A Clinician’s Guide to Discussing Obesity with Patients

© Springer Nature Switzerland AG 2021

S. ChristensenA Clinician’s Guide to Discussing Obesity with Patientshttps://doi.org/10.1007/978-3-030-69311-4_1

1. Recognizing Obesity as a Disease

Sandra Christensen¹  

(1)

Integrative Medical Weight Management, Seattle, WA, USA

Sandra Christensen

Email: [email protected]

Keywords

ObesityAdiposityChronic diseaseBariatric surgeryAnti-obesity medications

1.1 Introduction

Obesity is a global health concern that affects over 650 million adults worldwide. With another 1.6 billion who have pre-obesity/overweight, nearly one-third of the world’s population is an unhealthy weight [1]. Obesity is the most common chronic disease in the United States with 42.4% of adults [2] and 18.5% of children under the age of 18 [3] living with the disease. An additional 33% adults are classified as having pre-obesity/overweight [3], which means that over 75% of U.S. adults are an unhealthy weight. Given that obesity leads to serious health conditions and shortens lifespan, it is imperative that clinicians in every clinical setting discuss and address it with their patients. But before clinicians can initiate productive discussions about obesity, they need a clear understanding of obesity—its causes, pathophysiology, diagnosis, and treatment—and how it affects the health of their patients.

1.2 Obesity Is a Disease

The first official recognition that obesity is a disease came from the World Health Organization in 1997 when it published Obesity: Preventing and Managing the Global Epidemic [4]. This groundbreaking publication identified obesity as a complex, multi-factorial, chronic disease that affects persons across the lifespan and cited the health consequences of not treating it as such. This report declared that obesity is a population problem, rather than an individual problem, and called for a systematic approach to developing preventative and therapeutic strategies to address the growing worldwide health crisis.

However, it was not until 2013, when the American Medical Association (AMA) passed a resolution recognizing obesity as a disease that the concept began to gain traction [5]. The AMA declaration garnered sufficient attention that it increased awareness and moved the healthcare system and society closer to confronting the seriousness of obesity. In the years that followed, several declarations were made including the Canadian Medical Association in 2015 [6] and the World Obesity Federation in 2017 [7]. The most recent proclamation occurred on July 3, 2020 when the German Parliament declared obesity a disease [8].

While these official recognitions have moved the needle forward, awareness of obesity as a disease is still too low. Many clinicians, healthcare systems, insurers, and policy makers have not grasped the importance of recognizing and treating obesity as a chronic disease, illuminating the need for education and advocacy so that the doors to treatment can open for the millions who are in need of it.

Despite worldwide recognition that obesity is a disease, many still cling to the outdated notion that obesity is a lifestyle choice and that a few simple changes will resolve it. But the science tells a different story—obesity is a serious, complex, chronic health condition that adversely affects health. According to the Obesity Medicine Association, Obesity is a defined as a chronic, progressive, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences. ([9], p. 9).

Obesity is diagnosed in the adult patient when the body mass index (BMI) is ≥30 kg/m² and is classified as Class I (BMI 30.0–34.9 kg/m²), Class II (BMI 35.0–39.9 kg/m²), or Class III (≥40 kg/m²) based on BMI (Centers for Disease Control and Prevention, n.d.). Super obesity is diagnosed when the BMI ≥ 50 kg/m² and super, super obesity when the BMI ≥ 60 kg/m² [10]. For those of Asian descent, overweight is diagnosed when the BMI is ≥23 kg/m² and an obesity diagnosis is made at a BMI of ≥27 kg/m² [11].

1.3 Pathophysiology

Obesity is the result of a complex interplay of genetics and environment that manifests as the accumulation of excess adipose tissue that impairs health. Both genetic and epigenetic mechanisms contribute to susceptibility and the development of obesity. The mechanisms by which the body accumulates excess adiposity include genetic and developmental errors, infections, hypothalamic injury, adverse reactions to medications, nutritional imbalance, and environmental factors that may be social/cultural, immune, endocrine, medical, or neurobehavioral in nature. Epigenetic factors contribute to obesity in offspring and future generations [9].

Adipocytes function as endocrine glands that produce hormones which lead to widespread inflammation and influence metabolic and immune function throughout the body. As such, they are directly related to insulin resistance and contribute to many of the endocrinopathies that are related to the pathophysiology of obesity [12]. Adipocyte hypertrophy and adipose tissue expansion, particularly in the presence of abdominal obesity, contribute to alterations in adipocyte and adipose tissue endocrine and immune responses. It is these responses that contribute to the development of elevated blood glucose, high blood pressure, dyslipidemia, and other metabolic states that worsen health [9]. The anatomic changes created by fat deposition in organs and other areas of the body result in conditions such as Non-Alcoholic Fatty Liver Disease (NAFLD), cardiovascular disease, renal disease, among others. In addition to contributing to derangements in metabolic, endocrine, and immune function, the excess accumulation of adipose tissue exerts physical force on the body causing stress damage to other body tissues [9].

Weight and appetite are tightly regulated by multiple neuro-hormonal processes that involve adipose tissue, endocrine organs, gastrointestinal tract peptides, and the central and peripheral nervous systems [12]. The hypothalamus plays an instrumental role in energy metabolism, appetite regulation, and feeding behaviors [13]. When hypothalamic function is altered by genetic and environmental factors, obesity may develop and/or worsen.

1.4 Adverse Health Consequences

Obesity complications are the result of cellular and organ anatomic and functional abnormalities, pathogenic adipocytes, endocrine and immune dysfunction, and physical forces caused by stress on body tissues. As such, they are not simply risk factors or co-morbidities. They present serious threats to health [9]. Obesity is the root of 237 conditions that include some of the most common conditions found in clinical practice such as elevated blood sugar, elevated blood pressure, dyslipidemia, cardiovascular disease, non-alcoholic fatty liver disease, osteoarthritis, gastro-esophageal reflux disease, female infertility, polycystic ovary syndrome, urinary stress incontinence, male hypogonadism, and cancer. Obesity is associated with the development of 22 types of cancer and is responsible for approximately 5% of the cancers found in men and 10% in women, making it the second most common preventable cause of cancer [9, 14].

1.5 Obesity Management

Given the serious nature of obesity and the threat it poses to current and future health, the most effective strategy is to treat obesity first. When obesity is treated as the primary health threat, complications are likely to improve or resolve, and the development of new complications may be prevented. As is the case for other serious conditions, outcomes are improved when clinicians intervene early.

The benefits of obesity treatment go far beyond weight loss. Goals of treatment are to improve health, reduce body weight, improve body composition, and improve quality of life. Obesity treatment is most effective when clinicians and patients shift from a weight-centric to a health-centric approach. A weight loss of 5–10% provides clinically meaningful benefits with improvements to the anatomic, physiologic, inflammatory, and metabolic processes that occur with obesity. Given the pathogenic nature of adipocytes and the negative effects of the physical forces of adipose tissue on the body, treatment that is directed at the reduction of adipose tissue will contribute to the prevention, improvement, and potential resolution of obesity complications. Clinical improvements seen with weight reduction include improved glucose and lipid metabolism, reduced blood pressure, improved cardiac hemodynamic function, as well as improvement in conditions such as obstructive sleep apnea, osteoarthritis, polycystic ovary syndrome, and depression. Weight loss contributes to a reduction in obesity-related cancers, as well as an improved response to cancer treatment and a reduced risk of cancer recurrence. Due to the epigenetic transmission of obesity and metabolic risk, weight loss in child-bearing women and men may have a positive impact on the health of future generations [9].

Obesity treatment is most effective when it is framed as chronic disease management. As is the case with other chronic diseases, the objective is not to cure, but to improve health and function, improve quality of life, and prevent complications [15]. Treatment is more intensive until the disease is stabilized, then transitions to maintenance. Like other chronic conditions, obesity is characterized by periods of stability followed by relapses. Indicators of relapse are weight regain, the worsening of complications, and/or the appearance of new complications. When relapses occur, treatment should be intensified until stability is regained before transitioning back to maintenance [16].

Frequent follow-up improves adherence to the treatment regimen and is associated with better outcomes, including reduced weight, BMI, waist circumference, and systolic blood pressure [17]. An average of 16 face-to-face visits per year is associated with the best weight loss outcomes [18]. When obesity is stable, follow-up frequency can be reduced, but should be increased when relapses occur.

One of the major challenges of obesity treatment is managing the metabolic adaptation that occurs with weight loss. The body defends its weight and adiposity by increasing the appetite stimulating hormone ghrelin and decreasing hormones that promote satiety including leptin, insulin, peptide YY, cholecystokinin, and glucagon-like peptide 1 [17]. In addition to these hormonal changes, resting metabolic rate may be reduced by up to 15% [19]. When these adaptations occur, patients may experience more hunger and less satiety, which are likely to contribute to greater difficulty in adhering to the treatment plan, particularly eating. Even in cases where there is no change to the treatment regimen, weight loss may plateau, and weight gain may occur. When this occurs, clinicians need to intervene by modifying and potentially intensifying the treatment plan.

1.6 Evaluation

A thorough and targeted evaluation is one of the most important components of comprehensive treatment, as the information gleaned will guide the treatment plan. A thorough assessment includes a history, physical exam, and laboratory and diagnostic testing. The manner in which the clinician conducts the evaluation, particularly the history, lays the foundation for a trusting, collaborative partnership.

The purpose of the history is to identify the physical and psychological factors that have contributed to—or have resulted from—obesity. It includes a health history, weight history, review of systems, family history, socio-cultural history, assessment of support systems, as well as information about current eating, physical activity, and sleep patterns. The weight history identifies the factors that have contributed to weight gain and/or have prevented weight loss and elicits information about past efforts, successes, barriers, activities, and life circumstances that have affected weight. It should also include a review of preventative health screenings, as many with obesity delay healthcare appointments and screenings due to fear of being stigmatized [20].

An obesity-specific physical examination includes height, weight, BMI, blood pressure, heart rate, respiratory rate, and waist circumference. It focuses on identifying the presence and severity of obesity complications, as well as identifying any metabolic dysfunction or other issues that will impact health and treatment.

Laboratory and diagnostic testing are utilized to identify obesity-related complications, determine their severity, and establish a baseline from which health improvements can be measured. Adiposity-related labs include hemoglobin A1c, fasting lipid panel, a comprehensive metabolic panel with attention to fasting glucose, liver function, and kidney function, thyroid stimulating hormone, and vitamin D levels. Other tests may be warranted based on findings from the history and physical examination [9].

It is important to note that while BMI is a useful screening tool, it is not a true measure of adiposity and does not assess the physical, mental, or functional health of an individual. Further assessment such as waist circumference and body composition analysis may be needed to identify those with excess adiposity that threatens metabolic health, even when BMI does not fall in the overweight or obesity categories. Obesity staging systems can be utilized to determine the extent of the disease and inform decisions about treatment intensity [21].

1.7 Comprehensive Treatment

Given the chronic nature of obesity, a comprehensive, long-term treatment approach is needed. Effective treatment is individualized, patient-centered, and matched to the disease burden [16]. Comprehensive treatment utilizes five treatment modalities—nutrition, physical activity, behavioral therapy, pharmacotherapy, and bariatric surgeries and devices. The four pillars of treatment are nutrition, physical activity, behavioral therapy, and pharmacotherapy [9]. Bariatric surgery may also be added to the treatment plan, but it does not replace the four pillars. Implementation of the treatment modalities is best accomplished in a stepwise manner. While comprehensive lifestyle management is the cornerstone of obesity treatment, it is often insufficient [22]. Due to the numerous challenges of weight loss, metabolic adaptation, and the reality of weight regain, patients often require additional treatment modalities [23].

1.7.1 Nutrition

The most effective dietary interventions are those that are evidence-based, promote patient adherence, consider patient preference, and specify the quality and quantity of calories. A variety of nutritional plans are available and are chosen based on the individual needs of the patient. Consideration is given to the desired health and metabolic benefits of a specific intervention, as well as personal preferences, food availability, cost, cultural considerations, convenience, and likelihood of adherence [9]. Nutritional plans need to be continued long-term, although it may be necessary to modify or shift to another approach, particularly if there are health changes or weight