COURSE GUIDE - International Association for the Study of Obesity

Speaker Presentation SummariesTHURSDAY 28TH JULY 2011Stephan RössnerObesity 2011 – Where are we today?There is an old story about a scientist who happily submitted hispaper to a journal and got a letter back from the Editor. It read:Thank you for your manuscript. It was both new and interesting.The problem is that what was new was not interesting and whatwas interesting was not new.Clearly the information explosion concerning all aspects ofobesity has increased - but what is really new and interesting?The explosion is witnessed by the fact that we now have severalscientific journals, focusing on various aspects of obesity andmore to come. When the second journal OBESITY was launchedby NAASO in the 1980ies there was severe concern that the Int JObesity would be killed by the competitor- which certainly did nothappen. Today about half a dozen journals flourish…Although some experts have argued that the obesity epidemichas come to a halt, others disagree. On the other hand, itis obvious that we have never had so many obese children,adolescents and adults in the world as today. Journalists oftencannot distinguish between incidence and prevalence.It is appropriate that focus has recently been concentrated onprevention and particularly on prevention in the young and inadolescents. Clearly it is necessary to start early in life, sincethe prevention studies which have been carried out in adulthoodhave not been encouraging.A few years ago the health ministers of Europe unanimouslydecided to sign a Charter in Istanbul giving priority to an antiobesity‘war’. In reality most of these commitments have notbeen implemented and only a few countries have a strategic orcoherent approach to fight the uphill battle.Obesity is the end result of a powerful game and interactionbetween genes which are essentially unchanged from the StoneAge to the ‘toxic environment’ in which we live today. However, nosingle gene explains more than a minute fraction of the variation.Taken together it could be argued that we can explain about 50%of obesity by genetic factors. Clearly some people who happento be genetically well equipped by chance will never get obesewhatever lifestyle habits they exhibit, whereas others will fight alife long uphill battle.In most therapeutic fields an increased number of effective drugsbecome available with time and development. In this respectanti-obesity pharmacotherapy is in a unique setting. Around themillennium we had three well-established drugs available in manyparts of the world, although no means by all. When rimonabant waswithdrawn numerous drug companies immediately dropped theircannabinoid receptor blocker programmes and when sibutramineleft the stage in European countries only orlistat, the oldest drug withmodest weight loss effects, remained on the market, bringing boththerapists and patients back to square one. Numerous compoundswith various moods of action are in the drug company pipelines,but there is no obvious winner in sight. Hence companies look forold compounds, where safety has since long been established andcombine them. A few of these may reach the market within a year.They have reasonable weight loss effects and seem to be safe.Very low calorie (VLCD) or VLED (energy) diets are beginning tobe used in a more systematic fashion and a number of clinicalindications where rapid initial weight loss has positive long termconsequences have been identified.It is easy for politicians to demonstrate activity by setting resourcesaside for bariatric surgery. The techniques have improveddramatically and consequently postoperative mortality is almostdown to zero. However, repeat operations are common and eventhough many post-obese patients are very happy with the effects oftheir weight loss, there still remains several key problems. One ofthe most important issues to address for the future is who has theresponsibility for long-term follow-up of these patients. Obviouslysurgeons should do what they are expertly trained for, namely tooperate. They should not use their precious time for long-termfollow-up of patients. However, they have indeed the responsibilityto make sure that others do take care of this follow-up and givepatients consistent support. There is still uncertainty about thevery long-term consequences of bariatric surgery. At the outsetsurgeons, dieticians, physiotherapists and nurses have assumedresponsibility, but we have little information about what will happenten or twenty years in the future. Hence it is important that thosewho perform bariatric surgery today make sure that their patientsare carefully monitored throughout their lives.The obesity problem is escalating and what may force moreconcerted action is the ensuing explosion of Type 2 diabetes.Obesity may be ridiculed as self-inflicted and a disease causedby lack of willpower, but nobody disputes that Type 2 diabetes isa disease we need to address with the utmost importance, notleast for its financial implications. More detailed studies about thehealth economic consequences may result in the fact that theministry of finance rather than that of health takes action!In the meantime the depressing fact is that whatever miracle curepatients and therapists eagerly await, the old tools diet, exerciseand behaviour modification remain cornerstones. Well executedthey still remain quite effective tools and are definitely safe.Philip JamesEpidemiology and prevalence of obesityMeasuring weight for height is taken as an index of body fatnessdespite it being recognised for decades that the proportion ofbody fat differs between individuals, the sexes and with age.Pre-Second World War insurance statistics showed that heavieradults had a shorter life expectancy and the BMI was routinelyused from the late 1970s with an upper limit of 25 taken as thecrude – cut-off point on the basis of mortality. The BMI 30 waschosen as traditionally a 20% increase above normal was takento specify obesity. The lower limit of 18.5 was selected on thebasis of global analyses of physical capacity for heavy workwith BMI