In this issue of Australian Family Physician (AFP), we provide an update on the understanding and treatment of obesity. There has been much discussion in the media about the obesity ‘epidemic’ and it has long been recognised as a serious public health concern. Undoubtedly, we live in an obesogenic environment that has contributed to the increased rates of obesity seen around the world. Fast food, soft drinks and the contemporary sedentary lifestyle are all factors that need to be addressed through public health efforts and individual counselling. Dietary and lifestyle modifications are associated with multiple positive psychological and physical outcomes.1
There are, however, a number of problems with emphasising lifestyle modifications alone in the treatment of obesity. It is at times impossible to put these changes into effect. Often, patients are working long hours that prohibit a routine exercise regimen. It is easy to prescribe 30 minutes of exercise four to five times per week, but very difficult to achieve this for an individual who wakes at 5.00 am, works a 10-hour day from Monday to Friday, and spends the evening trying to get the children to bed. Additionally, the degree of obesity often makes exercise difficult. Going for a run with a body mass index of >30 kg/m2 can be hard on the knees, and trying to spare the knees by working out at a public swimming pool is nearly impossible in some under-resourced neighbourhoods.
Even if the individual is able to institute lifestyle changes, success at achieving and maintaining weight loss is often limited, as detailed in the article on the genetics of obesity by Campbell.2 I believe it is often at this point that negative stereotypes about obesity start to enter the picture: people who are unable to control their weight must be weak-willed or lazy or gluttonous. The reality is that research has shown a strong genetic component to obesity, not to mention an expanding body of evidence on powerful epigenetic factors, and in some situations judging patients for not being able to control their weight would be like judging them for not being able to heal their congenital heart lesion.
Taking all of this evidence into account, obesity starts to appear comparable to other chronic diseases that have strong environmental and genetic influences, as argued in the articles on pharmacotherapy and bariatric surgery by Lee and Dixon.3,4 In this model, obesity should be managed in the same way as diabetes and hypertension, where therapeutic interventions beyond lifestyle considerations are considered part of routine care. Bariatric surgery has been clearly associated with markedly improved outcomes in the management of obesity and is recommended in national and international guidelines.5 Pharmacotherapy may also play an important role as evidence for established medications continues to accumulate and new agents are developed.
Obesity is associated with numerous adverse health outcomes. The article by Hamilton and Joosten6 examines the relationship between obesity and obstructive sleep apnoea (OSA). Most of us are aware of this relationship, but I suspect not many would be aware that it is in fact bidirectional, which has important management implications. Further consideration is given to the most recent studies comparing the effectiveness of weight loss and continuous positive airway pressure (CPAP) in treating OSA and its associated cardiometabolic complications.
Public health interventions and lifestyle counselling will continue to have a critical role in the prevention of obesity. Measures to address fast food consumption, such as ‘sugar taxes’ and restrictions on powerful marketing directed at young and vulnerable minds, are important. Ensuring access to safe exercise facilities and nutritious food in appropriately designed and resourced communities across all sociodemographics is equally important, as is ensuring equal access to medical and surgical care. Above all, we need to be conscious, both as a society and as a profession, of our own prejudices and not judge people who are obese.
Glenn Duns MDCM, FRACGP, MPH is a medical editor at AFP and a general practitioner, Mill Park, Vic