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Tackling Obesity: Part 6: One Size Does Not Fit All 7.06.04 Source: Andrew Schwartz, for CHC exchange Despite the greater attention to obesity, the epidemic continues to grow. A number of treatments - usually some combination of diet, exercise, counseling, and drugs or surgery - have already been proven quite effective, but even the good programs seem to generate results in only about 15 percent of their patients. When groups do better than that, they tend to be self-selected and motivated, and not those hit hardest by the obesity epidemic - ethnic minorities in disadvantaged communities. Members of the CHC Obesity Center believe that the isolated nature of most obesity research and treatment contributes to the low success rate and the failure of today's prevention efforts. Certainly, all see the limits to their own particular discipline. Vaisse, for example, is leery of the way people associate miracle promises with genetics. "The epidemic in this country has occurred over the last thirty years," he says. "There cannot have been a lot of gene mutation over that period of time. In addition, genetic mutations that are solely or primarily responsible for an individual's obesity are extremely rare. That means the cause of the present epidemic lies elsewhere." Consequently, he believes that ultimately, success hinges on individuals and society doing the hard work of breaking old habits and changing the ways they approach diet and exercise. Lustig feels that as important as the role of insulin is, "We have to figure out what in our environment has changed and led to our insulin levels being overhyped." Unsurprisingly, then, one of the clear, early conclusions that the group has drawn is that there is no single solution for either prevention or treatment. "One size does not fit all" is a common theme. Consequently, "The first research question on the table is: if we could individualize the treatment, can we double our success rate?" says Baron. The group will strive to create what Andrea Garber calls "a treatment algorithm" for working with an obese patient. For example, patients with a genetic mutation that contributes directly to their obesity might move immediately to a drug treatment combined with a tailored diet and exercise regime. Those treatments might be supported by psychological and cultural insights that would help ensure compliance. In contrast, obese individuals for whom genetics and biology are not the primary contributors would undergo intensive counseling accompanied by a diet and exercise regime that accounts for familial and cultural patterns around food, as well as the surrounding community factors. In the case of a child, parents might receive culturally sensitive training in nurturing and limit setting. While creating and implementing such an algorithm is a complex challenge, "I feel tremendous cohesion across many disciplines," says Mietus-Snyder. "The attention we are all focusing on this may make it less of a David vs. Goliath proposition than it's been to date." Longer-term, the group intends to add its voice to the public health effort that is gathering steam in pockets across the country. Valente, who works with families whose children are chronically ill, says that such an effort might be helped by research into the differences from culture to culture in parent-child mealtime interactions. Mellin argues that public health efforts must aim, at least in part, to provide education about nurturing and limits. Tran talks about working with young mothers to encourage breast feeding, since there are suspicions that the excessive use of formula creates a metabolic set point that encourages obesity and which is very difficult to alter. Tools for the Here and Now Still others suggest that a large national effort could be supported by smaller, pilot-type efforts in the Bay Area that would have a more immediate impact. Bobby Baron, for example, would like to see the CHC group begin by transforming UCSF into an obesity prevention environment that could be used as a model for programs around the country. It is exactly that kind of short-term, grassroots effort that Tran would also like to see emerge. "At least 30 percent of our kids at SFGH are obese," she says. "Over the last few years, we've seen more Type II diabetes in younger people. Higher blood pressure. Higher cholesterol and triglycerides, even some hip and knee problems. We already know an awful lot and I want solutions that can work today." For her patients, kids like "Gilberto," the solutions cannot arrive too soon. On the face of it, of course, Gilberto should simply stop drinking soda and play basketball at the local park. But it is in understanding how to achieve and sustain such behavior change among large groups of people that the key to the epidemic lies. If groups like the CHC can begin to make progress in this area, then the downward curve on Gilberto's chart will no longer be an isolated case. That's when the providers who care for him will have a lot more reason to cheer. (See links to preceding parts below.) Part 1: Tackling ObesityPart 2: Genetics Provides Clues, Not All the Answers Part 3: "Our Biology Is a Mismatch for Our Environment" Part 4: Exploring the Intersection Between Body and Mind Part 5: A "Toxic" Environment Part 6: One Size Does Not Fit All |
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