Book Review

Treatment of the Seriously Obese Patient

N Engl J Med 1993; 328:1856June 24, 1993

Article

Treatment of the Seriously Obese Patient
Edited by Thomas A. Wadden and Theodore B. VanItallie. 524 pp., illustrated. New York, Guilford Press, 1992. $50. ISBN: 0-89862-879-2

Obese people have an increased risk of premature death and disability, mainly from cardiovascular diseases, diabetes, osteoarthritis, gallstones, and certain types of cancer. The more severe the obesity, the greater the excess risk, so any definition of a threshold at which the obesity is “serious” is arbitrary. In the white population of the United States, the prevalence of a body-mass index (the weight in kilograms divided by the square of the height in meters) above 30 is about 15 percent in men and 18 percent in women -- similar to the prevalence among men and women in northern and western Europe. Among black men and women in the United States, the prevalence is about 20 percent and 37 percent, respectively -- similar to that in Mediterranean countries, eastern Europe, and the former Soviet Union. For more than a decade, expert committees on both sides of the Atlantic have declared obesity one of the most important public health hazards of our time, yet longitudinal studies show that its prevalence has increased in the past 10 years.

Against this background, this book on the treatment of the seriously obese patient, written by a team of 30 distinguished authors, is most welcome. The book is well produced, the chapters cover all aspects of the problem -- epidemiology, energy balance, body composition, and the role of exercise, diet, drugs, behavior therapy, and surgery -- and each is well referenced. Anyone concerned with the management of obesity (which must mean virtually any clinician) will find much of value here.

Having said all that, I remain unconvinced by the central argument of the book, which is that serious obesity is best treated by a multidisciplinary team, with short-term use of a very-low-calorie diet. In my view there are three important objectives in treating severely obese patients: first, to achieve weight loss at the rate of about 1 or 2 lb (450 or 900 g) per week until a desirable weight is achieved; second, to maintain that desirable weight indefinitely; and third, to restore the self-esteem of the patient. These are difficult tasks, but I believe that the use of a very-low-calorie diet makes them even harder to achieve. The attractive feature of this diet so far as the patient is concerned is that it causes rapid weight loss. Although such a diet is said to suppress the hunger experienced with conventional low-energy diets, there is no evidence that this response is associated with better outpatient compliance with the very-low-calorie diet than with a conventional diet. We know that it must take the severely obese patient many months to lose excess weight, and all the evidence shows that the rapid weight loss achieved with the very-low-calorie diet is associated with greater weight gain afterward than when the weight is lost steadily on a conventional diet.

The lesson to the patient on a very-low-calorie diet is clear: rapid weight loss is possible, but only with the close (and expensive) supervision by a team of interdisciplinary experts; if patients try to go it alone, they will fail. I cannot bring myself to believe that this is a foundation on which it is possible to build an ability to maintain weight loss and restore self-esteem. I suppose this book on obesity is the best that I have read, but I fundamentally disagree with its recommendations.

John Garrow, M.D., Ph.D.
St. Bartholomew's Hospital Medical College, London EC1M 6BQ, United Kingdom