KUALA LUMPUR, Nov 1 – Some of the region’s leading experts on obesity are calling for obesity to be recognised and treated as a chronic relapsing disease, a categorisation that demands a medical-based approach to obesity beyond behavioural change strategies.
A group of endocrinologists and researchers in obesity, led by Asia-Oceania Association for the Study of Obesity (AOASO) president Prof Brian Oldfield, said recognising obesity as a disease, not an individual lifestyle choice, can help shift the deeply held societal belief that people with obesity simply lack willpower and need to eat less and exercise more.
“When we approach obesity as a chronic disease with a propensity for relapse and progression, we not only enable the provision of a whole-system approach for effective prevention and treatment for the long-term, but also shift the focus on people with obesity (PwO) and combat the stigma and discrimination associated with weight, which impedes PwO in seeking appropriate care,” said Dr Tham Kwang Wei, secretary of AOASO.
Dr Tham was speaking at an exclusive media roundtable organised by the AOASO at the International Congress on Obesity 2022 in Melbourne, Australia.
AOASO defined obesity as a complex condition driven by “a combination of factors” that includes biological and genetic, in addition to environmental, social and economic influences.
Understanding The Science Of Obesity
While obesity is often attributed to unhealthy lifestyles – a high-calorie diet and low physical activity – it was pointed out that a lifestyle change does not necessarily cure it.
Dr Tham said efforts to lose weight often trigger a whole set of bodily reactions to adjust the amount of energy used and preserved in the body. “Our body doesn’t see this (accumulation of excess energy) as overweight. What it tries to do is to balance the energy.
“So what happens is the body will recognise this higher amount of energy or weight as the new energy balance that needs to be kept.
“If that drops below a certain level, the body will try to do certain things to preserve and reserve that ‘bank account’ or energy balance. It will kick off this whole set of body reactions that makes us consume the energy we’ve lost so we eat more, get hungry more, and it makes us burn less,” Dr Tham said.
Dr Tham, who is also president of the Singapore Association for the Study of Obesity, likened obesity to diabetes as a chronic disease that does not happen overnight.
“It’s a whole series of things that happened. It’s five to 15 years where body functions have been disrupted, just like in diabetes. When somebody has diabetes, it takes a lot to, you know, reverse them back to normal. It’s now possible but for most people, it’s going to be a challenge, right? So it takes a lot to maintain the person in good form,” Dr Tham said.
Oldfield added that understanding the genetics and biology of obesity and why they contribute to the disease status of obesity is important, as such factors are powerful in creating a level of body weight that is “very hard to reverse”.
“We have to remember that over millennia, we have developed a genetic code that is designed to beautifully maintain body fat. It does it exquisitely because there may be a famine that is coming and we want to maintain our body fat in the case of that famine.
“Now that was okay. If it was all about genetics, why did we have an obesity epidemic before 1980? Well, the reason is that we had the genetics that would hang on to body fat, but what happened in the 1980s is the world discovered processed food – highly available, highly palatable, very cheap, high fat and highly sugary food.
“And so we had a perfect storm then, of genetics that wants to hold onto fat and more fat than we could possibly deal with. And I think that is what’s happening across the world,” Oldfield said.
How Obesity Is Defined Globally
The World Health Organization (WHO) recognised obesity as a chronic disease in its 1997 report “Obesity: Preventing and Managing the Global Epidemic”, in which obesity was described as a complex disease that was part of the non-communicable diseases (NCDs) cluster that requires prevention and management strategies at both individual and societal levels.
Countries in the European Union have since followed suit in recognising obesity as a chronic disease, while the American Medical Association passed a motion describing obesity as a “disease state with multiple pathophysiological aspects” in 2013.
In the United Kingdom, obesity is not considered a disease despite recommendations by the Royal College of Physicians (RCP) in 2018 that the recognition will offer clarity for health care professionals, prioritise access to treatment, reduce stigma surrounding the condition, and encourage governmental action to prioritise strategies to reduce the prevalence of obesity in the UK.
Some of the arguments or concerns raised against recognising obesity as a disease highlighted in the 2018 paper included labelling significant sections of the population with disease and overwhelming the health system, particularly general practice.
RCP experts, led by Oxford University’s Prof John Wass, a professor of endocrinology, however, argued that a brief physician-led intervention can be an acceptable way to discuss weight in patients who were already being seen in primary care.
They also alluded to potential improvements in the referral process that would allow general practitioners to direct patients to specialist weight management services that are better placed to manage severe complex obesity.
The Case In Southeast Asia
Countries in Southeast Asia have yet to unanimously declare obesity as a chronic disease. Despite being linked to various over 200 other chronic diseases including cardiovascular diseases, diabetes, and cancer, obesity is often neglected by primary care providers.
In Malaysia, recognised by medical journal The Lancet as the most obese country in Asia, obesity is defined as a “complex, multifactorial condition” with treatments covering exercise, diet therapy, behavioural therapy, medication and surgery.
In Singapore, obesity is similarly defined as a “condition of abnormal or excessive accumulation of body fat” to the extent that health may be adversely affected and is “associated with various major chronic diseases”, including cardiovascular disease, type 2 diabetes mellitus, and cancer, according to its 2016 Health Promotion Board-MOH clinical practice guidelines.
Data from the World Obesity Atlas 2022 show that the prevalence of obesity globally is predicted to double to over a billion people in 2030 from 2010.
In Southeast Asia, about 23 million men and 38 million women had a body mass index (BMI) of 30kg/m2 or more in 2010. Yet, this is likely an underestimation for the region as adults and children of Asian descent experience obesity at lower levels of BMI, compared to the cut-off points adopted for global estimations.
The current WHO guideline classifies cut-off points for overweight and obesity as 25 and 30 kg/m2 respectively. However, it has been argued that there is a high prevalence of type 2 diabetes and cardiovascular risk factors in parts of Asia below the cut-off points.
In Malaysia, the Ministry of Health’s (MOH) clinical practice guidelines on the management of obesity published in 2004 recommended that the cut-off point for overweight to be 23 kg/m2 and for obese at 27.5 kg/m2. In Singapore, similar cut-off points for overweight and obesity are used, according to the National University Hospital.
Apart from calls to recognise obesity as a chronic disease, the regional consensus – composed of 14 experts from 10 countries in South and Southeast Asia – has developed 42 recommendations to guide obesity care in the region.
The guideline covers medical goals of diagnosis and management, personal aspects of psychological and social support, as well as cultural nuances influencing dietary habits, beliefs, and attitudes.
“Despite the size and diversity of this region, there are sufficient cultural and social demographic similarities to justify this shared effort,” Oldfield said. “It is our hope that with clear definitions and recommendations, we are one step closer to optimum care for people living with obesity in South and Southeast Asia.”
The consensus was presented at the International Congress of Obesity in Melbourne on October 19. It is currently awaiting publication.