If you take your garden-variety medical disorder, there is usually a pretty standard treatment, with perhaps some possible modifications based on your personal situation. Example: Atopic dermatitis. First line treatment is avoidance of triggers that may exist (hot showers, dry air, soap) and moisturizing lotion. Second line treatment is topical steroids. There are further treatments if these fail to work (probably oral steroids but not sure) and finally experimental treatments if everything else fails to work.
It seems to me that the medical conditions of overweight/obesity have approximately one bajillion different prescriptions for treatment. I’m not even sure if the medical mainstream has one they agree on, but even outside that, there are as many individual tailored “solutions” as there are people. If I started a thread on “how did you lose weight,” the answers would range from, “ate no carbs” to “ate only rice and veggies” to “exercised two hours a day” to whatever. “I ate 5 small meals a day,” “I ate only one meal a day,” “I ate whenever I felt like it.” It seems like the possibilities that work are endless (even though everyone is still fat).
Why isn’t there a standardized set of first and second line treatments for overweight/obesity? Is it because we rely on people to basically treat themselves, with vague guidelines of “burn more calories than you eat” and “here is the USDA food pyramid”? Is it because this disorder can have multiple underlying causes? Is it because there is no standard medicine? And why isn’t there a standard medicine? Lots of drugs have been shown to cause weight loss while you’re on them (stimulants being the first that come to mind). I imagine that most people would say, “well, those drugs have adverse side effects and you can accomplish the same thing without them.” But, when obesity is such an epidemic and most people aren’t “getting better” without drugs, why not use them? Yes, amphetamines can cause hypertension, but so can being overweight.
In fact, why isn’t overweight/obesity treated like hypertension? On your first visit, if your usually-normal bp is 145/80, your doc will tell you to eat less salt and exercise more. If on your next visit it hasn’t improved, he’ll put on you on a loop-sparing diruetic or whatever. He won’t sit there and try to figure out if you really did follow his guidelines, he’ll assume that either you’re not gonna or you did and they didn’t work, time for the drugs. Which have side effects, but the side effects are generally considered better than the disease.
I would really like to hear y’alls opinions on why overweight/obesity is not treated by a strict set of guidelines like other conditions.
Because, while most cases of obesity have a pretty simple cause, there are some other actually medical issues that can cause it.
The truth is, for most people, the formula is “Burn more calories than you consume, and you will lose weight”.
Allow me to repeat myself: For most people.
But we have raised a generation of needy folks who are convinced that they are different, that they have a reason, it’s not their fault.
“I can’t exercise, I have bad knees”.
“I can’t eat less, or I get sick.”
" I cant work out, my schedule doesn’t allow it."
We are one people, united in our quest for a really good excuse. And doctors have, no doubt, gotten tired of telling people what they need to do, and getting ignored or getting excused to death.
I, myself, am fat. It’s not glandular. It’s not my mom’s fault. It’s mine. I eat garbage, and I don’t exercise much. I’m getting better, slowly, but it took me time to get here, it’s gonna take me time to get back.
But even knowing all that stuff I said up there, it’s hard not to make excuses.
But again, with many other diseases, if pts in general don’t comply with a treatment plan, docs have no problem with a work-around.
Example: type II diabetes. Many times can often be treated w/ diet and exercise, but if doctors feel like that’s not working and your blood sugar keeps rising, they don’t keeping saying, “Just eat less sugar and jazzercise more,” they say, “here, have some metformin.”
Why isn’t there such standardization with weight gain? Let’s say you get to a BMI of 30, why aren’t you immediately put on a stimulant or something? Or at least given the option?
From Wikipedia,
“Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problem.”
Yes, its effects are indirect in that it only increases your risk for x, y and z, but the same is true of hypertension.
One of the problems with treating obesity is that the bodies natural tendency is to gain weight. This is one of the things that has been programmed into us after many eons of evolution. Unlike most other diseases where we are only trying to put things the way they should be, with obesity we are trying to change the naturally order of things.
Also, all the major treatments currently available have some major side effects, plus they only help to an extent. Obesity is really a lifestyle disease, people just eat way too much food, and don’t have enough activity. Even if you give them all the drugs possible, if they don’t get more excersise, or eat less, it won’t help anything.
Ok, you already know the treatment for obesity is to eat less. Stimulants don’t guarantee weight loss, appetitie suppresants, even stomach-stapling don’t guarantee success. Even if you get lipo and continue to overeat and don’t exercise you’ll be right back where you were.
In addition, with the cases you mention, diabetes, hypertension, the treatment applies to the cause of the problem. The cause of overeating is rarely known. If it’s compulsive eating, the patient could be treated for compulsive behavior. There are other specific causes that could be treated, but most don’t have a physical basis that can be treated with medication.
Finally, why do you think all cases of other medical problems have only one or two methods of treatment?
Well, I think many conditions are “lifestyle” conditions, but I think your second point gets at the heart of the issue. I think we just don’t have any drug/treatment that works well enough to become a standard regimen.
Although I’m not sure what the standard for “well-enough” is. Or why we don’t have a good treatment yet.
Because there is no effective long term solution for obesity as of yet to base an effective treatment plan on. So people are desperate for solutions. And when someone loses 10 or 15 pounds and keeps it off for 3 months that tends to be extrapolated into that being a long term cure for obesity (curing obesity requires losing over 20% of your initial bodyweight and keeping it off permanently). The concept of ‘eating less/exercising more’ ignores all the complex biochemical mechanisms the body uses to maintain its weight. Manipulating them so the body can stabalize at a lower weight and fat percentage is what is going to help people lose weight and keep it off and we really don’t know how to do that yet.
The only thing that kindof works is surgery. And even with that I think the long term success rate is about 40-70%. Diet and exercise kindof work, but they work more as a short term treatment and work more for a 5-10% reduction in bodyweight (not the 20-40% reduction needed by the truly obese). And encouraging a lifestyle we have spent so many billions of years evolving not to do is not realistic. That is why abstinence only education fails too.
I believe there is no standardized A, then B, then C treatment plan because nobody really knows how body weight works well enough to manipulate it safely long term. At the same time it is an issue so filled with moral condemnation and desire to believe we have cures when we really don’t that it clouds the issue. Some people eat 1-2 large meals a day some recommend 5-6 small. Some recommend tons of carbs with little fat some recommend tons of fat and few carbs. Fundamentally, we don’t know yet. If we did it wouldn’t be so common.
There are drugs, but I think the side effect profile is high. Plus many of the deaths associated with obesity are due to CVD (something like 60-70% of the deaths people attribute to obesity are due to increased cardiovascular risk factors) and the drugs increase those risk factors too. So from a medical standpoint it would arguably be like giving someone a drug to treat hypertension that has the side effect of causing more strokes and heart attacks. It defeats the purpose.
Even so, I think health risks of bodyweight occur more at the higher end (BMI of 35+), and drugs alone aren’t really capable of taking someone with a BMI of 35 and getting them down to 25 or lower. If they did, they’d probably need 3 or 4 drugs.
I read an article about Qnexa being pulled (a combo of phentermine & topamax for weight loss) because of safety concerns. The argument was that there is such a massive market for obesity drugs that millions will take them. If they find out 10 years down the road that there is a hidden danger that means tens of millions of people with serious health problems. So I guess they are more cautious.
Personally I can’t wait until 40 years from now when effective, safe treatments for obesity exists. All the time and energy wasted on it can be redirected to something productive.
The argument I’ve heard is that bodyweight maintenance is a redundant system, so taking a drug may work but eventually the body will find a way around it. However I don’t know if that works for weight gain. People who take SSRIs, antipsychotics, steroids, etc. tend to gain weight and I think it stays on as long as you take the drug.
Plus obesity as a major medical problem worthy of attention is fairly recent in our history, probably less than 20-30 years old. So there hasn’t been as much time devoted to researching it. Leptin and ghrelin, two hormones considered key in bodyweight maintenance were only discovered in 1994 and 1999 respectively. Who knows what other mechanisms and signals we haven’t even discovered yet since I have CDs older than those discoveries.
Having said that, the profit motive to treating it is massive. It is a disorder of people in wealthy countries (or the better off sections of middle income countries). And people want treatments. But who knows.
Thank you for two really insightful posts, Wesley. I actually think you answered my question.
You’re absolutely right about the newness of obesity being the reason a cure hasn’t been found. I’m sure they’ll soon make a monoclonal antibody against ghrelin and we’ll all be supersvelte.
There are guidelines. Guidelines for treating adults and different one for children. Guidelines spelling out exactly when bariatric surgery should be considered and so on.
Wesley’s point however is cogent: guidelines do not tend to get paid much attention if they do not actually lead to effective results, and for adults, short of bariatric surgery for the morbidly obese, no treatment plan has a good track record of achieving long term fat loss of the magnitude he is talking about. And when there is no evidence of any specific approaches superiority then anecdotal reports hold court. Sure it is easy to blame the patient but generally if the approach fails almost every one blaming the patient is considered bad medicine. Adult docs might do more good by at least steering patients away from approaches that are more likely to do long term harm and by helping redefine success NOT as becoming normal BMI or 20% weight loss, but as achieving long term life style changes of healthy eating habits and regular exercise for their own sake and hopefully with at least a lasting 10% weight loss. Not sure if this WebMD article is behind a firewall, but it summarizes it well:
Because a diet isn’t a regulated prescription, and therefore anyone can sell it. And so anyone does. And theirs needs to be different to the others if people are to buy it.
The NIH now has some clear (well, not perfectly clear) indications and contraindications for bariatric surgery. The short version is that you are eligble with a BMI over 40, or a BMI of 35-40 if you have added healthproblems like diabetes. Most health insurance companies adhere to those guidelines.
You’re using a different standard for treating obesity and your examples in the opening post.
Obesity does have a standard first line, which is eating less. There are a million different strategies to accomplish this, but the base treatment is still decreasing calorie intake. A second line is increasing the number of calories you burn. Again, there are a million different ways to accomplish this but they all have the same underlying goal. A final line could be surgery, prescriptions, or figuring out there is some other underlying cause that needs to be treated.
It’s very analogous to your example of first, second, and third line of dermatitis treatments, though I’m not sure I agree with your claim that most common conditions have standard first, second, and experimental lines of treatment.
My guess is, if you ask two doctors about how to lose weight in your particular case, both will prescribe more or less the same program. The “different treatments” arise outside the medical profession, this being a field where people assume that, e.g., a gym coach has as much of value to say as a doctor.