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Metabolic syndrome

Should metabolically normal obese patients be treated?

What is a ‘metabolically normal obese' patient?
It is important to intervene because obesity precedes metabolic syndrome
Studies that have shown that losing weight can be unbeneficial

At the recent 18th European Congress on Obesity, in Istanbul, Turkey, two European experts debated whether obese patients who present ‘metabolically normal’ should be treated as they may develop metabolic syndrome later in life.


Professor Constantine Tsigos, Athens University Medical School. Greece, began the debate by asking what it actually means to be ‘metabolically normal obese’. He said there was no internationally agreed definition and many studies use different criteria. As a result, the prevalence of metabolically normal obesity varies from 6 to 40%. 


Metabolically normal obese

Nevertheless, Tsigos said that despite this variation studies have shown that metabolically normal people have an increased risk of cardiovascular disease and other diseases. In addition, they also have an increased risk of developing type 2 diabetes and studies have shown that the metabolically normal obese have the same risk of dying as the metabolically abnormal obese. 


He stated that some people have argued against treating the metabolically normal obese after a study showed that the exclusive use of diet-intervention in this group led to a reduction in insulin sensitivity, compared to those who were insulin resistant. 


“Obesity not only increases metabolic complications, it also significantly increases the risk of many types of cancer, mood and anxiety disorders, reproductive disorders, liver cases and musculoskeletal problems” Constantine Tsigos

However, Tsigos argued that the study sample was small and the results have never been repeated. Conversely another study reported that intervention using diet, exercise, or both, can significantly increase insulin sensitivity in the metabolically normal obese. A further study looking into gastric banding showed that after six months even those who were metabolically healthy had a significant increase in insulin sensitivity, leading to improvement. 


He concluded by stating that it was important to intervene because obesity precedes metabolic syndrome. “Obesity not only increases metabolic complications, it also significantly increases the risk of many types of cancer, mood and anxiety disorders, reproductive disorders, liver cases and musculoskeletal problems,” said Tsigos. “Although a small number of metabolically normal obese patients exist, the majority go on to develop the hallmarks of metabolic syndrome later in life and there are numerous benefits of weight loss and lifestyle intervention that appears to bring about benefits in this group.”


Losing weight can be unbeneficial

Professor Nick Finer, University College London Hospital Centre for Weight Loss, Metabolic and Endocrine Surgery, UK, began by stating that it was not possible to treat all obese patients: “Twenty five per cent of the population are obese and doctors are unable to provide medical care for most of these people.”


Nick Finer

He argued that patients who are metabolically healthy are not ill and do not have a disease, and scarce resources should be directed to those patients who are obese and metabolically unhealthy. He highlighted data from long-term epidemiological studies that have shown that losing weight can be unbeneficial.


In addition, Finer said that studies have shown weight loss can lead to an increase in osteoporotic fractures, loss of muscle tissue, nutritional deficiencies and numerous attempts at weight loss may lead to abnormal eating behaviours such as binge eating disorders. “The problem with intervening is that there are very few long-term studies of therapeutic interventions and the economic case for not treating the metabolically normal obese is compelling,” he said.


Finer added research has shown that cardiovascular event rates in metabolically healthy overweight or obese patients are low and they are very small compared to those metabolically unhealthy. With regards weight loss drugs, he said the only point at which Orlistat becomes cost-effective is when patients have co-morbidities. 


He concluded that patients with co-morbidities and who will benefit the most from treatment should be the group health professionals should be focusing, not those who are metabolically normal obese. “The advice for the healthy obese should be exactly that, advice, but not treatment, and the advice would be to follow a good diet, exercise and learn to relax,” he added.

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