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Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and Its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes Fall 2010, page 29
The approach taken in the current obesity article by James J Annesi, MD; Ann M Walsh, MS, RD; and Alice E Smith, MS, MBA, RD is so different than our observations gleaned from a quarter-century of experience treating obesity that some useful insight might be gained by comparison. Their essential conclusion from their carefully described and well-executed study is that a major treatment effort focusing on diet and exercise as the key treatment modalities failed to reduce weight meaningfully in a group of morbidly obese adolescents. Because the concepts of diet and exercise reflect conventional thinking about a problem whose treatment is rife with difficulty, we propose that they are describing a treatment approach whose basic premise is flawed.
The concept that obesity is the result of nutritional ignorance, while appealing, has no more demonstrable validity than does the supposition that poverty results from an inability to count money. Each, however, provides the comforting opportunity to busy ourselves in teaching rather than in understanding a more disturbing causality.
It is axiomatic in medicine that etiologic diagnosis is antecedent to treatment. Otherwise, we end up treating cough instead of Gram-positive bacterial pneumonia, or do not differentiate the shortness of breath of pulmonary embolism from that of anxiety. The question not addressed by Annesi et al (and by many others) is Why these children became obese, understanding that this is not to be confused with How they became obese. In what ways do their obese patients differ from demographically similar adolescents who do not significantly overeat? As we point out in our article in the Spring 2010 issue of The Permanente Journal (TPJ),1 with very rare exception, no one is born fat. Thus, the age at which weight gain first begins is a useful start in the differential diagnosis of the physical sign of obesity. Family history is also important, not because of genetics, but because it allows us to see how others in the same household have responded to life's stresses, whether internal to the family or external to it.
In a number of places Annesi et al hint at these stresses (“… self-concept, general self, and overall mood” and “Physical activity has also been shown to improve low mood, which is associated with obesity in adolescents”) but avoid exploration. Their conclusion thus rings particularly true: “… and attention to participants' self-concept and mood may be important treatment considerations.” Indeed, the psychoactive benefits of eating for the treatment of various levels of depression are profound. These benefits underlie the fact that almost every single “diet pill” has been a stimulant that has had antidepressant activity. So too, physical activity has antidepressant properties, just as inactivity is a commonplace marker for depression.
It is not our intent to engage in a polemic, sportive though that is in topics of difficulty and uncertainty. Rather, we propose that readers interested in the origins and treatment of obesity go to the TPJ Web site and review the Pre-Program Questionnaire (www. thepermanentejournal.org/files/Obesity/Preprogram-Questionnaire.pdf) that we have developed and used in San Diego during the past quarter-century. Having a few obese patients fill out that questionnaire at home will provide the information base underlying the needed new direction of our approach to obesity. Nutrition and arithmetic are both important subjects, but the one is no more relevant to the treatment of obesity than the other is to the resolution of poverty.
The change in direction that we propose will undoubtedly be resisted because it significantly raises the performance bar for those choosing to be involved. The article by Annesi et al has merit because it illustrates the ineffectiveness of the usual approach to obesity. Hopefully, it will lead to explorations of other possible treatment approaches for obesity that incorporate awareness of the benefits of overeating in unconsciously treating problems that are unrecognized, often distant, and almost never explored. Additionally, those approaches must incorporate an understanding of the benefits of obesity, which are not at all in conflict with the manifest risks of obesity. Indeed, in biological systems, the simultaneous existence of varying levels of opposing forces is the norm of all our control systems.