Michael Gliksman: Preventing cure?

CONSIDER this as a new treatment paradigm: orthopaedic surgeons tell their patients with compound comminuted fractures to cure the break by avoiding falls.

Or, immunologists tell patients with hepatitis B-associated liver cancer that they will be cured if they avoid the exchange of bodily fluids. Ophthalmologists tell patients the cure for traumatic cataracts is to avoid trauma.

It’s actually not a new treatment paradigm. Hands up those who tell their obese patients that the cure lies in diet and exercise?

For a while my hand would have been up too. I might as well have told them to burn chicken entrails.

We’re not fooled into identifying the removal of the cause as the cure in any other field of medicine. Prevention and cure are rarely confused elsewhere, so why the contrary approach to obesity?

Most doctors aspire to practise evidence-based medicine. So with obesity, what does the evidence show?

Bariatric surgery results in statistically and clinically significant sustained weight loss and reductions in mortality compared to matched controls. A Swedish study showed dramatic differences in weight loss over a 15-year period — the control group receiving “conventional treatment” showed about 1% change in body weight compared with as much as 30% mean percentage weight change for those who had undergone bariatric surgery.

Now look your obese patients in the eyes and tell them to diet and exercise to lose weight. This is not evidence-based medicine so much as the medicine of wishful thinking.

For many obese patients the hormonal defence of what has been built on past lifestyle choices is too strong — the body may be hormonally primed for some time after weight loss to regain weight.

Don’t get me wrong. A nutritious diet and exercise has many benefits, including possible delayed onset of metabolic syndrome in the obese but, for most people, sustained substantial weight loss isn’t one of them.

I suspect the reason evidence-based medicine is not practised in this area is that in the back of our minds lies the knowledge that if the evidence is accepted, we will be powerless to treat the already obese, except by surgical means. Yet like diet and exercise, bariatric surgery offers no basis for population-based curative interventions.

I’d argue this is not the philosophy of despair. Acknowledging the evidence, however unpalatable, offers guidance.

We need a truly multifaceted approach to what may prove the major population health problem in the developed world for the current and next several generations.

We need more research into the hormonal pathways to obesity and the non-surgical means to obstruct them. More equitable access to bariatric surgery on the basis of need is also required.

We cannot afford the promotion of junk food and junk lifestyles to the young. Our duty to them and their right to a life of good health should overwhelm the fast food industry’s clamour for unfettered marketing access.

A balanced diet and adequate activity levels are the cornerstone of obesity prevention and may have an important role in the secondary prevention of the metabolically adverse consequences of obesity.

However, while we continue to promote diet and exercise as a cure for obesity, we are little more than unwitting touts for the weight loss industry, whose financial success is predicated on clinical failure.

Dr Michael Gliksman is an occupational physician based in Sydney and chairman of the Professional Issues Committee of the AMA NSW. On Twitter @AFairGoForAll

Click here to read comment from Professor Louise Baur, who says obese adolescents are missing out on a proven therapy.

Posted 21 January 2013