Genetics, willpower and exercise: Top 10 obesity myths

Myths can be major barriers for people with obesity to access treatment, and educating patients to overcome them is critical.

Angie Golden, DNP, FNP-C, FAANP, a nurse practitioner at an obesity treatment clinic in Arizona, discussed 10 obesity myths at the Obesity Medicine Association’s conference to show how they can impact people with obesity and how physicians can help.

Golden said that, as a woman with obesity, she is “incredibly passionate” about the topic. The presentation was based on her opinions of the top 10 myths; there are no data that suggest these are the top myths related to obesity, Golden said.

The first myth she addressed was that obesity is a risk factor, not a disease.

“We hear this all the time,” she said. “Our cardiology colleagues will say that obesity is a risk factor for all of the cardiology diseases ... and I would argue that obesity is the cause of those, not a risk factor.”

Obesity is a chronic, treatable disease, Golden explained, and patients must know that their condition is treatable.

“Hippocrates recognized that people who were overweight were at a higher risk for sudden death. It sure took a long time for us to have medical organizations accepting obesity is a disease when Hippocrates knew 2,500 years ago,” she said.

The fact that many people do not recognize obesity as a disease in and of itself ties into the second myth: “it’s all about willpower,” Golden said.

“My cardiologist, with his hand on the doorknob, pointed his finger at me and said, ‘you need to eat less and move more.’ He was right,” she said. “From a behavioral perspective, eating less and moving more probably would have been beneficial for me. But he made it clear that was the cause of my excess adipose tissue, in his mind.”

Obesity is a disease, a neuro-endocrine disorder “with clear pathophysiology in the brain and in the dysfunction of the hormone system for energy regulation,” Golden said.

“Willpower is defined by being control exerted to do something or restrain impulses,” she added. “That’s not what obesity is. Not when we look at the hormonal aspects of it and what happens in the brain.”

Golden then jokingly asked women of childbearing age to “go home tonight and pop out an egg” to suggest that one has as much power over that as one has to combat the hormonal aspects of obesity.

“I can't control my level of ghrelin with willpower. Hunger and energy homeostasis is incredibly complex,” she said.

Along with the misconception that one can lose weight with sheer power of will, many people with obesity believe that they need to lose a lot of weight to have any benefit to their health.

“Fortunately, the fact is that 5% to 10% body weight loss can reduce obesity-associated complications,” Golden said. “Usually within 6 months, you can reduce cardiovascular risk, prevent or delay type 2 diabetes and improve osteoarthritis. You can also improve patient health and quality of life.”

Golden shared a story of a patient who said she wanted to be able to walk with her kids at Disneyland without them having to stop so she could rest. Once she lost 10% of her weight, she felt much better, and was able to walk 25,000 steps a day — enough for a Disneyland visit with no stops.

“She came back and said, ‘If I never lose another pound — as long as I keep this off — I’ve done what I set out to do,’” Golden said.

One theme from the myths that Golden discussed was a feeling of helplessness. Some patients ask, “What’s the use?” because they believe the weight all comes back, or they think they cannot change their weight because their family also struggles with obesity.

“There’s no question that genetics is part of this, but genetics is our susceptibility,” she said. “Something is turning on these genes. My genetic propensity was a susceptibility to disease, it wasn’t a given.”

Of weight returning, Golden said “well, that kind of does happen.” But she explained the physiology of weight regain is metabolic adaptation, “not the person getting lazy.”

“Obesity is not cured; it’s treated,” she said.

Even with treatments, myths can arise. For example, the idea that surgery is “cheating” is also a myth.

“We can’t attribute everything to just the surgery and simple mechanical alterations. We know that the surgery now lowers the defended level of adipose mass in some way,” she said. “A large percentage of patients have a lower defended mass, and that’s one of the big pathophysiology problems with this disease: increased adiposity and then a defense of that increase in adiposity.”

She also mentioned alterations in the gut-brain axis that occur quickly after surgery, like a change in the signaling with ghrelin, GLP-1.

“And then we see just how much resolution we can get on just a few of the obesity-related complications,” she said.

For example, data have shown that bariatric surgery is associated with remission of diabetes in 83% of patients, according to Golden.

“Type 2 diabetes: 83%. Sit with that a minute,” she said. “Is there anything else you do that you can get an 83% remission of a chronic disease? This is why we should be talking to our patients with a BMI of 35 or greater who have type 2 diabetes about surgery. It should be an option that is at the front of their thought process.”

Golden further said that she does not believe that everyone should have bariatric surgery any more than she thinks everyone should have a coronary artery bypass.

“Stenting works great for some people; medication works great for others. I think we have to have everything combined,” she said.

Two damaging myths that go hand in hand are the “calories in, calories out,” approach and that people should simply exercise more to lose weight.

“Find out what your metabolism rate is and do that! Obesity wouldn’t exist,” Golden said. “You have to go beyond [diet and exercise] because then you’re treating obesity like a disease.”

Golden also mentioned guidelines that tell people to eat 500 fewer calories every day to lose 1 pound every week but said this was problematic.

“We are not continuous eaters; we are discontinuous, and we are continuous metabolizers,” she said. “So, the scale will never be at an equal point like this.”

She also pointed out that “there is some hypothesis that, with the disease of obesity, our microbiome interacts with the food a little bit differently, and thereby actually absorbing more calories from our food than what we think we’re getting.”

Additionally, Golden noted that, during active weight loss, exercise alone will produce some “modest” weight loss — on average, about 2 kilos — but bouts of exercise also often increase sedentary activity for the rest of the day.

“You have to be really careful,” she said. “Just because you went to the gym, ran on the treadmill and lifted weights doesn’t mean that you can go home and be a couch potato the rest of the day.”

But that is what the body will try to do, she continued, because of the regulation of energy.

“Volitional exercise has been shown to decrease other types of exercise like our other sites of energy, like our basal metabolism rate,” Golden said.

Along with that, exercise and movement increase hunger hormones, so “we think we can eat a little bit more if we exercise.”

Once you exercise a certain amount, your body shuts down other expenditures, but that process looks different for everyone, “so we never know what our personal energy plateau might be,” Golden said.

In the end, though, Golden said that exercise is critical to one’s health and especially in obesity maintenance.

“Now that I am in maintenance, I need to have a lot of activity in my life to keep my weight down, and to keep all of those obesity-associated disorders out there knocking on the door instead of being inside,” she said.

The final myth that Golden worked to dispel was that of healthy obesity.

“The issue of the fact is we have clear evidence that cumulative obesity causes damage to the body,” she said, noting a U.K. study that illustrated complications related to obesity, such as a 50% increase in cardiovascular disease.

Golden ended her presentation with a plea.

“If you take nothing else from this, get the word obese out of your dictionary, out of your language. I am not an obese woman. I am not labeled for my disease, and your patients shouldn’t be,” she said.

“On a very cheerful note, obesity is a chronic, progressive, but treatable condition,” Golden said in closing. “Five to 10% weight loss can change the obesity-related complications; it's much more than calories in and calories out; medications are a critical tool in our toolbox for the treatment of this disease; exercise is critical for maintenance; and bias can impact treatment.”