Obesity is a chronic illness. And yet, we still treat it as a lifestyle choice. Researchers and patient groups attending the European Congress on Obesity (ECO)1 last week are determined to improve recognition of obesity as a disease and have been lobbying to have it included in the updated International Classification of Diseases (essentially a handbook of diseases that can be used for keeping and comparing records of patients’ diagnoses) as well as having it recognised by the UK Government. But why does the definition matter?
Without a definition, a person with obesity may not know that it is classed as a disease, and they may not be aware that they can ask for support from their GP. And it matters because, without formal recognition, GPs may not act accordingly. On average, of people who have had their BMI measured as being above the threshold for obesity, only 57% are then given a formal diagnosis; of those who are diagnosed, many do not leave their GP with a treatment plan or indeed any kind of follow-up.
It would be remiss of me to tell you all of this without also explaining the scientific case for obesity being classified as a disease. In a Media Masterclass at the ECO, Abd Tahrani took us through the underlying disease pathology. Obesity has characteristic signs and symptoms – such as increased body fat mass, joint pain, impaired mobility, and low self-esteem; and associated morbidities, such as cardiovascular disease and early death. Furthermore, there is reason to believe there are underlying biological causes. Genetic association studies have found that most of the gene variants that appear commonly in people with obesity are genes which affect the brain. This makes sense – weight is affected by the balance between our energy intake and our energy expenditure, and this is regulated in the brain. The hypothalamus is a small brain region which sends signals to the body to regulate appetite. Without the hypothalamus signalling properly, you may not feel satiated from eating and may eat more, tipping the energy balance. As obesity is a complex disease process, other things are happening too – another pathway may mean that your energy output is reduced (the inverse, I suppose, of your skinny friend who can eat four burgers and never apparently gain any weight), meaning you do not have to eat too much more before your body stores this as fat. Increased body fat mass can in turn lead to other complications – back pain, gout, depression, asthma, type-two diabetes, cancer, and cardiovascular disease. Even those who are obese but metabolically fit have a 96% higher risk of later ill health than those with a healthy body weight.
During a presentation at the ECO, lead author of the ACTION-IO study, an international survey into how people with obesity and doctors think about the disease, Professor Ian Caterson, described obesity as “the last socially acceptable form of prejudice”. And this prejudice may not just be a social issue; it may be creating barriers to treatment and, by extension, putting peoples health at risk.
These barriers may be in the form of delayed treatment. The stigma around obesity is such that, on average, people will live with it for 6 years before discussing it with their GP. Think of how long 6 years actually is; how much your health could change or deteriorate in that time if you left something untreated.
And while many people with obesity and many health care providers recognise obesity as a disease (68% and 88% respectively), many still believe that the onus should be on the person with obesity to manage their illness – 81% of people with obesity believe it is their sole responsibility, and, worryingly, 30% of healthcare professionals believe this too.
This seems to be a failing of people with a recognised health condition. While the stigma around mental illness has received growing attention (well needed and much deserved) over recent years, it seems obesity had been left behind in cultural conversations. Changing attitudes and increasing understanding of obesity as a disease process could be important for shifting public opinion away from a culture of blame and may translate to healthier conversations in the clinic too.
Doctors reported that they did not want to bring up obesity for fear of offending their patients; however, many people who brought it up themselves said that they had hoped their doctor would talk about it first and that fear of offence may be unwarranted – most people with obesity felt motivated and hopeful after discussion with their healthcare provider – only 3% felt offended, confused, or blamed. Better understanding all round is needed. If doctors understood their patients’ needs then they may be more willing to bring up the topic. If obesity was not so stigmatised at a societal level then doctors may be less likely to have these fears when speaking to patients.
Speaking from a patient representative, Sólveig Sigurðardóttir said that the stats from ACTION-IO back what patients have been dealing with over the years. She said, “Healthcare Professionals just think we don’t want help – can you imagine how difficult it is to ask for help when you have been beaten down and stigmatised?” I can’t, to be honest. We all make unhealthy decisions from time-to-time, but not all of us have the same genetic and environmental factors that put us at a greater risk of obesity. Being vilified for that seems counterproductive at best and damaging to people’s health at worst.
Now that we have data to back these experiences, it’s time to bridge this gap. An easy way to start is by taking advice from the director of the Obesity, Metabolism & Nutrition Institute, Lee Kaplan, who said: “[the] biggest gift of healthcare professionals is the gift of respecting them as normal people living with a disease.” For the rest of us non-healthcare-professionals, reducing stigma and separating people with obesity from their disease is a simple place to begin.
This article was specialist edited by Audrey Gillies and copy-edited by Sonya Frazier.