All about metabolic obesity

The widespread use of diabetes drugs that help people lose weight has transformed our society in ways we could never have imagined. We can now redesign our wardrobes, have more self-esteem, and spend less on food. But to an endocrinologist, not all weight is the same.

Metabolic obesity — where there is an excess of fat in the liver and abdomen — is associated with poor health. People with this condition have a higher risk of heart attacks and strokes, various types of cancer, sleep apnoea, hypertension, diabetes, and liver fibrosis. It is not necessarily worse than “metabolically healthy” obesity, which still burdens patients with back, hip, and knee problems and an increased cancer risk. However, the hidden cardiovascular risks of metabolic obesity are silent, and the measurement and treatment of these risk factors are often inadequate.

The problem requires specialist skills across a wide spectrum, including obesity experts, diabetologists, endocrinologists, hepatologists, respiratory physicians, gynaecologists, psychiatrists, and orthopaedic surgeons. Herein lies one of the reasons for patchy solutions.

Thus, the management of obesity through weight loss itself requires careful management. Diabetes may improve, but can there be too much weight loss? Has the risk of endometrial cancer been eliminated? Is there underlying coronary artery disease or untreated dyslipidaemia (high LDL cholesterol, low HDL cholesterol, and raised triglycerides)? How much weight loss is needed — and for which medical risk factor? Much smaller amounts of weight loss are required to improve glucose tolerance than are needed to relieve pain in osteoarthritic knees.

Weight loss does not remove the need to treat abnormal lipids to reduce the risk of future coronary events. Elevated blood pressure still requires treatment. Therapy is best tailored to the extent of existing disease and the time available to alter its progression. Metabolic diseases are complex and are best managed through a holistic approach to underlying cardiovascular risk.