Wheel Failure

Embracing Failure in Behavioral Obesity Care

Through the last four decades of relentlessly rising obesity, we’ve had two clinical strategies in play. The first approach – arguably dominant – has been to overlook obesity and merely treat the complications as they appear. The other is intensive behavioral treatment. But clearly, neither of these have been adequate. The burden of chronic diseases that result from untreated obesity continues to grow. How shall we respond to this failure in obesity care?

Two new commentaries offer starkly different ideas.

Embracing Failure

The first approach comes to us from Nature Medicine. Naveed Sattar, Jason Gill, and William Alazawi recommend “a willingness to embrace failure.” The key, they write, is to promote repeated attempts to lose weight and rely on behavior change. Change things up, they suggest. Use a range of tricks from simple to intensive strategies for helping patients change their lifestyles. A “simple leaflet” with a “top ten tips concept” can do the trick, they say. In short, we simply need “a more empathetic and helpful approach.”

From the perspective of these authors, surgery is rarely needed. “A minority of people may benefit,” they write. Anti-obesity medicines? The authors describe them as a “kick-start” for weight loss. But that’s just wrong. It’s not how they work.

Moving Past Failed Strategies

In contrast, Richard Atkinson suggests moving past the failed strategy of relying almost solely upon behavior change. He writes:

Einstein’s definition of insanity is “Repeating the same thing over and over and expecting a different result next time.” The only consistently successful treatment for obesity that produces long-term weight loss in most patients is obesity surgery.

However, he believes the real answer will come from understanding the underlying physiology of obesity:

In our hubris, we have concluded that we know the cause of obesity and the treatment is self-evident: eat less and exercise more. We need to go back to the drawing board and start to try to understand the fundamental mechanisms that cause obesity.

Bottom line, he says, we need better options that will come only when we really understand the disease.

Making Do and Doing Better

Despite their narrow view of obesity, we can find some good in the perspective of Sattar et al. Offering more effective behavioral support is better than nothing. And of course, empathetic care would be a big improvement over silence or harsh bias that is more typical.

But Atkinson is right. We need to be more curious to truly understand the physiology of obesity. We need better therapies and we have no doubt they are possible.

For now, though, we must employ the full range of options we have. Not just behavioral support. But also anti-obesity medicines and surgery. Through patience and persistence, skilled obesity care providers can deliver much better outcomes for people living with obesity.

Click here for the perspective from Sattar et al and here for the perspective from Atkinson.

Wheel Failure, photograph © Robert Couse-Baker / flickr

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March 13, 2020