Getting serious about obesityBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f1300 (Published 11 March 2013) Cite this as: BMJ 2013;346:f1300
All rapid responses
David Stuckler and Sanjay Basu are, of course, right that doctors alone cannot counter the obesity pandemic, but I don’t suppose anybody ever thought they could.
The authors write “There is no clear evidence that we can tackle obesity effectively without public regulation or the threat of regulation of unhealthy food industries,” but they could legitimately replace “without” with “with.” We don’t have clear evidence full stop.
Then the authors write “The history of tobacco control shows that progress against vested interests will not come without a fight.” Stuckler has argued elsewhere that food companies should be treated like tobacco companies—that is, as pariahs—but I think he’s wrong. (1) It’s too simplistic to extrapolate from tobacco to food, particularly in a world where so many people are undernourished.
I wrote last week about what Nestle are doing to make their food healthier, promote health, and reduce their use of carbon and water, (2) and other companies, including Unilever and Pepsico, have made similar moves. They make them partly because there is money to be made from healthier products as people care more about what they eat.
I’m sure that there will be a need for further regulation, and often big food companies argue for it themselves to avoid the predicament of losing competitive edge when they follow the law and smaller companies ignore it. But I think that we have a much better chance of countering obesity, undernutrition, non-communicable disease, climate change, and water shortages by working with these huge global companies than by treating them like tobacco companies.
1 Stuckler D, Nestle M. Big Food, Food Systems, and Global Health.
PLoS Med. 2012 Jun;9(6):e1001242+. Available from: http://dx.doi.org/10.1371/journal.pmed.1001242.
2 Smith R. Nestlé—a force for good or ill? http://blogs.bmj.com/bmj/2013/03/20/richard-smith-nestle-a-force-for-goo...
Competing interests: I work for a private company, which probably makes me more sympathetic to the private sector. I'm an unpaid trustee of C3 Collaborating for Health, which takes the position like WHO that a "whole of government whole of society" approach is essential to counter NCD and that includes working with food companies. I have no financial connection with food companies.
Given the ballooning epidemic that is obesity in the UK and many other western countries, it is hardly surprising that various educational interventions are failing disastrously. Given this, the figures quoted for those who will be eligible for bariatric surgery is astonishing, but again, not surprising.
But there is an obvious medical intervention which is conspicuous by its absence which lies somewhere between the poles of health promotion and invasive surgery--drugs.
Sadly, this is one area of pharmacological advances which has consistently failed to deliver results. There is a long history of drugs which have made it to market, and indeed to be relatively effective with respect to assisting weight loss, but which have ultimately been found to be have life-threatening potential complications.
The serotonin enhancing agent, fenfluramine, was marketed in the US in 1973. It became extremely popular, particularly in combination with a noradrenaline reuptake inhibitor called phentermine (combination was marketed as Fen-Phen). After thousands upon thousands of prescriptions were issued in the US and across the world, fenfluramine was discovered to precipitate cases of valvular heart disease and pulmonary hypertension. In one study which assessed ex-users of the drug, 20% of women and 12% of men were found to have valvular damage.
The amphetamine like drug, Phenylpropanolamine, had been marketed since the 1960s, and indeed was available over-the-counter in many countries as a diet aid. It was withdrawn from the market in most countries in 2001 after it was found to be associated with a significant risk of haemorrhagic stroke.
The cannabinoid receptor (CB1) antagonist, Rimonabant, was marketed in 2006, only to be withdrawn in 2009, after studies linked it to serious psychiatric complications, including suicidality.
The serotonin and noradrenaline reuptake inhibitor, Sibutramine, was the most recent culprit. It was marketed in, only to be withdrawn from most countries in 2010 after evidence suggested it was associated with a raised incidence of cardiovascular events, including myocardial infarction and CVA.
Such has been the failure of producing an effective AND safe appetite-suppressing anti-obesity agent, that we are only left with the lipase inhibitor, Orlistat, a drug with it's own unpleasant, if not life-threatening side-effects. This year will see the re-introduction of Phentermine, this time in combination with the anticonvulsant, Topiramate (it received FDA approval in July last year). Only time will tell whether it proves to be a safe anorectic agent. If it does, it would offer a valuable option prior to having to resort to serious surgical intervention. Fingers crossed.
Competing interests: No competing interests