The Importance of Treating Obesity First

Back in the mid-1990s, I experienced a clinical epiphany. It wasn’t the discovery of a new veterinary drug or diagnostic test but rather a shift in my clinical perspective when treating patients with obesity. Instead of managing each disease in isolation, I discovered that I could resolve many associated clinical signs and comorbidities by prioritizing the health threats and treating what I identified as the foundational or root cause of the ailments. Simply put, if I treated obesity first, many complications of other chronic diseases would improve or disappear. 

This shift began after I diagnosed a cat with diabetes that also had what we would now define as “clinical obesity.” This is an extremely common scenario I’d been drilled on in vet school: “Fat cats get diabetes.” The standard procedure was to conduct a battery of tests to confirm diabetes and start insulin treatment. Some veterinary nutritionists at the time advocated for starting a high-fiber therapeutic diet in an attempt to “stimulate the pancreas to secrete more insulin.” Occasionally, diet alone would control the symptoms, at least temporarily.

During my first few years of practice, I noticed that cats that lost weight while preserving lean muscle mass not only showed significant improvements in blood sugar and other tests but also maintained improved health for years. That first cat's diabetes resolved, and it enjoyed several years of high-quality life without daily insulin injections. By treating the patient’s obesity first, the diabetes improved or resolved. 

A similar pattern emerged with dogs suffering from arthritis and heart disease, as well as cats with high blood pressure and various other conditions. Reducing excess fat tissue and the associated systemic inflammation and biological dysregulations improved or eliminated many complications. 

This may appear obvious. It is. Yet many veterinarians and physicians hesitate to use an “obesity first” approach to treat their patients despite the medical evidence. A study of nearly 18,000 human patients with heart disease and obesity supports this strategy. Over 40 months, patients received either a GLP-1 or a placebo combined with lifestyle recommendations. At the end of the study period, those receiving semaglutide lost 9% of their body weight compared to 1% in the placebo group. More importantly, the authors of the New England Journal of Medicine (NEJM) paper found those on semaglutide had a 20% reduction in strokes, heart attacks, and deaths. This clearly indicates the effectiveness of improving cardiovascular health by treating obesity first, a simple yet powerful tool in our hands.   

In my experience and from collaborations with human obesity professionals, the primary reason many practitioners don’t prioritize treating obesity first is that it is a relatively new approach. The status quo has been to treat symptoms first, often masking the underlying disease and only addressing other issues if they cause additional problems. Another complicating factor is that treating obesity has historically taken significant time, and failure to adhere to strict diets or exercise regimens can derail even the best intentions and outcomes. Finally, discussing obesity with patients and clients can be challenging due to the stigma and bias associated with the term. 

I’ll go further and speculate that it’s also because physicians and veterinarians often need a quick therapeutic win. Veterinarians are understandably concerned that the owner will seek treatment elsewhere if they recommend weight loss for a limping dog. Once the medical treatment improves the symptoms, obesity can become an afterthought. The problem with this practice is that the more prolonged obesity persists, the greater the risk of complications. This is primarily due to the inflammation caused by the pathophysiology of clinical obesity. In the future, this dog with obesity may develop insulin resistance or diabetes, kidney disease, hypertension, respiratory problems, or other obesity-related disorders. Short-term clinical wins can lead to long-term failures in quality of life and longevity.      

This is not intended to suggest you ignore a patient’s pain or clinical signs while waiting for fat loss. Instead, it emphasizes that we must incorporate treating clinical obesity as a first-line treatment in a comprehensive, multimodal, and multidisciplinary approach to chronic disease management. In other words, if clinical obesity is not addressed, the number and severity of complications will likely increase over time. 

It’s time veterinary healthcare professionals begin treating obesity first. As veterinary obesity science progresses and newer treatments become available, this shift in clinical priorities will become even more critical. Treating obesity first, or at least not abandoning it, is essential to improving our animal patients’ quality of life and longevity. Join me in advocating for “Obesity First” in veterinary medicine.