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Shifting to Second Gear in Obesity Prevention?

Today, I am going to throw out a bold statement on the state of overweight and obesity in Western societies: The time for primary prevention is over!

With two-thirds of the population now overweight or obese, we must accept that primary prevention has failed, the obesity horses are out of the the barn, there is no longer any point in locking the doors.

Rather, it’s now time to move on to secondary prevention; so let’s round up a posse and chase after the horses to catch them before they gallop off a cliff.

In developed countries around the world (including the US), we are beginning to see rates of overweight and obesity leveling off. This is not because these countries have now implemented strict measures to prevent obesity or to be taken as evidence that any such measures are working. I believe that the leveling off in the rates of overweight and obesity simply means that everyone in the Western world, who can be overweight or obese is now overweight or obese. The remaining third, that still has a normal weight, is overweight resistant and will never become obese, so let’s stop worrying about them.

Epidemiologists know, that in every epidemic comes a time when everyone who can be affected is affected. Even during the worst flu epidemic, a significant number of people will not come down with the flu no matter how much they are sneezed on or or how close they live to those who are affected. Yes, they may even have the virus circulating in their blood, but will yet have no sign of clinical disease nor will they develop it.

Obesity is no different. We are all exposed to the same societal factors that drive obesity. We are all surrounded by food (mostly unhealthy), we are all deprived of sleep, we all have sedentary jobs, we are all short of time, less than 5% of us eat the recommended diets or receive the recommended amount of daily activity. So why are we not all overweight or obese?

Because some of us are simply obesity resistant. For whatever reason (genetics, different metabolisms, distinct gut bugs, more brown fat, exercise addiction, etc.), some of us are either simply not obesity prone or are managing well to keep it at bay. Even if circumstances were to become more obesogenic, this proportion of our population would still not gain substantial amounts of weight – they are either truly (genetically) resistant, or would simply double their efforts to ward off those unwanted pounds – these people (I often refer to them as the “mutants”) will simply never become obese baring a catastrophe (e.g. an immobilising injury or illness, being put on an obesogenic drug, post-traumatic stress, severe depression, losing their income, etc.).

These are not the people we need to worry about. Educating them about the merits of eating healthier or being more active is a waste of time and resources – they are already eating just fine (or are resistant to their junk food diets) and are already getting plenty of exercise (or simply don’t need exercise because they are “natural-born” fidgeters). Any dollar spent on educating or incentivising them (e.g. tax breaks) is a dollar wasted.

Rather, it is now time to switch gears, time to call a spade a spade, and time to move on to secondary prevention. As my epidemiologist colleagues are well aware, in contrast to primary prevention, secondary prevention is not about preventing anyone from getting the condition; it is about ensuring that the problem does not get worse in the people who already have the problem.

Normally, in secondary prevention, you focus your efforts solely on the people who have the problem. However, when two-thirds of the population have it, you may as well treat the whole population, because making exceptions for those who don’t have the problem may simply not be practical. When most people have iodine deficiency, supplementing foods with iodine makes sense, even if this means that some people who do not need more iodine will get more iodine (thereby slightly increasing their risk for hyperthyroidism).

But moving to secondary prevention also means using different and more intense interventions. Thus in the secondary prevention of heart attacks, it is no longer simply enough to cut out the salt and add 20 mins of exercise to your day. After that first heart attack, you definitely want to make sure that your blood pressure and cholesterol levels are well controlled, even if this means increasing your dose of medications. And we are no longer talking about smoking less – no, after that heart attack, smoking is an absolute “no-no”.

Similarly, in the secondary prevention of obesity, simply eating more fruit and vegetables or walking more steps will not be enough. It is likely going to take far more drastic changes to your diet and to your activity levels to halt progression or reverse your condition. Effective weight management is neither easy nor simple (if it was simple for you, you’d be in the weight-resistant category in the first place). Now that you already have the problem, you will need special attention, special dedication, perhaps even special treatments to stop gaining more weight and hopefully lose some of that excess weight and keep it off. To some readers, secondary prevention may sound much more like treatment than prevention – this is because secondary prevention is in fact far closer to treatment than prevention.

Indeed, moving to secondary prevention requires a drastic rethinking in how we address the overweight and obesity epidemic at a population level. The question no longer is, how to help thin people stay thin. The question now is, how to help overweight and obese people not gain any more weight and perhaps receive treatments that will help them lose some of that excess weight and keep it off.

This may still mean we need to rebuild our neighbourhoods, deal with food insecurity, improve our diets, promote physical activity, and everything else that we should have done years ago at the first sign of the epidemic. But, because today we should no longer be worrying about primary prevention (which may have been easier had we actually done it), we will need far greater resolve and efforts to support far more radical changes at a societal level (not dissimilar the lengths we go to to remove peanuts from schools) to begin seeing clinically significant changes in weight at a population level – I purposely use the term “clinical”, because we now talking of disease control rather than disease prevention.

Skeptics may ask, “But what about the children? Is there not still time for primary prevention there?” To them my answer is that I do not for an instant believe that we will make a dent in the childhood obesity epidemic without first (or at least concurrently) addressing adult obesity (see previous post on this). Thus, probably the best primary prevention for childhood obesity simply takes us back to more secondary prevention for their parents.

Simply distributing more condoms in a population where most people already carry HIV is a waste of perfectly good condoms. It’s now time to put the anti-retrovirals in the drinking water.

Banff, Alberta

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  1. Dr Sharma,
    Thank you for making this statement.
    Your work is relentless Pierrette & I both know.
    We at Thee Quest are leading a battle that means taking one step forward leads to two steps back.
    People have their ears blocked and primary care is not possible.
    Trying to implement secondary care will cost us many billions of dollars but it will be the price to pay to save “The Planet”.
    Thank you so much for all your great work.
    Pierrette & I and our whole Thee Quest team and supporters salute you.

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  2. Dr. Sharma – I am a big fan of yours, however your call to shift gears into secondary prevention with more intense population-based interventions for the currently obese makes me very nervous. Already in my eating disorder treatment work I see many young women who started out obese, develop severe eating disorders as they strive to make themselves into something ‘healthier’ and more culturally acceptable. Their fear of gaining any lost weight in this fat phobic world, makes treatment even more challenging. With eating disorders having the highest death rate of any other psychiatric disorder, I fear that renewed population based emphasis on the need to be more vigilant about diet and exercise will have devastating consequences for many vital young women and men. Any focus on prevention of any kind MUST ALWAYS be mindful of this. The caveat ‘first do no harm’ cannot be forgotten in this process – and is one which I know you ascribe to…so please keep it at the forfront of any further calls to action!

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  3. @Shelagh: You make a great point and we definitely need to be sensitive to not throwing out the baby with the bath water. While your concerns are valid, I have not yet seen convincing data that health messages (as opposed to fashion and body image messages) promote eating disorders. But nevertheless, your warning is certainly valid and important – first do no harm is always good (unless it leads to paralysis and inaction).

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  4. Perhaps it is time to look at what is common to those of us who have lost 100+ pounds by not following common media advise.

    I am down 55 kgs by not following your disciples advise. Start with Phil Maffetone two week test. Check out Jimmy Moore’s contacts, Beth Gerber, and CarbSmart, etc.

    When we start to not be hunger, the weight falls off. We need protein and fats, not many carbohydrates. Ban sugar in all forms, grains, manufactured oils. Eat real meat with fat, fish, liver, chicken, and plants. Life becomes simple. Learn to “live between meals”, and the problem goes away.

    Try living your post surgery diet, without surgery. Add vitamins.

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  5. Dr Sharma your comments option was closed for “Tuesday, October 19, 2010
    Shifting to Second Gear in Obesity Prevention?” post. I am not sure why…

    I hope this post will get its way to Globe and Mail/Scientific Journals to reach more and more poeple…the health care decision makres should hear you as loud and bold as you sound in here and hopefully be moved….

    Thank you and god bless you…

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  6. I agree with you that the time for primary prevention of obesity is over, but primary prevention of other conditions isn’t. Rather than classifying all people with BMIs greater than 25 as sick, assessing other indicators (I know your scoring system does this) is important.
    The perception of oneself as ill does not often help people to act well.
    I share Shelagh Bouttell RD’s concerns, particularly when it comes to interventions aimed at children.
    I admire your candor.

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  7. I think generalizing about Western societies can be misleading. E.g. apparently obesity is at 31% in the US and 8% in Switzerland. These are obviously very different situations, which probably warrant quite different tactics and strategies.

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  8. First of all I am not sure what primary treatment we are talking about here. My clinics offer supervised and non supervised exercise, (which I believe is the most important control factor to obesity) weight management counseling and nutrition education, disease prevention and physical therapy. We almost always are able to arrest growth among the MO and obese. Its a much bigger challenge to reverse obesity and help take the individual to a metabolic state that suits their psychological desire, however we are successful in many cases there too, it just takes time. I think a revisit of what primary care medicine should be, less drugs and more creative goal setting and education, as well as a secondary approach by government to encourage discipline in food choices, healthy weight attitudes and exercise. I certainly agree that current standards, even using BMI is ridiculous. I recently measured a woman who had lost 80 pounds from a roux en y, she was still half fat and had lost 45% of her lean tissue, what a mess! Her doctor has no role in the aftermath of what is left as a life of even more eating problems, rapidly advancing osteoarthritis and depression. There is so much left undone with obesity treatment….

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