How we view obesity has to change

Obesity as a disease: a milestone decision

A little under five years ago, in June 2013, the American Medical Association (AMA) took an historic step in recognising obesity as a “disease requiring a range of medical interventions to advance obesity treatment and prevention”.

It was a momentous decision. Until then, the medical community had treated obesity largely as a matter of personal failing that could only be overcome through lifestyle interventions. The formula was simple: obesity was an unfortunate but inevitable consequence of an imbalance between food intake and calories burned. In even simpler terms, obesity was the result of either eating too much or exercising too little (or both combined). When looked at through this lens, it was all too easy for society, for doctors, and for people with obesity themselves to see people with obesity as either gluttons or sloths (or both). The language of obesity was essentially the language of sin and of personal failure. It was a conception of obesity that led to shame and cycles of destructive behaviour which would inevitably lead to negative health outcomes.

The decision taken by the AMA didn’t overturn the biological fact of calories in versus calories out but what it did do was recognise the complexity that underpinned why some people are unable to manage intake versus usage. It recognised the subtle interplay between the calorific formula and a myriad of other factors, including genetic, physiological, psychological, sociological, economic and cultural. It offered hope to millions of people with obesity  and their doctors that a treatment paradigm shift might be on its way that would allow them to break patterns of behaviour which left them not only with obesity but also susceptible to a wide range of other health conditions.

Taking stock five years on…

As we approach the fifth anniversary of that decision, it is time to take stock of how far (or sometimes how little) we have travelled in our understanding of obesity and its treatment. I should be clear from the outset that my interest in this debate goes beyond the academic. The company which I represent, Novo Nordisk, has laid out its stall when it comes to obesity. We believe that there are molecular interventions that may, together with diet and exercise, improve the lives of people with obesity and have products either on the market or in our pipeline focusing on obesity and weight related comorbidities.

That said, this is a debate that transcends a narrow focus on treatment interventions. The World Health Organisation (WHO) has estimated that there are currently 1.9 billion people in the world who are overweight. Of these, they estimate there are 650 million people who live with obesity. These are truly staggering figures already but the picture becomes even more worrying when we delve into the data. If you look at the map below, drawn up by the World Obesity Federation (WOF), you will see that this is a global phenomenon and one that is not only confined to the developed world.

Credit: World Obesity Federation

And when we look at the ages of those with obesity, we can see that this is not just a problem for today but very much a problem for tomorrow as well. The WHO estimated last year that 41 million children under the age of 5 were overweight or obese in 2016.

They also estimated that over 340 million children and adolescents aged 5-19 were overweight or obese in 2016. The oncoming tide of obesity is turning into a tsunami and it is clear that we, as a society, are not doing enough.

Treatment has not caught up with the view of obesity as a disease

Let’s return then to the AMA decision of 2013 because that remains a milestone and an important starting point in recognising obesity as a disease. The rationale for the AMA decision was clear – regardless of the causes (although I will return to those in a moment because they are important), obesity constitutes a public health crisis particularly given prevalence. Obesity is associated with a decreased life expectancy and is the fifth leading cause of global deaths. It is associated with multiple complications, including type 2 diabetes, cardiovascular disease, hypertension, dyslipidaemia, chronic kidney disease, non-alcoholic fatty liver disease, sleep apnoea and certain types of cancers. Obesity is also associated with impaired physical functioning and impaired health-related quality of life.

Despite these sobering facts, there is plenty of evidence to suggest that obesity is still not viewed in the same way as other diseases, either by society, by doctors or by people with obesity themselves. Let me do a thought experiment to work you through that statement. We all now recognise smoking to have significant negative health consequences and we often castigate those who take the decision to smoke. Yet we would never make a claim that the consequence of that smoking, say lung cancer, was not a disease because of the causative factors. It is clear to me from conversations and simply looking at society that the same cannot be said of obesity. To deepen that thought experiment, even though smoking has an addictive element to it, the decision to smoke is a binary one: smoke or don’t smoke. With obesity, the causative factors are so complex, so entrenched in behavioural and societal patterns which are often unavoidable or unconscious, that the position on obesity seems absurd in comparison to how we view cancers or other non-communicable diseases. This is compounded by increasing evidence that for many people with obesity, underlying genetic factors make it significantly harder to balance calorific intake and burn and that the resultant health impacts really are not a choice that so many in society still believe makes them morally culpable for their condition.

The disconnect between the (still too esoteric) view of obesity as a disease and its real-world treatment can be seen in research on how the doctor/patient conversation happens around obesity. Many people with obesity lack support in their efforts to lose weight and the disease remains substantially under-diagnosed and under-treated.  The sheer cost of that failure to support people with obesity (beyond the clear human cost of the complications) is difficult to calculate but one estimate holds the number at $1.2 trillion per year by 2025. Given the high prevalence of childhood obesity, the costs will inevitably becoming more difficult to reduce if changes are not made soon.

Credit: World Obesity Federation

It would be unfair, however, to place the blame for this on doctors. Governments around the world have taken remarkable strides in developing public health campaigns around obesity but far too few have backed this up with meaningful treatment guidelines, reimbursement policies and national obesity frameworks. It is these kinds of policy reforms that would improve the patient-doctor conversations such that they initiate discussions and advice regarding weight loss that can help encourage patients to change their behaviour. Quite simply, many doctors do not have a full range of treatment alternatives and access to multidisciplinary networks that might help find the root of each patient’s own unique circumstances. How this might change is certainly a debate that needs to widen and I am very happy to engage in the comments section below with anyone who has views on how that might happen (or, of course, those that believe it should not happen for whatever reason). What I will posit is this: just as people with cancer can visit an oncologist or people with heart disease can see a cardiologist, the time should be near when a person with obesity can find specialists who view the disease holistically and who have access to solutions, which can truly reduce obesity.

Changing perceptions as a starting point

The WHO has said that, “curbing the global obesity epidemic requires a population-based, multi-sectoral, multi-disciplinary and culturally relevant approach.” I’ve alluded to a few of those factors above, in particular to the need for a more multi-disciplinary approach. I represent one of the sectors that will be part of any multi-sectoral solution but this will be in tandem with numerous other sectors, not least those who deal in nutrition and health. And clearly, we as individuals and parents have a role in educating ourselves and our kids to eat responsibly and get into good habits whatever our age but particularly in early years.

What really interests me about the phrase above from the WHO, though, is the mention of culture. Our doctors, our governments, we as people and as parents, are all part of a culture that works against viewing obesity as a disease. Too many children with obesity detest the thought of going to school because of fear of body-shaming and bullying from their peers. There are words that we use about people with obesity that have no corresponding comparative in other disease areas. No-one would think of mocking a person with diabetes, cancer or heart disease but there are those who abuse and belittle people with obesity in ways that can have far-ranging and counterproductive psychological impacts.

Perception is important. Even as our sector works to provide medical solutions to deal with obesity and healthy eating becomes an ever-present trend around the world, even as governments look to public health solutions and doctors discuss obesity as a disease, the perception shift that should have come five years ago has not, in my view, yet happened. I think we all owe it to the 650 million with obesity in the world, undoubtedly many of whom are in our families, are our friends, are perhaps ourselves, to change our perception together.

A first step might be to check our language. Second and third steps will not be far behind once we appreciate what we are discussing, who we are discussing and how we are discussing them. Until we regard obesity as we would any other disease, at least in our perception, we will never find solutions which can meaningfully impact what is clearly a crisis of public health and a major health problem for individuals and families around the globe.

References

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