Book Review

Treatment of the Obese Patient

Obesity: Epidemiology, Pathophysiology, and Prevention

N Engl J Med 2007; 357:2526-2527December 13, 2007

Article

Treatment of the Obese Patient
(Contemporary Endocrinology.) Edited by Robert F. Kushner and Daniel H. Bessesen. 440 pp., illustrated. Totowa, NJ, Humana Press, 2007. $129. ISBN: 978-1-58829-735-8

Obesity: Epidemiology, Pathophysiology, and Prevention
(CRC Series in Modern Nutrition Science.) Edited by Debasis Bagchi and Harry G. Preuss. 569 pp., illustrated. Boca Raton, FL, CRC Press, 2007. $149.95. ISBN: 978-0-8493-3802-1

Is obesity a treatable disease? The short answer is no. Clinicians who have been in practice for more than 20 years are aware of the facts. Despite the lip service that has been paid to healthful lifestyles, people of all ages, geographic origins, and nationalities have been steadily increasing their girth. Data from the Centers for Disease Control and Prevention (CDC) (www.cdc.gov/nchs/data/ad/ad347.pdf) show that from 1960 to 2002 the average weight of men in the United States increased by nearly 24 lb, resulting in an increase in the average body-mass index (the weight in kilograms divided by the square of the height in meters) from 25.1 to 27.8. Similar increases have occurred among women. The largest increase has been among the ranks of the obese and extremely obese.

Obesity is an appropriate target for intervention, and one would have thought that almost any weapon would help to make us a worthy opponent of the enemy. But clinicians have been humbled by obesity. Each new inroad researchers have made into understanding the mechanism of obesity appears to be met with yet another battalion in the enemy's army. Our efforts to manage obesity have been soundly defeated. We need new perspectives if we are to regroup and reenergize our treatment of this disease.

Two new books offer long answers for the treatment of obesity, and each comes from a different perspective. Treatment of the Obese Patient, a well-referenced book, is a detailed review of the various systems that regulate eating behavior and body weight. It includes discussions of neurobiology, gut peptides, adipokines, and ectopic fat. An entire chapter deals with the endocannabinoids; it is a timely chapter given the expected approval by the Food and Drug Administration of rimonabant, which blocks endocannabinoid receptors. The first section concludes with carefully written chapters on how to measure body composition and energy expenditure. The only flaws I found in this book were its poor index and its lack of a discussion of epigenetics in the chapter on perinatal programming for obesity in adults.

The second half of the book offers clinically useful tools for stepwise management. How should we assess the obese patient? What about polycystic ovarian disease? The chapter in which F. Xavier Pi-Sunyer translates the successful Diabetes Prevention Program into clinical practice makes the book worth purchasing. Separate chapters provide comprehensive reviews of energy density, the glycemic index, and low-carbohydrate diets. The chapter on motivational interviewing as a tool to assist change puts an interesting twist on the “stages of change” paradigm of behavioral therapy. The chapters on the use of drugs and surgery for weight loss include a practical review of the micronutrient deficiencies that are caused by bariatric surgery. The book concludes with two important chapters; one is a discussion of the National Weight Control Registry, established by James O. Hill and Rena R. Wing, and the other is a discussion of the evaluation and management of obesity in children. In summary, this book provides new tools for immediate application in clinical practice.

The second book, Obesity, takes a broader perspective. We are treated to short reviews of neurobiology, leptin, and ghrelin as well as chapters on environmental estrogens as endocrine disrupters, smoking and inflammation, and other oxidative stressors that may be contributing to the obesity epidemic. Regarding therapies, this book has solid chapters on diet and exercise but many more on specific “neutraceuticals” — foods with purported therapeutic benefits. These chapters fit well in this book, but the enthusiastic reader must be warned that the benefits of many of the treatments that are discussed are unproved. The authors offer thoughts, theories, and treatments that are “outside the box,” and they do so majestically.

The treatment of obesity remains a troubling challenge. I was particularly struck by observational data that are cited in Treatment of the Obese Patient that show increases in self-reported leisure time and time engaged in physical activity. This is not what I hear from patients in my clinic, who are rushed and distracted and complain of not having the time to devote to lifestyle changes. I am also struck by comparisons from successive databases of dietary recall — which are somewhat flawed because of different methods but are nonetheless intriguing. Americans are consuming more calories, according to a recent report of self-reported data from the CDC (www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm) — 7% more among men and 21% more among women.

The challenges we face are our caloric intake and lifestyle choices. Food is often eaten as an afterthought, on the run, with little concern for its ability to nurture us. Labor-saving devices may have given us more leisure time, but we are not spending this time wisely, and this includes our failure to devote enough time to rest. Sleep deprivation induces changes in ghrelin secretion, thus promoting weight gain. Committing to fewer things, doing less, and sleeping more may be part of the answer.

Margo A. Denke, M.D.
University of Texas Health Science Center, San Antonio, TX 78229
denke@att.net

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