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We Don’t Know Much About Obesity

Nature Outlook Obesity 2014For a condition as prevalent and dangerous as obesity, we know surprisingly little about its causes and cures.

This is the first sentence by Nature Outlook Editor Tony Scully, in a special edition dedicated entirely to obesity.

The volume features both articles by science writers as well as a selection of original contributions on topics ranging from AgRP and the FTO gene to food addiction and the microbiome.

This edition also features and updated map of the worldwide prevalence of obesity – many readers may well be surprised to learn that obesity rates are now as high in parts of central America, northern and southern Africa and in parts of the middle East as they are in North America. Indeed, obesity rates in South Africa are “off the chart”, no approaching almost 40% of the entire population.

This leaves millions of people around the world in need of more effective treatments. Blue-eyed utopian notions that we can somehow help these millions by re-engineering societies to eat-less and move more (as suggested in a rather unfortunate contribution to this edition by David Katz), are naive at best and present a disservice to those hoping for real and practical solutions at worst.

The simple truth is that for the vast majority of the folks with obesity we simply have no effective treatments, let alone a cure.

As Tully notes,

“The best way to lose weight is to eat less and exercise more. But as a strategy to combat obesity at the population level, this common-sense prescription is proving ineffective over the long term.”

Sure, not everyone carrying a few extra pounds has a “disease” and we are doing an increasingly better job of managing obesity related health problems – certainly one reason why people with excess weight are today living far longer than a few decades ago.

But for those who would rather treat their obesity than be on medications for their high blood pressure, diabetes, and joint pain and perhaps rid themselves of their CPAP machines, there are few treatment options: diet and exercise, i.e if you wish to live off 1400 Cal with 400 Cals of daily exercise (as the folks in the National Weight Control Registry manage to do) or opt for bariatric surgery (a rather drastic measure by any stretch).

Indeed, there is currently no greater “therapeutic gap” for a common chronic disease, than there is for obesity.

Hopefully, as science advances we will eventually stop playing the “shame and blame” game and rightly abandon the utopians who sit awaiting the day when Big Food and Big Cars will finally see the light (by mercifully going out of business).

Stay tuned for more on the articles in this issue – stay tuned.

Edmonton, AB


  1. “The best way to lose weight is to eat less and exercise more.”

    The problem with this recommendation is that it assumes we know what the problem is. Apparently we don’t. And while a solution of this sort may appeal to our sense of the obvious, it fails to take into consideration the impact of food choices on gut microbiota, appetite, hormonal balance, nutrient balance, and nutrient sufficiency. To complicate matters, gut microbe profile is also determined by what sorts of microbes have been ingested in the past and one’s history of antibiotic use.

    Fortunately, headway is being made in terms of sorting things out.

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  2. The NWCR estimates our exercise at 60 minutes a day, not 400. Its calorie estimates are horribly off. They don’t ask us what we calculate our calories to be, but ask us to recall various food groups we eat from, then they deduce based on our answers. However, they leave out important items, and recently they stopped offering an option of “never” on various food groups — you can only say that you “rarely” eat them. Guess what, there are foods I NEVER eat. It’s ridiculous that they assert anything about calorie count at all.

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    • Thanks Debra for picking up my little typo – it’s 400 Cal not mins – at least that’s the number that is floating around in their publications.
      I’ve changed it in the post.

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  3. I would like to see the national studies do a ten year 1400 calorie study and see how few reach the end of the study a few months sure a year maybe 10years will help the others see just how hard maintenance really is.

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  4. So …
    1400 cals a day
    (or thereabouts, depending on personal details)

    and 400 cals worth of moving around a day

    That doesn’t seem like too onerous a course of treatment, as treatments go.

    You can go through bariatric surgery and afterward you have to limit your diet to only 1400 cals with other food restrictions too, and you have to exercise.
    All that pain and expense and time and you still end up dieting and exercising.

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    • …with the difference that bariatric surgery allows you to live on 1400 cals a day without feeling starved or deprived, which is why it works. I have not met many people, who are willing to live off a 1000 cals a day for the rest of their lives (i.e. 1400 cals minus 400 cals in exercise).

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  5. People have long tended to assume that they know the causes behind BOTH extremes in weight, complete w biases against people at both extremes, yet the reality is that each is turning out to be more complicated than thought. I think the incorrect assumptions that both overweight and underweight are understood, and lack many possible causes, have resulted for too long in a failure to sufficiently study these extremes.

    Personally, I would like to see more research into BOTH extremes, since both need it and because knowing more about either might give leads for the other. Now that people finally are investigating one perhaps soon there will be research on both.

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  6. I’ve always been curious about the NWCR calorie number… 1,400 is indeed low, but how accurate is it? Studies have shown time and time again that people often grossly underestimate the number of calories they eat. Just some food for thought…

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    • Whatever the actual number, it is lower than most people would “spontaneously” eat. Importantly, it is far less than people “naturally of that size” (i.e. people who have not lost weight) would be eating to maintain their weight.

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  7. Should that quote be attributed to Scully?

    “without feeling starved or deprived” yes, well that may be a slight understatement of what drives people to food.

    Getting around the starving portion is possible during the rapid at loss phase by eating no sugar, grains or dairy; nothing that will cause insulin generation, allowing fat to come out of the fat cells easily. The remainder of the body does know where the fat is coming from, therefore no starvation. To feed the gut we will need to eat fat 3 or 4 times a day.

    But then there are the other 150 different “reasons to eat”, feeling deprived is one. Opening up to feel a bit of gratitude for life and the other wonders, even for the available real foods today may reduce the feeling of deprivation. To each negative thought, there is a work around to relieve that thought.

    Most people, the wild humans, still need to want to do the work. Most of society lives in happy blissful pre-contemplation of any change of lifestyle.

    But what do I know.

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  8. I think one reason why post bariatric surgery patients do not feel hungry or deprived is because they are on a diet that does meet their nutritional needs.

    Post bariatric surgery patients eat very few calories, yet they get adequate amounts of all the other nutrients. (Protein, vitamins etc.) If their very low calorie diet doesn’t meet their nutrient needs, they take special supplements.
    Also, post bariatric surgery patients get regular checkups. If they are lacking in a particular nutrient they will have their diet modified or they will take more supplements.

    Compare that to what is available to people who have lost weight without bariatric surgery.
    If they regain weight, it is usually assumed that they just gave up trying to eat right.

    More likely, those who lost weight without bariatric surgery were not told that losing weight had actually changed their metabolism. They were not educated in the special low-calorie/high-nutrient diet that they now need to follow. They were only told to eat healthy food, control portion sizes and limit calories – “don’t eat too much”.

    They were not tested regularly to find out exactly what nutrients were lacking when they tried to follow a diet low enough in calories to prevent weight gain.
    They were not told to take specific supplements to provide nutrients they lacked.

    They probably were given the impression that it was expected and inevitable that they would regain the weight. (There’s a self fulfilling prophecy).

    If their low calorie diet is inadequate in nutrients, these people will be hungry, tired, unhealthy, and generally functioning poorly. They’ll go off the diet to try to overcome the nutrient deficiencies and feel better.

    If non-surgical weight losers got specifically designed diets, monitoring, and nutritional supplements, like bariatric surgery patients, they would have a far better chance of maintaining weight loss.

    Getting adequate nutrition, including supplements, is only one of many reasons why post bariatric surgery patients do not feel hungry or deprived. However I think it is a very important reason.
    The well-researched methods used to keep bariatric surgery patients healthy on a long term low calorie diet would also help non-surgery weight losers maintain weight loss.

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    • While adequate nutrition might play a role, bariatric surgery reduces hunger and feeling of deprivation because it changes the chemistry of the stomach – the hormones of the gut are altered. This in turn changes the signals received by the brain, leading the person to feel less hungry and less deprived.

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  9. Maybe we do actually know quite a bit… Maybe it is easier/better for some to keep postponing solutions… The fact that Nestlé paid for this publication, doesn’t bother you at all?

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    • @RIIS Not really. They have their interests but so do governments, NGOs and virtually everyone else. I’ll read the articles and form my own opinions based on the actual content rather than on who sponsored it.

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  10. Don’t feel too bad, Dr. Sharma, about not knowing as much as you would like to know about body weight. The experts and “mental health professionals” seem to know very little about Complex-PTSD too (can’t even come to an agreement about the best, most appropriate diagnostic label.) I often learn more from other bloggers who share many of my struggles than I learn from admittedly well-written research reports and books by specialists in the field.

    There are some interesting overlaps in the two fields of study (weight loss and Developmental Trauma Disorders). For instance, when I saw this press statement, I got my hopes up briefly (well, fantasized that sub q leptin treatments could now be prescribed for people who are struggling to maintain significant adipose tissue losses):

    The HPA-stress axis can become dysregulated by both leptin insufficiency (after fat stores are diminished) and by extreme stress disorders (such as PTSD and Complex PTSD).

    I imagine this double whammy leaves people with pre-existing trauma/stress disorders in quite a pickle after they lose most of their excess adipose tissue and then attempt to maintain that seemingly “healthier” body size. Wait. I don’t have to “imagine”—I’ve been living with this (at times) horror show existence for about 4 years. For a long time, I really DID NOT want to believe that my great weight loss “success” had resulted in greatly intensified trauma re-experiences (sense and emotion “flashbacks”), abysmally worse insomnia, treatment-resistant depression and anxiety, and chronic fatigue associated with moderate stress levels.

    At this point, since MDMA-assisted therapy for Complex PTSD is still at least 7-8 away (in terms of FDA approval), the best option seems to be a junket to Peru to undergo shamanic facilitated rituals using Ayahuasca in hopes of achieving improvement in HPA-axis regulation and SNS tone improvement. Frankly, the number of intense psychedelic (ahem) adventures required for potential symptom improvement scares the heck out of me. I can’t help but ponder how much easier (and perhaps less risky) a couple years of sub q leptin therapy might be to yield more promising results (or so I fantasize). 🙂

    Plus, if I decide to take some of the prescription psychotropic drugs that have been suggested for chronic and extreme stress/trauma disorders, then my risks of becoming diabetic and also gaining weight increase.

    So, in the meantime, I dabble with dopiminergic-enhancing substances when the “S-word” thoughts get completely out of hand, and keep my eye on the ever-present and very real possibility (danger) of becoming chemically dependent on controlled substances (but definitely NOT the cheap but deadly ETOH. ) It’s probably a blessing that I am disabled—can’t imagine what a stressful nursing job on top of everything else would be like.

    Well, not asking for pity, just maybe for a nice clinical trial to come along that I could somehow qualify for…doesn’t matter which…leptin therapy or MDMA therapy or Ayahuasca shamanic ceremonies…I’m game!

    Who could have guessed that a *simple diet plan* and *life-style change* would lead to…this? 🙂

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