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OBESITY – A RIGHT OR A DISEASE
How far does medical science intervene?
Dr Chris Eliades*
A. Background
Hippocrates, believed to have lived between about 460BC and 357BC, is credited
with being the first to have written about preventive medicine. He was concerned
about preserving health through proper diet and activities, such as exercise and
getting enough rest.
“Everything in excess is opposed to nature”.
Hippocrates
Hippocrates considered obesity as the cause of disease and, in the extreme, death
• He believed that obesity was a deviation from the norm
• The cause of obesity he refers to as the surplus of one of the liquids
circulating in the body
• Thus treatment points mainly to restoring the balance of liquids. This is
accomplished by diet, herbs, and most importantly exercise
“If we could give every individual the right amount of nourishment and
exercise, not too little and not too much, we would have found the safest way
to health”
Hippocrates also wrote
“Corpulence is not only a disease itself, but the harbinger of others”
Hippocrates recognized that obesity is a medical disorder that also leads to many comorbidities.
Yet over the next 2000 years attitudes toward body weight became
more complex. Plumpness, particularly in women, was seen as desirable, a sign of
well-being and fertility, and the goddesses were often depicted as hefty matrons
“Let me have men about me that are fat, sleek-headed men and such as
sleep a-nights. Yon Cassius has a lean and hungry look. He thinks too
much. Such men are dangerous”1Throughout history men have gained credibility from their accumulated wealth and
power. Fatness was seen as an indicator of wealth and abundance, and thus viewed
as desirable
It was 2000 years after Hippocrates that medical science re-discovered the
association between obesity and disease.
Thomas Short writing in 17272 Identified Obesity as a health problem. More than a
century later, William Banting3, a London undertaker and dietician in 1863 published
the "Banting diet"4 as a treatment for obesity, prepared under the supervision of Dr
William Harvey. So-called Bantingism, a diet low in sugar and oily foods, swept
across England, making it the first fad diet craze of national proportions
The United States did not come into the forefront of obesity research until Hugo
Rony published his monograph Obesity and Leanness5 in 1940.
By the 1950s, the National Institutes of Health served as a catalyst for new
investigations into the causes and nature of obesity, launching a new era in
evaluating this potentially life-threatening condition
Excess bodyweight is the one of most important risk factor contributing to the overall
burden of disease worldwide
B. The obesity epidemic is international in scope
Prevalence of Overweight Adults
• United States 61%
• Australia 59%
• Russia 54%
• United Kingdom 51%
• Brazil 36%
• Malaysia 27%
• China 15%
These figures are based on the Body mass index (BMI). This is a calculation based
on height and weight - namely
BMI = (weight)/(height)2
"The modern scientific understanding of obesity is that it is a complex disease in its
own right. But what causes obesity? Set out below are seven main topics, with their
specific sub-groups:
Genetic predisposition
– Twin studies
– Adopted children
– “Obesity” gene
2. Physiologic
– Leptin6
– Decreased stretch receptors
– Loss of satiety mechanism (hypothalamus)
– Evolutionary
3. Behavioural
– Family tradition
– Food to comfort child
– Addiction
4. Gender (80% women)
– Higher fat component
5. Socio-economic factors
– High/low income classes
– Cultural views
6. Psycho-social factors
– Coping mechanism (i.e. stress, abuse)
7. Societal
– Technology has decreased energy expenditure
– Elevators, power windows, food delivery, remote controls, computers,
Sony Playstation, TV, cars
Modern society has led to an energy imbalance.
We are a modern society with stone age genes meaning:
Copious supply of food, low in cost, always available, attractive, tasty,
hygienic.
• Labour-saving technologies have virtually eliminated the need for physical
activity in everyday life - activity is now optional.
The Net Result = Increased Caloric Intake. This leads to reduced energy
expenditure.
C. Patient Rights
The following statement of the rights of patients has been adopted by the American
Obesity Association
1. Patients have the right to be treated with dignity and respect at all times;
2. Patients have the right to know of treatment options and degree of realistic
outcomes of various options;
3. Patients have the right to know that being overweight or obese is a serious
disease with known health risks;
4. Patients have the right to know that obesity is a chronic health disease,
requiring personal effort over many years and probably involving lifelong
changes in diet, exercise and behavior;
5. Patients have the right to know that rapid weight loss may cause serious
health problems;
6. Patients have the right to know the anticipated cost and duration of services;
7. Patients have the right to know the provider's qualifications;
8. Providers have a duty to maintain currency with obesity research and best
practices appropriate to their specific profession;
9. Providers have a duty to determine each patient's medical and psychological
condition prior to provision of services;
10. Providers have a duty to counsel each patient about realistic weight loss
goals, the timelines to reach those goals and the diet, exercise and behavioral
changes necessary to maintain weight loss and achieve associated health
benefits
11. Providers shall always provide for the best interests of the patient and will not
recommend or provide products or services which are not reasonably
expected to be effective without informing the patient that they are
participating in an experimental program and obtaining their informed consent
12. Providers shall inform patients of this Bill of Rights as a member of AOA and
their adherence to it
D. The Risk of Obesity
The risks with a BMI > 30 include:
55% increase in mortality
70% increase in coronary artery disease
75% increase in the risk of a stroke
400% increase in the risk of diabetes
A morbidly obese adult (BMI > 40) has only a 33% chance of living to age 65.
E. Medical Implications of Obesity
There are a series of very serious medical implications from obesity, which may
include one or more of:
• Diabetes type 2
• Hypertension, infertility and menstrual problems
• Obstetric complications
• Low back pain
• DVT & thromboembolism
• Depression
• Immobility
• Cancer (breast, colorectal, prostate, endometrial, etc.)
• Venous/stasis ulcers
• Skin infections
• Intertrigo
• Accident proneness
• Lipid disorders
• Heart disease
• Asthma
• Sleep apnea
• Gallstones
• NASH (non-alcoholic steatohepatitis)
• Urinary incontinence
• Gastroesophageal reflux
• Osteoarthritis and gout
Extreme remedies are very appropriate for extreme diseases
F. Treatment of Obesity
The most common approach is to:
– Eat less;
– Eat more sensibly;
– Exercise more.
Added to this there are also:
• Weight loss programs
• Appetite suppressants
As to these treatments for Obesity, the studies show that on balance diets, exercise,
and behavioral change result generally in up to 10% weight loss but then to be
ineffective in the long-term. The option of Pharmacotherapy is not powerful and
generally results in minimal sustained weight loss. This then leaves as options:
1. Bariatric surgery
This is effective, but trivial market penetration; 1:300 to 1:500
2. Obesity Surgery
This has good results in terms of weight loss, but there are drawbacks, including:
• High rate of complications
– Mortality rate 0.1% – 0.5%
– Morbidity rates 7 – 10%
Surgery is not an option for many patients
– Unacceptable anaesthetic risk
– Too many co-morbidities
– Surgery is not an option
3. The Intragastric Balloon
This is an effective means of weight loss and is performed endoscopically with
sedation, meaning that there are very few complications. More than 70,000
intragastric balloons inserted worldwide with the following indications;
• Non-surgical means no mortality
• Endoscopically placed within the stomach and inflated with saline
• Partially fills the stomach to induce a feeling of satiety, thereby reducing food
intake
• Can be safely and easily deflated and removed endoscopically
• Designed to reduce the gastric volume
– Induce a sensation of early satiety
– Reduce consumption of food
– Improve compliance to low-calorie diets
As to the Australian experience with the intragastric balloon, to date there have been
some 270 patients
• 170 female (average age 45; span 23 to 70)
• 100 male (average age 42; span 26 to 65)
Of the 270 patients now treated with the intragastric balloon, some 90% will lose
weight and their Average weight loss will be for Women, 22-kg and for men 26-kg.
In summary
As treating physicians in dealing with obesity, we should;
1. Apply scientific technology to Hippocratic principles;
2. Rediscover the Hippocratic principles regarding healthy behaviour;
Fulfill the Hippocratic values in treating the patient as a whole entity and not
just as a disease; and,
4. Uphold the Hippocratic tradition of “help and at least do not harm”
* Dr Chris Eliades, Sydney
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