by Barbara Berkeley, MD
Since the 1980s, we've seen our country transform into a sick, overweight, diabetic nation. This is no fantasy and no overexaggeration. Obesity experts are familiar with an animated map that shows the progression of fat percentage in the United States since 1985. You can see it here. By the way, this particular animation only reflects the changes up to 2008. Things have worsened since then.
As obesity grows, so grows heart attack, stroke, diabetes, cancer and virtually every other modern preventable disease. According to health economist Pierre Cremieux, the cost of obesity now equals 10% of our US deficit--- or 16.7% of ALL US EXPEDITURES. His comment: "I'm surprised that people are not more worried." We have never seen a modern epidemic that has affected health so profoundly and has grown so rapidly.
So what has changed in response to this worsening situation, who is paying attention to what is going on, and how far have we come in our understanding of the problem? I find the answers discouraging.
In the past ten to fifteen years, there has been an escalating interest in obesity on a scientific level and the number of clinicians who treat obesity has grown (athough the majority of them are not in practices that are solely devoted to obesity management).
Obesity focused clinicians now have their own organization (The Obesity Society: TOS) and a solid scientific journal (Obesity). Doctors who practice obesity medicine can also join the American Society for Bariatric Physicians which provides more office-based educational material and holds frequent conferences. Bariatric surgeons have their own professional organizations and have set up standards for surgical programs that allow superior ones to be designated "centers of excellence." Surgical organizations also partner with TOS. There are a growing number of well organized professional meetings and conventions each year.
Research into obesity is booming, with many excellent studies being done in the basic sciences. Clinical research is much more difficult to do because of the many variables that come into play when we look at diets in the real world. But many good studies continue to be attempted.
Most exciting from my perspective is the fact that the medical management of obesity is about to become its own recognized specialty. For the past 20 years, I have been just an internist who happens to treat overweight patients. In November, however, I will take the first formal boards in Obesity Medicine. If I pass, I will become double boarded, just as endocrinologists, gastroenterologists and cardiologists are. This is very important from a clinical perspective, because it acknowledges the fact that obesity specialists must accumulate a large knowledge base in basic science and clinical matters in order to be competent. This changes the paradigm which up until now has suggested that my specialty is no different than Weight Watchers.
All of this is good. But here is the discouraging part.
Despite all this movement, there is little in the way of new thinking about the day to day management of obesity. I just returned from a two day Obesity Summit at the Cleveland Clinic. The amount of detail involving research into brain chemicals, gut chemicals and the endocrine functions of fat cells was impressive indeed. Techniques for bariatric surgery are also getting more advanced and less risky. New techniques that may allow for endoscopic surgery rather than intra-abdominal approaches may be on the horizon. But when the discussion turned to the everyday office management of overweight people, the silence was pretty much deafening.
We do have a single new medicine available. Qsymia is a combination of phentermine, an appetite suppressant that has been around since the 50s, and topiramate, an anti-seizure drug. Used together, but in smaller doses than either would normally require, the combination appears to provoke a weight loss of around 10%. Of course, it remains to be seen how this plays out in the real life world of our clinics. Another medication called Belviq (lorcaserin) may work to promote a somewhat less brisk weight loss.
Aside from these developments, the weight loss conversation remains the same. Motivate patients. Try to get them to exercise more. Get them to self-monitor. All the same stuff you can read in any Women's Day or Family Circle. Worse yet, a break-out session that addressed weight maintenance failed to come up with any useful techniques. As cases were presented, the audience of approximately 200 was asked to provide management suggestions for hypothetical patients who had reached the maintenance phase. Not a one had a new idea to contribute.
Prominent Clinic cardiologist Steven Nissen gave the keynote address at the conference. In it, he noted the reluctance of the FDA to approve weight loss medications and echoed Cremieux's concern that the obesity epidemic was provoking alot less attention and concern than it should.
The profound change in the health of our nation, and the dangerous trend that echoes it worldwide, is going largely undiscussed. There are daily articles decrying the epidemic and calling for change, but they tend to be no more than lip service, petering out in vague recommendations that we all walk more and "make better choices."
I believe that we have reason to be both distressed and discouraged. We don't discuss obesity in any real way because we believe we know what causes it. As long as we cling to what has always been the explanation (ETMETL= eat too much, exercise too little) obesity remains a disease of choice and all we can do is throw up our hands. Basic science is seeking chemical and neurological pathways for interrupting our desire to eat or preventing food from fattening us. Surgical fixes are seeking better ways to interrupt absorption and change gut responses. But what about changing our entire orientation to obesity?
We need to be searching for the factors that have tipped us into a state of such increased susceptibility to weight gain in the last 30 years. If it is the macronutrient composition of our food, we should be looking into ways to make foods less fat promoting. We have fake sugars, but fake fats didn't work out so well. Are there others we could develop? Can we get more creative in this area?
There are suggestions that BPA and other chemicals are linked to obesity in children. Should we be advising patients to avoid plastic containers and cans? This is an easy intervention and can't do any harm. Why not adopt it?
Have we considered that the levels of drugs that are found in public water supplies might be causing changes in our metabolic processes? These drugs are not trivial and many of the most commonly used drugs (like beta blockers and antidepressants) cause weight gain. What about producing water that is filtered in a way to guarantee the elimination of these compounds?
And what about the many drugs Americans are using commonly? Every person in this country should know that a whole host of prescription medicines cause weight gain. Why not counsel doctors to spend more time evaluating drugs for those with a tendency to obesity?
Despite a research boom, despite constant nattering in the press, despite mounting evidence that the costs of obesity will bankrupt us, we are still left with clinical solutions that say that eating less and exercising more are the way to combat this epidemic. Neither of these solutions has worked to date....not even slightly. Let's open our minds to true alternatives so that we can move the obesity debate away from "personal responsibility" and onto a search for the hidden drivers that undoubtedly exist.