Some Limitations In Applying The Etiological Framework To Obesity Assessment

To conclude this series of citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, that guides us through a systematic assessment of factors influencing energy metabolism, ingestive behaviour, and physical activity, it is important to consider some limitations of this (and any other) etiological approach to obesity management:

While we have taken efforts to provide a comprehensive and wide‐ranging list of considerations in the assessment of obesity, we fully recognize that a full work‐up of all permutations of the proposed factors may well be beyond the scope of a busy practitioner. In this regard, the old saying applies: ‘when you hear hoofs, think of horses not zebras’. Thus, consideration should be first given to the most common and obvious reasons laid out in this paper, many of which should be immediately apparent to the experienced clinician (e.g. homeostatic hyperphagia resulting from meal skipping, hedonic hyperphagia related to depression, immobility due to osteoarthritis, weight gain due to atypical antipsychotics, etc.). Also, the use of comprehensive self‐directed questionnaires such as the Weight and Lifestyle Inventory, a multiple‐page self‐report questionnaire that the patient completes before treatment visits, designed to identify the root causes of obesity and perform an environmental analysis, may be helpful in this regard. Future efforts must also aim to provide simple clinical algorithms that will guide the busy clinician through the maze of factors that can potentially precipitate and/or exacerbate positive energy balance.

Nevertheless, as in a patient with oedema, despite complete recognition of the underlying factors, the clinician often has no option but to manage the patient with the judicious use of fluid restriction and diuretics. Similarly, in patients presenting with obesity, the underlying contributing factors (e.g. genetics, addiction, depression, back pain, etc.) may not be easily amenable to causal treatment. In these cases, ‘symptomatic’ treatment of obesity with caloric restriction and exercise regimens may well in many cases prove to be the only option. Nevertheless, we maintain that careful identification and management of the possible socio‐cultural, psychological and biomedical barriers will likely increase the feasibility, compliance and adherence to these measures. Recognition of the causes and barriers will also help set out realistic expectations regarding the degree of weight loss that is likely to be achievable and sustainable, an important aspect of weight management. Despite the increased time required for the comprehensive work‐up of an obese patient, we believe that this framework will eventually save costs by allowing clinicians to specifically identify and target the causes and barriers of positive energy balance, rather than resorting to the ‘one‐size‐fits‐all’ (eat less – move more) approach to obesity, which given its limited efficacy, can only be considered wasteful.

Commentary: While the proposed etiological framework can help understand why a given person may have obesity, and, more importantly, help identify important barriers to weight management, we must also realise that virtually every patient, irrespective of the underlying drivers or weight gain will face the same biological challenges when it comes to long-term weight loss – the fact remains, that our bodies can harness a host of powerful neuroendocrine mechanisms to defend against weight loss and promote weight regain. This is why in clinical practice, I often see that the best that addressing the underlying cause of weight gain achieves is the slowing or elimination of further weight gain. Thus, for example, even if painful arthritis and immobility may have caused weight gain in a given patient, a joint replacement will not automatically result in weight loss. Similarly, taking a patient of an atypical anti-pyschotic will not lead to much weight loss, nor will treatment of sleep apnea. When you remove the cause of weight gain – you stop weight gain – you do not generally reverse the process and end up with significant persistent weight loss. Thus, identifying and addressing the drivers of weight gain is only the first step in obesity management. Once weight is stabilized, we can proceed with developing a treatment plan for sustainable weight loss (as indicated).

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