Antonio Vidal-Puig MD PhD FRCP FMedSci EMBA
Professor of Molecular Nutrition and Metabolism.
Associate Director MRC Metabolic Disease Unit. Honorary Consultant in Metabolic Medicine.
Scientific Director Cambridge Phenomics Centre.
Associate Faculty Sanger Institute.
TVPLab, Metabolic Research Laboratories, Institute of Metabolic Science Cambridge University
Meis Moukayed PhD (Cantab.)
Professor of Natural Sciences at the American University in Dubai.
GCSRT Global Clinical Research Scholar in Clinical Trials and Epidemiology – Harvard University
Obesity is defined as an excessive accumulation of body fat that causes health problems. Current data indicate that the incidence of obesity has increased to epidemic proportions in the last 40 years. This is obviously worrisome, but before proposing solutions it is important to agree on who is obese. The most common measure of obesity used is the Body Mass Index (BMI) of a person, which calculates the ratio of a person’s body weight (kg) relative to the square of his height (m2). Individual’s scoring BMI of 30kg/m2 and above are considered obese. BMI although a globally accepted estimate, is not perfect. For instance, as a relative measure, BMI’s health implications can be different in certain cultures, e.g. individuals from East Asian countries, who have different genetically determined body proportions and sizes become diabetic at smaller BMIs than Caucasian. Also, the use of BMI misdiagnosed many USA athletes as obese (which made them unsuitable for the army) because their very large muscle mass increased their body weight. Thus, confirmation of obesity placing individuals at risk of health complications is best confirmed with additional measures of adiposity including Waist-Hip-Ratio (WHR), the relative amount of lean and fat mass, and the distribution pattern of fat on an individual’s body, e.g. abdominal deposition versus peripheral accumulation of fat. Moreover, defining obesity in children is more complex as BMI ranges are different for children under the age of 18 compared to adults. For these reasons more important than focusing on weight or BMI, is to determine whom amongst these patients will develop cardiometabolic complications. This view refocuses the problem of obesity towards their complications risk and may help to destigmatize the fat mass of an individual.
The magnitude of the obesity problem is colossal. The most current global World Health Organization (WHO) estimates of 2016, indicated that over 1.9 billion adults, were overweight (BMI between 25 kg/m2 and 30 kg/m2) and over 650 million were obese (BMI >30 kg/m2). Unfortunately, childhood obesity is also on the rise globally with over 41 million children under the age of 5 years, and 340 million children and adolescents ages 5-19 years, are characterized as overweight or obese. The global average of adult obesity rates is approximately 13%, in the USA obesity affects more than 39.8% of the population, and in some GCC countries, e.g. Kuwait, obesity is equally high having been reported to affect almost 42% of the population. When combined, overweight and obesity rates in GCC countries have reportedly risen to include over 60% of the population, notably with more women affected than men.
When considering the increase in adiposity and hence obesity, it is important to realize that fat mass is the result of a mismatch between the amount of energy eaten and energy expended. We know now that this mismatch is highly influenced by genes which operate predominantly in the brain, but also affected by environmental, social and culturally determined behaviors. These factors, genes and environment, play a role in determining a person’s food intake patterns and appetite and the amount of energy expended, as the main determinants of the amount of fat accumulation/adiposity. Recent genetic studies of obesity have been very successful and helpful to document that genes are important contributors to obesity. However, these studies also provide evidence of a huge complexity, with many genes having relatively small influence, which suggests that focusing on the genes may not be very useful to diagnose or treat common forms of obesity. In fact, more than 50 human genes including MC4R, FTO, PPAR-g, LEPTR and others have been shown to contribute to obesity and different patients may have a different combination of variants in these genes. Thus, being the genetic factors, an important determinant of obesity does not necessarily imply that we can use these genetic factors to develop personalized treatments or specific molecular diagnostic biomarkers for obesity. Unravelling this complexity may be feasible in the future, particularly if the promises of artificial intelligence to make meaning of big data and therapeutic opportunities provided by genetic engineering technologies are fulfilled.
An alternative point of view comes from the realization that obesity is a relatively recent problem emerging in the last 40-50 years. Genetic changes cannot explain the current epidemic of obesity as gene sequences do not change in this short period of time. We all will agree that the last 50 years have witnessed major social, culture, behavioural and environmental factors that certainly may have influenced the way these genes work.
Lifestyle shifts towards eating fast urbanized high-density foods, readily abundant yet cheap, accompanied by sedentary lifestyles, and mass consumerism habits may have contributed. In the USA and Europe, post-war industrialization and mass production of cheaper packaged foods laden with longer-lasting trans-fats, have influenced the social, biochemical and behavioural acclimatizing of Western palates to fattening sugary foods. It also shifted behaviours to using easy on-the-go readymade foods, moving families away from traditional healthy cooking and regulated meal consumption patterns. Mass availability of cheaper food options have also contributed to increasing consumption, obesity and malnutrition observed amongst lower socio-economic classes and in poorer countries. As for emerging affluent regions of the world, post-oil affluence for several countries in the GCC was commercially accompanied by the emergence and popularization of Westernized fast-food chain restaurants popping up in every corner of major cities, offering options packed with high fat, high carbohydrate, high salt but low fiber content foods. Moreover, in the GCC, affluence and hot arduous climates imposed a lifestyle of reliance on manual migrant workers such as household help and office caddies. Such reliance although financially affordable, meant a shift away from physical labour or work and hence promoted a lifestyle of sedentary activity. Across continents, exposure to unhealthy food advertising and marketing on TV, especially to younger generations, online and on different media channels have added to the factors that entice users to unhealthy food choices. Increasing social acclimatization to increasing food consumption and appetite, towards fat, salt and sugar-laden foods and drinks have also contributed to over-eating trends or consumption of poor-nutritional quality “fad” junk foods and beverages across societies. This suggest that tackling obesity will benefit from actions directed to improve this hostile environment.
In thinking how to tackle the problem, it is obvious that a necessary first step is to recognize obesity as a real disease. The American Medical Association (AMA) only agreed to recognize obesity as a disease in 2013, following the overwhelming scientific evidence undeniably linking obesity with increasing prevalence of type 2 diabetes. This was a major accomplishment but not enough to change the stereotypes and biases associated with the perception of obesity as a personal choice for bad habits associated to “laziness”, lack of character and irresponsibility. This stigma on the obese patient prevents tackling the problem as it prevents their social integration, diminishes self-esteem and mental power, and hampers their career progression while increasing frustration. Even from the point of view of science this stigma may decrease the research effort to tackle this problem as it detracts from the prioritization of resources and the necessary philanthropic support preferentially directed to other non-stigmatized priorities such as cancer, Alzheimer, or diseases related to pediatrics or ageing.
This stigmatized perception ignores the huge challenge confronted by the obese patient on their daily fight against their genes, in a hostile environment offering multiple appealing options to ingest excessive amount calories with minimum physical effort.
Even when the obese patient manages to lose weight, keeping it off is an exhausting effort against their genes and environmental conditions. Success in this endeavor requires mental strength and constant awareness to succeed in their attempt to remain healthy and clear from the grim prospects of devastating comorbidities including type 2 diabetes, hypertension, insulin resistance, dyslipidemia, microvascular complications such as neuropathy and nephropathy, stroke, inflammation-associated diseases, osteoporosis, depression and cancer among others. This is a harder task than any of the “lucky” lean individuals harboring the currently advantageous genes can imagine.
The stigma on the obese patient is also exacerbated by the reality that the increasing direct and indirect cost of obesity to health services worldwide make them very unpopular amongst tax payers. The McKinsey Global Institute reports that that obesity’s “global economic impact amounts to roughly $2 trillion annually, or 2.8 percent of global GDP”. This cost threatens the productivity, security and stability of nations by this metabolic epidemic. The economic burden posed represents expenditure on direct medical costs for treating obesity and its complications both physical and mental, as well as indirect costs including absenteeism, decreased productivity, premature disability or loss of mobility, and increased insurance charges. The burden of the disease to societies may even have a manifold of negative social repercussions impacting mental health and wellbeing, reducing quality of life for individuals and hence negatively impacting societies in ways hard to accurately measure.
Given the rife that obesity can cause in terms of human sufferance, health complications and economic loss, it is clear that finding a solution is necessary. Probably the easiest way not to feel guilty is to find a vulnerable scape goat, in this case the obese patients as they are directly affected by the problem. This justifies proposals that point a finger to the obese patient, proposing punitive actions and financial coercion as incentives for the obese patient to lose weight. However, this view is against the scientific evidence. The obese patient is not the villain in the story, in our view the obese patient appears as the anonymous hero who tries to defeat their obesogenic genes in a hostile hypercaloric sedentary environment.
This in our opinion changes the perception about the obese patient as well as influences the strategy to tackle environment. This involves promoting effective clinical, social, and behavioural interventions aimed at modifying risk factors causing morbidity and mortality, and which empower the obese patient to defeat their genes by increasing their mental willpower and providing a more supportive environment. A sustainable approach towards effective prevention needs to be multifaceted to achieve improved health for patients and a notable public health benefit for health systems and governments alike. Amongst those behavioural and social changes that can be implemented is increased education on nutrition. Whereas the metabolic resilience of a lean individual may not require in-depth nutritional education, the obese patient will benefit enormously from learning accurate useful information about food quality and consumption quantity i.e. meal sizes and portions, healthy versus unhealthy food ingredients, products, and eating habits a well as a genuine educational approach to combat the huge amount of fraud secondary nutritional information on the internet and social media. Nutrition education should also focus on making them aware of the potential consequences of obesity and providing hope for the future if they succeed in maintaining healthy weight and adiposity. Not only is the content of the information important, it is essential to provide this information in an efficient nonjudgmental way, empowering them and avoiding stigmatization. We would advise approaching the obese patient as a valued “customer” not as an enemy challenging the welfare of the state. The concept is to provide the patient with a tool kit to enable them make the right decisions when confronted by specific situations. Ideally, obesity education and prevention programs could become invaluable tools to curb the rising global prevalence of this disease. As part of the strategy of improving the environment of the obese patient, such programs should ideally start at the level of schools and communities and be adopted and funded by councils, health authorities and governments to affect public health benefits.
Exercise is also beneficial for the obese patient. Physical activity of up to 30 minutes a day, as recommended by the US Center for Disease Control and Prevention (CDC) and American Heart Association (AHA), may not decrease body weight but results in beneficial health effects derived from improved fitness, contributes to prevent weight regain and decreases metabolic risk in obese individuals. Destigmatizing obesity also implies refocusing emphasis on fitness and not on fatness. Also, exercising is certainly easier if you are lean than if you are obese. This too requires the obese patient to exhibit heroic discipline and sustained motivation to exercise in an environment that primes a stereotype of body. This is hard. For this reason, it is essential to make it easier by providing appropriate infrastructures and provide supportive healthy environments that promote active living as well as campaigns and support to promote adoption of active lifestyles. In this respect Dubai in the UAE, has been one of the GCC countries at the forefront leading the battle against obesity regionally by placing exercise, sports and increased physical activity firmly on the government agenda and expenditure. In recent years, the establishment of councils and initiatives such as the Dubai Sports Council (DSC), the 30×30 Dubai Fitness Challenge and the Government Games are all tribute to the continuing efforts of Dubai to inspire its community into healthy active lifestyles and to place health and wellbeing firmly on its agenda to meet its 2021 and 2030 vision goals. In addition to offering the obese patients with the best environment where to thrive, this should not be an excuse for health providers to evade/avoid the responsibility of offering the obese patient the best clinical or medical provisions like surgery e.g. Bariatric surgery or emerging new pharmacological therapies, where needed.
In 2018, it is of course an irony that obesity prevalence is at its highest peak while food scarcity and security as well as poverty have become increasing global concerns too. It would be more efficient if all these issues could be addressed together and tackled in an integrated strategic way focused on supporting the obese patient in their struggle to combat their genes and remain healthy. In the effort to reduce global obesity, improve public health and well-being to guarantee security and productivity for nations, the obese patient should not be perceived as the problem but as the hero that needs help to defeat obesity. It is a long-term journey, obesity’s rising rates are too important to be ignored, but at the end of the day behind these rates there are human beings struggling for survival who deserve and are entitled to society’s generous support.