While obesity has been thought of as a chronic disease by some, until recently, it was not officially recognized as such. Obesity impairs body function, with potentially negative impacts on physical activity and psychological well-being. It lines internal organs with fat, putting stress on the body; fat tissue may cause dysfunctional cell-signaling, potentially increasing inflammation in the body (Front Endocrinol (Lausanne). 2013 Jun 12;4:71).
The American Medical Association has taken an important step forward, declaring obesity a disease, unto itself. Obesity’s prevalence in the U.S. has increased by more than two-fold in the last two decades (JAMA 2010, 303(3):235-24). More than one-third of Americans are obese, defined as a body mass index of great than 30 kg/m2, according to the CDC.
The AMA’s move is a wake-up call that should be taken very seriously. They recognize that the first step to reversing this trend is increasing awareness among the medical community of its independent detrimental effects. This decision may impact government policy, medical reimbursement rates, and the social stigma patients have to withstand.
Unfortunately, obesity is also associated with many other chronic diseases. Integrative medicine physician Mark Hyman, M.D. entitled his book “Diabesity” to emphasize the association between diabetes and obesity. Other diseases associated with obesity include rheumatoid arthritis, cardiovascular disease, nonalcoholic fatty liver disease, osteoarthritis, and infection. I will discuss the RA association in more detail, since obesity was shown to potentially affect RA treatment.
Obesity treatment options include surgery, medications and lifestyle modifications. While it’s important for obese patients to lose weight, we have to be conscious about the way we do this. The drug Fen-phen, for instance, caused pulmonary hypertension and valvular heart disease. Surgery can potentially result in side effects, such as dumping syndrome and malabsorption. Even lifestyle modifications, including exercise and diet, need to be evaluated.
New launching of weight-loss drug
There are now two drugs approved by the FDA for weight-loss: Qsymia (phentermine hydrochloride/topiramate) and Belviq (lorcaserin). Both drugs have extensive side effects. Belviq was just recently launched in the United States (Medscape.com); however, it has not been approved by the European Union for fear of side effects, including tumors, disease of the heart valves and depression. It was also rejected by the FDA the first time because of its side-effect profile.
Effect on rheumatoid arthritis
On June 27 I wrote an article about RA, so I thought it appropriate to write about how RA is intertwined with obesity. A recent study found that greater than 50 percent of women who have RA are also obese (Arthritis Care Res (Hoboken). 2013;65(1):71-7). This was a cohort (those with disease compared to those without) study, involving over 1,400 participants. The reasons for this association may be underlying inflammation, greater amounts of estrogen or vitamin D deficiency. Obese men and women had a 24 percent increased risk of developing RA. The researchers are worried, since the prevalence of obesity in the general population continues to rise. This is not good news on the whole; women are more likely than men to develop RA, in general, according to a separate study (Ann Rheum Dis. 2007;66:1491-1496).
Obesity results in less robust outcomes when it comes to RA treatment. In an abstract presented at the European League Against Rheumatism Congress 2013, those who were obese had a two-fold greater risk of being on TNF (tumor necrosis factor) alpha inhibitors, compared to those who were of normal weight (BMI <25 kg/m2) (EULAR Congress 2013 Abstract OP0178). The researchers treated 346 RA patients with methotrexate plus or minus prednisone, but if they did not respond sufficiently, a TNF alpha inhibitor was added.
This occurred significantly more frequently with obese patients. Those who were obese had a less-than-ideal response to methotrexate plus or minus prednisone at a rate that was more than two times greater at 12 months than those of normal weight. Again, inflammation was postulated as the potential cause of poor response to the initial treatment in obese patients.
In yet another study, obese patients’ response to TNF alpha inhibitors was less robust compared to those who were not obese (Arthritis Care Res (Hoboken). 2013 Jan;65(1):94-100). At the end of the first year, remission rates of RA in obese patients were less than half those of normal patients. However, when the researchers analyzed the individual TNF alpha inhibitors, only Remicade’s (infliximab) poor response reached statistical significance, while the others were trending toward significance. This study involved 641 patients, but only 66 who were obese.
Let’s recap: patients with a history of obesity are twice as likely to develop RA and require TNF alpha inhibitors, but the effectiveness of these TNF inhibitors is reduced for them.
Lifestyle changes are critical to treating obesity; however, not all lifestyle modifications, including diet and exercise, are created equal. A recent study showed that those on a very low-calorie diet, or “crash diet,” were three times more likely to develop gallstones than those on a low-calorie diet (Int J Obes (Lond). Online 2013;May 22). The participants on the very low-calorie approach consumed liquid meals for 6 to 10 weeks, ingesting 500 calories per day, and then switched to a maintenance diet. The low-calorie group consumed liquid meals and solid foods totaling 1,200 to 1,500 calories per day for 12 weeks and then switched to a maintenance diet.
The reason for increased gallstones may be the impact of a very low-calorie diet on the bile’s composition and the gallbladder’s ability to discharge it. There were over 6,000 participants involved in the study. Thus, losing weight too rapidly is probably not the best approach.
In my experience, a high-nutrient, plant-based diet is one effective method for losing weight. I wrote about the quality of calories consumed, mindful eating and exercise in two articles published on Aug. 2, 2012 and April 30, 2013. I encourage you to read them, if you want to learn more about this topic.
Whether or not you agree with the AMA’s decision to elevate obesity to a chronic disease, it needs to be treated. Lifestyle modifications should be included in every paradigm, regardless of whether surgery or drugs are used as well. Some people may benefit from drug therapy, and some may benefit from surgery, but all will benefit from appropriate lifestyle modifications.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com or consult your personal physician.