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Dr. Crotty:
This is CME on PACE-CME and ReachMD, and I'm Dr. Michael Crotty. I'm delighted to be joined today by Sarah Le Brocq, who is a fantastic obesity advocate, who's going to tell us about her lived experience with obesity.
Ms. Le Brocq:
Thanks, Dr. Crotty. Hi everyone. My name is Sarah Le Brocq. So I have lived with obesity most of my adult life. And what that has meant is that I've tried every single diet. I have lost weight on these diets, but I've always regained that weight once I've lost it. The maintenance bit has always been the struggle. I've even done an extreme weight loss TV show where I had a personal trainer for 2 hours every day and was filmed over a 9-month period, and I lost 8.5 stone in that period. And that was the point where I thought, “This is it. I've kind of cracked it. I'm going to skip off into the sunset as a skinnier, healthier version of myself.” But the reality was that absolutely wasn't going to be what was going to happen.
I then, over the next few years, despite training hard, carrying on doing triathlons, running 5 and 10Ks, I started regaining my weight. And I couldn't understand why because I was doing everything that everyone was telling me I should do. I was eating less. I was moving more. So I started digging into the science around obesity, and this is where Dr. Crotty is going to talk a bit more about this shortly.
But I wanted to understand why this was happening. I wasn't just going to accept this was like a moral failing of me because I was doing everything that I was supposed to be doing. And it was that, by digging into the science, I kind of started to understand something called metabolic adaptation and set-point theory, which is where, when you lose a significant amount of weight, your body, it then starts fighting for you to get that weight back on through physiological responses that the body does. And this was quite a kind of eye-opener for me and actually the point where I started realizing that obesity was a chronic condition—and not a lifestyle choice like I'd been made to feel my whole life—and that this wasn't a choice, and it wasn't just me doing something wrong.
I think that my story resonates with lots of people because I think people spend their lives trying to lose weight, when I think, fundamentally, when we recognize when someone lives with obesity, it's not about losing weight. It's about managing their weight over a long period of time and focusing around health. And that's what I'm trying to do now, moving forward.
So I'll now hand it back to Dr. Crotty, but that's just a little snapshot of kind of my journey. So thank you for having me along just to share that with you today.
Dr. Crotty:
Thanks very much, Sarah. That's a fantastic segue into what I want to talk about, kind of discussing obesity as a chronic disease, discussing the complexity, the factors that are associated with obesity, and just, I suppose, trying to change that narrative in healthcare and society that obesity is due to a lack of willpower and motivation. It’s much more complicated.
And I think most of our patients, when we discuss obesity, when we discuss how the body regulates weight, they understand immediately because they have that lived experience. When we're talking about obesity, we're not talking about body mass index or size necessarily, we're talking about excess or atypical adipose tissue, or fatty tissue that is causing an impairment of health. It's a complex, chronic, progressive, neuroendocrine disease. When we talk about a disease, we're talking about something where there is an alteration of normal body function, which we see in obesity, there are characteristic signs and symptoms, which we see in obesity, and there's an associated harm or potential associated harm, which we see in obesity.
If we look at the factors that are associated with obesity, we can think about individual factors, and that could be genetics. It could be the lived experience. It could be metabolic health, hormones, sleep, stress, different events that happen over people's lives. We can also consider environmental factors, socioeconomic status, the food environment, ultra-processed foods, sedentary life. Many different, complicated factors lead to obesity. And our risk of obesity is different person to person.
I think, for me, one of the most interesting things is thinking about how the body regulates energy balance. And really, we all have inherited this unique appetite system that has evolved to protect us in a time where food is scarce. We are not supposed to lose weight. This leads us to talk about the hypothalamic set point, or the subconscious brain regulation of energy, balance, and weight. We can think about homeostatic mechanisms, the feedback of hunger hormones, fullness hormones, via neural and hormonal pathways to the hypothalamus, informing us of what's happening with muscle mass and fat mass. We can talk about reward pathways in the limbic system, opioid, cannabinoid, dopamine receptors, the chemical reaction we get from food. Everybodyis dealing with a different subconscious appetite system. Many patients may experience higher levels of hunger hormones, lower levels of fullness hormones. And they may have hyperactive reward pathways. And if I get a stronger chemical response from food, if I am biologically hungry or more driven toward food, then I'm potentially at higher risk of living with obesity. The prefrontal cortex, the executive function, making decisions day to day, trying to integrate that biological drive with the world around us, sleep and stress and the food environment, again, making it more and more challenging. So this is not simply willpower and motivation. It's more complicated.
For me, even more interesting is what happens when we see people lose weight. And most patients that I will meet have lost weight and significant amounts repeatedly over the course of their life, doing very intensive, very low-calorie and restrictive dieting—inflexible, disordered eating often. The fact that these interventions are not sustainable, but also the fact that our biology changes in response, is why many people will regain weight over time.
We see in response to weight loss, we see hunger hormones increasing, fullness hormones reducing, reward pathways getting more activated. We see thermogenic regulation, a downregulation of metabolism. So essentially, our body is tilting the pitch against us and encouraging our weight back to our previous set point. And when we return to that previous set point, these physiological mechanisms don't always switch off, so people may actually navigate to a higher weight and reset their set point at a higher level. So we know this is not simply due to willpower and motivation. It's more complicated.
We know telling somebody who's living with obesity to eat less and move more is overly simplistic. It's stigmatizing. It's a bit like telling somebody with depression to cheer up. This is a more complicated medical issue, not a lifestyle issue, and not due to a lack of personal responsibility.
I think that's all the time we have for this video, but I'd like to thank Sarah again for sharing her experience, and I hope it was valuable to explore how the body regulates weight and why obesity is a complex, chronic, progressive, relapsing, and remitting disease.
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