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Hope and change for 2011
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Another year has passed and yet nothing is new. It is the same old story of the obesity epidemic and our inability to overcome our own physiology. We are constructed of the thriftiest of metabolisms, capable of surviving the worst of famines, as often occurred in our history or even pre-history.
But now, all of that has changed. We are no longer dependent on regular flooding of river estuaries or monsoon rains because we have irrigated the desert and fertilized the fields with chemicals superior to our own excrement. Our seeds and trees are hardier than their environmental needs and our pesticides kill off most potential predators. With the advent of refrigeration and mass transportation, fresh foods from around the globe inundate our stores. Delicacies once available for a week or two per year are now available in every calendar month. It is all abundant and cheap, cheaper even than the efforts required not to eat it all. Multiple redundant hypothalamic circuits ensure that we eat often, that we enjoy what we eat and that we continue to eat, even when no longer hungry. Indeed, food has become our most pervasive drug habit, outperforming such staples as alcohol and cigarettes. Food is perhaps as addicting as opiates, when considering the recidivism rate after weight loss as compared with that seen after narcotic withdrawal.
Nevertheless, it is not the overabundance of food itself that drives ballooning obesity. Food limitation and newly attentive beaurocracy will do little to change the trajectory of weight gain in the general population. Limiting Happy Meals or banning high-fat foods is not the solution.
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Rather, we must also look to our sedentary physical lifestyle. Decades ago, our ancestors ate large quantities of highly fatty foods, but also did great amounts of physical labor. Lumberjacks used hand saws and burned upward of 10,000 calories per day. Now they use chainsaws and drive to work. Robots build the industrial products that we make; workers sit at the controls, just in case something needs to be done. And so it goes throughout the late 20th and 21st century workplace, a substitution of the sedentary and thoughtful for the active and the sweaty.
Home life is no better. There, we pay people to cut our grass and may also pay for an underused gym membership. But far worse is the change in our sporting habits. Where children once played in schoolyards before dark, now latchkey children play with electronic games and toys. Lives are increasingly centered on our electronic media, marking a profound transition from live interaction to electronic chatter that few hear or give much attention. Worse, because many of us bring work home, our dependence on electronic work devices fills more and more of our days, nights and even weekends.
The current economic environment is not conducive to radical workplace changes or even reductions in at-home non-physical work. Because of uncertainties surrounding the true future costs of employees, hours worked per week are routinely extended by employers rather than hiring more new employees who may be more expensive to support, especially if there should be a downward correction in economic activity. With less time available for physical exercise and work becoming more and more sedentary, there is a limit below which calories ingested cannot be further reduced. Worse yet, because of the economic uncertainties of our times, there is a shift toward less expensive fast foods containing large amounts of fat and sugar. These are not only less costly for strained family budgets, but these foods per se are a source of comfort and instant pleasure for an insecure and uncertain population.
These considerations regarding worsening obesity would be nothing more than a vanity and self-esteem issue, were it not for the resulting explosion of diabetes in the US population. With 28 million patients with diabetes and another 77 million with prediabetes waiting in the wings to become diabetic, doing nothing is not an option. The costs of diabetes and its chronic complications are a burden now on our health care system. As the prediabetic population inexorably deteriorates toward overt diabetes, these costs will only escalate.
Lifestyle modification is certainly the most direct approach to the management of worsening population obesity in America, but this is doomed to long-term failure. Worse, we have managed to stigmatize the overweight and obese without significantly changing behavior. Perhaps the stress of the public pressure to be thin may also cause sufficient loss of self-esteem as to produce stress overeating as a compensatory response in some of these patients.
Thus, the need for pharmacologic management of obesity and perhaps prediabetes itself is inescapable. This is especially important now that we see that the bulk of genetic traits predisposing toward type 2 diabetes are all beta-cell-specific genes. We may therefore conclude that obesity and perhaps the resulting insulin resistance likely worsens the beta-cell dysfunction and hastens diabetes appearance. Dealing with obesity and lifestyle-related insulin resistance is therefore mandatory if diabetes is to be prevented.
To that end, it is heartening to see that the recent FDA advisory board for an obesity-related drug has recommended approval for that agent. To the extent that obesity is a metabolic disorder, not a character disorder, it requires real medical interventions, which will work long term to thwart our bodies’ thrifty genes, and the frugal retention of every excess calorie ingested.
Our bodies are the product of an evolutionary environment that no longer exists. Until we understand how to change basic genetic makeup and alter metabolism, we are doomed to fight an unsuccessful battle against obesity and its long-term complications, such as diabetes, heart disease and stroke. These are medical issues that require medical interventions and medications where necessary. We simply must have more tools with which to address this epidemic. The FDA seems to be responding to this need and thus 2011 may be a better year than 2010 for at least 100 million overweight Americans.
Alan J. Garber, MD, PhD, is professor of medicine at the Baylor College of Medicine in Houston and a Cardiology Today CHD and Prevention Editorial Board member.
Disclosure: Dr. Garber reports no relevant financial disclosures.