Eat less, exercise more is a common refrain heard by millions of people with obesity. If only it were that simple. Decades of research shows obesity is a disease that is caused by a combination of genetic, environmental, biological, and behavioral factors that requires a range of interventions for treatment and prevention. The American Medical Association, the nation’s largest physician group, agreed when it officially recognized obesity as a disease in 2013. Yet, “eat less, exercise more” or “have more willpower” are simplistic and stigmatizing, and unfortunately enduring, and are doing more harm than good as America’s obesity epidemic reaches new heights.
The Centers of Disease Control and Prevention (CDC) reports that nearly 40 percent or 93.3 million U.S. adults have obesity with 7.7 percent of them having severe obesity. But along with the diabetes, heart disease and high blood pressure that often go hand in hand with the disease of obesity, a nationally representative survey of 1,059 adults conducted by NORC at the University of Chicago found more than one-third are also dealing with the issue of fat-shaming or weight bias either personally or through someone they know, and they’re experiencing it in all kinds of settings.
The survey found over the last year people confronted it in media portrayals (58 percent), social situations (37 percent), hiring decisions (29 percent), and, sadly, in interactions with health professionals (18 percent), where they felt it led to people receiving a lesser quality of care.
As an obesity medicine specialist whom has seen thousands of patients over many years, this is troubling, but not surprising. I can think of only a handful of patients who haven’t experienced some sense of shame, blame or embarrassment over their weight before finally arriving at our center for treatment. Most say they would have seen an obesity specialist sooner but for a discouraging or judgmental doctor, family member or friend telling them ‘you don’t need a specialist, you just need a diet and exercise more.’
This kind of thinking keeps people from talking about obesity with their doctors and exploring more effective treatments, and it keeps doctors more focused on treating the medical consequences of obesity rather than treating obesity itself. This is particularly concerning when it comes to severe obesity, where diet and exercise alone have been proven to be largely ineffective over time. Studies show that while patients with severe obesity may be successful in the first few months of a weight loss program, 80 to 95 percent will eventually regain their weight.
Nonetheless, according to the NORC survey, 9 in 10 Americans feel the best way for people with severe obesity to lose weight is through diet and exercise. Far fewer (55 percent) support weight-loss surgery, which medical experts consider the standard of care and most effective long-term treatment. In fact, nearly 1 in 5 Americans still think it’s a cosmetic procedure, and 24 percent say they would actually oppose a family member’s or close friend’s decision to have it. Obesity medications are even less popular with the American public, with half saying they support their use for someone with obesity.
While weight-loss surgery and obesity medications are not for everyone, they are clearly only being used by a fraction of those who could benefit. The American Society for Metabolic and Bariatric Surgery (ASMBS) reports that less than 1 percent of the eligible patient population get weight-loss surgery each year, and a recent study showed fewer than 2 percent of individuals with obesity are offered and fill a prescription for an obesity medication. Can you think of another disease where the most effective treatments are used by the fewest people and the least effective treatments are used by the most people?
Insufficient insurance coverage or overly stringent eligibility requirements is certainly a barrier for many people, but no less a barrier than misperceptions and stigma that treating obesity with a pill or surgery is somehow cheating, an ‘easy way out’ or something to be embarrassed about.
As health care professionals, let’s stop blaming and let’s start framing the discussion and treatment of obesity in a larger context. Clearly, there is a bigger role for obesity treatments that go beyond diet and exercise alone. The scientific evidence supports a broader strategy, but stigma and misperceptions keep getting in the way. It’s time for a new approach and an open mind. Let’s make that our New Year’s resolution.
Christopher Still is an internal medicine physician and director, Center for Nutrition and Weight Management, Geisinger Medical Center, Danville, PA.
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