Obesity Diagnosis: A “Silent” and Multifactorial Disease

How many doctors consider their patients’ food choices, physical activity level, weight, and BMI as vital signs during an assessment and when analyzing the clinical picture? How many of them feel comfortable to discuss weight issues with their patients or are interested to go through the certification process to become Obesity Specialists? And, how many have received the proper training in Obesity Medicine prior to graduating from medical school? Dr. Harminder Kaur explains “Obesity medicine is a form of primary care that uses an individualized, scientific, and comprehensive approach for patients with health problems due to excess weight. With the certification, doctors learn about the various factors that influence a particular patient’s obesity”. (9)

Obesity, also known as “the weight gain emergency” (14), is the second leading cause of death in the US. (4) It is a chronic and complex disease that is not recognized by many people and underdiagnosed by many doctors. Obesity is a disease like any other; and, like other diagnoses, it has its own unique code that is often not documented following a doctor’s visit. There is a genetic basis for obesity and like any other disease, it must be addressed professionally. This is in alignment with the work of Dr. Fredric Abramson who’s U.S. Patent: a System and Method for Evaluating and Providing Nutrigenomic Data, Information and Advice (7877273) which describes matching genes to nutrient ingredients to lower disease risk. (15)

A recent study by McMaster University researchers has proved that there are nine genes that predispose one to weight gain if he/she has a high BMI. These nine genes include FTO (rs1421085 and rs6499653), PCSK1 (rs6235), TCF7L2 (rs7903146), MC4R (rs11873305) FANCL (rs12617233), GIPR (rs11672660), MAP2K5 (rs997295), and NT5C2 (rs3824755). (3) As indicated on the CDC website other genes than those mentioned above that are linked to obesity include ADIPOQ, LEP, LEPR, INSIG2, and PPAR. (6) According to Dr. Sara Gottfried, five genes that make it harder to lose weight are FTO (affects food intake), PPARG (affects fat metabolism), ADRB2 (affects fat breakdown), and PGC1-alpha and Tfam (affect methylation). (7)

More people are obese these days as compared to previous years, leading to our current obesity epidemic and public health crisis with an increase in the number of bariatric surgery patients. “Worldwide, obesity has more than doubled since 1980, with more than 600 million adults affected” (Obesity Action Coalition). This does not include childhood obesity which is also on the rise. “Obesity rates among children in the U.S. have doubled since 1980 and have tripled for adolescents. 15% of children aged 6 to 19 are considered overweight. Over 60 percent of adults are considered overweight or obese” (Stanford Health Care). Kudos to pediatricians who are addressing obesity professionally, by neither fat shaming nor ignoring the issue. When obesity is addressed early, it can help prevent it from being a diagnosis later on in life. Also, when obesity is treated properly, it can reduce the risk and even reverse chronic conditions that go hand-in-hand with it.

In order for us to be aware of this “silent” disease that often leads to other diseases like diabetes, hypertension, hyperlipidemia, fatty liver disease, cancer, osteoarthritis, sleep apnea to name a few, we need to realize there is a physiological, psychological, genetic, as well as a lifestyle component. Heather Flannery’s Twelve Pillars® Model, depicts the complexity of obesity which explains how one must manage his/her “individual pillars” as well as the “population pillars” in order to achieve and maintain a healthy weight. These individual pillars include “cognition, addiction, nutrition & microbiome, hormones & metabolism, exercise & activity level, and sleep, stress, & immunity”. (13) The population ones include “education system & parenting, workplace & business culture, community & lifestyle planning, food policy production & delivery, healthcare policy & delivery, and finance instruments & funding”. (13) Even if we cannot control the genetic aspect, we definitely have control over the lifestyle. It is a choice and a way of living to be healthy individuals, whether at home, at work, or even at gatherings/functions. In my practice, I have seen my clients not only lose the weight, but also have better health and quality of life, by having fewer diagnoses, an improvement in their blood test results, and a decrease in their medications. Some clients even did not need any medications after the weight loss. These success stories contribute to my passion for Obesity Medicine.

There is a “lifetime progression” of obesity, from maternity to childhood into adulthood and finally to elderly years. And, there is also different levels of treatment or coordination of care which include “prevention programs; commercial, non-clinical programs, medical obesity treatment programs, pharmacotherapy, non-surgical endoluminal procedures, primary metabolic & bariatric surgery, revision bariatric surgery, and post-weight loss reconstructive surgery”. (11) Just like any other disease, anyone affected by obesity is fighting a battle and needs to receive equal and comprehensive treatment. In addition, their unique needs and goals must be respected and addressed by healthcare professionals with no fat shaming. Rather than focusing on weight loss, health care providers can work with patients on making healthier food choices, incorporating physical activity, and managing stress. The end result is seeing the positive effects of cognitive therapy which helps patients to lose weight as well as maintain the weight loss. If primary care physicians do not feel comfortable addressing weight issues with their patients or do not know how to treat obesity, then they need to refer these patients to local obesity specialists. Dr. Harminder Kaur emphasizes, “It is critical to consider all components that contribute to the complex etiology of obesity when assisting patients with weight loss and health goals”. (9) All healthcare professionals should use a more positive and non-judgmental approach while caring for their patients. In other words, they would focus on their patients’ strengths as they work together on the challenges to reach the identified health goals. This simple shift in thinking can encourage patients to accept themselves and use their inner strengths to deal with their current health issue or situation, regardless of what they are going through or their present body image. And, of course, it also promotes a sense of trust and collaboration between healthcare professionals and patients which leads to better health outcomes. Dr. Melody Covington outlined five key points for treating obese patients. These include “1) be empathetic, 2) check weight management bias at the door, 3) avoid weight gaining medications when possible, 4) do not dismiss weight loss solutions, and 5) refer to an obesity specialist”. (5)

Since 2003, Walk from Obesity has helped focus more attention on obesity as a disease as it supports the mission of The American Society for Metabolic and Bariatric Surgery (ASMBS) Foundation, namely to “raise funds that directly support critical research and education on obesity, increase scientific and public awareness and understanding of obesity as a disease, and improve access to quality care and treatment for Americans with obesity”. (2) Since 2015, National Obesity Care Week has been in place to help cure this obesity epidemic while supporting those affected by this serious disease. Because of the severity of obesity and the need to raise awareness of this disease, there are other annual events such as National Obesity Day, Anti-Obesity Day, and National Childhood Obesity Awareness Month as well as companies targeting this patient population such as CoreLife, Ideal Protein, Lindora, and MyShapers to mention a few. More primary care doctors and specialists such as cardiologists, endocrinologists, and obstetricians and gynecologists are beginning to see the importance of incorporating the Ideal Protein Protocol in their practice. In addition, organizations that work hard to reverse weight bias include American Board of Obesity Medicine, ASMBS Foundation, Eisai US, Ethicon Inc., Medtronic, Novo Nordisk, Obesity Action Coalition, Obesity Medicine Association, and The Obesity Society.

Obesity Medicine almost goes hand in hand with Culinary Medicine. Cooking is an Instrumental Activity of Daily Living (IADL) skill that should be taught to clients to help put an end to the fast food culture which has encouraged the obesity epidemic and health crisis. Dr. John La Puma describes Culinary Medicine as a “new evidence-based field in medicine that blends the art of food and cooking with the science of medicine”. He explains “Culinary medicine, like prescribed exercise, should become another tool in a clinician’s toolkit. One such format for writing culinary medicine prescriptions is FOOD: Frequency (of the food, beverage, or meal to be eaten); Objective (its goal); Options (how much, and different methods to prepare, serve, shop for it, or grow it); Duration (how many times per day, week, or month the prescription should be consumed). This format is simple to follow and patterned after how clinicians prescribe medication”. (10) Dr. Shad (Farshad Marvasti) has been working hard to redesign the medical school curriculum. He explains “my goal is to transform medical education to equip future doctors with the tools they need to advise their patients on how to use food as medicine and therapeutic lifestyle changes such as regular exercise and mindfulness activities such as yoga or tai chi to prevent sickness and maintain health”. (12) In his practice, Dr. Shad is using food prescriptions” as part of his treatment plan for patients. (1) Dr. Travis Stork emphasizes “The biggest emergency in ERs across the United States is the food we willingly, knowingly, happily choose to eat. Our food choices are so dangerously unhealthy that eating-related diseases send twice as many people to the hospital ER than injuries and accidents”. (14) As Hippocrates said “…eating alone will not keep a man well; he must also take exercise. For food and exercise, while possessing opposite qualities, yet work together to produce health”. (8, p. 229) In other words, food and exercise is medicine. At the ESSA Conference 2018, Dr. Robert Sallis explained the notion of “A Drug Called Exercise”. If this really existed and if there was another one called Food, then there would be definitely more preventative measures, less chronic conditions (including obesity), leading to more positive outcomes and better health.
After we have an awareness about obesity, we can decide if we are truly ready for this “new life” and way of living. By choosing a healthy lifestyle, it means choosing healthier meals and snacks, incorporating exercise into our daily routine, managing stress, and having better sleep habits. With these preventative measures, we actually lessen our chances of having other illnesses and reduce the number of medications we take or even eliminate them altogether. I have seen this in practice during my patients’ healthy lifestyle & weight loss journey. Whether you or a loved one are suffering from obesity, it is never too late or impossible to make a change to embark on the journey of optimal health. It requires an understanding, a commitment, patience, and goal setting. Believe in yourself, set small achievable goals, and “be the change” one step at a time.

REFERENCES

1. About Me. Retrieved from https://www.doctorshad.com/about
2. About Us. Retrieved from https://www.walkfromobesity.com/about-us/
3. Abadi, A., Alyass, A., du Pont, S. R., Bolker, B., Singh, P., Mohan, V., … & Meyre, D. (2017). Penetrance of polygenic obesity susceptibility loci across the body mass index distribution: an update on scaling effects. BioRxiv, 225128.
4. Boseley, S. (2016, July 13). Obesity causes premature death, concludes study of studies. Retrieved from https://www.theguardian.com/society/2016/jul/13/obesity-causes-premature-death-concludes-study-studies
5. Covington, M. For Providers: 5 Tips for Treating Obesity in Your Patient. Retrieved from http://melodycovingtonmdconsulting.com/blog/
6. Genes and obesity. Retrieved from https://www.cdc.gov/genomics/resources/diseases/obesity/obesedit.htm#table
7. Gottfried, S. 5 genes that make it hard to lose weight, and what you can do to combat them. Retrieved from http://www.saragottfriedmd.com/%E2%80%8Efive-genes-that-make-it-hard-to-lose-weight-and-what-you-can-do-to-combat-them/
8. Hippocrates. Hippocrates, translated by Jones WHS, translator. London: William Heinemann, 1923, vol. 1.
9. Kaur, H. (2018, July 25). Understanding Obesity. Retrieved from https://www.linkedin.com/pulse/understanding-obesity-medicine-dr-harminder-kaur/
10. La Puma, J. (2016, February 1). What Is Culinary Medicine and What Does It Do? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4739343/
11. Managed Ecosystem℠ for Integrated Obesity Treatment. Retrieved from http://www.obesityppm.com/managed-ecosystem
12. Marvasti, F. Redesigning Medical Education. Retrieved from https://www.doctorshad.com/redesigning-medical-education
13. Obesity PPM’s Etiological Framework: The Twelve Pillars®. Retrieved from http://www.obesityppm.com/our-point-of-view https://www.facebook.com/TwelvePillars/
14. Stork, T. (2015) The doctor’s diet. New York, NY: Grand Central Life & Style
15. System and method for evaluating and providing nutrigenomic data, information and advice. Retrieved from https://www.google.com/patents/US7877273