Challenging assumptions in obesity researchBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5303 (Published 22 November 2017) Cite this as: BMJ 2017;359:j5303
All rapid responses
Thanks for Sturgiss et al paying attention to my response . Of course, I agree with Sturgiss et al that obesity management is and remains a very big challenge for society as a whole . There are two aspects at the authors' reply worth mentioning.
Firstly, in my response, I pointed out that the basic problem of obesity has historically been known for a long time. I have not claimed that Hippocrates time is comparable to the present time. Furthermore, I have also mentioned that the English surgeon William Wadd (1776-1829) has already referred to the serious psychosocial side effects of obesity such as depression, social isolation and discrimination .
Secondly, I have explicitly written : "Today we know the complexity of obesity and the associated multiple comorbidities." Of course, I am also aware of the many multicausal and multidimensional interacting factors influencing overweight/obesity and their consequences :
- Energy balance: results from the balance between energy intake and energy consumption
- Biological factors: genetic predisposition, hormones/cytokines/other factors, age, sex
- Prenatal and infantile factors: infant nutrition, birth weight, gestational diabetes
- Lifestyle factors: nutrition behavior (food preferences, food selection and food preparation), physical activity, media consumption, sleeping behavior, smoking
- Social change: affluent society, fast-paced life style, ideal of beauty, urbanization, women’s employment, household structures, religion
- Socio-economic status: education, income, profession/occupation
- Agents of socialization: media, peer groups, family, kindergarten/school
- Food supply: advertising, food availability, serving size, external stimuli, price, food composition, labelling, food production/processing
- Infrastructure and neighbourhood: recreational/sports facilities, walkability, foodscape, environmental pollution
- Mental factors: emotions/stress, traumatic experiences, body image, self-esteem, depression, isolation, discrimination
- Comorbidities: metabolism, cardiovascular system, lungs, gastrointestinal tract, connective tissue/skeleton, carcinoma and others
- Costs: loss of workers‘ productivity, adaption to body size, clothing, diagnostics/therapy/rehabilitation
- Other interacting factors, which also have an indirect effect on the development of overweight/obesity: technological progress/globalization, nutrition competences, eating disorders, migration, quality of life and other factors
I support the proposed approach of Sturgiss et al for clinical practice, because this multidimensional process inevitably requires interdisciplinary and transdisciplinary collaboration in the planning and long-term implementation of preventive measures. Furthermore, I agree with the authors that obesity management should not focus exclusively on behavioral control of the individual, which I did not claim in my response. The following practical advice I have made : "In many cases, patients as well as physicians do not know that the period of consciously executing lifestyle change takes an average of eight weeks before it becomes an automated habit. Most people who wish to change do not pass this time span - often because they themselves had prescribed too much change in their eating and physical activity at the beginning - and then fall back into the cage of old behaviors. It is essential for permanent implementation in everyday life to focus on just a small lifestyle change! For example, a simple and effective tip to creating a long-term behavioral change would be: Drink 2 cups of water (500 ml) before each meal." In summary, I have just said that it is very important for the health of patients who are obese to internalize : 'I want to implement a small change in everyday life for eight weeks. And I know why I do it.' Why the authors discredit this practical action tip, I cannot understand. Most patients feel that medical practitioners have a crucial role in obesity management. And consumers also expect concrete and practical tips for action [5-8], especially because the obesogenic environments are so powerful.
1. Hofmeister M. Obesity management - an old health problem. BMJ Online [eLetter] 2017. Available at http://www.bmj.com/content/359/bmj.j5303/rr-0 [Accessed 9 January 2018].
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4. Hofmeister M. One tablespoon of dietary fiber more. Aust Fam Physician 2017;46(12):889.
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Competing interests: No competing interests
Hofmeister provides an interesting review of the history of obesity in response to our analysis of obesity trial outcomes. It is true that obesity is not a diagnosis that is limited to our time, but today’s prevalence of obesity is completely different to that in Hippocrates time.
Hofmeister suggests that this increasing prevalence, and lack of response to obesity management lies with the inability of individuals to make healthy choices about their everyday behaviour. But it would seem unlikely that today’s humans have vastly different choice-making ability to those in Hippocrates time. A common assumption of many physicians is that individual behaviour and choice is responsible for obesity. It is common for physicians to underestimate the implications of obesity biology. For instance, we know that once a patient with obesity successfully loses weight via lifestyle change, their metabolism slows and their hunger hormones increase.
Another change since the time of Hippocrates is that society has moved from a millennia of deficiency in the availability of food, to a recent 50 – 100 years of abundance. There is a clear association for the development of obesity and diabetes in individuals born into a food-rich environment who are epigenetically regulated for a low-calorie environment. This genetic drive towards obesity in the context of modern life is not accounted for when focusing solely on individual behaviour.
The changes in our lived environment, the pressures of working and family life, and the access to nutrition have definitely changed in recent times, and the interaction between the environment and the individual is and we have yet to understand how to best address the interaction between the environment and the individual in the clinical setting. The influence of environment on individual “choice” is well recognised in areas such as marketing and behavioural economics. These influences are yet to be recognised in medical practice. .
Furthermore, we know obesity pathophysiology is tied to complex neurohormonal mechanisms that protect against weight loss. Once the body has carried excessive weight for some time, the body will work to maintain this higher weight. Weight loss results in increased efficiencies of neurohormonal systems to maintain weight meaning it is more effort to just stay weight stable. For many, weight stability is a success.
As physicians we cause patients harm when we overemphasis individual choice, and do not help our patients to understand the hormonal and biological changes that occur when excessive weight is on the body for extended time periods. We do a disservice by suggesting that if only they made less “sinful” choices then weight would be lost and their BMI would return to a healthy weight range. A return, and maintenance, of BMI to a lower weight category is not the experience of large numbers of patients in observational studies or clinical trials.
Simply suggesting that patients try harder is not going to solve obesity. Patients have been telling us for many years that this does increase stigma, shame, and guilt and leads to them avoiding medical care. Weight bias and stigma are perpetuated by the mistaken notion that weight loss is solely under the individual’s behavioral control. Hopefully combatting this ignorance in clinicians will lead to improved patient-centered approaches to obesity prevention and management with a focus on optimisation of health.
A more helpful approach in clinical practice would be to:
- Educate ourselves and our patients on why it is difficult to reduce long-held body weight and to then maintain weight reduction;
- Emphasise to our patients the importance of weight gain prevention;
- For those that are living with obesity, help them to shift their focus away from body weight alone and onto health outcomes;
- Work with policy makers to influence our lived environments to become places where making a healthy choice is an easier one.
And finally, shaming medical practitioners for having obesity is not helpful. The work-life of medical practitioners has been associated with increasing rates of depression and burnout, factors that are also associated with the development of obesity. Doctors are human beings that live and work in the same obesogenic environment as everyone else. We need a humanistic approach to educating and supporting health professionals to provide a better standard of obesity care.
1. Sturgiss E, Jay M, Campbell-Scherer D, et al. Challenging assumptions in obesity research. BMJ 2017;359 doi: 10.1136/bmj.j5303.
2. Tsai AG, Histon T, Kyle TK, et al. Evidence of a Gap in Understanding Obesity among Physicians. Obesity Science & Practice:n/a-n/a doi: 10.1002/osp4.146.
3. Nolan CJ, Damm P, Prentki M. Type 2 diabetes across generations: from pathophysiology to prevention and management. Lancet (London, England) 2011;378(9786):169-81 doi: 10.1016/s0140-6736(11)60614-4.
4. Schwartz MW, Seeley RJ, Zeltser LM, et al. Obesity Pathogenesis: An Endocrine Society Scientific Statement. Endocrine reviews 2017;38(4):267-96 doi: 10.1210/er.2017-00111.
5. Dolan P, Hallsworth M, Halpern D, et al. Influencing behaviour: The mindspace way. Journal of Economic Psychology 2012;33(1):264-77
6. Fothergill E, Guo J, Howard L, et al. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition. Obesity 2016;24(8):1612-19 doi: 10.1002/oby.21538.
7. Fildes A, Charlton J, Rudisill C, et al. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American journal of public health 2015;105(9):e54-9 doi: 10.2105/ajph.2015.302773.
8. Holzapfel C, Cresswell L, Ahern AL, et al. The challenge of a 2-year follow-up after intervention for weight loss in primary care. International journal of obesity (2005) 2014;38(6):806-11 doi: 10.1038/ijo.2013.180.
9. Lewis E. Why there’s no point telling me to lose weight. BMJ : British Medical Journal 2015;350 doi: 10.1136/bmj.g6845.
10. Fernandez Nievas IF, Thaver D. Work–Life Balance: A Different Scale for Doctors. Frontiers in Pediatrics 2015;3:115 doi: 10.3389/fped.2015.00115.
11. National Mental Health Survey of Doctors and Medical Students. Australia: beyondblue, 2013.
12. Kimura D. Work and Life Balance “If We Are Not Happy Both in Work and out of Work, We Cannot Provide Happiness to Others”. Frontiers in Pediatrics 2016;4:9 doi: 10.3389/fped.2016.00009.
Competing interests: No competing interests
Thanks for Sturgiss et al paying attention to our response. We have read the reply carefully, and we hope to make a further explanation to the authors' responses so that editors and readers can better understand the relationship between weight loss and compliance.
Sturgiss et al pointed out that medication and lifestyle intervention differ in compliance because of individual differences. Although complying with lifestyle regime is more complex than medication adherence, the ultimate goal of both is consistent. Thus, clinicians pay the same attention to the practice and effect of lifestyle regime despite of individual differences. To solve this problem, we suggest that shared decision making between physicians and patients may help to develop a patient centered treatment, during which patients can act as partners and will be able to fully comply with such interventions (see http://www.bmj.com/content/359/bmj.j4218). On the other hand, weight loss and compliance are never “unconditional”, and are indeed considered in the overall health and willingness of the individual. Regarding the potential health risks of weight loss in obese patients, we believe that these are usually discovered and solved during follow-up, as treatment of chronic diseases is a long-term and interactive process.
In addition, although the clear relationship between weight loss and health outcomes needs further clinical trials to prove, we believe that weight loss may help when treating obese patients with metabolic risk factors or other chronic conditions. A recent study published in the Lancet on December 5th indicates that by intensive weight management, overweight patients with type 2 diabetes can achieve remission to a non-diabetic state and off anti-diabetic drugs (see http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)33102-1/fulltext). This is really exciting news to clinicians.
Based on the above reasons and our previous statements, we insist that weight loss, to some extent, can reflect the compliance of obese patients in the clinical practice. Thus, the value of weight loss should not be overlooked.
We welcome the authors’ further reply if any of our statements does not make sense.
Competing interests: No competing interests
Xu et al have stated that they believe weight loss is a sign that patients are compliant with a suggested lifestyle regime. We would like to point out that adherence to a medication differs from adhering to lifestyle changes in several ways. For instance, the expected clinical outcome of taking a prescribed medication are more consistent across the population than the outcomes of lifestyle change in obesity. Work in epigenetics reveals that the same physical activity level will have varying weight results in different people.1
Further, genetic profiles each hold different potentials for an obese phenotype.2 We would also further emphasise our point that weight loss may not always be a sign of health improvement. It is well recognised that weight loss is a “red flag” for serious health conditions in people without obesity, and this needs to be remembered in those living with obesity too. We encourage clinicians to look beyond simply weight loss, and look to markers of health improvement.3 Thus, we do not agree that weight loss should be considered an unconditional sign of patient “compliance”.4 Weight loss, even when intended, should be considered in the overall health and wellbeing status of the individual. In particular, when someone who has never been able to lose weight suddenly does.
1. Klimentidis YC, Bea JW, Lohman T, et al. High genetic risk individuals benefit less from resistance exercise intervention. International journal of obesity (2005) 2015;39(9):1371-5 doi: 10.1038/ijo.2015.78.
2. Locke AE, Kahali B, Berndt SI, et al. Genetic studies of body mass index yield new insights for obesity biology. Nature 2015;518(7538):197-206 doi: 10.1038/nature14177.
3. Sturgiss E, Jay M, Campbell-Scherer D, et al. Challenging assumptions in obesity research. BMJ 2017;359 doi: 10.1136/bmj.j5303.
4. Aronson JK. Compliance, concordance, adherence. British Journal of Clinical Pharmacology 2007;63(4):383-84 doi: 10.1111/j.1365-2125.2007.02893.x.
Competing interests: No competing interests
Clearly outlined prospects for research – I congratulate Sturgiss, Jay, Campbell-Scherer and van Weel for their article "Challenging assumptions in obesity research" . However, obesity is not just a disease of the early modern period. Already 2500 years ago, the physicians faced the problem of obesity. The Indian physician Susruta (about 600 BC), Herodicus of Selymbria (fifth century BC), Hippocrates of Kos (460-377 BC), Aulus Cornelius Celsus (25 BC-50 AD) and Claudius Galen of Pergamon (129-199 AD) knew that obesity is a serious threat to life and favors the development of many diseases. For long-term treatment, they recommended their patients moderation in eating and regular endurance and resistance training [2-5]. One of the timeless valid advices of Hippocrates was, for example, "Walking is man’s best medicine."
Regardless of these ancient findings, obesity was not considered a disease in the Middle Ages, and hardly mentioned except for case reports by some physicians, such as the German Balthasar Timaeus von Güldenklee (1600-1667). It was not until the end of the 17th century that doctors began to deal more intensively with the life-shortening disease. One of the first adipogenic dissertations published the German physicians Georgius Melchior Widemann (1652-1735) and Michael Ettmüller (1644-1683) in 1681 with the title "Disputatio Medica De Corpulentia Nimia" . In the early 19th century, the English surgeon William Wadd (1776-1829) published reports on obesity in his monograph "Cursory Remarks on Corpulence or Obesity Considered a Disease", which appeared in four editions . In addition to the physical effects of obesity such as dyspnea, sleep apnea, clumsiness, somnolence and general sluggishness, Wadd pointed to the serious psychosocial side effects such as depression, social isolation and discrimination. In 1952, the American Heart Association finally identified obesity as a clear cardiovascular risk factor. The Symposium on prevention of obesity by the American Heart Association on May 26, 1959 in the New York Academy of Medicine already stated in the conclusion : "The prevention of obesity should stand high on the list of health programs in order to make the best progress in controlling our health problems of the future."
Today we know the complexity of obesity and the associated multiple comorbidities . Many people who are overweight as children or adolescents are also obese in adulthood, as demonstrated by a recent NEJM analysis using simulation models . However, it is very common for obese patients today - and let me put it succinctly - to put the following thoughts to the physician again and again: "Doctor, the pill against it, but the sins maintained." Many people are less active in helping themselves stay healthy. They often do not listen self-responsibly to their biological system, ignore the really obvious 'fat' alarm signs and weaken through carelessness and unreasonableness almost purposefully the most valuable of their lives, namely their own body. In many cases, patients as well as physicians do not know that the period of consciously executing lifestyle change takes an average of eight weeks before it becomes an automated habit . Most people who wish to change do not pass this time span - often because they themselves had prescribed too much change in their eating and physical activity at the beginning - and then fall back into the cage of old behaviors. It is essential for permanent implementation in everyday life to focus on just a small lifestyle change! For example, a simple and effective tip to creating a long-term behavioral change would be: Drink 2 cups of water (500 ml) before each meal. However, primary care physicians/practitioners and other front-line health care professionals urgently need support for the long-term implementation of lifestyle behavioral principles and techniques in obesity management [12-14]. This also applies to the physicians' own obesity management, because it is hardly known that almost half of the physicians themselves are overweight or obese .
1. Sturgiss E, Jay M, Campbell-Scherer D, van Weel C. Challenging assumptions in obesity research. BMJ 2017;359:j5303
2. Tipton CM. Susruta of India, an unrecognized contributor to the history of exercise physiology. J Appl Physiol 2008;104:1553-6.
3. Christopoulou-Aletra H, Papavramidou N. Methods used by the Hippocratic physicians for weight reduction. World J Surg 2004;28(5): 513-7.
4. Kefalas N, Boriani F, Bellezza E, Bruschi S. Aulus Cornelius Celsus and his pre-modern patho-physiologic notions on obesity-associated morbidity and mortality. Obes Rev 2008;9(1):87.
5. Papavramidou NS, Papavramidis ST, Christopoulou-Aletra H. Galen on obesity: etiology, effects, and treatment. World J Surg 2004;28(6):631-5.
6. Widemann GM, Ettmüller M. Disputatio Medica De Corpulentia Nimia. Leipzig: Typis Krügerianis; 1681.
7. Wadd W. Cursory remarks on corpulence; or obesity considered as a disease: with a critical examination of ancient and modern opinions, relative to its causes and cure. London: J. Callow; 1816.
8. Sebrell WH Jr. Symposium on prevention of obesity. Summary of reports. Bull N Y Acad Med 1960;36:407-14.
9. Upadhyay J, Farr O, Perakakis N, Ghaly W, Mantzoros C. Obesity as a Disease. Med Clin North Am 2018;102(1):13-33.
10. Ward ZJ, Long MW, Resch SC, Giles CM, Cradock AL, Gortmaker SL. Simulation of Growth Trajectories of Childhood Obesity into Adulthood. N Engl J Med 2017;377(22):2145-2153.
11. Hofmeister M. One tablespoon of dietary fiber more. Aust Fam Physician 2017;46(12):889.
12. Hofmeister M. Obesity management: General practitioners need support. Aust Fam Physician 2017;46(9):630.
13. Kahan S, Manson JE. Nutrition Counseling in Clinical Practice: How Clinicians Can Do Better. JAMA
14. Hall KD, Kahan S. Maintenance of Lost Weight and Long-Term Management of Obesity. Med Clin North Am 2018;102(1):183-97.
15. Hofmeister M. Overweight/obese physicians: Data from different countries? Canadian Family Physician Online [eLetter] 2017. Available at www.cfp.ca/content/63/2/92/tab-e-letters#overweight-obese-physicians-dat... [Accessed 1 December 2017].
Competing interests: No competing interests
We agree with the idea proposed by Sturgiss et al. that weight loss does not necessarily improve health (1). Weight loss by non-scientific approaches may cause serious health issues. We are pleased to notice that these facts have been gradually accepted by the public. However, many clinicians emphasize the importance of weight loss when treating obese patients with metabolic risk factors (e.g. hyperlipidemia) or other chronic conditions (e.g. diabetes mellitus), because they believe that weight loss, to some extent, reflects patients’ compliance.
Patients’ compliance is extremely important for the outcome of clinical treatments. Albeit without a uniform definition, according to World Health Organization, compliance refers to the extent to which a patient’s behaviors, including medication-taking behavior, diet, and changes in lifestyle, coincides with health care providers’ recommendations (2). Noncompliance has always been a global problem in chronic disease management. It has been shown that, in developed countries, medication compliance rate among patients suffering chronic diseases averages only 50%, which is higher than that in developing countries (2). Noncompliance due to changes in lifestyle, such as changes in dietary habits and exercise regimens, is also common. Previous research demonstrated that only about 1/3 of patients comply with dietary regimens for one year (3).
Sturgiss et al. suggested that obese patients can benefit from lifestyle interventions even if their weight remains stable (1). We doubt this because compliance rate will likely decrease with increasingly complex recommendations from health care providers. Obese patients who are unwilling to make efforts to lose weight are unlikely to comply with complex lifestyle interventions. In fact, measures coping with metabolic risk factors or other chronic conditions usually help obese patients lose weight (4). Also, clinicians can assess such patients’ compliance based on weight changes within a period of time so as to find ways to enhance compliance. On the other hand, with the thought that health may be affected by overweight, obese patients are likely to turn to health care providers for advice. These patients usually comply with tailored lifestyle interventions very well. It is common that, compliance rate usually decreases over time, and maintaining a healthy body weight requires patients’ long-term compliance. By observing weight changes, obese patients themselves can constantly monitor their compliance as well, thereby overcoming problems caused by noncompliance in lifestyle interventions over time. Weight loss may not always improve health, but its significance in compliance cannot be overlooked.
Although a variety of strategies have been proposed in the literature, currently there is no “gold standard” for measuring compliance behaviors. Based on clinical findings, we believe that weight loss can help clinicians and obese patients with metabolic risk factors or other chronic conditions assess the extent to which medical advice have been followed. However, further clinical studies are required for understanding whether weight loss is a valid parameter for assessing the compliance of obese patients.
1 Elizabeth S, Melanie J, Denise CS, et al. Challenging assumptions in obesity research. BMJ 2017, 359: j5303 doi: 10.1136/bmj.j5303 PMID: 29167093
2 World Health Organization. Adherence to long-term therapies evidence for action. 2003. http://www.who.int/chp/knowledge/publications/adherence_report/en/
3 Miller NH. Compliance with treatment regimens in chronic asymptomatic diseases. American Journal of Medicine 1997, 102(2A):43-49 doi: 10.1016/S0002-9343(97)00467-1 PMID: 9217586
4 Anonymity. Losing Weight. 2015. https://www.cdc.gov/healthyweight/losing_weight/
Competing interests: No competing interests