A recent study in the Journal of the American Medical Association (JAMA) indicates that though rates of diabetes and prediabetes are still pretty high, affecting close to half of U.S. adults, the rates of Type 2 diabetes have undeniably begun to level off. Given the relationship between Type 2 diabetes and obesity, it seems that obesity rates may have also begun to plateau.
Based on findings from the National Health and Nutritional Examination Survey (NHANES), between the years 1988-1994 and 2007-2008, rates of both diagnosed and undiagnosed diabetes increased. However, data from 2011-2012, showed “little change,” indicating a leveling off of the disease. This has given health experts a glimmer of hope. Experts suggest this may be due to a cultural shift in attitudes toward diabetes, identifying obesity as a disease (American Medical Association), and more focus and emphasis on food policy and home and work environments where we spend much of our “eating time.”
I spoke with Nikhil Dhurandhar, PhD, FTOS, President of the Obesity Society, professor and Chair of the department of nutritional sciences at Texas Tech University. Dr. Dhurandhar has been involved in obesity treatment and research for over 30 years, coined the relatively recent term infectobesity, and has been directly involved in garnering more investigation into the obesity disease to find more novel preventive and treatment options.
What is your perspective on the study’s findings?
Although Dr. Dhurandhar expressed being heartened by the data, he added that we still need to acknowledge that rates of diabetes and obesity in the U.S. are, “still too high.” When asked why the plateau in obesity has occurred, he replied that causes of obesity are multifactorial and complicated - so it’s nearly impossible to isolate specific factors that caused it. But after referencing a math model, he did indicate that in most diseases there is a maximal saturation point, and that U.S. rates may have possibly hit that moment. Of course, other countries have been pacing at different rates, which is why they may still be experiencing the uptick in their rates of obesity.
How can we have obesity and starvation pacing side by side?Dr. Dhurandhar suggested that lower socio-economic level (not knowing if and when your next meal is coming) can be associated with fueling obesity, as it often does in the U.S. He suggested that perhaps when you don’t know when food may come next, there’s a tendency to overeat. In a country such as India, Dr. Dhurandhar explained, the opposite is true; food insecurity more often fuels starvation, whereas the wealthy and affluent are more likely to have excess weight issues. This again pins the reality that obesity has multiple causes and influences.
What about the energy balance formula and its role in obesity?
Calories in versus calories out and the steadfast theory of needing to burn or create a deficit of 3500 calories in order to “lose a pound” is certainly still a principle that stands. But Dr. Dhurandhar did highlight current PubMed research that identifies the almost 90 different “contributors” of obesity. Having a sluggish metabolism (for a variety of reasons), becoming predisposed to obesity in the womb based on choices made by our mother during pregnancy, viral infections, gut microbe influences, chronically sleeping too little or too much and more, all set the stage for obesity and enable its persistence. So just turning to the “eat less, move more” equation is way too simplistic. Calories, Dr. Dhurandhar suggests, are one piece of a very complicated process.
What is the role of doctors and pediatricians in influencing obesity trends?I pointed out that many pediatricians seem to avoid conversations regarding obesity, which impedes early intervention. We also both agreed there is great reticence in adult medicine when it comes to weight issues and obesity. He reminded me that obesity only recently became recognized as a “disease.” So doctors were mostly left to make casual references to “eat better and exercise more,” based on the patient's receptiveness to even discuss their weight.
Now there are new certifications specific to the care of patients diagnosed with obesity, as well as adjustments to communication skills on the topic of obesity. If the doctor can’t begin the conversation with the right words and attitude, he or she will likely have a resistant patient, and no chance at forging the successful patient-doctor relationship that yields long-term weight-loss goals.
_ “The awareness is coming slowly…..we need this skill set or we’ll run into a brick wall.”hat do we need to fight obesity and to create a downward trend?
We need better treatment options. Dr. Dhurandhar has treated tens of thousands of patients during his long career. He notes that in his early years as an obesity specialist his limited arsenal included dietary and lifestyle modifications and yielded some results. However, once he introduced even the less-than-perfect medications we have, he noted a drastic shift in success rates of weight loss. The gain in popularity of bariatric surgery has also helped to drive better success rates.
“We need to blame the patient less and get a better toolbox of possible treatments.” He indicated that we need to “use it all” - diet, exercise, better sleep habits, medications and bariatric surgery, when indicated.
Obesity as a chronic disease
I pointed out that it seems when people lose massive amounts of weight, they believe that they’ve been cured, when in fact they are really in remission. He agreed and suggested that though a patient may hit goal weight or close to it, they merely have the disease “under control.” The potential or propensity to gain weight (easily) still remains.
Unlike an addiction to drugs or smoking or alcohol, substances that you can live without, you have to co-exist with food.** Certainly you can use techniques that help to limit temptations, but at the end of the day, you need food to live.**
This is all the more reason to choose certain types of foods, limit less healthy refined and highly processed foods, and certainly to employ portion control, move as much as possible throughout the day, exercise daily, join a support group, have an ongoing relationship with a dietician and your physician, and use other behaviors to achieve weight loss and weight maintenance.
What’s the role of the food industry in reducing obesity?Dr. Dhurandhar said that obesity is not due to one single food product. It’s due to calories, and a day’s worth of eating choices. He offered the example of an extensive buffet and asked, “If we take away one or even two specific food items, will that really impact the buffet or the individual’s choices? It’s like digging a hole in water…removing one specific food choice (from hundreds of potential choices a person has in a given day) will not yield big results when it comes to solving obesity. “
From a personal perspective, I’m convinced a big part of the solution begins in the home, and that parents must buy into how crucial their choices are to the well-being and healthy weight goals of their growing children. Dr. Dhurandhar believes part of the answer lies in getting different food companies, the big ones who yield influence, to partner together to use their reach in people’s dining rooms in finding solutions.
_ He asks, “Can we get stakeholders together from this community?” I’m not sure we have the answer on that yet.e should all be following a healthy lifestyleWe agreed it’s a bit hypocritical to suggest that only someone who's been diagnosed with obesity should be focused on those healthy behaviors.** But if you look at families where one child grapples with weight issues, or one adult has the disease, you will often see them being isolated, with the mandates of a better lifestyle solely focused on them.**
We should all be mindful of trans fats, high levels of added sugar, over-sized portions of food, sweetened beverages, track physical minutes of activity and move more. That’s not just an equation for obesity treatment, that’s an equation for healthy living.
What can we do now?Dr. Dhurandhar acknowledges that it will take changes and improvements in the home, general environment, community, healthcare and the arsenal of therapies for significant improvements to occur in the current obesity trends. We need awareness and we need to limit the stigma associated with the disease in order to make inroads. Doctors do need better skill sets and training to deal with the disease. “No country is doing a better job right now at treating or intercepting obesity.”
But there is hope.
When we start to treat obesity like a complicated and serious disease, it will likely inspire more sensible, fact-driven treatments at the consumer level, and drive research to find better therapies.
Referring back to the initial study, Dr. Dhurandhar emphasizes the complexity of the obesity disease: “One big meal does not lead to obesity and one small meal does not make you lean…diabetes cannot be cured or may not improve (just) because ‘you choose to do it,’ and the same holds true for obesity.”