Partha Kar: Our approach to tackling obesity needs rethinking
BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3034 (Published 06 August 2020) Cite this as: BMJ 2020;370:m3034All rapid responses
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Dear Editor
Partha Kar rightly suggests that we need to update our obesity guidance (Our approach to tackling obesity needs rethinking BMJ 2020;370:m3034). Indeed, we have already conducted reviews1,2,3,4,5,6 of our weight management guidance and concluded that our guidance should be updated in several areas. In 2019 and early 2020, before we needed to prioritise COVID-19 therapeutically critical topics at the start of the pandemic, we carried out extensive stakeholder engagement to help us begin to restructure and reposition all our weight management guidance. We believe that, by taking a different approach and looking at our whole suite of weight management guidance at the same time, rather than looking at each one separately, this will make updating them more efficient and timely in the long run.
References:
1. https://www.nice.org.uk/guidance/ng7/resources/surveillance-report-2017-...
2. https://www.nice.org.uk/guidance/ph47/resources/surveillance-report-2017...
3. https://www.nice.org.uk/guidance/ph53/resources/surveillance-report-2017...
4. https://www.nice.org.uk/guidance/ph42/resources/surveillance-report-2017...
5. https://www.nice.org.uk/guidance/cg43/resources/surveillance-report-2017...
6. https://www.nice.org.uk/guidance/cg189/resources/surveillance-report-201...
Competing interests: No competing interests
It is timely that half a century on from Hart's Inverse Care Law the key messages have yet to be applied to nutrition and weight management in England. In order to sustainably tackle the obesity epidemic, we must review the socioeconomic driving forces behind it, rather than simply reviewing the current guidelines. Despite Hippocrates first noting the huge impact of environment on health, two and a half millennia later the burden of responsibility is still placed on the obese individual (1).
Socioeconomic status (SES) determines reliable food access and diet quality. The Food Standards Agency estimated that 34% of those in the lowest income quartile experienced food insecurity in 2017, increasing their risk of malnutrition (2). This is reflected in UK obesity rates; childhood obesity in 2017 was 15.4% higher in those of a low SES (3). As 730,000 more people were not paid between March and June 2020 the percentage of the population falling into this category will only increase (4).
Hall and Kahan demonstrate that sustained weight loss requires long term lifestyle change with regular healthcare contact and support (5). Such changes are greatly hindered by the current obesogenic market environment, where ultra-processed calorie dense foods are still much cheaper than fresh produce (2). Increased education on healthy lifestyle and diet is inconsequential if these changes remain unaffordable and out of reach to those most in need.
A sustainable obesity strategy must therefore include changes to the market environment, working to increase the affordability of healthy options. A two-tiered approach may be beneficial, but any medical strategy is likely to fail whilst wider market inequalities exist.
1. Hobbs M, Radley D. Obesogenic environments and obesity: a comment on ‘Are environmental area characteristics at birth associated with overweight and obesity in school-aged children? Findings from the SLOPE (Studying Lifecourse Obesity PrEdictors) population-based cohort in the south of England’. BMC Medicine. 2020;18(1).
2. Power M, Doherty B, Pybus K, Pickett K. How COVID-19 has exposed inequalities in the UK food system: The case of UK food and poverty. Emerald Open Research. 2020;2:11.
3. Public Health England. Patterns and trends in child obesity: national and regional data. 2020.[cited 18 August 2020] https://www.gov.uk/government/publications/child-obesity-patterns-and-tr...
4. Office of National Statistics. Labour market overview, UK - Office for National Statistics [Internet]. Ons.gov.uk. 2020 [cited 18 August 2020].https://www.ons.gov.uk/employmentandlabourmarket/peopleinwork/employment...
5. Hall K, Kahan S. Maintenance of Lost Weight and Long-Term Management of Obesity. Medical Clinics of North America. 2018;102(1):183-197.
Competing interests: No competing interests
Dear Editor,
Partha Kar calls for a rethink on how we tackle obesity (1). I suggest that we do not waste too much of our resources on trying to treat obesity but focus more on measures to prevent obesity.
The paper by Hall and Kahan, that Kar refers to, explains it all (2). Most of the weight lost during “treatment” is regained. This is because of overlapping physiological responses to weight loss – metabolic slowing and endocrine adaptations that increase appetite and decrease satiety.
Consistent with this reality, an analysis of weight changes in 278,982 participants in the UK Clinical Practice Research Datalink over 9 years found that the probability of an obese person reducing to “normal weight” over 12 months was less than 1% and that most of those who did succeed would eventually regain that weight (3).
One explanation for the resilience of the modern obesity epidemic is that it represents a phenotypic plastic response to the increased consumption of refined carbohydrates (4,5).
Thus, the only solution is regulation and taxation of the food environment, particularly the food environment directed at children.
Recently, Prime Minister, Boris Johnson, made a relevant announcement. He has proposed a ban on the advertising of “junk foods” on television before 9 pm, a ban on the positioning of lollies and chocolates near supermarket checkouts and an increase in the tax on sugar sweetened beverages and other “junk foods” consumed by children. This is the way forward.
1
Partha Kar: Our approach to tackling obesity needs rethinking. BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3034 (Published 06 August 2020)Cite this as: BMJ 2020;370:m3034
2
Hall KD, Kahan S. Maintenance of lost weight and long-term management of obesity. Med Clin North Am 2018;102:183-97.
3
Bradley, P. Refined carbohydrates, phenotypic plasticity, and the obesity epidemic. Med. Hypotheses 2019, 131. 109317 [Google Scholar] [CrossRef]
4
Bradley P. The role of phenotypic plasticity and palatability | The BMJ
https://www.bmj.com/content/361/bmj.k2538/rr-0
Competing interests: No competing interests
Re: Partha Kar: Our approach to tackling obesity needs rethinking - Treating chronic diseases without tackling excess adiposity promotes multimorbidity
Dear Editor
Its timely to have a discussion on obesity, and Partha Kar makes some excellent points (1) that should spark wider discussion. The reality is we need to do much more on both prevention (changing the obesogenic environment, though no easy task) and treatment of obesity. In the UK alone, near 4-5M people are living with obesity and an associated medical condition and would benefit from sustained weight loss. Ongoing trials are providing hope that many conditions can meaningfully improve with such weight loss, but we need much more investment in both lifestyle and drug related trials since, as Kar suggests, we lack sufficiently powered trials in many areas.
Furthermore, in a recent paper (2), we explained how paradoxically part of the reason for rising number living with long term chronic conditions is due to great successes in other aspects of care and prevention. For example, advances in cardiovascular treatment (including large reductions in smoking) have led to substantial declines in related outcomes including premature cardiovascular deaths. At the same time, treatment gains in many other chronic diseases e.g., diabetes, heart failure, rheumatoid arthritis, multiple cancers etc. mean many more are now living far longer with chronic diseases and often with greater weight levels than ever before. In addition, rising population obesity levels allied to less smoking leads excess weight to be a more common player in many conditions. The result is greater lifetime obesity exposure in many. As obesity is either a cause or accelerator of multiple conditions, more people living with one chronic condition now go on to develop a 2nd, 3rd or multiple complications linked to obesity in one way or other, increasing suffering and health care costs. Health care professionals see many such patients in clinics and wards on a near daily basis.
Based on such evidence, we suggested that policy makers need to be more proactive in obesity prevention and effective weight management should receive research funding to match the search for novel therapeutics for secondary chronic diseases (2). Whether weight targeting should occur far earlier in the management of numerous conditions is a critical and timely question but, for this to happen, we need to generate the relevant evidence. Finally, we need to empower all health care professionals with the best knowledge on weight management (via mandatory and well-developed e-learning) and to provide a range of imaginative patient-friendly tools to better help tackle and prevent obesity.
1. Partha Kar: Our approach to tackling obesity needs rethinking BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m3034
2. Sattar N, McMurray JJV, McInnes IB, Aroda VR, Lean MEJ. Treating chronic diseases without tackling excess adiposity promotes multimorbidity. Lancet Diabetes Endocrinol. 2023 Jan;11(1):58-62. doi: 10.1016/S2213-8587(22)00317-5. Epub 2022 Nov 29. PMID: 36460014.
Competing interests: Consulting/speaker honoraria: Abbott Laboratories, Afimmune, Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Hanmi Pharmaceuticals, Janssen, Merck Sharp & Dohme, Novartis, Novo Nordisk, Pfizer, Roche Diagnostics, Sanofi Grant: AstraZeneca, Boehringer Ingelheim, Novartis, Roche Diagnostics