What is Obesity?
Today, the answer to the question “what is obesity” is different than it was 20 years ago. It has taken us a long time to recognize the direct health impact of obesity.
That is not to say that the connection between weight and illness is anything new. In fact, it dates as far back as ancient Greek and Roman times. But traditionally, obesity has been viewed as a stepping-stone to illness rather than the direct cause of illness itself.
We now have proof that stored body fat behaves like other organ systems in the body, releasing hormones and other bioactive substances that can worsen our health when we have too much of it.
In 2013, the American Medical Association officially named obesity a disease based on research and evidence. Clinicians nationwide began the process of trying to find evidenced based ways to help patients lose weight. (It was harder than anyone thought!)
Obesity and BMI
So, what is obesity? Obesity occurs when the amount of body fat is sufficient to directly worsen your health. How much is that? Healthcare providers use a calculation known as body mass index, or BMI. The BMI data from studies of large populations showed us that health worsens with higher weight and can shorten our life expectancy.
A BMI is a calculation of weight and height only. A BMI of 30 or higher is considered obese. However, it does not consider where fat is located or even how much fat you have, both of which are important when it comes to health. Biometric scales that accurately give more information are currently too expensive for everyday clinical use.
What causes obesity?
Before discussing obesity further, it is worth pointing out that like any disease, no one intends to get obese. There is a lot of blame thrown around for having an unhealthy amount of body fat. But when you start life with a normal body weight and become slightly overweight, you cannot imagine that your weight will keep climbing into obesity range.
Often a health issue is the first time someone realizes their weight has climbed too high. For others, weight has been something they have battled for years, having felt the social pressure to be thin. They have tried to avoid obesity at all costs and still ended up with it.
When we think “what is obesity?” we also must understand what causes it. Obesity is a combination of genetic susceptibility (inherited from your parents) and lifestyle factors.
Many of us have genes that make it quite easy for us to gain weight. When we see members of our family with obesity it is a clue that we are likely to also gain weight easily.
Not everyone has the same genetic tendency and family history. This can lead to misplaced judgements about lifestyle. Because of a focus on appearance, most of society tends to blame someone who has obesity for not trying hard enough or failing to control their weight. People with a normal body weight are let off the hook or even envied if they are not eating a healthy diet or exercising. You cannot consider yourself the judge of someone’s lifestyle without first knowing their genes!
How to manage obesity
Because we all eat, everyone has an opinion on this. Many (mistakenly!) believe that this is an easy problem to solve. They tell us, “Energy in versus energy out!” or “Eat less, exercise more!” These approaches work well for preventing weight gain or keeping us at the lower end of our own natural weight range. Unfortunately, it is not effective for those needing significant weight loss.
Once we gain a certain amount of extra body fat, our body “re-programs” us at a higher weight range and actually wants to keep us there, even if it is bad for our health.
Try as we might, for example starting a new diet or exercise class, we cannot reclaim our old weight or reach a new fantasy weight. Why is that? One reason is that leptin, our own natural weight loss hormone, no longer works properly in patients with obesity. This is an intense area of research. Until we can prevent this "leptin resistance,” or reverse it, we need to manage obesity as a chronic disease.
We need to recognize that there is no specific nutrition, exercise, medication, or surgical procedure that can take away our excess body fat for it never to return. We need long term obesity treatment.
To manage obesity, we look at all potential benefits of treatment choices. We reject short term diets and focus on a sustainable lifestyle that prevents weight gain along with small losses over time. We encourage the use of FDA approved obesity medications and metabolic surgery for whom the health benefits are clear.
For the patient with obesity, a combination of some or all these measures can lead to substantial improvements not only in health but also quality of life.
What is obesity medicine?
Obesity medicine is the field of medicine that aims to improve the health of patients with obesity. It covers a broad range of topics such as nutrition, psychology, exercise, medications, and when to consider bariatric surgery, as well as the diagnosis and management of obesity-related conditions.
Physicians specializing in this area need a subspecialty board examination and ongoing education to maintain certification. To stay up to date, practitioners read peer reviewed published obesity journals and attend conferences.
When should someone see an obesity medicine physician?
Anyone with obesity who is concerned about their current or future health should consider seeing an obesity specialist. Rather than making it a last resort, seeing a specialist early can prevent common lifestyle mistakes and allow patients to better understand obesity. Early intervention can prevent obesity from worsening and improve health.
Are prescription weight loss pills the focus of obesity medicine?
Lifestyle behaviors and obesity medications work together, each helping the other, in a biological way.
For example, consider two scenarios. In the first, we prescribe you a highly effective FDA approved obesity medication that works by increasing your sensation of fullness. We do not spend much time telling you about how this medication works, instead we say, “Keep up your diet and exercise efforts, take this, and you will lose weight.”
But maybe you are doing Weight Watchers and never think about fullness, you only think about points! By only focusing on points, you are missing out on how this medication is helping you.
Let’s now consider a second scenario. This time, we spend time explaining to you how the medication works, and we ask you to check in when you are eating a meal and think about how full you feel. Now you are in synch with the medication and more likely to find success.
Patients who are attuned to how they feel in terms of hunger, fullness, and even mood will respond better to obesity medications than those who do not. Most medications work to alter behavior, so having self-awareness or mindfulness gives you the best chance of a good response.
For this reason, in our practice we teach patients a mindfulness approach to eating so that we can tailor medications and behaviors together to find the most effective and sustainable path forward.
What medications are available to help patients with obesity lose weight?
There are several medications to consider for weight loss, such as Phentermine with Topiramate, Bupropion with Naltrexone, and Liraglutide, or Semaglutide. Each works in different ways.
Many factors go into choosing the right medication for each individual patient. We must consider things such as contraindications, potential side effects, and possible medication interactions.
Unfortunately, the most frustrating factor that comes into decision making is the lack of insurance coverage for weight loss medications, especially the most effective and metabolically advantageous ones.
The future of obesity medicine
I hope for broader recognition that diet and exercise alone will not solve the obesity problem. I hope that a better understanding of the cause of obesity will lessen the bias and prejudice against those with obesity in our society. I look forward to an open-minded approach to treatment for this disease that makes effective medications not seem like a lifestyle failure but a proactive approach towards better health.
For individuals with obesity, lifestyle modifications and FDA-approved obesity medications are recommended. This combination has proven benefits in reducing diabetes, high blood pressure, fatty liver, and sleep apnea. With earlier interventions, we can prevent severe disease.
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