Fat people eat too much ...

Blame the patient, blame the parents, blame the government, TV, fast food, modernity. Virtually all information in the media on obesity slants blame somewhere.

“Doctor’s don’t understand or are just pushing drugs or operations.” “Fast food industry is just interested in sales.” “Individuals focusing on specific diets lack scientific training.” “Patients just eat too much.”

These headline grabbing issues may make for entertaining reading but often do not add much towards remedying the situation.

If one starts with the assumption that most people concerned about obesity would eventually accept a therapeutic approach that works, the way forward is to find such an approach.

Identifying causal factors that can be remedied is different from assigning blame. Identifying causes is the way forward to developing effective therapy. Assigning blame leads nowhere except to reaction or over-reaction by those blamed. Clear identification of causal factors, whether this involves genetics, the type and quantity of food eaten, lifestyle and exercise, education and child-rearing practices would allow progress towards effective therapy.

Different practitioners have different predictions as to what will work, but honesty compels us to admit, in 2008, we do not know the best way to manage the ongoing army of obese and over-weight children, adolescent and adults.

What is the answer? What to do? Should we apportion blame, fight for resources, bitch and moan?

Several things are crystal clear. The only way to find appropriate management is more research, much more research.

We need to find out why identical twins are the same weight even if they are reared apart. We need to discover why subjects who are desperate to reduce their weight, regain all the weight lost after having worked very hard to lose it. We need to complete the picture on how the brain regulates body weight.

We need to discover all of the circulating factors that make us hungry or take away our hunger. More than 20 of these factors have been already discovered. They are made in the gut, in fat cells and in the pancreas, but almost certainly there will be more. How is obesity imprinted in the off spring of starving mothers? Does the food we eat change the way genes are expressed leading to permanent obesity? How does obesity cause disease?

The underlying cause of obesity is certainly genetic. Overfeed identical twins and they gain exactly the same amount of fat. An overwhelming amount of evidence identifies the genetic basis of this problem. These genes regulate hunger, food intake, energy storage and energy expenditure, as well as yet unidentified pathways.

Why has obesity occurred now? One could argue that human genes have not changed substantially in the last 50-100 years.

What has changed in the West, and in a number of developing countries, is free access to unlimited quantities of high calorie food. The most satisfying hypothesis is that obesity is currently an interaction between susceptibility genes and an environment with unlimited access to calories. There is much we don’t know. Which genes, and what are the environmental interactions? Are particular food types more likely to affect these pathways?

Finally, when we understand all this, are there approaches, most likely pharmacological, to modulating these systems.

Is it likely the solution to the problem in 10 years time will just be specific diets and more exercise? Many think this is unlikely.

Will the solution simply be a series of tablets? Most think this unlikely too.

The solution is likely to involve continuing attempts at dietary restriction, combined with exercise and an appropriate mix of medications. These medications will regulate the function of those genes predisposing to obesity. Will we have these medications within 10 years? Time will tell.

Many have advocated other approaches including; more physical activity training for children, encouraging life long exercise patterns, stricter regulation of food advertising in the media particularly aimed at children, stricter regulation of food outlets, education campaigns, advertising, peer pressure.

Who would argue against some of these sensible approaches? We are all in favour of promoting healthy lifestyles and suggesting people should eat less and exercise more. This approach to lifestyle delivers many important health benefits, and may help slightly overweight people get back to their normal weight. However, it will not cure obesity, no matter how much is spent on advertising.

We should not be too pessimistic however. Can we commence treatment currently? Of course. Appropriate lifestyle and diet, regular exercise, tablets in some, operations in a few. Will these effectively solve the problem? Most do not really believe this.

Fat people do eat too much, otherwise they would lose weight, but there is no point blaming them.