Obesity is a very important public health problem. The rates are now very high, with over 25% of the UK population and 33% of the US population classified as obese.
Obesity itself results in significant reductions in quality of life but it also leads to a range of serious health issues, such as type 2 diabetes, cardiovascular diseases and cancer.
Changes in diet and exercise seem to be the most sensible first-line solution, however health education programs have failed to halt the rising numbers of obese people. This suggests that intrinsic factors, such as genetics, might be important.
This raises an important question: Is obesity a disease or a choice?
A recent poll on Medscape revealed some interesting opinions about obesity among healthcare providers. One of the questions asked was ‘How often do you think lifestyle choices are the underlying cause?’ 75% of medical professionals chose either ‘often’ or ‘always’.
When asked what interventions they typically recommend for their obese patients, over 90% selected ‘diet and exercise’. Further, more than 30% of healthcare providers do not consider obesity to be a disease state. However, if obesity is viewed as a disease it may aid toward objectively assessing the factors that lead to it, thus offering better prevention and treatment strategies.
What makes obesity a disease?
Obesity is a complex entity that can have many causes. The first, most obvious, argument for why obesity is a disease is that it is associated with impaired body function. It causes, exacerbates, or accelerates more than 160 co-morbid conditions that arise as metabolic, structural, inflammatory, degenerative, neoplastic, or psychological complications. Further, it can significantly affect quality of life or impair longevity.
Taking this into account may prove effective in dealing with its biopsychosocial and economic ramifications.
Common assumptions about obesity
It is a common assumption among both healthcare providers and the general public that obesity is a self-inflicted condition. In other words, obesity is thought to be the result of a lack of self-discipline due to addiction to excess or unhealthy foods, and thus these patients are largely responsible for this condition. If patients are not losing weight with diet and exercise, it is because they are not trying hard enough or are cheating on their lifestyle modifications.
Another assumption is that obesity started only in the past 50 or so years. Although the incidence has increased significantly in the recent past, it is in fact a centuries-old condition.
Lifestyle modifications have an increasingly robust representation in evidence-based medicine. However, given the complex and multifactorial nature of obesity, management can fail despite earnest efforts by patients and is often successfully augmented by the addition of pharmacotherapy or surgery.
Treatment must be individualised
It is important to realise that for many patients, obesity is multifactorial. There is a wide heterogeneity in the causes and manifestation of obesity, which leads to wide interpatient variability in the response to different therapeutic strategies. It is for this reason that management of obesity needs to be individualised for each patient.
It is therefore important to accept that obesity is not merely a condition arising from ‘food addiction’. In fact, more than 100 aetiologies of obesity have been identified, and we’ve merely scratched the surface at recognising the causal factors.
The question of obesity being a disease or choice is like the false dichotomy of nature vs nurture. There is no simple either/or answer to this question. It is much more likely to be a combination of both factors.
Obesity involves a complex interplay of underlying medical conditions, such as genetic or endocrine factors, in addition to environmental influencers. Environment plays an important role. Factors such as eating schedules, physical activity, sleep health and medications, can affect weight management.
The ultimate consequence is failure of the homeostasis of weight and energy regulatory mechanisms, leading to an elevated body fat set-point.
Only when we recognise that obesity is a disease can we take the next steps of screening, diagnosing, assessing, preventing, and treating this condition.