Good Question

Why Has Progress in Reducing Obesity Been So Elusive?

Today we have the privilege of presenting at the Methodist Health System Digestive Institute Symposium in Dallas. Mixed in with some truly distinguished experts on gastroenterology, we’ll be exploring evolving policies on obesity. But most important, we’ll be examining why progress in reducing obesity has been so elusive. And above all, how can we make better progress?

Four Decades of Ineffective Efforts

It all started out four decades ago in relative innocence. Cara Ebbeling, Dorota Pawlak, and David Ludwig saw a public health crisis looming. History has proven them right.

But they were also quite wrong. They wrote in the Lancet that common sense could offer straightforward solutions. They did note that those straightforward solutions might be politically difficult.

A masterful understatement.

Whatever the Question, Low Fat Was the Answer

As epidemic growth in obesity gathered steam in the 1980s, common sense offered up an obvious answer. If too much fat in our bodies is the problem, low-fat diets must be the answer.

Explaining this obvious answer, Mark McCarty wrote in 1986:

An unrefined low-fat diet, eaten to satiety and accompanied by regular exercise, may be the ideal means of maintaining a trim figure throughout life while minimizing one’s risk for “Western” degenerative diseases.

This was an idea that persisted, doing little good, through the rest of the last century.

Clinical Guidelines

Finally, in 1998, a small group of visionaries decided it would take more than common sense to overcome obesity. By then, the prevalence was really soaring. So under the auspices of NIH, a group of wise clinicians and scientists issued guidelines for identifying, evaluating, and treating obesity in adults.

Just one teensie little problem got in the way of glorious success flowing from this milestone. Clinicians and the whole healthcare system ignored it. They mostly continued with the common sense approach they’d always followed. Advise the patient to lose weight. Educate consumers to make healthier choices. Eat less, move more.

Obesity rates continued soaring.

The Diabesity Narrative

As we entered the new millenium, a new narrative emerged. Obesity rates were soaring and as a result, so was diabetes. Diabesity and metabolic syndrome became part of popular clinical jargon. People started questioning the wisdom of treating diabetes with drug regimens that made people gain weight. Definitely a good idea.

These concepts got everyone’s attention. The U.S. Surgeon General even issued a call to action for reducing overweight and obesity. The call was loud and clear. The action? Not so much.

Let’s Move!

With a new decade in 2010, we had a new and exciting effort aimed at reducing obesity – Let’s Move! Backed by a popular first lady, Michelle Obama, it got lots of attention. It did lots to promote physical activity. We raised the bar for nutrition on many fronts. But it didn’t do much to address the physiology of the disease itself. Obesity rates continued growing.

Recognizing the Disease

Some things are moving in the right direction, though. In 2013, the AMA finally came out and said it. Obesity is not a purely social problem. It’s also a medical concern with roots in physiology. The regulation of adipose tissue has gone awry when obesity becomes a serious problem.

Options for dealing with obesity are getting better. Objectivity and curiosity helps. Time has become our friend in a perverse way. As Winston Churchill supposedly said, after we’ve exhausted all the other possibilities, we always come around to do the right thing.

We have hope that this is what we’re seeing unfold now.

Click here for our presentation to the MDI symposium and here for more on regarding obesity as a disease.

Good Question, photograph © Eric / flickr

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February x, 2020

8 Responses to “Why Has Progress in Reducing Obesity Been So Elusive?”

  1. February 08, 2020 at 7:35 am, Al said:

    Wait…so you’re telling me that companies fining employees if their BMI is too high doesn’t work? Shocking!

  2. February 08, 2020 at 9:43 am, Ted said:

    Actual, Al, as you know, it likely does work. It likely works to make people sicker, less productive, and more cynical about their employers. 🙄

  3. February 08, 2020 at 10:20 am, Mary-Jo said:

    I would also like to add to all your great highlights is that, actually, since the late 70’s when the Fogarty International Obesity Task Force teams got started, the physiology of obesity, identifying and describing the multifactorial components of obesity, was clearly showing disease dynamics applied, But, these facts and discussions were largely kept constrained within research and academic circles. Thus, access to appropriate multidisciplinary care was just not made available. If it was, it was extremely expensive, only available for people who could afford to pay out of pocket. Look how ‘far’ we’ve come since then on that!.🙄

  4. February 08, 2020 at 10:24 am, David Brown said:

    I wonder if it wouldn’t be a good idea to regard obesity as a symptom. After all, fat accretion depends on what and how much a person eats in relation to energy expenditure.

    How much one eats is regulated by food availability and appetite. Energy expenditure and appetite are regulated by complex biochemical feedback mechanisms that can remain normal in an obese individual or become deranged in a normal weight individual who ends up obese. Society sees two obese individuals; one healthy, the other diseased. One does not have inflammation. The other suffers from fat accretion in places where fat should not appear.

    The changes responsible for the current global epidemic of obesity and diabetes must be a subtle ones because there is little agreement regarding cause and effect. By way of illustration, here is the opening paragraph of a 2012 ASBMBTODAY article by Rajendrani Mukhopadhyay.

    “Is a particular dietary recommendation harming people in the U.S.? For almost 20 years, scientists have been arguing over whether Americans and others on a typical Western diet are eating too much of omega-6s, a class of essential fatty acids. Some experts, notably ones affiliated with the American Heart Association, credit our current intake of omega-6s with lowering the incidence of cardiovascular disease. Others, which include biochemists, say the relatively high intake of omega-6 is a reason for a slew of chronic illnesses in the Western world, including asthma, various cancers, neurological disorders and cardiovascular disease itself.”

    Then there’s this comment in a 2011 New York Times article entitled Today’s Lab Rats of Obesity: Furry Couch Potatoes.

    “Dr. Hansen, who has been doing research on obese monkeys for four decades, prefers animals that become naturally obese with age, just as many humans do. Fat Albert, one of her monkeys who she said was at one time the world’s heaviest rhesus, at 70 pounds, ate ‘nothing but an American Heart Association-recommended diet,’ she said.”

    A book published in 2012 contains a chapter entitled Importance of Dietary Fatty Acid Profile and Experimental Conditions in the Obese Insulin-Resistant Rodent Model of Metabolic Syndrome. Author Annadie Krygsman notes that “The rising incidence of childhood obesity and T2D, high blood pressure, hyperinsulinemia and dyslipidemia are particularly worrisome as these children often mature to be obese adults.This risk of developing obesity and T2D has largely been blamed on the increased consumption of energy dense foods and fat intake, particularly saturated fat, but it is interesting to know that the mean fat intake of the human population has not increased much in the past 50 years.It is true that the vast advancement in technological developments has led to a reduction in physical activity worldwide, but as obesity now involves infants and the populations of developing countries, this obesity pandemic cannot be attributed to this alone.In addition, laboratory and other domesticated animals have also been subject to the increased prevalence of obesity, despite having largely unchanged living conditions for many years.”

    That subtle change mentioned earlier was discussed in these two video presentations.

    An even more subtle change in the food supply, one that I did not begin to appreciate until three years ago, is the increase in the arachidonic acid content of the meat we consume. Norwegian animal scientists Olav Christophersen and Anna Haug recommend some changes in government farm policies to correct the problem.

    “The combination of inadequate intakes of EPA and DHA with overconsumption of arachidonic acid (AA) is now one of the major causes of high rates of cardiovascular death in many of the ‘old’ industrial countries, and there is reason to fear that some of the countries in Asia with rapidly growing economies may soon follow because of the modernization processes affecting much of the animal food production in those countries as well. At the same time, it is likely that a high dietary AA/(EPA + DPA + DHA) ratio also may lead to more rapid development of most cancers, especially in such cases where the tumour cells are expressing COX-2, and to aggravation of several chronic pain conditions and chronic inflammatory diseases. AA comes nearly exclusively from animal foods, and the best strategy for reducing the average AA intake at a population level is to make it mandatory for the farmers (and for the feed industry) that animal products shall have an omega-6/omega-3 fatty acid ratio that must not be higher than what might be considered natural for the species concerned (when the animals live in their natural habitats). Since endogenous synthesis of AA from LA is also substantial (and similar to the average intake of AA from the diet), we believe it may be almost equally important also to reduce the average LA intake from edible fats and oils, compared to the situation in several countries today.”

    How long have scientists been concerned about arachidonic acid? In a 1992 Symposium entitled “Biological Effects of Dietary Arachidonic Acid” J. Bruce German and colleagues told the audience, Considerable research has examined the role of diet on membrane composition, yet few investigators have appreciated that the relative abundance of its precursor, linoleic acid (LA), is not synonymous with that of fully formed arachidonic acid (AA)… Plants consumed for food do not desaturate and elongate LA to AA, hence the majority of AA is derived from animal products. As pointed out above, AA is the most abundant PUFA in animal membranes, thus when animal products are consumed as food, the AA content varies with the amount of membrane. In this way, AA can be considered analogous to cholesterol. In fact, cholesterol and AA vary in rather close parallel in overall diets.

    To conclude this, note that epidemiologists blame saturated fat and cholesterol for effects that really ought to be attributed to linoleic acid and arachidonic acid.

  5. February 08, 2020 at 6:30 pm, A John Menchaca said:

    Are we ignoring the epigenetic effects of the abnormal milieu of a mother with obesity at the time of her offspring conception? Could those epigenetic effects affect the function of the offspring’s hypothalamus as it is pertains to its control of appetite ?

  6. February 08, 2020 at 11:27 pm, mike said:

    Off topic slighlty Ted, but not totally, and curious your thoughts. 100% the most effective treatment based on decades of research is bariatric surgery in terms of medium and long-term obesity / weight reductions and t2 diabetes improvements and other metabolic markers correct?

    One issue is cost, with it roughly being 20-30k in US. In mexico or india it is roughly $6-10k. So between 3-4 surgeries could be done for cost of 1 domestically, so instead of 200k done now in US you could do 800k and be pretty close to the long-run average rate needed. For this to occur you need 3 things:

    1) accredidation / partnership with US institutions (if you have for example Mayo clinic, john hopkins, cleveland clinic etc endorsed overseas facilities the quality would be comparable) – these institutions are loathe to give up lucrative procedures here unless legal changes I get

    2) a ramp up period to increase forgein bariatric surgeons. Don’t have exact data, but I understand there currently wouldn’t be capacity to add 600-800k more surgeries

    3) US consumers having the right incentives (financial) and confidence / faith in medical tourism

    Personally I think this is a very obvious solution (especially given the fact I acknowledge you need 3 elements above, which MANY instituions and doctors will push back on) that is part, and frankly i think a LARGE part of fixing obesity epidemic since bariatric surgery is so much more effective, despite a rather negative view by many people (including many with obesity)

    Sorry for rambling, but just curious your initial thoughts on an issue frankly I don’t think is at least mentioned as what a possible solution would be towards credibly taking a HUGE bite out of long-term obesity

  7. February 09, 2020 at 5:35 am, Ted said:

    John, the throughline to parents, both mother and father, is important, but not simple. Where does it start? We are all products of our parents and the environment into which we are born. The question becomes one that requires curiosity to discover what factors can change to reverse the trends that we see. Presupposing that we know the answer has not worked very well.

  8. February 09, 2020 at 5:49 am, Ted said:

    You have a point worth considering, John. I have friends who have had surgeries in Mexico with good outcomes. But, coincidentally, I just spent the evening on a long flight with a gentleman who has been miserable ever since he had a gastric sleeve done in Mexico five years ago. This is purely anecdotal, but it illustrates a point. This is not a simple solution for all because prep and follow-up are so important.

    In a similar vein, Walmart is making bariatric surgery available to its employees through a kind of domestic medical tourism: