Obesity, Liver Disease, and the Patient Voice: A Clinical Dialogue Podcast

Abstract

Obesity is a chronic, progressive disease defined by excess adiposity that can negatively affect a person’s health. Approximately one billion people are living with obesity globally, though this estimate is shaped by the ongoing evolution in how the condition is measured and diagnosed. Although obesity is traditionally diagnosed by body mass index (BMI), it does not adequately assess body fat distribution, particularly visceral fat, which is specifically linked to an increased risk of poor metabolic health and cardiovascular disease. Other anthropometric measures such as waist circumference and waist-to-height ratio assess an indirect measure of visceral adiposity and are better predictors of cardiovascular risk than BMI alone. Obesity can increase the risk of developing type 2 diabetes, lipid dysfunction, and metabolic dysfunction-associated steatotic liver disease (MASLD), a condition in which the liver stores too much fat because the body’s metabolism is not working properly. Around 75% of people with obesity have MASLD, with 12% to 40% progressing to metabolic dysfunction-associated steatohepatitis (MASH; the advanced form of MASLD) within 8–13 years. MASH and MASLD are largely underdiagnosed because someone affected by these conditions does not show symptoms. In this podcast, a patient and doctor specialising in obesity medicine share their perspective on the experience and best practice relating to the diagnosis of obesity, the need for screening of obesity complications, and the importance of the assessment and management of liver health as part of a holistic delivery of obesity care.

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Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-026-03648-7.

Key Summary Points

Obesity is a chronic disease affecting approximately a billion people worldwide.

Obesity is strongly associated with a condition called metabolic dysfunction-associated steatotic liver disease, or MASLD for short.

In this podcast, a patient living with obesity and doctor specialising in obesity medicine share their perspective on the diagnosis of obesity, the importance of screening for obesity-related complications, and the role of liver health assessment and management within a holistic approach to obesity care.

Podcast Content

The podcast video can be downloaded from the article’s Figshare page here: 10.6084/m9.figshare.32300847. Alternatively, you can stream the podcast by searching for ‘Adis Journal Podcasts’ on your preferred podcast platform.

Transcript

Megha Poddar [00:06]

Hello, my name is doctor Megha Poddar, and I’m the Medical Director of the Medical Weight Management Centre of Canada.

I’m an endocrinologist and obesity medicine specialist, and I am so pleased and excited to be joined today by Joe Nadglowski to discuss the patient journey of someone living with obesity, highlighting the barriers of diagnosis, discussing typical comorbidities experienced by people with obesity, with a focus on the importance of liver health in the management of obesity. Joe, please tell us a little bit about yourself.

Joe Nadglowski [00:36]

Hello, I’m Joe Nadglowski, president and CEO of Obesity Action Coalition. I have a lifelong experience with obesity and lots of experience working in patient advocacy, public policy, and education. Thanks for including me today.

Megha Poddar [00:48]

Of course, thank you so much for talking with me. We all know obesity is a chronic disease [1, 2]. Around a billion people worldwide live with obesity, which, in part was due to this definition we have around body mass index, or BMI, of more than 30 but we now know that obesity is really characterized by excess fat that can lead to many other serious health conditions [3, 4].

Joe, I would love for you to take us back to when you were first diagnosed; what was that experience like, and who brought [it] up to you?

Joe Nadglowski [01:20]

The very first time a physician spoke to me about my weight was when I was 20 years old, so now nearly 35 years ago. During the visit, my doctor wagged his finger at me and told me that I needed to lose 25 lbs. As you can imagine, it was not a pleasant experience, not really a conversation. I understood that I struggled with my weight—most of us with obesity do—but telling me to lose weight without offering any guidance didn’t feel like the best way to handle it.

I’ll fast forward to almost 15 years later. I’m now in my role at the Obesity Action Coalition, where I had a visit with a very caring primary care physician for my annual checkup. She did a quick exam, wrote me my blood pressure and knee osteoarthritis medicine and said, “Joe, all looks good, we’ll see you next year.” But as she was walking out the door, I said, “can we talk about my weight?” And she says, “oh, Joe, don’t worry about it. You’re within normal range.” And I said, “I don’t think that was the case. I think you wrote me some medicines that we might be able to adjust if I wasn’t overweight.” She then sat down and had a caring and empathetic conversation with me. And that’s the first time that I really felt like a doctor truly cared about my concerns with obesity. She went on to share her own lived experience. I had no idea that she had also struggled with obesity, so her story was very relatable. Even though I had read about obesity extensively, that conversation really provided me an “aha” moment about my condition being a complex disease. Her story resonated with my own, and I felt that I could allow myself a little bit of compassion. It was a turning point and it really got me focused on how we could address the health issues that I had that were related to obesity. Importantly, I realized that obesity wasn’t just about a magic number on the scale. In fact, her first reaction to me, “don’t worry about it, Joe, you’re normal” took away the judgement that this was about my body size and actually got me to the point when we could actually talk about the health side of it, to help me better understand that this can impact my risk of getting type 2 diabetes, cardiovascular disease, and other metabolic conditions. Being treated with a little compassion, empathy, and understanding really made a huge difference in my life and it started me on the journey to where I am today to make me as healthy as possible.

Megha Poddar [03:39]

Wow, that’s amazing Joe, thanks for sharing that. I think the reality behind your story is that it probably does reflect so many other people’s stories and journeys.

It just highlights how different someone’s experience is depending on which doctor that they see, but it is also pretty clear that you had to advocate for yourself. The problem is really one of delayed treatment; people living with obesity have had obesity for at least 6 years before they even discuss their problem with their doctors [5].

So, what do you think prevents people from coming to their doctor about their weight; is there something that [you] feel that your doctor could have done from day 1 that might have changed your outcome?

Joe Nadglowski [04:19]

I really think what prevents someone from going to their doctor about their weight is the societal attitude around obesity; that this is something I should be able to control on my own. Add to that, from my experience during my very first visit where my doctor just told me to lose weight, I actually believed that this was my fault and I should be able to address this on my own.

I think the best way doctors or nurses could handle this would be to be compassionate, to be empathetic, and to ask for permission. I really wish someone would have said to me, “hey Joe, is it ok if we talk about how your weight is impacting your health?” Almost all of us struggle and we want help, we just don’t know how to ask for it.

On the other hand, if the clinician offers to have a conversation and the patient says no, or if they’re not ready to discuss it, that’s ok as well; you simply respect those wishes. When they’re ready to have the conversation, have an empathetic, compassionate one that’s based on the science of obesity and not about self-judgement.

Megha Poddar [05:17]

I love that, especially that part about bias and stigma because, as a doctor, I think it’s the biggest differentiator to the experience of the patient. People are almost expecting me to tell them that you just need to diet and exercise or that you’re not trying hard enough. I generally don’t take that approach; the minute I open the conversation up by an invitation, as you mentioned, there is a total shift [in] my patients’ demeanour, they’re just more relaxed. For example, saying to a patient “your blood pressure is high and this could related to weight. Is weight something that you want support with?” that conversation is dramatically different. As a doctor, it actually makes my job easier when I open the conversation that way, by reducing stigma right at the beginning. We all have our own bias and our own lived experience.

Not all of us agree or understand that obesity is a chronic disease and how we need to approach obesity in that way. From a physician’s perspective, I would recommend that this is actually the most critical first step. We have to fundamentally understand why obesity is a chronic disease and learn the science behind it. When we understand this concept, then we can appropriately address bias and the stigma, we can learn what real treatment is and help patients to undertake a successful journey to better health.

Joe Nadglowski [06:39]

One of the things that really helped me was my doctor’s recognition that obesity is a disease; that it wasn’t my fault, and it made me realise why many interventions I had tried in the past weren’t effective for me.

So I’m curious; from your perspective, when do you raise the “disease” word with your patients?

Megha Poddar [06:56]

I approach this in many different ways; I describe what is happening and I ask permission from my patients. If they grant it, then my next step is to really learn about their story, because I want to describe the disease of obesity and how it works, by relating back to their own lived experience; that way they can understand what’s happened in the past, why it happened, and then they really understand what they can do about it. So I ask them about their journey with weight, how long have they had difficulty losing weight and keeping it off. The average patient tends to describe multiple attempts at reducing calories, increasing exercise and seeking support, losing weight and regaining it. Then the critical piece is summarising it back to them, this way they know that I’ve actually heard them. Then I’m able to explain that our body defends against weight loss by increasing our appetite and decreasing our metabolic rate; this is why obesity [is] a chronic disease and why we weight cycle despite diet and exercise. This approach has had a huge impact on their ability to just be kinder to themselves and honestly it allows them to more likely accept treatment. So that’s my approach; it’s really personalising the chronic disease piece of it.

Joe Nadglowski [08:17]

One of the things that I realised early on in my journey was that I used to think primarily about weight loss, but now that’s changed to think more about my general health, such as not being in pain, being functional, being able to move, not having other chronic diseases. How do you talk to your patients when it comes to consider things other than the reading on the scale?

Megha Poddar [08:36]

I think this conversation needs to happen very early on, right at diagnosis. Many people are being diagnosed with obesity based off their weight and height calculation, known as the BMI. However, because of how it’s calculated, the BMI focuses overall on someone’s weight, but it fails to provide an understanding of these two key things: first is what proportion of fat that makes up someone’s overall weight is actual fat as opposed to muscle or bone; and secondly, where that fat is located within the body. As physicians, we need to be more concerned about the fat that’s around our abdominal organs, known as visceral adiposity, rather than the fat underneath the skin. When I’m diagnosing obesity, I talk about BMI to provide a frame of reference to help understand the disease overall, but I’m also doing other key things. I’m also assessing waist-to-height ratio or waist circumference; this gives me an indirect measure of that visceral adipose tissue. This is my stepping stone to then being able to have a conversation with patients about their elevated risk of metabolic diseases like type 2 diabetes, heart disease, and high blood pressure. Then the last part of my assessment is what we call the Edmonton Obesity Staging System: this is a score that determines how much of someone’s weight is affecting their mental health, mobility, and metabolic health [6]. From an assessment perspective, if you take these three parameters—the BMI, the waist-to-height ratio, and the Edmonton Obesity Staging System—you get a very holistic view of how obesity is affecting this patient and then you can really understand how best to treat it. Some of my patients at follow-ups, they’re so excited to tell me how much weight they’ve lost since their last visit, but I’m always looking at the other parameters, what’s their waist circumference, their metabolic health, mechanical health, or mobility, have those things improved? I frame it back to the patient so that they can understand how I’m defining successful treatment. A big challenge that we know we have in obesity is that often the physicians’ definition of what successful treatment is, is actually really different to what the patient thinks. So in every single visit, I try and relate treatment back to those health parameters of success that the patient originally described, and I’m truly focused on patient-centred outcomes, and what matters to them the most. There’s been so many times where I’ve seen patients lose weight, but their disease state is not getting better, their mobility is not getting better. That’s not successful treatment; that’s just losing weight. On the other hand, I’ve seen lots of patients who haven’t lost that much weight, but their metabolic parameters actually improve significantly; they’re sleeping better and their mood is better. That’s real effective treatment. We really need to be able to define successful treatment at the beginning and help patients and doctors come together so that they’re on the same page

Joe Nadglowski [11:38]

In the patient community, a lot of what you described are called “non-scale victories”. They’re oftentimes just as, or even more, important. I will tell you that from my own experience, I finally realised that my obesity treatment was successful when I noticed that I was able to walk long distances without pain. As someone who’s suffered from knee osteoarthritis and had functional issues around it, it was the moment that I finally felt that we were moving forward.

Dr Poddar, one of the things that has always stood out to me from early on in my diagnosis was that my clinician would often trivialize my liver testing by telling me that my liver enzymes were elevated, but then they would say there was nothing they could do about it and they would assess it again next year. So can you help me understand the impact of obesity on the liver?

Megha Poddar [12:21]

Obesity is strongly associated with this condition that we call metabolic dysfunction-associated steatotic liver disease, or MASLD for short. About three-quarters of people with obesity have MASLD [7], so it’s super strongly related, but actually very underdiagnosed. Some of the reason for this is because this condition doesn’t necessarily show many symptoms. So even in your own experience, you mentioned you didn’t even know you had a liver issue until the blood work was done, and the blood work is actually not a good measure for liver health.

MASLD is a manifestation of what we call metabolic syndrome [8]. This occurs when you get excess fat stored in the liver, which causes another condition called insulin resistance, where the body starts to become less sensitive to this natural hormone called insulin [9]. So insulin, it’s released from our pancreas [and] it helps our body use a type of sugar called glucose as a form of energy. Insulin also causes storage of fat in the liver [10]. When the body starts to become more resistant to insulin, it needs more insulin to be able to use that glucose for energy. The more insulin the body makes, the more resistant the body becomes to it, and the more fat ends up getting stored in the liver. Around 12% to 40% of people with MASLD end up getting a more severe form of MASLD called metabolic dysfunction-associated steatohepatitis, or MASH, within 8 to 13 years [11]. MASH is characterized by inflammation in the liver due to these excess fat deposit, because of insulin resistance. Obesity is the biggest risk factor for insulin resistance; many patients that have inflammation in their liver are not being adequately followed up when their liver enzyme levels are found to be high, just like you mentioned. If we leave MASH untreated, that inflammation in the liver can end up leading to more severe issues like liver scarring and even liver cancers. There is a need to improve diagnosis of MASLD and MASH, as well as regular monitoring of people’s liver health. This is really important given the fact that people don’t really have symptoms, especially at those early stages of MASLD. So it’s even more important that anytime we’re thinking about the obesity assessment, we’re also thinking about the liver; it needs to be proactive.

Obesity treatments, especially pharmacotherapy and bariatric surgery, fortunately have actually been shown to improve MASH and inflammation in the liver [12–14] because we’re treating that obesity, and because obesity and excess fat are the underlying causes of so many of these issues.

Joe Nadglowski [15:10]

So going back to my experience with my clinician many years ago not knowing what to do with my elevated liver enzymes, what would better care look like today for liver health?

Megha Poddar [15:20]

As a doctor, we all work in this paradigm where we have guidelines and we have algorithms. Fortunately we have very clear screening algorithm pathways for MASLD and MASH [15–18]. There’s an index called the Fibrosis-4 index, or Fib-4: it’s a really easy blood test, it uses age, platelet count, and liver enzyme levels, like the ALT and AST. It’s a super easy screening test for all patients living with obesity for fibrosis—we recommend using a Fib-4 test [19].

Now if your Fib-4 is elevated, we would refer you to a diagnostic screening, or a high-risk screening centre, or proceed with a test called a FibroScan, it’s a non-surgical procedure that allows us to look at how much fat is actually in the liver, and also how stiff the liver has become. The liver stiffness, or liver elasticity, this helps us to assess the amount of scarring that’s actually in the liver [15–18]. Overall, these tests allow us to determine how severe or advanced a patient’s liver disease is. If a patient has a high risk of liver scarring, then that’s when we start to think about specialists like hepatology being involved. It is true that while the availability of more advanced liver tests can vary from clinic to clinic, all of us have the ability to do a Fib-4 because it’s just a simple blood test. So the key learning here is that Fib-4 screening is the first step to opening the conversation about understanding someone’s liver health.

On that note, Joe, how surprised were you that obesity could affect the liver?

Joe Nadglowski [17:03]

My doctors were just ignoring my liver enzyme levels, it made me feel like I didn’t understand what it meant. If my doctors were ignoring it, it probably wasn’t that important. I probably had the same reaction as many other patients tend to have; my only understanding of the liver is its role with alcohol. I was a very light drinker at that time, so it didn’t make sense to me, and I didn’t know how to interpret it at all.

Maybe you can help me better understand that now. What is the function of the liver, and why does it matter so much?

Megha Poddar [17:30]

We think of the liver as this organ system responsible for recycling in our body. It helps metabolise glucose, it’s responsible for helping us absorb what we need while similarly removing any toxic substances [20]. So you can imagine if this machinery is not working as it should, then you start getting toxicity build-up in the body. If you have liver disease, the problem is it can affect other organs in the body. A lot of the time when we’re doing an assessment for obesity, we find lots of different problems, elevated blood sugar, elevated cholesterol, pre-diabetes, MASH or MASLD and it leaves people quite shocked. They don’t feel that living with obesity is associated with all these different organs, and the liver is the biggest one because there’s very little symptoms until the most severe forms of MASLD. So I really try to holistically show my patients that these are not all separate problems.

The root cause of all these things is often obesity and insulin resistance. Insulin resistance leads to elevated blood sugar, cholesterol, and inflammation in the liver. We need to help support and treat that underlying cause so that all these things get better, but equally, we also need to proactively do the monitoring and measurements, especially in the liver health. This is critical because we commonly associate obesity with diabetes and heart disease, cholesterol, but we actually forget the liver most of the time, and obesity is one of the strongest risk factors for MASLD and MASH.

So as an endocrinologist, we’re constantly advocating for this idea that we need to look at the liver more often. There’s not enough hepatologists available, nor does everyone with MASLD or MASH need to see a hepatologist. But in primary care, in endocrinology, internal medicine, we all need to be aware that the liver is part of the metabolic syndrome, and we need to start putting the liver into our algorithms, our clinical pathways, and our practice guidelines.

Joe Nadglowski [19:34]

What does that individualised treatment look like for people who have obesity complications? And what advice would you give to our listeners today?

Megha Poddar [19:41]

Where you get your treatment, it ends up having a big impact on the outcome that you get. Because if we’re just looking at obesity as a weight problem, then the goal of obesity treatment is just going to be weight loss—we end up missing all the negative health outcomes and potential health benefits that we could actually be targeting. We also now have more treatment options than we ever had before. So how are we going to decide which medication is best suited for which patient? This is where we need to start having a really good understanding of comorbidities related to weight; how much of this weight is impacting which organ system, because certain medications treat certain organ-related dysfunction better than other medications. I am not trying to suggest that every patient living with obesity needs to lose 15% of their body weight to improve their liver. I’m actually suggesting that there are certain obesity medications that better target the liver: they’re going to have a better outcome, regardless of the amount of weight they lose. When you go to somebody who doesn’t necessarily understand this pathophysiology or you’re getting medications online, they’re probably just picking the medication that provides the most weight loss. That’s one of our biggest challenges: that people are not being diagnosed properly, especially those with liver disease, and their disease isn’t being monitored or treated properly. You can imagine the amount of people with liver scarring and liver cancer that have been diagnosed far later than they ever should have, because their liver health was never assessed or monitored in the first place.

To arc back to the start of our conversation, I think it would be really short-sighted of us to think of obesity as a simple BMI calculation. We have to do a full assessment, understand all the organ systems involved and treat those organ systems with the right obesity medication.

Joe Nadglowski [21:37]

The key message I hear from this is that obesity treatment goes well beyond weight loss.

What advice would you give to clinicians looking to better support their patients?

Megha Poddar [21:46]

I would say that understanding the national guidelines is important to make sure you’re doing a full assessment, and then learn about the things that you can bring into your own clinic environment that are going to be helpful for patients. For example, can you do a Fib-4 test, or what about the further diagnostic testing and imaging? Who else around you is there to support you in that? Do you have a dietitian, psychologist, or exercise physiologist? If you don’t, where are you going to refer your patient to? We started this conversation actually talking about bias and stigma. The worst thing that I could do for my patient is refer them to a colleague who is then going to reinforce that negative bias and stigma after I spent the first visit trying to address internalised weight bias. If I can’t help my patient in my own clinic, I need to make sure that the doctor I am referring the patient to is also aligned with the concept of obesity as a chronic disease and has the same ideals that I do.

I would say for all doctors, knowing what needs to be done to properly assess and monitor your patients, and then figuring out how much of this can I do myself versus how much of this needs to be referred out and where are they going to go. You’ll find very quickly that you need to refer patients much less because you get more confident managing the comorbidities on your own. But if we don’t talk about it at the beginning, we’ll never find out.

So today, I would just leave everyone with this message that holistic obesity assessment includes a full understanding of comorbidities related to excess weight. It’s an integral part of the diagnosis, treatment and management.

Thank you so much for joining me today Joe, and thank you for sharing your personal story with us.

Author Contributions

The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE) as supported by Good Publication Practice (GPP) guidelines. Megha Poddar and Joe Nadglowski drafted, reviewed and approved the podcast transcript. The authors did not receive payment related to the development of this podcast.

Funding

The podcast was supported and funded by Boehringer Ingelheim. The journal’s Rapid Service Fee and Open Access Fee were funded by Boehringer Ingelheim.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Conflict of Interest

Megha Poddar reports receiving royalties or licences from the Medical Weight Management Centre of Canada; consulting fees and honoraria for education in obesity and diabetes management from Bausch Health, Novo Nordisk, Eli Lilly, EOCI Pharmacomm, CCRN, Janssen, Merck, Antibody Solutions, CPD Network Association, Johnson & Johnson, Boehringer Ingelheim, Rhythm Pharmaceuticals, and the College of Physicians and Surgeons of Ontario; and travel support from Bausch Health, Novo Nordisk, and Eli Lilly. Dr. Poddar has participated on the data safety monitoring board for the OK-TRANSPLANT-2 clinical trial and serves as a chief medical officer for Nymble Health and medical adviser for Shoppers Drug Mart. Joe Nadglowski is an employee of the Obesity Action Coalition.

Ethical Approval

This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.