Obesity is more complex than just overeating , Not just fat

 In conjunction with World Obesity Day yesterday, we take a look at how the understanding of this condition of excess weight has evolved.

We need to avoid weight bias where we make the assumption that people are obese solely because of their own choices. — Photos: 123rf.com

For as long as she could remember, Jane had always been plus-sized.

As a child, her family doted upon her as she was never picky about food and would eat anything given to her.

In school, she was always physically bigger compared to the rest of her peers.

She was often teased by her friends for her body size, but she was constantly reassured by her family that she was just “big-boned”, just like the rest of her siblings and family members.

However, by the time she reached young adulthood, she started feeling more self-conscious about her body size and embarked upon multiple cycles of crash dieting and exercise regimes.

She successfully lost weight a few times; however, each time she lost weight, she would eventually lapse into bouts of uncontrollable binge-eating.

As a result, she constantly struggled to keep the weight off and would always gain back the weight she lost, if not more.

With time, she became resigned to the fact that she was probably fated to be fat for life.

This led to body image issues, self-blaming, and even clinical depression that negatively affected her life and relationships.

The scale of the problem

Jane is not exactly a real person, but her story is very real – a coalescence of the lives of many people struggling with weight issues everywhere.

The global obesity epidemic, aptly coined “globesity”, is arguably one of the most important public health concerns of the late 20th and early 21st century.

As of 2016, the World Health Organization (WHO) estimated that 650 million adults worldwide were obese.

According to the World Obesity Atlas, these numbers are expected to increase, with the global obese population projected to breach the one billion mark by 2030.

It is also no longer news to us that Malaysia is effectively the fattest country in the region.

The 2019 National Health and Morbidity Survey (NHMS) reported that one in two Malaysian adults were either overweight (30.4%) or obese (19.7%), and one in three Malaysian children were overweight (15.0%) and obese (14.8%).

On top of this, if we account for the rampant weight gain seen during the Covid-19 movement control order, the current true numbers of obese people in Malaysia is likely even higher.

Traditionally, being overweight and obese has been viewed as a risk factor that increases an individual’s chances of developing metabolic diseases such as type 2 diabetes, hypertension (high blood pressure), cardiovascular (heart) disease, obstructive sleep apnoea, and musculoskeletal disorders such as osteoarthritis, among others.

This fact still very much holds true today.

However, in 2014, the American Medical Association declared obesity as a disease state in itself.

This actually had very far-reaching implications.

It effectively changed the way we view obesity – as more than just excessive fat deposition contributing to other diseases.

Obesity itself is now seen as a disease state that requires formal medical attention, proper treatment plans and prevention efforts.

The complexity of obesity

Experts worldwide have been calling for measures to be taken to curb this growing issue for decades, but the rates of obesity have continued to rise regardless.

.The idea that obesity is a disease of the brain is gaining traction among scientists as the hypothalamus (in yellow) plays a key role in regulating our appetite and metabolism.>>

This is because obesity is a very complex issue with a lot of interconnected causes.

In the past, it was assumed that as our society became richer, we had to physically work less to get our food and this led to over-nourishment.

However, we now know that it is overly simplistic to think that obesity develops as a result of an individual just “eating too much”.

Instead, there are often multiple factors beyond our control that contribute to an individual developing obesity.

For example, people who come from disadvantaged socioeconomic backgrounds may not have the financial privilege of accessing healthy food options.

They may also not be educated enough to choose better quality food with their available resources.

Children born into these families with a history of obesity have higher chances of developing obesity later on in life.

This is partly contributed by genetic factors, as well as enduring lifestyle habits inculcated from a young age that may be difficult to change.

Obesity is also closely linked to the development of mood disorders such as depression and anxiety.

People suffering from depression also have a higher chance of developing eating disorders that subsequently lead to obesity.

A lot of these factors form vicious cycles that span generations.

On a population scale, we are living in an increasingly “obesogenic environment”.

This refers to the multiple physical, economic and sociocultural factors that collectively contribute to the development of an obese population.

For example, our built environment promotes a sedentary lifestyle.

Our roads are hardly pedestrian or bicycle-friendly.

Our public transportation system is not optimised, as the lack of last-mile connectivity remains a major hindrance for many.

As a result, most Malaysians are heavily dependent on motorised vehicles to get around, rather than walking or cycling.

Globalisation and industrialisation of the food supply chain have made ultra-processed foods more common now than ever.

Ultra-processed foods refer to those that have gone through a series of industrial processes, often with ingredients like high-fructose corn syrup, modified oils, food colouring and other additives to make the final product hyper-palatable.

These foods are commonly high in calories and easily over-consumed.

They are generally mass-produced and marketed by large companies, and are often much cheaper and more readily available compared to whole, nutritious food options.

As we start to understand more about obesity, it has become increasingly clear that it is, in essence, a disease of the brain.

The hypothalamus located in the brain plays a key role in regulating our appetite and metabolism.

The satiety centre in the hypothalamus is largely responsible for controlling our sensation of hunger.

When an individual develops obesity, the accumulation of excessive fat tissue actually leads to a host of hormonal changes within the body.

These hormonal changes not only suppress the satiety centre and increase hunger, but also slow down our metabolism rate.

Essentially, our body has a weight “setpoint”, and will try to revert to this setpoint despite our best efforts.

These underlying biological mechanisms are largely out of our voluntary control.

They also explain why people with obesity who embark on lifestyle changes to lose weight tend to hit a plateau after an initial weight loss.

In fact, after some time, they may regain some of the weight they lost initially.

Weight bias

 

The easy availability and affordability of ultra-processed foods is part of the obesogenic environment that makes it easy to gain excess weight. — TNS

It is precisely because of these underlying complexities that we should be careful not to indulge in weight bias.

Weight bias, or weight stigma, refers to negative attitudes, beliefs and judgments toward individuals who are overweight and obese.

In other words, we have to avoid the over-simplistic assumption that people with obesity are the way they are as a result of their “poor life choices”.

This stigma is very common because body weight is a physical characteristic that is visible and is often the first thing we notice about a person.

Studies have shown that even doctors are guilty of weight bias.

These can range from explicit behaviours, such as outright fat-shaming and teasing, to implicit beliefs, such as seeing someone who carries excessive weight and immediately considering them to be lazy, undisciplined or unmotivated.

Shaming individuals with weight-related issues does not motivate positive behavioural changes.

Instead, it often leads to the development of unhealthy behaviours such as compulsive exercise, as well as eating disorders such as cycling between extreme fasting or dieting, and episodes of binge eating.

Worse still, when this becomes internalised, an individual believes that they deserve the stigma and discriminatory treatment because of their weight.

Internalised weight bias is strongly associated with unhealthy eating patterns, poor body image, low self-esteem and depression.

Striking a balance

Conversely, this by no means indicates that we should normalise obesity or dismiss the deleterious health effects associated with it.

Instead, an individual’s body fat excess needs to be objectively taken into context as one part of their overall health.

The body positivity movement promotes acceptance of all body types, shapes and sizes, and not assigning self-worth solely to outward appearances.

This need not be mutually exclusive with taking obesity seriously as a public health emergency requiring urgent attention.

Over the last few decades, there have been major advances in the medical treatment of obesity.

Bariatric surgery has long been proven to be very effective, but it comes with its own set of complications.

New medications have been developed to specifically target the hormonal changes in obesity and induce very effective weight loss.

However, these medications are still very expensive and may not be widely available.

It also does not take away the fact that prevention is still better than cure.

Once established, obesity is very difficult and arduous to treat due to the reasons explained above.

Preventing obesity requires a concerted effort.

Government policies need to be drafted holistically, keeping in mind that economic and structural development often have indirect population-wide health consequences in the long run.

The food industry needs to be regulated for responsible manufacturing and marketing practices.

Society as a whole also has a collective responsibility to recognize that obesity is a disease and consciously adopt a healthy culture to address and prevent it.

The theme for World Obesity Day 2023 is “Changing Perspectives: Let’s Talk about Obesity”.

It is apt that we keep the conversation going, correct misconceptions, end stigma, and collectively shift towards a rational and sustainable strategy to tackle this perennial issue.

Dr Lim Quan Hziung is a lecturer and internal medicine physician training to become an endocrinologist at University Malaya. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only, and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this article. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information. 

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Not the best for weight

 Although BMI is widely used as a measure of weight, it is not very accurate and can lead to the mistreatment of obesity and eating disorders.

Measuring a person’s waistline might give a better representation of their health than their bmi, as those with abdominal obesity are prone to developing certain chronic medical conditions. — Photos: TNS

 

BMI in Adults: Is Yours Healthy, and if Not, How Can You Lose ...

PEOPLE who seek medical treatment for obesity or an eating disorder do so with the hope their insurance plan will pay for part of it.

But whether it’s covered or not often comes down to a measure invented almost 200 years ago by a Belgian mathematician as part of his quest to use statistics to define the “average man”.

That work, done in the 1830s by Adolphe Quetelet, appealed to life insurance companies, which created “ideal” weight tables after the turn of the century.

By the 1970s and 1980s, the measurement, now dubbed body mass index (BMI), was adopted to screen for, and track, obesity.

Now it’s everywhere, using an equation – essentially a ratio of mass to height – to categorise patients as overweight, underweight or at a “healthy weight”.

It’s appealingly simple, with a scale that designates adults who score between 18.5 and 24.9 as within a healthy range.

But critics – and they are widespread these days – say it was never meant as a health diagnostic tool.

“BMI does not come from science or medicine,” said Dr Fatima Stanford, an obesity medicine specialist and equity director of the endocrine division at Massachusetts General Hospital in the United States. 

She and other experts said BMI can be useful in tracking population-wide weight trends, but it falls short by failing to account for differences among ethnic groups, and it can mislabel some people, including athletes, as overweight or obese because it does not distinguish between muscle mass and fat.

Still, BMI has become a standard tool to determine who is most at risk of the health consequences of excess weight – and who qualifies for often-expensive treatments.

Cut-offs for coverage

Despite the heavy debate surrounding BMI, the consensus is that people who are overweight or obese are at greater risk for a host of health problems, including diabetes, liver problems, osteoarthritis, high blood pressure, sleep apnoea and cardiovascular problems.

The BMI measure is commonly included in the prescribing directions for weight-loss drugs.

Some of the newest and most effective drugs, such as semaglutide, limit use to patients who have a BMI of 30 or higher – the obesity threshold – or a lower level of 27, if the patient has at least one weightrelated medical condition, such as diabetes.

Doctors can prescribe the medications to patients who don’t meet those label requirements, but insurers might not cover any of the cost.

While most insurers cover some forms of bariatric surgery for weight loss, they might require a patient to have a BMI of at least 35, along with other health conditions, such as high blood pressure or diabetes, to qualify.

With medications, it can be even trickier.

US national health insurance programme Medicare, for example, does not cover most prescription weight-loss drugs, although it will cover behavioural health treatments and obesity screening. Coverage for weightloss medications varies among private insurance plans.

“It’s very frustrating because everything we do in obesity medicine is based on these cut-offs,” said Dr Stanford.

Over and under

Critics say that BMI can err on both ends of the scale, mistakenly labelling some larger people as unhealthy and people who weigh less as healthy, even if they need medical treatment.

For eating disorders, insurers often use BMI to make coverage decisions and can limit treatment to only those who rank as underweight, missing others who need help, said Serena Nangia.

Nangia is the communications director for Project Heal, a US non-profit organisation that helps patients get treatment, whether they are uninsured or have been denied care through their insurance plan. 

“Because there’s such a focus on BMI numbers, we are missing people who could have gotten help earlier, even if they are at a medium BMI,” she said.

“If they are not underweight, they are not taken seriously, and their behaviours are overlooked.” 

Dr Stanford said she too often battles insurance companies over who qualifies for overweight treatment based on BMI definitions, especially some of the newer, pricier weight-loss medications, which can cost more than US$1,500 (RM7,114.50) a month.

“I’ve had patients doing well on medication and their BMI gets below a certain level, and then the insurance company wants to take them off the medication,” she said, adding she challenges those decisions.

“Sometimes I win, sometimes I lose.”

Not accurate for health

While perhaps useful as a screening tool, BMI alone is not a good arbiter of health, said Dr Stanford and many other experts.

“The health of a person with a BMI of 29 might be worse than one with a 50 if that person with the 29 has high cholesterol, diabetes, sleep apnoea, or a laundry list of things,” said Dr Stanford, “while the person with a 50 just has high blood pressure.

“Which one is sicker? I would say the person with more metabolic disease.”

Additionally, BMI can overestimate obesity for tall people and underestimate it for short ones, experts say.

And it does not account for gender and ethnic differences.

Case in point: “Black women who are between 31 and 33 BMI tend to have better health status even at that above-30 level” than other women and men, Dr Stanford said.

Meanwhile, several studies, including the long-running Nurses’ Health Study, found that Asian people had a greater risk of developing diabetes as they gained weight, compared with whites and certain ethnic groups.

As a result, countries such as China and Japan have set lower BMI overweight and obesity thresholds for people of Asian descent.

Other measurements

Experts generally agree that BMI should not be the only measure to assess patients’ health and weight.

“It does have limitations,” said David Creel, a psychologist and registered dietitian at Cleveland Clinic’s Bariatric and Metabolic Institute.

“It doesn’t tell us anything about the difference between muscle and fat weight,” he said, noting that many athletes might score in the overweight category, or even land in the obesity range due to muscle bulk.

Instead of relying on BMI, physicians and patients should consider other factors in the weight equation.

One is being aware of where weight is distributed.

Studies have shown that health risks increase if a person carries excess weight in the midsection.

“If someone has thick legs and most of their weight is in the lower body, it’s not nearly as harmful as if they have it around their midsection, especially their organs,” he said.

Dr Stanford agreed, saying midsection weight “is a much better proxy for health than BMI itself”, with the potential for developing conditions like fatty liver disease or diabetes “directly correlated with waist size”.

Patients and their doctors can use a simple tool to assess this risk: the tape measure.

Measuring just above the hipbone, women should stay at 35 inches or less, and men at 40 inches or less, researchers advise.

New ways to define and diagnose obesity are in the works, including a panel of international experts convened by the prestigious Lancet Commission, said Dr Stanford, a member of the group.

Any new criteria ultimately approved might not only help inform physicians and patients, but also affect insurance coverage and public health interventions.

She has also studied a way to recalibrate BMI to reflect gender and ethnic differences.

It incorporates various groups’ risk factors for conditions such as diabetes, high blood pressure and high cholesterol.

Based on her research, she said, the BMI cut-off would trend lower for men, as well as Hispanic and white women.

It would shift to slightly higher cut-offs for Black women.

(Hispanic people can be of any race or combination of races.)

“We do not plan to eliminate the BMI, but we plan to devise other strategies to evaluate the health associated with weight status,” she said. – Kaiser Health News/tribune News Service

Although BMI is widely used as a measure of weight, it is not very accurate and can lead to the mistreatment of obesity and eating disorders.

Kaiser Health News (KHN) is a US national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programmes at Kaiser Family Foundation (KFF). KFF is an endowed non-profit organisation providing information on health issues to the US. 

-The Star Malaysia By JULIE APPLEBY 

 

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Father's diet has effect on health, weight of his children, new studies show

 
Two independent studies by teams in China and North America have found evidence to suggest that a father's diet can influence the health and weight of his children. — AFP pic

Two independent studies by teams in China and North America have found evidence to suggest that a father's diet can influence the health and weight of his offspring.

Published in the journal Science, both studies looked at the effects of different diets of male mice on their offspring.

The first study, by a group of researchers in China, took sperm from two groups of mice, one receiving a high-fat diet and one receiving a normal, healthier diet, and used it to impregnate female mice. Once the offspring were born, the team monitored their weight, level of glucose intolerance and insulin resistance.

The results showed that although the offspring of the males who were fed the high-fat diets did not gain more weight than the offspring fed the normal, healthier diet, they did show a decreased resistance to insulin and a glucose intolerance, both factors in the development of diabetes.

In the second study, researchers from the US and Canada instead fed mice a low-protein diet and compared the results to a control group. In their study, the team found changes to a group of genes responsible for the development of stem cells, which in early life can develop into many different types of cells within the body, as well as repair and replace body tissue; however, no other changes were found.

The results go against the previous assumption that the only impact males have on their offspring is from their DNA, and support the findings of other recent studies which suggest that the diet and lifestyle habits of males, like females, can have an important effect on their offspring's health.

A 2013 study by McGill University found that when male lab mice had a diet that was low in vitamin B9, also known as folate, they fathered offspring with a 30 per cent higher rate of birth defects, compared to the offspring of mice who had consumed sufficient amounts of folate.

The results led the team to conclude that although women are often encouraged to take folic acid supplements to reduce the risk of miscarriage and birth defects, “(the) research suggests that fathers need to think about what they put in their mouths, what they smoke and what they drink and remember they are caretakers of generations to come.”

A 2014 study from the University of New South Wales in Sydney, Australia, also showed similar results when the team of researchers mated two groups of male rats with slim, healthy female rats. One of the groups of male rats was fed a high-fat diet, while the other received a normal, healthy diet.

The results showed that the offspring born to the obese fathers who were fed a high-fat diet showed a genetic predisposition for obesity and changes to the pancreas, the organ responsible for producing insulin and regulating blood sugar levels, both important factors in diabetes.

And in the first study to be conducted on humans, after collecting medical information from both parents, as well as DNA from the umbilical cords of newborn babies, a team from Duke University, USA, found a link between obesity levels in fathers and an increased risk in their children developing health-related cancers. — AFP=Relaxnews

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