Some realism in treating obesity

February 15th, 2015 No comments »

Apropos of the discussion of Dr. Eve Guth’s Patient Page in JAMA, The Lancet recently published an editorial by four prominent obesity researchers and clinicians. Drs. Christopher N. Ochner, Adam G. Tsai, Robert F. Kushner and Thomas A. Wadden, “Treating obesity seriously: when recommendations for lifestyle changes confront biological adaptions.” Their comments are worth repeating in detail:

“Many clinicians are not adequately aware of the reasons that individuals with obesity struggle to achieve and maintain weight loss, and this poor awareness precludes the provision of effective intervention. Irrespective of starting weight, caloric restriction triggers several biological adaptions designed to prevent starvation. These adaptions might be potent enough to undermine the long-term effectiveness of lifestyle modification in most individuals with obesity, particularly in an environment that promotes energy overconsumption. ..Additional biological adaptions occur with the development of obesity and these functions to preserve, or even increase, an individual’s highest sustained lifetime bodyweight. For example, preadipocyte proliferation occurs, increasing fat storage capacity. Importantly, these latter adaptions are not typically observed in individuals who are overweight, but occur only after obesity has been maintained for some time. Thus, improved lifestyle choices might be sufficient for lasting reductions in body weight prior to sustained obesity. Once obesity is established, however, bodyweight seems to become biologically stanped in and defended. Therefore, the mere recommendation to avoid calorically dense foods might be no more effective for the typical patient seeking weight reduction than would be a recommendation to avoid sharp objects for someone bleeding profusely.

Evidence suggests that these biological adaptions often persist indefinitely, even when a person re-attains a healthy BMI via behaviorally induced weight loss. Further evidence indicates that biological pressure to restore bodyweight to the highest-sustained lifetime level gets stronger as weight loss increases. Thus, we suggest that few individuals ever truly recover from obesity; individuals who formerly had obesity but are able to re-attain a healthy bodyweight via diet and exercise still have ‘obesity in remission’ and are biologically very different from individuals of the same age, sex, and bodyweight who never had obesity. ..”

Contrary to the simplistic recommendations by Dr. Guth in JAMA, these authors recommend

“Specifically, clinicians should be proactive in addressing obesity prevention with patients who are overweight and, for those who already have sustained obesity, clinicians should implement a multimodal treatment approach that includes biologically based interventions such as pharmacotherapy and surgery when appropriate…We recommend that the use of lifestyle modification to treat individuals with sustained obesity, but it should be only one component of a multimodal treatment strategy.

(The authors conclude) We urge individuals in the medical and scientific community to seek a better understanding of the biological factors that maintain obesity and to approach it as a dises that cannot be reliably prevented or cured with current frontline methods.”

Amen.

 

British PM to Penalize Persons with Obesity

February 15th, 2015 No comments »

British Prime Minister David Cameron is evidently considering cutting health benefits to persons with obesity who do not undergo therapy, reports the BBC.

 

More Misleading Information for Patients

February 15th, 2015 No comments »

So, “misleading” is a pretty strong term. Unfortunately, misleading advice to patients, the public and policy makers is so widespread in the obesity field as to acceptable as the norm, not the exception. For example, recently several obesity researchers (David Allison, Diana M. Thomas and Steven B. Heymsfield) commented on a “Patient Page” in JAMA. In the page, Dr. E. Guth w rote, “A total of 3500 calories equals 1 pound of body weight…This means if you decrease (or increase)your intake by 500 calories daily, you will lose (or gain) 1 pound per week. (500 calories per day X 7 days= 3,500 calories.)”

Allison et al pointed out that “over time the calorie deficit slowly closes as energy expenditure gradually declines with the loss of body mass and metabolic adaptations. Unlike the linear weight loss pattern described by Guth, actual weight loss follows a smooth curve and then plateaus at the new energy requirement level…For example, if a 5’6”, 30-year-old woman weighing 180 lb and consuming 2622 calories daily reduced her intake by 500 calories per day, the 3,500 calorie rule would estimate her weight loss at 1 year to be almost 52 lb. The validated dynamic model predicts a weight loss of 12 lb. At 10 years, the 3,500-calorie rule would yield a negative body weight, whereas the weight loss prediction of the dynamic model would stabilize at a 31-lb loss after 3 years.

(The validated dynamic model is available at http://www.pbrc.edu/researc-and-faculty/calculators/weight-loss-predictor.)

Interestingly, Dr. Guth replied with a curt toss of this point, stating that the Patient Page was intended to provide “easily understood information and accessible guidelines for the majority of patients.” Dr. Eve Guth acknowledges that since most patients regain their weight after loss, “it is unlikely that an individual would continue to restrict calories for 10 years, ultimately resulting in a negative weight.” (ED: also known as death.) After dumping on patients too ignorant to starve to death, Dr. Guth dumps on primary care providers who are seeking to meet patient demands for simple advice involving minimal effort on their part, oh, and by the way, there isn’t good reimbursement either for misleading patients.  Dr. Guth’s perception is that this is all between the physician providing simplistic advice to an overweight or obese patient too dumb or ill-informed to know better. Small wonder that physicians don’t counsel and patients don’t think doctors know what they are talking about. Moreover, these  simplistic strategies spill into policy-making, implying that weight loss is easy and, with the right incentives, maintainable over the long-term.

For more information on

More accurate weight loss calculators:

http://www.downeyobesityreport.com/2012/02/the-calorie-out-math-is-all-wrong/

http://www.downeyobesityreport.com/2012/05/the-new-math-of-obesity/

Adaptive thermogenesis effect on weight loss:

http://www.downeyobesityreport.com/2014/01/where-is-your-new-years-resolution-or-where-did-i-put-my-adaptive-thermogenesis/

 

Puerto Rico Does Not Have the Answer

February 14th, 2015 No comments »

I’m sorry. There, I said it. I was wrong. In 2008, a Mississippi legislator proposed that restaurants should be prohibited from serving customers who were obese. In a USA Today article, I called the bill “the most ill-conceived plan to address a public health crisis ever proposed.” I was wrong. Puerto Rico legislators are going one better. (See Ted Kyle’s post.)They are proposing to impose a fine on parents of children with obesity. Yes, a fine. Oh, that will help! “Parents: Starve your children and you save a few bucks!” Wow, what a deal! That will overcome the cries of hungry children.

This kind of proposal is easy to shoot down. However, it reflects a grave public policy problem. Most of the public policy debate is now dominated by behavioral economists who only see incentives and penalties as valid interventions. They disregard any contribution of biology in their research. Some may see the contribution of the environment. However, their recommendations trend to changing individual behavior, not in environmental changes. That leaves the only option for policy-makers, led on by behavioral economists, to propose ever more and more brutal penalties on persons with obesity (such as the penalties on workers in ‘employer wellness’ programs) or, in this case, on the parents of children with obesity.

The origins of this kind of policy direction lie not in Puerto Rico. A prominent obesity researcher and clinician David Ludwig called on state child protective services to take children with obesity away from their parents. It used to be that political thought was opposed to visiting the sins of the father on his children. Behavioral economists have turned this inside out to visit the parent with the ‘sin’ of the children, in this case, being overweight. This is public policy madness  which will not solve the obesity problem but only put off any real, grown-up policy development.

 

Rose Frisch, Pioneer in body fat research, passes away

February 14th, 2015 No comments »

Rose Frisch, a pioneering researcher on body fat and reproduction has died. A New York Times obituary pays tribute to her contribution which laid the theoretical basis for the discovery of leptin.

 

Gallup Survey Shows Increasing Rates of Obesity

January 30th, 2015 No comments »

The Gallup Organization and Healthways have tracked adult obesity in the United States over seven years. In their most recent report, they found that rates have continued to tick up, rising more than 2% points since 2008 reaching 27.7%. The rate for overweight and normal weight have decrease to 35.2% from 36.7% and to 35.1% from 36.1%, respectively. These results are based on self-reported results unlike the NHANES data which use clinical measurements. Significantly, rates of morbid or severe obesity  (a BMI of 40.0 or more) have reached 4%, the highest in the history of the survey. Obesity rates among seniors showed the sharpest uptick, a 4% point increase since 2008. The survey showed a relationship between obesity and lower incomes and long-term unemployment. Gallup research indicates that overall well-being predicts future obesity more than obesity predicting future well-being. Gallup suggests that weight management programs should address financial and social wellbeing.

 

Bases for obesity public policies basically worthless

January 30th, 2015 No comments »

Policy-makers, employer wellness programs, many physicians, the First Lady and most of the public health establishment espouse lifestyle changes, especially increased physical activity as the way (with or without caloric restriction) to prevent and reduce obesity and its related cardiovascular diseases. Millions of dollars have been spent to get Americans to increase their physical activity levels. For such programs to succeed they must have accurate information on levels of physical activity in the general population.

Virtually all of the studies on which these leaders rely come from self-reported answers to questionnaires, especially the National Health and Nutrition Examination  Survey (NHANES). Richard S. Cooper and colleagues who have compared NHANES results to objective data from accelerometers in 3,370 adults. The results are pretty shocking. They found:

“The estimates of both vigorous and moderate activity were extremely low, and contrast dramatically with those obtained by self-report. Vigorous activity lasting even 1 minute was only observed in 2% of any of  gender-race/ethnic groups and a 10 minute episode of moderate activity- the intensity obtained by walking up stairs was recorded in only one-third of the participants on any day of monitoring. ..

The major finding from these analyses is the demonstration that the population that population estimates of activity levels from surveys by questionnaire are markedly at variance with those obtained by objective managements. As the only source available from past surveys, questionnaires have been used in analytic research and have informed public policy for the last 50 years. If the data presented here are correct, a re-evaluation of the conclusions from much of this literature would be required. For example, based on national survey data it was assumed in Healthy People 2010 that 23 percent of adults engaged in vigorous activity of more than 20 minutes per episode at least 3 times a week at the beginning of this decade. However, in the NHANES data presented here, <1% of the population achieved this level of expenditure. Likewise, current guidelines recommend 150 minutes of moderate or 75 minutes of vigorous activity per week for adults. Only 0.3%, or 10 of the 3,370 individuals in this sample achieved that level.

Despite the widely held perception that low levels of energy expenditure in activity is an important risk factor for obesity, prospective data do not support this view. Randomized trials, where activity levels are rigorously measured and no attempt is made to restrict calories, likewise show that even substantial increases in energy expenditure in exercise do not result in weight loss because of compensatory increases in intake. We conclude, therefore, that the associations observed in the NHANES data presented here between activity and relative weight are spurious – i.e. the direction of the causality is most likely from obesity to lower activity.”

Things are not any better on the energy-intake side. Self-reported energy intake values are far inferior to objectively measured double-labelled water method, rendering energy intake information virtually useless according to a letter from 15 distinguished obesity researchers in 2013. A similar group of distinguished made the observation that “this extreme lack of validation of self-reported energy intake can be credibly drawn about energy intake derived from self-reported energy intake measures.”

So, the ground of almost all obesity pubic policies regarding energy intake and expenditure is at least questionable and maybe misleading. A similar group of research leaders has concluded that, ” We argue here that it is time to move from the common view that self-reports of (energy intake) EI and  physical activity energy expenditure (PAEE) are imperfect, but nevertheless deserving of use to a view commensurate with the evidence that self-reports of EI and PAEE are so poor that they are wholly unacceptable for scientific research on EI and PAEE…it is unacceptable to use decidedly inaccurate instruments which may misguide health-care policies, future research and clinical judgment…Researchers and sponsors should develop objective measures of energy balance.”

The Obama Administration and the First Lady have shown their commitment to addressing obesity. Now is their time to get serious and direct the National Institutes of Health, the Food and Drug Administration and the Centers for Disease Prevention to combine efforts to develop more accurate and reliable measures.

EEOC Under Pressure for Employer Wellness Guidance

January 30th, 2015 No comments »

The Senate Health, Education, Labor and Pensions Committee (HELP) held a hearing on Jan. 29, 2016 on employer wellness programs. (See video here.) The purpose of the hearing appeared to be to put pressure on the Equal Employment Opportunity Commission (EEOC) which has recently sued several companies alleging that their wellness programs violated the Americans with Disability Act.

Ranking Democrat Patty Murray indicated that the EEOC would be issuing a proposed guidance in the near future, as reported earlier.

While billed as a debate over employer wellness programs, most of the witnesses were representatives of business groups, with the exception of one representative of the Consortium for Citizens with Disabilities, Jennifer Mathis, who gave the most detailed statement. The business representatives gave the usual pep rally cries of “these programs work” line, citing a couple of positive anecdotes and avoiding the volume of studies showing incentives and penalties do not work.