems,
- Respiratory: asthma, obstructive sleep apnoea, shortness of brath
- Gastrointestinal: reflux, gallstones
- Endocrine: Type 2 diabetes
- Renal and Urological: Kidney disease and incontinence
- Increased risk of many types of cancer
BMI
While BMI is commonly referred to when classifying obesity, it was never designed to be used in obesity management. It is more likely a question of when rather than if BMI will cease to be used to classify obesity. At present, obesity is both classified by BMI (WHO criteria, Figure 1) and staged by disease process. Patient decision-making is more likely to be meaningfully guided by staging the disease. Currently, the most widely researched obesity staging tool is the Edmonton Obesity Staging System
Obesity Stigma
“Fat-shaming is the only way to beat the Obesity Crisis” was the horrifying headline printed in The Times on 28 October 2022. This spurred appropriately intense and swift reaction from both experts as well as patient advocacy groups. It is important to note that complications from obesity are not limited to those from the weight itself, but also directly from the weight stigma. Multiple studies of shown that patients who experience weight stigma also have higher rates of depression, negative body image, reduced self-esteem and increased cardiovascular and metabolic complications…
…studies have shown that patients with obesity are reluctant to seek healthcare when necessary due to their negative experiences with weight bias in healthcare. Weight stigma itself – with or without the reluctance to seek healthcare when needed – can also lead to delay in diagnosis.
Obesity and Treatments
As I discuss with my own patients: weight management is not about weight loss for sake of weight loss, it is certainly not about aesthetics – the goal of care is health gains….Weigh loss is unfortunately targeted by both the cosmetic/aesthetics, social media influencers, and the wellness industry, many aspects of which are unregulated. Much of what is marketed is not evidence-based or is frankly predatory, including restrictive diets, unsafe practices, expensive supplements, or unrealistic weight loss goals.
Let’s Talk about Lifestyle Medicine: It’s worth first defining a term that is used so loosely, including by non-medics and influencers….Lifestyle medicine plays a key role in the evidence-based management of many chronic diseases, and in this respect, its use in the treatment of obesity should not be considered differently. Lifestyle medicine is based on the pillars of good nutrition (including a healthy relationship with food), physical activity, good mental health, stress management, restorative sleep and social connections. The role of lifestyle medicine in the management of obesity is not an iteration of the outdated “eat less, move more.” Lifestyle medicine has an essential role in the multi-disciplinary approach to the prevention of obesity as well as [treatment.]
Let’s Talk about Pharmaceutical Management: The most effective pharmaceutical options available to patients in Ireland currently include GLP-1 analogues liraglutide and semaglutide. … The advantages of GLP-1 analogues is that there is extensive data on pharmacokinetics and drug safety as it is has been used for years in the management of diabetes. The disadvantages can include cost as many patient are not currently eligible for reimbursement. The most common side effects include nausea, belching, bloating, and change in bowel habit though for many patients this can be managed with careful prescribing, patient-led increase of dosing, and attention to diet….
Let’s Talk about Surgical Management:
Bariatric surgery – specifically gastric bypass or sleeve gastrectomy – is the most effective treatment for weight loss in patients with BMI over 40 or over 35 with associated co-morbidities.
However, patients in Ireland currently face significant challenges accessing timely and safe bariatric surgery, including:
- For patients with private health insurance, the reimbursement commonly requires patients to have a BMI of ≥45 or ≥ 40 with weight-related co-morbidities. Not all aspect of care may be covered or reimbursed.
- For patients depending on public services, patients can currently expect to spend up to 5 years on waiting lists…
- Travel tourism, or traveling abroad to have bariatric surgery, has risks including the recently well-publicised surgical complications. The low-risk option often presented to patients – especially those centres abroad marketing their intervention packages as cosmetic or all-inclusive – is the placement of a lap band. Globally, up to 40% of patients who have a lap band will seek to have it removed within 10 years due to side effects or complications. It is also has its limitations as a treatment for obesity as it has no metabolic effect. Treatment through these centres rarely includes access to necessary post-operative multi-disciplinary care.
Obesity is a chronic disease and patients should be counselled from the outset that care will be lifelong…. The biology is such that the patient’s body will, in short, take steps to defend its highest weight. Goals of care should include a plan for ongoing care and avoidance of weight cycling, which increases cardiometabolic risk.
Obesity and Current Challenges
The Sars-CoV-2 pandemic has demonstrated that those with obesity are not only more likely to suffer from severe infections but also long term side effects. In multiple studies, women with obesity make up a disproportionate percentage of patients in long covid clinics. While the aetiology of long covid is still not understood, emerging data does that obesity is an independent risk factor for continuing symptoms including brain fog, fatigue, pain, and shortness of breath more than 12 weeks after the infection.
The continued framing of obesity as an aesthetic or cosmetic problem poses a challenge in itself. Obesity is a disease; not a cosmetic or aesthetic issue. The continued perspective of obesity as cosmetic problem only serves to perpetuate weight stigma or obstruct reforms to insurance reimbursement guidelines, support for increased public funding, and/or patient access to properly qualified experts.
Let’s Talk about Obesity – with understanding. Not just because of the Oscars or to mark how many years have passed or because of sensational headlines or a day of action on the calendar. It is time for this conversation because it is an epidemic with the potential for significant impact on patient mental and physical health outcomes and on the Irish healthcare system.
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