Archive for February, 2015
February 15th, 2015
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.”
February 15th, 2015
British Prime Minister David Cameron is evidently considering cutting health benefits to persons with obesity who do not undergo therapy, reports the BBC.
February 15th, 2015
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:
Adaptive thermogenesis effect on weight loss:
February 14th, 2015
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.
February 14th, 2015
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.