The Treatment of Obesity: Overview

Obesity is the most pressing public health problem of the moment. The average weight of Americans, adults and children, has skyrocketed over the past few decades. The medical complications secondary to obesity have risen precipitously as well. With infectious disease and food-borne contamination largely in the past, the medical establishment has hoped that longstanding health followed age-related illness would predominate routine care. Instead, diabetes, high cholesterol and hypertension are the bread and butter of the primary doctor bent on helping an obese population survive. Meanwhile, the current efforts of government and industry, the parties primarily accountable for this crisis, may reluctantly raise awareness but accomplish little else to find a solution.
The reasons for the obesity epidemic are clear although their relative importance is hotly debated. The transformation of the food industry and available choices in the local market has changed the way we eat. Fast food, sugary drinks and junk food comprise a significant percentage of our diets and explain why literally twice as many calories are produced in our country than what we need to survive. On top of that, the average American leads a much more sedentary life than a few decades ago. And our attitude towards food and weight has changed drastically. The most salient theory of the cause of the obesity crisis combines all three social forces--food options, sedentary lifestyle and preoccupation with food and weight. However, without a fully accepted theory, industry can blame lack of exercise, food pundits can blame industry and government can avoid needed regulations. The overall effect is to dilute the message and splinter the drive for a solution.
The government has finally signed on at least to acknowledge this issue. Despite the lobbying power of the food industry, Michelle Obama has devoted much of her energy to food choice and exercise, especially in children. There is no doubt that placing her powerful spotlight on an issue the corporate food world can easily evade was necessary to have any impact. In addition, government-sponsored nutrition education has taken a big step forward. The new food plate replaced the confusing food pyramid to make much clearer the basics of meals and nutrition. None of this changes the reality that fast food and junk food remain a much tastier and affordable way to feed yourself and your family. Although new initiatives can spearhead debate and, subsequently, awareness, more regulation of the food industry along with incentives to provide healthful food at reasonable costs will be necessary to stem the tide of obesity.
Faced with the deterioration of the health of the population, the medical profession has to tackle the myriad consequences of an obese population and, more to the point, try to devise strategies to fix the problem. Preventive medicine has a history of success with vaccines and vitamin fortification, but those were public health initiatives to combat preventable diseases, the wheelhouse of medical success. The conflicting forces at play in the rise of obesity, both within and outside health care, largely overshadow the good will of the medical community. While many physicians toil away to ensure the health of obese patients, our profit-driven cohorts endorse new, exploitative measures that purport to offer a quick fix for an intractable problem, such as medical weight loss programs and surgical intervention. But these band aids only mask the problem.
As of now, no doctor or specialty has the answer. Primary care doctors, with almost no formal training in weight management or nutrition, advise patients with their own personal and often distorted views of food and weight. Nutritionists recommend modified versions of weight loss diets with short-term benefit but almost guaranteed long-term failure. Studies show that about 95% of people who lose weight dieting gain it back and more within 6-12 months. After years of futility, patients seek a consultation from a Bariatric surgeon. The FDA recently lowered the BMI needed to consider this option, and many more people, some not even considered obese, are now eligible. While surgery has faster and longer-lasting effectiveness, it's already clear this is no panacea. Complications, subsequent health risks and unclear long-term safety and effectiveness are apt to plague the post-surgical population. Plus, how can we as a society abide lives of overeating followed by surgical remediation? This is no real solution.
As in past decades, frustration within the medical community at large leads to the general consensus that the underlying pathology is psychological. Increasingly, the road to obesity treatment goes through the mental health community and, more specifically, eating disorder specialists. Clinicians who treat eating disorders have two things going for them: a non-judgmental stance on food and weight and a willingness to tackle a challenging public health concern. Initial attempts at treatment combine behavior changes around food with a mandate to not let the weight impede on daily living. Losing weight becomes an obstacle to overcome through gradual lifestyle change rather than an actual disease. The crux of the therapy is a collaboration to change one's relationship with food, an approach fundamentally no different from treating an eating disorder, while simultaneously reinforcing the need to be engaged with the world. It's unclear how successful that philosophy will be, but the increasing number of obese patients referred for therapy will test this treatment quickly. The next post will explain obesity therapy in more detail.

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