Is Obesity Self Inflicted?

Several years ago I observed a doctor consulting with an extremely obese lady, who was clearly suffering from several obesity related comorbidities. She was short of breath, had wet swollen and ulcerated legs, and struggled to mobilize on two walking sticks that wobbled precariously under her weight. I remember thinking this was a lady with a short and unhappy future. I heard the doctor say to her “You know what the problem is, it’s what you put in your mouth, and you know what to do about it”.

Obesity is becoming an increasingly prevalent health care problem in the UK and the world over with 38% of adults in the UK being overweight and 24% obese in 2006. In 2006 24% of people aged 16 or over in England were classified as obese. This was almost double the 15% observed in 1993 demonstrating an alarming increase in population obesity^{1 2}. In 2002 the National Institute for Health and Clinical Excellence (NICE) estimated there were 1.2 million morbidly obese people in England and Wales, and that this would increase by 5% per annum.

Obesity has a significant number of serious co-morbidities, such as Type II Diabetes, Heart Disease, Hypertension, Sleep Apnoea, Osteoarthritis, Gall Bladder Disease, Fatty Liver Disease, Cancer, Asthma, Chronic headaches, Varicose veins, Coronary artery disease, GORD, and Hernias. Each of these carries a significant burden upon the NHS budget, as well as being a significant cause for public concern. The loss of life expectancy in obese patients is significant with a loss of 12 years of life for a 25-year-old morbidly obese man³. Obesity is also linked to increased levels of anxiety and depression^{4 5}.

In 2006 NICE estimated that the costs to the United Kingdom from obesity were between £6.6 billion – £7.4 billion per annum. These costs are due to the increased prescriptions received, higher frequency of medical contact, and loss of productivity associated with obesity (estimated at £2 billion by the National Audit Office, 2001).

Traditionally, the first choice for treatment of obesity has been through the modification of diet and the uptake of exercise. Diets have become so popular that it has supported a multi billion pound industry. There are no official statistics for spending on diet products, but estimates vary from $40bn to $100bn in the US⁶ alone.

Despite this large amounts of money and effort spent on dietary weight control, the evidence suggests the results are poor in the long term with up to 66% of patients regaining their weight within 2 years and 95% within 10 years^7-9 .

In conjunction with dietary modification, some success has been observed in the short term (up to 4 years) with pharmacotherapy (e.g. Orlistat, Sibutramine, Rimonabant). Patients receiving drug treatment are more likely to achieve 5% and 10% weight loss thresholds^{10 11}, however, the long term results are also disappointing with 90% of people regaining their weight upon cessation of the drug^{11 12}.

Despite the poor long term outcome of diet modification and pharmacotherapy, these are still the medical treatment of choice, meaning thousands of obese patients in the UK and worldwide are receiving inadequate treatment of their obesity, and have little hope of avoiding the associated co-morbidities and an early death. It seems that for decades the health care profession’s main approach to obesity is diet and exercise, and despite increased public awareness, constant diet and exercise advice, and billions being spent on diet products; obesity is still increasing. Wasn’t it Einstein who said only a fool would repeat the same experiment twice and expect different results?

How long is it until we stop banging this square peg into a round hole and recognize something doesn’t make sense? Should we be treating this significant health problem with what is essentially behaviour modification? Is weight really under complete conscious control, or is it similar to respiratory rate where it can be wilfully altered in the short term only. Isn’t weight really under homeostatic control, and isn’t hunger and satiety part of this mechanism? 

I’m 100% behind the promotion of good diet and exercise for healthy life and disease prevention, but as a treatment for obesity I wonder whether we are failing our patients by prescribing it and then assuming it’s their fault when it doesn’t work? Is obesity self inflicted, or is it a serious disease that is remains poorly treated and misunderstood?

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1. The Information Centre. Statistics on obesity, physical activity and diet: England, January 2008: The Information Centre, 2008.
2. Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obes Surg 2003;13(3):329-30.
3. Kevin R. Fontaine PDTR, PhD; Chenxi Wang, MD; Andrew O. Westfall, MS; David B. Allison, PhD. Years of Life Lost Due to Obesity. JAMA 2003(289):187 – 193.
4. Sullivan M, Karlsson J, Sjostrom L, Backman L, Bengtsson C, Bouchard C, et al. Swedish obese subjects (SOS)–an intervention study of obesity. Baseline evaluation of health and psychosocial functioning in the first 1743 subjects examined. Int J Obes Relat Metab Disord 1993;17(9):503-12.
5. Dixon JB, Dixon ME, O’Brien PE. Depression in association with severe obesity: changes with weight loss. Arch Intern Med 2003;163(17):2058-65.
6. Laura Cummings. The diet business: Banking on failure: BBC News, 2003.
7. National Institute of Health. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults : NHLBI produced publications, 2000.
8. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393-403.
9. McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003;139(11):933-49.
10. Li Z, Maglione M, Tu W, Mojica W, Arterburn D, Shugarman LR, et al. Meta-analysis:pharmacologic treatment of obesity. Ann Intern Med 2005;142(7):532-46.
11. Padwal R, Li SK, Lau DC. Long-term pharmacotherapy for overweight and obesity: a systematic review and meta-analysis of randomized controlled trials. Int J Obes Relat Metab Disord 2003;27(12):1437-46.
12. Derosa G, Cicero AF, Murdolo G, Piccinni MN, Fogari E, Bertone G, et al. Efficacy and safety comparative evaluation of orlistat and sibutramine treatment in hypertensive obese patients. Diabetes Obes Metab 2005;7(1):47-55.