Obesity: A Chronic Relapsing Disease Process

The title “Obesity: A Chronic Relapsing Disease Process” comes from the position paper by the World Obesity Federation related to the ongoing discussion of whether obesity is a disease1. It focuses on the implications for ill-health and social disability that are associated with excess body fat. That obesity is a chronic problem which frequently relapses after treatment is well known2. Indeed, this concept was suggested prior to the American Revolution more than 250 years ago by Malcolm Flemyng MD, an English physician in the 18th century who said: “Corpulency, when in an extraordinary degree, may be reckoned a disease, as it in some measure obstructs the free exercise of the animal functions; and hath a tendency to shorten life, by paving the way to dangerous distempers.”3. Although this phrasing is not one we might use today, the sentiment is the same – obesity is a disease process. Fifty years later in 1816, William Wadd, a British surgeon picked up the torch again with this statement: “Fat….. when in excess – amounting to what may be termed OBESITY – is not only in itself a disease, but may be the cause of many fatal effects, particularly in acute disorders.”4.

Obesity-related diseases and complications

Excess body fat, particularly fat located centrally in the body, produces a variety of diseases through the chemicals made by enlarged and often more numerous fat cells. Obesity also produces disability by its external appearance and the weight of the extra load on bones and joints. Both endometrial and breast cancer, for example, are related to the female hormone, estrogen, which can be produced in fat cells – more fat equals more estrogen. This is particularly true after menopause when body fat becomes the main source of estrogen. The metabolic demands from extra fat can also exacerbate the risk of diabetes by increasing the demand for insulin. Reducing body weight reduces the risk of developing diabetes in individuals with prediabetes and increases the likelihood of reverting from diabetes to normal glucose tolerance.

We don’t choose to be obese!

One important idea, however, is missing from the statement by the World Obesity Federation. It is the fact that obesity is a “stigmatized state”. No one voluntarily decides they want to be “obese”, since people with obesity are often looked on with derision by others in our society. Children with obesity are often the victims of teasing and bullying. This concept of obesity as a stigmatized state has permeated the field of obesity research since before the founding of the International Journal of Obesity in 1977. It is widely believed that if people with obesity weren’t so weak-willed their problems would dissolve away. This idea has also biased many healthcare workers who view obesity as a personal, if not moral, responsibility.

Weight loss is the key to prevent most of obesity’s detrimental effects

The idea behind focusing on the “chronic relapsing” nature of this disease process is to provide a new and more appropriate focus for the concept that obesity is a time-bomb – a time-bomb that threatens to further exacerbate such important health problems as diabetes and heart disease. The good news is that weight loss can lengthen life span, reduce the incidence of cardiovascular disease, reduce the risk of developing diabetes and the problem of non-alcoholic fatty liver disease. Reducing the risk of developing diabetes among people who have a high risk of diabetes can occur with a weight loss of only 5%. Larger weight losses of 10% or more reduce the risk of cardiovascular diseases. The World Obesity Federation position paper sets the ground work for health care workers who wish to help individuals with obesity achieve a more healthy weight. This important position statement follows the lead for the American Medical Association and several other professional societies that claimed in 2013 that “Obesity is a disease”4. The World Obesity Federation statement extends this idea by focusing on the “process” by which obesity can produce its many detrimental effects and noting its chronic and relapsing nature. Weight loss is a key strategy in reducing the risk of the time-bomb for obesity from expanding further and the World Obesity Federation statement provides a framework for moving forward toward helping reduce the prevalence of obesity.

Based on: Bray GA, Kim KK, Wilding JPH; World Obesity Federation. Obesity: a chronic relapsing progressive disease process. A position statement of the World
Obesity Federation. Obes Rev. 2017 Jul;18(7):715-723.

  1. Bray GA, Heisel WE, Afshin A, Jensen MD, Dietz WH, Long M, Kushner RF, Daniels SR, Wadden TA, Tsai AG, Hu FB, Jakicic JM, Ryan DH, Wolfe BM, Inge TH. The Science of Obesity Management: An Endocrine Society Scientific Statement. Endocr Rev. 2018 Apr 1;39(2):79-132.
  2. Bray GA, Kim KK, Wilding JPH. Obesity: A Chronic Relapsing Progressive Disease Process: A Position Paper of World Obesity. Obes Rev 2017 Jul;18(7):715-723.
  3. Flemyng, M. A discourse on the nature, causes, and cure of corpulency. Illustrated by a remarkable case, read before the Royal Society, November 1757, and now published by Malcolm Flemyng. London: L. Davis and C. Reymers, 1760.
  4. Wadd, W. Cursory remarks on corpulence; or obesity considered as a disease: with a critical examination of ancient and modern opinion, relative to its causes and cure. London: J. Callow, 1816, 3rd edition.
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