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Writer's pictureValerie Sutherland, MD

The Multiple Faces of the Disease of Obesity

We have come a long way in researching and treating obesity as a disease. But, there are actually multiple types of this disease. Now that safe and effective medical treatment is available and people have been using them for a few years, the longitudinal evidence of the efficacy of treatment in an individual is self-evident, powerful, and frequently inarguable. But, we still have a long way to go. We are already seeing limitations, complications, and therefore opportunities to improve both how we use currently available treatment tools as well as avenues to develop new ones. For example, why does one treatment work “better” for one person than another? Why do some people eat one time a day and their weight does not go down? Why do some people have high hunger and some people are never hungry? While there is so much that has not been studied and has yet to be elucidated, the Obesity Treatment Algorithm from the Obesity Medicine Association goes beyond BMI to classify two types of the disease of obesity. While many people have factors of each, this schema can be very helpful to further understanding and tailor treatments. 


Fat Mass Disease: Abnormal and Pathological Physical Forces


In this type of obesity, health complications tend to be due to excess weight on the body, rather than primarily from metabolic dysfunction. 


This type can be recognized by patterns such as:

  • Normal or near-normal blood work for lipids, blood sugar, etc.

  • Higher BMI (>40)

  • Higher lean body mass (skeletal muscle)

  • Higher physical fitness level

  • Weight  more evenly distributed throughout the body

  • Higher physical hunger for healthy foods


Complications from this type of obesity tend to be:

  • Joint pain

  • Obstructive sleep apnea

  • Congestive heart failure

  • Varicose veins and blood clots

  • Hernias


Effective treatment for this type of obesity may include:

  • Treating hunger to allow reduced calorie intake while still being active

  • Adjusting activity to include moderate intensity activities like walking whereas it may start with mostly high intensity activity

  • Medications such as phentermine that are catabolic


Pitfalls in treating this type of obesity may include: 

  • Exercise at too high a volume at too high intensity that impairs weight loss

  • Consuming too much protein, based on their current lean body mass instead of ideal lean body mass

  • Overly focusing on muscle mass rather than body fat percentage, weight distribution, quality of muscle, and strength



Adiposopathy: Abnormal Endocrine & Immune Responses 


In this type of obesity, health complications tend to be due primarily from metabolic dysfunction rather than simply excess weight. 


This type can be recognized by patterns such as:

  • Abnormal blood work for lipids, blood sugar, often showing prediabetes, metabolic syndrome, fatty liver

  • Lower BMI, may even be in the normal range

  • Higher body fat percentage and higher visceral adiosity

  • Weight  more distributed in the trunk with a higher waist to hip ratio

  • May have low hunger and low food volume intake


Complications from this type of obesity tend to be:

  • Abnormal glucose and lipid metabolism

  • Pre-diabetes, metabolic syndrome, elevated liver enzymes, PCOS

  • Obstructive sleep apnea

  • Congestive heart failure

  • Varicose veins and blood clots

  • Hernias


Effective treatment for this type of obesity may include:

  • Increasing protein intake throughout the day 

  • Increasing resistance exercise to allow use of skeletal muscle mass to offset metabolic dysfunction

  • Adjusting activity to include  bursts of high intensity exercise if safe to transition white fat to beige fat

  • Medications that target metabolic dysfunction such as metformin or GLP 1 / GIP RA


Pitfalls in treating this type of obesity may include: 

  • Reducing calorie intake without changing the type of intake

  • Focusing on the scale rather than metabolic dysfunction

  • Failing to address the metabolic dysfunction first



Take a look at your body composition analysis, your blood work, and see if this helps you and your provider understand your health in more depth. If your provider is not trained and educated in the treatment of obesity, find one who is. While pharmacotherapy is crucial, it is just a tool, and like all tools, using it wisely makes a difference!



Take Back Your Metabolic Code,


Valerie Hope-Slocum Sutherland, MD













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