Changing the Conversation: Obesity as Chronic Disease

Obesity is a common disease, defined by excessive body fat, that occurs in approximately one in five children and two in five adults in the United States.¹

“Most diseases are caused by an interplay of genes and environment,” said Melanie R. Jay, MD, MS, obesity researcher and director of the NYU Langone Comprehensive Program on Obesity. “Obesity is definitely polygenetic, but [it] is also affected by environment—access to a lot of increased calories and decreased physical activity—and by medications, stress, and many other factors that interact with genes to cause the phenotype of obesity.”

What makes obesity a chronic disease, Dr. Jay said, is that there is currently no cure, because even when people can lose weight, they often relapse.

Although the healthcare community commonly recognizes obesity as a disease, it is not yet universally recognized as such.^2,3 Increased recognition of obesity as a disease could not only have a positive effect on the treatment of patients with obesity, but it could help to eliminate weight-bias in healthcare settings and promote more empathetic, non-stigmatizing interactions between providers and patients.

A Chronic Disease

There is increasing evidence to support the view that obesity is a chronic disease, as evidenced by studies examining appetite regulation, hormonal signaling, and metabolic adaptation.

One study supporting these changes analyzed 50 patients with overweight or obesity who participated in a 10-week weight loss program that included a very-low-energy diet. The average weight loss in the study was 13.5 kg, resulting in significant reductions in circulating levels of leptin, a satiety hormone; insulin; and peptide YY. However, it also led to a significant increase in ghrelin, a hormone that stimulates appetite. Patients also reported a significant increase in subjective appetite.⁴

“What that study showed was that if you took people and helped them lose weight, then looked at them a year later, their hunger levels were still higher,” said Adam Gilden, MD, associate director of Colorado University’s Medicine Weight Management and Wellness Clinic. “The level of ghrelin, as well as their subjective hunger ratings, did not come back to their pre-weight loss levels.”

Evidence has also shown that even without weight loss, most people with obesity may experience leptin resistance, driving hunger and appetite.⁵

There is also evidence of a phenomenon that Dr. Gilden and others called metabolic adaptation.

“This is a theory based on scientific observations that when people lose weight, there is a drop in metabolism that is more than you would expect based on the amount of weight loss,” Dr. Gilden explained.

The idea of metabolic adaptation is supported by data from a study of 14 participants in “The Biggest Loser” reality television competition. Participants had an average of 58.3 kg weight loss with a resting metabolic rate decrease of 610 kcal per day. At follow-up six years later, most of the weight had been regained; however, despite this, the resting metabolic rate was 704 kcal per day, approximately 500 kcal per day lower than expected.⁶

A more recent study also supported the idea of metabolic adaptation. Among premenopausal women with overweight, each 10 kcal per day increase in metabolic adaptation increased time to reach weight loss goals by one day.⁷

“Even studies of more current medications [for weight loss] demonstrate that a large number of individuals that stop these medications will have their weight start to come back soon after,” said John Jakicic, PhD, professor in the Department of Internal Medicine in the Division of Physical Activity and Weight Management at the University of Kansas Medical Center. “We also see this with bariatric surgery.”

Common Biases

Despite the increasing evidence supporting obesity as a chronic, progressive disease, many patients who are overweight or obese still experience biases in clinical settings.

“More than 50% of people with obesity report stigma in the healthcare setting,” Dr. Jay said. “Even when healthcare providers are trying not to create stigma, just the way clinics are set up, with scales in the hallway, for example, can cause it.”

One review of 32 studies characterizing weight stigma found that people with obesity report experiencing discrimination, judgment, shame, and blame.⁸ In healthcare interactions, it may be assumed that these patients lack self-control or are personally at blame for their struggles with weight.⁹

“Some clinicians, when faced with a patient with obesity, don’t yet understand the biology of why this person is struggling with the condition,” Dr. Jakicic said. “Their mindset goes to telling the patient to focus on eating healthier and getting more exercise. The patient comes back in three to six months, and nothing has changed.”

There are myriad ways that patients may experience bias, Dr. Gilden said, but one more recent way that bias may present is in the refusal of primary care physicians to prescribe anti-obesity medications.

“There are certain types of medications that are difficult to prescribe in the primary care setting—opiates for chronic pain or smoking cessation drugs—but if you were to say that you don’t prescribe these, you wouldn’t last very long in practice,” Dr. Gilden said. “With anti-obesity medications, you can still get away with saying, ‘I don’t prescribe anti-obesity medications,’ and nobody bats an eye.”

Another bias patients may experience is when physicians fail to ask about a patient’s current stage in their weight loss journey, Dr. Jay said.

“People make assumptions when you are overweight,” she said. A patient may have already lost a significant amount of weight but still be overweight or obese. Physicians should not discuss weight loss goals without first determining a patient’s current stage in their weight loss journey and taking a comprehensive dietary and physical exercise history. “Someone who doesn’t know this may still lecture about losing weight.”

Communication Strategies

People may benefit from discussions about weight or weight loss, but it is important that these are done with respect and in collaboration with the patient. Using person-first language is recommended, including avoiding terms like “fat” or “obese.” Instead, terms such as “weight” or “having too much weight” can be used to describe their health concerns. Additionally, discussions can include a goal of maintaining a healthy weight range instead of focusing on a single ideal weight.¹⁰

“The condition that person is facing does not define the person,” Dr. Jakicic said. “It is important to recognize the individual as a person and recognize that they have a condition that needs treatment.”

Dr. Jay said that conversations about weight can start by asking the patient’s permission. “Tell your patient, ‘I would like to hear more about how you manage your weight, can we talk about that?’” she said. “Ask questions like, ‘What have you been doing? What works for you and what doesn’t?’”

Motivational interviewing techniques that employ a patient-centered approach, incorporate active listening, and support a patient’s motivation can be effective. However, Dr. Jay said that it is not always enough to treat obesity,¹¹ with one meta-analysis finding that there is no evidence to support the notion that this approach increases the effectiveness of behavioral weight management programs in controlling weight.¹²

“For a lot of people, it is not a question of motivation,” Dr. Jay said.

Dr. Jakicic agreed. Instead of getting hung up on motivational interviewing techniques, he said that listening and allowing the patient to help guide their care is important. Help them identify their struggles, what has worked, what hasn’t, and explore potential solutions.

It is also important to know your patients, Dr. Jakicic said.

“If someone mentions they are trying to exercise but struggling, a physician may say that a good strategy is to do it first thing in the morning,” Dr. Jakicic said as an example. “But if the physician never asks the person about their barriers to exercise, they may not know that the person has five children to get ready for school each morning, or that they have to be at work by 8 AM, making early exercise an unrealistic solution for that patient.”

Multidisciplinary Care

This type of individualized care also demonstrates why a multidisciplinary approach may be necessary for some patients with obesity. An interdisciplinary team for weight loss can include a weight loss specialist, a primary care physician, a registered dietitian, a surgeon, a psychologist, a certified exercise physiologist or physical therapist, and others, but this approach may vary depending on the scenario.

“Every patient is going to be a bit different,” Dr. Gilden said. “Some people don’t need a ton of multidisciplinary support, but just a tool to help control hunger. Others need to meet more frequently or need the support of a registered dietitian or the support of a psychologist.”

Dr. Jay agreed, “Certain patients just need more support.”

Regardless of the team of people involved in the treatment plan, Dr. Gilden emphasized the importance of remembering that obesity is a chronic disease with no cure, and it must be treated accordingly.

“There is a biological drive to regain weight,” Dr. Gilden said. “Instead of thinking about obesity as lifestyle choices—just pushing away from the table and having more discipline—obesity needs to be managed like any other chronic condition that may be managed in the primary care setting.”

References

1. Centers for Disease Control and Prevention. Accessed May 22, 2025. https://www.cdc.gov/obesity/php/about/index.html
2. World Health Organization. Accessed. May 22, 2025. https://www.who.int/health-topics/obesity#tab=tab_1
3. Luli M, et al. EClinicalMedicine. 2023 Apr 6:58:101962. doi:10.1016/j.eclinm.2023.101962
4. Sumithran P, et al. N Engl J Med. 2011;365(17):1597-1604. doi:10.1056/NEJMoa1105816
5. Farr OM, et al. Curr Opin Endocrinol Diabetes Obes. 2015;22:353–359. doi:10.1097/MED.0000000000000184
6. Fothergill E, et al. Obesity (Silver Spring). 2016 Aug;24(8):1612-9. doi:10.1002/oby.21538
7. Martins C, et al. Obesity (Silver Spring). 2022 Feb;30(2):400-406. doi:10.1002/oby.23333
8. Ryan L, et al. Obes Rev. 2023 Oct;24(10):e13606. doi:10.1111/obr.13606
9. O’Donoghue G, et al. PLoS One. 2021;16(11):e0260075. Published 2021 Nov 29. doi:10.1371/journal.pone.0260075
10. National Institute of Diabetes and Digestive and Kidney Diseases. Accessed May 22, 2025. https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/weight-management/talking-with-your-patients-about-weight
11. Wittleder S, et al. Ann Intern Med. 2022 Jun;175(6):901-902. doi:10.7326/M22-0715
12. Michalopoulou M, et al. Ann Intern Med. 2022 Jun;175(6):838-850. doi:10.7326/M21-3128