Sasha High, MD, is the medical director of the High Metabolic Clinic in Mississauga
Comedian James Corden recently aired a compelling and poignant segment expressing his experience with fat-shaming. His message that fat-shaming has no place in the treatment of obesity is timely and should prompt us all to reflect on our personal bias toward this disease. As an obesity medicine physician, my hope is that Canadians will start talking about obesity as a medical condition, and not as someone’s fault.
But the reality is that Canadians living with obesity face widespread bias and discrimination, from neighbours, co-workers, health-care providers, friends and even family. This discrimination is rooted in the societal misconception that people with increased weight are somehow to blame – that they are lazy or don’t have the self-control to manage their weight. Sadly, this sentiment is often shared by the people living with obesity themselves, resulting in much shame and guilt.
We need to tackle this bias head on.
We’ve all seen (or personally experienced) an attempt to lose weight, only to have it all come back on – and then some. This has perpetuated our belief that people with increased weight lack the willpower to keep it off. This phenomenon of loss and regain has been reproduced in study after study – the fact is that weight regain is the norm. Are all seven million Canadians living with obesity lacking in willpower? Or is there another biological explanation?
We now understand that obesity is a complex, chronic medical condition caused by the interplay of a multitude of factors. It is not a simple matter of “calories in, calories out." This inaccurate assumption has led to the longstanding weight-loss prescription: eat less, exercise more. But this prescription doesn’t work, and it hasn’t been working for a very long time. We need to shift our old paradigm toward a new understanding: obesity is the result of disordered weight regulation owing to a number of factors including our genetics, our current food environment, the brain’s hormonal control of appetite, medical conditions and medications, emotions, stress and poor sleep, to name a few.
In addition, efforts to lose weight are met with strong biological resistance. Our brain is programmed to defend against weight loss. When body-fat stores decrease, a warning signal is sent to the brain to do everything in its power to retain fat. Our metabolic rate slows and we have an increase in hormones controlling hunger, appetite and feeding behaviour. Weight regain is the result.
People with obesity may even experience food differently than thin people. For example, studies using functional MRI (magnetic resonance imaging) have found that the reward centre of the brain is more active in people with obesity than lean people, when shown pictures of highly palatable foods. Furthermore, the reward centre activation in people with obesity does not turn off in response to a meal the way it does in a thin person.
So, is long-term weight management an impossible task? The good news is that with more research and understanding, we are becoming better equipped to manage what the World Health Organization considers a chronic disease.
While dietary changes and increasing activity levels are valuable, they are often not enough. A recent Canadian study called ACTION, found that although 75 per cent of people living with obesity believe that it is their own responsibility to manage their weight (let’s muster up some more willpower!), only one in 10 people are able to maintain a 10-per-cent weight loss at one year.
Obesity management requires a multimodal, long-term strategy. One that takes into account individual factors and addresses the propensity to weight regain, with a focus on long-term weight stabilization. Evidence-based treatments include lifestyle changes bolstered by cognitive behavioural therapy (CBT), learned behavioural skills, anti-obesity medications, and for some, bariatric surgery. Until we recognize that this is a chronic condition requiring a long-term solution, “Six Week Weight Loss Challenges” or “Lose Weight Fast” strategies will continue to fail people.
Obesity affects one in four Canadian adults, and one in 10 children, with prevalence expected to reach 30 per cent of our population by 2030. Medical complications affect virtually every part of the body, including cardiovascular disease, cancer, diabetes, depression, fatty liver disease, respiratory problems and arthritis. Let’s stop blaming people for their weight and instead, as a society, put efforts and finances toward research, prevention and treatment of this serious medical condition.
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