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A Candid Discussion of Obesity

Published:October 14, 2014DOI:https://doi.org/10.1016/j.amjmed.2014.09.024
      This editorial is in response to the 3 articles in the August issue of The American Journal of Medicine regarding the ongoing and arguably still worsening epidemic of obesity in the United States.
      • Hannley P.P.
      Move more, eat less: it's time for Americans to get serious about exercise.
      • Alyeshmerni D.
      • Jackson L.
      • Palma-Davis L.
      • DuRussel-Weston J.
      • Eagle K.
      A university health system partners with community schools to focus on health and wellness.
      • Ladabaum U.
      • Mannalithara A.
      • Myer P.A.
      • Singh G.
      Obesity, abdominal obesity, physical activity, and caloric intake in US adults: 1988 to 2010.
      All physicians, and many nonphysicians, know the first rule of Medicine: Primum non nocere. First, do no harm. I'm not sure there is a second rule, but common sense suggests that if what you are doing isn't working, do something different. In fact, it is often best to do the exact opposite.
      Despite tremendous efforts, we have made little, if any, progress in the war on obesity. I think we have become so enamored with various tactics, from creating food and beverage environments to expanding the role of schools, health care providers, insurers, and employers, that we have forgotten the core strategic objective: get obese people to lose weight.
      For this discussion, the final common integrator of the adequacy of a diet is the patient's weight. Whether the patient's diet is high in fast foods, processed sugars and fats, or one with more vegetables, fruit, and natural starches and sugars, if they are overweight, they are eating too much. If an 80-year-old man whose only activity is attending the local Bingo game on Wednesday night consumes 1500 calories per day yet has a body mass index greater than 30, he eats too much. If a 25-year-old construction worker burns 4000 calories per day but has a body mass index greater than 30, he eats too much. If a middle-aged woman super-sizes her cheeseburger and fries and washes it down with a diet soft drink and has a body mass index greater than 30, she eats too much. We will not make progress until we tell obese patients they eat too much, and it is their personal responsibility to eat less.
      Obesity advocacy groups have, unfortunately, in my opinion, been too successful, that is, their advocacy has, if anything, increased obesity. No reasonable person will purposefully say anything to hurt another person's feelings. But by labeling almost any term that refers to being overweight as pejorative, the rhetoric of obesity advocacy groups has become so shrill that it precludes an objective discussion of the problem. Crying foul when there is no foul, accusing someone of bigotry when none was intended for comments that are not prejudicial, is a blatant attempt at intellectual intimidation. By trying to prevent stigmatization, they have encouraged overweight people to continue their unhealthy habits.
      We must stop shifting causation. I purposefully avoid the word fault, because that implies a judgment. It is the business of the fast food industry to turn a profit by making tasty, inexpensive food. They do not force anyone to eat too much. The soda industry does not force anyone to drink too much. Many thin people, including me, enjoy occasional fast food in moderate amounts and a daily soft drink. Television, computers, video games, the government, society in general, the microbiome, or some as yet unidentified environmental toxin or mysterious force is not the cause of obesity. Obese people must recognize that their weight and health are their personal responsibility.
      People show a range of metabolic rates. Those blessed with a high rate seem to have a hollow leg, eating (almost) everything they desire while maintaining a svelte figure. Those cursed with low metabolism sometimes just glance at a donut and must let their belt out a notch or 2. Some patients make a conscientious, good-faith effort on their diet and exercise yet still have so much difficulty with their weight that an intervention such as bariatric surgery is indicated. Those who lament another 10-lb weight gain with “Doc, I only eat 1000 calories a day” would clearly profit from further dietary consultation. In the end, the scale is the final arbiter: unbiased, totally objective, cold, calculating, even sometimes cruel. No matter what their metabolism, if people eat more calories than they burn, they will gain weight. If they eat less than they burn, they will lose weight.
      Alyeshmerni et al,
      • Alyeshmerni D.
      • Jackson L.
      • Palma-Davis L.
      • DuRussel-Weston J.
      • Eagle K.
      A university health system partners with community schools to focus on health and wellness.
      at the University of Michigan, have conducted a wide-ranging and well-intentioned effort involving public schools, foundations, industry, and health care providers called “Project Healthy Schools.” I believe the best contribution the public schools could make to fight the obesity epidemic is to drop culinary arts classes and have mandatory physical education every day.
      I consider some of the recommendations of “Project Healthy Schools” to be personally intrusive, such as changing vending machine design and options and understanding the implications of sugary beverages. They advocate “evaluating the culture of a community.” What does this have to do with an obese person eating too much? Possibly the Ann Arbor group would agree to a “cultural evaluation” of their community.
      I worked at Granite City Steel (1970-1973) in the summers between college and medical school. My mother packed my lunch bucket: a ham and cheese sandwich on white bread, a dill pickle, a fresh vegetable in season, and a 2-pack of Twinkies, all washed down with a thermos of whole milk. My snack at break time was a Coke and a bag of potato chips or a Snickers bar. Surely such a diet now would cause me to be reported to the school's “wellness champion.” Would an “empowered volunteer” take it upon themselves to confiscate my Twinkies? “It's for your own good.” We must be careful indeed, when someone who thinks they know better tells another person what to eat and how to run their life.
      It is my intention that this editorial stimulates conversation and new ideas and directions, because the current proposals seem to be making no progress against obesity. It is not my intention to offend anyone, although some will say they are. I strongly suspect that many think as I do about obesity, but have been unwilling to speak up for fear of suffering the opprobrium of their colleagues. Now is your chance.
      The Institute of Medicine suggests that “a bold, sustained, and comprehensive approach is needed” to tackle the problem of obesity.
      • Institute of Medicine
      Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.
      I wholeheartedly agree and suggest the best place to start is by simply telling the patient the truth. “Sir or Madam, it's not OK to be obese. Obesity is bad. You are overweight because you eat too much. You also need to exercise more. Your obesity cannot be blamed on the fast food or carbonated beverage industry or on anyone or anything else. You weigh too much because you eat too much. Your health and your weight are your responsibility.”

      References

        • Hannley P.P.
        Move more, eat less: it's time for Americans to get serious about exercise.
        Am J Med. 2014; 127: 681-684
        • Alyeshmerni D.
        • Jackson L.
        • Palma-Davis L.
        • DuRussel-Weston J.
        • Eagle K.
        A university health system partners with community schools to focus on health and wellness.
        Am J Med. 2014; 127: 687-688
        • Ladabaum U.
        • Mannalithara A.
        • Myer P.A.
        • Singh G.
        Obesity, abdominal obesity, physical activity, and caloric intake in US adults: 1988 to 2010.
        Am J Med. 2014; 127: 717-727
        • Institute of Medicine
        Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation.
        The National Academic Press, Washington, DC2012

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