Issue 1 / 21 January 2013

CONSIDER this as a new treatment paradigm: orthopaedic surgeons tell their patients with compound comminuted fractures to cure the break by avoiding falls.

Or, immunologists tell patients with hepatitis B-associated liver cancer that they will be cured if they avoid the exchange of bodily fluids. Ophthalmologists tell patients the cure for traumatic cataracts is to avoid trauma.

It’s actually not a new treatment paradigm. Hands up those who tell their obese patients that the cure lies in diet and exercise?

For a while my hand would have been up too. I might as well have told them to burn chicken entrails.

We’re not fooled into identifying the removal of the cause as the cure in any other field of medicine. Prevention and cure are rarely confused elsewhere, so why the contrary approach to obesity?

Most doctors aspire to practise evidence-based medicine. So with obesity, what does the evidence show?

Bariatric surgery results in statistically and clinically significant sustained weight loss and reductions in mortality compared to matched controls. A Swedish study showed dramatic differences in weight loss over a 15-year period — the control group receiving “conventional treatment” showed about 1% change in body weight compared with as much as 30% mean percentage weight change for those who had undergone bariatric surgery.

Now look your obese patients in the eyes and tell them to diet and exercise to lose weight. This is not evidence-based medicine so much as the medicine of wishful thinking.

For many obese patients the hormonal defence of what has been built on past lifestyle choices is too strong — the body may be hormonally primed for some time after weight loss to regain weight.

Don’t get me wrong. A nutritious diet and exercise has many benefits, including possible delayed onset of metabolic syndrome in the obese but, for most people, sustained substantial weight loss isn’t one of them.

I suspect the reason evidence-based medicine is not practised in this area is that in the back of our minds lies the knowledge that if the evidence is accepted, we will be powerless to treat the already obese, except by surgical means. Yet like diet and exercise, bariatric surgery offers no basis for population-based curative interventions.

I’d argue this is not the philosophy of despair. Acknowledging the evidence, however unpalatable, offers guidance.

We need a truly multifaceted approach to what may prove the major population health problem in the developed world for the current and next several generations.

We need more research into the hormonal pathways to obesity and the non-surgical means to obstruct them. More equitable access to bariatric surgery on the basis of need is also required.

We cannot afford the promotion of junk food and junk lifestyles to the young. Our duty to them and their right to a life of good health should overwhelm the fast food industry’s clamour for unfettered marketing access.

A balanced diet and adequate activity levels are the cornerstone of obesity prevention and may have an important role in the secondary prevention of the metabolically adverse consequences of obesity.

However, while we continue to promote diet and exercise as a cure for obesity, we are little more than unwitting touts for the weight loss industry, whose financial success is predicated on clinical failure.

Dr Michael Gliksman is an occupational physician based in Sydney and chairman of the Professional Issues Committee of the AMA NSW. On Twitter @AFairGoForAll

Click here to read comment from Professor Louise Baur, who says obese adolescents are missing out on a proven therapy.


Posted 21 January 2013

6 thoughts on “Michael Gliksman: Preventing cure?

  1. Anonymous says:

    Obesity is a simple issue. Stop eating. We do not have to ask questions about evolutionary preservation mechanisms, do more research on hormonal pathways or devise new drugs. We are fat because we eat, not because we don’t exercise. The questions we need to ask is why do we eat so much and how do we reverse that? We do know that the cost of calories has halved in the last 30 years, we earn more and work less hence spend more time eating and socialising. Fast food outlets don’t make you eat their produce, parents let their children eat it after buying it for them. We are better off getting rid of breakfast, morning tea,lunch and afternoon tea. 1 meal a day is enough and when entertaining we need to institutionalise sucking celery and drinking water

  2. Roland Owen says:

    Very interesting & painful reading. A daily issue for me as a GP.
    BUT I do wonder on the ‘evidence’ of “conventional treatment” that you quote as ineffective from the study. That was the outcome as they measured. BUT what was the compliance rate. The empirical truth we know is that the problem with lifestyle changes is that our patients need to change but too often DONT WANT TO CHANGE. Bariatric surgery forces dietary changes.
    Are you really infering from that study that consuming less kJs & doing more exercise is ineffective?? Or just that people struggle to do it & are “non-compliant”???
    To me the question is not that it doesn’t work but how do we make it work. Yes primary prevention (as always) is the most effective- lets get stuck into educating the kids.
    BUT we must come up with more successful ways getting people to make the positive changes. Its about “change management”.

  3. Dr rosemary Stanton says:

    I have no basic disagreement with this viewpoint, but I do wish those who conduct bariatric surgery could extend their reach to ensuring that their patients follow a better diet after the surgery than they had before. Many of these patients are expert at giving doctors or dietitians an expert account of a healthy diet, with the implication that this is what they eat. In fact, it is not and some eat appallingly – less total kilojoules with a band in place than before but basically a poor diet, often made up largely of sweeets or foods with plenty of cream added to foods to make them “slip down more easily” or foods ‘washed down’ with drinks such as hot or iced chocolate. They may now eat less, but their general diets are poor and the fact that they add vitamin supplements to such a diet may not be an ideal recipe for future health.

    I applaud those teams that arrange to eat a few restaurant meals with their patients after the band is in place (and the initial pureed phase has passed).

    Talking to some people who have had gastric banding and who eat the way I have described above, I am told that they basically ignore any information given because they prefer the sweet largely liquidised food they now consume.

    I have often observed that some obese people don’t seem to chew. Presumably the gastric band makes their previous simple swallowing uncomfortable, and hence they turn to foods that are largely liquidised.

  4. Bariatric Surgeon says:

    I applaude the comment made by Rosemary Stanton who argues what many bariatic surgeons who work in a multidisciplanary environment recommend. Left alone and without regular follow up by not only the surgeon but also experienced nutritionists, bariatric surgery patients shall in general develop inappropriate eating habits.The surgery needs to be accompanied by life style change and is the catalyst for lifestyle change and eating habits in the long term.
    Michael Gliksman’s article also highlights one of the great frustrations of bariatric surgery and that is its inaccessability for a significant proportion of our population who do not have private insurance cover. The recommendations in both this and the article on the adolescents are pertinent, supported by evidence and their recommendations can potentially produce significant cost savings to the health budget in the long term. And yet ,short term budget priorities deny deserving people access to effective therapy.

  5. Dominique says:

    This is a thought-provoking article.
    I believe that there comes a point, especially in life-style related disease, where a patient is responsible for the health choices they make. But this line is less clear when the patient in question is younger and whose health has been subject to the poor decisions of others. And also in the current environment where much can be done to address the social determinants of obesity, it’s hard to take such a hard line as people will fall through the cracks, miss out on the health benefits (and use up more health dollars). Current healthcare expenditure is unsustainable and I fear that if bariatric surgery was made available to *all* then less would be available for prevention, whose benefits will take sometime to eventuate, but is the ultimate definitive treatment.

    My opinion is that in the short term bariatric surgery should be made more available to the public if the patient is an adolescent, providing there is adequate follow-up. At the same time I think the societal factors for obesity (access to quality and healthy food (especially in remote communities), improving public transport (including bicycle paths), targeting junk food advertising and decreasing problematic alcohol consumption), should not suffer a decrease in health care dollars in favour of unrestricted or restricted public-funded bariatric surgery.

  6. Ben Ewald says:

    The collective hand wringing about obesity ignores the evidence that it is not the serious health problem generally imagined. The meta analysis this month by Flegal (JAMA 2013;309(1):71-82) shows convincingly that in cohort studies, overweight and obesity below BMI 35 are not associated with any increase in total mortality, and those with BMI 25-30 have the lowest all cause mortality. This contradicts the well established associations of obesity with certain diseases, but from the patient perspective they don’t specifically want to avoid diabetes as much as they want to avoid ANY serious disease or death.
    The much bigger threat to the health of the community is lack of fitness, as demonstrated by the Aerobics Centres Longitudinal Study. Being fit is of great health benefit at any BMI. We should stop measuring success on the scales and start measuring physical activity as step counts or fitness as maximal oxygen uptake as tools to guiding our patients to better health.
    At the prevention level we should stop making it easy to go through life sitting down. Sedentary transport carries people to sedentary jobs and sedentary entertainment, and the most promising policy option is to make active transport the safe, easiest and cheapest option.

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