In developed countries throughout the world, more than 20% of the population is obese. The obesity epidemic is everywhere, and it affects adults and children alike. Because obesity is linked to a variety of serious illness like heart disease and diabetes, these statistics are troubling… yet obesity is not perceived as a disease in its own right. Instead see being overweight or obese as a reflection of poor lifestyle choices. This point of view is shifting, though, as many are now categorizing obesity as a disease–and with this shift comes new changes in obesity management.
In recent years, there have been several new drugs that appear to be much more effective on promoting weight loss. In contrast to yo-yo dieting and frustrating gym results, improved weight control is being realized by thousands. But these changes in obesity management are not available to all as a result of insurance and financial barriers. This is one reason why professional organizations are encouraging all to begin perceiving obesity as a disease. This is not their only motivation as notable science is now backing up such a claim. But it remains to be seen if the existing social stigma associated with obesity will make this transition impossible.
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“These anti-obesity medications are the best we’ve ever seen. They’re a huge boost to our armamentarium of obesity treatments.” – Dr. Shauna Levy, Obesity Medicine Specialist and Medical Director, Tulane Bariatric Center, New Orleans
Evidence Supporting Obesity as a Disease
The prevailing notion concerning obesity over the years has been one linked to diet and exercise. Those who are overweight or obese were presumed to have poor diets or insufficient physical activity. More calories in and fewer calories burned resulted in weight gain. Thus, the obvious solution was to eat less, exercise more and avoid highly caloric foods. But after decades of these approaches, very little evidence supports this point of view. This led scientists to explore other explanations in an effort to identify changes in obesity management that might work. And as it turns out, it seems there are brain-related pathways to account for individual variations in weight.
Basically, there are two primary pathways in the hypothalamus portion of our brains that affect weight. The first is termed the POMC pathway (pro-opiomelanocortin), which tends to encourage us to eat less and store fewer calories. The other is the AgRP pathway (Agouti-related peptide), which does exactly the opposite. Seemingly, individuals prone to obesity have a predilection for the AgRP pathway, and therefore, eat more and store more calories. These pathways determine a specific weight range for people that is nearly impossible to change via willpower, diet and exercise. Given this, seeing obesity as a disease appears much more logical. And the latest changes in obesity management are attempting to target these areas of the brain.
“Evidence suggests that patients may not be able to maintain their weight loss once they stop taking the drug. There is also limited long-term evidence to show that patients on these medications see lasting benefits in reducing risk of co-morbidities like diabetes or cardiovascular disease.” – David Allen, AHIP [America’s Health Insurance Plans] spokesperson
New Drugs and New Controversies
For several years, there have been a few medications that demonstrated weight loss benefits. Topiramate is a drug that acts on the brain’s GABA receptors. Phentermine is another that is a norepinephrine reuptake inhibitor. The weight loss associated with these medications was discovered by chance. But as it turns out, they actually work within the hypothalamus to encourage the body to eat les and store fewer calories. This was early evidence that changes in obesity management might offer better outcomes. And it hinted that rather than being a lifestyle issue, obesity as a disease made more sense.
Today, an entirely new class of anti-obesity medications are being used. Change sin obesity management are moving toward these drugs because they are so much more effective. Named GLP-1s, these medications stimulate glucagon receptors in the brain. This promotes a shift from the AgRP pathway to the POMC pathway, resulting in a new healthy weight set point. The effects of these new drugs are profound, and many can be taken once a month. But at the same time, they are extremely expensive (>$1300 per month) and are not routinely covered by health insurances. Thus, this lack of access is why many physicians are pushing for the public to see obesity as a disease.
“As a society, we still very much have the mindset of obesity as a cosmetic issue, and not a metabolic issue or a disease. It’s not to say that behavioral components don’t have a place in the treatment plan, but it can’t be the only thing.” – James Zervios, VP and Chief of Staff, Obesity Action Coalition
Overcoming Stigma and Promoting Health
There’s little question that future changes in obesity management should include more than drugs alone. All agree that a multifaceted approach is best involving diet, activity, sleep and healthy lifestyle behaviors. Some with obesity may also require surgical therapies, which have been shown to produce good results in some patients. But with new medications showing such promise, these certainly need to be included in obesity care. By seeing obesity as a disease rather than a lack of willpower, this shift becomes more likely. But overcoming social stigma can be challenging to say the least.
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Recently, the American Academy of Pediatrics came forward and encouraged seeing obesity as a disease. In its recommendations, it encouraged consideration of anti-obesity medications in select cases as changes in obesity management. Some physicians and healthcare experts have pushed back against this stance. They worry that calling obesity an illness could be detrimental psychologically to kids. But this again buys into the preexisting notion that weight issues can be solved by diet, activity and lifestyle alone. Research evidence now supports a change in how we as a society perceive obesity. And if we can make this shift, millions can receive the care they need to lead higher quality lives.
