You need to read this post if you secretly still think obesity’s all about lifestyle, processed food, and willpower.
1) Park your preconceptions
Long story short, about a third of the world’s population is obese, and there is not a single documented example of population-wide weight reduction anywhere on the globe. It’s not just affluent countries or developed countries. Nor is it just poor countries.
And it’s not geographically defined, either – Bhutan is nearly 5X more obese than Nepal, its near-neighbor.
Bottom line: almost everyone, almost everywhere is fatter, but there’s no clear association with wealth, geography, dietary habits or anything else. Blaming it on junk food and inactivity can’t be the (only) answer because dietary habits and physical activity levels vary wildly around the globe, even in obese countries.
2) It’s not just people, either
It’s also lab animals, even though they’re fed a very specific and portion-controlled diet. It’s also domesticated animals and feral animals. It’s tempting (though perhaps inaccurate — we don’t really know) to assume that pets and rats are living off the caloric bounty found in many homes, garbage cans and alleys. But what about the lab animals? They’re not getting under-the-table snacks, and they’re not foraging in dumpsters.
3) And perhaps it isn’t all that recent
This RAND/University of Illinois study makes an interesting point: although the CDC obesity trend charts often imply that the obesity problem began in the early 1980s, in fact folks in the U.S. have been gaining weight steadily since the mid-1900s.
If this is true, is it even a bad thing? If we knew the reasons behind these trends, would they be useful in changing the trend line today? Hard to say.
Remember, thanks to climate, war, and an economic crash, poor nutrition was a common theme around the globe for most of the years between 1900 – 1945. For example, malnutrition among young men made it difficult for the United States to draft enough soldiers to fight in World War I. At least some of this weight gain was undoubtedly healthy.
One thing’s for sure: if we see today’s obesity “epidemic” as simply the continuation of a trend that began with more leisure time and consumption of a healthier diet following the end of World War II, it certainly reframes the conversation away from the usual suspects.
Of course, this study doesn’t begin to explain why lab animals weigh more. Or what’s happening in Bhutan. Or why folks in Asian countries haven’t gained much weight, despite affluence.
4) Facts you’ll hate
The most effective treatment available for Type 2 diabetes associated with obesity — in terms of improved health outcomes — is bariatric surgery.
It definitely isn’t medication. The handful of prescription weight loss meds currently available produce minimal weight loss even when taken as directed, with an exercise program. Their risks and side-effects make docs and patients reluctant to try them. And I don’t expect Contrave, the most likely next new weight loss drug, currently under review by the FDA, to change this.
And to be honest, it isn’t a healthy lifestyle or lifestyle change either. Much as many of us would like to believe that food and exercise beat surgery, that’s not factually true for most people.
On the other hand, high blood sugars flat-out disappeared for about 20% of gastric banding and bypass patients — and for 0% — that’s right, NONE — of those in a rigorous lifestyle change and weight-loss program. And while 60% of surgical patients studied experienced partial remission of diabetes, only about 15% of those in lifestyle interventions experienced partial diabetes remission.
My first thought was “Yeah, but how long did the good news last?” Well, 15 years later, 30% of the surgical patients were still in complete remission. Less than 10% of the lifestyle patients were free of detectable diabetes.
My second thought was “Okay, but what about post-surgical complications?” In fact, there were no major surgical complications. So while complications, post-surgical revisions and non-compliance are certainly realities for some patients, they don’t appear to be the boogeymen that we’ve historically feared.
Despite those facts, as I type this post in 2014, I frankly have a hard time imagining bariatric surgery being the treatment of choice for millions of people.
I’m sure people had the same reaction in 1960 when the first heart bypass surgery was performed. “That’s great, but it’ll never be available for most people.” Of course today it’s quite common.
On the other hand, bypass surgery is typically seen as an urgent life-or-death matter, whereas obesity is life-or-death in slow motion.
And in my opinion, differences in values and beliefs play a much bigger role in how we advocate for the treatment of obesity than they do for the treatment of a blocked artery.
5) But all is not lost!
I first identified vagal blocking devices as a trending item a couple years ago. These pacemaker-style devices intermittently block signaling from the vagus nerves, reducing feelings of hunger and increasing feelings of satiety. It’s an appealing approach, because it doesn’t require major surgery, conscious lifestyle change, or anatomical rearrangement, and has no risk of medication side-effects.
Human trials are encouraging. Half of the participants dropped 20% or more of their excess weight and about 1/3 dropped 30% or more. They kept it off, and more importantly saw statistically significant improvements in lipids, blood pressure and heart rate.
Most important, the FDA’s advisory committee just concluded that at least one of these new devices was safe. The only question was effectiveness. Compare that to Contrave, sent back in June 2014 for another three months of review of heart risks.
6) And before we give up on healthy lifestyles…
We focus so much on what’s wrong with the thinking of people who don’t adopt healthy lifestyles. And we’re constantly telling them what they should do, based on data of dubious quality (the National Weight Control Registry’s “eat breakfast” finding, for example).
My two cents: we need to study the lifestyle habits of a large and easy-to-find group of people who actually makes and sustains an extraordinarily demanding level of lifestyle change: folks with Type 1 diabetes.
After all, management of a disease that is difficult in the extreme to manage is front and center in their lives. It pervades literally every decision they make about every bite of food, every activity whether it’s sex, mall-crawling, or running a marathon, tweaking their insulin dose and often, their food intake literally hour to hour based on these factors. Many choose to eat a restrictive, highly predictable and unvarying diet simply to try to improve blood sugar control.
Despite all that effort and attention, some days they end up with great blood sugars — and some days, their blood sugar’s sky-high or bottoming out, for no obvious reason. Do they give up? Mostly, no. The next day, they do it all over again.
Yet it’s a regime that is so intrusive and unpleasant that many non-diabetics respond by saying “Well, I could never do that.”
Now, it’s easy to say “Well, they HAVE to keep going — they don’t really have a choice, right?” And yet, like obesity, failure to control blood glucose is for the most part a slow-motion life and death matter. It’s not usually a medical emergency.
So why don’t we have any reliable studies on why so many of these folks are able to adopt and maintain a healthy lifestyle despite repeated daily, even hourly “failures” dutifully reported by their blood glucose meters?
We also need to study people with Type 2 diabetes who are leading healthy lifestyles. There are lots more of these folks than you probably realize. Many aren’t svelte, yet they’re achieving good A1C results through medication, mindful food choices, AND, yes, plenty of exercise.
Weight loss meds aren’t game changers
Frankly, there’s not much happening on the medication front anyway. In fact, I doubt seriously that this is likely to be the right treatment pathway for obesity. I do think you’ll see more bariatric surgery, and I think vagal blocking devices may well get some traction in the U.S. It’s a low-risk device that’s already approved in Europe, which is often ahead of the U.S. in areas like these.
More surgery, more complications
As studies continue to show that bariatric surgery results in full or partial sustained remission of detectable diabetes in a large number of patients, I have to think that more doctors will start offering these procedures and no doubt insurance companies will increase coverage. That said, I’d also expect a jump in surgery-related issues due to lack of surgical expertise and poor patient selection as the net widens.
More emphasis on un-obvious causes
Whether it’s BPA, the role of the gut biome, antipsychotic medications or other factors, there’s quite a bit of evidence that many factors other than food intake and activity level affect weight gain, loss and maintenance. Understanding these elements and how they affect weight in the individual is largely unaddressed but clearly needs attention if we want to move the needle.
More research into successful healthy behaviors
Here I’m talking NOT about the anectodal “eat breakfast” example, but about the systematic investigation of successful healthy lifestyle behaviors – what works, why does it work, and when do different practices work? How do people with chronic health issues successfully adopt, change and maintain healthy lifestyle behaviors? I love the “stages of readiness to change” model but it doesn’t even begin to explain how healthy behaviors really work, day in and day out, among people with chronic health issues like Type 1 and Type 2 diabetes.
Finally, a challenge to health and wellness practitioners:
Ethical practice requires that health and wellness professionals check preconceptions and opinions at the door and base client and patient recommendations on data and facts — up-to-date information, gathered in a responsible and methodical fashion, and analyzed by researchers without vested interests in the outcome.
There is no universally valid explanation for global and local obesity and overweight — so the cause can’t be only super-sized combo meals. Or sugar. Or wheat. Or dairy. Or whatever your favorite scape-nutrient is. Nor can it be screen time. Or lack of sidewalks. Or lack of discipline and willpower. Or lack of exercise. There are too many examples where these factors aren’t even present, so they can’t possibly be the cause for obesity everywhere, in everyone.
Professionals need to identify and name their own biases: “I tend to assume overweight people are emotional eaters” or “I tend to assume fast food is always a bad choice” or “I tend to assume obese people have never been active” or “Bariatric surgery isn’t as good as losing weight the normal way.” Then they can test their thinking against external information and ask themselves if they’re looking only at data from sources that are likely to reinforce what they already believe.
Then, and only then, can they be confident that they’re treating patients and clients as individuals rather than as manifestations of their own belief systems.
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