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George Bray Part 1, The Chronic Disease of Obesity

In part 1 of this Exclusive Interview, George Bray talks with Diabetes in Control Medical Editor Joy Pape about the chronic disease of obesity and the primary messages from the World Obesity Federation position statements.

George A. Bray, MD, MACP, MACE is Professor of Medicine Emeritus at the Louisiana State University Medical Center in New Orleans.


Transcript of this video segment:

Pape: I’m Joy Pape with Diabetes in Control. We’re here in Boston for AACE 2018 Meeting. And I am honored to have the privilege to interview Dr. George Bray today. Dr. Bray, you’ve done so much. You’re one of the great pioneers of the field of obesity medicine. I want to thank you for all of your work in the field. And we don’t have the time (laugh) to be here a week to go over things. But you were the lead author on two recent high profile papers. One was a position statement from World Obesity saying “Obesity: a chronic relapsing progressive disease process,” a position paper of World Obesity. The other is a statement from the Endocrine Society on “The Science of Obesity Management: An Endocrine Society Scientific Statement.” Can you tell us some of the main messages from these papers?

Bray: I think the “obesity is a chronic disease process” one is trying to counter the long standing idea that obesity is something for which you are responsible. It is because you don’t push yourself away from the table. It is because you’re a weak-willed slob; it’s that kind of attitude that the public has. It’s a stigmatized state, if you want. And that, it makes it difficult to treat in any way except changing your moral character, which is something it clearly is not. About in 1996, leptin was discovered and since then a large number of genes have been identified that indicate that there clearly is a genetic basis for what’s going on. And because of that, the idea that obesity is a disease which was suggested 200 years ago has become more and more prominent. And the idea is to replace the moral naughtiness of being obese with the underlying disease processes which go on. So, the World Obesity statement was intended to do that. It was reviewed by the countries that are members of that group, which is most of the countries that have obesity societies. And they signed onto a statement which was drafted by a group of us for the World Obesity, stating, I think the truth of the matter, “Obesity is a chronic relapsing stigmatized disease process.” And the disease process part really reflects the fact that when you are obese a number of things are going on because of the enlarged fat cells, extra fat, that produce disease in and of itself. And so, if you reversed obesity, you will reverse many other processes, and this is particularly important with diabetes. If we are going to get a handle on the diabetes epidemic which has been going on along with the obesity one, we’re going to have to get a handle on the obesity epidemic because they’re going hand-in-hand. And the more people who become obese, the more people who will become diabetic. The diabetes prevention program clearly showed that a small weight loss of 5% or more will reduce the likelihood of getting obesity — diabetes, sorry, over a three and half year period by almost 58%, nearly 60%. And same thing with was shown in a Finnish diabetes study, similar figures from China and Japan. So, it’s clear that worldwide that we can reduce the risk of diabetes by modest weight losses and that’s a very important message to take home. We can do something with modest weight loss for people who are at risk for diabetes. So, shifting the emphasis from a moral weakness to a disease process makes it possible to think about it in a different framework.

The statement from the Endocrine Society attempted to take that message and broadened it out into what can we do about it, where are some of the gaps in what we can do, how are we going to move forward. And a couple of messages from that — and again, I’ll reemphasize what I said from the World Obesity Society, the obesity is a time bomb. It’s waiting to explode and one of the products will be more diabetes. So, dealing with that is important and we haven’t made much progress. When I started in the field many years ago, the prevalence of obesity was 14% in the United States. The latest figures show it to be 39.7%, nearly 40% of the adult population have a body mass index greater than 30. That’s I’d say almost 40%, that’s two in five people which is an enormous number. And the health implications of that are truly staggering. One of the best things we could do is to reduce that because it reduces the problem with diabetes. It will also do something good for cardiovascular disease but you need more weight loss for that than you do to reduce the risk of diabetes. So, that’s one message out of the Endocrine Society paper, that obesity is getting more prevalent. Not plateaued as some people thought, at least not the most recent data. It’s going up in children. It’s going up in adults. It’s going up in almost — in every country in the world, some more rapidly than others. The other interesting message in it is that not everybody gets obese. And one of the questions is what is it about the people who are thin that keeps them from becoming obese? And that’s one of the real mysteries we have. We don’t fully understand. We know that people like me, who will get fat acutely, will lose weight. I experimented some years ago. I gained 30 pounds just to see what happened and we did some studies on me once I had gotten fat. But when they were finished, my weight came down to what it’s been before and for 40 years since then. And there are lots of these studies now of conscious overfeeding to look at the consequences of that. And essentially every patient who does that comes down to their baseline weight from which they started. So, there’s something different between acute weight gain in people who are not basically overweight to start with, and people who are — who become overweight over time, because when you do that something gets changed.

Pape: Yes.

Bray: And it isn’t easy to reverse it if you do it slowly. Like a pound, a pound and a half a year and you do that for 10 years, you’re 10 to 15 pounds heavier. Losing that 10 to 15 pounds or 20 to 30 pounds, you go 20 years, and 30 — or 40 to 50 pounds, you go five years is very difficult thing to do. So, that’s one of the things we do not understand at all. One of the other messages that came out of this study was that we don’t have very good ways of knowing who will and who won’t respond to treatments. In the large trial Look AHEAD, which is a study of intense behavioral management for a large group of diabetic patients, 5,000 in number, we got a substantial weight loss at the end of one year, 8.5%, but the variability was enormous. A big group lost more than 10% and most of them kept that off. But there were 25% or so who loss essentially no weight, who were less than 3% below in spite of as intense a weight loss program as you can afford to put together. So, we have a great range of responses. And we don’t have any really good information about how to predict it ahead of time and only a few indicators about things that will work at the other end. So, we need a lot more information about those parts of the problem.

Pape: That reminds me of when we’re talking about treatment, what “diet” works best for someone and what medications will they respond to best. It kind of goes with what you’re saying. We don’t know.

Bray: That’s correct. We don’t know. We can’t tell how people will do on diets or medications. Some do very well on the medication or on diet, some do not, and only after the fact can you tell.

Pape: Right.

Bray: It’s an area that we need to understand better, if we’re going to make progress in deciding how to help people overcome this serious problem for their health in general and general well-being.

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