A few months back, I was having a casual discussion with a medical doctor on the growing number of obese children in Malaysia: we rank second highest in child obesity among children in ASEAN aged five to 19 years, and we come in first as the “fattest” nation in the region — the general numbers of obesity in adults reached the highest prevalence in South-East Asia, where a 2019 National Health and Morbidity Survey reported a 50.1% overweight population.
Along the lines of this discussion was a valid concern of where this health epidemic would lead to: the facts and numbers were frightening enough, and the rapid rate of COVID infections at that time made us think that the public health sector was a little over its head. But as we continued to gush over obesity in Malaysia, the medical doctor concluded that the best way to solve the crisis was for “fat people to just stop eating”.
I was appalled.
I grew up with a father who was clinically diagnosed with, among other things, obesity and diabetes — in a lot of the social cases that I work with at Doctors On Ground (DnG) and Women For Refugees (WFR), the two almost always come hand in hand. “Diabesity” was actually newly-termed to refer to the worldwide epidemic of increasing numbers of patients who were suffering from both obesity and Type 2 diabetes.
Throughout those years, I’ve personally witnessed how much of a role fancy diets and exercise, mass media and the medical-pharmaceutical industry play in determining the ups and downs of my father’s recovery process. This would always be accompanied with the narrative that obese people are lazy and unclean (Weight Bias & Obesity Stigma is discussed later on in the last chapter) — a narrative that I was then interacting with on a casual discussion with a medical doctor.
As convincing as the medical terms she threw around to justify her argument was, I was sure that recovering from being obese was more than just “to stop eating altogether”. There are huge gaps where psychosocial support, mental health and new advances in pharmacotherapy can come in to develop more effective recovery programmes, especially ones that physicians and other healthcare providers could adopt and advise their patients on, instead of writing it off as “eat less”.
This “Caring For Obesity As A Medical Issue” article is inspired by my many interactions with people from the healthcare industry, who by some context, assume the same opinion. The decision to start writing and publishing again on theflyingolives is rooted back to my belief that some stories are not told enough; differing opinions on Malaysia’s medical industry and global developments in medicine is gatekept to healthcare providers and personnel to ensure that there isn’t a falseness in what is being published — so as I explore this new obsession with medicine and politics, I will tread lightly with my opinions, and secure them with the relevant references and citations necessary to get my point across.
Obesity Week Run-Through: The Future of Obesity Care
In the past week, ObesityWeek ran its annual meeting — this time, virtually, to accommodate the discussions surrounding obesity, and attended/hosted by world-renowned experts, scientists and medical professionals.
In his lecture What Does The Future Of Obesity Care Look Like? , Lee M. Kaplan, MD, PhD, asked his audience an interesting question: “If it (obesity) were diabetes, cancer, HIV, or Alzheimer’s, how would you discuss it, approach it, assess it, treat it?”
Dr. Lee, who is the director of the Obesity, Metabolism, and Nutrition Institute at Massachusetts General Hospital and an associate professor at Harvard Medical School, summarised his talk by introducing better pharmacotherapy treatments through a shared understanding on obesity as an illness, and the role of primary care in proper implementation.
He made the case that the sheer magnitude of obesity as a prevalent problem starts at first contact. The acknowledgment of obesity as a disease must be prioritised especially among primary care physicians who are more often than not the frontline providers in diagnosis and treatment prescription, but are generally not specialised in obesity as a medical disease.
There is a common understanding that obesity is a result of a patient’s poor personal habits, and not a dysfunction of the body.
Dr. Lee argues that while this absence of understanding obesity is no one’s fault as it’s not taught in medical schools; it is the responsibility of modern medical institutions to acknowledge that this very understanding is the critical first step of recognising obesity as a disease that reflects disruption in body physiology. Within this same context, the loss of fat is done autonomically, executed by a regulatory system that’s programmed into each individual.
The development of non-invasive therapies that are challenging bariatric surgery to be more effective in weight loss outcomes was introduced through semaglutide — a recently-approved anti-diabetic medication used to treat Type 2 diabetes and chronic weight management.
It is assumed that when a shared understanding of what obesity is and what it is not is achieved, only then can the medical community start developing and implementing strategies that are within the practice model of primary care, and one that implements effective weight management predicated on the belief that obesity is a disease disrupting normal physiology and autonomic regulation.
In his lecture, Dr. Lee puts forth the question of biology: “Obesity results from inappropriate pathophysiological regulation of body fat mass,” he explains in the beginning, and as such, recovery and treatment programmes vary widely among individual patients.
The general treatment plan for obesity starts with lifestyle changes, pharmacotherapy, then possibly bariatric surgery. The patient would be prescribed in some manner to phentermine/topiramate, orlistat, naltrexone/bupropion, or liraglutide — which in comparison to the semaglutide, the latter could contribute to treatment options that are much more affordable and accessible for patients in the future.
This route would lead to more familiarity using pharmacotherapy for obesity as routine among frontline providers. The size of the obesity epidemic requires the leadership of the primary care community as the future of effective treatment has to be within the normal scope of primary care practice. This can be achieved by simply allowing primary care providers to do what they naturally do — evaluate patients, diagnose diseases and treat them with a variety of medical approaches and prescriptions — and as their practices don’t generally include long-term counselling, surgery or other invasive procedures, it becomes a lot easier to incorporate effective treatment into a routine primary environment.
The Famed Drug, Semaglutide
The clinical trial of semaglutide at the University of Alabama at Birmingham (UAB) found that a combination of pharma and behavioural intervention in patient weight loss has been a game-changer, where participants would lose an average of 37 pounds, or anywhere near the 15–20% margin of their body weight.
The trial is consistent with the Obesity Treatment Guidelines by the American Association of Clinical Endocrinology, authored by Timothy Garvey, M.D, who expressed that higher doses of semaglutide could treat and prevent diabetes, osteoarthritis and other related diseases, and similarly, cure the consequences and complications of obesity.
The drug was designed to regulate the body’s production of insulin and decrease appetite. This, coupled with mostly mild gastrointestinal side effects, does not take away the disease completely, but it has been proven to elicit significant weight loss and make a real medical and aesthetic difference. It could essentially represent the preferred and improved weight management — lifestyle interventions like diet and exercise remain to hold that cornerstone — and propose long-term sustainability in weight loss, which is usually the biggest challenge.
To determine the long-term effectiveness of the new hormonal drug, however, Dr. Robert F. Kushner, an obesity researcher and clinician at Northwestern University, suggests that more trials are required to understand the larger biological context of the body’s response to the drug. Nonetheless, the potential for semaglutide to reduce the risk of cardiovascular events and overall, decrease the number of hospitalisations linked to obesity-complications is incredibly promising for the entire medical community to be venturing into.
Weight Bias & Obesity Stigma
In a New York Times article written by Gina Kolata, she reported that people suffering from being obese are more likely to be treated poorly by doctors and other healthcare workers, who would then offer fewer preventive servies and effective medication. The belief that the excess weight is the patient’s own fault, and that they need to eat healthier and exercise, has been conditioned and enforced by the medical community.
The continued stigma and discrimination towards obese people are not only pervasive, but also pose countless consequences that, in one way or other, may interrupt their journey of recovery and treatment. It is usually justified as motivation for patients to adopt healthier behaviours. This, more often than not, threatens the patient’s psychological and physical health, generates health disparities, and interferes with intervention efforts.
“We may need to use a term like ‘disease.’” Dr. Kushner says when addressing the persisting bias surrounding obesity. He likens it to conversations on alcoholism and drug addiction, which, owing to the years of research and outreach programmes, has successfully shifted to accessible treatment for drug or alcohol abuse. It was once thought to be indicative of having weak morals.
Similarly, a 2010 study on obesity highlighted that weight stigma serves as both a social justice issue and a priority for public health. In their report titled “Obesity Stigma: Important Considerations for Public Health”, Rebecca M. Puhl, PhD and Chelsea A. Heuer, MPH documented the common stereotypes that the overweight and obese lack self-discipline and are lazy, as extremely harmful within multiple domains of living: the workplace, healthcare facilities, educational instiutions, mass media and even in relationships.
On the topic of public health, stigma is a known enemy, with the common narrative of immoral, unclean and lazy targeted at groups suffering from an illness. Historically, this is replicated in the 1990s cholera outbreak of Irish-born immigrants and a century later, the tuberculosis wave killing large numbers of African Americans.
The social construction of disease has always incorporated moral judgements that are driven by preexisting hostility. For an obese individual, they’re regarded as architects of their own ill health who brought it upon themselves due to their laziness and overeating.
The connection between generalised weight stigma and mental health is commonly linked as it can invoke psychological stress leading to poor outcomes reflected in physical health. It, as such, threatens access to quality healthcare where both self-report and experimental research demonstrates that negative perceptions of obese people are shared among healthcare providers and fitness professionals.
The lack of effort to regard obesity as a serious medical issue and not a cosmetic one prevents better understanding of the cumulative effects of weight stigma on public health.
Concluding Chapter
When I first came across the developments of the semaglutide drug, it was on a Medscape article summarising the events covered by ObesityWeek. I vividly remember mentally categorising Dr. Lee’s presentation as an extended agenda of the Medical-Pharmaceutical Industrial Complex, which simply refers to a handful of corporations supplying healthcare products and services at maximum cost for profit. This could essentially look like investing in research and medical institutions, or funding physicians to adopt a specific product and service to limit consumer options.
On one end, a debate can be made against the ruling that a new drug in the market would completely ignore the way sugar drives metabolic derangement, and the fact that it, in totality, significantly contributes to the diabesity epidemic. This opinion, in particular, was spearheaded by V. Johnson and Dr. Titus Abraham, a registered nurse and internal medicine specialist based in the United States.
On the other, one could argue that lifestyle changes and diet doesn’t always work for the many people suffering from obesity. Take Marleen Greenleaf, for example, who was briefly discussed in the New York Times article I referenced in the previous chapter: she, like many others, have tried diet after diet, but only saw significant change when she participated in a clinical trial for semaglutide. If pharmacotherapy is the answer to triggering physical improvements quicker than getting on a treadmill or micromanaging calories — wouldn’t that be the best step to recovery?
While more PSA and education campaigns should take on the processed and fast foods industry to prevent the numbers of diabesity from scaling up higher, I don’t think semaglutide and the introduction of newer drugs work in opposition to that — it’s definitely a better option for someone scheduled to undergo a bariatric surgery. It specifically counters the idea that tackling obesity is an intrusive procedure when it shouldn’t be.
However, it is what it is — the advocation of investing in more drug, drug studies and drug promotions begs the literal question: do obese people need more drugs?
References
https://www.medscape.com/viewarticle/962302#vp_1
https://reference.medscape.com/drug/ozempic-rybelsus-wegovy-semaglutide-1000174
https://health.clevelandclinic.org/diabesity-the-connection-between-obesity-and-diabetes/
https://www.uab.edu/news/research/item/11961-who-will-benefit-from-new-game-changing-weight-loss-drug-semaglutide
https://www.nejm.org/doi/full/10.1056/NEJMoa2032183
https://health.clevelandclinic.org/diabesity-the-connection-between-obesity-and-diabetes/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/
https://www.nytimes.com/2021/05/11/health/obesity-drugs.html
