Obesity: Getting past the stigma and treating the disease

Welcome to the world of obesity, where – as Dr Karl J. Neff explains, stigma is a huge barrier to treatment and respect

Obesity is a chronic disease that affects more people in Ireland than any other. It is a disease that carries significant morbidity. The morbidity associated with obesity is so significant that it limits life expectancy.1-3 Obesity has been put forward as one of the factors which may explain the recent disimprovement in life expectancy in the US, where more than 35% of the population are living with obesity.1

This article outlines how obesity stigma blinds us to this insidious chronic disease, reviews the pathogenesis of obesity, and briefly describes the available treatment options.

Obesity stigma is the term used to refer to discrimination based on weight. We live in a society that feels free to openly discriminate against people based on their weight. Obesity stigma is everywhere. People living with obesity are portrayed or understood as unmotivated (‘lazy’) and undisciplined (‘greedy’). When we understand people living with obesity as unmotivated, undisciplined people who do not take responsibility for their own health and wellbeing, it gives us license to blame them for their poor health, to criticise them for their life choices, and even to decline to employ them.4,5

This leaves people living with obesity feeling very alone in a world that judges them for their disease. Given the extent of obesity stigma in our society, it is no surprise that obesity is associated with depression, anxiety, reduced social participation, lower incomes, and reduced quality of life.5

In healthcare, we are just as prone to obesity stigma as any other section of society. People with obesity and medical symptoms will often report deferring visits to healthcare providers as they expect that every symptom will be attributed to their weight, and that the proposed solution to their problem will be ‘just lose some weight’: something that they have probably heard and tried to do many times before (usually without success). Therefore, if someone attends us with symptoms or a medical complaint, then we should deal with that issue first – before addressing their obesity.

If we do address their obesity, we should do it compassionately and sensitively, and allow the patient to lead the conversation. If someone wants to treat their obesity, then there are three main treatment options. Diet and exercise-based approaches, medical therapy and surgical treatment.

Diet and exercise-based treatments can be effective in a minority of people living with obesity.

However, in most people their effects are limited. This is not due to a lack of adherence or willpower but rather to the underlying dysfunction in energy metabolism that is the pathological basis of obesity.

In the majority of people with obesity, the physiological regulation of body fat is dysfunctional and prevents sustainable weight-loss. When people with obesity go on a diet to lose weight, their physiology defends against the loss of body fat – this happens despite having excess body fat that could be used for energy. In obesity, the hypothalamus (the energy homeostat of the body) has lost the ability to accurately gauge the amount of body fat present, and so responds to weight loss attempts in the same way as it would to starvation; by activating the two primary physiological defences against weight loss.

The first physiological defence mechanism is hunger. Reduction in food intake results in increased hunger. Hunger is an unconscious physiological reflex, but people on a diet can consciously resist their hunger in an effort to lose weight.

While this can result in some weight loss, living in a constant state of perceived starvation is challenging to maintain, and requires constant conscious resistance of hunger, no matter how much fat mass is present.6-8

The other major physiological adaptation that resists weight loss is reduction in energy expenditure. If hunger does not stimulate calorie ingestion, then the hypothalamus will downregulate the basal metabolic rate so that we burn fewer calories. This is why people will find that despite sticking to a diet that initially resulted in weight loss (while feeling extremely hungry throughout), they ultimately hit a weight loss plateau. This occurs because the energy homeostat adjusts energy expenditure downwards to meet the reduced calorie intake.

This means that people will continue to burn fewer calories as long as there is calorie deficit. Presumably, this mechanism evolved as an adaptation to prevent death in times of famine.

The only way to overcome these mechanisms is to consciously reduce calorie intake to extremely low levels (approximately 600kcal per day). However, even if someone can achieve this, reintroduction of normal diet (calorie intake within recommended limits (e.g. 2000kcal per day) will produce weight regain, as their healthy 2000kcal a day diet will be in excess of the calories that they are expending by the end of their diet (which could be less than 1000kcal per day).8-10

Given the above, it should be no surprise that for at least 80% of people with obesity, diet and exercise alone will not achieve durable weight loss. Of course, this means that as many as 20% of people with obesity will achieve significant durable weight loss with a structured diet and exercise programme, and so this is a reasonable first line treatment for obesity if the individual has not completed such an intervention before.

Ideally, a structured diet and exercise programme would be provided in the public sector as dietician and exercise physiologist led, with psychologist support. In the absence of such a programme, most commercially available class-based programmes can at least offer advice on calorie reduction and peer support, and would be a good idea as a first step.

When diet and exercise based programmes are unsuccessful, the addition of medication should be considered as next-line therapy. There are three medical options at present licensed in Ireland; orlistat, liraglutide (at a dose of 3mg daily rather than the 1.8mg dose used for diabetes), and naltrexone/bupropion.

All of these can be prescribed safely in primary care. For prescribing information, please see www.medicines.ie.

If medical therapy is ineffective, then surgery should be considered. Obesity surgery (also called bariatric or metabolic surgery) is the most effective intervention in treating obesity and obesity-associated disease.

All procedures are performed laparoscopically, with a very low rate of complications, and result in a mean ten-year weight reduction of 25%.11-13 The weight loss associated with surgery is usually durable, and occurs in tandem with significant improvements in multiple health outcomes, including a reduction in all-cause mortality.

At present, the only public sector surgery centres that we can refer to are in St Columcille’s Hospital in Dublin and University College Hospital in Galway. Many private insurers now cover these procedures, so policy holders can now access a number of private sector providers across the state. Obesity affects all aspects of human health resulting in other chronic diseases, disability and a reduction in life expectancy.

However, obesity can be successfully treated and so people with obesity need to be recognised and offered treatment. Treatment can save lives, reduce morbidity and improve psychosocial functioning.

Covid has demonstrated how obesity complicates care and adds risk. People living with obesity were more likely to be admitted to ICU and to die when infected with Covid.14

This led to significant worry among people living with obesity: a group who are living with a chronic disease without being offered treatment.

The pandemic brought to light the effect of obesity stigma on obesity care in Ireland. Even when people were at risk of death as a result of Covid, obesity stigma persisted and the old paradigm of blaming people for their obesity persisted.

As a healthcare system, we need to do better for people with obesity, both in terms of our understanding of obesity and in provision of treatment. In 2021, the HSE Model of Care for obesity was launched. Hopefully, this will be the start of a new programme of expanded public sector provision of all treatment options for obesity so that we help people living with obesity to overcome this insidious chronic disease.

This article has been funded by Novo Nordisk. Novo Nordisk has not influenced the content of the article.

Author
Dr Karl J. Neff, St Vincent’s Healthcare Group, Dublin, Diabetes Complications Research Centre, Conway Institute, University College Dublin.

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