Disease in disguise
As obesity reaches epidemic levels globally, experts are reflecting on the mixed results of policies implemented over the past decade and asking if obesity should be treated as a disease more than as a lifestyle choice that individuals can modify
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The world is getting heavier, with obesity spreading at an alarming rate across the globe. Worldwide incidence of obesity tripled between 1975 and 2016. According to the World Health Organization (WHO) most people on the planet live in countries where they are more likely to die because they are overweight and obese, than because they do not have enough to eat.
“Obesity is a gateway disease for other chronic conditions,” says Ximena Ramos-Salas, policy and research officer for the European Association for the Study of Obesity (EASO). “It’s increasing all over the world, not just in rich nations. To keep ignoring it will just increase the burden on health care services and society generally.”
The WHO recognised obesity as a disease in its own right (as a nutritional disease) as far back as 1948, but so far only a handful of governments have officially acknowledged the categorisation. Portugal recognised obesity as a disease back in 2004 and Italy in November 2019. Others to do so include Sweden and Turkey.
“The scientific evidence is pretty clear that the increase in obesity is as a result of an obesogenic environment,” says Simon Capewell, professor of epidemiology at Liverpool university in the UK and a member of the steering group of the Obesity Health Alliance, a UK umbrella group for health professional groups and charities that campaigns for prevention and better treatment of obesity.
“Three decades ago, obesity was a rarity. There were not many doctors who specialised in it. Our genes have not changed since then, but what has changed is that the world around us is now full of calories,” Capewell says. Children now swim through a torrent of messages, exhorting them to consume sweet things from the moment they wake up and turn on the TV, tablet or smartphone, he notes. Outside, as well, they are regularly confronted by shops advertising two-for-one offers on cheap sugary drinks and food, he adds.
“Pointing the finger at overweight people and saying it is now the norm to be completely immune to these clever marketing messages is to blame the victim,” Capewell says. “We absolutely reject the idea that obesity is a lifestyle choice.”
John Wass, professor of endocrinology at Oxford university and another member of the same UK group points out that genes, as well as environment, can also play an important role. “Weight is influenced by genes at both ends of the spectrum, it isn’t the whole story, but forty to seventy per cent of a person’s weight is determined by genetics,” he says. “If you talk to obese people, they believe they have something wrong with them and certainly do not feel they chose to be like they are. Obesity is definitely a disease and this approach is now gaining much wider acceptance.”
“The main advantage of recognising obesity as a disease is that it will go up the political agenda and we can de-stigmatise it because people should feel less guilty about their weight, it being largely genetic,” he adds.
Stigma Obesity is still viewed as something that is self-inflicted
The argument for self-help
Not everyone agrees that classifying obesity as a disease is helpful, least of all some governments which fear treatment of it will be a further drain on resources. Richard Pile, a medical general practitioner (GP) with a special interest in lifestyle medicine who practises in Hertfordshire, UK, has argued in the British Medical Journal that self-determination is vital when it comes to individuals taking control of their lives and making the best decisions for themselves.
“Labelling obesity as a disease risks reducing autonomy, disempowering and robbing people of the intrinsic motivation that is such an important enabler of change,” Pile says. “It encourages fatalism, promoting the fallacy that genetics are destiny. I don’t need to quote randomised controlled trials and systematic reviews here because I have seen it the mindset of patients every day for almost twenty years in general practice,” he adds.
“There is an important difference psychologically between having a risk factor that you have some responsibility for and control over and having a disease that someone else is responsible for treating,” Pile continues. Making obesity a disease may not benefit patients, he observes, but would benefit healthcare providers and the pharmaceutical industry when health insurance and clinical guidelines promote treatment with drugs and surgery.
Roy Taylor, professor of medicine and endocrinology at the UK’s Newcastle university, argues that obese people have acquired a physical state, characterised by a measurable property of the body such as height, waist circumference, weight or body mass index (BMI), rather than a disease state, which suggests a requirement for medical attention. “We should avoid medicalising obesity and prevent the physical state happening. Labelling people as having a disease could make things far worse, as it could be seen as self-inflicted and risk more stigma,” he warns.
Ten years ago, the WHO recommended countries take action to control marketing of high fat, sugar and salt foods to children. In 2018, it reported back that steps had been taken by around half of the 53 countries in the WHO defined European region.
Mexico was the first country in the world to bring in a sugar tax in 2014, when it added a one peso per litre excise tax on any non-alcoholic beverage with added sugar, a 10% price increase for the consumer. A 2017 study following the introduction of the tax, “In Mexico, Evidence of Sustained Consumer Response Two Years After Implementing A Sugar-Sweetened Beverage Tax,” showed a 7.6% reduction in sales of sugary drinks. The fall was even bigger in poorer households, where it dropped by 11.7% .
Portugal introduced a soft drinks levy in 2017. Francisco Goiana Silva, at the time a member of government and a health ministry lawmaker, told the WHO the policy intervention was estimated to have had a far greater impact on the population’s diet than all the education and self-regulation mechanisms combined. A study by Imperial College London published in March 2020 found consumption of sugar sweetened beverages fell by 6.6 million litres a year in Portugal after the tax was introduced.
Many other countries and regions have introduced their own versions of a sugar tax, including Spain’s Catalonia, South Africa, some US states, Hungary, Brunei, Thailand, and the UK. “Some countries, such as Iceland, Finland, Cuba and Canada, have already been much firmer with controlling junk food advertising targeted at children, which makes total sense,” Capewell says. “If advertising and marketing doesn’t work, why is the food industry spending so much money on it?”
Doctors can help
Good evidence is emerging that obesity treatments do work. An Obesity Society study from February 2020, showed that combining intensive behavioural therapy with an appetite suppressant drug can produce clinically meaningful weight loss.
In the UK, now officially the most overweight nation in Europe, doctors say they are “drowning” in illnesses connected to obesity, with 876,000 obesity-related hospital admissions in England in 2018/19. During the same year, 67% of men and 60% of women were categorised as overweight or obese, according to “Statistics on Obesity, Physical Activity and Diet, 2020,” published by the National Health Service.
Newcastle University’s Taylor has shown in the DIRECT Trial how putting patients with type 2 diabetes (and a BMI of no more than 34) on a very low calorie liquid diet of 700 calories a day for eight weeks, plus carbohydrate-free vegetables, can not only put their diabetes in remission, but lead to weight loss of around 15 kg on average.
“We then stop to offer psychological support to help patients maintain their weight,” Taylor explains. “The success of the diet was in its simplicity; a lot of the current public health advice is confusing and not that useful. One particularly important point is that people are often told to exercise more and eat less. But this takes no account of the characteristics of the people typically involved.”
Taylor notes that those who are starting an exercise programme often engage in unconscious compensatory eating and this is especially so far those who are overweight. “The simple fact is that most people with type 2 diabetes cannot do both of these at the same time—if they are older or overweight, with joint problems, for instance. Increased activity can be phased in once the weight has been reduced by restricting food intake,” he adds. “Trying to do both at the same time is counterproductive. The role of energy expenditure is relatively small in the process of losing weight; public health advice needs to be focused very much on food.”
Taylor’s very low-calorie diet is now being evaluated by the UK National Health Service (NHS) as part of a pilot exercise for achieving remission of type 2 diabetes that was about to launch before the coronavirus crisis. “If I was in charge of the NHS, I’d be looking at how this diet could be offered to a wider range of patients,” he says. “Britain is suffering from a gross excess of fatty liver disease, for instance, and premature coronary heart disease—all diseases associated with obesity.”
In New Zealand, researchers at the University of Otago published research in 2019 evaluating different types of weight loss diets and found that the Mediterranean Diet, intermittent fasting (IF) and Paleo diets each had health benefits, although adherence to the diet dropped off over 12 months. Intermittent fasting, where dieters limit their calorie intake to 25% of normal for two days a week—around 500 calories a day for women and 600 for men, led to slightly more weight loss than other diets (4 kg on average compared to 2.8 kg for intermittent fasting and 1.8 kg for Paleo). IF and Mediterranean diets were also found to reduce blood pressure and the latter also improved blood sugar levels.
David Unwin, a British GP in the northern town of Southport, is also using an approach developed to put type 2 diabetes in remission, to tackle obesity and other obesity-related diseases. “When I was a young doctor, I never saw anyone under the age of 55 with type 2 diabetes, but now the patients are much younger, including one who is just ten years old,” he says. “This is why I am upset and why doctors all over the world are saying wake up.”
Unwin has run a Low Carb Programme for his patients, offering dietary advice about following a low carbohydrate diet, as well as support groups and regular check-ups, plus psychological support with food addiction provided by his psychologist wife, Jen.
So far, the couple have data from 297 patients on a low carb approach for 25 months, he says. The average starting weight was 98 kg and the finishing weight 87 kg; 153 of them had type 2 diabetes, 76 had prediabetes and 68 had some form of metabolic disease. Of those 153 with diabetes, 70 managed to put their type 2 diabetes in remission, reports Unwin.
Pile, the UK local doctor in Hertfordshire, has also launched a local initiative to help his overweight patients shed some kilograms. He runs group sessions called ”cardiac prehab” where people who are at risk of conditions such as heart disease and diabetes join him for well-being talks and also hear from experts on smoking cessation, exercise on referral, and weight management. Patients draw up their own wellbeing plan for Pile to follow up on with them at three to six months. The programme has led to consistent improvements in weight, blood pressure, cholesterol and reports of physical and mental wellbeing he says. Its now operates in 56 practices covering 620,000 people in Hertfordshire.
Making obesity a disease may benefit the health industry but not help patients
Removing the stigma
Viewing obesity in a similar way to cancer or heart disease without attaching blame (consciously or unconsciously) seems to be the key to improving treatment of obesity. Ramos-Salas of the European study group EASO argues that obesity must be destigmatised and that means treating it as a disease. “We don’t have a cure for obesity, but we do have evidence-based treatments including drugs, behavioural change techniques and bariatric surgery,” she says. “But few people are offered these as obesity is still viewed as something that is self-inflicted and not something the taxpayers’ money should be spent on or offered under private medical insurance.”
“There is still so much stigma about being obese and this has to change—we need action from policy makers at government level, but also from health care professionals in primary care who are ideally placed to help with preventing weight gain and also to offer treatments.”
TEXT By Jo Waters — ILLUSTRATION Clara Selina Bach