Obesity

Corpulence is not only a disease itself, but the harbinger of others
Hippocrates

Hippocrates, the father of medicine, referred to obesity as a disease around 400 BCE. Then in 2013 the American Medical Association finally caught up and added obesity to its list of diseases. Their reluctance is understandable since obesity is not actually a disease, it is a sign of disease, although this depends on how we define obesity (a sign of disease is a physical state that can be observed and measured).¹

The World Health Organization defines obesity as a chronic complex disease of excessive fat deposits that can impair health. This is difficult to evaluate because people can have a high body fat percentage and still be healthy, and a normal body fat percentage and be unhealthy, with many of the signs and symptoms associated with obesity. To define obesity as a disease the definition should, and sometimes does, include other signs or symptoms, such as elevated cholesterol or blood pressure. If we are going to define obesity simply as having excess body fat that may or may not impair health, then it should be categorised as a condition rather than a disease.²

The WHO’s criteria for diagnosing obesity in adults is having a body mass index over 30, and overweight as a body mass index between 25 and 30. This is problematic since some people, such as bodybuilders, can have a high BMI and a low body fat percentage. According to The American Society of Bariatric Physicians, body fat in excess of 25% for men and 32% for women constitutes obesity. It is difficult to determine body fat percentage though, whereas BMI is easily measured, and a good indicator of a weight related health issue in the vast majority of cases.²

If obesity is really a sign of disease rather than a disease itself, then what diseases is it a sign of? You probably know some of the answers to this already, such as type 2 diabetes and heart disease. It can also be a sign of cancer, kidney and gallbladder disease, and osteoarthritis, although it is really more a risk factor than a sign of disease. And of course it is the poor dietary choices that lead to obesity that increase the risk of developing these diseases, so the real risk factor is a poor diet, and obesity a sign that the diet is poor.

Obesity is also associated with sleep apnoea, anxiety and depression, although it may be a direct cause of these disorders rather than a sign of them. And obesity is a direct cause of impaired mobility, but for some reason we rarely talk about this. If you want to get an idea as to how much effort it takes an obese person to carry the extra weight around then the next time you go to the supermarket pick up a couple of cases of soft drink and walk up and down the aisle with them. A case of thirty 375ml cans weighs 12kg. Someone who is 178cm tall (5’10”) with an ideal weight of 70kg (BMI 22) would weight 95kg if their BMI was 30, so the excess weight they are carrying is more than two thirty can cases of soft drink. Imagine having to carry this around all day every day.

If obesity were simply due to poor diet and lifestyle choices it would be an easy fix, because good choices are readily available. Obesity, though, is a complex condition that can be very difficult to reverse. Indeed, obesity is due to what has been termed an ‘obesogenic environment’, a combination of psychological and social factors that push us towards gaining weight.

Addressing the problem at a societal level will require changing this obesogenic environment. The changes should aim to create a supportive environment that encourages healthy eating habits and regular physical activity, and should make healthy food the most accessible, available, and affordable option. It is essential that we do this because the global obesity epidemic is rampant. According to the 2022 WHO Fact Sheet on obesity:²

• 2.5 billion adults were overweight. Of these, 890 million were obese.
• Over 390 million children and adolescents aged 5-19 were overweight, including 160 million who were obese.
• 37 million children under the age of 5 were overweight.
• From 1990 to 2022 obesity in adults more than doubled worldwide, and adolescent obesity quadrupled.

The problem is not just the suffering of the afflicted, it is also the financial cost to society, which is high and rapidly increasing. The medical costs of obesity in the US were estimated to be $260.6 billion in 2016, and other developed countries are facing similar costs. If current trends continue the global cost of overweight and obesity is predicted to reach $3 trillion per year by 2030, and more than $18 trillion per year by 2060.³

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To say someone is overweight because they eat too much is too simplistic. We eat what we do because we crave these foods, and we usually crave food because we need nutrients. We can only crave the foods we know, so if you rarely eat fruit and vegetables you are not going to crave them. If the foods you eat are high in calories, like bread, pasta, cakes, pastries etc, then these are the foods you will crave.

If you are craving food because you need vitamins and minerals, and you are sourcing them from high calorie foods, then you are going to get fat. If you then go on a crash diet to lose weight, all you are doing is teaching your body that you cannot be trusted to provide it with the nutrients it needs, so it will regain the weight as soon as you stop, and maybe add a bit more to prepare for next time. The solution to this is to change the foods you eat, not eat less of what you currently eat.

If you eat junk food because it makes you feel good, rather than because you are hungry, then you will need a different approach. These ‘comfort foods’ are invariably the foods high in sugar, fat, and salt that trigger the release of feel-good chemicals in the brain, or those that we grew up eating and remind us of our childhood.

To address this issue you need to find another way to feel good. For most people with a weight problem, losing weight is a great way to improve your mood, so if you can get into a good routine then you should do well. I suggest you start by eating three healthy meals a day, and the comfort foods only at night. Think of the comfort foods as your reward for eating well during the day so that you do not feel guilty about it. Then slowly reduce the amount of junk food you eat at night until it is a single serve per day (see food tables in the appendices). You should do some form of exercise too, but make it something you enjoy. Walking is okay to start with, but as you lose weight you should increase the intensity of the exercise.

If you struggle to lose weight then put it back on easily, even without eating a lot of calories, you may have a high fat set point, and you need to change the way you eat. The traditional view that dieting is all about calories in versus calories out does not apply to you. Your body has decided how much fat it wants to carry, and it can be very stubborn about keeping it. Research into how to lower our fat set point is ongoing, but periodic modified fasting and time restricted eating are showing promise.⁴

One version of periodic fasting is the 5:2 diet, where you restrict your caloric intake to 25% of your regular intake for two, usually consecutive, days a week. This has been shown to facilitate weight loss in people with a high fat set point, and to improve metabolic biomarkers.⁵

With time restricted eating you maintain your overnight fast for 14 or 16 hours, so that you only eat during an 8 or 10-hour period during the day. A 14 hour overnight fast can help with symptoms of IBS, especially if it is associated with SIBO. And a 16 hour overnight fast can reduce insulin resistance and help you lose weight, although it should be done under medical supervision if you have diabetes or cardiovascular disease. Something else that has shown to lower a high fat set point is exercise.^{5, 6}

The problem of obesity can be exacerbated if our digestion is poor. Considering what we know about our gut microbiome’s role in nutrient availability, it should be no great surprise that it plays a role in obesity. The fact that our gut flora provides us with the B vitamins involved in energy production shows how important it can be. A disordered gut flora can promote weight gain through a variety of mechanisms, including altered energy production, and immune and gut hormone regulation.⁷

Another factor driving the obesity epidemic is environmental pollutants, especially endocrine disrupting chemicals. ECDs, which include heavy metals, pesticides, and the BPA emitted from plastic, can disrupt fat and glucose metabolism, modify our genes, and effect our leptin level, which regulates our appetite. Even exposure to ECDs in the womb can be enough to lead to weight gain later in life.⁸

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If you cannot manage to lose weight by yourself then you should seek professional help. First see your doctor to ensure that you do not have a medical condition that is adding to the problem, such as low thyroid function. Then consider joining a weight loss group and attend regular meetings. And think about going to see a natural therapist of some kind. Anything you do to improve your general wellbeing will help you lose weight and to keep the weight off.

If you have done all this and you are still struggling to lose weight then you might want to talk to your doctor about using a weight loss drug. This must be done under medical supervision, because anti-obesity drugs can have severe, and in some cases lethal, side effects. Of the 25 anti-obesity drugs withdrawn from the market between 1964 and 2009, seven were linked to the deaths of their users. Having said this, there is a new drug on the market that is effective and appears to be safe—semaglutide (AKA Ozempic and Wegovy).⁹

Semaglutide works by slowing down stomach emptying and inducing a feeling of fullness. It also increases insulin production and inhibits the release of glucose from the liver, making it particularly useful for obese people with type 2 diabetes. Ozempic is given to people with diabetes and Wegovy to those without, but they are the same drug, given in the same way, with some minor differences in their dosing regimens.¹⁰

Clinical trials have shown semaglutide to be remarkably effective considering it does not directly facilitate weight loss. In a study published in the New England Journal of Medicine, 1,961 overweight or obese participants who did not have diabetes were given either semaglutide 2.4mg weekly or a placebo for 68 weeks. They were then encouraged to eat 500 calories per day less than they had been, and to complete two and a half hours of exercise a week. Dietary intake and exercise were recorded daily, and participants received lifestyle counselling every four weeks to help them adhere to the program.¹¹

At the end of the trial period the semaglutide group had lost an average of 14.9% of their body weight, whereas the placebo group had lost an average of just 2.4% of their body weight. There were also significant improvements in cardiometabolic variables such as blood pressure and cholesterol in the semaglutide group.¹¹

A follow-up study 12 months later found that the semaglutide group had regained about two thirds of the weight they lost, with similar reversals in their cardiometabolic variables. Although this is somewhat disappointing, they had still lost 5% of their body weight, twice as much as the placebo group had lost at the end of the trial, whereas the placebo group had regained virtually all the weight they had lost during the study 12 months after the study ended.¹²

While this trial shows that semaglutide is an effective aid in losing weight long-term, it also exposes the underlying issue with weight loss. When overweight and obese people go on a reduction diet whereby they eat less of the same foods, rather than eat different foods, they have to make a constant effort not to revert to their old ways and eat the same size portions as before. The result is that, for most people, it is just a matter of time before they regain the weight that they lost.

I grew up in a family of overeaters, and when I was 13 my BMI was 30. I managed to lose weight by taking up sport, but I did not change the way I ate. By my late 20s I had to give up intensive exercise for health reasons, and I would have put the weight back on if I had not changed my diet at the time. The dietary changes were forced on me due to these health reasons, and a key one was that I had to stop eating tomatoes. This meant no pizza, lasagna, or spaghetti Bolognese, which were the most calorie dense foods I ate. I replaced them with healthier foods, such as stir fries, and I have stayed in a healthy weight range since. The rest of my family, however, continued to gain weight as they aged, with my older brother reaching 175kg (BMI 55) before he died at 57 due to the complications of diabetes.

And herein lies the harsh reality for many overweight people. If the foods you are eating are killing you then you need to stop eating them, not just eat less of them. Eating less of them might stop the rot if you can maintain it, but if you can’t then it won’t. If you have tried eating less several times and not managed to stick with it for long then you need to accept that it is not the way for you and change your diet rather than reduce your intake. The best way to do this is to see food as fuel for the body, and a pleasurable experience if you are lucky. Eat foods that are good for you first and foremost, and if they taste good see that as a bonus. If you only eat healthy food then you should soon find some you like, and your taste buds should adapt to them so they taste better with time. There are many resources available to help with this, including companies that will deliver healthy food to your door, so it is just a matter of making the decision, then making the effort.

If you think life will not be worth living if you cannot eat the foods you love then think again. Millions of people have changed their diet from indulgent to healthy, and if they stick with it for six months or more then very few go back to their old ways. Far more of them become preachers of their new faith and annoy the crap out of their friends and family.

Personally, I’m on a 14/10 extended fast diet, so I am not eating until around noon each day when I have a superfood salad. Then around 3-4pm I have a detox smoothie or a juice. At 6pm I eat cooked vegetables with a protein source, and at 10pm I have a fruit salad with yoghurt. This might sound boring, but it works for me. I have a number of health issues that require avoiding several different foods, and the 14-hour overnight fast helps to control my SIBO related IBS symptoms. I also live a sedentary lifestyle, so I do not need a lot of calories.

The superfood salad is a good example of healthy and tasty. I make it with home-made aioli (the recipe is in Survival), Danish feta, tofu or chicken, raw cashews, and various salad vegies. It contains healthy fats, including avocado and a good dose of omega-3s, apple cider vinegar and raw garlic in the aioli. If I want a change I have a chicken and salad wrap, or eat sushi if I go out. I enjoy the food I eat, so it is not a hardship, and the benefits of eating well mean I do not miss the junk foods I used to eat.

As previously stated, obesity is a sign of disease rather than a disease itself, but this is not to say it isn’t serious. Even if you are still relatively healthy it is often a sign of things to come, including some of our biggest killers—cardiovascular disease, diabetes and cancer. If you’re obese, or even just overweight, then you need to change the path you’re on, not just slow the pace you’re travelling at. Eat different foods, not less of the same foods. Exercise routinely, and get help if you need it. And be prepared to spend money on getting healthy. If you can afford thousands of dollars on electronic devises then you can spend the same amount on getting healthy.

For those who are hopelessly addicted to food, and especially if they are morbidly obese, an inpatient facility may be the only way to help them. This should be a home-like environment which can cater for the entire family, not a hospital. Clients must prepare their own foods so that they can continue to do so when they go home, and they will need support when do go home to ensure that they do not regress. This may be expensive, but the financial benefits, to the individual and to society as a whole, should outweigh the cost.

References

1. https://policysearch.ama-assn.org/policyfinder/detail/obesity?uri=%2FAMADoc%2FHOD.xml-0-3858.xml – AMA obesity.
2. www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Lin TY, Lim PS, Hung SC ‘Impact of Misclassification of Obesity by Body Mass Index on Mortality in Patients With CKD’ Kidney International Reports. 3 (2): 447-455, 23 December 2017.
3. https://pubmed.ncbi.nlm.nih.gov/33470881/ – Cost of obesity in US; Colagiuri, S, et al. ‘The cost of overweight and obesity in Australia.’ The Medical Journal of Australia (Comparative Study). 2010, 192 (5): 260-4. Okunogbe et al., “Economic Impacts of Overweight and Obesity.” 2^nd Edition with Estimates for 161 Countries. World Obesity Federation, 2022.
4. www.sydney.edu.au/news-opinion/news/2023/07/05/its-time-to-bust-the-calories-in-calories-out-weight-loss-myth.html – Cal in-out myth.
5. https://pmc.ncbi.nlm.nih.gov/articles/PMC5783752/ – Fasting methods.
6. https://diabetesjournals.org/diabetes/article/63/8/2800/15730/Exercise-Training-Induces-Mitochondrial-Biogenesis – Exercise and insulin resistance.
7. www.bmj.com/content/361/bmj.k2179 – HMB nut and health.
8. https://pubmed.ncbi.nlm.nih.gov/39767584/#:~:text=Methods:%20This%20is%20a%20systematic,;%20obesity;%20overweight;%20pesticide – EDCs and obesity. https://www.endocrine.org/topics/edc/what-edcs-are/common-edcs/metabolic – EDCs and obesity.
9. https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0735-y – Obesity drug deaths.
10. https://pmc.ncbi.nlm.nih.gov/articles/PMC8736331/#:~:text=Semaglutide%20improves%20the%20efficiency%20of,as%20postprandial%20glucose%20%5B26%5D – Semag mechanism.
11. https://www.nejm.org/doi/full/10.1056/NEJMoa2032183 – Semag study.
12. https://pubmed.ncbi.nlm.nih.gov/35441470/ – Semag study 12 months on.