Lorna Rothery spoke to Jacqueline Bowman-Busato, Head of Policy at the European Association for the Study of Obesity (EASO), to find out the true causes of obesity and the system-wide changes needed to improve health outcomes for citizens and patients.
Search the term ‘obesity’ online, and you will be confronted with articles predominantly centred on lifestyle and diet as key drivers of the condition. Long-standing misconceptions surrounding pre-obesity (overweight) and obesity have not only diluted awareness around the true causes of obesity, and the huge impact it can have on people’s lives, but hindered policy-level changes and public health recommendations that could improve diagnosis, screening, treatment, and long-term management.
Given the prevalence of obesity – currently the fourth highest independent cause of premature mortality – and the measures in place to address other non-communicable diseases, it is clear that changes are urgently needed across the board. Effecting change is part of EASO’s remit, a leading voice of obesity research, medicine and community in Europe committed to reframing the narrative surrounding overweight and obesity at policy level and across healthcare, ultimately to improve the lives of the almost 60% of adults and 30% of children affected in the WHO European Region. Lorna Rothery spoke to EASO’s Head of Policy, Jacqueline Bowman-Busato, to find out more.
Do you think clinicians and the wider public suitably understand the risk factors and symptoms of obesity? What are some commons misconceptions about the disease?
There is a massive misconception and lack of understanding of what obesity is. We have seen a chicken and egg-situation whereby within the health professional and research environments, until 2013, there was no consensus that obesity was a chronic disease, which aligned with the World Health Organization’s definition of chronic diseases.
Historically, there has been this misconception that obesity simply equals weight, which is not true. Weight is one of the many signs and symptoms of the disease of obesity; the actual disease is caused by the malfunctioning and dysregulation of adipose tissue. Unfortunately, this information did not go beyond the scientific community, and subsequently, it was embedded in policy but was a lot more difficult to exorcise. As a result of this lack of consensus, we have ended up with a lack of standard, accurate and precise vocabulary and a mantra centred around ‘eat less and move more’.
When thinking in general health promotion terms and health promotion of the dietary-related chronic diseases – which include cancer, type two diabetes, and cardiovascular diseases – because of this misnomer of obesity, people think that simply following a bad diet is one of the primary causes of obesity. Therefore, you just need to ‘eat less and move more’ in order to get rid of it.
It is important to understand that when people consume certain ingredients, regardless of quantity, it causes inflammation, which can block the neural pathways that help you recognise when you are full. Certain inflammation-causing foods are more potent than others and because people with obesity have distinct neural pathways, it can be even more difficult for them to know when they are full.
When we talk about biological underpinnings of obesity, there are six key pillars relating to hormones, genetics, mental health, drug-induced, post-operative acute trauma, and lifestyle factors such as sleep and stress. Biological markers of the onset of the disease and the malfunctioning of the adipose tissue can include inflammation and insulin sensitivity; when you see the weight that everybody thinks they recognise as obesity, disease progression is quite far gone.
The science has progressed, and we are clear that there are different phenotypes for childhood and adult obesity. Many children are born with the biology of obesity, but again, this is not being discussed. A risk factor for childhood obesity is that one or both of your parents had obesity when you were conceived. Either a child is larger when born and/or grows up with a biological predisposition of 30 – 80% to develop early onset obesity.
We cannot simply reduce obesity risk factors to obesogenic environments; we need to look at the biology that is triggering disease onset and then, with regard to disease progression, look at – as we would for different types of diabetes and cancers – the physical and other environmental impacts on that biology that makes the disease progress, and what is needed in order to get that disease under control.
We do not have a chronic care model for obesity in most countries that is actually embedded into the health system and reimbursed, and no way of going beyond prevention for the vast majority of people.
What impact did the COVID-19 pandemic have on those living with obesity?
Many health services related to obesity were side-lined. At the EU level, we worked hard to ensure the ECDC saw the evidence that those living with severe obesity should be designated as a medically vulnerable population. This would make them feel safer when going for vaccinations and into hospitals for their various appointments. The vast majority of countries did not implement this for obesity, so people with obesity and severe obesity, who probably had other diagnoses, had to continue going to work, could not always get to the hospital, and their services were deprioritised (if indeed they had services in their area). Teleconsultations were also few and far between because of GDPR, and most hospitals and specialist centres were not equipped to give this, particularly mental health services. On top of that, obesity treatment and long-term management, for the most part, are not reimbursed, and certainly not 100%. Because this vulnerable status was not properly implemented, it meant that people were not protected to shield at home.
Due to this lack of reimbursement, healthcare professionals also have little incentive to train as psychologists and specialise in obesity. We had this awful scenario of skill shortage across the region and a lack of resources availability. Many health professional resources were redistributed during the SARS virus outbreak in the early 2000s, and they never got replenished. Then during the COVID-19 pandemic, many health professionals were moved into COVID wards; all of this meant that, on average, 60% of the Europe-wide population was not accessing their needed treatment.
What is the situation like now in terms of raising awareness of these issues?
After all of this initial panic, many people have tried to go back to business as usual, so it has become increasingly challenging to make those points. Equally, people are not speaking the same language; unlike policy-prioritised diseases like cancer and type two diabetes which have a common language, everything related to obesity – despite the more than 200 medical complications associated with the disease – is whittled down to lifestyle.
We shifted the dial a bit, but we also discovered the extent to which there is a lack of knowledge around the causes of obesity. Usually, when people say, ‘let’s tackle obesity’, it equates to health promotion centred on eating less and moving more.
Some countries, notably Italy, Germany, and Belgium have managed to come up with so-called disease management plans. Portugal is the only country that has actually had something in place since 2004, looking at the chronic care continuum. The WHO is trying to effect change at a global level, but obesity sits within nutrition and physical activity, so they are struggling with establishing chronic disease models.
We have to deconstruct decades of myth. We produced a gap analysis of what is missing in the EU research agenda related to obesity along the chronic care continuum, and there are many gaps. For example, on the EU health portal, out of 46 examples for obesity, not one goes beyond basic health promotion.
What is the typical care pathway a person with obesity would go through? How could clinical treatment evolve?
Care pathways vary between countries and are dependent on EU competencies as well as international agreements made at global level, which define how obesity needs to be approached. Early diagnosis and screening for obesity is the biggest challenge currently; BMI is the primary measurement. It can take, on average, six years for doctors to approach the subject of obesity with their patients. Of course, by this point, somebody might have developed pre-diabetes or living with other conditions like arthritis or hypertension.
There are typically three levels or tiers within the care pathway; the first is centred around lifestyle interventions. Subsequently, patients may get referred to an obesity centre where they may be given more specialised care, including psychological support, which could be CBT therapy, and following that, a patient may receive care from a multidisciplinary team. EASO has over 140 collaborating centres of obesity management, or Centres of Excellence, which must be accredited. Some of which are childhood obesity specific, and others that deal only with adults.
Unfortunately, in reality, a lot of people do not even get referred to these specialist centres, so they have to rely on the knowledge of their GP and/or nurse practitioners or dieticians. Following recommended lifestyle interventions, the next level should be pharmacotherapy, and there are several different solutions which should be built around the so-called lifestyle interventions.
If a patient has not been diagnosed early enough, which is the case for the majority of people, then there is surgery. But again, patients are only monitored for two years post-surgery. Equally, the required care associated with bariatric surgery is not fully reimbursed. If you are lucky, you end up with combination therapy for life, but the reality is a lot of people with obesity are left on their own; they have the surgery reimbursed, and nothing else. As a result, we start to see a ‘non-responsive to treatment rate’ of around 65% within two years because people cannot afford it.
On top of this, there is a lack of suitably trained healthcare professionals who can support patients; there is no interlinkage with complications of obesity or proper tracking of data because the only thing in the national survey is BMI. The policy community also only tends to look at their particular geographic area.
As opposed to looking at obesity policies, we need to look at the policies that can impact obesity health outcomes and health system transformation to that end.
What measures could be taken at a policy level to better address the disease and create an enabling environment to support those living with the condition?
The 2025 UN high-level meeting on NCDs is a key opportunity to reframe the obesity agenda. At the WHO UN level, we need to be part of that NCD package for early diagnosis, screening, and long-term management, as a prioritised NCD in our own right; 80% of type two diabetes, 35% of ischemic heart disease and 20% of preventable adult cancers are caused by non-treatment of obesity. Instead of hoping that obesity will fit somewhere, let’s actually do this properly.
At EU level, we need a Joint Action under the Healthier Together NCD Initiative which we have been asking for. The EU has no competency for obesity per se; in EU terms, obesity is consistently treated as a modifiable lifestyle risk factor.
EASO works with health economists, and we are about to launch the cost of inaction of not implementing obesity under the NCD framework at the European Parliament. Working with health economists allowed us to make simulation models and generate data that asks the right questions.
Additionally, we need a very clear, unified NCD vocabulary, particularly when discussing obesity with policymakers and decision-makers for the health system, and this is something EASO is working on. Often, self-management and lifestyle interventions are central themes when discussing obesity, merely diluting the impact the disease can have. Aside from obligatory medical training, we want to see more Centres of Excellence and a decent research agenda. The sharing of data is also an important factor.
Everything really boils down to the need to implement obesity under the NCD framework, it may not be complete from day one, but we need to at least start mapping to see what is missing. In the meantime, we also need to work out how the billions of euros unnecessarily being spent on complications can be better rationalised so we can keep that 60% of the population managed, and enable them to live as best a quality of life as possible.
This article is from issue 25 of Health Europa Quarterly. Click here to get your free subscription today.
