In 2021 the European Commission published a brief defining obesity as ‘a chronic relapsing disease, which in turn acts as a gateway to a range of other non-communicable diseases’.¹  

The acknowledgement of obesity as a chronic disease challenged the wide-held belief that it is a primarily a lifestyle choice, which can be reversed simply by exercising willpower, noted Burki in a 2021 article published in The Lancet.¹ 

Rationale for classifying obesity as a chronic disease management approach to obesity 

Obesity is defined as a body mass index (BMI) of ≥30kg/m2, and overweight as a BMI 25kg/m2–29.9kg/m2. According to Garvey et al, the rationale for classifying obesity as a chronic disease was based on the fact that it met the essential criteria of a disease:^2,3 

• Overt signs and symptoms (e.g. BMI).
• Underlying pathological dysfunction (e.g. dysregulated satiety hormone control of caloric intake). 
• Having complications that confer morbidity and mortality. Obesity can reduce healthy-life years and can reduce life expectancy by six to 14 years. 

Complications associated with obesity include cardiovascular disease, type 2 diabetes, hypertension, non-alcoholic fatty liver disease, polycystic ovary disease, obstructive sleep apnoea, gallbladder disease, osteoarthritis, pain, gastroesophageal reflux disease, incontinence, lymphoedema, plantar fasciitis, certain cancers (colon, kidney, oesophageal, postmenopausal breast, and endometrial), as well as mood, anxiety, and eating disorders.^2,3 

Managing patients living with obesity 

Chronic indicates that a disease is ‘life-long, associated with complications that confer morbidity and mortality, and has a natural history that offers opportunities for primary, secondary, and tertiary prevention’.²  

Breen et al recommend a five step approach to effectively manage patients living with obesity:^3,4 

Step 1: Recognising obesity as a chronic disease and obtaining patient permission 

Obesity should be recognised and treated as a chronic disease characterised by excess or dysfunctional adiposity, which impacts patients’ overall health. To effectively manage patients living with obesity, healthcare professionals need to overcome their own biases. Furthermore, caution the authors, do not assume that all ‘larger’ patients are obese and recommend that they lose weight. Ask your patient permission to discuss his/her weight. Breen et al recommend using the ‘5 As’ framework (ask, assess, advise, agree, and assist) to initiate the discussion.  

Step 2:  Clinical assessment 

If the patient agrees to discuss his/her weight, start with a clinical assessment, which should include comprehensive medical, physical, functional, psychosocial, and behavioral evaluations. The goal of the assessment is to identify the root causes of weight gain (e.g. genetics, environmental factors, sedentary lifestyles, and stress), as well as potential barriers to treatment. Evaluations should take the patient’s cultural beliefs and practices into consideration. Findings of the assessments should guide the development of a long-term, personalised treatment plan, and should be based on a chronic disease management model. 

Step 3: Discussion of treatment options 

A comprehensive treatment plan should incorporate the following:  

• Behavioral interventions (e.g. how to improve sleeping and eating patterns, and incorporating physical activity as well as education about medication use) 
• Nutritional interventions (collaborative care with a registered dietitian who has experience in medical nutrition therapy for obesity management is recommended) 
• Physical activity interventions (aerobic and resistance training are recommended to improve cardiorespiratory fitness, mobility, strength, muscle mass, health-related quality of life, mood, weight and fat loss, and weight maintenance after weight loss) 
• Psychological interventions (e.g. cognitive behavioral therapy, acceptance, as well as commitment and compassion-focused therapies) 

• Pharmacotherapy (recommended for weight loss and weight loss maintenance in adults with a BMI ≥30kg/m2 or BMI ≥27kg/m2 with adiposity-related complications, to support medical nutrition therapy, physical activity, and behavioral and psychological interventions). The American Gastroenterology Association recently published a guideline on prescribing weight-loss treatment for patients living with obesity and overweight. The guideline ranked liraglutide as on of the four best pharmacological options for the management of obesity. Liraglutide 3mg is a glucagon‐like peptide‐1 receptor agonists, approved for the treatment of obesity in South Africa. 
• Bariatric surgery (may be considered for adults with BMI ≥40kg/m2 or BMI ≥35kg/m2 with at least one adiposity-related health complication).  

Step 4: Agreeing goals of therapy and care plans 

The treatment plan should be a collaborative effort between the patient and healthcare professional. Both parties should be in agreement about health-focused goals, expectations, possible treatments, and behavioral interventions. Because of the chronic nature of obesity the treatment plan must be long-term.  

Step 5: Follow-up and advocacy 

According to Breen et al, healthcare professionals play a key role in helping patients living with obesity to manage barriers to treatment and referring them to other providers for specialised care if needed. 

REFERENCES 

1. Burki T. European Commission classifies obesity as a chronic disease. The Lancet Diabetes & Endocrinology, 2021.
2. Garvey WT, Mechanick JI. Proposal for a Scientifically Correct and Medically Actionable Disease Classification System (ICD) for Obesity. Obesity (Silver Spring), 2020.
3. Breen C, O'Connell J, Geoghegan J, et al. Obesity in Adults: A 2022 Adapted Clinical Practice Guideline for Ireland. Obes Facts, 2022.
4. Grunvald E, Shah R, Hernaez R, et al. AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity. Gastroenterology, 2022.