Obesity is a complex, chronic disease, influenced by a variety of factors from genetics to lifestyle and many variables in between. This statement is often a source of controversy online, among patients, and with providers and clinicians alike. I’d like to share why it does not need to be so controversial, and help you bridge the gap between misinformation and evidence-based information. My hope as always is that this education equips you with the right tools to take action and improve your health, whether applied to weight or any other chronic disease.

(Short on time? Click here for The Bottom Line)

For decades, many have said, “eat less and move more,” “weight gain is your fault,” or “you are overweight because of your choices.” This not only brings judgement (from others and ourselves… and we just talked about self-compassion, right?), but also creates shame, guilt, stress, and never helps anyone actually manage weight, especially long term.

Fast forward to today, we know with certainty that obesity is indeed a chronic disease with so many invisible components at play. Large evidence-based organizations, such as the WHO, Canadian Medical Association, American Medical Association, Obesity Canada, and many other similar bodies, also agree that obesity is a chronic disease. Let’s explore the clinical definition first, followed by a closer look at how obesity works in real life.  

  • Obesity is a complex chronic disease where abnormal and/or excess body fat (known as adiposity) impairs health, increases risk of long-term medical conditions and complications, and reduces lifespan. It is a progressive and relapsing chronic condition.

Simply, obesity is not only about excess fat, and certainly cannot be reduced to “the number on the scale”. It is more about how obesity impacts your overall health. We have long known how obesity is a risk factor for many other conditions, such as Obstructive Sleep Apnea and Heartburn, but obesity also puts you at a higher risk of developing other chronic conditions such as Type 2 Diabetes and Heart Disease.

So, what are the invisible variables that influence obesity?

  1. Biology: when it comes to energy balance, rather than “calories in, calories out” reductionism, this actually involves your brain (and central nervous system), your physiology, and how your appetite, energy, fat storage, and metabolism are regulated and controlled.
  1. Genetics & Epigenetics: influence regulation of the above systems and weight. May be common such as through environments and family exposure, or more rare such as gene deficiencies and syndromes from birth that directly impact appetite and satiety regulation.
  1. Psychology: involves individual complexities of behaviour change, stressors (internal and external), self-esteem, education level, time management, as well as societal and social psychology impacted by what we consume digitally, and the reality that we want to belong and fit in with those around us.
  1. Nutrition: more than “good vs bad foods”, this encompasses food exposure, availability, abundance, food behaviours, relationships with food, substances such as alcohol, calorie density, nutrient density, portions, how fast we eat, etc. Food production, economics, cost of ingredients, cost of living, are other significant considerations.
  1. Physical Activity: includes non-exercise activity thermogenesis (calorie burning) and dedicated exercise, levels of activity at home/work/school/in life, level of education, societal and cultural norms and expectations around activity, costs, environment, etc.

We can begin to see that there is a lot more at play here than simply “your weight is your fault”. We live in an environment with an abundance of tasty, high-calorie, nutrient-poor foods that are convenient, far too easily accessible, and designed to make us want more and more. Pair this with biology, physiology, and psychology, and you get a recipe for chronic diseases.

It is important to address the “I should be able to manage my weight myself” mentality. This is a common experience I hear from patients and it creates a lot of frustration and negative self talk. The desire to do this on your own is valid and understandable. I completely get how irritating it is to know what you need to do but feel paralyzed when it comes to doing it… and then to do it consistently, long term, without pressuring yourself (hence, we now chase progress not perfection!).

Given the myriad factors we face when it comes to managing weight or any other chronic disease, having appropriate support in doing so does not make you lesser than. Whether the support for you looks like anti-obesity medication, a physician health coach like myself, bariatric surgery, or a combination of supports, that is okay. In fact, that is essential to managing your obesity long term and finally stop weight cycling. Medications are great supports for treating chronic diseases and are tools in the toolbox which afford us more opportunities to improve our lifestyle and behaviours. These aspects of care work together beautifully. Synergistically, even. I’m lucky to see people improve their lives and health using these treatment modalities harmoniously.

Now don’t get me wrong, your lifestyle, choices, habits and behaviours, do matter. Greatly. They are just not the only component involved in chronic disease management. Here’s an analogy looking through the lens of another chronic disease, High Blood Pressure (BP):

When a person is diagnosed with High Blood Pressure, the patient is usually told to modify the pillars of Lifestyle Medicine first: nutrition, movement, sleep, stress, substances, social connection. At the next follow up appointment, if BP does not meaningfully improve, a medication is usually prescribed to help. And folks then take their BP pill once a day forever, no questions asked.

When following up again in about a year, many people’s BP improves to close to normal, and a common patient question at that time is to request being taken off of the medication, since readings are normal. This misses the mark on two fronts:

  1. The medication is what is controlling the numbers.
  2. There is no assessment or acknowledgement of the impact of lifestyle, environment, biology, genetics, and the invisible factors.

If the hypothetical patient is not able to improve their nutrition, leads a sedentary lifestyle, smokes cigarettes, carries a high stress burden, and eats too much sodium, then medication might be the only factor treating the BP. And what would happen if the only treatment for the BP is taken away? The numbers would go up, right?

It’s the same for diabetes and cholesterol management. Stop the medication, no other factors change, A1c or lipid markers become abnormal. Then why would obesity be any different? It’s not. Although we do have powerful anti-obesity medications today, they are meant to be used lifelong to treat the chronic disease of obesity, and work best in conjunction with lifestyle, psychology, surgery, and environment modifications. The best care we can provide for obesity is tailored to each individual and considers a whole person with a disease, not just the disease in isolation. It cannot and must not be “one size fits all”.

To me, the most critical reason why we as a society (including all types of healthcare providers, patients, etc), have treated obesity differently, is bias and stigma. This is a judgemental approach that helps no one and harms each of us individually and collectively. This is why I am such a strong advocate for Person First Language, which is a proactive step each of us can take to create a societal shift. Recognizing obesity as a chronic disease helps reduce stigma, and acknowledging our biases and their roots also helps reduce judgement and shame. We must not discriminate based on appearance or size. Respect is paramount.

Choosing to focus on health optimization and impacts instead is a great first step towards reframing how we care for people with obesity. Shifting the narrative from blaming people to evidence-informed management strategies is key. The bias and stigma around obesity has real life consequences, such as patients avoiding seeking care, delayed diagnosis and treatments, and worsened mental well-being, all because of fear of judgement.

It is inappropriate to continue oversimplifying obesity. It is influenced by so many components, absolutely including (but not exclusively) your choices. Moving away from a narrative that places blame on individuals leads to higher quality, whole-person-focused healthcare, and allows us to work with evidence-based strategies to improve quality of life and long term chronic disease treatment. Moving towards compassion, empathy, and more accurate knowledge and understanding, creates a supportive environment for helping people manage their weight most appropriately.

Lastly, please remember, if you struggle with weight management, that does not make you a failure. Your willpower, discipline, and/or motivation are not lacking… these never last and are not consistently reliable even when they are there anyway.

Focus on what you can control, accept that there are many aspects that influence weight and health that we cannot control, and engage with appropriate support and tools to help your health and chronic disease management journey. Anti-obesity medications and/or bariatric surgery, when appropriate, can work wonders in synergy with improved positive health behaviours, lifestyle modifications, and psychology through various kinds of therapy.

As always, remember to chase progress, not perfection.

I believe in you,

Dr. Khimji

The Bottom Line

Obesity is a complex, chronic, relapsing disease that is influenced by an incredible number of factors, from genetics and biology to environment and socioeconomics, to our behaviours, and lifestyle. You are responsible for your choices and actions but you may not be able to control many invisible forces when it comes to your weight. Recognizing obesity as a chronic disease helps shift the narrative away from inappropriately blaming individuals and instead towards evidence-informed health strategies and treatment options. Anti-obesity medications and bariatric surgery have an important role in clinical practice to help manage obesity, and they can (and ideally are) used in synergy with lifestyle modifications and behaviour changes. Weight stigma and bias, which are closely followed by shame, guilt, stress, and low self-esteem, are critical aspects of obesity care that we must do a better job around. Use person first language when speaking about obesity and check your own biases. Focus on improving your health behaviours and whatever you can control and manage. Accept support of tools that can help, whether that means medication, surgery, psychotherapy, or other support. Be kind to yourself and practice self-compassion as you continue on your weight and health journey. You got this.