Obesity – not just a question of willpower

Weight loss efforts are difficult, not because of a character flaw or lack of motivation and not because of the wrong diet or inactivity. When patients struggle with weight they are struggling with a real medical condition that goes undiagnosed and untreated in the vast majority of people.

Obesity has long been misunderstood, trivialised, and stigmatised as a simple ‘lifestyle’ or willpower issue that can be effectively addressed by the mantra of ‘eat-less-move-more’. 

This overly-simplistic and stigmatising view of obesity disregards both the experience of people living with the condition as well as an overwhelming body of scientific evidence.¹ Telling someone who is living with obesity to “eat less and move more” long term, is like telling someone living with depression to “cheer up” or telling someone with asthma to simply “take a deep breath”. We must shift the current focus from primary prevention to early diagnosis, early intervention and evidence based treatment based on a chronic disease management model.

Common criteria for defining a disease include an impairment of the normal physiological function, characteristic signs or symptoms, and an associated harm or morbidity. Obesity fulfils all of these criteria. There is a dysregulation of appetite and an alteration in our physiology (including inflammation, blood flow, hormone function and energy use). Characteristic signs and symptoms include an increased body fat mass and symptoms related to the accumulation of adiposity (joint pain, immobility, sleep apnoea, and low self-esteem). It is also associated with an increased risk of approximately 236 other harmful conditions including type 2 diabetes, hypertension, cardiovascular disease, depression and certain types of cancers.² Studies show that obesity can reduce lifespan by up to eight years.³

A diagnosis of obesity is not defined by size or body mass index but instead by the presence of excess or atypical adiposity that impairs health.⁴ Not every person living in a bigger body will have obesity, but if there are functional, metabolic or psychological issues related to excess weight then we should consider a diagnosis.

Our risk of this chronic, progressive disease is genetically conferred, with studies showing a heritability of up to 70% in certain populations.⁵ It is a condition that is predominantly centred in the brain where, under normal circumstances, long-term energy balance is regulated. Each of us inherits a unique appetite system or “drive to eat” that evolved to protect us in a time when food was scarce - it resists weight loss and encourages weight regain. Our hypothalamus regulates hunger and fullness to maintain our weight (‘homeostatic eating’). Peripheral signals are received from adipose tissue, the pancreas and the gut about our energy stores and nutritional state via neural and endocrine pathways. Dopaminergic pathways in our mesolimbic system regulate our reaction to food (‘hedonic’ or reward-based eating).

The normal function of these subconscious areas can be disrupted by genetic, biological or environmental factors. Once disrupted, for example by dieting, this leads to a dysregulation of appetite (increased hunger hormones, reduction in fullness hormones)⁶ and hyperactivation of our reward system (increased craving/wanting and neurochemical response to calorie dense, hyper-palatable foods). 

Despite our ongoing efforts, these hormonal adaptions encourage our weight back up to its previous “set point”, the weight our hypothalamus considered normal before we started dieting.⁷ Unfortunately, once we return to our previous weight our appetite hormones do not return to baseline and we remain more driven towards food, often leading to further weight increase.⁶ The adaptions that protected humans when food was limited (I’m pretty sure our prehistoric ancestors were not into dieting) are now responsible for weight cycling with repeated weight loss followed by inevitable weight regain over time.

We cannot simply think ourselves less hungry or more full; this would be like trying to think ourselves warmer or colder. Long term, those of us with genetic risk and environmental activation consume more than our body requires and maintain a positive energy balance. It is not us overeating that causes obesity but rather the chronic disease of obesity that causes us to overeat. Many factors in our “obesogenic” environment further contribute to our risk of obesity: stress, lack of sleep, mental health, medications, physical inactivity, food insecurity, marketing and socioeconomic status to name a few. We live in an environment where food is not only cheap and plentiful but ultra-processed, ultra-portioned and calorie-dense.⁸

Understanding the pathophysiology of obesity

An understanding of the pathophysiology of obesity helps me understand why 80% of people who lose five per cent of their body weight, through diet/lifestyle modification, had regained it after five years.⁹ This is not personal failure, lack of discipline or motivation - in reality, our body and brain are doing exactly what they were designed to do. Thankfully, as our understanding of body weight regulation improves we are better armed to provide more effective and appropriate treatments to our patients who live with obesity. We can also confidently tell them that struggling with weight is not their fault and safe effective treatments exist to manage this chronic disease. 

Weight bias refers to negative attitudes and stereotypes about obesity and people living with obesity - judging a person’s values, skills, abilities, or personality based on their body weight or shape.¹⁰

People with obesity may be stereotyped as lazy, gluttonous and lacking in willpower - this is unfair and stigmatising! Experiencing weight bias can have negative consequences for individuals (shame/blame, internalised stigma, anxiety, depression, poor self-esteem or body dissatisfaction)¹¹ and can lead to unhealthy weight control practices. 

Weight bias from healthcare professionals can lead to an avoidance or delay in seeking medical care, reduced participation in screening programmes, reduced compliance with weight management strategies and overall worse health outcomes.¹² The pervasiveness and ingrained nature of weight stigma and discrimination is not only evident in healthcare but across education, workplaces and the media. Up to 88% of people living with obesity report that they have been stigmatised, criticised or abused as a direct result of their weight.¹³

Starting the conversation

Many practitioners find starting a conversation about weight challenging. As such, we may either avoid it or if we do bring it up we do so obliquely when discussing other medical issues. Obesity is not afforded the same time or resources in clinical practice as other non-communicable diseases.¹⁴

Studies have shown that the main reasons we avoid this topic are a fear of causing offence, a lack of confidence discussing weight and a perceived lack of time and resources.¹⁵ There may also be a belief that a person living with obesity is not motivated to lose weight.¹⁰ Some practitioners may be concerned about a lack of referral pathways or even have our own personal issues with weight.

We know that when the topic of excess weight is brought up sensitively and at an appropriate time that this is acceptable to our patients. The ACTION-IO study showed that 68% of people living with obesity wanted their HCP to start a conversation and only 3% reported that they would be offended.¹⁶

The single most important step in starting a conversation about weight is to ask permission.¹⁷ Unless the topic is introduced by our patient, we should always seek permission to discuss their weight. This puts our patient in control of the conversation and not only gives people the opportunity to raise concerns or ask for advice but also to say that they don’t want to talk about their weight at this time. We could say “Would you mind if I asked about weight?” or “Would it be OK for me to ask how you feel about your weight?” 

The words we use have great potential to help or even harm our patients. For many people, speaking about weight can be daunting; sharing personal details about their life, eating habits and body. It is vital that we use language that is free from judgement, negativity or euphemism. ‘Person First’ language should be used when talking to anyone with a chronic disease, including obesity. This is one way that we can address and eradicate weight bias in the healthcare setting. We should avoid labelling a person as their condition. We should talk about ‘a person with obesity’ rather than an ‘obese person’ in the same way that we would talk about a ‘person with cancer’ rather than a ‘cancer person’. We should talk about ‘severe obesity’ not ‘morbid obesity’ – I’ve never come across morbid asthma or morbid psoriasis.

We must never blame or shame someone for having a real medical condition. We must particularly try to avoid threatening people with long-term health consequences or giving out to them and patronising them about their weight. We must endeavour to look beyond weight and assess all possible causes for a person presenting with symptoms rather than immediately attributing every ailment to adiposity. It can be challenging to separate the concepts of health and weight. They are invariably linked but not every person living in a bigger body will have health issues as a result of their weight. It is not the cause of or solution to all the world’s problems.

When treating obesity it is important that we don’t just think about changes on a scales as our sole marker of success. Success for our patients may mean having more energy to be active with friends or family, reducing self blame and internal stigma, improving self-esteem, preventing further weight gain, improving sleep, blood pressure or blood glucose. We should focus on gaining health rather than just losing weight.

The 5As of Obesity Management is a tool developed by Obesity Canada specifically for use in primary care.¹⁷ It has been shown to increase comfort in starting a conversation, adopting a chronic disease approach and using person first language. In studies, it led to a two-fold increase in the initiation of obesity management.¹⁸ It encourages a shift in the patient-provider relationship from the provider as the expert to that of the collaborator.

We ask permission to discuss weight. We assess the root causes of obesity, severity and whether there are weight-related complications or comorbidities. We can advise about the benefits of weight management and evidence-based treatment options. We agree on expectations and a management plan. Finally, we can assist with educational resources, follow-up or even referral (soon to be made easier with the continued roll-out of the Model of Care for Obesity).

Above all, we must recognise obesity as a complex chronic disease and treat it the same way we treat other non-communicable diseases, without blame or shame, and using evidence based interventions (specifically, behavioural support, pharmacotherapy and bariatric surgery). 

In general practice we are experts in chronic disease management and I believe we are perfectly placed to support, treat and advocate for our patients living with obesity. 

Reference

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