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Obesity Designated as a Disease: A Paradigm Shift in Healthcare and the Fall Out from It

In a world where the pursuit of the "perfect" body has never been more prevalent, the temptation to turn to pharmaceuticals as a shortcut to induce weight loss, can be irresistible. The promise of shedding pounds effortlessly, can be extremely alluring.

What we are currently witnessing as a global Western society in the 21st Century, is a headlong rush into unknown territory, in the form of tacit approval for the use of medical drugs for rapid weight loss. An example of the current global craze to use diabetes drugs as a quick fix for weight loss, even though they may not have a medical need for it, is reflected in the hashtag #OzempicWeightLoss which has over 84 million views on TikTok.

Ozempic is the brand name for a medication called semaglutide, which was launched in 2017 to treat type 2 diabetes in adults. It’s one of number of molecules in the class known as GLP-1 receptor agonists, or incretin mimetics. GLP-1R agonists mimic the effects of a natural hormone in the body, called GLP-1 (glucagon-like peptide). GLP-1, amongst other things, plays a crucial role in regulating blood sugar levels and metabolism in the body by promoting insulin release, inhibits glucagon release, slows down digestion, and reduces appetite by sending signals to the part of your brain that makes you feel full and regulates how much you eat.

It didn’t take long before both patients and doctors began to observe noticeable weight loss results, as well as successfully managing blood glucose levels and within four years, in 2021, the medication was approved by the FDA to also treat obesity.

A Poor Result From a Good Intention

This shift in mindset, to use a medication to manage obesity, can be traced back to 2013, when the American Medical Association (AMA) officially designated obesity as a disease, in recognition that it had become a health concern of epidemic proportions in the US. The purpose was to recognise obesity as a complex and multifaceted medical condition, with underlying physiological and genetic components, rather than obesity being solely a consequence of poor impulse control.

No doubt the benefits of officially changing the perception of obesity has had the potential to improve outcomes for many individuals struggling with their weight, and the shift away from fault has been a good one. Classing obesity as a disease though, has had the opposite of the intended effect, however. Instead of acknowledging obesity as a multifaceted issue of lifestyle, environmental and genetic factors that cannot be easily solved through a single mechanism; medicalising it oversimplifies the problem, and relying solely on medical interventions may neglect the importance of sustainable, long-term behavioural changes.

Ten years down the track from that AMA decision, obesity is now a global epidemic, and aspects of concerns that were expressed at the time about the medicalisation of obesity, appear to be materialising in the form of recent headlines like this: "Big Pharma's blockbusterobesity drug battle is just getting started, and it it's headed for $100 billion".

While addressing obesity as a medical condition became essential for many individuals who required medical intervention, it also created a narrow clinical mindset that was crucial to recognise, and the time has definitely come to address some of the concernes associated with this approach.

There’s no question that pharmaceuticals have greatly benefited humanity in a number of ways by:

  • preventing diseases (vaccines)
  • fighting off invaders (antibiotics)
  • improving health by replacing something that is not working (e.g. insulin for people living with Type 1 diabetes)
  • extending lifespans by switching off triggers (e.g. combating cancer cells by preventing uncontrolled cell division)
  • alleviating pain (analgesics)

 all of which have enhanced our overall quality of life. They are a cornerstone of modern medicine and rightly deserve respect.

However, as the epidemic of obesity has continued, unchecked, around the globe, the development of pharmaceuticals for controlling weight loss, is ever gaining rapid momentum. Which raises the question, whether it’s possibly time to query the now widely accepted label that obesity is considered a disease, and instead propose that the underlying premise of obesity, is that it may actually be a symptomatic form of malnutrition and gut dysbiosis?

This concept may seem counterintuitive, but a deeper examination of the relationship between obesity and malnutrition reveals a very complex interplay of factors that extend far beyond the simplistic notion of calories in versus calories out.

In January 2023 an article in Psychology Today raised this question of whether obesity can really be called a disease. It explored a range of issues and stressed that lifestyle interventions have been shown to be very effective, and that environmental factors related to highly processed food and sedentary lifestyle were hugely important to consider.

Re-Defining Malnutrition

To truly understand the connection between obesity and malnutrition, it’s useful to re-define the perception of malnutrition. While it’s traditionally been associated with access to too few calories and hunger, it can also encompass a combination of too many calories, while still lacking nutrients essential for good health. In this context, obesity can be seen as a form of malnutrition because it often involves the overconsumption of calorie-dense, nutrient-poor foods, leading to a state of chronic imbalance.

Modern diets, especially in developed countries, are often rich in highly processed foods that are high in calories but low in essential nutrients. These foods are often laden with sugars, unhealthy fats, and additives, while lacking in vitamins, minerals, and fibre. Consuming such a diet can lead to obesity while still resulting in nutritional deficiencies.

The Role of Micronutrients in Obesity

To understand how this is possible it is necessary to understand the way our body controls food consumption. Macronutrients such as carbohydrate and protein provide the body energy and building blocks for repair, but micronutrients are actually what make the body work. The vitamins and minerals that we get from our food are what make the cogs that process energy, allow chemical reactions to happen and nerves to transmit information. Iron, for example, makes up only 0.03% of the haemoglobin molecule but without it we couldn’t get oxygen to cells, and we would not be able to survive. Because micronutrients are so important to life, they are one of the key triggers of the hunger response. Of the macronutrients, it is protein that determines hunger levels. Neither fat nor carbohydrate stop you from feeling hungry. This means that when we consume calorie dense, ultra-processed foods high in fat and carbohydrate it is possible to eat many more calories than we need and still feel hungry. As a result, our bodies may crave more food in an attempt to satisfy these unmet nutritional needs, perpetuating a cycle of overeating leading to obesity.

The Gut Microbiome Connection

In 2022  BioMedicine and Pharmacotherapy commented that “In the past ten years, the gut microbiota has been identified as a crucial player affecting the onset and progression of obesity and obesity-related diseases, especially with respect to changes in its composition and metabolites during obesity progression”. There is now a growing body of research to indicate that the gut microbiome plays a significant role in obesity and malnutrition. A diet high in processed, nutrient-poor foods can negatively impact the diversity and balance of gut bacteria, which can, in turn, affects metabolic processes, appetite regulation, and the absorption of essential nutrients. This disruption in the gut microbiome can contribute to both obesity and malnutrition.

Socioeconomic Factors

Socioeconomic factors play a crucial role in the obesity-malnutrition connection. In many cases, individuals with limited access to fresh, nutritious foods rely on cheaper, calorie-dense, highly processed options to meet their daily caloric needs. This can result in obesity coexisting with nutrient deficiencies, particularly in low-income communities, further highlighting the link between obesity and malnutrition.

Lack of Education

Good nutritional education plays a pivotal role in supporting people to understand how their body really works. It empowers individuals to make informed dietary choices, understand portion control, and develop healthy eating habits. However, many people who are obese receive inadequate or misguided nutrition guidance, exacerbating their struggle to manage their weight effectively. The internet and media are saturated with conflicting dietary advice, fad diets and quick fix solutions, and confusion can lead to frustration and ultimately deter people from seeking help or adhering to a healthy eating plan. Underlying emotional coping mechanisms can also perpetuate unhealthy relationships with food and many people with obesity don’t understand they may use food as a means of dealing with stress, anxiety, or depression.

The idea that weight loss can only be achieved through pharmaceutical intervention is not only scientifically ridiculous but morally bankrupt. For years people were made to feel that being obese was some kind of failure on their part. We finally have reached the point of acknowledging that obesity is a health issue and now that message is being perverted into a way to force people into thinking they are powerless to fix the problem without expensive and potentially harmful drugs. The truth is that for many people obesity isn’t their fault, rather it is the failure of the food industry to provide nutritious foods and a failure of the health industry to properly inform people about how to manage their health needs through diet control.

Addressing the underlying premise that obesity is a manifestation of malnutrition could shift the focus to a far more holistic approach to the management of obesity.  A balanced perspective is needed, one that acknowledges the complexity of obesity as a health issue influenced by various factors. Promoting access to nutritious foods, improving food education, and addressing the complex factors contributing to both obesity and malnutrition, should be a priority, rather than reaching for a pill or an injection, as a first line of defence against obesity.

By doing so, we can create a more compassionate and effective approach to addressing the global obesity epidemic that respects the dignity and individuality of those affected.

Dr Malcolm Ball