25/10/2017...25/10/2017 6 •not that they have no hope; they just need more help •life happens:...
TRANSCRIPT
25102017
1
ObesityLifestyle problem or metabolic
disease
Dr Georgia Rigas
MBBS FRACGP
RACGP Obesity Management Network Chair
General Practitioner
Bariatric Medical Practitioner Sydney
Acknowledgement and Disclosures
bull Chair RACGP Obesity Management Network
bull RACGP Clinical Examiner
bull Medical Advisory Committee Medical Steering Committee iNOF16 amp Consultancy work-iNova
bull Consultancy work- Apollo (formerly Allergan)
bull Consultancy work- Medtronics (formerly Covidien)
bull Consultancy work- Dietitians Association of Australia
bull GP Medical Advisory Committee amp Consultancy work- Novo Nordisk
Letrsquos begin with first principles
bull WHO definesbull Health as a state of complete physical mental and social well-being not
simply just the absence of disease
bull Healthy Living as the steps actions and strategies one puts in place to achieve optimum health
bull A healthy lifestyle is defined as a particular way of living which helps to keep and improve peoples health and well-being
bull The ways to being healthy include healthy eating physical activities weight management and stress management
World Health Organisation October 2011
Therefore it follows thathellip
bull A ldquodiseaserdquo is defined as bull ldquoa morbid condition of the body or some organ or part an illnessailmentrdquo(1)
bull WHO defines obesity as ldquoabnormal or excessive fat accumulation that presents a risk to an individualrsquos healthrdquo (2)
bull Meaning of ldquoexcessrdquo is hard to define
bull Calculated by BMI gt30
(1) Macquarie Dictionary
(2) WHO Obesity and Overweight In Fact Sheet No 311
bullA ldquodiseaserdquo is defined as ldquoa morbid condition of the body or some organ or part an illness an ailmentrdquo -Macquarie Dictionary
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
bull Obesity risk of mortality cfthose never had obesity
bull Mortality risk uarrthe longer the duration of obesity
25102017
2
bullA ldquodiseaserdquo is defined as ldquoa morbid condition of the body or some organ or part an illness an ailmentrdquo -Macquarie Dictionary
Excessive accumulation of fat cells can make some people ldquosickrdquo
bull Two types of functional impairments are associated with the increased size and mass of fat cells in obesity
1) The mechanical consequences to the fat mass such asbull osteoarthritis sleep apnoea amp the psychosocial responses to the individual
with obesity
2) the metabolic and inflammatory consequences resulting frombull the excessive secretion of products by the enlarged fat cell and
bull ectopic deposition of lipid
bull Obesity is characterised by a chronic systemic low
grade state of inflammation
bull Biomarkers of inflammation (secreted by the
adipocytes) are increased in obesity eg TNF alpha
IL 6 and CRP and predict the development of
diabetes and cardiovascular disease
bull Obesity adipocytes macrophages rarr release
cytokines rarr participate in inflammatory process
bull Hence a pathophysiological process underlies
obesity
Slide courtesy of Dr Anthony Brancatisano
Contributors to obesityinside the person
Contributors to obesityinside the person
Contributors to obesityinside the person
25102017
3
Contributors to obesityoutside the person
Contributors to obesityoutside the person
Contributors to obesityoutside the person Lifestyle choicehellipPro
Figure 4 Individual-Level Standard Deviation in Body Mass Index by Baseline Weight Classification Framingham Heart Study Offspring Cohort 1979ndash2008
Block JP Subramanian SV Christakis NA OrsquoMalley AJ (2013) Population Trends and Variation in Body Mass Index from 1971 to 2008 in the Framingham Heart Study Offspring Cohort PLOS ONE 8(5) e63217 httpsdoiorg101371journalpone0063217httpjournalsplosorgplosonearticleid=101371journalpone0063217
25102017
4
Analogy of smoking (is imperfect)
bull Smoking causes a wide range of diseases eg cancer CVDampresp dx
bull Every year 15000 Australians die from smoking related diseases ie 40 preventable deaths every day
bull However no one ever proposed labelling smoking a disease
bull The suggestion that obesity is not a disease is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes
Using BMI gt30 is a crude metric
PRO LIFESTYLE LABEL
bull An estimated 30 of those classified as having obesity are actually cardio-metabolic healthy
bull Whilst obesity is a risk factor for many medical conditions carrying extra kgs does not destine people to develop those diseases
AGAINST LIFESTLE LABEL
bull Long-term follow-up studies show that ˃ frac12 will develop obesity-related disease during their lifetime (Framingham Study)
bull Obesity is heterogeneous amp is expressed as a variety of phenotypes
bull Clinicians use medical amp clinical judgement by examining each patient as an individual and not rely on BMI solely
Lifestyle choice-Pro Obesity is not a disease of the individual
bull makes much more sense to view obesity as a societal problem or more accurately as a problem involving the interaction of the individual with what has been called the ldquoobesogenicrdquo society
bull The society-wide obesity problem is much more complex than smoking and tackling it will require a much more sophisticated and nuanced approach than what worked for smoking
bull We do need medicine to treat obesity but more often than not it is lifestyle medicine Lifestyle is the best medicine wersquove got mdash but it is cultural medicine not clinical
Metabolic Disease
bull Metabolic disease defined as any of the diseases or disorders that disrupt normal metabolism the process of converting food to energy on a cellular level
bull Metabolic diseases affect the ability of the cell to perform critical biochemical reactions that involve the processing or transport of proteins (amino acids) carbohydrates (sugars and starches) or lipids (fatty acids)
bull Metabolic diseases are typically hereditary eg Haemochromatosis
Is obesity a metabolic disease too
25102017
5
bull Hunger is controlled by very powerful hormones -gt affecting pleasure pathways-gt cravingsbull Many people with obesity have impaired function of these hormones -gt strong physiological drive
to eat morebull The brain has a reward centre which lights up and starts secreting dopamine and other feel-good
chemicals when we eat bull Junk food releases much more of these feel-good chemicals than unprocessed food -gt yields a
much more powerful ldquorewardrdquo in the brainbull For some the brain may then seek more reward by causing powerful cravings for these junk foods
-gt a vicious cycle that resembles addiction
Metabolic disease-pro
Brain doesnrsquot sense that insulin is produced = thinks wersquore starving-gtpowerful physiological drive to eat more
Metabolic disease-pro
bull Leptin is produced by fat cells -gttells our brain to stop eatingbull Leptin regulates the amount of calories we eat and expend
as well as how much fat our bodies storebull LEPTIN RESISTANCE the brain doesnrsquot see or recognize it
When the brain doesnrsquot receive the leptin signal it wrongly thinks that it is starving even if it has more than enough body fat stored -gt causes the brain to change physiology and behaviour in order to regain the fat that it thinks wersquore missing
Metabolic disease- Prothe role of gut microbiota
bull Interestingly people with obesity tend to have different gut bacteria than genetically lean people [more Firmicutes amp fewer Bacteroidetes]
bull The gut bacteria in overweight or obese individuals may be more efficient at harvesting energy from food increasing the total caloric value of the diet
bull This may cause obese people to store more fat
bull Area of ongoing research
25102017
6
bull Not that they have no hope they just need more helpbull Life happens not everything is in our own hands
bull ldquoTelling someone with obesity to eat less is like telling someone with depression to cheer uprdquo PROF ARYA SHARMA Canadian Obesity Network
Heritability of Body Weight
Twin Overfeeding studiessignificant similarity within each pair of twins in response to overfeeding wrtbull Body weightbull fatbull Estimated sc fat
Metabolic disease-ProGenes and Epigenetics
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
Lifestyle changes over the last 50+ years
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
2
bullA ldquodiseaserdquo is defined as ldquoa morbid condition of the body or some organ or part an illness an ailmentrdquo -Macquarie Dictionary
Excessive accumulation of fat cells can make some people ldquosickrdquo
bull Two types of functional impairments are associated with the increased size and mass of fat cells in obesity
1) The mechanical consequences to the fat mass such asbull osteoarthritis sleep apnoea amp the psychosocial responses to the individual
with obesity
2) the metabolic and inflammatory consequences resulting frombull the excessive secretion of products by the enlarged fat cell and
bull ectopic deposition of lipid
bull Obesity is characterised by a chronic systemic low
grade state of inflammation
bull Biomarkers of inflammation (secreted by the
adipocytes) are increased in obesity eg TNF alpha
IL 6 and CRP and predict the development of
diabetes and cardiovascular disease
bull Obesity adipocytes macrophages rarr release
cytokines rarr participate in inflammatory process
bull Hence a pathophysiological process underlies
obesity
Slide courtesy of Dr Anthony Brancatisano
Contributors to obesityinside the person
Contributors to obesityinside the person
Contributors to obesityinside the person
25102017
3
Contributors to obesityoutside the person
Contributors to obesityoutside the person
Contributors to obesityoutside the person Lifestyle choicehellipPro
Figure 4 Individual-Level Standard Deviation in Body Mass Index by Baseline Weight Classification Framingham Heart Study Offspring Cohort 1979ndash2008
Block JP Subramanian SV Christakis NA OrsquoMalley AJ (2013) Population Trends and Variation in Body Mass Index from 1971 to 2008 in the Framingham Heart Study Offspring Cohort PLOS ONE 8(5) e63217 httpsdoiorg101371journalpone0063217httpjournalsplosorgplosonearticleid=101371journalpone0063217
25102017
4
Analogy of smoking (is imperfect)
bull Smoking causes a wide range of diseases eg cancer CVDampresp dx
bull Every year 15000 Australians die from smoking related diseases ie 40 preventable deaths every day
bull However no one ever proposed labelling smoking a disease
bull The suggestion that obesity is not a disease is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes
Using BMI gt30 is a crude metric
PRO LIFESTYLE LABEL
bull An estimated 30 of those classified as having obesity are actually cardio-metabolic healthy
bull Whilst obesity is a risk factor for many medical conditions carrying extra kgs does not destine people to develop those diseases
AGAINST LIFESTLE LABEL
bull Long-term follow-up studies show that ˃ frac12 will develop obesity-related disease during their lifetime (Framingham Study)
bull Obesity is heterogeneous amp is expressed as a variety of phenotypes
bull Clinicians use medical amp clinical judgement by examining each patient as an individual and not rely on BMI solely
Lifestyle choice-Pro Obesity is not a disease of the individual
bull makes much more sense to view obesity as a societal problem or more accurately as a problem involving the interaction of the individual with what has been called the ldquoobesogenicrdquo society
bull The society-wide obesity problem is much more complex than smoking and tackling it will require a much more sophisticated and nuanced approach than what worked for smoking
bull We do need medicine to treat obesity but more often than not it is lifestyle medicine Lifestyle is the best medicine wersquove got mdash but it is cultural medicine not clinical
Metabolic Disease
bull Metabolic disease defined as any of the diseases or disorders that disrupt normal metabolism the process of converting food to energy on a cellular level
bull Metabolic diseases affect the ability of the cell to perform critical biochemical reactions that involve the processing or transport of proteins (amino acids) carbohydrates (sugars and starches) or lipids (fatty acids)
bull Metabolic diseases are typically hereditary eg Haemochromatosis
Is obesity a metabolic disease too
25102017
5
bull Hunger is controlled by very powerful hormones -gt affecting pleasure pathways-gt cravingsbull Many people with obesity have impaired function of these hormones -gt strong physiological drive
to eat morebull The brain has a reward centre which lights up and starts secreting dopamine and other feel-good
chemicals when we eat bull Junk food releases much more of these feel-good chemicals than unprocessed food -gt yields a
much more powerful ldquorewardrdquo in the brainbull For some the brain may then seek more reward by causing powerful cravings for these junk foods
-gt a vicious cycle that resembles addiction
Metabolic disease-pro
Brain doesnrsquot sense that insulin is produced = thinks wersquore starving-gtpowerful physiological drive to eat more
Metabolic disease-pro
bull Leptin is produced by fat cells -gttells our brain to stop eatingbull Leptin regulates the amount of calories we eat and expend
as well as how much fat our bodies storebull LEPTIN RESISTANCE the brain doesnrsquot see or recognize it
When the brain doesnrsquot receive the leptin signal it wrongly thinks that it is starving even if it has more than enough body fat stored -gt causes the brain to change physiology and behaviour in order to regain the fat that it thinks wersquore missing
Metabolic disease- Prothe role of gut microbiota
bull Interestingly people with obesity tend to have different gut bacteria than genetically lean people [more Firmicutes amp fewer Bacteroidetes]
bull The gut bacteria in overweight or obese individuals may be more efficient at harvesting energy from food increasing the total caloric value of the diet
bull This may cause obese people to store more fat
bull Area of ongoing research
25102017
6
bull Not that they have no hope they just need more helpbull Life happens not everything is in our own hands
bull ldquoTelling someone with obesity to eat less is like telling someone with depression to cheer uprdquo PROF ARYA SHARMA Canadian Obesity Network
Heritability of Body Weight
Twin Overfeeding studiessignificant similarity within each pair of twins in response to overfeeding wrtbull Body weightbull fatbull Estimated sc fat
Metabolic disease-ProGenes and Epigenetics
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
Lifestyle changes over the last 50+ years
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
3
Contributors to obesityoutside the person
Contributors to obesityoutside the person
Contributors to obesityoutside the person Lifestyle choicehellipPro
Figure 4 Individual-Level Standard Deviation in Body Mass Index by Baseline Weight Classification Framingham Heart Study Offspring Cohort 1979ndash2008
Block JP Subramanian SV Christakis NA OrsquoMalley AJ (2013) Population Trends and Variation in Body Mass Index from 1971 to 2008 in the Framingham Heart Study Offspring Cohort PLOS ONE 8(5) e63217 httpsdoiorg101371journalpone0063217httpjournalsplosorgplosonearticleid=101371journalpone0063217
25102017
4
Analogy of smoking (is imperfect)
bull Smoking causes a wide range of diseases eg cancer CVDampresp dx
bull Every year 15000 Australians die from smoking related diseases ie 40 preventable deaths every day
bull However no one ever proposed labelling smoking a disease
bull The suggestion that obesity is not a disease is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes
Using BMI gt30 is a crude metric
PRO LIFESTYLE LABEL
bull An estimated 30 of those classified as having obesity are actually cardio-metabolic healthy
bull Whilst obesity is a risk factor for many medical conditions carrying extra kgs does not destine people to develop those diseases
AGAINST LIFESTLE LABEL
bull Long-term follow-up studies show that ˃ frac12 will develop obesity-related disease during their lifetime (Framingham Study)
bull Obesity is heterogeneous amp is expressed as a variety of phenotypes
bull Clinicians use medical amp clinical judgement by examining each patient as an individual and not rely on BMI solely
Lifestyle choice-Pro Obesity is not a disease of the individual
bull makes much more sense to view obesity as a societal problem or more accurately as a problem involving the interaction of the individual with what has been called the ldquoobesogenicrdquo society
bull The society-wide obesity problem is much more complex than smoking and tackling it will require a much more sophisticated and nuanced approach than what worked for smoking
bull We do need medicine to treat obesity but more often than not it is lifestyle medicine Lifestyle is the best medicine wersquove got mdash but it is cultural medicine not clinical
Metabolic Disease
bull Metabolic disease defined as any of the diseases or disorders that disrupt normal metabolism the process of converting food to energy on a cellular level
bull Metabolic diseases affect the ability of the cell to perform critical biochemical reactions that involve the processing or transport of proteins (amino acids) carbohydrates (sugars and starches) or lipids (fatty acids)
bull Metabolic diseases are typically hereditary eg Haemochromatosis
Is obesity a metabolic disease too
25102017
5
bull Hunger is controlled by very powerful hormones -gt affecting pleasure pathways-gt cravingsbull Many people with obesity have impaired function of these hormones -gt strong physiological drive
to eat morebull The brain has a reward centre which lights up and starts secreting dopamine and other feel-good
chemicals when we eat bull Junk food releases much more of these feel-good chemicals than unprocessed food -gt yields a
much more powerful ldquorewardrdquo in the brainbull For some the brain may then seek more reward by causing powerful cravings for these junk foods
-gt a vicious cycle that resembles addiction
Metabolic disease-pro
Brain doesnrsquot sense that insulin is produced = thinks wersquore starving-gtpowerful physiological drive to eat more
Metabolic disease-pro
bull Leptin is produced by fat cells -gttells our brain to stop eatingbull Leptin regulates the amount of calories we eat and expend
as well as how much fat our bodies storebull LEPTIN RESISTANCE the brain doesnrsquot see or recognize it
When the brain doesnrsquot receive the leptin signal it wrongly thinks that it is starving even if it has more than enough body fat stored -gt causes the brain to change physiology and behaviour in order to regain the fat that it thinks wersquore missing
Metabolic disease- Prothe role of gut microbiota
bull Interestingly people with obesity tend to have different gut bacteria than genetically lean people [more Firmicutes amp fewer Bacteroidetes]
bull The gut bacteria in overweight or obese individuals may be more efficient at harvesting energy from food increasing the total caloric value of the diet
bull This may cause obese people to store more fat
bull Area of ongoing research
25102017
6
bull Not that they have no hope they just need more helpbull Life happens not everything is in our own hands
bull ldquoTelling someone with obesity to eat less is like telling someone with depression to cheer uprdquo PROF ARYA SHARMA Canadian Obesity Network
Heritability of Body Weight
Twin Overfeeding studiessignificant similarity within each pair of twins in response to overfeeding wrtbull Body weightbull fatbull Estimated sc fat
Metabolic disease-ProGenes and Epigenetics
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
Lifestyle changes over the last 50+ years
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
4
Analogy of smoking (is imperfect)
bull Smoking causes a wide range of diseases eg cancer CVDampresp dx
bull Every year 15000 Australians die from smoking related diseases ie 40 preventable deaths every day
bull However no one ever proposed labelling smoking a disease
bull The suggestion that obesity is not a disease is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes
Using BMI gt30 is a crude metric
PRO LIFESTYLE LABEL
bull An estimated 30 of those classified as having obesity are actually cardio-metabolic healthy
bull Whilst obesity is a risk factor for many medical conditions carrying extra kgs does not destine people to develop those diseases
AGAINST LIFESTLE LABEL
bull Long-term follow-up studies show that ˃ frac12 will develop obesity-related disease during their lifetime (Framingham Study)
bull Obesity is heterogeneous amp is expressed as a variety of phenotypes
bull Clinicians use medical amp clinical judgement by examining each patient as an individual and not rely on BMI solely
Lifestyle choice-Pro Obesity is not a disease of the individual
bull makes much more sense to view obesity as a societal problem or more accurately as a problem involving the interaction of the individual with what has been called the ldquoobesogenicrdquo society
bull The society-wide obesity problem is much more complex than smoking and tackling it will require a much more sophisticated and nuanced approach than what worked for smoking
bull We do need medicine to treat obesity but more often than not it is lifestyle medicine Lifestyle is the best medicine wersquove got mdash but it is cultural medicine not clinical
Metabolic Disease
bull Metabolic disease defined as any of the diseases or disorders that disrupt normal metabolism the process of converting food to energy on a cellular level
bull Metabolic diseases affect the ability of the cell to perform critical biochemical reactions that involve the processing or transport of proteins (amino acids) carbohydrates (sugars and starches) or lipids (fatty acids)
bull Metabolic diseases are typically hereditary eg Haemochromatosis
Is obesity a metabolic disease too
25102017
5
bull Hunger is controlled by very powerful hormones -gt affecting pleasure pathways-gt cravingsbull Many people with obesity have impaired function of these hormones -gt strong physiological drive
to eat morebull The brain has a reward centre which lights up and starts secreting dopamine and other feel-good
chemicals when we eat bull Junk food releases much more of these feel-good chemicals than unprocessed food -gt yields a
much more powerful ldquorewardrdquo in the brainbull For some the brain may then seek more reward by causing powerful cravings for these junk foods
-gt a vicious cycle that resembles addiction
Metabolic disease-pro
Brain doesnrsquot sense that insulin is produced = thinks wersquore starving-gtpowerful physiological drive to eat more
Metabolic disease-pro
bull Leptin is produced by fat cells -gttells our brain to stop eatingbull Leptin regulates the amount of calories we eat and expend
as well as how much fat our bodies storebull LEPTIN RESISTANCE the brain doesnrsquot see or recognize it
When the brain doesnrsquot receive the leptin signal it wrongly thinks that it is starving even if it has more than enough body fat stored -gt causes the brain to change physiology and behaviour in order to regain the fat that it thinks wersquore missing
Metabolic disease- Prothe role of gut microbiota
bull Interestingly people with obesity tend to have different gut bacteria than genetically lean people [more Firmicutes amp fewer Bacteroidetes]
bull The gut bacteria in overweight or obese individuals may be more efficient at harvesting energy from food increasing the total caloric value of the diet
bull This may cause obese people to store more fat
bull Area of ongoing research
25102017
6
bull Not that they have no hope they just need more helpbull Life happens not everything is in our own hands
bull ldquoTelling someone with obesity to eat less is like telling someone with depression to cheer uprdquo PROF ARYA SHARMA Canadian Obesity Network
Heritability of Body Weight
Twin Overfeeding studiessignificant similarity within each pair of twins in response to overfeeding wrtbull Body weightbull fatbull Estimated sc fat
Metabolic disease-ProGenes and Epigenetics
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
Lifestyle changes over the last 50+ years
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
5
bull Hunger is controlled by very powerful hormones -gt affecting pleasure pathways-gt cravingsbull Many people with obesity have impaired function of these hormones -gt strong physiological drive
to eat morebull The brain has a reward centre which lights up and starts secreting dopamine and other feel-good
chemicals when we eat bull Junk food releases much more of these feel-good chemicals than unprocessed food -gt yields a
much more powerful ldquorewardrdquo in the brainbull For some the brain may then seek more reward by causing powerful cravings for these junk foods
-gt a vicious cycle that resembles addiction
Metabolic disease-pro
Brain doesnrsquot sense that insulin is produced = thinks wersquore starving-gtpowerful physiological drive to eat more
Metabolic disease-pro
bull Leptin is produced by fat cells -gttells our brain to stop eatingbull Leptin regulates the amount of calories we eat and expend
as well as how much fat our bodies storebull LEPTIN RESISTANCE the brain doesnrsquot see or recognize it
When the brain doesnrsquot receive the leptin signal it wrongly thinks that it is starving even if it has more than enough body fat stored -gt causes the brain to change physiology and behaviour in order to regain the fat that it thinks wersquore missing
Metabolic disease- Prothe role of gut microbiota
bull Interestingly people with obesity tend to have different gut bacteria than genetically lean people [more Firmicutes amp fewer Bacteroidetes]
bull The gut bacteria in overweight or obese individuals may be more efficient at harvesting energy from food increasing the total caloric value of the diet
bull This may cause obese people to store more fat
bull Area of ongoing research
25102017
6
bull Not that they have no hope they just need more helpbull Life happens not everything is in our own hands
bull ldquoTelling someone with obesity to eat less is like telling someone with depression to cheer uprdquo PROF ARYA SHARMA Canadian Obesity Network
Heritability of Body Weight
Twin Overfeeding studiessignificant similarity within each pair of twins in response to overfeeding wrtbull Body weightbull fatbull Estimated sc fat
Metabolic disease-ProGenes and Epigenetics
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
Lifestyle changes over the last 50+ years
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
6
bull Not that they have no hope they just need more helpbull Life happens not everything is in our own hands
bull ldquoTelling someone with obesity to eat less is like telling someone with depression to cheer uprdquo PROF ARYA SHARMA Canadian Obesity Network
Heritability of Body Weight
Twin Overfeeding studiessignificant similarity within each pair of twins in response to overfeeding wrtbull Body weightbull fatbull Estimated sc fat
Metabolic disease-ProGenes and Epigenetics
Obesity A National Epidemic and Its Impact on Australia (2014) J Leung Obesity Australia
Lifestyle changes over the last 50+ years
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
7
Metabolic disease-ProCould it be a First World problem
The Fattening of America Health Economist Eric Finkelstein argues that obesity is a lifestyle choice [2008]
bull ldquoWith labor-saving devices and low-cost easily accessible foods people are going to eat more and exercise less
bull When you have a first-rate medical system that can cure the diseases that obesity promotes you no longer need to worry so much about being obese
COUNTER-ARGUEMENT
bull There would appear to be more at play here than sheer wealth Japan boasts over 3000 McDonalds restaurants 2nd in No only to the US amp is home to many other fast food outlets
bull Yet Japan has one of the lowest obesity rates in the world
Restrictiveenvironment
Resistant Prone
ldquoObesogenicrdquoenvironment
Obesity Predisposition
BM
I
Ravussin E Bouchard C Eur J Pharmacol 2000410131-145
Genetics vs Environment
Metabolic disease-ProFood deserts amp environmental disruptorsbull In some areas buying healthy food is simply not an option
bull Not being able to buy healthy and fresh foods limits the diet substantially and increases the risk of problems like obesity
bull Other environmental factors may also play a role in obesity including artificial light from electric light bulbs computers phones and televisions
bull Even though the link between screen use and obesity has been well established most studies chalk this up to lack of exercise
bull However night time exposure to light and changes to the inner circadian rhythm may also contribute to obesity
Metabolic disease-Pro
bull Obesity can be a genetic disorder such as sickle-cell anaemia and Tay-Sachs which are classified as diseases
bull Researchers have ID 79 genetic syndromes associated with obesity
bull Studies have shown that obesity can be inherited like height
bull Genetic disposition plays a large role in determining if a person will be obese
bull The FTO gene reportedly lowers activity in the part of the brain that controls impulses and the response to the taste and texture of food so people with the gene are more likely to eat more fatty foods and eat more impulsively as they age
bull NEJM study 1990 on body mass in twins not raised in the same home concluded genetic influences on body-mass index are substantial
bull In addition to genetic predisposition almost 10 of morbidly obese people have defects in the genes that regulate food intake metabolism and weight
Metabolic Disease-ConObesity is a side effect not a disease
bull Obesity can be caused by hypothyroidism Cushings syndrome Prader-Willi syndrome polycystic ovary syndrome arthritis increased insulin levels (from carbohydrate-heavy diets or diabetes treatments) and depression
bull Certain drugs like antidepressants anti-seizure medications diabetes medications anti-psychotic medications antihistamines anticonvulsants steroids beta blockers and contraceptives can contribute towards obesity
bull Obesity is associated with lack of sleep (or sleep debt) ingesting endocrine disrupters (such as BPA DDT and phthalates) consuming high-fructose corn syrup a lack of temperature variation (due to air conditioners and heaters) etc
Metabolic disease-ConIs Obesity an addiction to food
bull When you become addicted to something you lose your freedom of choice Your brain chemistry starts making the decisions for you
bull In fact up to 20 of people may suffer from food addiction and this number goes up to about 25 in overweight and obese people
bull Further research is required
Nutrients 2014 Oct 216(10)4552-90 doi 103390nu6104552The prevalence of food addiction as assessed by the Yale Food Addiction Scale a systematic reviewPursey KM1 Stanwell P2 Gearhardt AN3 Collins CE4 Burrows TL5
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano
25102017
8
Obesity is no different from these other chronic diseases where short-term treatments do not change the underlying biology that drives and maintains them
Obesity is multi-factorial
Sumithran P et al N Engl J Med 2011 3651597-604
Body weight is vigorously defended
hormonally
bull Changes in gut hormones after weight loss 1 increased hunger amp2 greater desire to eatbull These persist even when the lost weight is regained
Slide courtesy of Dr Anthony Brancatisano