Obesity May Be a "Disease," but Stigma Remains a Barrier to Care, Kyrillos Says

Evidence-Based Diabetes Management, Patient Centered Diabetes Care 2016, Volume 22, Issue SP9

Coverage from Patient-Centered Diabetes Care, April 7-8, 2016. Presented by The American Journal of Managed Care and Joslin Diabetes Center.

Only 5% of patients with obesity who lose weight keep it off. Coverage for obesity drugs is improving, but remains uncommon. Plus, only a tiny fraction of the candidates for bariatric surgery have the operation, in part because 70% of physicians won’t give referrals.1

All this leaves 93% of those who live with obesity with unmet medical needs,1 according to Janine V. Kyrillos, MD, FACP, ABOM, an obesity specialist at Thomas Jefferson University Hospital in Philadelphia. Kyrillos led off the April 8, 2016, session on the needs of those with obesity at Patient-Centered Diabetes Care, presented by The American Journal of Managed Care and Joslin Diabetes Center.

The stigma associated with obesity—the idea that patients “did this to themselves”—still pervades thinking among many physicians, insurers, and employers, Kyrillos said, despite the 2013 declaration by the American Medical Association (AMA) that obesity is a disease.2 She shared a study that found healthcare providers ranked only below patients’ own family members in being associated with obesity bias.3

The AMA’s declaration “has been met with a lot of controversy among providers,” she said. There has been concern that patients will view managing obesity as futile, that it absolves them of responsibility. “But the real hope was also to [increase] research and bring more awareness to obesity. And I think that’s happening very, very slowly—but it is happening.”

As Kyrillos explained, the idea that patients can just be told “eat less, exercise more,” fails to capture the many factors, including genetics and environmental causes, that have given rise to the epidemic. “Epigenetics is a newer field, which is so fascinating. What the mother does, and what the parents do, affect the gene expression of the children,” which means if a woman is obese and gets pregnant, she is more likely to have a child who is overweight and diabetic than if she lost weight before becoming pregnant.

Even the basic understanding of the role and behavior of the adipocyte, or fat storage cells, has undergone a revolution, Kyrillos said. The same goes for the knowledge of the signals from the gut to the brain, and the interaction of key organs like the liver and pancreas in processing energy and producing insulin.4 “There are over 100 different individual neurotransmitters and receptors in the gut that talk to the brain that control hunger and satiety,” she said. They cannot all be turned off because humans are designed to see, eat, and store food. “If we knock out that instinct, the species would die, and we just have not evolved as fast as technology or the food supply,” Kyrillos said.

Medicine had best take obesity treatment seriously, she said, and not only because it is linked to more than a dozen comorbid conditions. If current trends continue, states with the highest obesity rates today—in ranges above 35%—will reach 60% by 2030, Kyrillos said, showing a series of US maps that trace the march of the disease (FIGURE).5

Provider behavior, and especially bias toward patients who are not managing obesity, is a huge stumbling block, research finds. Harsh words directed at obese patients can cause 79% of them to simply eat more, and 75% will not try to diet at all.3

Kyrillos shared a powerful video that won an award from the American Society for Metabolic and Bariatric Surgery, featuring patients talking about taking responsibility for obesity while asking for an end to judgment and misunderstanding.6 No one can assume an obese person overeats, doesn’t exercise, or that their parents failed to raise them properly, as one young woman stated. One young man looked straight at the camera, and said:

You don’t believe me. You don’t believe obesity is a disease. You think I lack willpower.

Kyrillos said she knows many physicians have an outdated approach to obesity. “Many of my colleagues get frustrated. I know I do, in trying to get my patients to take personal responsibility,” she said. “But I also get frustrated by the barriers to care, by the lack of coverage, the lack of resources. And I’m really hoping that more and more resources will go into figuring this out.” 1. Kyrillos JV. Obesity as a disease turns 2 years old: how do we celebrate? Slides adapted from lectures by Kaplan LM, Massachusetts General Hospital. Presented at: Patient-Centered Diabetes Care; April 8, 2016; Teaneck, NJ;

2. Pollack A. AMA recognizes obesity as a disease. The New York Times website. http://www.nytimes.com/2013/06/19/business/ama-recognizes- obesity-as-a-disease.html?_r=0. Published June 18, 2013. Accessed May 13, 2016.

3. Puhl RM, Brownell KD. Confronting and copying with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring). 2006;14(10):1802-1815.

4. Apovian CM, Aronne LJ, Bessesen DH, et al; Endocrine Society. Pharmacological management of obesity: an Endocrine Society Clinical Practice Guideline [published online January 15, 2015]. J Clin Endocrinol Metab. 2015. doi: 10.1210/jc.2014-3415.

5. F acts in Fat: how obesity threatens America’s future. Trust for America’s Health website. http://healthyamericans.org/report/100/. Published September 2012. Accessed May 13, 2016.

6. “It Starts Now” film and video contest. American Society for Metabolic and Bariatric Surgery website. https://asmbs.org/articles/2015-starts-nowvideo- contest-winners-announced. Posted December 2015. Accessed May 13, 2016.