I attended the Obesity Medicine Association Conference last month and wanted to share some of the information that I learned. One of the presenters, Dr. Craig Primack, who co-wrote the book Chasing Diets: Stop The Endless Search and Discover the Solution, (Ziltzer & Primack, 2019) shared the latest scientific research and discussed why we struggle to lose weight and why it’s really not our fault.
Many people including health care professionals think being overweight /obese is a self-treatable condition that just requires patients to move more and eat less. Society looks at overweight people as lazy and lacking self-control. That way of thinking is out of date and has been scientifically proven wrong (Ziltzer & Primack, 2019). The World Health Organization (WHO) recognizes obesity as an “abnormal or excessive fat accumulation that presents major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer” (World Health Organization [WHO], 2019).
The CDC defines chronic disease as “conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both” (Centers for Disease Control and Prevention [CDC], 2019, para. 1). They also list “heart disease, cancer, and diabetes as the leading causes of death and disability in the U.S.” (CDC, 2019, para. 1). What do all 3 of those have in common? Obesity is the leading cause of all three diseases.
In 2013, the American Medical Association (AMA) finally recognized obesity as a chronic disease, which is controlled by physiology (Ziltzer & Primack, 2019). This means that the body has a physiologic response that causes us to gain weight. Although the AMA now recognizes obesity as a disease, the mainstream medical community and insurance companies have not caught up with a comprehensive treatment plan or cost coverage. Insurance companies pay for medications for many chronic diseases but not the ones that will prevent chronic disease which are the obesity medications.
Do you ever wonder why you struggle losing weight and keeping it off? It’s not because you have no self-control or lack motivation. You don’t consciously make a choice to be overweight, just as people with cancer or diabetes don’t choose to have those diseases. “Obesity causes our organs to function improperly leading to heart disease, diabetes, fatty liver, cancer, arthritis, lumbar disc disease, sleep apnea, edema, and increased pressure on the brain” (Ziltzer & Primack, 2019, p. 12). Therefore obesity is the underlying cause of many chronic diseases and must be treated long term. You wouldn’t take blood pressure medicine for 3 months and then stop or take diabetic medicine for a few months and stop. Why would we treat obesity any different?
As part of the chronic disease process of obesity, our fat can become sick leading to adiposopathy where the fat cells blow up like a balloon and release inflammatory markers like interlukin and tissue necrosis factor; which leads to high blood pressure, high blood sugar, and swelling of the arteries (Ziltzer & Primack, 2019). The inflammation process can lead to metabolic syndrome which is why obesity can be put in remission but not cured. Losing weight is a way of gaining control of your obesity just like taking medication for other chronic diseases.
So why do we lose weight only to regain it all back and more? When we lose weight it alters the hormones in our body that increase hunger (grehlin) and fullness or satiety (leptin). These changes can continue until we regain the weight back to our baseline or highest lifetime weight, sometimes called a set point (Ziltzer & Primack, 2019). Even though we are decreasing our calorie intake, our body will store those calories as fat get back to the set point. This also decreases our metabolism. In order to increase metabolism, we need to exercise. Hunger can be controlled with medication and eating small frequent meals throughout the day.
The physiological response to weight gain can be due to thyroid hormones, insulin, and cortisol. The thyroid hormones responsible for controlling metabolism are T3 and T4. The release of T3 can rapidly increase metabolism but as we lose weight, T3 decreases causing the “famine response” (Ziltzer & Primack, 2019). The body stops losing weight as it holds onto every calorie consumed even though it is very calorie restricted. Long term dieting causes T3 to be converted to reverse T3, which is a less active form.
Insulin controls weight by moving sugar from the bloodstream into the cells. The pancreas secretes insulin when blood sugar levels are high. If sugar levels remain high it can lead to organ damage. So to protect the body, the pancreas secretes more and more insulin so that the sugar can be moved out of the blood and stored as fat to be used later as energy. “Insulin is the primary driver of fat storage” (Ziltzer & Primack, 2019, p. 20). That is why a high carbohydrate diet leads to increased weight gain.
Cortisol affects weight gain. It is released from the adrenal glands above the kidneys in response to stress. Cortisol is necessary in times of acute or chronic stress to help us live and respond. High levels of cortisol increase sugar, which increases insulin, which leads to increased fat storage. When we have high levels of stress or we don’t get enough sleep (another stressor), cortisol increases and causes fat to be stored around our abdomen, waist, and thighs. This is why people who take high doses or corticosteroids gain weight around their midlines and their extremities remain skinny. That is the effect of high cortisol.
Obesity must be treated by someone who specializes in Obesity Medicine, just like diabetes or heart disease are treated by specialists in Endocrinology and Cardiology (Ziltzer & Primack, 2019). Physicians specialized in Obesity Medicine are qualified to treat obesity and utilize the four pillars: Nutrition, Activity, Medicine, and Behavior. Treating obesity requires intensive counseling that takes more time than putting someone on a pill and asking them to come back in 2 weeks. Most primary care physicians don’t have time to counsel weight loss patients. That is why specialists on Obesity Medicine are important in the management of this epidemic. Their only focus is treating obesity, which improves other chronic conditions at the same time.
Centers for Disease Control and Prevention. (2019). About Chronic Diseases. Retrieved from www.cdc.gov/chronicdisease/about/index.htm
World Health Organization. (2019). Obesity. Retrieved from www.who.int/topics/obesity/en/
Ziltzer, R., & Primack, C. (2019). Chasing Diets Stop the Endless Search and Discover the Solution. Dublin, OH: Telemachus Press.