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Obesity emerges as a critical public health threat, with numerous nations witnessing a staggering surge in prevalence over recent decades. This escalating health crisis increases the risk of diseases, including type 2 diabetes mellitus, fatty liver disease, hypertension, cardiovascular diseases, dementia, osteoarthritis, and various cancers, contributing to morbidity and mortality. The consequences of obesity extend beyond health, including unemployment, social disparities, and impaired quality of life. The ineffectiveness of conventional methods to control obesity highlights the need for a new approach to public policy that shifts away from an emphasis on individual behavior change toward strategies that address environmental factors. The role of a multidisciplinary team, including nurses, dietitians, and psychologists, to support patients through their weight loss journey should not be neglected. Multidisciplinary management of obesity has been recognized as an effective means to improve weight loss and associated health outcomes.
Division of Gastroenterology and Endoscopy, Ibrahim Bin Hamad Obaidullah Hospital (IBHO), Emirates Health Services, Ras Al Khaimah, United Arab Emirates
*Address all correspondence to: dr.maryam.alkhatry@gmail.com
1. Introduction
Obesity, defined as an excess accumulation of body fat, is a serious health condition and a public health threat that continues to be on the rise worldwide [1]. In 2016, more than 1.9 billion adults worldwide were overweight, and 650 million of them, accounting for 15% of the world’s adult population, were classified as obese by the WHO Global Health Observatory [2, 3]. Owing to the significant and rapid increase in obesity prevalence globally, the condition has been classified as a pandemic, similar to the COVID-19 pandemic [2].
The alarming increase in the prevalence of obesity could be attributed to multiple factors such as urbanization, sedentary lifestyle, and the consumption of high-calorie processed foods. Unfortunately, childhood obesity rates are also increasing, which could lead to a greater burden on healthcare systems in the future [1]. Around 38.2 million children under the age of five were considered obese in 2019, and more than 340 million children and adolescents between the ages of 5–19 were overweight or obese in 2016 [3]. Obesity is no longer considered a disease specific to high-income countries. Overweight and obesity are increasing in low- and middle-income countries all the same [2, 3, 4].
Obesity contributes to global morbidity and mortality, with around 2.8 million people dying yearly due to overweight or obesity [2]. Preventing obesity is crucial in reducing the risk of developing related health issues such as diabetes, cardiovascular disease, stroke, hypertension, cancer, and psychological problems [1].
The ineffectiveness of conventional methods to control obesity highlights the need for a new approach to public policy that is non-stigmatizing. This requires shifting away from an emphasis on individual behavior change toward strategies that address environmental factors. Another significant challenge related to overweight, and obesity is weight bias and discrimination. Obese individuals often experience discrimination in various public settings such as work environments, healthcare facilities, and educational institutions [1].
This chapter explores the burden imposed by obesity, its consequences, current management strategies, and the pivotal role of a multidisciplinary approach in addressing this pressing global health challenge.
A little over a decade ago, the American Medical Association (AMA) officially declared obesity as a chronic disease that requires treatment and prevention [5]. Obesity has been identified as a chronic relapsing progressive disease similar to other chronic disorders, such as hypertension [5, 6].
In order to evaluate the impact of obesity, it is important to first understand what obesity is. According to the World Health Organization (WHO), obesity is “abnormal or excessive fat accumulation that may impair health, caused by energy imbalance between calories consumed and calories expended” [3, 7].
Obesity can be diagnosed using the “body mass index” (BMI), which is measured by calculating [(weight in kg)/(height in m2)]. Although there are some debates regarding the use of BMI, it remains the most common and the simplest tool used to classify adults into one of three categories: “underweight,” “overweight,” or “obese” (Table 1) [7, 8].
BMI (kg/m2)
Class
25–29.9
Overweight
30–34.9
Class I obesity
35–39.9
Class II obesity
≥40
Class III obesity
Table 1.
Classes of obesity in adults.
This WHO classification can detect individuals at increased risk of developing associated comorbidities and, consequently, death due to obesity [7, 8].
2.2 Underlying factors and causes
Obesity is a complex problem that cannot be solved with a single or simple solution. It is a multifactorial issue that requires a multifactorial approach. The causes of obesity are extremely intricate, but they ultimately result in an energy imbalance between the calories consumed and the calories expended. Societal and environmental changes cannot be ignored as they lead to changes in dietary habits and physical activity. Other factors that contribute to obesity include gender, ethnicity, socioeconomic status, and genetics [7].
Despite recent research on obesity’s genetic and epigenetic influences, obesity is still regarded as an acquired disease that develops due to lifestyle patterns and personal choices, including sedentary lifestyles and a tendency to overeat [7].
It is also worth mentioning that binge eating disorder (BED) is often linked to obesity [9, 10]. BED is the most prevalent eating disorder among the general population, and those who have it are more likely to experience both physical and psychiatric comorbidities. BED is known to be associated with an earlier onset of being overweight and a history of obesity. Furthermore, it is independently linked to an increased risk of physical comorbidities such as diabetes, hypertension, back/neck pain, chronic headaches, and various other types of chronic pain [10].
It is crucial to comprehend the root causes and contributing factors that lead to obesity. This understanding is vital for the creation of effective policies and programs aimed at preventing obesity and its associated complications. Without a detailed, science-based understanding of the risk factors and their interconnections, efforts to combat obesity are unlikely to succeed [7].
Obesity has been linked to various health consequences and comorbidities. Overweight and obesity are the most common risk factors for the development of numerous associated health conditions that not only adversely affect individuals but also create significant challenges for healthcare systems (Figure 1) [1, 7, 8].
Figure 1.
Underlying causes and consequences of obesity.
3.1.1 Cardiovascular diseases
Obesity significantly raises the risk of cardiovascular diseases (CVDs), including hypertension, coronary artery disease, and stroke [3, 8]. The surplus adipose tissue contributes to increased blood pressure, dyslipidemia, and systemic inflammation, collectively fostering the development of atherosclerosis [11].
3.1.2 Type 2 diabetes
The correlation between obesity and type 2 diabetes is firmly established. Excessive adipose tissue, particularly visceral fat, plays a role in insulin resistance and the onset of diabetes [12]. The escalating prevalence of obesity has substantially fueled the global diabetes epidemic [13].
3.1.3 Cancer
Recent data suggests that approximately 4–8% of all cancer cases are connected to obesity. Although the exact mechanism remains unclear, obesity has been correlated with various prevalent cancers such as those affecting the liver, breast, colorectal, and endometrium [14].
3.1.4 Psychological impact
Obesity is linked to an elevated risk of mental health disorders, including depression and anxiety [15]. Stigma and discrimination related to body weight can intensify psychological distress, creating a challenging cycle for individuals dealing with obesity [15].
3.1.4.1 Depression and anxiety
Obesity is strongly associated with an increased risk of depression and anxiety disorders. The stigma and societal prejudice faced by individuals with obesity can lead to negative self-perception and contribute to the development or exacerbation of mental health conditions [15]. Coping with body image issues, societal pressures, and discrimination can result in heightened levels of stress, leading to a vicious cycle of emotional distress.
3.1.4.2 Eating disorders
Obesity is linked to various eating disorders, including binge eating disorder (BED) and emotional eating. The interplay between psychological factors and disordered eating behaviors can contribute to the maintenance of obesity and hinder successful weight management efforts [16].
3.1.4.3 Low self-esteem and body image disturbances
Individuals with obesity often face challenges related to body image and self-esteem. Social comparisons and unrealistic societal standards can contribute to negative body image, impacting self-worth and self-perception [17].
3.1.5 Obesity in women
Obesity has a significant impact on reproductive health in women, and one of the most common reproductive disorders is PCOS, which can be impaired or even caused by visceral obesity [18]. Obesity negatively affects fertility and contraception in women due to hormonal and metabolic alterations.
During pregnancy, obesity is associated with various complications. It increases the risk of early loss of pregnancy, higher rates of cesarean section, and high-risk obstetrical conditions. Maternal and neonatal mortality rates are also higher in obese women, and there is an increased risk of congenital malformations. Abnormal weight gain during pregnancy further worsens maternal health.
In addition to these reproductive health issues, obesity in women is closely linked to other health problems. It is associated with an increased risk of certain types of cancer, including breast, endometrial, gallbladder, esophageal, and renal cancer. Obesity is also closely linked to mental health disorders such as depression, anxiety disorders, neurodegenerative diseases, and sleep disorders.
Overall, obesity in women has significant consequences for both physical and mental health, and it is important to address and manage obesity to prevent these complications and improve overall well-being [18].
3.2 Economic and societal implications
Healthcare costs: the economic repercussions of obesity extend to healthcare costs, with obesity-related illnesses significantly contributing to global medical expenses [19]. Direct medical costs for treating obesity and indirect costs related to productivity losses constitute a considerable economic burden.
Workplace productivity: obesity is associated with reduced workplace productivity due to absenteeism, presenteeism, and disability [20]. Health-related limitations imposed by obesity can impede individuals’ full participation in work-related activities, affecting overall productivity.
Social stigma and discrimination: individuals with obesity often experience societal prejudice and discrimination, leading to social exclusion and negative impacts on mental health [17]. Stigmatization can impede efforts to seek healthcare and perpetuate a cycle of weight gain.
Despite the well-documented health risks associated with obesity, a failure to address this global issue leads to escalating public health challenges. The rising prevalence of obesity contributes to a higher incidence of chronic conditions, putting an additional strain on healthcare systems worldwide [21]. This inaction exacerbates the burden of preventable diseases, contributing to increased mortality rates and reduced overall life expectancy [22].
4.2 Long-term effects on individuals and communities
Inaction regarding obesity has profound long-term effects on both individuals and communities. Individuals with untreated obesity face a heightened risk of developing severe health complications, including cardiovascular diseases, diabetes, and certain cancers [23]. Moreover, the intergenerational transmission of unhealthy lifestyles perpetuates the cycle of obesity, leading to a compounding effect on future generations [24].
Management is a challenging task as weight loss is often followed by weight regain. Due to the associated metabolic changes that co-occur, obesity has been labeled a “chronic relapsing progressive disease” [6]. Eating less and exercising are not enough to achieve sustainable results. The management of obesity has included an array of interventions in recent years, including pharmacological treatment, endoscopic and surgical interventions, alongside dietary changes, other lifestyle changes such as exercise, and counseling [8].
While procedural interventions, such as bariatric surgery and endoscopic therapy, offer numerous advantages in terms of weight loss and reducing comorbidities, they are accompanied by side effects and may not be a viable option for every patient [8]. Therefore, these interventions should be employed not as substitutes but as complementary measures to other nonoperative approaches in the management of obesity. This includes incorporating dietary and lifestyle modifications, providing psychosocial counseling, and considering pharmacotherapy [8].
While it might seem like individuals are mainly responsible for their habits, such as eating and exercising, these behaviors are often shaped by the society we belong to. Changes in our surroundings, such as health policies, transportation, and education, can significantly affect our habits. In the absence of supportive policies in different sectors such as health, agriculture, and education, simply advising people to eat better or exercise more may not be very effective. The World Health Organization (WHO) emphasizes the need to encourage healthy eating and more physical activity for everyone through policies and actions in society [8].
5.1 Lifestyle interventions
There is evidence to support the role of lifestyle and behavioral intervention in weight loss. Obesity management should include monitoring caloric intake, physical exercise, and exercising control over food through behavioral therapy [25]. A comprehensive lifestyle intervention through diet, exercise, and behavioral modifications is recommended for individuals with a BMI ≥ 25 kg/m2 [25]. It is built on three pillars:
5.1.1 Diet
The rapid urbanization has led to a predominant diet of fast foods, sweets, and processed snacks [26]. Patients aiming to lose weight should seek the help of a nutrition specialist or an expert dietitian who would be able to prescribe an individualized and tailored meal plan specific to their needs, health conditions, and food preferences. The diet should aim to elicit an energy deficit of 500–750 kcal/day compared to the patient’s current calorie intake. Overall guidance would be to prescribe 1200–1500 kcal/day for women and 1500–1800 kcal/day for men. Regular follow-up and assessment of patient adherence to the meal plan is recommended, and changes should be implemented depending on their ability to follow the diet.
5.1.2 Physical activity
Physical activity and movement are part of comprehensive lifestyle interventions for effective weight loss. Increased aerobic physical activity (such as brisk walking) is recommended for ≥150 min/week. Higher levels of physical activity, approximately 200–300 min/week, are recommended to maintain lost weight or minimize weight regain in the long term (>1 year). A combination of a moderately reduced caloric diet and exercise is more effective at reducing weight and maintaining weight loss compared to either intervention alone.
5.1.3 Behavioral therapy
A comprehensive lifestyle intervention usually includes a structured behavior change program that includes regular self-monitoring of food intake, physical activity, and weight. These same behaviors are recommended to maintain lost weight with the addition of frequent monitoring of body weight.
An in-depth psychological assessment is necessary to identify factors that may hinder goals for weight loss. While some patients can achieve their weight loss goals with little to no psychological intervention, others need psychological support to resolve factors that can pose a risk to the weight loss plan. Common psychiatric disorders that may coexist with obesity are depression, anxiety, and binge eating disorder. These disorders can affect patients’ eating habits and lower their tendency to follow a weight loss program.
A multifactorial, comprehensive lifestyle program that revolves around the three above pillars, which include a reduction in calorie intake, an increase in physical activity, and measures to support behavioral change, is recommended as a baseline therapy in all overweight and obese patients according to the guidelines reviewed.
5.2 Pharmacological weight reduction
All recent guidelines mention pharmacologic therapy as an effective treatment modality for obesity [8, 27, 28, 29]. The guidelines recommend pharmacotherapy for the treatment of obesity to be considered in patients with a BMI > 30 kg/m2 with no comorbidities or BMI ≥ 27 kg/m2 with comorbidities and used in addition to lifestyle intervention. When lifestyle interventions alone fail at reducing a patient’s weight, pharmacotherapy is also recommended. Pharmacological weight reduction should only be maintained when a person has lost at least 5% of their initial body weight during the first 3 months or at least 2 kg during the first 4 weeks of treatment. In some patients with obesity, anti-obesity medications should be considered for chronic weight maintenance.
The choice of weight loss medication should take into account multiple factors, including contraindications and safety profile, associated comorbidities, efficacy, cost, and availability [25].
5.3 Bariatric surgery
The American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) have released new guidelines for metabolic and bariatric surgery in 2022. The recommendations state that individuals with a BMI of ≥35 kg/m2 should consider metabolic and bariatric surgery, regardless of any comorbidities. Metabolic and bariatric surgery should also be considered for individuals with metabolic disease and a BMI of 30–34.9 kg/m2 [30].
Long-term data consistently demonstrate the safety, efficacy, and durability of metabolic bariatric surgeries in the treatment of severe obesity and its comorbidities, resulting in reduced mortality compared to conventional treatment approaches. It has been proved that bariatric surgeries provide superior weight loss outcomes compared to nonsurgical approaches. Benefits beyond weight loss, including improvement of metabolic disease and decrease in overall mortality, were also observed [30, 31]. On the other side, it is worth mentioning that patients need to go through a strict assessment to be eligible for surgery. Patients must be physically and psychologically capable of undergoing surgery and comply with post-surgery instructions. Common complications of surgery include weight regain and surgical complications such as hemorrhage, anastomotic leak, bowel perforation, and bowel obstruction [32]. While the cost of bariatric surgery is higher compared to conventional treatment, studies have investigated the cost-effectiveness of this therapeutic modality. Bariatric surgery might be a cost-effective intervention for moderately to severely obese people as opposed to nonsurgical interventions. However, more data is needed to establish conclusions [32, 33].
5.4 Endoscopic management of obesity
One of the recent interventions recommended for the management of obesity is endoscopic bariatric therapies (EBTs). EBTs are considered a treatment option that provides superior efficacy to pharmacotherapy and a safer and less invasive alternative to traditional surgical treatment. The cost of some endoscopic treatments may also be lower than those of bariatric surgery [34].
EBTs increase the total body weight loss and improve metabolic profile as observed with bariatric surgeries.
Even though there are no formal guidelines for EBTs, the American Society for Gastrointestinal Endoscopy (ASGE) has issued a guidance on the use of EBTs in patients with obesity [35]. According to their recommendations, EBTs are recommended for patients who have failed nonsurgical weight loss or weight maintenance with lifestyle intervention alone and have medical conditions requiring weight loss for additional benefits [35].
Recently published guidelines of the American Association of Clinical Endocrinologists (AACE), the Obesity Society (TOS), and the American Society for Metabolic and Bariatric Surgery (ASMBS) have also included endoscopic bariatric and metabolic therapies as part of their recommendations [30]. The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) guidelines recommended metabolic and bariatric surgery (MBS) for individuals with a body mass index (BMI) 35 kg/m2, regardless of presence, absence, or severity of comorbidities. MBS should be considered for individuals with metabolic disease and a BMI of 30–34.9 kg/m2 [30].
Endoscopic bariatric therapies (EBTs) mainly involve the stomach, but they also include remodeling procedures for the duodenum or small bowel [28]. Gastric interventions work on the receptors in the gastric fundus to delay gastric emptying and alter orexigenic hormones, whereas small bowel interventions act by bypassing the stomach to affect satiety and gastric motility [34].
The currently available EBTs include endoluminal procedures such as an intragastric balloon (IGB) placement, endoscopic sleeve gastroplasty (ESG), gastric bypass revision, and aspiration therapy, among others. These procedures are divided into two categories based on the mechanism of action into restrictive or malabsorptive. Both methods enhance weight loss by altering gastric motility, hormones, and function [34].
Addressing obesity requires a comprehensive and integrated approach that involves collaboration among various healthcare professionals. A multidisciplinary management strategy acknowledges the multifaceted nature of obesity and tailors interventions to individual needs, considering both physical and psychological aspects. Healthcare providers, medical authorities, governments, and insurers should recognize and treat obesity as a chronic disease, using a multidisciplinary team approach similar to that used for other chronic diseases, such as diabetes and cancer.
Since obesity is a leading cause of chronic disease, disability, and increased healthcare costs, all medical and public authorities should cooperate to address this problem systematically.
Physicians play a pivotal role in diagnosing and treating obesity-related comorbidities. Nurses, as frontline healthcare providers, contribute significantly to patient education and follow-up care [36]. Together, they form the primary healthcare team responsible for coordinating patient care and monitoring progress.
7.2 Dietitians and nutritionists
Dietitians and nutritionists focus on developing personalized dietary plans, considering nutritional needs, preferences, and cultural factors. Nutritional guidance is essential for sustainable weight management and overall well-being [37].
7.3 Psychologists and mental health experts
Psychological factors contribute significantly to obesity, and psychologists play a crucial role in addressing emotional eating, body image issues, and underlying mental health concerns. Integrating mental health expertise into obesity management enhances treatment outcomes [38].
7.4 Physical therapists and exercise specialists
Physical activity is a cornerstone of obesity management, and the expertise of physical therapists and exercise specialists is invaluable. Tailored exercise programs not only contribute to weight loss but also improve overall fitness and reduce obesity-related health risks [39].
Effective obesity management requires seamless communication and collaboration among healthcare professionals. Regular interdisciplinary team meetings facilitate a holistic understanding of the patient’s needs and enhance treatment strategies [8]. A patient-centered approach is fundamental to successful multidisciplinary management. Involving patients in decision-making, setting realistic goals, and considering their preferences enhances treatment adherence and long-term success [40].
Several initiatives have been taken by globally recognizable bodies to halt the progress of the obesity epidemic [41, 42, 43]. Interventions, such as dietary modifications, physical activity, lifestyle changes, pharmacologic treatment, bariatric surgery, and minimally invasive endoscopic surgery, are recommended for people who are overweight or obese [27]. Family physicians and primary healthcare physicians play an essential role in helping patients achieve their weight loss goals. The role of a multidisciplinary team, including nurses, dietitians, and psychologists to support patients through their weight loss journey, should not be neglected [44].
Multidisciplinary management of obesity has been recognized as an effective means to improve weight loss and associated health outcomes [45, 46]. The need for multiple stakeholders in this process is rooted in the multifactorial nature of the disease, which has genetic, social, dietary, cultural, and psychological factors [47]. There is a need to create policies that lead to social and behavioral changes that sustainably impact obesity. In addition, there is an emphasis on the importance of tackling obesity through collaboration across multiple domains between healthcare professionals (HCPs). At the same time, a broader strategy incorporating multiple disciplines acting on implementing lifestyle changes produces more tangible and long-lasting outcomes [44]. Effective approaches to tackling obesity in the early stages include one-to-one sessions for over six months led by various healthcare team members because weight loss requires commitment from the client and the specialist [44, 45, 46, 47, 48]. Group-based interventions have also proved beneficial for patients in terms of weight loss, providing group support, and other therapeutic benefits, including HbA1c and systolic pressure improvement. From a socioeconomic perspective, group-based interventions facilitate access to care for a large number of patients at the same time while efficiently utilizing staff efforts [49].
In some patients, medication and lifestyle changes have been shown to have a minor impact on weight loss. Although bariatric surgery has been demonstrated to be effective in the treatment of obesity, many patients are afraid of surgeries and dread their long-term side effects [34]. Using state-of-the-art technology, bariatric endoscopy can replicate weight reduction surgery without the comorbidities [34].
According to the latest guidelines from the Obesity Medicine Association, obesity management follows a pathway that starts with data collection and ends with interventions provided by HCPs at various levels, including dietitians, behavioral therapists, physicians, surgeons, and other professionals [50].
In this book chapter, we embarked on a comprehensive exploration of the multifaceted landscape of obesity, delving into its burden, consequences, current management approaches, and the pivotal role of multidisciplinary care. Our exploration of the complex relationship between biology, behavior, and societal factors uncovered the impact of obesity on physical and mental health.
From the epidemiological rise of obesity to its profound consequences on cardiovascular health, mental well-being, and societal structures, it became evident that obesity extends far beyond a mere issue of body weight. The economic burdens, workplace implications, and the perpetuation of a cycle of chronic diseases underscored the urgency of addressing this global health challenge.
Navigating through different management approaches, we analyzed lifestyle interventions, medications, and surgeries. Each option has its own considerations and effectiveness, emphasizing the need for personalized treatment plans.
In our exploration of multidisciplinary management, we emphasized the indispensable roles of healthcare professionals from diverse fields—physicians, nurses, dietitians, psychologists, physical therapists, and more. The collaborative efforts of these professionals create a holistic framework, addressing not only the physical aspects of obesity but also the psychological and behavioral components crucial for sustained success.
As we conclude this chapter, we stand at the intersection of challenges and opportunities in the realm of obesity. The path forward demands a united front—researchers, healthcare professionals, policymakers, and communities—to unravel the complexities of obesity and forge innovative solutions. With a commitment to multidisciplinary care, a deep understanding of the social determinants at play, and a focus on prevention and early intervention, we can envision a future where the burden of obesity is mitigated, and individuals thrive in both physical and mental well-being.
As we continue working toward a healthier world, our combined efforts can bring about significant change, freeing ourselves from the weight of obesity and building a society where everyone can enjoy a lively and fulfilling life.
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Written By
Maryam Alkhatry
Submitted: 24 January 2024Reviewed: 27 January 2024Published: 23 February 2024
Open access peer-reviewed chapter
