DR. CHIKA V. ANEKWE Structural inequities helped create America's weight problem, and science and understanding can help solve it.
I gravitated to medicine rather than research because I had a deep desire to work with people. As a physician, I can feel proud and happy that I’m making a difference in my patients’ everyday lives.
Our health care system tends to focus on treating illness instead of preventing it. My focus has been on preventive medicine. That means not just helping people when they’re suffering, but preventing them from suffering in the first place.
As physicians, we can help preserve health – and maintaining a healthy weight is a key factor in that.
The rate of obesity in this country is staggering, more than 40%, and weight has increased for many Americans during the pandemic. The health implications are significant.
Weight can affect every organ system and body part. We’ve identified 195 different diseases that are influenced by excess weight, ranging from migraines to liver disease, acid reflux, cardiovascular disease, asthma, high blood pressure, venous issues, type 2 diabetes, urinary incontinence.
In addition to its physical impact, fat tissue has metabolic effects, changing the hormonal system. You may not respond well to hormones such as insulin that help keep your body’s blood sugar at a normal range. You may not respond to the hormones that regulate blood pressure. Metabolic factors can increase your risk for poor cardiovascular outcomes.
And this year, we’ve seen stark evidence of how obesity and metabolic dysregulation can increase inflammation, decrease your immune response and heighten vulnerability to illnesses such as COVID-19. Obesity won’t necessarily make you more likely to catch COVID, but it may increase your risk of having a severe illness, severe complications, and potentially dying.
There’s a significant psychosocial effect too. People tend to lose self-confidence when they are not happy in their body and they may be limited in what they can do socially because of excess body weight. This can lead to depression, anxiety, fear of going outdoors and aversion to social situations.
Treating the disease
Obesity medicine is a specialty that recognizes obesity as a complex, treatable disease. That in itself is somewhat revolutionary, because in the very recent past obesity was considered a lifestyle choice, a problem of willpower or laziness or a lack of a desire to be healthy. We approach it as a metabolic condition that affects, significantly, a person’s quality of life and health and longevity. We assess each person as an individual and consider what’s affecting their weight and their health, and then we provide treatment options, based on their specific circumstances.
As physicians focused on obesity, we need to understand how people think, what’s driving them, why they make the decisions they do, and how that affects their health and their life. So we do a lot of counseling with patients as part of our treatment approach, sometimes one-on-one and sometimes with our psychologists or dieticians.
For me, in my work at the MGH Weight Center, my greatest joy is when somebody achieves their goal and I get to share the happiness and relief they experience from overcoming something they’ve struggled with for a long time.
What is the ideal weight?
For many years, clinicians determined a patient’s ideal weight by looking at what is known as the “body mass index” chart, which calculated what a person’s weight should be based on their height, with a BMI under 25 as a target. But the BMI was never meant to be used in individual health care – the data was originally developed to determine how much to charge people for life insurance. And the index was based on a mostly male population of European heritage, which means it doesn’t fit everyone.
These days, we still look at BMI, but we also do a more in-depth assessment. We look at blood pressure, waist circumference, cholesterol levels and blood sugar levels — what are known as “metabolic risk factors.” The diagnosis of metabolic syndrome includes having three or more of these risk factors, but if you have excess weight and just one risk factor, you can see the body shifting toward metabolic dysfunction. That’s the state of abnormal responses to hormones that affect your health and your weight and your long-term survival.
We view ideal weight today more as a picture than a number.
It’s a combination of your own personal goals and the metabolic measures that determine how healthy you are.
Race, racism and obesity
Black Americans have some of the highest rates of obesity in the U.S., and structural inequities are a big factor in that.
Racial inequality in poverty, unemployment, and homeownership is associated with higher obesity rates. It can be difficult to get outdoors and exercise in neighborhoods that lack greenspace, such as those created through the longstanding racist practice of redlining. There are higher rates of food insecurity – a lack of consistent access to enough food for an active, healthy life -- in low-income Black and Hispanic households. People who are working long hours or multiple jobs may struggle to find time to plan, shop and cook healthy meals – and Black Americans, in particular women, work multiple jobs at a higher than average rate. When you’re working multiple jobs, you’re likely sleep deprived, which also leads to increased hunger -- you’re looking for sugar, coffee or snacks to give you energy.
Psychosocial stress also plays a role in obesity, and Black Americans are subject to chronic stress from cultural, and structural racism, as well as from disproportionately high rates of poverty.
When people are under significant stress, the hormone cortisol is released. And when cortisol levels increase, the cells of our body can become resistant to insulin, leading to an increase in blood sugar, weight gain and potentially type 2 diabetes. Cortisol may cause fat to be deposited around the belly, which in turn releases more cortisol, creating a vicious cycle. It can increase the “visceral” fat around your major organs, which can lead to inflammation and high blood pressure.
It’s important for obesity specialists to discuss stress. I ask my patients, “What do you do when you are feeling overwhelmed? How do you relieve that stress?” If they’re overeating or drinking large quantities of alcohol, we explore alternative options, like taking a walk, taking up a new hobby, journaling, meditation or yoga. Are there people in their lives who can help them engage in activities that are positive for their health and can help them relieve stress? We build from there.
Healthy weight management
It’s important to take time to think about your motivation when you are trying to lose weight. Is it for your family? Is it for your friends? Your children? Because your knees hurt? Your back hurts? What’s motivating you? Remembering what is driving you will help you keep going when you face challenges.
It’s important to have realistic expectations, too. When we are treating obesity, we want to see a 5% body weight reduction in the first 12 weeks of dietary modification or medication implementation. If you weigh 200 pounds, that’s about 10 pounds in 3 months, less than a pound a week. When you hit that 5%, you start to see important reductions in your risk factors and improvement in your health.
We encourage exercise, but we don’t consider it a weight loss tool, because in general, it does not help people lose weight. It is very important, however, for helping to maintain weight once it has been lost. Studies have found that people who successfully kept significant weight off exercised an hour a day or more. Exercise improves your metabolism and helps you build muscle, which weighs more but also burns more calories at rest. And exercise improves mood, boosts immunity and helps with sleep.
We don’t recommend over-the-counter diet supplements, the kind you see advertised on TV or social media. Most of those are not evidence-based and any benefit that you might get from them is most likely either a placebo effect or an effect of what you’re doing along with taking it. So if you’re taking it and then also eating all your greens and eliminating the added sugars, that’s probably what’s helping you to make progress, not that high-priced exotic-sounding supplement you saw on Instagram.
If you’re losing weight quickly, five pounds in two weeks as many fad diets promise, then a significant amount of that is likely water or muscle — so you’re dehydrated and you’re now burning even fewer calories than you were at baseline. Beware of those diets.
We can all help combat America’s obesity epidemic.
City planners can increase the walkability of our neighborhoods so we can feel free to walk and play. Being able to safely enjoy outdoor physical activity should be a right, not a privilege.
As a community and as a society, we can address structural racism and interpersonal racism, which lead to so many health inequities, including obesity. We can recognize obesity as a disease of metabolism rather than a disease of choice or lifestyle.
Primary care physicians can learn more about treating patients with obesity. The Obesity Medicine Association, The Obesity Society, and the Obesity Action Coalition have a wealth of resources.
If you have obesity, remember, it is a disease, and it’s not your fault. Know that there is help available for you. You can start by reaching out to your primary care doctor and talking about your options.
Don’t lose hope and don’t let this define or limit you.