My medical education began in 1992, at a time when there was still belief that obesity was a problem of self-control or lack of motivation. There was minimal training in obesity itself, let alone nutrition and its impact on health. As I practiced primary care, it became apparent that weight management impacted many other medical conditions.
I was ill-equipped on how to counsel patients and manage obesity, as I had to give priority to the other associated conditions, such as diabetes, sleep apnea, heart disease, etc. I had to stay vigilant to keep up with the new science and tools. So, in 2014 I decided to become bariatric board-certified, which means learning management of obesity.
I wanted more training about the barriers of weight management as chronic disease, while also understanding that a patient’s weight can greatly impact the quality of their life. That is not to mention the associated stigma which can also affect mood, self-confidence, employability and relationships.
Unfortunately, many patients have been made to feel ashamed or deemed failures for not being successful in losing weight. I don’t believe providers intended to make them feel this way, but it still happened. Now that we have improved knowledge and tools, my hope is that we are better equipped to meet our patients’ needs.
Obesity wasn’t designated as a chronic medical disease by the American Medical Association until 2013. This designation began new thinking on how to approach it as more of a metabolic process instead of a lack of self-control. I cringe at the thought of how many times I may have said to a patient that they should just “eat less or move more.” Or that I even made someone feel as if their extra weight was entirely their fault.
With new research and science, there is better understanding that there is more involved with hunger, fullness and balancing energy burned versus stored. Hormones and feedback systems between the brain, gut, pancreas, muscles and even fat cells help regulate weight. Metabolism acts a “thermostat” of our body, telling us how much energy to burn, or when to burn energy that we have eaten as fuel or stored in a fat cell.
While this balance depends on age and gender, evidence is emerging there may also be a genetic preset that could predispose some to obesity more than others. How many times have we looked at a family picture and wondered how some of those living in the same home – with access to the same food and the same activity levels – appeared to struggle more than their siblings?
There is research on hormones such as ghrelin, leptin and insulin-like peptides that give us our “go” and “stop” with food intake, which can have varying effects on a person. Depending on the balance of these hormones, some may have more self-control than others.
The emergence of new tools such as the GLP-1 injections have proven effective as interventions in this disease process. Enhancing the natural brake system within your stomach and small bowel to improve portion control and stay within true caloric needs is life-altering for many patients. Turning down the volume of food noise and hunger within the feedback system can keep a person within the necessary guardrails to prevent excessive intake and weight gain. These medications can decrease the reward system of comfort foods and processed foods that are less healthy for us. GLP-1 injections can be an incredible adjunct to support the necessary changes that support weight loss.
There is the added benefit of the prevention of major adverse heart events, diabetes and possibly even managing addictive behavior with food and other substances. In the hands of experienced prescribers, there are limited risks and side effects. Being vigilant with protein intake and hydration is key and should be monitored. Measurements of total body fat, visceral fat (active metabolic fat), and muscle mass should also be taken consistently. Decreased numbers on the scale by itself may not always reflect improved health, as there can be muscle loss which is not desirable.
There is also the need to make lifestyle changes. Decreased consumption of processed foods, along with exercise, does improve effectiveness of any tool being used to combat obesity. However, it can be difficult to start making changes without calming down the hormones that affect food noise and cravings. That would be like telling a person with inattention and poor focus (ADHD) they need to concentrate and focus, before giving them medications that allow them to do so. Asking patients to manage their unmanageable disease before they can get help just doesn’t make sense.
A permanent tool such as bariatric surgery – which decreases the size of the stomach with or without bypassing bowel – has proven to be safe and successful. Innovations in surgical intervention for obesity has also proven to be effective in bringing about sustainable weight loss as well as resolution of associated medical conditions. Success depends on having an experienced surgeon along with a multidisciplinary team to support patients before and after the procedure. Despite successes, many still shame those considering surgery when we say “that seems drastic” or “that should be your last resort.” This is even though the overall risk of obesity itself may be greater than the risk of the procedure.
Obesity is a chronic disease that requires interventions in the form of medications and even surgery with trained medical professionals. To those who can successfully manage their weight the “old-fashioned” way, congratulations. But, let us offer grace and understanding to those who may not have the ability to do so without help.
Nicole Florence has practiced medicine in Springfield for 25 years. She currently manages patients with obesity full time at Memorial Wellness Center.
This article appears in REGEN Fall 2025.
