Treat the Obesity First?

So, I've been struggling with an internal debate about the new guidelines from the Endocrine Society about treating obesity and comorbidities.That's why I'm late to this party.

On the one hand, I think recognition of obesity as something that can and should be treated is great. On the other, I worry that putting obesity--defined here solely by BMI--above actual health problems is a risky, dangerous proposition.

The Good

It's refreshing to see guidelines for obesity treatment that view medications as positive and not as last-resort efforts. Of course, these are the guidelines for "Pharmacological Management of Obesity".

There is a clear recognition of the array of factors that cause obesity. 

The Bad

The labeling of individuals with obesity is clear from the start. Throughout the document, individuals are referred to as "obese patients" while diabetes is "patients with diabetes", not diabetics. The first and most important step in treating obesity appropriately is recognizing it as a disease, not a characteristic of the person.

One of the only recommendations they make based on the highest-quality evidence is that lifestyle modifications be included in all obesity treatment. I'm not pretending for moment that lifestyle modification is NOT useful, but it doesn't work long-term. A wide variety of reasons exist for this, from an unsupportive environment to metabolic changes occurring as a result of weight loss. The evidence is just not that good.

Successful treatment is defined only as weight loss. If someone stays at exactly the same weight, but show clear improvements in health, have we failed?  If weight loss occurs and there are no improvements in comorbidities, have we succeeded?

Health, not weight

I suppose my greatest concerns are with the media reporting of the guidelines, more than the guidelines themselves. Most articles report, and the lead author comments, that the "new paradigm" is the "treat the obesity first, then the comorbidities". I think the message should be "treat the obesity along with the comorbidities" and that's actually closer to what's in the actual guidelines.

Treating obesity is something that we absolutely, 100% need to do, and do more effectively. However, I can't overstate my opinion that we must view everything through the lens of health. Obesity is not simply size.

The Ever-Repeating New Year's Resolution

 A year ago I wrote:

"As a rule, I do not make New Year's Resolutions. I won't go into why, lest you think I'm some crunchy granola hippie, which I'm definitely not. But New Year's Resolutions are usually about doing something that's hard, something that you believe will make you a better person. A singular focus on weight loss is not about being a better person, it's about self-hatred of the person you are. You can't change the external you, no matter how much you hate it. You can change the internal things you feel and the choices you make. Perhaps external changes will follow, but if they don't have you truly failed?"

I guess not much has changed in the last year. The introduction to the New Year has come with all of the typical ads for diet and exercise products. Although I think I'm seeing more "get healthy" and less "lose weight", Slim-Fast is still front and center at my Walmart. I'm fighting crowds (crowds!) at my gym, and clearly everyone else has determined *my* elliptical is best. And, of course, all will return to normal by February, sadly.

Last year, we decided to try to eat sugar-free, which is actually turning into no added sugar and as little processed food as possible. It's working fine, though I must admit it wasn't a life-changing cure for all that ails us, as many other bloggers insisted it would be. Maybe we didn't eat enough processed food to begin with. But it has highlighted one of the problems we are facing in this world. A few months into really doing this with gusto, I'm STILL reading every. single. label. I can't trust that all tortilla chips are just corn, or that sour cream is just cream, or even that apples are just apples.

So, for the New Year, we have a bunch of people who are trying to get healthy (or lose weight, or whatever other positive or negative conception of that goal), and the deck is stacked against them. The part of my field that cares about nutrition still can't decide what's actually best, so we keep creating interventions without even knowing what to change. We try to help people individually, but no amount of education will ever overcome what we see in grocery stores. People try and try, and maybe they are healthier but the scale hasn't changed, or maybe they aren't feeling better, or maybe they just get tired of reading every single label, and they give up.

I don't blame them. Our knowledge base is a mess. The environment is designed to make them fail. The medical treatments, though better, are shameful. The only part of this obesity equation that isn't a disaster are all the individuals who live with it. They are trying--at the gym, at the grocery store, not just sitting around being lazy. People are doing what we tell them to do, but the message that gets told is from a mess of a dietary knowledge base, an environment that uses green boxes and "gluten free" to sell health, and doctors who don't know about or offer the few available medical treatments.

I'll come back to this in 2016, and everyone will be back again, trying, hoping, that this year will be different. Some year, maybe it will be.

**I promise my next post will not be so pessimistic! But that's not a New Year's resolution...