Beyond blame: Treating obesity as a complex chronic condition

Treating obesity as a complex chronic condition: ©New Africa - stock.adobe.com

Recent discussions surrounding the treatment of obesity have been gaining more traction than usual, particularly in light of groundbreaking medical advancements such as Ozempic/GLP-1 drugs. While traditional perceptions often stigmatize obesity, our understanding of obesity is changing, and how we treat obesity should reflect this new understanding.

There has been a longstanding perception that obesity is caused primarily by poor dietary choices and lack of exercise. But there are many other less obvious factors that contribute significantly to it, including hormonal, economic, social and genetic factors. While typically helpful, improving diet and exercise alone is often not enough. A relatively new class of medications called GLP-1 agonists represents a promising frontier in obesity management, offering new hope for millions worldwide grappling with its challenges.

As the medical community navigates these developments, a crucial shift is underway—from viewing obesity solely as a personal failing to recognize it as a nuanced medical condition deserving of comprehensive treatment strategies.

Hidden factors: Metabolic syndrome

Obesity is most often part of a constellation of disorders called “metabolic syndrome,” which includes conditions like hypertension, Type 2 Diabetes (or insulin resistance) and high cholesterol. All components of metabolic syndrome should be treated aggressively with diet and exercise, but we shouldn’t stop there.

Most patients with uncontrolled cholesterol or blood sugar are advised and willing to take a statin or diabetes drug, because they understand the importance of managing these conditions. We don’t stigmatize diabetic patients for poor diets, lack of exercise or taking meds, and we don’t hesitate to prescribe medication in most cases, because the benefits outweigh the risks. So, if we wouldn’t prescribe only diet and exercise to a diabetic, how can we believe the same treatment will suffice for an obese person?

Another way to consider this is to think of the components of metabolic syndrome as “preconditions” for a disease. People with diabetes or high blood pressure may feel well for years before any symptoms develop, even if uncontrolled. Being obese in itself can cause symptoms earlier than these other conditions, such as more difficulty moving, fatigue, back pain and social and emotional stigma. And obesity is a significant risk factor for cancer, osteoarthritis, and premature death. People seeking care for obesity deserve the same aggressive treatment as those with hypertension or diabetes.

Approaching obesity with patients

The shame surrounding obesity is often the biggest obstacle to people seeking treatment as it is a more visible illness to stigmatize. There are some people who know they are overweight and have no interest in treating it, and others who would like to lose weight but are unwilling or unable to make the necessary lifestyle changes. Then, there are those who want to lose weight, are willing to make lifestyle changes, but don’t believe those changes will result in weight loss (possibly because of past failures), so they do not see the point in making the effort. As physicians, we must convince these patients that lifestyle modification is important, possible, and effective.

Obesity is a chronic disease, not a character flaw or personal failing. Patients didn’t set out trying to become obese, and they often judged themselves harshly for their inability to control their weight. We must explain to them that obesity is a result of many internal and external factors, many of which are out of their control, and try to approach the topic without judgment. Addressing the variables they can control will most often make a difference in their weight and how they feel.

Once the patient has expressed a desire to lose weight and believes they can, it becomes a joint effort between the patient and medical professional to mitigate the risks associated with obesity. What are they willing to do to lose weight? The best plan is not “one size fits all” — the best plan is the one that makes the most sense to each individual, as this is the plan they are most likely to follow.

To set the patient up for success, they must begin small and keep expectations low; this is most successful when developed with and tracked by their doctor, as they are more likely to follow a plan that they helped devise than one that was just prescribed to them. Realistic expectations are key when creating a treatment plan, because when weight loss goals are too steep, patients are less likely to try in the first place, and more likely to get frustrated during the process. Slow progress is still progress.

Empowering patients to be active in their obesity treatment

There are small but impactful steps people can take to treat their obesity. The most underappreciated component of obesity treatment is adequate sleep. Poor sleep can lead to obesity, which in turn can result in disorders such as sleep apnea, which can further worsen weight. People who get less than seven hours of sleep per night have a 55% greater likelihood of becoming obese than similar people who get seven to nine hours per night. Getting restful sleep just might lead off their weight-loss journey.

Along with fixing their sleep schedule, there are many other incremental changes patients can make to lessen the emotional, social, and economic factors that lead to obesity and other conditions. A knowledgeable physician can help create a personalized treatment plan that can address many of these factors.

For more severe or refractory cases, we can prescribe medications that work in tandem with lifestyle modifications to help patients lose weight. New GLP-1/GIP medications, such as Wegovy and Zepbound, are a massive improvement over previously available treatments. Once they become less expensive and more commonplace, we will likely see a sharp decrease in other conditions, such as hypertension, high cholesterol, and blood sugar, as weight comes down. As overall conditions improve, we will likely spend far less on these other conditions and their complications, which may ultimately result in better health outcomes at a lower cost to society.

Be aware, GLP-1/GIP medications are not for everyone, nor should they be. Like any chronic medical condition, a reasonable trial of lifestyle modification is always the first step. Weight loss medications should be reserved for patients with more severe disease and/or comorbidities, such as arthritis, that might limit the ability to address their condition without pharmaceuticals. If prescribed appropriately, these medications can transform lives and change the health care landscape in this country. If used inappropriately, there will be high costs and shortages, as we are seeing now, as well as unnecessary side effects endured by patients that could have been avoided.

Taking action

Targeted weight loss is a concerted effort between medical professionals and patients. There are many practical steps for patients to take an active role in their treatment to make significant changes without feeling overwhelmed.

Patients will fare better by working with health professionals that have adopted a more compassionate, informed, and proactive approach to obesity treatment, without shame or admonishment. If we are going to make any strides controlling the epidemic in this country, obesity needs to be recognized as the chronic disease that it is and deserving of the same attention and care as other chronic conditions like diabetes and hypertension.

L. Kenneth Zweig, M.D. is an internist at Northern Virginia Family Practice Associates.