Obesity is a disease! It’s time to treat it like one.

For decades, obesity has been viewed as a personal failure, an oversimplified equation of willpower, diet, and exercise. The prevailing assumption is that individuals with obesity must overeat, move too little, or lack discipline. This narrative is deeply ingrained in our culture, media portrayals, and unfortunately within the healthcare system itself. This perception is not only incomplete, it is counter to scientific evidence and clinically harmful to patients.

More than ten years ago, the American Medical Association (AMA) formally recognized obesity as a disease state. Obesity is not simply a result of taking in excess calories and failing to burn it off with exercise. It involves dysregulation of metabolic pathways, hormonal signaling, genetic predisposition, environmental influences, socioeconomic factors, and countless other variables. One cannot expect to master advanced calculus with only a basic understanding of addition and subtraction.

Despite this formal recognition by the AMA, the disease model of obesity has not been integrated into everyday medical practice. Unfortunately, many patients seeking help for their obesity are met with “eat less and exercise more” by their clinician. While nutrition and physical activity are undeniably important components of health, reducing obesity management to these two variables alone overlooks the underlying pathophysiology. The human body is extraordinary in its ability to maintain homeostasis. Maintaining a body temperature of 98.6F regardless of the environment is a prime example. The reality is that the body actively resists sustained weight loss through hormonal and metabolic adaptations designed to preserve energy stores. These mechanisms evolved for survival in times of scarcity, but work against patients who are trying to lose weight.

During starvation, there is downregulation of insulin and other hormones as the body transitions away from carbohydrates as an energy source. The body slows down many metabolic functions to try and preserve energy. A 100 calorie snack is handled very differently by the body in these conditions compared to normal conditions. This is why most diets and attempts to lose weight often result in weight loss stalls. The body accommodates and the scale doesn’t change despite taking in very few calories. Even worse, muscle mass and “healthy weight” is often what is lost during dieting. Eating less is not always the answer. Not every calorie is treated equally. Exercise during catabolic states without appropriate nutritional intake can actually be harmful. When patients get frustrated by the lack of progress and go back to eating normally, there is typically a rapid regain of weight since the body is still in survival mode. The yo-yo effect is real.

Even within healthcare, gaps in education and training contribute to the disconnect between scientific evidence and medical recommendations. Healthcare providers who have not had focused exposure to obesity medicine may unintentionally perpetuate outdated models of treatment. Advice that is well-intentioned may lack alignment with contemporary evidence-based strategies. Modern management of obesity should include availability of behavioral therapy, dietary education and guidance, pharmacologic interventions targeting appetite and metabolic pathways, and surgery. These treatment modalities are not shortcuts or cosmetic measures. They are all legitimate medical therapies offered by trained professionals and supported by robust clinical data. Offering medication without dietary guidance often leads to unintended side effects and potentially patient harm. Surgical intervention outside of a dedicated multidisciplinary program has higher failure rates and more complications, which in turn propagates the narrative that surgery “is dangerous” or “doesn’t work”.

The persistence of stigma has consequences far beyond hurt feelings or social discomfort. It negatively impacts access to care, insurance coverage, legislative decisions, and patient willingness to seek treatment. The evolution of our understanding of obesity can be compared to shifts in how society came to view depression, PTSD, addiction, and cardiovascular disease. When obesity is viewed as anything other than a medical disease, individuals delay medical attention, internalize blame, and devalue the importance of follow up. A lack of understanding negatively impacts policy decisions and resource allocation, which further limits development of comprehensive care models.

Reframing obesity as a disease does not negate the importance of lifestyle choices. Rather, it places those choices within an accurate biological and clinical context. It acknowledges that sustainable change often requires structured support and evidence-based medical guidance. It shifts the responsibility toward a partnership between patient and healthcare provider. If we as healthcare providers expect the patient to do their part, it is on us to deliver informed, compassionate, and evidence-based care.

The truth about hiatal hernias

So, Your Doctor Says You Have a Hiatal Hernia—Is That Bad?

Let’s break it down.

First Things First: It’s Common

Hiatal hernias are actually pretty common. There are different types, each with varying symptoms, risks, and treatment approaches. In this post, I’ll cover the basics and offer a clear overview—no complicated jargon (for the most part). We’ll save the deep dive for your appointment!

What Is a Hiatal Hernia?

Your diaphragm, a large muscle that helps you breathe, separates your chest (thoracic cavity) from your belly (abdominal cavity). Above the diaphragm: your heart, lungs, and esophagus. Below it: your stomach, liver, intestines, etc.

There’s a natural opening in the diaphragm—called the hiatus—that allows your esophagus to pass through and connect to your stomach. A hiatal hernia happens when part of the stomach pushes up through this opening into the chest.

Why the Hiatus Matters

The area where the esophagus transitions to the stomach is called the gastroesophageal junction—and it’s where your body’s natural reflux "valve" lives. This valve relaxes to let food into the stomach, then contracts to keep stomach contents from coming back up.

But when pressure increases in your abdomen—like from coughing, sneezing, lifting, weight gain, or pregnancy—it can push the stomach upward through the hiatus. That disrupts the valve and often leads to acid reflux or GERD (gastroesophageal reflux disease).

Types of Hiatal Hernia

There are four types of hiatal hernia:

• Type 1: Sliding Hernia
  The most common kind. The gastroesophageal junction moves (or “slides”) above the diaphragm. These typically cause reflux and are managed with medication. Surgery is only needed if symptoms persist despite treatment.

• Type 2: Paraesophageal Hernia
  The junction stays in place, but part of the stomach pushes through the hiatus. Much less common and more likely to cause swallowing issues than reflux.  These should be repaired surgically.

• Type 3: Mixed Hernia
  A combination of types 1 and 2—the junction and part of the stomach move above the diaphragm. These vary in size and severity, but often require surgical repair.

• Type 4: Complex Hernia
  The stomach plus another organ (like the colon or spleen) move into the chest. These also typically require surgical repair.

Why Fix a Hernia?

You might wonder, “What happens if I don’t fix it?” Let’s break this down into two main types of problems that can develop.

1. Reflux-Related Problems

Acid reflux might seem like a nuisance, but it’s more serious than you think. Chronic exposure to stomach acid can cause:

• Inflammation

• Ulcers or bleeding

• Barrett’s esophagus (a risk factor for developing cancer)

• Esophageal cancer

Concerned about long-term medication use? It's a common question. Yes, acid-reducing meds have side effects. But overall, they’re safer than surgery and much safer than letting reflux go unchecked.

2. Mechanical Problems from the Hernia Itself

When the stomach lives in the chest, it crowds out space meant for your heart and lungs. This can lead to:

• Trouble swallowing

• Chest pain or shortness of breath

• Aspiration (food/liquid going into the lungs)

• Pneumonia or chronic lung disease

• Gastric volvulus – a dangerous twisting of the stomach, which can cut off its blood supply and become life-threatening without emergency surgery

Bottom Line

Hiatal hernias are common—and not always a cause for alarm. Here’s what to ask your doctor:

• What type of hernia do I have?

• Are my symptoms under control?

• Do I need a surgical opinion?

If you have a small sliding hernia with manageable symptoms, you probably don’t need surgery. But if it’s larger or your symptoms are worsening, it’s worth seeing a specialist—even if you’ve been told your hernia is “too big to fix” or has come back after prior surgery.

When in doubt, ask and find out.