Weight and Inflammation Part 1

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In discussions around weight and health, the concept of “inflammation” almost always arises. This is a complex discussion and so I am thrilled and honored to share a four-part series in which Zed Zha, MD, FAAFP (Fellow of the American Academy of Family Physicians) and I explore assumptions around weight, weight loss, and inflammation.

Part 1: Patient Story

Part 2: Operational definitions and quantification methods for weight loss and inflammation

Part 3: A deep dive into assumptions and realities about weight loss and inflammation

Part 4: The possible impact of weight cycling and weight stigma on inflammation

In this first installment, Dr. Zha shares a common patient story to illustrate the importance of moving beyond assumptions around weight and health when it comes to inflammatory conditions.

Content note: These pieces are extensively referenced, please be aware that the references cited contain weight stigma

Here now, Part 1 - Patient Story - as told by Dr. Zha

“Can I see your sores?” I asked.

Ruth raised her aims slowly to take off her shirt, wincing in pain. When she pointed to a huge, red, “weepy” lesion under her right arm, I couldn’t help but said: “Oh, my goodness Ruth. This looks incredibly painful!”

Tears ran down her cheeks.

“I know it’s cuz I’m fat, but…” Ruth kept her head down.

“But it’s not,” I try not to interrupt patients when they talk, but I sensed that Ruth didn’t know how to finish her sentence. “What you have is called hidradenitis suppurativa – HS—and it happens to people of all sizes.”

At age 34, Ruth has suffered from hidradenitis suppurativa (HS), a painful, inflammatory condition that causes boils in private areas of the body, for over 20 years without receiving a diagnosis. A significant delay in diagnosis is typical for patients living with HS, especially for people of color.¹ And in my extensive experience working with Latinx patients like Ruth, the delay can easily be decades. In these decades, almost everyone has been told, repeatedly², to “just go lose weight” and their skin problems would go away.

The crazy part is that almost every patient I’ve met had been “prescribed” weight loss for years before they got the right diagnosis. Some received no diagnosis at all! In fact, if they knew this was HS, then they would know that living in a larger body is only an association with HS,³ not the cause.⁴ Not only do we not have consistent evidence to support weight loss as a treatment,⁵ some studies show that drastic weight loss can lead to worsening of HS.⁶ How could the doctors know what the (wrong) treatment was without knowing what they were treating?

Answer: fatness is the “end all, be all” player of the popular game called “patient blaming.” When I asked people in the #AskThePatient community if they’ve been told to “just go lose weight” by their doctors, over 600 people voted, and an overwhelming 90% said they had.

Needless to say, Ruth has tried to lose weight for many years. “How can I exercise when raising my arms or moving my thighs give me excruciating pain?” she rightfully retorted. After I told Ruth that her weight did not cause her to have HS, I supported her right to doubt the uninformed clinicians by adding a question of my own: “Plus, how can you lose weight when your body has so much inflammation in it?”

In recently years, a large body of studies have emerged that confirm what patients already know: chronic inflammation and higher body weight are intimately connected.^7,8 And it is entirely plausible that inflammation is the chicken and “ob*sity” is the egg.⁹

Interestingly, inflammation is an immunological phenomenon. And adipose tissue as an organ has active immunological functions, as such acting like a reservoir for the immune system in fighting infections.¹⁰ In fact, the immunological function of fat in the body has been identified since 1874.¹¹ In the case of pneumonia, for instance, “ob*sity” is associated with lower all-cause mortality in the long term.¹² Yet research that show the link between fatness and its immunological function still questions the real protective effects and refers to this phenomenon as the “ob*sity paradox.”¹² After a deep dive into the medical literature regarding fatness and inflammation, the only things I find “paradoxical” are 1) the universally lopsided conclusion of “obesity leads to inflammation” despite unclear causality, and 2) the serious downplay of fatness as a plausible state of health.

These days, Ruth and I are actively dismantling weight stigma in our HS support group. As a physician, a scientist, and a patient advocate, I owe it to my patients to challenge and reshape the harmful narratives surrounding fatness and inflammation and perhaps, in doing so, we can begin to undo the damage that weight stigma has inflicted on people like Ruth.

In part 2 we’ll begin to unravel the assumptions and relationships between weight, weight loss, and inflammation.

(Scroll down for reference list)

Check out Dr. Zha’s substack

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.

References:

1. Serrano L, Ulschmid C, Szabo A, Roth G, Sokumbi O. Racial disparities of delay in diagnosis and dermatologic care for hidradenitis suppurativa. J Natl Med Assoc. Dec 2022;114(6):613-616. doi:10.1016/j.jnma.2022.08.002

2. Garg A, Neuren E, Cha D, et al. Evaluating patients' unmet needs in hidradenitis suppurativa: Results from the Global Survey Of Impact and Healthcare Needs (VOICE) Project. J Am Acad Dermatol. Feb 2020;82(2):366-376. doi:10.1016/j.jaad.2019.06.1301

3. Goldburg SR, Strober BE, Payette MJ. Hidradenitis suppurativa: Epidemiology, clinical presentation, and pathogenesis. J Am Acad Dermatol. May 2020;82(5):1045-1058. doi:10.1016/j.jaad.2019.08.090

4. Foundation H. 6 Myths about Hidradenitis Suppurativa (HS). Accessed February 20, 2023. https://www.hs-foundation.org/fact-or-fiction

5. Choi F, Lehmer L, Ekelem C, Mesinkovska NA. Dietary and metabolic factors in the pathogenesis of hidradenitis suppurativa: a systematic review. Int J Dermatol. Feb 2020;59(2):143-153. doi:10.1111/ijd.14691

6. Golbari NM, Lee Porter M, Kimball AB. Response to: Remission of hidradenitis suppurativa after bariatric surgery. JAAD Case Rep. Apr 2018;4(3):278-279. doi:10.1016/j.jdcr.2017.11.024

7. Maqdasy S, Lecoutre S, Renzi G, et al. Impaired phosphocreatine metabolism in white adipocytes promotes inflammation. Nature Metabolism. 2022/02/01 2022;4(2):190-202. doi:10.1038/s42255-022-00525-9

8. Matarese G. The link between obesity and autoimmunity. Science. 2023/03/31 2023;379(6639):1298-1300. doi:10.1126/science.ade0113

9. Aroor AR, DeMarco VG. Oxidative stress and obesity: the chicken or the egg? Diabetes. Jul 2014;63(7):2216-8. doi:10.2337/db14-0424

10. Trim WV, Lynch L. Immune and non-immune functions of adipose tissue leukocytes. Nature Reviews Immunology. 2022/06/01 2022;22(6):371-386. doi:10.1038/s41577-021-00635-7

11. Ranvier L. Du development et de l'accroisement des vaisseux sanguins. Arch de Physiol. 1874;1:429-450.

12. Braun N, Gomes F, Schütz P. "The obesity paradox" in disease--is the protective effect of obesity true? Swiss Med Wkly. 2015;145:w14265. doi:10.4414/smw.2015.14265