Obesity: Death, Dollars, and the Prospects for Treatment

Abstracts & Commentary

Synopsis: The management of the obesity epidemic is complex, but there are some interventions that can be helpful.

Sources: Mitka M. JAMA. 2003;289:1761-1880; Science. 2003;299:845-360.

The year 2003 has been accompanied by an avalanche of data and information concerning the incidence, consequences, causes, cost, and potential treatments of obesity.

The urgency to reverse the trend in increasing obesity is documented in 2 major scientific journals: the Journal of the American Medical Association and a recent issue of Science. Both journals have devoted significant portions of a single issue to the review of what is known and the potential for significant improvements in the way we manage this disorder. Newspapers, television, and radio have given many hours of time reporting the cost of this epidemic, in death and dollars, and as a result our public has more information about the dire consequences of this disorder than ever before.

A seminal publication in the New England Journal of Medicine spelling out the association between obesity and most types of cancer may help motivate our patients to a greater extent than the fear of vascular disease or diabetes. Cancer scares the hell out of us, while we seem more blasé about vascular disease.1

The JAMA articles reported the obvious relationship between sedentary behaviors such as watching television and the resulting increase in body weight and type 2 diabetes.2 It also reviewed the results of weight loss and the ability of patients to maintain weight loss with commercial programs and an internet weight loss counseling programs to prevent diabetes. Commercial programs were better than self-help programs, but the results were best for the e-mail counseling group.3

Weight loss and increased physical activity decreased markers of inflammation (interleukin 6 and 18 and C-reactive protein) and increased the anti-inflammatory marker adiponectin.4

Not surprisingly, the quality of life in severely obese adolescents is comparable to adolescents being treated for cancer.5

The soaring demand for surgical treatment of morbid obesity is receiving both scientific and ethical review. Improvement in laparoscopic methods and a 1991 Consensus Statement by the National Institutes of Health that established criteria for eligibility for surgical treatment of morbid obesity (BMI > 40) opened the door for insurance coverage. This has lead to an explosive increase in the number of operations for obesity. Some institutions have a year-long waiting list. Weight loss at 5 years varies between 48-74% of the patient’s original weight.6

The single most important article in this issue is the editorial by George Bray. He notes that "obesity is a chronic, relapsing, neurochemical disease that occurs in genetically susceptible people." Further, current treatments do not cure obesity and are only palliative. Two kinds of treatment are available for obesity: cognitive and noncognitive.

Cognitive treatments—such as lifestyle change, diet and exercise—produce weight loss when they are being used, but when they are stopped, relapse occurs. Non-cognitive treatments include drugs, surgery, and some environmental manipulations, and they may produce long-standing weight loss.

Bray further discusses the controversy regarding low carbohydrate diets. The rapid weight loss with the low carbohydrate diet is largely a diuresis as the body mobilizes endogenous glycogen stores from the muscle and liver. The rapid weight-loss period lasts 7-14 days. The disadvantage is the potential for bone mineral loss over a period of time, and one potential advantage is the loss of gustatory stimulation by sweets. Not noted in these discussions is the potential for a decline in renal function in those patients who have decreased renal function at the onset of the low-carbohydrate diet, which is by definition a high-protein diet.

In Science, Nestle outlines one of the biggest challenges in the management of obesity. "When the interests of corporate institutions that control the distribution of food and its advertisement (with the goal of maximizing food consumption) conflict with public good who is to intervene and how?"7

Researchers are picking apart the roles of the molecular signals that the body uses to regulate its weight. Leptin, the first anti-obesity hormone which was identified in 1994, has not resulted in significant changes in our treatments. Other hormones that control appetite are under intense investigation. Ghrelin is produced in the upper portion of the stomach and acts through the arcuate nucleus to stimulate short-term appetite. It is removed by gastric surgical procedures, which remove the upper portion of the stomach from the stimuli of food and may account for the decreased appetite in patients undergoing these operations. Ghrelin is increased in persons who lose weight with dieting and may undermine the dieters’ ability to lose weight.8

The potential for new drugs and their mechanisms of action is reviewed. The search for new drugs is frustrating, but because of the huge potential for their use, pharmaceutical companies are salivating over the prospect of creating anti-obesity medications. However, it is hard to treat such a complex disease, and the potential for adverse results is great. There are drugs in the second and third phases of FDA trials now, but they will not reach the general public in the next year.9

In the "Where Do We Go From Here?" article, Hill and colleagues state: "Biology clearly contributes to individual differences in weight and height, but the rapid weight gain that has occurred over the past 3 decades is the result of the changing environment." These changes encourage consumption and discourage expenditure of energy. Using data from the National Health and Nutrition Examination Survey, they calculate that the average weight gain in persons 20-40 years of age is 1.8-2 pounds/year. This is only 50 Kcal/d. This means that reducing the energy gain by 50 Kcal/d would offset weight gain in 90% of the population. Walking 1 mile per day increases energy expenditure at least 100 kcal and would result in a gradual weight loss. They make very useful recommendations for putting this information into a daily plan.10

Comment by Ralph R. Hall, MD, FACP

The article by Hill et al gives us information that enables us to approach our patients with a reasonable plan for life style changes that cost little in time or money. The key to implementing a plan is to take time to identify the barriers to change in our patients’ life styles. This may take more time than we usually have and may ultimately mean that we have to partner with others to get the desired results. The article by Hill et al is essential reading for anyone treating patients for obesity.

The implication of Nestle and other nutritionists is that, somehow, laws should be passed to prevent advertising and to change our environment. This is impractical. We would have to stop advertising automobiles, large houses, etc. The individual has to take responsibility for their acts. Hill and his associates have given the majority of the population the knowledge and tools to successfully prevent and reverse obesity.

Dr. Hall is Emeritus Professor of Medicine, University of Missouri-Kansas City School of Medicine.

References

1. Calle EE, et al. N Engl J Med. 2003;348:1625-1638.

2. Hu FB, et al. JAMA. 2003;289:1785-1791.

3. Heshka S, et al. JAMA. 2003;289:1792-1798.

4. Esposito K, et al. JAMA. 2003;289:1799-1804.

5. Schwimmer JB, et al. JAMA. 2003;289:1813-1819.

6. Mitka M. JAMA. 2003;289:1761-1762.

7. Nestle M. Science. 2003;299:781.

8. Marx J. JAMA. 2003;299:846-849.

9. Gura T. JAMA. 2003;299:849-852.

10. Hill J, et al. JAMA. 2003;299:853-855.