Hide and Seek

Why Is Obesity a Hidden Disease? 

How can it be that obesity is a hidden disease? In a 2009 study of patient records, Jun Ma and colleagues found that healthcare providers seldom diagnose obesity. Of patients with a BMI in the range of obesity, 70% do not receive a diagnosis.

Misperceptions in Rural Patients

In self reports, people consistently say that they are taller and lighter than they are. A new study in the Journal of Health Care for the Poor and Underserved looks at the gap between actual and perceived weight status in rural patients. This study does a fine job of showing that men and African American patients are especially prone to underestimate their weight status.

But they are mistaken about one thing. Education “to help individuals accurately self- assess their weight” will not solve the problem.

Weight Bias Below the Surface

Quite a bit of energy goes into studying weight misperception. Repetitive studies showing that parents don’t label their kids with obesity are getting tiresome. Just below the surface lies an undercurrent of weight bias. “What is wrong with these people? Why don’t they recognize the problem?”

This might be the only aspect of obesity that’s not very complex. It’s simple ego protection. People with obesity face bias every day that is overwhelming. Kids face it from a very early age. In our culture – obsessed with thinness – excess weight is not hard to recognize.

First Things First

What is hard, though, is figuring out what to do about it. Evidence-based care can help to improve the health of people with obesity. But access to such care remains very poor. And often, it’s hidden behind authorization rituals that serve to further stigmatize patients.

When a problem doesn’t have a good solution, people naturally focus on solving other problems first. Efforts devoted to persuading more people to worry that they have obesity are not helpful right now. First, we must clear the hurdles that stand in the way of people who are already seeking care. Also, we must develop better options for treatment and systems for delivering care.

Until we do those two things, promoting obesity recognition simply wastes limited resources.

Click here for the study of actual and perceived weight status in rural patients.

Hide and Seek, painting by James Tissot / WikiArt

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March 3, 2017

One Response to “Why Is Obesity a Hidden Disease? ”

  1. March 03, 2017 at 9:56 am, David Brown said:

    Quote from blog post: “When a problem doesn’t have a good solution, people naturally focus on solving other problems first. Efforts devoted to persuading more people to worry that they have obesity are not helpful right now. First, we must clear the hurdles that stand in the way of people who are already seeking care. Also, we must develop better options for treatment and systems for delivering care.”

    Obesity, like most chronic disease conditions that get progressively worse as time passes, lies on a continuum ranging from slim and healthy to morbidly obese with associated mental and physical disturbances of the brain and body. Modern medicine doesn’t have “a good solution” to the problem of preventing obesity because it is treatment oriented. Attempts to prevent obesity and chronic disease with dietary advice have failed because some of the assumptions upon which the dietary advice is based are incorrect. For example. “Barbara C. Hansen of the University of South Florida said calories, but not high fat, were important. ‘To suggest that humans and monkeys get fat because of a high-fat diet is not a good suggestion,’ she said. Dr. Hansen, who has been doing research on obese monkeys for four decades, prefers animals that become naturally obese with age, just as many humans do. Fat Albert, one of her monkeys who she said was at one time the world’s heaviest rhesus, at 70 pounds, ate ‘nothing but an American Heart Association-recommended diet,’ she said.” http://www.nytimes.com/2011/02/20/health/20monkey.html

    Over the past 20 years or so Science has developed the means to detect disturbances in the cell signaling mechanism (the endocannabinoid system) that maintain homeostasis. Unfortunately, much of the research aims at developing pharmaceutical approaches that correct cell signaling. The remainder of research involves supplementation. For example, in a paper entitled “Care and Feeding of the Endocannabinoid System: A Systematic Review of Potential Clinical Interventions that Upregulate the Endocannabinoid System” there’s no mention of dietary interventions that can be used to correct cell signaling. Excerpt:

    The “classic” endocannabinoid (eCB) system includes the cannabinoid receptors CB1 and CB2, the eCB ligands anandamide (AEA) and 2-arachidonoylglycerol (2-AG), and their metabolic enzymes. An emerging literature documents the “eCB deficiency syndrome” as an etiology in migraine, fibromyalgia, irritable bowel syndrome, psychological disorders, and other conditions. We performed a systematic review of clinical interventions that enhance the eCB system—ways to upregulate cannabinoid receptors, increase ligand synthesis, or inhibit ligand degradation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3951193/

    “Care and feeding” of the endocannabinoid system are not the same as “clinical interventions that upregulate the endocannabinoid system.” Care and feeding have to do with the fatty acid profile of the diet. Excerpt from an :International Journal of Endocrinology” article:

    “Linoleic acid has been found to modulate endocannabinoid synthesis due to its ability to be converted to AA by the human body, although the effect of dietary linoleic acid on human endocannabinoid synthesis has not been investigated. This is a pertinent area of research due to the rapid increase in linoleic acid content in the Western diet as a result of a shift to plant-derived fats and the greater use of soy and corn oils in food production and manufacturing. These dietary changes have resulted in a shift in the n-3 to n-6 FA ratio, as reviewed by Simopoulos, with more than 84% of PUFA fats consumed in the USA being in the form of the AEA precursor linoleic acid. High linoleic acid diets promote obesity in both animals and humans and are correlated with increased fasting blood glucose, fasting insulin, and insulin resistance in humans, making this an important area of further research.” https://www.hindawi.com/journals/ije/2013/361895/

    Imbalance in essential fatty acid intake make appetite control problematic. Another excerpt from the above article.

    “The endocannabinoid system is implicated in both homeostatic and hedonic food intakes, with activation of the system resulting in an increase in hunger. Specifically, anandamide (AEA) and 2-arachidonoyl glycerol (2-AG), which are derivatives of arachidonic acid (AA) bind to the main two receptors, cannabinoid receptor 1 (CB1) and cannabinoid receptor 2 (CB2), leading to activation of pathways to initiate food intake in the limbic system, hypothalamus and hindbrain.”

    Excessive meat intake of any sort can lead to an imbalance in tissue concentrations of 20-carbon chain omega-6s and omega-3s. For example:

    “Arachidonic acid (AA) in the diet can be efficiently absorbed and incorporated into tissue membranes, resulting in an increased production of thromboxane A2 by platelets and increased ex vivo platelet aggregability. Results from previous studies have shown that AA is concentrated in the membrane phospholipids of lean meats.” http://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-5-97

    The highest level of AA in lean meat was in duck (99 mg/100 g), whereas pork fat had the highest concentration for the visible fats (180 mg/100 g). The lean portions of beef and lamb contained the higher levels of n-3 polyunsaturated fatty acids (PUFA) compared with white meats which were high in AA and low in n-3 PUFA. The present data indicate that the visible meat fat can make a contribution to dietary intake of AA, particularly for consumers with high intakes of fat from pork or poultry meat. https://www.ncbi.nlm.nih.gov/pubmed/9590632

    These last excerpts are from a 2003 Orlando Sentinel article by global obesity expert Barry Popkin.

    If you go back to those same villages or slum areas today … their diet includes a lot of vegetable oil … In China … Rice and flour intake is down, and animal-source foods such as pork and poultry and fish are way up, and the steepest increase is in the use of edible vegetable oils for cooking … “People are eating more diverse and tasty meals; in fact, edible oil is a most-important ingredient in enhancing the texture and taste of dishes … The edible-oil increase is found throughout Asia and Africa and the Middle East as a major source of change. http://articles.orlandosentinel.com/2003-09-28/news/0309270148_1_overweight-or-obese-women-were-overweight-south-africa

    We see, then, that traditional vegetarian cultures are now consuming more meat (cell membranes contain arachidonic acid) and they’re preparing that meat with culinary oils rich in linoleic acid. Does is not make sense to design a study to determine what effect these dietary changes have had on the endocannabinoid system? A good study design would reduce meat intake and have subjects switch back to traditional culinary and baking fats that have a high saturated fatty acid profile. Problem is, a study of that sort would never get funded because the nutrition experts remain staunchly anti-saturated fat. Excerpt:

    A public attack on diet dogma from fats to vegetable intake got leading cardiologist Salim Yusuf, MD, DPhil, into scalding water with nutrition experts. http://www.medpagetoday.com/PrimaryCare/DietNutrition/63527?xid=nl_mpt_DHE_2017-03-03&eun=g911565d0r&pos=0