As major contributors to poor health outcomes, overweight and obesity plague the modern world. Obesity increases the risk for common illnesses. These include type 2 diabetes, hypertension, degenerative joint disease, sleep apnea, and cancer. It is also linked to other diseases. People with obesity face stigma. This is largely due to the erroneous belief that obesity is mainly caused by personal unhealthy behavior.
Fortunately, advances in our understanding of the pathophysiology of obesity are helping to counter some of that stigma. These advances are also ushering in novel pharmacologic, surgical, and behavioural interventions.
A COMPLEX CONDITION
Firstly, obesity is a complex condition resulting primarily from an interaction of genes and the environment. It is heritable, so persons who have family members with overweight or obesity are at greater risk for it themselves. For such persons, preventive interventions are important.
As with many chronic diseases, obesity can progress, and extra or different treatment strategies be needed over time.
Second, effective obesity care demands a multidisciplinary approach. Care should be tailored to individual patients. It need involvement of primary care physicians, medical subspecialists, and surgeons. Dietitians and behavioural and psychiatric health professionals also need to be involved.
The intensity of early treatment should be guided by the severity of obesity and the presence of comorbidities. Given the prevalence of obesity, all disciplines should devote more attention to preventing it. They should also focus on managing it in clinical education and training. This focus should be greater than is presently the case.
Third, patients with overweight and obesity suffer from stigma. Physicians and other clinicians must approach discussions of healthy body size with patients without judgment. They must avoid blaming and shaming patients. It is vital not to immediately assume that a patient’s symptoms are due to their weight. Consider other possible causes thoughtfully.
STIGMA
Because of stigma, patients may avoid seeking care altogether. They put them at risk for suboptimal management of not only obesity but also associated comorbidities. While dealing obesity with patients, we need to recognize its complex pathophysiology rather than using language that implies that obesity is a condition that patients bring on themselves.
Fourth, we need better measures of overweight and obesity. Body mass index (BMI) is now used to signal suboptimal body size. It also determines eligibility and health care coverage for various treatments. Unfortunately, BMI is an imperfect measure of body composition that differs with ethnicity, sex, body frame, and muscle mass.
Fifth, modification of diet and exercise alone is unlikely to result in long-term benefit. Fewer than 50% of patients who participate in evidence-based, intensive, multicomponent lifestyle interventions lose 5% or more of body weight. Clinicians must recognize that the most effective diet is one that a patient can sustain while limiting calories.
As effective pharmacologic and surgical therapies advance, lifestyle modification should be seen as a crucial element. It is one component among multiple interventions. It is also essential in preventing overweight and obesity.
Finally, choosing the best treatment strategy should involve shared decision making between patients and their clinicians. Patients should receive information about the anticipated benefits and harms of all options—pharmacologic, surgical, and behavioural—for which they are eligible.
Pharmacologic therapies are rapidly expanding and include bupropion–naltrexone, orlistat, phentermine– topiramate, liraglutide, and semaglutide.
Surgical options include sleeve gastrectomy, gastric bypass, and an increasing array of less invasive endoscopic procedures.
We are entering an age of increasingly effective therapeutic options for treating overweight and obesity — better understanding of the pathophysiology of this complex condition will not only enable the development of new preventive and therapeutic strategies but will also help alleviate weight stigma and bias.
(Dr Naresh Purohit is Executive Member of the Indian Academy For Preventive Health. The views expressed here are of the author)