COMMENTARY

Weighty Matters: Public Health Aspects of the Obesity Epidemic; Part V -- Treatments and Public Health Approaches to Combating the Problem

Martin Donohoe, MD, FACP

Disclosures

April 10, 2008

 

Introduction

Parts I though IV of this series covered medical, economic, and some public health aspects of the obesity epidemic. This final column examines treatments, as well as public health approaches to combating obesity.

 

Treatments for Obesity

Treatment for obesity involves decreasing caloric intake (especially simple carbohydrates, which can contribute to diabetes, and trans-fatty acids, which are highly atherogenic and increase risk of cardiovascular disease), exercising more, and possibly getting more sleep.[1] Adults should receive 45% to 65% of their calories from carbohydrates, 20% to 35% from fat, and 10% to 35% from protein.[2] However, with the exception of 1 trial conducted with individuals enrolled in Weight Watchers, the evidence to support the use of the major commercial and self-help weight loss programs is suboptimal.[3]

In some countries, insurance companies cover obesity treatment. Although most in the United States do not, they do cover the myriad of expensive health consequences of obesity.[4] Americans spend an estimated $30 billion each year on diet pills, diet foods, exercise videos, health club dues, and other weight loss tools.[5]

Weight loss drugs are a 1-billion-dollar per year business in the United States.[6] One study showed that nearly 5 million US adults used prescription weight loss pills between 1996 and 1998.[7] However, one fourth of users were not overweight, suggesting that such medication may be used inappropriately. Use was especially common among women.

Drug therapy may be appropriate for patients with a body mass index (BMI) > 30 or a BMI > 27 with additional risk factors, such as diabetes. Sibutramine and orlistat are approved for long-term use, but they have been found to reduce weight only by about 10% when combined with diet and exercise, and sibutramine can increase blood pressure.[8]

The anti-obesity drugs fenfluramine and dexfenfluramine were taken off the market in 1997, after numerous reports of cardiac valvulopathy.[7] Nonprescription supplements, essentially unregulated with respect to purity, composition, and effectiveness, can be dangerous, and should be avoided. In particular, compounds containing ephedra, which has been banned by the US Food and Drug Administration (FDA) but can still be found in a number of preparations sold in the United States and purchased abroad should not be used. Future pharmaceutical treatments will likely be directed against hormones involved in the regulation of satiety, such as leptin and ghrelin, and may include vaccines.[5]

Those with a BMI > 40 may be eligible for bariatric (weight loss) surgery. Procedures include the Roux-en-Y gastric bypass, stapled gastroplasty, and adjustable gastric banding, all designed to reduce stomach size and control caloric intake.[9] Although complication rates of almost 40% over a 180-day period have been reported, substantial health benefits are common, including excess weight loss of up to 70% and resolution of diabetes in 77% of patients.[10,11]

In particular, recent data suggest a long-term mortality benefit from bariatric surgery for the severely obese.[12,13] More than 200,000 bariatric procedures are performed annually, and almost 1 billion dollars was spent on such surgeries in 2002, even though only 0.6% of eligible adults underwent a procedure -- suggesting a huge untapped market.[12,14]

 

Public Health Measures to Reduce Obesity

One objective of the Department of Health and Human Services' Healthy People 2010 is reducing the prevalence of obesity to 15%.[15] Accomplishing this objective will require a multifarious approach involving providers, public health advocates, citizens, and legislators.

While less than half of obese US adults visiting a primary care physician for a well-care visit are counseled about weight loss, those counseled were more likely to attempt weight loss than those who do not receive counseling.[16] Improving healthcare provider education in nutrition might improve patient counseling, as would the increased use of nutritionists in primary care settings, a move which would likely be cost-saving. Providers need to counsel patients frequently regarding body weight, and be observant for signs and symptoms of body image problems and pathologic weight loss/gain behaviors. Healthcare professionals should promulgate guidelines regarding normal body weight, healthy dieting behaviors, and the value of regular exercise.

School- and community-based health education campaigns tailored to cultural background, gender, and age group, as well as health messages widely disseminated in the entertainment and news media, can help correct misperceptions regarding weight and promote healthy behaviors.[17] Public schools should enhance their health curricula at all levels, provide more healthful meal choices, and resist the invasion of fast foods, soda pop machines, and exclusivity contracts. Enhanced state funding for public education will relieve the financial pressures that lead administrators to even consider these contracts. Hospitals, too, should provide healthful selections in their cafeterias, and refuse to have fast food franchises on their premises.

The provision of healthier menu options in federally sponsored school lunch offerings has been shown to increase student participation in the National School Lunch Program.[18] Use of local produce from community-supported agriculture, especially organically grown produce, would decrease the adverse consequences of pesticides on the environment and the amount of harmful greenhouse gasses produced in the transportation of food over long distances.[19,20,21,22]

A school wellness policy provision included in the Child Nutrition and Women, Infants, and Children Reauthorization Act of 2004 mandated that schools that participate in federal nutrition programs create wellness policies on how to improve students' nutrition and health as well as set guidelines for all foods sold in school by 2006.[23] The Child Health Nutrition Promotion and School Lunch Protection Act, introduced in both the US Senate and House of Representatives, called for updating decades-old federal nutrition standards for snack foods sold in cafeterias, stores, and vending machines on school grounds.[24] Furthermore, in 2005, 40 states introduced about 200 bills addressing nutrition in schools.[23]

Measures to optimize the amount of exercise undertaken by the obese include expanding the number of pedestrian malls in public places; increasing the availability of recreational centers, parks, and workplace gyms; encouraging people to walk or ride bicycles to work and school; requiring physical education at school; and providing insurance coverage for membership in athletic clubs and insurance discounts for participation in exercise programs.[17]

Health insurers should provide enhanced coverage for obesity prevention and treatment. Finally, governmental bodies should be purged of those with industry connections, so that they can provide more aggressive, unbiased oversight of the weight loss industry. As noted in part III, a number of food and beverage companies have taken steps to restrict advertising to children.[25]

Because most consumers are unaware of the high levels of calories, fat, saturated fat, and sodium found in many menu items, provision of nutrition information on restaurant menus could potentially reduce the consumption of less healthful foods, and might spur restaurants to offer healthier choices.[26] As of January 1, 2006, all conventional food were required include information regarding the amount of trans-fatty acids (the most atherogenic type of lipids) they contain.[27] The FDA estimates that such labeling will prevent from 600 to 1200 cases of coronary heart disease and 250 to 500 deaths each year.[27]

Public health authorities in New York, Chicago, and Los Angeles have proposed a ban on the use of artificial trans-fatty acids in these cities' restaurants.[28] Additionally, a bill was introduced in Congress to require food manufacturers to adjust the labeling of their products to better inform consumers of their trans-fat content.[29] Some claim that trans-fatty acids add flavor and texture to fried foods, but suitable, less dangerous cooking oil substitutes are available, yet underutilized.

Other measures that might decrease rates of obesity include prohibiting the distribution of toys and promotional games, the presence of play equipment, and the presence of video or other games at fast food outlets; requiring fast-food outlets to locate a minimum distance from youth-oriented facilities such as schools and playgrounds; limiting the total number or per-capita number of fast-food outlets in a community; limiting the proximity of all fast-food outlets to each other; charging a fee to fast food outlets and using the proceeds to mitigate the impact of poor nutritional content (eg, construct parks, fund after-school programs, or provide nutrition education); and prohibiting drive-through service.[30]

A majority of Americans believe that the government should be involved in fighting obesity, particularly by regulating the marketing of "junk foods" to kids.[31] As of 2000, 19 states taxed non-nutritious foods, such as soft drinks and candy.

Finally, some have brought lawsuits against purveyors of junk foods to reclaim healthcare costs. Some states are considering class action suits of this nature, reminiscent of the partially successful lawsuits against the tobacco industry.

 

Conclusion

The obesity epidemic in the United States has multifactorial causes and is responsible for serious health consequences. Its contribution to suffering and death and its effect on national healthcare costs calls for urgent action. Confronting the obesity crisis will require the concerted efforts of healthcare providers, educators, legislators, and social advocates.

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