Obesity – the last acceptable prejudice

Obesity is the last socially-acceptable prejudice, wrongly seen as an avoidable condition which people bring upon themselves. Unfortunately, this prejudice carries over to the NHS – an issue that I have witnessed first hand.

What I now know, as an obesity clinician and researcher for the last 14 years at University College London, is that obesity, which now affects 27 per cent of adults in the UK, is not a lifestyle choice.

It is down to a combination of environment, genes and compensatory biological changes, which lead to increased hunger, increased interest in food and reduced energy expenditure and these changes mean it is exceptionally difficult to maintain weight loss.

A recent report by the Royal College of Surgeons found that 70 per cent of Clinical Commissioning Groups in England and Wales, which are now responsible for funding obesity surgery instead of NHS England, have no plans to fund bariatric surgery, which is the key weapon we have against severe obesity (BMI of 40 or more). Weight loss operations cost around £6000. Many class it as on a par with nose jobs and breast reduction surgery, yet bariatric surgery can save someone’s life.

In 90 per cent of cases, bariatric surgery, which include sleeve gastrectomy  and gastric bypass surgery, leads to substantial, permanent weight loss. Sleeve gastrectomy involves removing around 80 per cent of the stomach. Gastric bypass, which has been done for longer and is more common, involves keeping the stomach intact but partitioning off most of it so you end up with a small pouch which leads directly into the gut.

In 60 per cent of patients, bariatric surgery puts their type 2 diabetes – immediately into remission (they have normal blood sugar and are off all treatment). Stroke risk drops by a third after 10 years. This isn’t wishful thinking. This is a fact, and it is a scandal that UK surgeons only perform around 6000 of these life-changing procedures in 2016, as compared with 50,000 in France, which has a much lower obesity rate than we do. The number of referrals for bariatric surgery in the NHS has dropped by 30 per cent in the last five years, when the obesity crisis is getting worse. That is despite the fact NICE guidelines clearly state that eligible people (those with a BMI of 35 and over who also have type 2 diabetes) should have access to bariatric surgery. CCGs are completely ignoring the guidelines, and no one is holding them to account because obesity is seen as an easy target.

The facts are these:

Human beings are evolved to deal with a world when fat wasn’t an issue.

The 365-day-a-year calorie-rich society is a modern phenomenon and evolution is way behind. Our complex systems are controlled by hormones which is designed to take advantage of rare ‘feasts’ and cope with long periods of deprivation. I have spent many years researching the role of these hormones which work together to control appetite and satiety.

Essentially, these hormones encourage people to eat when they can, but take little account of fat deposits someone already has. In the evolution disconnect, human beings never had substantial fat reserves. So, there is no way for the brain to regulate hunger based on how fat you already are.

Everyone is susceptible to weight gain in the modern ‘feast’ age. But one in sixteen people in the UK is born with a gene variation in their FTO (fat mass and obesity associated) genes that means they are more likely to become obese. We did a study on UCL volunteer students in 2013 and pinpointed the ones who had this gene variation. Everyone was given a meal of 2800 calories and we measured hormone levels before, during and afterwards as well as doing brain scans. The students who had the gene variation were still interested in dessert after this massive meal and brain scans showed that the pleasure areas of their brain were still lit up at the prospect of more food. Students without the gene variation had absolutely no interest in eating anything more, no matter how tempting, after that massive meal. The brain scans showed no activation of pleasure zones when they were offered tempting chocolate puddings.

Importantly, the gene variation affects levels of a hormone called Ghrelin, which is produced in the gut when we haven’t eaten for a long period.

It makes you feel hungry and the higher it is, the hungrier you feel. In the students who had the gene variation, levels of Ghrelin were higher at the start and stayed high right through the meal. Their Ghrelin levels also didn’t drop back down, which they should have done and reduce hunger pangs.

Another gut hormone, peptide YY,  which I discovered controls appetite in 2002, also has an important role to play in the obesity epidemic. This rises when you eaten and tells the brain that you can stop. If you give someone an injection of peptide YY infusion, they feel sated and we can see the reward centres of the brain lighting up in scans. Unfortunately, we have shown that children and adults who are obese have very low levels of peptide YY – so they don’t get the same feeling of fullness.

Unfortunately, diet are not the solution when it comes to helping to restore normal gut hormone levels. As soon as someone starts to diet, their levels of Ghrelin rise dramatically, making them hungrier and less able to feel full after mealtimes. What we know is that 75 per cent of people who lose weight in diets put all the weight back on again, but the Ghrelin levels stay sky high, making them eat even more. Strenuous exercise for around 60 minutes each day can temporarily lower Ghrelin levels but few obese people can realistically manage this. At an evolutionary level, your brain is convinced by your failed dieting regime that you live in a ‘risky’ environment where famine is common so it makes you more keen to eat when you can and as much as you can.

We only have one proven way to reset the gut hormones for someone who is already obese. That is bariatric surgery. After sleeve gastrectomy or gastric bypass surgery, levels of Ghrelin plummet immediately and stay low, so hunger pangs are less intense and cease quickly after eating. And peptide YY levels rise sharply, five to tenfold what they were before, making someone feel full more quickly after eating. These levels peak after 90 minutes and stay elevated for up to 12 hours. This is because the gut cells that produce both helix and peptide YY are exposed to far more nutrients, which have bypassed the stomach. This triggers them back into normal action. They react as they should to the calories they detect in the gut.

Another gut hormone, known as Glucagon-like-peptide 1 (GLP-1), regulates blood sugar by acting on the pancreas. When exposed to a flood of nutrients that are now longer absorbed in the stomach, the GLP-1 producing-cells work normally. This puts type 2 diabetes immediately into remission and the majority of patients leave hospital without needing to take their medication any more. If you think about the huge cost of dealing with complications of type 2 diabetes, including foot amputation, blindness and kidney failure, this is a stunning success story that more than justifies the expense of bariatric surgery. Yet CCGs refuse to see this because they only look at the short term cost benefit.

Gastric band surgery, which is performed on around 10 per cent of obese patients in UK hospitals. does not have the same effect since it only slows down the passage of food through a stomach which is effective corseted by a band. Many people who have gastric band surgery continue to eat large amounts of meltable calories that can easily pass through the small space and the gut hormones are not restored to normal.

It could be that we develop an obesity pill in the next five to 10 years which recalibrate gut hormones without surgery, but in the meantime, we all need to change our preconceptions about obesity. Someone with breast cancer is not more deserving of our help than someone who suffers from obesity. Both should be a priority.

And people who are obese need to start becoming more vocal and understanding that they are worth more than being ignored. For this reason, I helped to found the patient advocacy group, Obesity Empowerment Network UK. www.oen.org.uk. Our mission is to improve access to healthcare for individuals with obesity issues, but also to advocate for a nationwide obesity prevention and treatment strategies and fight to eliminate weight-bias and discrimination.

At the end of the day, this should be a matter of self interest to everyone. When one in four adults in the UK is already obese, we are only discriminating against ourselves if we refuse to engage with this serious chronic health problem.