Obesity is complex. Why aren’t its treatments?

 

 

 

 

 
Obesity is arguably the largest medical epidemic we face today—in the U.S. and around the world. It’s also one of the leading causes of preventable chronic diseases and healthcare costs. Yet we aren’t doing enough to combat it.

Part of the challenge is that, culturally, we often assign blame to individuals suffering from obesity, implicitly accusing them of causing their own disease. The more we do this, the less we empathize with sufferers, and the less able we are to marshal the necessary resources to treat the disease effectively. In contrast, blame is rarely part of the discussion around cancer, or even conditions related to obesity like heart disease.

In 2014, obesity affected 28.9 percent of the U.S. population according to the National Institutes of Health. Yet in fiscal year 2015, the disease received just $900 million in funding. That may sound like a lot, but contrast it with cancer, which affects 8.5 percent of the population and received $5.4 billion — nearly six times the amount. This, of course, is just public funding, but the same trends hold for non-profits. There is no Susan G. Komen or Movember for obesity.

To begin to address the human and financial costs of obesity more effectively, we need a big cultural shift in the way we think about and treat this disease. This shift starts with understanding the science behind obesity, and then requires developing research-backed, tailored solutions for individuals.

Evolution is working against us
First, let’s take a step back and look at the science of obesity. There is an evolutionary basis to our current predicament: Our bodies have evolved in a world where high-calorie food has historically been scarce and valuable, with starvation a constant danger. This is one reason obesity is so difficult to treat; our bodies are wired to protect our weight. A recent study surrounding Biggest Loser contestants brought this into high relief. It found that, over the six years after the show ended, their metabolisms slowed dramatically. Their bodies didn’t burn enough calories to maintain their new, lower weights.

Why does this happen?

Well, to conserve nutrients critical to survival, 200,000 years of Homo Sapiens evolution have carved pathways in our body that are redundant and secure. Today, many of us are fortunate enough to live in societies where nutrition is not scarce. But our bodies still have those grooves carved deep. This is why if you try to lose weight by eating less or exercising more, your body has dozens of methods to fight back. Your basal metabolic rate might drop, or your hunger hormones might kick into overdrive.

So while many people see obesity as a behavioral problem, the reality is that our bodies are not well-adapted to a world in which high-calorie food is always at our fingertips.

What’s more, we don’t fully understand the most fundamental aspects of nutrition today. For example, the low-fat vs. low-carb diet debate has been raging for decades. We still don’t know exactly how our bodies metabolize various macronutrients. We don’t know why some people are able to lose weight or maintain a healthy weight more easily than others. Nutrition isn’t a simple math problem; it’s inherently complex.

Nutrition Versus Nurture

To top it off, as challenging and as mysterious as the nutritional and physiological aspects of obesity are, these are not the only aspects we struggle to understand. Studies have shown that it is possible to become addicted to certain foods. But it’s still unclear whether some people are predisposed to food addiction, or whether certain eating habits lead to food addiction.

Obesity can be triggered or at least affected by developmental trauma. The Adverse Childhood Experiences Study and related obesity research demonstrated that food is often used for its psychoactive benefits and that obesity itself can come with unrecognized benefits. (For example, it can serve as a protective excuse for avoiding social situations.) In other words, obesity itself may best be considered a symptom of an underlying condition.

These are not easy thickets to untangle, but the more we understand why specific individuals struggle with their weight and the more we acknowledge how complex the problem we are up against is, the closer we’ll get to solutions.

How we treat obesity today

There is a spectrum of treatments available for obesity today, ranging from non-invasive (e.g. diet and exercise) to pharmacologic (e.g. weight loss drugs) to surgical (e.g. gastric bypass). But while we have many tools in our toolbox, it has become clear that not every tool works for every person. We now must work to understand which tools (and combinations thereof) work for which people.

This isn’t something doctors can solve alone. Physicians are strapped for time as it is. They often have just 15 minutes to evaluate a person struggling with weight issues and don’t have the resources to assess the specific causes and challenges each individual is facing when it comes to weight.

Many doctors default to “eat less, exercise more.” It’s simple, noninvasive, and it can work (at least for a time). Some recommend medications, but side effects are significant and it’s hard to know which pill will work for which individual. In order to qualify for more extreme measures like surgery, individuals must tip from overweight to obese or morbidly obese, and that liminal space is where many wind up languishing.

Taking matters into their own hands, some individuals try nutritionists or dieticians, but these specialists can be pricey and are not reimbursed by health insurance. People who manage to access these resources may achieve some near-term results, but they often fail to achieve long-term success (such as in the Biggest Loser study).

It’s often a unique combination of these tools—the right diet and the right type of exercise, combined with appropriate medications, counseling, lasting lifestyle changes, and surgery when necessary—that works for any given individual. But doctors are trained to write prescriptions, not lifestyle plans.

To get closer to the dream of personalized obesity treatments, we need more data—demographic, behavioral, environmental, socioeconomic—to piece together which combinations of solutions work for which types of people. If we can begin to tailor treatments to individuals, we hypothesize that we’ll start to see far better results and begin to address this epidemic.

Photo Credit: Obesity Traffic Sign from Big Stock Photo