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Arguments For Calling Obesity A Disease #4: Limited Response To Lifestyle Treatments



Continuing in my miniseries on why obesity (defined heresharma-obesity-exercise2, as excess or abnormal body fat that affects your health) should be considered a disease, is the simple observation that obesity responds less to lifestyle treatments than most people think.

Yes, the internet abounds with before and after pictures of people who have “conquered” obesity with diet, exercise, or both, but in reality, long-term success in “lifestyle” management of obesity is rare and far between.

Indeed, if the findings from the National Weight Control Registry have taught us anything, it is just how difficult and how much work it takes to lose weight and keep it off.

Even in the context of clinical trials conducted in highly motivated volunteers receiving more support than you would ever be able to reasonably provide in clinical practice, average weight loss at 12 – 24 months is often a modest 3-5%.

Thus, for the vast majority of people living with obesity, “lifestyle” treatment is simply not effective enough – at least not as a sustainable long-term strategy in real life.

While this may seem disappointing to many (especially, to those in the field, who have dedicated their lives to promoting “healthy” lifestyles as the solution to obesity), in reality, this is not very different from the real-life success of “lifestyle” interventions for other “lifestyle” diseases.

Thus, while there is no doubt that diet and exercise are important cornerstones for the management of diabetes or hypertension, most practitioners (and patients) will agree, that very few people with these conditions can be managed by lifestyle interventions alone.

Indeed, I would put to you that without medications, only a tiny proportion of people living with diabetes, hypertension, or dyslipidemia would be able to “control” these conditions simply by changing their lifestyles.

Not because diet and exercise are not effective for these conditions, but because diet and exercise are simply not enough.

The same is true for obesity. It is not that diet and exercise are useless – they absolutely remain a cornerstone of treatment. But, by themselves, they are simply not effective enough to control obesity in the vast majority of people who have it.

This is because, diet and exercise do not alter the biology that drives and sustains obesity. If anything, diet and exercise work against the body’s biology, which is working hard to defend body weight at all costs.

Thus, it is time we accept this reality and recognise that without pharmacological and/or surgical treatments that interfere with this innate biology, we will not be able to control obesity in the majority of patients.

Whether we like it or not, I predict that within a decade, clinical management of obesity will look no different than current management of any other chronic disease. Most patients will require both “lifestyle” and probably a combination of anti-obesity medications to control their obesity.

This does not take away from the importance of diet and exercise – as important as they are, they are simply not enough.

Despite what “lifestyle” enthusiasts will have us believe, diet and exercise are no more important (or effective) for the treatment of obesity, than they are for the treatment of hypertension, diabetes, dyslipidemia, depression, or any other condition that responds to “lifestyle” interventions.

In the end, most patients will require more effective treatments to manage their obesity and all of the comorbidities that come with it. The sooner we develop and make accessible such treatments, the sooner we can really help our patients.

@DrSharma
Edmonton, AB

4 Comments

  1. In my experience the best treatment for diabetes, hypertension, hyperlipidemia, and depression
    is precisely weight loss through diet and exercise and other lifestyle changes (cognitive therapy self-talk for depression, not medications for most people. And the cure can be permanent without medications.
    Sorry , for being one of those lifestyle enthusiasts. I estimate about one third of patients have some other inborn error of metabolism/hormones/etc. that require override with medication for correction.

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    • Hi Barbara, I happen to be a person living with obesity. I have been fighting this for over 45 years. I have done the lifestyle change over and over again. I have lost and gained hundreds of pounds I have spent thousands of dollars. It is absolutely too simplistic to say change your lifestyle. People around you don’t change because you do. You can’t get rid of your parents because you don’t like the food they cook, it would be wonderful to think that some cognitive therapy would work. Believe me I have looked into that one a great deal. How brutally unfair it is for people to say try for the rest of your life to fix it, all the while we live with stigma, shame a low self worth because somehow we didn’t change our lifestyle enough, change jobs, change friends and family on the remote chance just to maybe…maybe one day be healthy. It’s like saying how dare we stick our heads out of the sand and ask for some medication to help. It’s time to take a long hard look at your attitude about obesity and ask yourself do I think of diseases like this, or just fat people because they don’t deserve the same options for treatment as all other diseases?

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      • Well said Jodi. This narrative of calories in/calories out is just accepting a cultural belief that is not backed by those who live with this condition. It’s a “blame the victim” mentality that just has to change. It is much more complex.

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  2. I understand the argument against previous intervention studies. However, due to the time restraints of the studies the argument that MOST need more than a lifestyle behavior change is exaggerated. I do think that there r those that need more; I just disagree with the verbiage of MOST.

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