Golden A. Top Ten Myths About Obesity. Presented at: Obesity Medical Association conference; April 27 – May 1, 2022; (hybrid meeting).
Golden reports financial relationships with Acella, Gelesis, Currax and Novo Nordisk.
Myths can be a major barrier for obese people to access treatment, and educating patients to overcome them is critical†
Angie Golden, DNP, FNP-C, FAANP† a nurse practitioner at an obesity treatment clinic in Arizona, discussed 10 myths about obesity at the Obesity Medicine Association conference to show how they can affect obese people and help doctors.
Golden said that as an obese woman, she is “incredibly passionate” about the subject. The presentation was based on her opinion of the top 10 myths; there’s no data to suggest these are the main myths associated with obesity, Golden said.
The first myth she addressed was that obesity is a risk factor, not a disease.
“We hear this all the time,” she said. “Our cardiology colleagues will say that obesity is a risk factor for all cardiological diseases … and I would argue that obesity is the cause, not a risk factor.”
Obesity is a chronic, treatable disease, Golden explained, and patients need to know that their condition is treatable.
“Hippocrates recognized that overweight people had a higher risk of sudden death. It certainly took a long time for us to have medical organizations that accepted obesity as a disease when Hippocrates knew 2,500 years ago,” she said.
The fact that many people don’t recognize obesity as a disease in itself ties into the second myth: “It’s all about willpower,” Golden said.
“My cardiologist pointed at me with his hand on the doorknob and said, ‘You need to eat less and exercise more.’ He was right,” she said. “From a behavioral perspective it would probably have been beneficial for me to eat less and exercise more. But he made it clear that that was the cause of my excess fat tissue, in his head.”
Obesity is a disease, a neuroendocrine disorder “with obvious pathophysiology in the brain and in the dysfunction of the endocrine system for energy regulation,” Golden said.
“Willpower is defined by exerting control to do something or restraining impulses,” she added. “That’s not what obesity is. Not if we look at the hormonal aspects of it and what happens in the brain.”
Golden then jokingly asked women of childbearing age to “go home tonight and get an egg out of it” to suggest that one has as much power over it as fighting the hormonal aspects of obesity.
“I can’t control my ghrelin level with willpower. Hunger and energy homeostasis is incredibly complex,” she said.
In addition to the misconception that you can lose weight with sheer willpower, many obese people believe that they need to lose a lot of weight in order to have any benefit to their health.
“Fortunately, the fact is that 5% to 10% weight loss can reduce complications associated with obesity,” Golden said. “Usually within 6 months you can reduce cardiovascular risk, prevent or delay type 2 diabetes and improve osteoarthritis. You can also improve patient health and quality of life.”
Golden shared a story of a patient who said she wanted to be able to walk with her children at Disneyland without stopping so she could rest. When she lost 10% of her weight, she felt much better and was able to walk 25,000 steps a day – enough for a visit to Disneyland without stops.
“She came back and said, ‘If I never lose another pound — as long as I keep this off — I’ve done what I set out to do,'” Golden said.
One theme from the myths Golden discussed was a sense of helplessness. Some patients ask, “What’s the point?” because they think the weight will all come back, or they think they can’t change their weight because their family is also struggling with obesity.
“There’s no question that genetics is part of this, but genetics is our sensitivity,” she said. “Something is turning on these genes. My genetic predisposition was prone to disease, it wasn’t a given.”
When the weight returned, Golden said, “Well, it sure does.” But she explained that the physiology of weight gain is metabolic adaptation, “not the person getting lazy.”
“Obesity cannot be cured; it’s been treated,” she said.
Even with treatments, myths can arise. For example, the idea that surgery is “cheating” is also a myth.
“We can’t attribute everything to just the surgery and simple mechanical adjustments. We know that surgery now lowers the defended level of fat mass in some way,” she said. “A large percentage of patients have lower defended mass, which is one of the big pathophysiological problems with this disease: increased adiposity and then a defense of that increase in adiposity.”
She also mentioned changes in the gut-brain axis that occur soon after surgery, such as a change in signaling with ghrelin, GLP-1.
“And then we see how much resolution we can get on just some of the obesity-related complications,” she said.
For example, data has shown that bariatric surgery is associated with diabetes remission in 83% of patients, Golden said.
“Type 2 diabetes: 83%. Sit down with that for a while,’ she said. “Is there anything else you do that can give you an 83% remission from chronic disease? That’s why we should talk to our patients with a BMI of 35 or higher who have type 2 diabetes. should be an option that is at the forefront of their thinking process.”
Golden went on to say she doesn’t believe everyone should have bariatric surgery, any more than she thinks everyone should have coronary artery bypass.
“Stenting works great for some people; medication works great for others. I think we should combine everything,” she said.
Two harmful myths that go hand in hand are the ‘calories in, calories out’ approach and that people simply need to exercise more to lose weight.
“Find out what your metabolism is and do it! Obesity wouldn’t exist,” Golden said. “You have to move on” [diet and exercise] because then you treat obesity as a disease.”
Golden also mentioned guidelines telling people to eat 500 fewer calories each day to lose 1 pound each week, but said this was problematic.
“We are not continuous eaters; we’re discontinuous and we’re continuous metabolizers,” she said. “So, the scale will never be at an even point like this.”
She also pointed out that “there’s a hypothesis that, with obesity disease, our microbiome interacts with the food a little bit differently, and as a result actually absorbs more calories from our food than we think we get.”
In addition, Golden noted that, during active weight loss, exercise will only cause “modest” weight loss — about 2 pounds on average — but bouts of exercise also often increase sedentary activity for the rest of the day.
“You have to be very careful,” she said. “Just because you went to the gym, ran on the treadmill and lifted weights doesn’t mean you can go home and be a couch potato for the rest of the day.”
But that’s what the body will try to do, she continued, because of the regulation of energy.
“Voluntary exercise has been shown to reduce other types of exercise, such as our other energy sources, such as our basal metabolic rate,” Golden said.
In addition, exercise and exercise increase hunger hormones, so “we think we can eat a little more when we exercise.”
Once you exercise a certain amount, your body shuts down other expenses, but that process looks different for everyone, “so we never know what our personal energy plateau might be,” Golden said.
Ultimately, though, Golden said exercise is critical for health and especially for obesity maintenance.
“Now that I’m on maintenance, I have to have a lot of activity in my life to keep my weight down, and to keep all those obesity-related ailments from knocking on the door instead of sitting inside,” she said.
The last myth Golden tried to dispel was that of healthy obesity.
“The point is, we have clear evidence that cumulative obesity causes damage to the body,” she said, pointing to a UK study that illustrated complications related to obesity, such as a 50% increase in cardiovascular disease.
Golden ended her presentation with a plea.
“If you get nothing else out of this, take the word obese out of your dictionary, out of your language. I am not an obese woman. I’m not labeled for my disease, and neither should your patients be,” she said.
“On a very cheerful note, obesity is a chronic, progressive, but treatable condition,” Golden said in conclusion. “Five to 10% weight loss can change obesity-related complications; it’s much more than calories in and calories out; drugs are a critical tool in our toolbox for treating this disease; exercise is critical to maintenance; and bias can affect treatment.”
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