We need to talk about excess body fat

Reluctance of patients to seek advice about excess weight and hesitation among healthcare professionals to offer it leads to a huge time lag between onset and treatment of obesity.

Research in the UK among people living with obesity found it had taken them nine years, on average, between starting to struggle with their weight and having a conversation about it with a healthcare professional.

There is no reason to think it is any different on this side of the Irish Sea.

“That is a long time and that is a conversation that is often prompted by some other health complication,” says dietitian Karen Gaynor, a committee member of the Association for the Study of Obesity on the island of Ireland (ASOI). “So people aren’t having that conversation early enough in order to prevent the complications of obesity.”

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Primary prevention to avoid the development of excess weight involves the lifestyle measures we should take to reduce the risk of any chronic disease such as cancer, diabetes, heart disease, as well as obesity. These include healthy eating, sufficient physical activity, good sleep routine and management of stress. In the context of obesity, we should be talking more about earlier secondary and tertiary interventions, she says.

This week, from May 17th to 20th, some of the most up-to-date research and thinking about this chronic disease will be shared among 1,800 participants at the 30th European Congress on Obesity (eco2023.org) in Dublin’s Convention Centre. Ireland is hosting the event at a time when the Government and the HSE have made addressing obesity a priority, says Gaynor, who is programme manager with the HSE Obesity National Clinical Programme. Yet, historically, there have been very limited specialist services here and that situation won’t change overnight.

A Model of Care for the Management of Overweight and Obesity was launched on March 4th, 2021. But a HSE spokeswoman says that “to realise the benefits, in health and economic terms at individual patient, health service and societal level”, a 10-year time frame is recommended for its full implementation. Expansion of specialist services for adults and children has started, along with the setting up of new community-based multidisciplinary obesity management services in Dublin and Waterford and dietitian-led, community-based obesity management programmes within the HSE’s enhanced community care chronic disease hubs. Meanwhile, last October, Ireland became the first European country to adopt new clinical practice guidelines for obesity care based on Canada’s pioneering approach.

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We know that 60 per cent of Ireland’s population have a body mass index (BMI) of over 25; by that measure they are classed as overweight (up to 29.9) or in the obesity range (30 or over). “What we are not so clear about is the exact percentage who have excess body fat impairing their health,” Gaynor explains. That, not size, is what matters.

On an individual level, the only way to find out is to have that conversation with a doctor who can run relevant tests to see if excess body fat is impairing your health, or likely to be soon. Perhaps there is a complication brewing, she suggests, that could be caught before you arrive in the GP surgery with fatty liver disease, diabetes or heart disease.

The focus of any treatment should be health gain rather than weight loss. “It’s not really about the shape and size, it’s about how is this impacting on your health,” she explains. As weight goes on, people’s bodies store fat in different places and in different ways. If it is being stored under your skin and on your legs and thighs, that does not tend to impact your health as much as if your fat is stored around your middle and around your organs. “And BMI isn’t going to tell you that, it’s only a measurement of size.”

Stigma and misunderstandings around obesity, among both patients and health professionals, are delaying intervention, says Gaynor. To people living with obesity, she would say: “It’s not your fault and it’s not your responsibility alone to fix. It’s a biological issue.” While they might believe that if they only dieted harder and exercised more, they would get the desired results, their body is primed to fight against that.

“We know diets in the short term lead to weight loss but that weight will go back on. That just shows how complicated this disease is.” Even after treatment as extreme as bariatric surgery, people are at risk of regaining the weight.

“The message we want to get across is go to your doctor, have that conversation, run those tests. You could be absolutely fine and they will say ‘come back in a year’ or it could be ‘there is something off, let’s watch that’.”

Stigma is also a barrier to healthcare professionals raising the issue with patients. “They will think that maybe the individual in front of them isn’t interested or isn’t motivated to lose weight and there is no point in bringing it up,” says Gaynor. “Or, it is a very sensitive topic and some healthcare professionals don’t feel equipped to have that conversation; maybe they feel they don’t have the time; maybe they have their own struggles or issues with weight. It’s a very difficult conversation to bring up and healthcare professionals do need support and training around that.”

Despite greater scientific understanding in recent decades of body weight processes, a societal belief persists that thin is desirable and equals healthy, while big or fat equals unhealthy

People tend not to go for treatment for excess weight until complications set in, agrees Susie Birney, executive director of the Irish Coalition of People living with Obesity (ICPO). In your 20s, the “rollercoaster of lose, regain, lose, regain” is about your looks and not being able to get clothes in your size, she says. Later, it becomes more about your health.

If both external and internalised stigma prevents people seeking treatment for obesity in the first place, it’s even worse second time around. After you have had treatment, with professionals having worked with you, your family delighted to see you healthier, there’s huge shame if it happens all over again. The relapsing nature of the disease tends to be overlooked, she says,

“It is not that you have failed the diet or the treatment; the treatment may have worked but then at some point it may fail you because your circumstances have changed.

“If you already live with obesity, you need treatment. But people who have had treatment still need prevention because it is a chronic relapsing disease. You may lose weight and get healthier through treatment, whether it is through bariatric surgery or lifestyle management, but because obesity is complex something can happen that will trigger you.”

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After surgery, somebody with obesity might drop from 25 stone (159kg) to 10 stone (63.5kg), she says. “They are living their best life; they don’t need a seat belt extender on the plane, they can fit in the car and they can buy clothes in Penneys. Then when the regain comes, it’s that devastation, it’s back, and the shame.”

While Birney has neither gained nor lost weight in the past 18 months, she says “I am looking at pre-menopause now and my treatment may need to be adjusted.” She is 16 stone (102kg) and knows people look at her and think she needs to lose weight. “I don’t, because I am actually probably at the best I will ever be right now because of everything that has gone against me. I am at my best health and all my bloods are fine.”

However, she fears the menopause “could skew everything for me and I will be back to the drawing board”. Although her behaviour won’t have changed, she knows others will “assume I’m overeating or stopped walking; it’s outside factors people don’t understand”.

When it comes to the lack of patient-doctor conversations about excess weight, she believes the issue is not so much that GPs should raise it sooner but how they broach the topic. For somebody attending a GP on a bad day with some completely different health concern, a “can we talk about your weight?” is not likely to be well received, she points out. “If there was less shame around weight issues, more patients would be prompted to talk about it first.”

It would be great if every GP knew how to talk about obesity and could refer their patients to services, she adds, “but our system couldn’t cope with that. It’s a vicious circle.”

Birney will be one of 14 ICPO members participating in the congress, along with another 44 patient advocates from across Europe, and they will report back daily to support groups. She believes the four-day event will be “invaluable” in raising awareness and sharing knowledge.

“You don’t realise the reality of obesity until you hear the experts talking about it and you hear the lived experience talking about it. When you have the two, it gives a clear understanding.”

Despite greater scientific understanding in recent decades of body weight processes, a societal belief persists that thin is desirable and equals healthy, while big or fat equals unhealthy. We’ve seen internationally that as much more effective, new-generation drugs to treat obesity become available they are being “hijacked by people who want to become thinner”, comments Gaynor, “which means the people who need it to become healthier aren’t getting it. It’s just disappointing.”

There are genetic, environmental, health and social layers to obesity, all affecting calories in and calories out. But it doesn’t stop there because, back to biology, we now know that one person’s body uses calories differently to another.

There is no one single fix to obesity, “this is cross-governmental, cross-societal,” she stresses. “It needs to be everyone’s business.”