We need a long-term strategy for treating obesity

Obesity is increasingly talked about as a disease with many causes. Why can’t we assume that only high-calorie foods and little physical activity are responsible for its development?

Obesity is a disease with multiple causes in which environmental factors overlap with genetic susceptibility. If a patient has signal disturbances in the central nervous system and/or metabolic disorders, the disease takes on a life of its own, and the patient’s good will is not enough to cure it. Of course, we are always dealing with a violation of energy homeostasis, that is, with excessive food consumption in relation to the energy expended. However, this is influenced not only by the patient’s good or bad will (in the category “I like to eat, I don’t like to move”), but also, for example, by a violation of the signaling system in the center of satiety and hunger. . At some point, excessive secretion of ghrelin occurs in the stomach, which is why the patient constantly feels hungry (the hunger center is constantly stimulated). The body even requires food. Another thing is a violation of the feeling of satiety. Some of my patients even say that they have obsessive thoughts about food. If you tell them to eat less, it won’t change anything because they won’t be able to eat less.

The second center that operates independently in the central nervous system is the reward center. When we are sad, we eat something sweet or our favorite salty food: we reward ourselves. This is how we often react to stress. The problem is that when the reward center is deregulated, you have to eat more and more to feel the pleasure of the reward. One of my patients described it this way: first she “rewarded” herself with two cubes of marshmallows, then she had to eat one layer, and finally she had to eat the whole package. If these centers are not functioning well, the patient is unable to maintain energy homeostasis.

Another thing: visceral adipose tissue is a powerful endocrine organ; it secretes a number of cytokines. This causes systemic inflammation - mild to moderate. This affects all other organs. Insulin resistance appears, which gives rise to carbohydrate and lipid disorders in the patient, and then arterial hypertension, diabetes, atherosclerosis and some types of cancer. So we are approaching 200 complications caused by obesity. Thus, the influence on the development of obesity in the patient is only available at the beginning, perhaps only while he is still overweight.

So we need to act at a much earlier stage to prevent the development of obesity?

Scientific research shows this. The sooner we begin to treat the disease, the greater the chance of preventing its complications. In the future, it is necessary to treat diseases that arise as a result of complications (hypertension, type 2 diabetes mellitus, lipid disorders, sleep apnea syndrome). There are also different phenotypes of obesity - the distribution of adipose tissue is different. In case of first degree obesity, especially with the peripheral phenotype, i.e. gluteofemoral obesity, metabolic disorders may not yet exist and non-drug methods, such as increasing physical activity and changing eating style, can help; some patients will also require behavioral therapy. However, if a patient develops metabolic disorders, according to the current level of knowledge, pharmacotherapy is necessary to change his lifestyle, ensure proper nutrition, physical activity, sleep and rest. Treatment will allow him to do this.

Modern pharmacotherapy makes it possible to improve signaling in the central nervous system: the patient begins to feel full at the right time, so he is able to take care of the appropriate size of food intake. Drug therapy also improves signaling in the reward center—the patient no longer has to “reward” himself with as many sweets or salty snacks, for example. We can work with the patient to change these eating habits.

Why are we, as a society, becoming more and more obese?

The pandemic has opened our eyes to this problem more broadly by 6%. The number of people who are obese has increased and even more people are overweight. Working from home, studying from home, less exercise, more time to eat have all led to an increase in the number of overweight and obese people. Poland already ranks first in Europe for childhood obesity, which is alarming because these people will soon become obese adults, and the longer the disease lasts, the more complications there are.

At the initial stage of disease development, the environmental factor is very important. Then, as hormonal and metabolic changes develop, the patient may no longer be able to cope even with changing his habits. Moreover, the more obesity, the greater the patient’s reluctance to engage in physical activity and take care of himself. He often does not try to seek help from a doctor, because he does not yet treat this condition as a disease, but blames his own negligence for it and perceives it as his fault.

The pandemic is over, but the number of obese people has not decreased?

Unfortunately no. We live in the hustle and bustle of civilization, we work longer and longer, we have no time for physical activity or rest, we experience stress, we eat a lot during the day after returning home, and then sit down at the computer or TV and continue eating, which contributes to the accumulation of energy, which accumulates in adipose tissue. Therefore, the civilizational impulse favors the accumulation of adipose tissue.

What does the obesity treatment system look like in Poland? What has already been achieved and what is still missing?

As President of the Polish Society for the Treatment of Obesity, I can say that a lot has been achieved - the pilot program KOS BAR 40 Plus has appeared: comprehensive care for patients with morbid obesity, i.e. with BMI => 40 or with BMI. => 35 years old and with concomitant diseases. We are in the process of working through the results of the pilot, we want to show that it is worth investing and providing patients who have undergone bariatric surgery with two years of free care from the therapeutic team. We hope that this program will operate throughout Poland. The KOS BMI 30 Plus program is being developed - free assistance to patients with BMI => 30. We are trying to launch the program this year. The program “KOS BMI – Children” is already at the stage of public consultations.

As part of PTLO, we are creating centers for comprehensive treatment of obesity: soon there will be places on our website where patients can seek comprehensive help from therapeutic teams. Together with the Polish Society of Family Medicine, we are trying to train family doctors so that they can start treating obesity. We have certified doctors from all over Poland to systematize the treatment of this disease in individual clinics and centers.

The stigmatization of obese patients continues to be a big problem in Poland…

A survey we recently conducted shows that 35 percent of patients feel excluded, and approximately 25 percent report stigmatization. Patients say that none of the doctors discussed the disease with them, and they themselves believed that obesity was to blame, so they never sought advice. We work with patient trusts to educate people that obesity is a disease and that you should go to the doctor and ask for help, rather than thinking it is just a problem of poor diet and lack of exercise.

When does lifestyle change alone not help and drug therapy or bariatric surgery is necessary?

In the case of obesity of the second, third and often even first degree, behavioral (and sometimes even pharmacological) interventions will not help. Behavioral methods can reduce body weight, but the biggest challenge is maintaining it. Moreover, obesity is a disease that does not go away and is prone to relapse. We used to talk about the yo-yo effect, today we know that it is a relapse of the disease, clinically even worse than what was at the beginning.

Of course, it is necessary to change habits - the way you eat, and this will remain for life. I’m not talking about restrictive diets, but about changing habits (caring about the quality, quantity and regularity of food). However, in the case of obesity, changing habits alone is not enough. Effective pharmacotherapy and bariatric surgery already exist, but of the 8-9 million people in Poland, only 1 percent are obese. uses pharmacological treatment. This is a drop in the ocean and that must change. But it is also true that we need to work on drug reimbursement.

Do you need a long-term strategy for treating obesity?

Really necessary. We have created the “Partnership for the Prevention and Treatment of Obesity” platform, which includes medical experts associated with the Polish Society for the Treatment of Obesity and Family Medicine, health system experts, as well as representatives of patient advocacy organizations. Our goal is to disseminate reliable and comprehensive knowledge about obesity. We have begun cooperation with parliamentarians. We are pleased that the Parliamentary Group on Combating Obesity and Healthy Nutrition has been created in the Sejm, which gives us hope for a permanent place to discuss the necessary systemic changes in the field of prevention and treatment of obesity. We are also trying to discuss with parliamentarians a broadly understood strategy such as, among other things: using the sugar tax to prevent and treat obesity. We want to interest the ministries of health, national education, sports and family, labor and social policy in this topic, since prevention and broadly understood education are very important. Education is the basis for preventing this disease, but in the case of sick people, comprehensive treatment is necessary.