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.”