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Institute of Medicine Big on BMI, Eat Less and Move More

This week, the US Institute of Medicine released an impressive 500-page thome called “Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation“.

The report extensively reviews population and policy issues relevant to obesity prevention.

However, it also includes a brief chapter on obesity treatment and access in health care systems.

The following are some of the key recommendations from this section pertaining to health care:

Goal: Expand the role of health care providers, insurers, and employers in obesity prevention.

Recommendation 4: Health care and health service providers, employers, and insurers should increase the support structure for achieving better population health and obesity prevention.

Strategy 4-1: Provide standardized care and advocate for healthy community environments. All health care providers should adopt standards of practice (evidence-based or consensus guidelines) for prevention, screening, diagnosis, and treatment of overweight and obesity to help children, adolescents, and adults achieve and maintain a healthy weight, avoid obesity-related complications, and reduce the psychosocial consequences of obesity. Health care providers also should advocate, on behalf of their patients, for improved physical activity and diet opportunities in their patients’ communities.

Potential actions include

• health care providers’ standards of practice including routine screening of body mass index (BMI), counseling, and behavioral interventions for children, adolescents, and adults to improve physical activity behaviors and dietary choices;

• medical schools, nursing schools, physician assistant schools, and other relevant health professional training programs (including continuing education programs), including instruction in prevention, screening, diagnosis, and treatment of overweight and obesity in children, adolescents, and adults; and

• health care providers serving as role models for their patients and providing leadership for obesity prevention efforts in their communities by advocating for institutional (e.g., child care, school, and worksite), community, and state-level strategies that can improve physical activity and nutrition resources for their patients and their communities.

Strategy 4-2: Ensure coverage of, access to, and incentives for routine obesity prevention, screening, diagnosis, and treatment. Insurers (both public and private) should ensure that health insurance coverage and access provisions address obesity prevention, screening, diagnosis, and treatment.

Potential actions include

• insurers, including self-insured organizations and employers, considering the inclusion of incentives in individual and family health plans for maintaining healthy lifestyles;

• insurers considering (1) benefit designs and programs that promote obesity screening and prevention and (2) innovative approaches to reimbursing for routine screening and obesity prevention services (including preconception counseling) in clinical practice and for monitoring the performance of these services in relation to obesity prevention; and

• insurers taking full advantage of obesity-related provisions in health care reform legislation.

While all of this is well intended – it is really much of the same with little new insights for the practitioner.

As readers of these pages are well aware, if recording people’s BMIs and counselling them on eating less and moving more only worked, we’d probably have solved the obesity problem by now.

I may have missed it (have yet to work my way through all of the 500 pages) but I certainly did not see much that would actually help practitioners address and manage the ‘root causes’ of obesity – which, are not simply eating too much and not moving enough!

Nowhere do I see the authors address the importance of mental health, stress, time, genetics, medications, and countless other issues relevant for weight gain and its management. Nor do I see much on the urgent need for medications or the role for surgery. Entirely missing is a recommendation to address bias and discrimination in health care settings (this would have been my #1 recommendation for the entire document!) or in simply accommodating those with obesity so that they can even access proper health care in a professional, sensitive, and caring environment.

Like I said, I may have missed these passages – if yes, I apologise – if they are actually missing, this report is unlikely to change much in obesity management.

Lyon, France


  1. Now isn’t that just peachy, Dr. Sharma? Another 500 pages of “nonsense” published by a bunch of bureaucrats. And, at what cost to the U.S. taxpayers?

    Oh, well, if NOTHING ELSE, the U.S. Institute of Medicine provides employment in the States.

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  2. why do they keep pushing the very thing which has failed for 40 years? I think it must be moneyed interests suppressing any real answers, solutions or exploration of other causes.

    This statement is absolutely correct…

    “As readers of these pages are well aware, if recording people’s BMIs and counselling them on eating less and moving more only worked, we’d probably have solve the obesity problem by now.”

    I wrote this addressed to obesity researchers, but it could be for obesity policy makers too.

    “Why isn’t anyone caring to find out, how fat bodies [especially super-sized ones]really function?

    I suppose this really doesn’t surprise me:

    BIRMINGHAM, Ala.—Researchers at the University of Alabama (UAB) at Birmingham School of Public Health say a “white-hat bias” abounds in obesity research, and may skew reported results. White-hat bias is described as the “tendency to distort information about products regardless of the facts, when the distortions are perceived to serve good ends.”
    In the case of obesity research, results may be misrepresented by scientists operating with particular biases on topics related to weight, nutrition and the food industry, as well as biases toward products like sugar-sweetened beverages, and practices like breastfeeding, according to the UAB study

    There are a few of you thinking outside the box, not letting lies about obesity blind you, but there needs to more in that category.

    Some questions to ask yourselves as you go forth with more research:

    If we do not know these things, then how can anyone help fat people?

    1. Why are fat people hungrier?

    2. Why do some people stop at a certain weight and some keep gaining?

    3. Why with even the pressure of immobility, severe health problems and worse etc, do so many people fail in losing weight?

    4. What is the actual human range in metabolism?

    5. Why is so much of the research focused on weight loss surgery? Surely other options should be explored?

    6. Why can’t more people admit that fat bodies operate differently then thin ones?

    It’s time to really study the severely obese, this country is getting fatter, and more needs done. Some out there need to do a LOT BETTER. “

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  3. Somedays, I’m just weary. I want to shake scientists by both shoulders and say: You know, you just need to Assume Less and Think More! Why don’t you try the thinking lifestyle?!

    The cultural mythology advances.

    Keep talking, Dr. S. The tide’s just gotta turn someday.

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  4. Hopefully some of those points will have a trickle down effect and actually become useful. Perhaps in the next decade or so, but I doubt it.

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  5. I wish there were some way to get the food industry to make this all easier for people by improving the quality of the product.

    As for me, I’ve been successful at weight management by eating less and moving more, but I know I’m in a minority that way.

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  6. Debra, I’ve been feeling much the same way with the recent hype over the “Weight of a Nation” thing. Tired, tired, tired, and not enough time or mental energy to try to counter the general heaping of abuse for fat people this will lead to.

    The best part about beating your head against a wall is stopping, and this nation simply needs to stop equating weight with health. I don’t know if we could have created a better way to push people up the scale than scaring them and then prescribing calorie deprivation. Yep, let’s disconnect people from their body’s own signals and screw up their metabolisms. As an added bonus, why don’t we shame them if they dare to exercise in public? I read blogs and books from women much larger than me who have shared photos of themselves as teens. They didn’t look much different than I did. The big difference I hear in their stories again and again is that someone “helped” them start dieting, which mercifully didn’t happen to me.

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  7. I think everyone is ultimately successful by eating less and moving more, but the whole complexity of the problem lies in how each person’s brain reaches that point. Saying that you can cure obesity by eating less and moving more is like saying you can cure insomnia by falling asleep. Well yes … but how do you GET there is the real problem.

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  8. Why don’t we treat obesity like Arterial Hypertension ? First of all , a correct assesment, ending in a risk stratification (like EOSS). Next, a “life long coaching” (just like hypertension), because in most cases there is in 2012 no clear etiology, no cure …
    Treatment is today a mix of : medication (?? which one is left ? Xenical ?), lifestyle management, surgery and …. waiting for “environmental change” (if possible ??) We are animals, not robots. We are mammals, not insects. We are Homo Sapiens (neocortex) and no more Cro Magnon (paleocortex). We live in Western Europe, not in Africa. So why isn’t it “the survival of the fittest” in an obesogenic toxic environment. The “fittest” in these decades is maybe that human being managing his “energy balance” in a changing environment. Western society can be helpfull to change the obesogenic environment, but do they understand it ??? like (b)advertising, promote and sustain meat production, ..

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  9. Hi Dr. Sharma,

    I am super-obese. Unlike most SO people, I never yo-yo dieted. I’ve never been on any medication except once briefly on digitalis (I was born with a slight heart murmur) and once briefly on asthma inhalers (and a few antibiotics over the course of life). I work full time, I am almost never ill or off work (and am always irritated at the “fat people are sick more” thing–if you “confound the variables” by including SICK people then why yes, but how about you remove all the people who aside from fat do not have a present-disease? Since it’s very possible that the adipose system is connected to the immune system, so people aren’t sick because they’re fat (although there’s some of that) but fat because they were getting sick?). I have always had a mid to upper management role, although now I work from home via computer and have become incredibly sedentary.

    I was well over 520# at one point. That happened after two years of going downhill confusingly. Went to the doctor and explained I had a level of exhaustion no mortal should ever have. He pointed out I worked a day job, evening/weekend second job from home, and had a toddler. Yes, but it didn’t use to be like this, I assured him. My short term memory was gone. I was falling asleep in micro-naps on the highway. Sometimes memory was so bad it was like ‘factoids in first person’ were floating around “unattached to a timeline.” I wasn’t sure if something happened a week before or 5 years before. Terrifying. He tried to prescribe me prozac. I told him, I don’t mean I emotionally feel like sleeping, I mean my body is exhausted so bad something is wrong! He wouldn’t check thyroid (my request), since it he said given my size, enlarged heart would just give me all the same symptoms anyway, so he’d like me to eat less and move more and when I was thinner we could talk again. As I thanked him and left his office he called after me, “I could make it St. John’s Wort if you prefer something natural!” OMG talk about missing the point.

    Well it turns out, in addition to severe sleep apnea which I might add, was made way exponentially worse by the weight gain accompanying this lack of real diagnoses, I’d had “chronic bronchitis” (which I mentioned to him) for a long time. Turns out they were untreated “asthma” lung infections. I’d never had asthma in my life, why now? When the symptoms reached the point that my body wouldn’t allow me to sleep because it believed I would not wake up, I went to ER (after cleaning the house, showering… I’m a bit type A). They checked me in immediately. I was so oxygen deprived it’s terrifying I was driving a car at all. The brain problems were pure hypoxia, deadly, lack of oxygen to the brain. The exhaustion was lack of O2 body-wide. After 4 days in the hospital breathing heated steroid, they sent me home with an oxygen tank to regrow the villi in my lungs. Once that was taken care of, I was much better of course, although alas, I was also about 200# heavier than I’d been when I first went to the doctor. Not his fault, he didn’t know. The respiratory specialist gave me a bunch of expensive inhalers. I asked him what the cause was. I got a bunch about how NC Texas was so allergenic. I pointed out I was now in NE OK. Another about how exposure to new things might relate. Not a single mention of food. I was a single mom then with no insurance but I paid out of pocket. My assigned cardiologist (from a 4-days-of-steroids, missed-vein-pain and family-stress combo when in the hosp) was much more helpful. He ‘prescribed’ me the protein power lifeplan book and I bought it, changed my eating, and much improved.

    I lost down to 370# via low carb. Having energy for the first time since my early 20’s was like suddenly being “me” again. And then that stopped. Who knows why? The experts when people say this online act like they’re making it up. I also then had reactive hypoglycemia even to an egg/sausage breakfast, and I saw other people reporting that too and a couple experts flatly told them no it wasn’t happening–a way of obviously saying, “You’re either a moron or you’re lying.” These are lowcarb-specializing doctors, for godssakes. Don’t you know, according to researchers, fat people just can’t quit lying.

    I went up and down a little bit (30#) for a few years (I went on LC when I was 40, I will be 47 later this year), as I tried to find a carbohydrate source that might make me feel better, enough energy to function–even a third as good as I had while losing the weight–and usually the minute I upped carbs, I was gaining weight again (or eating everything in sight once I ingested a decent chunk of carbs).

    I am currently 440# and have completely abandoned weight loss as an effort, as it serves only to injure and demoralize me, is my experience. Not gaining any more and being as healthy as I can work out at this weight, is my goal. It took a long time to get my head around this and let go of resentment as I “didn’t dare hope” for nearly 20 years and then when I did, all the guru MDs made it sound like if you just didn’t eat carbs you’d magically end up skinny, and the initial weight loss made me “hope” a ton I hadn’t dared, and then dashed that when my body really just wasn’t up to letting that much weight go and changed how it reacted to me eating the same things and was trending so hard toward regain it was ridiculous.

    I believe I further damaged my body by a different kind of malnutrition that might have affected both liver and thyroid function. VLC did work for me losing a lot of weight fast but changed my body in other ways that didn’t seem for the better. This is not a fault of the concept or eating plan, it’s the fault of how I implemented it. I was happy to eat muscle meats (later only once a day in ‘intermittant fasting’), maybe some minimal veggie/cheese, and that was it. More seemed a pointless effort; having energy to plan / shop / prep / cook / clean is tough at this weight (and as a FT+ working single mom). I expect if I’d been eating bone broths and organs it would have been fine but I wasn’t.

    At one point my body wouldn’t go into hard ketosis. I had a crisis response (I literally believed I would die if I didn’t get carbs within minutes, and I think I was probably right; I had never before considered that maybe at a certain level of health or size, the liver sometimes just cannot put out enough ketones. If I did not head toward food within about 10 seconds my body would burst out bawling on its own as if I were not even the one crying, very weird). I decided maybe my liver wasn’t up to it anymore, so I did an experiment I called “Hypernutrient” where I collected supplements for nearly a year (I’m a single mom, so it took awhile to afford them!), everything that sounded useful (vitamins, minerals, herbs, and misc.), and then just intermittantly took a variety of stuff. Too many variables to track so I tried to do it in such a way that any poor reaction would have some ‘venting’ time for the body and whatever it needed most it would at least be getting intermittantly. About 9 months later I was able to shift into ketosis again. I still felt no energy at all, not acceptable, but at least I wasn’t having crisis response.

    I discovered gluten intolerance. Ditching gluten made my severe asthma, severe allergies, severe acid reflux, a degree of brain fog, and several other symptoms vanish in <2 weeks, and severe sleep apnea lessened greatly. I discovered I don’t much react to intake of magnesium for example unless it’s extreme, but if I put the oil all over my torso, arms and thighs at night it’s a really major change (energy) the next day. This got me thinking that a whole life of gluten damage likely made malnutrition far worse and hence my weight.

    I have a secret suspicion that if you took a graph of the population, grabbed the highest weight segment (say 400# and up), and then looked into a random collection of those using tests of the sort enterolab does and some nutrient-absorption-tests, that you might find that is the category of people who are
    (a) intolerant to “the culture’s most common foods” in this case that would usually be gluten and dairy (and sometimes corn), but
    (b) NOT so intolerant that pain or actual disease came into play. If there are different genetic ways to manifest reaction to a problem, the people who react by ‘getting fatter’ (without any seeming limit), rather than getting another disease or pain (as the latter would either catch the problem earlier, or kill them before they reached that weight, or put them on other medications that might interfere with the weight variable), they might be the biggest people.

    I never dieted until I was 40. Well, once. After a huge sudden weight gain in my early 20s (~ I have often talked with other MO and SO people about lowcarb, as it dropped at least some weight quite fast. (I theorize that most women won’t lose more than 200# on any eating plan [let alone keep it off] no matter what their starting weight…. years of watching thousands online suggests it’s true.) They all said to me, “Oh, I could never live without bread.” Seriously. Nobody ever says that about broccoli, you notice? In pretty much every case, by now those people are either severely diabetic or dead. I think someone should make something akin to the effect of methadone when you do drugs, except for wheat. Just getting most huge people off that single food and upping their protein, when people are willing to try, I’ve seen that make a world of difference.

    PPS> Last time I checked, my blood pressure was good, my lipids panel was good, my heart rate is fairly high but given my weight and sedentary that’s expected. My blood glucose is fine, with a tendency to being too low (reactive, doesn’t go very high but drops really low). I’m 47 so I think some hormone issues are starting to arise but that might not be fat’s fault. Aside from allergy to codeine and intolerance to my culture’s dominant foods, I am actually ridiculously healthy, seldom ill, and highly functional outside the physically sedentary issues. And if I had even a shred of energy so I could get back to weight lifting and walking I’m sure I would return to my previous state at this weight (when the weight was coming down)–I was doing heavy landscaping work on my property to rival the pros I hired to help me, and I was fine. This idea that you have to be skinny to be strong and oxygen adapted is bunk.


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  10. I would like to know how many of those who are considered of normal weight nipped weight gain in the bud through “eat less, move more”. I doubt these cases are documented. “Eat less, move more” has been given a bad rap but how do we know it has not been perfectly successful for many people?

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