Dispelling the Myths About Obesity

Akshay B. Jain, MD


September 21, 2018

As a long-time Medscape reader, I was surprised to see the results of a recent poll on Medscape titled "Is Obesity a Disease or a Choice?" When asked whether obesity is considered a disease, only 57% of respondents answered in the affirmative. More than one third of healthcare providers (HCPs) do not consider obesity to be a disease state, with the percentage of those answering "no" highest among primary care physicians.

As long as we as medical professionals do not take obesity seriously, we will be ineffective in dealing with its biopsychosocial and economic ramifications.

Eighty percent of respondents feel that obesity is always or often the result of poor lifestyle choices, and only 12% indicated that their obese patients always or often succeed at long-term weight management. Despite this, one third of the HCPs polled do not offer counseling to their obese patients and only about 30% of HCPs recommend surgery for help with weight loss. The percentage of HCPs recommending medications is even lower.

In the interest of definitively addressing a situation that is attaining pandemic proportions, it is high time that we recognize obesity as a disease. As long as we as medical professionals do not take obesity seriously, we will be ineffective in dealing with the subsequent biopsychosocial and economic ramifications of what arises in its aftermath. Calling out obesity as a disease is the first step toward objectively assessing the factors that lead to it and working toward its prevention and treatment.

What Makes Obesity a Disease?

Arguments for why obesity is a disease:

  • It is associated with impaired body function.

  • It results from dysfunction of a complex physiologic regulatory system, precipitated by multiple factors in modern society.

  • It causes, exacerbates, or accelerates more than 160 comorbid conditions that arise as metabolic, structural, inflammatory, degenerative, neoplastic, or psychological complications of obesity and significantly affect quality of life or impair longevity.

Some doctors argue that obesity is a risk factor for disease but not a disease itself. By that reasoning, however, such conditions as hypercholesterolemia or hypertension should not be classified as diseases.

Recognizing this, the American Medical Association classified obesity as a disease in 2013 after an overwhelming vote in favor of doing so. Multiple other national and international bodies followed suit by issuing statements in support of classifying obesity as a disease. Obesity is defined as a state of excessive fat accumulation that presents a risk to health. This takes into account the amount, distribution, and function of the adipose tissue.

The American Association of Clinical Endocrinologists has proposed rechristening obesity with the diagnostic term "adiposity-based chronic disease," for the purpose of recognizing the condition as an actual health threat and not merely an aesthetic issue.[1] The idea was to destigmatize weight issues and increase awareness about the health aspects of this condition.

Addressing the Elephant in the Room

Despite the recognition of obesity as a disease for more than 5 years now, we are still unable to address it with our patients. Weight challenges are seldom discussed during clinical visits, even though the treatment of complications arising from those very challenges are discussed in detail. Why are we unable to address the proverbial elephant in the room? I discussed this question with several colleagues, both in primary care as well as specialty.

One of the commonest responses I received is that doctors are not well-equipped to talk about weight management. The issue often takes a lot of time and requires breaking established boundaries—boundaries in the minds of patients who feel that they have "tried everything but nothing works" and are hence discouraged, and boundaries in the minds of HCPs who may think that weight issues are a sore point for the patient, that addressing it might take too much time, or that the effort-to-effect ratio may be unremarkable.

Many patients admit that they are afraid to bring up this topic with their doctors because they are almost certain to get a sermon on "eat less and exercise more" as the only way out of this condition.

It is because of this disconnect that patients often take to unverified and unreliable avenues for help with weight loss. One study[2] showed that more than 30% of adults who made a serious weight-loss attempt have tried weight-loss supplements. Many users and nonusers of dietary supplements believe that these are evaluated for safety and efficacy by the US Food and Drug Administration (FDA) before marketing, and that dietary supplements are safer than over-the-counter or prescription medications.

The makers of dietary supplements are responsible for ensuring the safety of their product and making honest claims about possible benefits, but their claims are not subject to FDA review or approval before marketing. Also, the types and quality of research used to support claims vary.

Lack of a structured medical approach to obesity has led to a thriving multimillion-dollar industry spawning all sorts of nonprescription products and supplements that claim to help with weight loss. The fact that growth rates of obesity across the globe continue to rise exponentially shows the weak effect these therapies are having.

Let's Dispel the Myths

To deal with obesity effectively, it is important to change some popular notions about this condition that exist even in the medical community. I read the 100+ comments on the Medscape poll to come up with the following list of the most popular myths that many HCPs harbor about obesity:

  • Obesity is a self-inflicted condition. Patients should know better than to eat uncontrollably and are solely responsible for this condition.

  • Weight management is a simple mathematical equation: weight = energy intake (food consumed) – energy output (exercise performed).

  • Obesity is the result of a lack of self-discipline due to addiction to excess or unhealthy foods.

  • Obesity is a problem found only in developed nations, where it exists because of exploitation by the food industry.

  • Dietary modifications are fads that are bound to fail and have no scientific backing.

  • Obesity started only in the past 30-50 years and didn't exist at all before then.

  • If patients are not losing weight with diet and exercise, it is because they are not trying hard enough or are cheating on their lifestyle modifications.

  • Bariatric surgery is an aesthetic procedure that purely works by reducing stomach size and is too risky, without any significant benefits to morbidity or mortality.

It has been well proven now that weight is not merely a mathematical equation but is associated with the crucial role of altered physiology. Obesity is not just limited to developed nations, either. India is among the top five nations with the highest number of people with obesity, and percentage population with obesity is highest in countries in the Pacific Islands and the Middle East.

Obesity is a centuries-old condition whose incidence has increased significantly in the recent past. Lifestyle modifications have an increasingly robust representation in evidence-based medicine. However, given the complex and multifactorial nature of obesity, management can fail despite earnest efforts by patients and is often successfully augmented by the addition of pharmacotherapy or surgery.

Bariatric surgery is gaining widespread recognition for its effects on hormonal pathways and ability to successfully prevent worsening of and even reverse many of the complications of obesity and its comorbid conditions.

Treatment Must Be Individualized

It is important to realize that for many patients, obesity is multifactorial. There is a wide heterogeneity in the causes and manifestation of obesity, which leads to wide interpatient variability in the response to different therapeutic strategies. It is for this precise reason that management of obesity needs to be individualized for each patient.

It is with this notion that moving forward, we must understand that obesity is a multifactorial disease. We need to accept that it is not merely a condition arising from "food addiction." In fact, more than 100 etiologies of obesity have been identified, and we've merely scratched the surface at recognizing the causal factors.

In addition to underlying medical conditions (eg, genetic, endocrine), macroenvironmental influencers (eg, 24-hour lifestyle, economic structure, global stressors), and microenvironmental influencers (eg, eating schedules, physical activity, sleep health, drugs) lead to the manifestation of obesity. The ultimate consequence is failure of the homeostasis of weight and energy regulatory mechanisms, leading to an elevated body fat set-point. Only when we recognize that obesity is a disease can we take the next steps of screening, diagnosing, assessing, preventing, and treating this condition.


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