Homogeneous Policies for a Heterogeneous Disease

For decades now, health policy advocates have been pursuing a solution to the growing effects of obesity on public health. The banners shift over time, but the goal is pretty consistent. It’s better diets and more physical activity across the population to reverse the trend in obesity prevalence. Low fat everything! Let’s Move! Tax and regulate high fat, salt, and sugar foods! A succession of rather homogeneous policies aim to address a very heterogeneous disease.

So why are we surprised that none of this is moving the needle?

Obesity Has Many Causes

Obesity is deceptively simple. For years, people have presumed it is simply the result of eating too much and moving too little. But literally hundreds of genes have links to obesity. Multiple factors interact to cause it. A truly exhaustive accounting of all the factors that may contribute does not exist. But in 2015, the Obesity Society assembled this infographic that identifies an impressive range of them.

Obesity Is Different in Every Individual

All these different factors mean that obesity is very different from person to person. Nikhil Dhurandhar et al explain:

“Multiple causative and contributory factors may be present in an individual, and the combination of such factors varies inter-individually, leading to distinct expression of obesity in each individual.”

Reversing Obesity Requires Different Approaches in Different Individuals

From person to person responses vary greatly with different interventions. In a few individuals, dietary change can produce results that are similar to the typical results from bariatric surgery. But for others, the effect is nil. Likewise, bariatric surgery is highly effective most of the time. But for some people it simply doesn’t work well.

No Surprise That Population-Wide Interventions Have Limited Effects

So why would we expect that a population-wide dietary intervention – like taxing soda to reduce consumption – would have much effect on such a heterogeneous disease? One-size-fits-all approaches to obesity almost never work.

Yet Policy Often Denies Access to Individualized Care

If a person needs bariatric surgery, they must jump through ridiculous hoops to get it. Many people wind up paying for it out of pocket. Medicare will cover surgery, but the program denies coverage for anti-obesity medicines. Evidence-based programs for diet and exercise are hard to access, so most people take a DIY approach. That can easily do more harm than good because all of the quackery in self-help diets and dietary supplements.

Actual, individualized obesity care from a skilled provider can make a big difference for people with obesity. But few people have access because of bone-headed policies in health plans.

So It’s Little Wonder That the Problem Keeps Growing

Pursuing population health strategies that will eventually curb the growth in obesity is hardly futile. But it’s not easy, either. Pretending “we know what works” is absurdly deceptive. With clear-eyed objectivity, we should study approaches that will have an impact across the population.

But this is not a zero sum game. While we look for effective prevention strategies, we should stop punishing people with obesity by denying them access to effective obesity care. Healthcare professionals are important for improving population health. Let them do their job.

Click here for more on the pursuit of better health policies to address obesity.

In the Crowd, etching by Paul-Albert Besnard / WikiArt

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March 29, 2022