October 11th, 2010
Obesity: Good News and Bad News
Larry Husten, PHD
Two new trials and accompanying editorials published online in JAMA offer hope that lifestyle interventions can result in significant weight loss. The bad news: The results are fairly modest, and it is difficult to obtain reimbursement for lifestyle interventions.
In one study, Cheryl Rock and colleagues compared usual care with a program that included free prepared meals and counseling in 442 overweight or obese women. After 2 years, weight loss in subjects who received prepared meals and either center-based or telephone-based counseling was significantly greater than weight loss in subjects who received usual care (7.4 kg and 6.2 kg vs. 2 kg, P <0.001 for intervention effect). But in an accompanying editorial, Rena Wing writes that the results “probably represent a best-case scenario” and that “it is time to directly compare the outcomes achieved in a variety of different commercial weight loss programs and to examine whether providing these programs free of charge to participants would be a cost-effective approach.”
In a second study, Bret Goodpaster and colleagues randomized 130 severely obese adults (mostly women) to diet and exercise for 12 months, or to a 6-month period of diet alone followed by 6 months of diet and exercise. At 6 months, people in the combination diet-exercise group lost more weight than the diet-only group, but at 12 months, weight loss was similar in the two groups. In an accompanying editorial, Donna Ryan and Robert Kushner note that reimbursement for nonsurgical treatment of obesity is rare, adding: “Physicians should not be discouraged from implementing nonsurgical medical care approaches in this population, but payers need to rethink their policies.”
6 Responses to “Obesity: Good News and Bad News”
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You know, I have never seen an overweight anorectic. But it is hard to deny yourself some food. It’s not like stopping all cigarettes. For what other addiction do we tell our patients to have some of the addicting drub, but not too much? Besides, by two weeks of age we are all as addicted to food as Pavlov’s dogs: we cry or are uncomfortable, our mother picks us up and feeds us, and we feel better. We have a strong positive link between feeling well and being fed.
I think the medical community has let down the US population in allowing the obesity epidemic to explode without effective preventative and treatment strategies. Since the epidemic just appeared this generation, it strikes me that the foods Americans eat, and perhaps lack of sleep from overwork, TV and the internet must be playing a role. Should the medical community play a more proactive role in regulating the food being put on our patients’ shelves?
Physicians have little to do with this. While it is part of an office evaluation, and should be addressed fully, the obesity and diabetes epidemics are 95% social issues, a result of widespread failures in education, attitudinal problems that touch on politics regarding individual responsibility, control of the environment–which means utter failure of the government to meaningfully keep the food supply healthy (safe, salt-free, and hypocaloric, hypoglycemic). Without getting into “minor” off-shoots, I do not believe, now that obesity is rampant, and up to 53% of subpopulations have the metabolic syndrome, that now it should be medicalized. We must offer and follow up within the confines of guidelines, but not buy into responsibility and guilt. No physician has the time, and few the inclination, to spend hours jawboning people into following common-sense rules about food and activity choices. I have done so repeatedly over the past 45 years to no avail. Sophisticated academic programs to “reduce cardiometabolic risk” (the modern word for “fat farm”)have dismal results, because until the obesogenic environment is corrected, and the public sharply reeducated, and faddish, misinformation is removed from the web, what physicians can do is trite.
The government will not do what is needed, for they are too connected with industry to even consider effective action.
Given the effectiveness of the medical community with respect to effecting clear, evidence-based changes in Washington that have simple treatments, the probability that being proactive in food regulation will be meaningful is pie-in-the-sky.
I strongly disagree with the idea that, because it is cost-effective to supply Jenny Craig dinners free to the public, rather than finance bariatric surgery, it is a viable solution. Rather, medical school-affiliated weight loss programs should be sponsored. Counselors at Craig may be affable, but in my opinion, untrained.
While I admire Goodpaster et al for their efforts, there are many programs that have good results published that are inapplicable to the real world. I agree with the editorial–it just won’t be reproduced outside of the investigative environment.
Additional commentary is summarized in my discussions in (1)risk reduction as part of the managment of chronic stable angina http://www.dovepress.com/recent-advances-in-the-management-of-chronic-stable-angina-ii-anti-isc-peer-reviewed-article-VHRM and (2) effects of macronutrient contents in diets upon vascular risk due October in ASPEN’s Nutrition in Clinical Practice.
Richard Kones
Competing interests pertaining specifically to this post, comment, or both:
None at all.
Dave-what preventive strategies or treatment? There are no really effective treatments. Good hints and strategies are basically social and personal, not medical. The RDs have hundreds they keep in circulation… do little good for most, because of apathy, lack of a serious attitude/willingness to apply the strategies, and no motivation to try. Those are the problems and obstacles.
Richard Kones
Competing interests pertaining specifically to this post, comment, or both:
None at all.
To treat obesity is a mundane task,and as a clinician we should treat on case to case basis,not only diet or exercise,family members support is essential to get the optimum results,and stress management is very important.
Stop eating while you are still hungry,,,if you eat more you ll hv to carry it but if you eat less it shall carry you,,,,,,,wisdom from East