TRIM THAT FAT

Obesity is neither an external nor a cosmetic worry but an urgent health concern, says Dr Ivan Chow

THE INTERNET IS LITTERED with the false promises of getting abs while you sleep, losing fat instantly and several other click-worthy, misinformation-loaded links to sites selling snake oil and hope. Private gyms guarantee muscles and dieticians offer instant weight-loss solutions, both catering to superficial body-image-related triggers and insecurities. But obesity isn’t a cosmetic concern; it’s a serious health hazard.

Dr Ivan Chow, a specialist in family medicine, expresses concern at the rate of increase in Hong Kong, a steady incline over many years that’s recently been compounded by the inactivity brought on by the pandemic. “According to a survey by the Hong Kong Department of Health, 29.9 percent of persons aged between 15 and 84 are considered obese – 24.4 percent of females and 36.0 percent of males,” says Dr Chow. “Obesity is most common among females aged 65 to 84, at 34.3 percent, and among males aged 45-54, at 51.1 percent.” And because of the medical problems caused by being overweight, these statistics are worrying.

Dr Chow defines a healthy person thus: “You should be physically well, with no diseases or illness. Your psychological health – your mental health – is a component too, whether you have depression, anxiety or stress. And socially, how you interact with others at home or at work, whether you function well at a workplace and in your personal role as spouse, parent or child. So it’s a combination of all three – mental, physical and social health. When all three are in harmony, you’re a healthy person. Being morbidly obese is often an imbalance of all three.”

To state the obvious, the fundamental cause of obesity is an energy imbalance between calories consumed and calories expended. Given the increased intake of foods high in fat and sugars, and a corresponding decrease in physical inactivity due to the sedentary nature of work, changing modes of transportation and increasing urbanisation, it’s not hard to work out how the rise in obesity has come about.

Dr Chow, who is more concerned about greater health ramifications than arbitrary notions of size and beauty, says we need to change the dialogue about obesity and see it for what it is. “Sometimes I’ve had to tell patients that this is a clinic, not a beauty shop. I’m not looking at your size, I’m looking at your Body Mass Indix (BMI). Raised BMI is a major risk factor for noncommunicable diseases, such as cardiovascular disease, diabetes, musculoskeletal disorders – especially osteoarthritis, a highly disabling degenerative disease of the joints – and some cancers, including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon.

“The World Health Organisation, the US Food and Drug Administration and the European Medicines Agency all recognise obesity as a disease,” says Dr Chow.

“It’s a chronic disease that’s increasing in prevalence globally, and a major contributor to poor health in most countries. Obesity is associated with a significant increase in morbidity and mortality. Without screening, many high-risk patients may not receive counselling about health risks, lifestyle changes, obesity treatment options, and risk-factor reduction.”

Many people try losing weight through diet and exercise only, but when typically they find they can lose no more kilograms, they often get demoralised and begin putting on weight again. So why is it so hard to adhere to a regime of healthy diet and exercise?

“Appetite changes likely play a more important role than slowing metabolism in explaining the weight-loss plateau,” says Dr Chow. “That’s because the feedback circuit controlling long-term calorie intake has greater overall strength than the feedback circuit controlling calorie expenditure.

“Consumption of a reduced-calorie diet, frequent self-weighing and participation in a lifestyle-intervention programme are strategies to help maintain weight loss. However, the body appears to have a ‘set point’ of adipose tissue mass, and strategies that assume the effective treatment of obesity is only a matter of an individual’s willpower may lead to repeated failure, due to the body’s tendency to revert to its set point.”

When people cross that line, from “could lose 5 kilograms” to their weight becoming a health hazard, what treatment options are available? Dr Chow says that the Glucagon-like peptide-1 receptor agonist (GLP-1 RA) (Liraglutide) is a drug used to treat obesity. Others approved for long-term use include Bupropion-naltrexone, Orlistat and Phentermine-topiramate.

“Most prescription weight-loss drugs work by decreasing appetite or increasing feelings of fullness. Some do both. The exception is Orlistat, which works by interfering with the absorption of fat. Even a modest loss of 5 to 10 percent of your total body weight is likely to produce health benefits, such as improvements in blood pressure, blood cholesterol, blood sugars, the severity of obstructive sleep apnoea and health-related quality of life, and a reduction in all-causes mortality.”

After observing results in clinical trials showing around 10 percent body-weight reduction in one year, Dr Chow discusses the use of GLP-1 RA medication in obesity management. “GLP-1 RA is similar to a naturally occurring hormone called glucagon-like peptide-1 (GLP-1), which is released from the intestine after a meal. It works by acting on receptors in the brain that control your appetite, causing you to feel fuller and less hungry.”

This isn’t a magic pill or cure-all for those hoping to shed a few pounds for the New Year, says Dr Chow. “It has to be diagnosed by a doctor; it’s an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients, especially in the presence of a weight-related comorbid condition, like hypertension, Type 2 Diabetes mellitus or Dyslipidemia (high cholesterol).”

As for patients requesting life-changing advice and prognosis, Dr Chow says that a realistic goal is key. “When people come here, it’s most important I manage their expectations. If there’s any discrepancy between the expectation and the outcome, then they’ll get frustrated or disappointed.

”I first explain to people that I need to clarify what their targets and expectations are. If you come to see me and your expectation is, ‘Oh, I’m going to lose 40 percent of my body weight in three months,’ then I always say, ‘No, you can’t get that here! This could only be achieved by surgery.’ I clarify the expectation. And then I’ll tell them it’s a physiological change. If you have a static or plateau weight, it’s not your fault. I need to reassure them about this and then focus on realistic targets – getting people’s blood pressure and blood sugar back to normal, and lowering cholesterol. I shift the focus to the health benefits of weight reduction.”

And for those people working on their New Year’s resolution to get back into shape, Dr Chow has these words of encouragement. “Obesity is not a fault, nor a mere issue of willpower. Sustainability and maintenance are key.”