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Obesity: Discover new treatments and the cultural change about the disease

In the last 20 years, the prevalence of obesity among the adult population in Brazil has more than doubled, from 12.2% to 26.8%, according to the IBGE.

By Martha San Juan França — For Valor, from São Paulo 08/12/2022 05:04 am

Obesity is a chronic disease. Complex, multifactorial, a global epidemic from which Brazil cannot escape. Here, this disease has only increased. In the last 20 years, the prevalence of obesity among the adult population has more than doubled, from 12.2% to 26.8%, according to the IBGE. It is estimated that if the growth rate remains the same, we could reach almost the same speed as the United States, the country of hamburgers and fries, where more than 36% of the population lives overweight or obese. If that wasn't already worrying, doctors warn that the accumulation of body fat contributes to a massive list of health problems, such as hypertension, cardiovascular disease, type 2 diabetes, osteoarthritis, esophageal reflux, and various types of tumors. But, despite all this evidence, are people, including healthcare professionals, so reluctant to consider obesity a disease and treat it as such?

For starters, this is a relatively new definition. It was not until 2013 that the American Medical Association (AMA) officially established the concept of obesity as a chronic disease. And it was only in 2015 that the World Health Organization (WHO) set a global goal to stop the increase in overweight rates and to contain the number of deaths from non-communicable diseases by 2025 - a goal that is already known will not be achieved. Not by chance, the epidemic was dubbed globesity. For decades, researchers working on this topic focused on the behavioral part, as if body fat were a particular condition, resulting from the inability to control the scale, close the mouth and practice physical activity, rather than the result of molecular changes and metabolism of the organism. Many cultures saw obesity as a result of character defects, and it is not a coincidence that gluttony was considered one of the seven deadly sins. Being overweight was, and still is, associated with laziness, overeating, lack of willpower, and other negative stereotypes.

“Weight control is a complex phenomenon that does not depend exclusively on willpower,” contrasts endocrinologist Maria Edna de Melo, director of Abeso (Brazilian Association for the Study of Obesity and Metabolic Syndrome). Obesity can be measured according to BMI (Body Mass Index): a person's weight divided by their height squared. If the result is greater than 25, the person is overweight. If you go over 30, you are obese, and if you have associated diseases, such as diabetes and hypertension, you need to review your habits and seek help urgently. Inheriting genes from parents that favor the accumulation of energy and make it more difficult for a person to lose weight partly explains the problem. “Humanity was selected to store energy and save it for periods of restriction when food is scarce,” explains the director of Abeso. “But the world has changed, and today we have an abundance of food. We are vulnerable to acquiring obesity and accumulating fat throughout our lives. In this case, there may be a genetic and a biological predisposition.” This question explains why obesity has become a worldwide epidemic that has only increased in the last 50 years. “During this period, changes in the food system, which stimulated the consumption of ready-to-eat, processed and ultra-processed products, such as soft drinks, cookies, frozen meals, sausages, etc., were accompanied by changes in the population's lifestyle, which went to be more sedentary,” says nutritionist Ana Paula Bortoletto Martins, a researcher at Nupens/USP (Nucleus for Epidemiological Research in Nutrition and Health). “At the same time that the large food industries began to develop technologies that improved food production, there was also an increase in the composition of saturated fat in the diet of the population.

The Nupens team, of which Martins is a part, was a pioneer in associating changes in industrial food processing with the obesity epidemic that affects most countries worldwide, even low-income countries. In Brazil, not coincidentally, the population had become overweight in recent decades, when there was a change from traditional food to a menu rich in saturated fats and high in calories, and the marketing of industrialized foods on TV and the internet became popular. More widespread, including among children and adolescents. Research has shown that this is not just a problem for those who struggle with the scales. If before, many families had difficulty accessing ready-to-eat or processed foods; today, soft drinks, packages of instant noodles, stuffed cookies, and snacks have become cheaper and more available than fresh food. As a result, both hunger and the growing obesity epidemic affect the most vulnerable population.

Until the 1990s, it was believed that ingesting large amounts of fat through consuming processed foods alone caused obesity. In recent years it has been shown that this is not only because fat is high in calories but also because it promotes neuronal damage. According to physician Lício Velloso from Unicamp, who directs the Center for Research on Obesity and Comorbidities, it is now known that excessive consumption of saturated fat also causes inflammation in the hypothalamus, which causes neurons in this region of the brain, which controls hunger and energy balance, function in a strange way.

Studies carried out in several countries and by the center directed by Velloso, composed of more than 80 researchers from Unicamp, USP, Unesp, and Unifesp, have linked excessive consumption of saturated fat with the functioning of the region of the brain that controls hunger. “When the hypothalamus works properly, you eat enough food to be healthy and don't accumulate excess energy in the body; that is, you won't be obese,” explains Velloso. “When you develop a change in the functioning of these neurons, they lose their ability to bind to insulin, which facilitates the uptake of glucose into cells, a common situation in obese or diabetic people. In this way, you do not adequately control hunger and the feeling of satiety and start eating more and more.” According to the doctor, the problem is cumulative. “A person who eats too much and inadequately from childhood is more at risk of developing this type of damage to the hypothalamus and, as a result, becoming obese.” Studies have also shown that exercising, in addition to burning calories, helps to reduce inflammation in the neurons of the hypothalamus and restore the feeling of satiety. Other problems such as unregulated sleep, stress, and hormonal and emotional changes can also influence weight gain.

Often, the desire to eat does not arise from a biological need, in which the body needs calories, but is related to the pleasure of eating certain foods, in general, and not by chance more fatty, sugary, and created to be more palatable. . “Restrictive diets, without taste, without pleasure, also frighten the brain and reinforce the so-called accordion effect,” observes nutritionist Sophie Deram, a researcher at Ambulim (Ambulatory of the Eating Disorders Program at the Hospital das Clínicas at USP). “The most appropriate thing is to eat better, not less. Focus on quality, and consume more fresh and homemade food. Adopt better, more conscious, and less restrictive eating behavior.” The discoveries about the neural circuits of hunger and satiety have opened the possibility of finding targets for more effective drugs to treat obesity. Researchers at the Danish pharmaceutical company Novo Nordisk have developed a new generation of drugs over the last ten years to control type 2 diabetes and, more recently, obesity. These drugs can mimic the effect of GLP-1, a type of hormone produced by the gut that increases insulin secretion and sends satiety signals to the brain.

Liraglutide is part of the first generation of these drugs called GLP-1 analogs, which can reduce weight from 9% to 10%. According to a study published in the New England Journal of Medicine, semaglutide, a second drug initially approved against diabetes, reduces weight by about 15% or more. Other pharmaceutical companies develop research with the same principle. Elly Lilly has already announced good results with tirzepatide, which can reduce weight by 20%, and Pfizer, AstraZeneca, and several startups are also studying versions of this hormone. Liraglutide is already used in Brazil to treat obesity and was approved by Anvisa in 2016. On the other hand, semaglutide, approved in June in the United States, is used off-label in Brazil (with medical approval but outside the indication provided for in the package insert). ). The main difference is in the frequency: while liraglutide needs a daily application, semaglutide has a longer duration and can be applied once a week.

“When we talk about reducing obesity, it doesn't mean thinness,” reassures the Clinical Nutrition Support Physician Andrea Pereira, with a doctorate in obesity and bariatric surgery from Unifesp's Endocrinology. Therefore, Abeso and SBEM (Brazilian Society of Endocrinology and Metabology) propose a new classification of how much weight it takes to be healthy. The calculation starts from the percentage of the maximum weight that a person has reached in life. If, for example, the BMI is between 30 and 39.9 kg/m2, losses representing 5% to 10% of the maximum value reached indicate reduced obesity. Losses above 10% point to controlled obesity, significantly reducing health risk.

“It is necessary to consider that there are obese people and there are fat people, and in both cases, they are the object of fatphobia,” says Mariana Vieira, a lawyer from Espírito Santo. He, along with activist Rayane Souza, also trained in the law, created the project Fat in the Law, an Instagram profile on the rights of fat people that offers information about the possibility of legal action in cases of fatphobia. “We tried to show that sometimes the fat person does not have a disease, they are happy with their body, unlike an obese person who has health problems linked to body weight.” For the Clinical Nutrition Support Physician Andrea Pereira, in addition to prejudice, there is a lack of information about the disease obesity. “Patients themselves feel discouraged from seeking treatment, arrive at the office looking defeated, ashamed and almost apologizing for not having lost as much weight as they and the people around them think they should.” She says that the need to inform the population about what the disease is, its treatment and diagnosis and to combat discrimination led her to create, with bariatric surgeon Carlos Schiavon and clinical psychologist Andrea Levy, the NGO Obesidade Brasil, affiliated with the World Obesity Federation and the Global Obesity Patient Alliance, organizations that help people with obesity. “The mistaken idea that weight loss depends only on one's behavior ends up martyring patients because the environmental stimulus is much greater than the ability to self-regulate,” says psychologist Andrea Levy. “No one chose to be fat in life; these people need treatment and often have no idea they have a disease. Life gets easier when they understand and seek out the right experts.”

Lawyer Mariana Vieira recalls that many health professionals care for fat patients in a non-humanized way because weight loss is seen as the solution to all problems. “Many times the person goes to the doctor to treat a situation and feels embarrassed and humiliated by the professional because of his weight,” she says. “The person who is not a specialist has the right not to have information, but the health professional does not,” reinforces the Clinical Nutrition Support Physician Andrea Pereira. “Obese people can and should demand respect when being treated. Due to lack of information and training, health professionals often do not consider obesity a disease and treat it with prejudice.” To increase the stigma, there is still a pre-judgment based on physical appearance and the appreciation of thinness, comments Rayane Souza from the Project of law called Obesity. “I believe and am part of the body acceptance movement that seeks to break the standards of beauty and idealization that society imposes. But I understood that, even though I thought I was a well-resolved woman, this did not shield me from day-to-day prejudices, and I saw the need to bring legal advice to this debate.” She says that no matter how much awareness has increased, there is still a disregard and prejudice against fat people that manifests itself in jokes, contempt, and social rejection of various natures.

The movement of which Souza is a part has extended to other spheres. The expression fatphobia gained prominence in the country; it was the theme of “Big Brother Brasil,” led singer Anitta to challenge beauty standards by including overweight women in videos of her, and sparked heated criticism when country music star Marilia's weight gains and losses Mendonça, who tragically died in a plane crash, were repeatedly mentioned by the press.

“I don’t think there is any fat person who hasn’t been through some kind of embarrassment, from the seat belt on the plane not closing or going into a store and not finding anything that fits,” says actor and presenter Tiago Abravanel, who starred in this type of discussion at the BBB and launched a clothing brand for those who wear plus size. “I was never a skinny person; for a long time, I went on crazy diets, went to the spa, and worried about following the pattern,” he says. “Today, I understand that I don't need to be hostage to my body; I accept it as it is. Of course, I take care of my health, but I believe that aesthetic pressure causes so many physical and psychological problems that these should be the plan and not just the shape of our bodies.”


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