Obesity management: at the forefront against disease stigma and therapeutic inertia

Luca Busetto,Paolo Sbraccia,Roberto Vettor

doi:10.1007/s40519-021-01217-1

Abstract

Obesity is a complex chronic relapsing disease, resulting from the interaction between multiple environmental, genetic and epigenetic causes, and supported by changes in the neuroendocrine mechanisms regulating energy balance and body weight. Adipose tissue dysfunction contributes to obesity-related complications. However, the prevalent narrative about the causes and mechanisms of obesity remains a much more simplistic one, based on the false assumption that individuals can fully control their body weight through appropriate behavioural choices. According to this narrative, obesity is simply reversible “persuading” the patient to follow healthier and more virtuous individual behaviours (moral judgement). This persistent narrative forms the deep root of the stigmatisation of people with obesity at the individual level and creates a clear discrepancy on how obesity prevention and cure are designed in comparison with the case of other non-communicable chronic diseases (clinical stigma). The promotion of systemic preventive measures against obesity is not supported at a political and social level by the persistence of a narrative of obesity as the simple consequence of individual failures and lack of willpower. The simplistic narrative of obesity as a self-imposed condition with an easy way-out (“eat less and move more”) creates a clear discrepancy on how obesity is managed by health care systems in comparison with other NCDs. The over-estimation of the efficacy of therapeutic intervention solely based on patients education and lifestyle modification is responsible of therapeutic inertia in health care professionals and in clinical guidelines, limiting or delaying the adoption of more effective therapeutic strategies, like anti-obesity medications and bariatric surgery. In conclusion, the persistence of a narrative describing obesity as a self-induced easily reversible condition has profound consequences on how obesity prevention and management are build, including the design and implementation of obesity management guidelines and a tendency to therapeutic inertia.Level of evidence: No level of evidence.

Highlights

Nowadays, many international medical organizations and scientific societies consider obesity as a complex chronic relapsing disease, resulting from the interaction between multiple environmental, genetic and epigenetic causes, and Vergata, Rome, Italy 3 Clinica Medica 3, Azienda Ospedale-Università di Padova, Via Giustiniani 2, 35128 Padua, Italy supported by changes in the neuroendocrine mechanisms regulating energy balance and body weight [1]
Single-gene mutations or polygenic traits interact with environmental factors altering the normal functioning of the neuroendocrine mechanisms regulating food intake, energy expenditure and the energy balance
Guidelines specify, according to body mass index (BMI) levels, fat distribution and the presence of comorbidities, in which patients more intensive therapeutic strategies can be used, but they do not specify in which patients these interventions should be used or are recommended

Summary

Obesity as a chronic disease and stigma against obesity

Many international medical organizations and scientific societies consider obesity as a complex chronic relapsing disease, resulting from the interaction between multiple environmental, genetic and epigenetic causes, and. Notwithstanding these recent advances on the comprehension of the patho-physiologic mechanisms causing and maintaining obesity in the long-term, the prevalent narrative about the causes of obesity in the general audience, the media, the policy-makers, the health-care professionals and the patients with obesity themselves remains a much more simplistic one According to this persistent narrative, individuals can fully control their body weight through appropriate behavioural choices, and overweight and obesity appear as the direct consequence of inappropriate individual behaviours characterised by laziness, gluttony, and so on [10]. Examples of such a policy are taxation on sweetened beverages, nutritional labelling of foods that can educate consumers toward the consumption of more healthier dietary patterns, restricting marketing of unhealthy foods, especially those aimed at children and teenagers, and ensuring the availability of healthy food choices and supporting regular physical activity practice in the workplace [38] The implementation of these systemic preventive measures is not without political costs and involves several stakeholders with important economic interests. Funding may only be diverted towards projects that are seen as effective (implementation of behavior and lifestyle interventions), reducing support for the research of new methods of prevention and treatment, and the implementation of therapies (anti-obesity medications or bariatric surgery) already available that are effective and safe according to scientific evidences [10]

Therapeutic inertia

Findings

Conclusion and actions for changing