Relevance of the Metabolically Healthy Obesity Phenotype
Relevance of the Metabolically Healthy Obesity Phenotype
Despite the lack of consensus, the simultaneous rise in the prevalence of obesity in almost all countries seems to be driven mainly by changes in the global food system, with the reduced physical demands of many modern occupations possibly playing a role. Worryingly, no country in the world to date has reversed its obesity epidemic. Some barriers to action were recently discussed by Roberto et al.: lobbying from the food and restaurant industry, limited ability or unwillingness of governments to implement policies, absence of pressure from civil society for political action, and the lack of empirical assessment of the effects of many policies. Many debates about the causes and solutions of the obesity epidemic are based on dichotomies—for example, treatment versus prevention priorities. Indeed, we agree with Kleinert and Horton that this debate is at best distracting and hinders progress. It must be clearly stated that both types of strategies (individual- and population-level) are needed.
Efforts based on pharmacological, behavioral, or surgical therapies may ameliorate the medical consequences of obesity. Undoubtedly, clinical practice is extremely useful in many situations. Nevertheless, it should be openly recognized that further investments in this predominantly individual approach will not reverse the obesity epidemic, because 1) medical therapies or dramatic lifestyle changes do not modify the distal causes of obesity (i.e., modern processed food and the built environment) and 2) individualized lifestyle modifications are commonly unsuccessful and inaccessible. Human behavior is largely automatic, cued by environmental stimuli. Thus, further progress in the prevention of obesity should target environmental variables instead of focus on the disproportionate importance assigned to human conscious reflection. As suggested by Kleinert and Horton's words, the current growing scientific interest in the heterogeneity of obesity may potentially distract us and perhaps hinder further progress on the core issue: how to shift (to the left) the whole population BMI distribution.
Importantly, some detailed solutions have appeared. For example, there is certain consensus on actions that should be taken to promote healthy diets (the NOURISHING framework). Raising taxes on certain foods could produce huge public health benefits, as historically occurred with tobacco smoking or alcohol consumption. Governments could selectively tax unhealthier products and use that revenue to subsidize the production of nutrient-rich foods. In addition, changes in urban design promoting active methods of transport should be massively adopted. However, these types of initiatives will face enormous resistance, because they threaten the principles and values of globalization (i.e., reliance on motorized transport, free trade, privatization, less government intervention). The World Health Organization's Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 has a modest target of no increase in the worldwide prevalence of obesity between 2010 and 2025. A key message in the Lancet Obesity Series, published in 2011, was that "the obesity epidemic will not be reversed without government leadership", p. 2326). Therefore, the main challenge is whether governments will implement regulatory actions to halt the obesity epidemic.
Prevention Strategies and Obesity
Despite the lack of consensus, the simultaneous rise in the prevalence of obesity in almost all countries seems to be driven mainly by changes in the global food system, with the reduced physical demands of many modern occupations possibly playing a role. Worryingly, no country in the world to date has reversed its obesity epidemic. Some barriers to action were recently discussed by Roberto et al.: lobbying from the food and restaurant industry, limited ability or unwillingness of governments to implement policies, absence of pressure from civil society for political action, and the lack of empirical assessment of the effects of many policies. Many debates about the causes and solutions of the obesity epidemic are based on dichotomies—for example, treatment versus prevention priorities. Indeed, we agree with Kleinert and Horton that this debate is at best distracting and hinders progress. It must be clearly stated that both types of strategies (individual- and population-level) are needed.
Efforts based on pharmacological, behavioral, or surgical therapies may ameliorate the medical consequences of obesity. Undoubtedly, clinical practice is extremely useful in many situations. Nevertheless, it should be openly recognized that further investments in this predominantly individual approach will not reverse the obesity epidemic, because 1) medical therapies or dramatic lifestyle changes do not modify the distal causes of obesity (i.e., modern processed food and the built environment) and 2) individualized lifestyle modifications are commonly unsuccessful and inaccessible. Human behavior is largely automatic, cued by environmental stimuli. Thus, further progress in the prevention of obesity should target environmental variables instead of focus on the disproportionate importance assigned to human conscious reflection. As suggested by Kleinert and Horton's words, the current growing scientific interest in the heterogeneity of obesity may potentially distract us and perhaps hinder further progress on the core issue: how to shift (to the left) the whole population BMI distribution.
Importantly, some detailed solutions have appeared. For example, there is certain consensus on actions that should be taken to promote healthy diets (the NOURISHING framework). Raising taxes on certain foods could produce huge public health benefits, as historically occurred with tobacco smoking or alcohol consumption. Governments could selectively tax unhealthier products and use that revenue to subsidize the production of nutrient-rich foods. In addition, changes in urban design promoting active methods of transport should be massively adopted. However, these types of initiatives will face enormous resistance, because they threaten the principles and values of globalization (i.e., reliance on motorized transport, free trade, privatization, less government intervention). The World Health Organization's Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 has a modest target of no increase in the worldwide prevalence of obesity between 2010 and 2025. A key message in the Lancet Obesity Series, published in 2011, was that "the obesity epidemic will not be reversed without government leadership", p. 2326). Therefore, the main challenge is whether governments will implement regulatory actions to halt the obesity epidemic.