It has been several decades since obesity is considered socially and medically undesirable in most of the world. Intense efforts at research, community and individual intervention and policy levels are underway. Yet, the prevalence of obesity is increasing. So, where does the shoe pinch? Here is a perspective about what are some of the barriers in effectively addressing obesity and why they continue. The first barrier seems to be in recognizing the onset of overweight or obesity by the patient themselves (and at times even by their providers) . It does not help that significant physiological or functional impairment due to obesity takes a while to set in. This further delays any urgency for corrective action on an individual’s behalf. Individuals with obesity first tend to turn to self-treatment or advice from friends and family, who typically provide generic guidance about eating less and/or moving more. Whereas, individuals with other chronic diseases like diabetes, high blood pressure, or cancer, turn to their health care providers (HCPs). Moreover, training of HCPs for obesity management is near zero in many medical schools and many HCPs carry their own stigma against individuals with obesity. So, it is not common for HCPs to proactively address obesity in their patients and not easy to effectively help individuals seeking weight loss . Ironically, patients with obesity likely have a bias against HCPs who have obesity and prefer those without obesity (who are more likely to have a bias against them) . It seems that a combination of these factors, along with poor reimbursement for medical management of obesity and a relative lack of highly effective treatment, contributes to HCPs treating metabolic or functional comorbidities of obesity instead of the root cause . Those individuals who overcome these barriers and face treatment choices, experience a new set of concerns: whether drug treatment or surgery are worth the risk for obesity management. Even dietary management of obesity is complex. Long-term treatment compliance is not easy, and weight regain is common. Expecting an individual to chronically eat less than their body needs to create and maintain a negative energy balance, is a highly unnatural ask, especially when various environmental or physiological signals are prompting the individual to eat more. Obesity is one of few chronic diseases where the treatment relies more on a patient’s willpower and less on medical intervention.
For effective control of obesity, these barriers need to be overcome. Then why do they persist? A common underlying theme that seems to hinder overcoming these barriers is the simplistic view of obesity and its treatment. Sadly, the prevailing view that obesity is simply due to ‘laziness and greediness’ seems to touch each of the barriers mentioned above. While not justified, this view makes it easier to understand why patients would hesitate to turn to HCPs for a so-called “behavioral issue” that is thought to be under their control, or why HCPs or policymakers would not consider it a serious medical disease worthy of their attention or reimbursement. Although all therapeutic drugs and surgeries have potential side effects and their risk-benefit ratio should be considered, it is easy to consider them as high risk for obesity, if it is a “mere lack of willpower” issue. If obesity is a “lifestyle choice” and losing weight is merely a matter of deciding to do so, then it is difficult to appeal against social stigma or advocate for better obesity management drugs or strategies or commit precious resources for reimbursement. A lot of resources were diverted to addressing HIV-AIDS because it is a very challenging and serious disease. This would have been different, if it was continued to be thought as a simple behavioral issue that could easily be addressed. The view that the development of obesity is simple to explain, and its treatment requires simple measures, has been a curse that is hindering serious consideration of the disease.
Multiple measures may be needed to effectively address a simplistic view of obesity by different stakeholders. At the very least, the medical and research community needs to consider obesity as a complex disease of multifactorial etiology that requires serious medical or surgical management. This also means avoiding “…stigma-inducing focus on self-failing (e.g., coping through food, laziness, lack of self-regulation) (which) does not address biological processes that make obesity a lifelong problem for which there is no easy solution” .
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Dhurandhar, N.V. The simplistic view of obesity management: a curse in disguise. Int J Obes (2022). https://doi.org/10.1038/s41366-022-01144-w