As I prepare to spend the rest of this week educating health professionals in Ontario on how to better manage obesity in their practice, it is perhaps appropriate to remind ourselves that Canada is not alone in attempting to tackle this problem.
Indeed, we need to look no further than the Australian Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children for a succinct summary of reasons just why obesity management is so difficult:
- Regulation of body weight involves complicated feedback systems that result in changes in appetite, energy intake and energy expenditure.
- While excess weight in individuals usually results from a prolonged period of energy imbalance, the causes of overweight and obesity are complex.
- Diet and physical activity are central to the energy balance equation, but are directly and indirectly influenced by a wide range of social, environmental, behavioural, genetic and physiological factors—the relationships between which are not yet fully understood.
- Individuals may be at greater risk of weight gain at particular stages in their lives.
The guidelines remind practitioners of the fact that body weight underlies tight regulation through a complex homeostatic system:
“While this system defends against weight gain as well as weight loss under normal circumstances, energy balance cannot be maintained when an energy surplus is sufficiently large and sustained. Weight gain will begin and usually continue until a new weight results in increased energy expenditure and energy balance is re-established. The same physiological mechanisms then seek to maintain energy balance at the higher weight, and will defend against weight loss by increasing appetite and reducing energy expenditure) if there is an energy deficit. As a result, most overweight and obesity results from upward resetting of the defended level of body weight, rather than the passive accumulation of excess body fat.”
This acknowledgement is a vast step forward from previous simplistic views of obesity which falsely view it as just a matter of “calories in” and “calories out”, which falsely imply that individuals should be able to achieve any desired weight simply by volitionally changing this balance through willpower alone.
Indeed, the reality is that the vast majority of individual attempting this “balance” approach to weight management will fail miserably only to gain the weight back.
Thus, the Australian guidelines are not shy about declaring a better need for pharmacological treatments and promoting the more extensive use of bariatric surgery for individuals with sever obesity related health problems.
A clear reminder to all of us that current treatments for obesity are insufficient and better, safer and more accessible treatments are urgently needed.