is a long-standing medical condition with enormous and pervasive health implications for millions around the world. As nurses, it’s essential to have a solid grounding in the science of obesity and to advocate for our patients who are struggling with the condition and pursuing effective treatment.
Why is Obesity at Such Epidemic Levels at This Time?
Thomas George, DNP, APRN, FNP-C, NASM-CPT, is a family nurse practitioner, assistant professor at Frontier Nursing University, clinic director, and obesity specialist with Wellspring Weight and Wellness, a medical startup in rural Idaho. As an obesity specialist, Dr. George is well-positioned to provide scientific and current information on obesity-related research.
When discussing why there are such staggering levels of obesity, Dr. George states, “Globally, obesity prevalence has nearly tripled in children and adolescents, and prevalence among adults in the US is approaching 43%. It is estimated that nearly 80% of US adults have pre-obesity and obesity, and these statistics have given rise to the term ‘globesity’.”
He continues, “This is a complex, multifactorial disease. The global food supply has shifted to more calorically dense yet nutritionally sparse, ready-to-eat, highly processed foods. At the same time, our energy expenditure started decreasing as technology and automation increased the efficiency of our activities.”
“Obesity is highly heritable. Our genes are like the engine and basic design of a car, and our lifestyle is like how we drive, maintain, and operate that car. In obesity, genes contribute about 70%, while lifestyle contributes the other 30%.”
“An estimated 200-500 genes directly contribute to the development of polygenic obesity, and when obesity genes are ‘turned on’, they can cause increased appetite, cravings, overconsumption, and higher amounts of adipose tissue.”
According to George, researchers have identified obesity phenotypes that allow providers to treat patients more precisely with improved outcomes, including:
Hungry Brain (abnormal satiation): These individuals need to eat more calories than others to feel full.
Emotional Hunger (hedonic eating): These individuals eat in response to emotional cues, and they are characterized by negative mood, emotional eating, cravings, and reward-seeking behaviors.
Hungry Gut (abnormal satiety): These individuals feel full with a normally portioned meal, but the feeling of fullness (satiety) disappears quickly; characterized by reduced duration of fullness and quantified objectively by rapid gastric emptying.
Slow Burn (decreased metabolic rate): People with this phenotype have a measurably reduced resting energy expenditure (REE).
George identifies other factors that can epigenetically “turn on” obesity genes:
Poor sleep quality or insufficient sleep (< 7 hours)
Endocrine-disrupting chemicals
Stress
Microbiome changes
Decreased physical activity
Obesogenic medications, foods, and beverages
Regarding comorbidities, George shares, “There are more than 236 conditions associated with obesity, including 13 cancers. Excess adiposity, the major sign of obesity, leads to comorbid conditions through two primary pathways: adiposopathy (sick fat disease) and fat mass disease. Adiposopathy involves complex metabolic and inflammatory processes, whereas fat mass disease is primarily related to mechanical stress.”
Unhealthy adipose tissue, altered endocrine and immune function, systemic inflammation, osteoathritis from excess weight-bearing on joints, compression of organs, sleep apnea, GERD, stress incontinence, and many other conditions and symptoms can result from unmitigated obesity.
What About Medications?
“Many healthcare professionals are surprised to learn that there are technically eleven antiobesity medications (AOMs),” advises George. “Overall, AOMs have a good safety profile, though data is emerging about genetic differences that may predispose some patients to side effects.”
Importantly, George states, “The biggest caveat with AOMs is they are never intended to be used as a sole intervention. The evidence shows that AOMs are most effective when used in combination with regular physical activity, nutritious eating, and behavioral health interventions like cognitive behavioral therapy.”
He adds, “Low and slow is the way to go! One of the best ways to mitigate potential side effects is to titrate up to a therapeutic dose. And the final caveat is to individualize treatment interventions to patients’ predominant phenotype.”
“The most widely discussed AOMs are the game-changing molecules semaglutide and tirzepatide. Semaglutide (Wegovy) and its early predecessor liraglutide are glucagon-like peptide-1 receptor agonists, sometimes also referred to as GLP-1 analogs or incretin mimetics. One of the mechanisms of action includes delaying gastric emptying, making this class of AOMs a good fit for people with hungry gut phenotype.”
GLP-1 receptor agonists can:
Stimulate insulin release from the pancreas
Block glucagon secretion
Slow stomach emptying
Increase feelings of fullness after eating
Thomas describes the benefits of GLP-1 receptor agonists as including “glycemic control, weight loss, and cardiovascular risk reduction in patients with type 2 diabetes, with side effects including nausea, vomiting, diarrhea, constipation, increased heart rate, dyspepsia, and abdominal pain.”
When it comes to the dual agent tirzepatide (Zepbound), the most recent AOM approved for the treatment of obesity, George states, “The results are astounding, with some patients reporting more than 20% reduction in total body weight when combined with other pillars of obesity treatment (nutrition, physical activity, and behavioral interventions). [This medication] improves insulin sensitivity and glycemic control and reduces the production of stomach acid (which slows digestion and increases the feeling of fullness. It can also suppress appetite and food intake, and even reduce food cravings in some people.”
According to Dr. George, many other medications can be found in the anti-obesity arsenal. However, these lie far beyond the scope of this article, and nurses are advised to seek appropriate education regarding treatment regimens, side effects, and contraindications.
Empathize, Educate, Encourage, and Empower
Dr. George has advice for nurses in terms of broaching this difficult topic with struggling patients.
“First, we must address our own internal bias. Unfortunately, obesity is highly stigmatized, and bias among healthcare professionals adversely impacts the health and wellness of people with obesity. Consider taking an implicit bias test to explore your own attitudes. Sadly, there are still healthcare professionals who feel obesity is a lifestyle choice and not a disease.”
George adds, “The evidence is astounding: obesity is a real, complex, highly heritable, progressive, relapsing, yet treatable disease! Even something as simple as using person-first language can help destigmatize obesity. For example, instead of referring to someone as ‘an obese patient,’ use ‘person with obesity’ instead.”
George is adamant that “We must be the change agents in healthcare so patients can receive competent and compassionate care. Would we judge someone for having another condition? Disrupt the status quo and lead efforts to combat obesity bias and promote compassionate and competent care!”
Continuing his advice, he states, “We need to see real people who are struggling with a real problem. Listen to their stories. Learn more about the pathophysiology and treatment of obesity so you can provide clinical insights and, more importantly, hope for people that have often experienced roadblocks and pushback from the healthcare system. Partner with patients to find local resources, reputable websites, and clinicians with obesity training. Empathize, educate, encourage, and empower!”
“We should examine our patient care spaces and ensure that our furnishings and equipment are suitable for people with obesity. Are extra large BP cuffs, wide chairs, and appropriately sized gowns available? Is the scale in a private area? Many people with obesity eschew healthcare because they’ve been embarrassed or shamed in medical settings…and that’s terrible!”
George adds, “Asking for permission is a great way to start the conversation about weight. Our colleagues at Obesity Canada created the “5 As” model to help providers talk to patients about obesity.”
ASK for permission to discuss weight and explore readiness to change
ASSESS obesity-related risks and ‘root causes’ of obesity
ADVISE on health risks and treatment options
AGREE on health outcomes and behavioral goals
ASSIST in accessing appropriate resources and providers
“Many of my patients are surprised to learn that obesity is a real disease. After sharing the basics of obesity pathophysiology, one patient said, ‘I’ve tried so hard and felt like I was doing something wrong or lacking willpower, but now I feel like I’m fighting a disease instead of fighting myself!’”
George concludes, “Nurses play an important role in the competent and compassionate, evidence-based treatment for people with obesity. Look for opportunities in local health departments, school systems, bariatric medicine practices, or with obesity medicine specialists. Consider attending an obesity-specific conference or take continuing education courses focused on obesity. Join others in policy and advocacy groups. Visit an obesity medicine specialist and see if you can shadow them for a day. Spend time with people who have obesity and hear their stories. Strive to reduce obesity stigma and bias in your work context. Be the change agent!”
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