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“We need to devote more time to the obese patient”

Frühbeck, co-director of the Obesity Area of ​​the Clinic Universitat de Navarra, assures this in an interview with EFESalut on the occasion of the commemoration of World Obesity Day, on March 4. The researcher claims that this disease should not be stigmatized, nor should the patient with obesity be singled out, that in the absence of funded drugs, treatment must be paid out of pocket.

Graduated in Medicine and specialist in Endocrinology and Nutrition, Frühbeck is professor of Nutrition and Bromatology at the Faculty of Medicine of the University of Navarra; director of the Metabolic Research Laboratory of the Clínica Universitat de Navarra and has received several national and international distinctions for her work in the field of obesity.

Obesity is a global problem. According to the World Health Organization, since 1975, obesity has almost tripled worldwide. With data from 2016, it indicates that 39% of adults are overweight and 13% are obese.

In Spain, figures from the Ministry of Health show, with data from 2020, that 16% of the population suffers from it: 15.5% of women and 16.5% of men. And for minors between 2 and 17 years old, the figure is 10.3%.

Doctor, when is a person considered obese?

It is a disease with multiple implications, the diagnosis is based on the body mass index, that is, our weight relative to our height. We establish that there is obesity when the index is higher than 30, a value set by the WHO.

The thing is that this index does not reflect excess body fat adiposity. That is why there is another way to establish the diagnosis in a more precise way, we do it by looking at the percentage of body fat that varies in men and women.

Women have a higher percentage of fat than men and it is related to reproductive functions. For men, above 25% fat and for women we add ten, above 35%.

What is the protocol when a person with obesity comes to the consultation?

The first is not to stop only at the diagnosis of this body mass index, knowing that the patient’s excess fat can be accompanied by other associated diseases, such as cardiovascular disorders…

If we have increased cardiometabolic risk, we will have to explore it. Also if the obese patient is hypertensive, if he has sleep disturbances, type 2 diabetes, obstructive sleep apnea, or if there are other complications that may be psychological or psychopathological.

It is very important not to dwell on a diagnosis of obesity but to see the repercussion of excess weight and adiposity.

In this case we have to be very realistic, we can’t just tell the obese patient that he has to follow a high-calorie diet and do more exercise because we’re not making much progress. Over decades of research, we have seen that the first thing we should try to do is identify the patient’s obstacles or difficulties that have led to this obesity.

What therapeutic tools are available to address obesity?

Thanks to research we know how to tackle it with conventional treatment, but now we have different treatments depending on the type of obesity and the associated complications. They can be pharmacological in some cases – multiple drugs have been developed that we now know are safe and effective – there are endoscopic procedures and if the patient with obesity is a candidate for this, bariatric surgery.

Surgical approaches allow us to directly affect the gastrointestinal system to ensure that the patient does not have the constant feeling of hunger. In addition, it produces hormonal changes that will safely promote this long-term loss.

patient obesity
Bariatric surgery. EPA/GEORG WENDT

Which are the most indicated?

We must always think that any therapeutic approach, either pharmacological, endoscopic or surgical, must always be accompanied by lifestyle changes.

There has been a major drug revolution with GLP1 receptor agonists, a type of hormone produced in the gut in response to food. What the pharmaceutical industry has done is replicate what bariatric surgery is seen to produce and is so effective.

Depending on the type of drug there are different presentations. They tend to be injectable, for weekly use. They have been shown to have a good effect and, above all, they are safe, because in the treatment of obesity we have had a somewhat unfortunate history. Drugs appeared that in the long term could produce alterations in neurotransmitters, alterations in the state of mind or increased cardiovascular risk.

Are these drugs reaching everyone who needs them? They are funded by public health?

This is the great drama that we have for the people who work in this field and above all, for the patients. It is one of the few diseases whose treatment is not funded in the same way as hypertension or type 2 diabetes, which, on the other hand, many patients who suffer from diabetes are due to excess weight.

We are trying to make our politicians and all people aware of the great stigmatization that occurs with this disease, it is no longer just that the patient is singled out but on top of that when we have treatments that are effective, they are not subsidized by the public system.

It’s paradigmatic because we don’t mind giving a pill for hypertension or type 2 diabetes, and yet obesity, which is the cause of many of these problems, we don’t fund the drugs.

Bariatric surgery is covered in some cases, but there is a long waiting list.

Is it a disease that affects more men or women?

Women tend to have a higher percentage of body fat and what we also notice is that in most cases we have more subcutaneous fat, which is located in the femoral glute, the so-called cartridge pockets. Men, on the other hand, have more of a visceral obesity type, this beer belly.

It is proven that visceral fat has a greater cardiometabolic risk. What’s going on? That when women reach menopause, this profile changes and our fat distribution also changes. We no longer have so much at the subcutaneous level that it can even sometimes be protective, but it becomes part of this more visceral, abdominal obesity, which carries more risk.

In general, there may be more prevalence among men because of this visceral fat, but we see that more women tend to go to the doctor for treatment.

How is obesity addressed in the child and adolescent patient?

In children we are seeing a very high prevalence, which leads to these associated alterations that we used to say and that we did not see at such early ages. Now we see children with hypertension or type 2 diabetes.

The approach tends to be a little more conservative, however, given the high prevalence and the big problem we now have with childhood obesity, pharmacological treatments are already being carried out, drugs are prescribed for weight loss and diabetes type 2 in children and adolescents and even both endoscopic and surgical approaches are being practiced, but are reserved for specific cases.

He has recently coordinated a work published in The Lancet that analyzes the advances in the treatment of obesity and the need for personalized medicine in this field…

One of the things that we look at in a very detailed way is the response to each of these therapeutic modalities, which is very variable. We can find that the response to both diet, exercise and drugs exhibits great variability in the patient.

There are people who will respond wonderfully to a type of approach with a drug or diet or surgery, while there will be others who do not see these beneficial effects.

Our challenge is really to be able to choose on an individual basis which obese patient will benefit from each of the drugs in an optimal way and this is a research challenge because right now we have not yet identified these biomarkers that will allow us to start this patient with the approach that will really benefit you the most.

Obesity study Frühbeck
Dr. Frühbeck together with Carolina Perdomo, specialist in the Obesity Area of ​​the Clínica de Navarra and co-author of The Lancet study

On the occasion of World Day What are your demands?

We have several and we have been dealing with them in the interview. One is that obesity is seen as a disease, that the patient is not stigmatized, and also that he is not stigmatized in terms of treatment, that is, that he does not have to pay for it out of pocket.

Within these claims there is also the fact that time is dedicated to these patients, it cannot be that someone arrives at the consultation and that the only thing they tell him is to follow this 1,500 calorie diet and go more, because the poor patient it leads to the best a lifetime trying to make these recommendations. You have to stop, reflect, analyze well where the difficulty really is, what the obstacles are.

We cannot pretend that in two minutes of consultation he will make radical changes in his life because none of us are capable of that.

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