“Obesity in Remission” was a new turn-of-phrase
for me in 2015. I discovered it in a long and provocative comment online in Lancet Diabetes and Endocrinology (registration
required). A link to the Lancet
summary and the full text was provided by a Medscape Medical News piece. Why it
was provocative will be the subject of Part 2 of this series. This post is an excerpt
from the comment to explain, in context, their phrase, “Obesity
in Remission.”
“Many clinicians are not
adequately aware of the reasons that individuals with obesity struggle to
achieve and maintain weight loss, and this poor awareness precludes the
provision of effective intervention. Irrespective of starting weight, caloric
restriction triggers several biological adaptations designed to prevent
starvation. These adaptations might be potent enough to undermine the
long-term effectiveness of lifestyle modification in most individuals with
obesity, particularly in an environment that promotes energy overconsumption.
However, they are not the only biological pressures that must be overcome for
successful treatment. Additional biological adaptations occur with the
development of obesity, and these [adaptations] function to preserve, or even
increase, an individual's highest sustained lifetime bodyweight. For example,
preadipocyte proliferation occurs, increasing fat storage capacity. In
addition, habituation to rewarding neural dopamine signaling develops with the
chronic overconsumption of palatable foods, leading to a perceived reward
deficit and compensatory increases in consumption. Importantly, these
latter adaptations are not typically observed in individuals who are
overweight, but occur only after obesity has been maintained for some
time. Thus, improved lifestyle choices might be sufficient for lasting
reductions in bodyweight prior to sustained obesity. Once obesity is
established, however, bodyweight seems to become biologically stamped in and
defended. Therefore, the mere recommendation to avoid calorically dense foods
might be no more effective for the typical patient seeking weight reduction
than would be a recommendation to avoid sharp objects for someone bleeding
profusely.
“Evidence
suggests that these biological adaptations often persist indefinitely, even
when a person re-attains a healthy BMI via behaviorally induced weight
loss. Further evidence indicates that biological pressure to restore
bodyweight to the highest-sustained lifetime level gets stronger as weight loss
increases. Thus, we suggest that few individuals ever truly recover from
obesity; individuals who formerly had obesity but are able to re-attain a
healthy bodyweight via diet and exercise still have ‘obesity in remission’ and
are biologically very different from individuals of the same age, sex, and
bodyweight who never had obesity. For most individuals, these biological
adaptations need to be addressed for weight loss to be sustained long-term. We
believe these mechanisms largely explain the poor long-term success rates of
lifestyle modification, and obligate clinicians to go beyond mere
recommendations to eat less and move more.”
N.B.: These paragraphs were footnoted with references to the scientific
articles supporting the statements.
“Thus, we suggest that few
individuals ever truly recover from obesity; individuals who formerly had obesity but are able to re-attain a
healthy bodyweight via diet and exercise still have ‘obesity in remission’
and are biologically very different from individuals of the same age, sex, and
bodyweight who never had obesity.” Boy, who among us who ever was overweight
and obese cannot relate? The authors of this “comment” in Lancet, all recognized authorities in obesity, have explained in
understandable terms the dilemma that so many of us formerly overweight and
obese have experienced…and overcome. I commend them for their
efforts to share their understanding with other clinicians, urging that they
should “go beyond mere recommendations to eat less and move more. For this, I
say, “Bravo!”
I am also encouraged by their
recognition that losing weight in the first place is not a matter
of caloric restriction alone; and that why it is a struggle for
the overweight and obese to achieve weight loss in the first
place.
These experts in obesity have
described how “these mechanisms” [to sustain weight loss once
achieved] specifically “these biological adaptations,” “need to be addressed
for weight loss to be sustained long-term.” I love it that they think it should
“obligate clinicians” to go further, and I look for them to
explain how. My hopes soar with phrases like “promotes energy overconsumption”
and “increases fat storage capacity” that suggest they might know the
mechanism, but then they associate “avoiding
calorically dense food” with a means of “seeking weight reduction.”
Alas, my hopes were dashed. See Part
2 (#298) to see how these experts managed to do that.
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