HJNO May/Jun 2023

CHANGING THE CARE: OBESITY 32 MAY / JUN 2023 I  HEALTHCARE JOURNAL OF NEW ORLEANS   thing happens under reinvented business mod- els. Primary care becomes the entry point that loses money but drives referrals to the higher margin service lines where surgeries, imaging, procedures, drug rebates, and 340B revenue become the focus of their “no margin, no mis- sion” philosophy. For these traditional health systems, the goal of improving health is as- sumed, but rarely objectively measured or reli- ably delivered. Systems that deliver health, on the other hand, rethink their business models and attempt to figure out how to transform for tomorrow in a way that delivers value more responsibly for society and the greater good. As healthcare confronts this obesity epidem- ic, multiple battles will ensue. Part of the battle is internal to our profession and requires rede- signing primary care to better confront obesity as a disease. But part of the battle is external, as the healthcare industry takes on the food in- dustry, in much the same way that courageous healthcare leaders of the past challenged the tobacco industry. It is a difficult battle to fight, fraught with controversy, denial, deflection, and misinformation; but it is clearly a battle worth fighting. Just as cigarette manufacturers sought to deflect blame and deny the problem, the food industry will do the same. Lobbyists and proponents of the tobacco industry assert- ed that it is a person’s right to smoke, invoking their agency over their own decisions. Those assertions continued as the cost to society from cigarette smoking mounted logarithmi- cally in ways that were hardly imaginable. Heart disease became the leading cause of mortal- ity, stroke the leading cause of disability, and lung cancer was far from the only type of cancer where tobacco played a key causative role. Sec- ondhand smoke was also eventually recognized as a danger to others. Gradually, society came to see the harm reaped by the tobacco indus- try. Cigarette manufacturers have responded to these decreased sales by introducing new lines of products, such as enticing flavors of inhal- ants and the vaping devices that deliver them. These new products have cultivated their own harms, as some people now find themselves on a lung transplant list induced by vaping-in- duced lung injury. And so, the battle continues. As it relates to obesity, the very first battle is acknowledging that obesity is indeed a disease. It is a chronic condition that is not caused by a lack of will power. It is not due to some type of personal failure or weakness. It should not be associated with shame on the part of the affected individual, nor should they or the parents of children suffering from it be blamed for their condition. Just like all chronic diseases, it should be treated and man- aged as a disease, usually with a combination of lifestyle modifications — such as diet and exercise — but also sometimes with medica- tions, and rarely even surgery. Having said that, obesity is one of those “wicked” prob- lems that is influenced by a diverse array of variables including genetics, epigenetics, neu- robiology, hormonal changes related to age and gender, adverse childhood experiences, impairments in mental health, maladaptive coping mechanisms, and socioeconomic fac- tors. Regardless of the complex multifactorial nature of obesity, make no mistake about it, we are indeed facing an epidemic of this disease. What is obesity? How is obesity defined? Body mass index (BMI) is determined based on a person’s height and weight. In children, obesity is defined as BMI that exceeds the 95th percentile for age and gender. Because BMI does not correlate exactly with the amount of water, fat, or muscle in a person’s body, it is an imperfect measure of the potential health consequences of obesity. Nevertheless, in adults a BMI > 30 is consid- ered diagnostic of obesity. Waist circumfer- ence may be a better indicator of the health consequences associated with obesity, and yet it is not even routinely measured in many doc- tors’ offices, which is yet another example of where we could do better to align the practice of medicine with the latest scientific evidence. Indeed, one of the biggest mistakes made in the history of the medical profession is that we have too often ascribed blame and judg- ment around diseases like obesity, correlat- ing it with gluttony and detaching ourselves from responsibility for effectively managing this condition. Often, we address it with little more emphasis than “telling” patients they should adhere to a healthy diet and engage in at least 150 minutes of cardiovascular exer- cise weekly. Sometimes, we deploy fear-based motivation to warn or scare people of its po- tential consequences. However, nearly all the literature regarding the use of fear-based motivation shows that while it may sometimes result in short-term behavioral change, these changes are usually not sustainable, and pa- tients inevitably fall back into their usual habits and patterns of behavior. Not only is obesity a disease, but it is also a disease characterized by enormous layers of complexity, and only by addressing these many layers will we ever sub- stantially impact its course and consequences. Those who would advocate that people have agency for their own decisions and just need to make healthier choices need to also realize what persons with obesity may be up against. A vast amount of money is spent by the food industry trying to influence consumer choices and purchasing decisions, with a large propor- “[Obesity] is a chronic condition that is not caused by a lack of will power. It is not due to some type of personal failure or weakness. It should not be associated with shame on the part of the affected individual, nor should they or the parents of children suffering from it be blamed for their condition. Just like all chronic diseases, it should be treated and managed as a disease.”