For brevity purposes I am using the word obesity instead of obesity and overweight throughout most of the text.
Obesity has been one of the most talked-about topics for a long time, yet we still don't have this largely preventable condition under control. Last year WHO (World Health Organization) introduced a target to halt obesity by 2025 [1]. But if we have not succeeded in halting the increase in obesity rates in three decades, is it reasonable to expect success in another 10 years without major changes in strategy?
"If immediate action is not taken, millions will suffer from an array of serious health disorders," states WHO's website [2]. The reality is that millions of people have been already and continue suffering. Moreover, millions of people have lost and continue losing their lives prematurely.
The urgency for action cannot be underestimated. But first we have to make sure we are on the right course (which we are clearly not, as evidenced by data gathered over the last decades).
As with any project of this magnitude, it is important to assess the reality and evaluate the progress on a regular basis. Since the progress with obesity is not significant, it is critical to understand the reasons behind futile efforts. It is also necessary to be clear about the goal and, finally, it is absolutely vital to revisit, rethink and refine the strategy -- now more than ever before.
Following are just a few facts to remind us where we currently stand with obesity:
• Worldwide, the prevalence of overweight and obesity have been steadily rising in children and adolescents in both developed and developing countries during the same period (according to International Obesity Task Force, IOTF) [3].
• In the United States the obesity rates in children doubled during past three decades and quadrupled in adolescents [4].
• About one-third of all adults are obese and two-thirds are overweight in the United States [5].
• Among people who are 65 and older, 72.2 percent of men and 66.7 percent of women are overweight or obese [6].
• 65 percent of the world's population lives in countries where overweight and obesity kill more people than underweight [7].
• More than 40 million children under the age of 5 were overweight or obese in 2012 [7]
• While in some countries the rate of increase in obesity slowed down, obesity is not slowing down worldwide [3].
• No country reports a downward trend in rates of obesity and overweight during past three decades [3].
It is clear that there is no (significant) progress in our efforts to stop and reverse obesity trends. The question is where we went wrong and, most importantly, what should we do in order to successfully end this epidemic.
Identifying the Cause/Effect relationship
In my opinion, the first place where we have gone wrong is in defining the problem. We are fighting obesity, blaming it for causing many diseases and premature death. Yet obesity is not the cause of the problem but rather the consequence -- one of the many consequences.
Obesity doesn't cause cardiovascular disease, diabetes and cancer. Unhealthy lifestyle choices -- along with, in some cases, certain medical conditions, genetics and environment -- lead to obesity, cardiovascular disease, diabetes, cancer... While there are some things we currently have no control over (e.g., some medical conditions that we can't treat effectively), we have control over a large number of factors that affect our health (and weight) -- it is important to keep this in mind if we want to end the obesity epidemic.
Because of the mistaken emphasis many people attempt to lose weight following the logic of "the end justifies the means." In other words, when the goal is to lose weight many people hurt their health even more in the process of losing the weight. People hurt their health by following restrictive, stringent diets and/or by taking supplements that claim to shred away pounds and inches around the waist. It has been shown time and time again that none of those approaches are effective and that, in many cases, you harm yourself and your wallet by falling for these "promises." Yet the multi-billion weight loss industry -- including drinks, supplements and other products and services aiming at weight loss -- is still thriving.
In June of 2014 the FTC (Federal Trade Commission) testified before Congress on its efforts to combat fraudulent claims for weight-loss products [8]. "The FTC's most recent fraud study shows that more consumers were victims of fraudulent weight-loss claims than of any other specific fraud type covered by the survey," said Mary Engle, the associate director for advertising practices at FTC.
While federal regulations need to be in place to hold companies responsible for making deceptive claims, I see patient education as a major key to preventing people from falling for dubious promises about weight loss -- not just with products but with any misleading advice. In addition, close attention should be also paid to professional education -- so the health care professionals are equipped with the knowledge and tools to provide reliable information to the patients in order to effectively reverse and prevent obesity.
Major emphasis should be made on the complexity of the topic and the importance of a healthy life style that addresses all dimensions of the well-being -- including physical, mental, psychological, and others. We have to understand this in order to combat the other major problem we have with obesity -- maintaining the reduced weight.
Obesity is associated with many diseases. I listed some of the conditions that are associated with overweight or obesity in Fig. 1. Note that there are no arrows originating from the center of the diagram, as the aim is to show the association between overweight/obesity and diseases/conditions. Such associations also exist between some of the diseases too but, again, observing an association doesn't establish the cause/effect relationship.
Besides being associated with diseases, obesity may even worsen the prognosis or the risk of developing a particular disease. But still obesity is not the root cause. Until we get this, we will continue battling the wrong battle. And when we get the cause-and-effect relationship right, we will never overlook the necessity to address the underlying causes which affect much more than the number on the scales or the dress size.
Complex topics require complex approach
Another major problem that I see in our efforts is singling out one factor as the sole, or biggest, contributor to weight gain. Obesity is a condition that results from a complex interaction of a multitude of factors. Naming one factor (even two or three factors) as the root of the problem oversimplifies a complex issue and is largely misleading.
Even in the 21st century the alchemists in us are still looking for a panacea -- if not by administering something (a supplement, a "magic" fruit, etc.) then by finding The Problem. We "identified" such problems in the past. They said that fat is to blame for the obesity epidemic, so people started consuming fat-free products -- yet the obesity rates didn't drop. They said carbohydrates are to blame -- yet obesity rates didn't decrease.
Now they say that sugar is the villain of the story, so people get on diets that eliminate any possible source of sugar -- not only the added sugar but also fruits and vegetables that are naturally sweet...
There is no question that for many people the daily intake of sugar exceeds the recommended amount. The problem is that we are, once again, handed one factor that is alleged to be the sole source of the obesity epidemic.
Taking out one part of the puzzle and claiming that it represents the whole picture is misleading and we no longer can afford to be misled. It is critically important for us to finally look at the whole picture and address many important factors that collectively (and separately) have huge impact on our health and our weight:
• assuring access to healthy food,
• raising the minimum wage to a level that allows a person to obtain healthy food,
• educating health care professionals and the general public about various aspects of a healthy lifestyle,
• building an infrastructure that allows working people time for cooking at home regularly,
• investing in promoting prevention,
• taking measures on various levels for improving quality of food available in the stores,
• building neighborhoods where children can play safely,
• holding companies to standards that assure better food quality,
• and more...
Factors that may contribute to obesity can be grouped in different ways. We can classify them as inherited or acquired. They can be categorized as physiological, psychological and societal. We can also group them into the following three categories: genetic, epigenetic, and environmental. The most important classification to me, however, is as follows: factors that can be controlled by the individual and factors that are beyond one's control. If we act upon what we already know and change what we can -- we will achieve profound results.
Most talked-about causes of obesity are diet, portion control and exercise -- which collectively support the "calories in vs. calories out" philosophy. While it is absolutely important to exercise and to be mindful about what and how much we eat, our bodies are much more sophisticated than that.
First of all, it has been proven that a calorie is not just a calorie, when it comes to our nutrition -- it really matters where those calories come from. And even when the calories come from healthy sources, you still cannot bring the question of your weight gain to a simple equation of calories in vs. calories out, disregarding a myriad of other factors. Besides nutrition (calories in) and exercise (calories out), factors that affect ones weight include changes in the gut microbiome, hormonal imbalance, stress, sleep related problems, psychological well-being and others -- all of which cumulatively affect one's weight.
It is important to keep in mind that not only do the different factors interact with each other, but they can be also interdependent. On one hand, this makes the control of the matter challenging, because it makes it difficult to dissect what is the cause and what is the effect. On the other hand, the very same complexity is also quite helpful, because by addressing one factor you are indirectly lessening or even eliminating other contributing factors. The best example that everyone is familiar with is the one of the exercise. When you exercise -- provided it is a type of exercise that you really enjoy -- you are not only burning calories, but you also achieve effective stress relief and improved psychological wellness, among other things. All of this together doesn't just affect person's weight -- it impacts health overall, from cardiovascular health to diabetes, bone density, sleep problems and so much more.
Lastly, I would also like to address another factor. On the other end of a largely overweight population we have eating disorders, including anorexia and bulimia, on the rise. Just between 1999 and 2006 the hospitalization rates for eating disorders increased by 18 percent [9]. This, by and large, is caused by the culture that we cultivated. When a young woman with a dress size 4 at 5'5'' height wants to lose weight to be perceived as beautiful there is something wrong with our perception of beauty.
In sum, to turn obesity trends around, changes should be made on various levels, including individual, family, community and government. As mentioned above, factors that affect one's weight and health include nutrition, physical activity, stress, certain medical conditions, and certain medication among others. We should address not just one factor (e.g., sugar consumption) but rather all areas of the well-being. Only a complex approach to the underlying causes can warrant a successful end to the obesity epidemic and reduce premature morbidity and mortality. Only by looking into the whole picture can we save lives and improve the quality of life for billions of people.
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