TREATMENT AND PREVENTION
Modern epidemics and health crises have demanded vigorous and sweeping responses from healthcare practitioners. But, they have also required vigorous responses from many other segments of society including everyone from teachers to political leaders. Think of the complexity and relative effectiveness of the response to the AIDS epidemic. Health researchers would now generally agree that the most effective response to the deadly virus has come from a combination of efforts that involve policy changes to enhance prevention efforts, combined with effective treatments for those already afflicted.
As horrific as the AIDS epidemic has been and continues to be on a worldwide basis, it is dwarfed by the obesity epidemic by any measure including the measure of premature deaths. So how can we best formulate a response to the obesity epidemic that will minimize needless suffering, premature disease and premature deaths?
Clearly the lessons from the last major health crises are that we must respond with vigorous and sweeping efforts at all levels including those aimed at prevention and those aimed at treatment for those already afflicted.
Just like other major health crises, many factors in the obesity epidemic serve as distractions and undermine positive efforts toward prevention and treatment. For example, debates about the degree to which obesity is a self-inflicted disease serve to undermine research efforts, treatment efforts and prevention efforts. Although the complex nature of obesity is one that requires solutions that draw from many disciplines including those associated with mental health, the complex social, psychological and cultural aspects of obesity must not stand in the way of logical research, prevention programs and effective treatments. At the end of the day, our response as healthcare providers, community leaders and stewards of our future generations must focus on health, wellness and longevity and nothing less.
Ultimately, the successful eradication of such a complex disease will need to happen through sweeping obesity prevention efforts. We see the initiation of such efforts at many levels including public and private awareness campaigns, emphases on fitness and physical activity, community movements toward locally grown and produce based diets, school district efforts aimed at replacing high calorie meals for kids, legislative efforts that focus on calories, carbohydrates or fats and many more. Undoubtedly during this process there will be measures that help the prevention cause and there will be missteps that hinder the cause and obfuscate the solutions or drown us in polemic. Nonetheless, the driving force must be to prevent more kids from acquiring what is indisputably a deadly disease.
Treatment must also be a twin priority with prevention. While the National Institutes of Health and the CMS have exhibited objectivity and fairness in endorsing bariatric surgery as early as 1991, many other advisory policies from professional societies and governmental agencies lag far behind the currently available data and they fail to appreciate the seriousness of obesity as a disease. Newer and better treatments will continue to become available and these treatments are likely to include a mixture of medications, surgical procedures and implanted devices. Eventually, a select number of these treatments will be excepted as superior interventions, which can help induce increasing correction of obesity and durable weight loss results.
To date, modest success has been achieved with structured medically supervised programs utilizing evidence based tools such as meal replacement, diet formulations low in sugar, psychological and dietary counseling, diet logs, support groups and regular exercise such as walking. Surgical programs have achieved markedly greater success and increasingly, the most successful programs employ each of the proven elements from the non-surgical experience to boost outcomes and maintain their durability.
In the past, rather arbitrary guidelines have arisen from specialty societies that recommended very stingy use of obesity treatments only in the most severe of cases. For example, many specialty societies and currently available references will recommend the use of the appetite suppressive drug, Phentermine or its analog, Tenuate only at certain body mass index thresholds. Working on the theory that these “conservative recommendations” will be better for patient safety, they have served to deter practitioners from prescribing much needed obesity therapy and overemphasized the risk of very safe drugs while markedly underemphasizing the risks of the disease of obesity.
Our hope is that as we move forward such miscalculations will be eliminated and the seriousness of obesity as a health crisis will be appreciated, and the treatment and prevention efforts evaluated in their proper light.