by November 21, 2022
On September 28, the White House held a Conference on Hunger, Nutrition, and Health. Unfortunately, obesity was omitted as a main topic for the conference. Yet, on the day prior to the conference, the CDC reported that the number of states with high rates of adult obesity has more than doubled in the last 4 years, with the pandemic exacerbating this rise. With food insecurity rates stable or declining and obesity rates climbing, why wasn’t obesity top of mind for a White House conference on health and nutrition?
Hunger invokes sympathy while obesity evokes shame and loathing. Stigma and blame have often been associated with disease. As Susan Sontag pointed out in Illness as Metaphor, a disease like cancer or obesity is not a result of moral failure or personality. Notably, the Biggest Loser study demonstrated that patients with obesity are supremely motivated to lose weight through lifestyle changes, even under a national spotlight, but often will regain their weight.
Weight regain is a consequence of physiology not psychology. Dieting will elevate the hunger hormone ghrelin, decrease the satiety hormone GLP-1, and literally turn down the thermostat by decreasing calorie expenditure by 15%. When dieting, the body will defend its set weight, making weight loss challenging because maintenance of weight is a biological imperative.
Surprisingly, the conference mentioned obesity only fleetingly, and just in the context of prevention and dietary counseling as treatment. However, with existing and emerging obesity treatments available, it’s important to consider these treatments in tandem with other healthy lifestyle interventions.
Time to Treat
Although laudable, prevention can’t treat the millions of patients with obesity currently at risk from diabetes, hypertension, heart failure, cancer, and COVID-19. Of note, the two leading risk factors for COVID-19 consequences are weight and age, and our national obesity rates may account for worse national COVID-19 mortality when compared to other countries. We can’t change our age but we can change our weight.
While nutrition is important, patients with clinical obesity cannot be treated by nutrition alone. The current administration has medicalized nutritional counseling and the Obama administration promoted the “Let’s Move!” initiative — these interventions can help, but not in isolation for most patients with obesity. At times, too much emphasis on nutrition or exercise can also lead to delays in medication intervention for patients who would benefit. Weight loss for patients with obesity is achieved metabolically — generally not by motivation alone.
Medical Inflation
The long litany of the consequences of obesity should be enumerated consistently, by health professionals and government officials, to focus attention upon it. Medical costs and complications, and even national security, are affected by obesity when our recruits cannot complete basic training due to weight. Obesity is the medical equivalent of economic inflation. The value of medical advancements will be eroded and diminished by obesity, which increases the prevalence and consequences of multiple diseases while simultaneously undermining the effectiveness of their treatment. A prime example is type 2 diabetes, with obesity as a strong contributing factor. If obesity in the setting of diabetes is not treated, then diabetes will remain difficult to treat, akin to providing aspirin for a fever that needs antibiotics. A recent National Clinical Care Commission report on diabetes barely emphasized optimizing current treatment options for obesity. Historically, instead of strong medicine, patients with obesity and diabetes have been offered the weak tea of initiatives such as less sugary drinks, more breast-feeding, and food label changes. While these can offer some health benefits, they don’t go far enough alone.
This makes the decision of the conference not to engage obesity and its treatment disheartening to patients with obesity and healthcare professionals devoted to their care. Reliance on changing food labeling may result in more regulatory burden and confusion for the public without enough benefit of the proposed voluntary labeling. Nutritional advice is notoriously conflicting and difficult to message, and even more so when the message changes.
Treatment Has Arrived
These old approaches are even more confounding as treatment for obesity is now innovative, safe, and effective with 900 hospitals providing accredited bariatric surgery and two new anti-obesity medications (AOMs) demonstrating groundbreaking results. Bariatric surgery can decrease overall mortality by 40%, cancer mortality by 52%, and even COVID-19 hospitalization by 49% on a long-term basis, and can increase the likelihood of type 2 diabetes remission. AOMs can lead to as much as 20% total body weight loss, with 5% total body weight loss being a metric of meaningful health improvement. If cost is a consideration, please consider that we are already paying for the consequences of obesity at the conservative estimate of $260 billion annually, which is likely an underestimate given the role obesity plays in multiple diseases. Obesity treatment can also be cost-effective as noted in the example of bariatric surgery.
What Can We Do?
Here are 10 important steps for government officials and healthcare professionals:
Treating obesity is our healthcare moonshot. If we accomplish this mission, our destination will be increased quantity and quality of life with less cancer, heart disease, diabetes, and even COVID-19 complications. To accomplish this goal, we need to treat obesity seriously. This is not a democratic or republican issue — this is an American issue. Obesity affects northern inner-city minorities and southern rural communities and even board rooms. We need to provide more than counseling. Patients with obesity need treatment.
John Magaña Morton, MD, MPH, MHA, is professor and vice chair in the Department of Surgery at Yale School of Medicine.
Disclosures
Morton disclosed consulting payments from Ethicon (which makes surgical staplers used in bariatric surgery), Novo Nordisk (a manufacturer of obesity drugs), and Olympus.
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