Rethinking obesity

Obesity is one of the commonest diseases. Any epidemiological survey in westernised countries will confirm that this disease has reached epidemic proportions.

Malta places firmly at the top of international league tables, confirming the size of the problem and the compelling call to action. Obesity does not only weigh heavily on the individual’s well-being, but it also strains the country’s resources. Its direct and indirect costs are really and truly weighty.

What causes obesity? Is this just about cosmetic and body image or a justified health concern? What of the much-flaunted benefits of the Mediterranean diet? Are wonder drugs the solution? Is corrective complex surgery justified?

The cause of the vast majority of diseases is multifactorial and obesity is no different. Of course, heredity (genetics) plays an important role that is hardly modifiable. But there are surely plenty of risk factors that we can tackle. Exercise and meal size are the obvious starting points.

Obesity may be ranked as one of the nastiest conditions because it virtually affects every bodily system and function.

Imagine carrying about a whole sack of sugar and more, every minute of one’s life. This excess weight will necessarily hasten the wear and tear in the lower back, hips and knees. That excess weight will raise blood pressure and this will, in turn, push the heart muscle into failure.

The abnormally high blood pressure will compound the effect of high cholesterol from fatty foods. This is a wicked conspiracy that is intent on damaging the delicate blood vessels supplying the heart muscle, those in the kidneys and the ones  meandering in the brain. Therefore, heart attacks, kidney failure and strokes are just round the corner.

A thick neck will trouble your sleep pattern (obstructive sleep apnoea) and decrease the availability of oxygen in your blood. This will further depress heart and lung function.

The excess weight resists insulin function, pushing the pancreas gland into giving up, resulting in diabetes. Diabetes, in turn, worsens every other harmful effect that I have already described.

Further delights include a fatty liver, which scars up and shrinks (cirrhosis), and hormonal upsets that reduce fertility, cause depression and give rise to a definite increased risk of cancer of the breast, ovary, stomach and colon.

If this litany of woes has not scared you all the way to the sports section yet, you might agree that the only way to address this problem is a whole-government and whole-society approach. And this can hardly be regarded as a pre-emptive strike. The truth of the matter is that we are struggling to catch up.

From the emergency rooms (heart attacks, strokes, organ failure), to our operating theatres (cancer surgery, stents, bypass procedures, amputations, back surgery, joint replacements), to our clinics that monitor long-term medications for chronic diseases (high blood pressure, angina, dialysis, psychiatry, diabetes), the cost and effort are immense.

Awareness campaigns, while important, are limited and carry the odious risk of stigmatising obesity and heightening the adverse mental health component that is enmeshed with it. The promotion of a healthy lifestyle with plenty of exercise and dietary suggestions is a cornerstone but it needs to be simplified and adapted to different age groups. Diets work but many a time the weight loss is not sustained in the long term.

This yo-yoing in weight is a frequent cause of frustration, diminished self-esteem and a sense of failure. Intense follow-up improves results. Taxation on salt, sugar and fats may sound draconian but is probably effective. One-stop shops providing the advice of dieticians, psychologists, physicians and surgeons are the way to go.

Deceptively, obese persons can be seriously malnourished, a case of starvation in the midst of plenty. This field of medicine is never straightforward. Our country badly needs healthcare professionals that are specialised in this field and should not content itself with half-way measures.

Imagine carrying about a whole sack of sugar and more, every minute of one’s life- Jo Etienne Abela

The so-called wonder drugs have taken a firm hold in the public’s imagination and are certainly being prescribed and dispensed with gusto. When prescribed correctly, these drugs are by and large effective and safe to use.

Minimal access procedures to treat obesity are also in fashion. Surgery is done through the keyhole route which is relatively painless and leads to a fast recovery. The operations that are most commonly offered are the sleeve gastrectomy and the mini-bypass. These operations restrict the amount of food and drink that one is able to take in and limit the absorption of nutrients. These operations are effective and typically provide sustained weight loss in the region of 15 to 40 per cent.

Malta has seen a slow but steady growth in this surgical field over the past 12 years. Admittedly, this effort has been much stronger in the private sector as compared with government hospitals.

A considerable number of Maltese and Gozitan patients have their operations abroad, mainly Turkey. This country has shrewdly expanded its medical tourism portfolio, especially in weight loss and cosmetic corrective surgery.

Malta has a proud history of excellent surgical, medical and high dependency skills. Sharpening our focus on weight loss surgery in our country is doable. And it will pay dividends in the long term because this treatment does not only cure excess weight, indeed it cures high blood pressure, heart failure, diabetes, sleep apnoea, arthritis and prevents liver disease and many types of cancer.

The more we do, the better we get at it and the better the pricing we can achieve. With proper follow-up it has the potential to reduce hospital admissions and operations, reduce expenditure on long-term medications and reduce disability across the board.

The question is: should the government do it alone? Should the government compete with the already thriving private sector and set up its own services from scratch?

In 2024, the government took a few tiny steps forward by raising awareness, launching the non-communicable disease strategy for public consultation. It is engaging with its surgeons to operate more and we have allocated more funds for out-of-hours operations at attractive rates. The government is in the process of employing a dedicated weight loss consultant surgeon to provide services in Malta and Gozo.

Should the government consider this as a private sector niche suitable for public-private collaboration, a joint venture leading to centres of excellence outside the state hospitals? Or should it just invest in its own assets? Certainly, there is no low-hanging fruit, but apply passion and experience to the right model and I can see no reason why this should remain beyond us.

The well-being of our society needs a holistic approach with all hands on deck. No more time to lose.

Jo Etienne Abela is Minister of Health and Active Ageing.