Obesity and the Bitter Pill of Truth

Akshay B. Jain, MD


September 23, 2020

About 2 years ago, I wrote my first commentary for Medscape on obesity, a topic that is both close to my heart and something we encounter ubiquitously in clinical practice. I was thrilled to see hundreds of responses pouring in.

But the excitement quickly faded as I started reading through the comments.

"Making [obesity] a disease only gives cover to the obvious and excuses the obese individuals from owning up to their responsibilities in modifying their behavior."

"Please don't medicalize everything. Only you decide what and how much to shove down your throat."

"Eat too much, don't exercise, and most people will get fat."

"Get off the video games and TV, online streaming, etc., and take care of your priorities, for god's sake."

And the worst: "Would someone please show me a picture of an obese POW or obese person in a concentration camp?"

Judging from these comments, you'd think that treating obesity is simple, that the patient simply needs to make some quick and easy modifications to their behavior.

Interestingly, the results of a Medscape survey showed that HCPs are seeing an average of 60-70 patients with obesity/overweight every month, and that these HCPs are recommending dietary modification for about 85% of patients. And guess what? Rates of obesity are still rising.

Take a moment to think about that. Can you think of any other medical condition where 85% of those afflicted are unable to adhere to physician recommendations? Is there any medical condition where 85% of those afflicted are unmotivated to improve their health? Would 85% of those with myocardial infarction refuse to go for cardiac rehabilitation, or 85% of those with COPD continue to smoke?

So, what makes obesity so different? Could it be that 85% of patients with obesity don't all suffer from gluttony, laziness, or a pervasive lack of willpower? Perhaps the underlying, bitter truth is that we are doing a shoddy job of identifying the real causes of obesity and keeping up with evidence-based medicine.

Let's take a look at the reader comments and see what the evidence says.

"It's an addiction to food and/or a lack of willpower."

The majority of people who commented on my first piece stated in some form that people with obesity have an addiction to food and that the blame lies completely with them.

The term "addiction" not only has strong, negative social connotations but also has precise medical definitions that cannot be used loosely. Although some models suggest similarities between substance use disorder and chronic consumption of energy-dense foods causing changes in the brain's reward pathway, the use of food addiction as a diagnostic category is premature.

The model rests on the central assertion that some categories of foods or specific nutrients exert a direct effect on the brain, enacting changes that ultimately hijack reward-related behaviors. However, central features of substance addiction do not plausibly translate to food and consumption. The validity of measures such as the Yale Food Addiction Scale has come under question with arguments that warrant classification of obesity as a distinctive disease phenotype rather than an expression of strong habits and preferences. "Food addiction" as a concept needs to be considered as a distinct entity from obesity, as conditions such as bulimia nervosa that meet the criteria of hedonic dependence on food do not necessarily translate into obesity.

"Weight loss medications are not effective."

What is the definition of efficacy? Effective control of diabetes is achieved when an individual's A1c is < 7.0%. Effective control of blood pressure is when blood pressure is at target. Depending on the starting point, a single medication may not be enough to bring a patient to the glycemic or blood pressure target. Often, we require multiple medications in addition to lifestyle modifications in order to achieve these targets. Why is it, then, that we expect a weight loss of 50-80 lb with a single medication for patients with obesity?

We treat diabetes and hypertension to goals that are not in the normal range for blood sugars or blood pressure, but rather to a level that mitigates the occurrence of complications arising from these conditions. So why are we so fixated on weight loss targets that involve a specific number on the scale or an ideal body weight rather than the recommended 5%-10% weight loss recommended by guidelines?

Unrealistic expectations or being dismissive of the weight loss achieved can dangerously undermine its benefits. Patients already often expect weight loss that is two to three times greater than what can realistically be achieved. Clinicians must help patients accept more modest weight loss outcomes. This highlights the need for personalized care that considers the patient's specific profile.

It's time to move away from an ideal body weight target and toward a healthy body weight concept to avoid disappointment and premature discontinuation of medications when they have actually worked but not to the degree that was expected.

"They just eat too much."

No one would choose to be unhealthy. We might think we are doing our part by counseling patients on lifestyle modification, but it needs to be much, much more than a cursory, patronizing "Eat less and move more."

A study evaluating audio recordings of 40 primary care physicians counseling 461 of their patients with obesity/overweight found that only 13% of patients received counseling that went beyond "eat less and move more." Only 5% of patients were encouraged to book a follow-up visit to discuss results. When pushed into a corner, it's easy for clinicians to turn the blame on patients and say that they are the ones at fault. We need to do more than this for our patients with obesity.

"If they would only follow this particular diet…"

Multiple comments reflected all types of macronutrient-based approaches, meal replacement strategies, dietary patterns (eg, Nordic, Ornish, vegetarian, low glycemic index, etc.), intermittent fasting, and intensive lifestyle intervention techniques. All of these approaches produce the caloric deficit required to initiate weight loss, but sustaining the loss may be difficult over the long term because of compensatory mechanisms that promote positive calorie intake by increasing hunger and the drive to eat.

To date, no single nutrition intervention has been shown to best sustain long-term weight loss, and literature continues to support the importance of long-term adherence, regardless of the intervention. In fact, according to the US Preventive Services Task Force, it is not the diet itself but the support and attention patients receive while on it that make it effective. Individualized nutrition consultation by a registered dietitian has been shown to result in greater weight loss compared with usual care or written documentation, highlighting the role of individualized dietary plans performed in a multidisciplinary setting as one of the best ways to administer medical nutrition therapy for those seeking weight loss.

Outlier Statements

I sincerely hope that the few statements about the lack of obesity in WWII concentration camps do not reflect our community as a whole. Surely, we are not purporting that human beings undergo abject starvation and the associated mental trauma just for the sake of losing weight, are we?

Weight loss is not just a number on the scale, and those losing weight due to starvation experience not only the loss of adipose tissue but also significant multicomponent malnutrition and sarcopenia, not to mention the biopsychosocial ramifications.

As medical professionals, we pride ourselves in providing the best care for our patients. We would never treat a patient with a heart attack on the basis of our personal beliefs, so why do we do so for our patients with obesity? We need to have a structured, multidisciplinary, evidence-based approach that acknowledges the far-reaching effects of obesity, tackles the issue bereft of all bias and stigma, and encourages healthy and realistic goals, conceding that there may be triumphs and disappointments along the way, as with any chronic condition. Blaming patients will lead to little benefit.

I'd like to end with what was perhaps my favorite comment that the article received:

"People often reserve their harshest judgments for those conditions about which least is known."

Akshay B. Jain, MD, is a clinical endocrinologist who has practiced in three countries, focusing on mitigating the complications of diabetes and obesity. He is fluent in six languages and has spoken at more than 500 programs internationally.

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