Is obesity curable

The results of the conservative treatment of obesity so far are unsatisfactory. Probably not even every tenth attempt at weight loss has lasting success. As a result, a nihilistic attitude towards obesity therapy is widespread among physicians, and all too willingly in earlier years this ungrateful task has been taken out of hand. Numerous providers have therefore established themselves on the market and try in a more or less qualified, but mostly lucrative way, to support obese people with weight loss. The classification of obesity as a chronic disease and obesity therapy as a primary medical task is becoming increasingly widespread. Coincidence or not, the growing number of medical professionals engaged in obesity therapy coincides with the approval of two new drugs for the treatment of obesity. Adam's overview in this issue deals, among other things, with the pharmacological principles of medicinal weight reduction (1).
Taking Orlistat (Xenical) prevents the absorption of about 30 percent of the fat in food. With hypocaloric nutrition at the same time, this is accompanied by an additional weight loss of around 4 kg (3, 11). Sibutramine (Reductil), on the other hand, leads to an increased feeling of satiety, reduced food consumption and an increase in energy consumption, which is associated with a dose-dependent weight loss of around 4 to 6 kg (8, 12). Both substances have a beneficial effect on obesity-associated risk parameters. They lead to a significant reduction in hypertriglyceridemia and hyperinsulinemia, a slight decrease in high cholesterol and blood sugar levels and, in the case of orlistat, also to a slight decrease in blood pressure. The extent of these therapeutic effects correlates with the level of weight loss achieved. After a few months of therapy with orlistat or sibutramine, there is usually no further weight loss. After discontinuing the respective preparation, there is usually even a renewed increase in body weight, unless other measures, such as exercise therapy, are used successfully. This observation should come as no surprise to us. Likewise, blood pressure that has been successfully lowered by medication would not remain at the lowered level on its own after discontinuation of the antihypertensive drug, unless simultaneous non-drug treatment is successfully applied. Although obesity has mostly been a problem that has lasted for decades, unlike hypertension, long-term drug therapy is currently not an alternative. It is therefore not advisable to take orlistat or sibutramine without changing your lifestyle.
Predisposition and lifestyle are decisive
Genetics and lifestyle together determine body weight or the "Body Mass Index" (BMI). Hereditary factors, which have proven beneficial for survival with limited food resources over the past millennia and thus prevailed in evolution, now encounter the wrong environmental conditions of today (4). As a result of this constellation, almost half of the adult German population is overweight (BMI> 25 kg / m²) and almost every sixth person is obese (BMI> 30 kg / m²) (5, 6). To regard overweight and obesity as merely cosmetic problems would mean grossly underestimating the importance of their epidemic prevalence for the health status of our population. Multifactorial health problems can only be treated successfully through multifactorial and interdisciplinary therapy concepts: energy- and fat-reduced nutrition, increased physical activity and mediation of long-term behavior modification (2, 7, 10). If such a basic therapy does not achieve sufficient success, defined by a weight loss of more than 5 kg in three months, the additional use of a drug can be considered. Even with orlistat or sibutramine, with a few exceptions, it will not be possible to normalize body weight, but it will make it much easier to achieve the therapeutic goals that apply to the majority of patients: the permanent loss of ten percent of body weight and the associated improvement in the risk factor profile. A swift initiation of placebo-controlled studies must now be demanded, which examine a possible effect of orlistat and sibutramine on hard endpoints such as cardiovascular events. As long as only surrogate parameters are investigated, it is difficult to be convinced of the long-term benefits of drug-based obesity therapy. Proof of long-term harmlessness must also be provided as soon as possible.
The assessment that one can achieve weight loss with the most varied of strategies, but that obesity is ultimately hardly curable, remains valid even after the introduction of orlistat and sibutramine. Is the effort that we now put into interdisciplinary, structured therapy programs to permanently lose ten percent of body weight, therefore, at all justified, or are we wasting valuable resources? Unfortunately, there is still no sufficiently precise analysis of the costs associated with overweight and obesity in Germany. The calculated share of three to seven percent of the total costs incurred in the healthcare system is probably clearly too conservative (7). Given the difficulties in calculating the true costs of obesity and the lack of intervention studies, it is naturally very difficult to assess the potential savings from effective therapy. Whether a loss of ten percent of body weight is associated with a cost saving that outweighs a significant part of the treatment costs, we will not find out for many more years.
Increased risk of abdominal obesity
What shall we do in the meantime? We should check our overweight and obese patients with regard to their prerequisites for structured therapy, whereby the ability and willingness to cooperate are the decisive prerequisites. We must concentrate the greatest efforts on obese people with a pronounced cardiovascular risk profile. Disturbed glucose homeostasis, dyslipidemia and hypertension are disproportionately common in women with a waist circumference of more than 88 cm and men with a waist circumference of more than 102 cm (9). The diagnosis of abdominal obesity with, according to international guidelines, a significantly increased risk by simply applying a measuring tape is, in addition to the question of a familial burden for vascular complications, an important decision-making aid regarding the effort with which a weight reduction should be attempted. Patients with abdominal obesity will probably benefit most from an intervention, although the data situation with regard to a possible reduction in the risk of mortality through weight loss is unsatisfactory and should urgently be improved. The quality of structured obesity treatment must also be examined, with a period of three years being required for the evaluation of long-term results. Treatment of obese people can only be improved by optimizing therapy programs based on such data. New drugs with different mechanisms of action, such as orlistat and sibutramine, expand the possible options in the treatment of obese patients. The optimization of obesity therapy in close cooperation with nutritionists, exercise and behavior therapists must not distract us from a central problem: the increasing prevalence of obesity in children and adolescents is alarming and the early manifestation is a very unfavorable prerequisite for obesity Therapy (13). The actual solution to the problem does not lead to drugs or fat simulators, but only to obesity prevention.

How this article is cited:
Dt Ärztebl 1999; 96: A-3240-3242
[Issue 50]

1. Adam O: Pharmacological basics for the use of fat simulators, inhibitors of nutrient absorption and anorectics for the therapy of obesity. Dt Ärztebl 1999; A-3243-3247.
2. Clinical guidelines on the identification, evaluation and treatment of overweight and obesity in adults - the evidence report. National Institutes of Health. Obes Res 1998; 6 (Suppl 2): ​​51-209.
3. Guerciolini R: Mode of action of orlistat. Int J Obes Relat Metab Disord 1997; 21 (Suppl 3): 12-23.
4. Hamann A: Genetics of Obesity. Clinic doctor 1998; 27: 214-220.
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6. Hoffmeister H, Mensingk GBM, Stolzenberg H: National trends in risk factors for cardiovascular disease in Germany. Prevent Med 1994; 23: 197-205.
7. Lauterbach K, Westenhöfer J, Wirth A, Hauner H: Evidence-based guideline for the treatment of obesity in Germany. 1998.
8. Lean ME: Sibutramine - a review of clinical efficacy. Int J Obes Relat Metab Disord 1997; 21 (Suppl 1): 3036; discussion: 37-39.
9. Lean ME, Han TS, Morrison CE: Waist circumference as a measure for indicating need for weight management. Br Med J 1995; 311: 158-161.
10. Scottish Intercollegiate Guideline Network. Obesity in Scotland. Integrating prevention with weight management. A national clinical guideline for use in Scotland. Edinburgh: SIGN, 1996.
11. Sjostrom L, Rissanen A, Andersen T et al .: Randomized placebo-controlled trial of orlistat for weight loss and prevention of weight regain in obese patients. European Multicentre Orlistat Study Group. Lancet 1998; 352: 167-172.
12th floor MJ: Sibutramine: a review of the pharmacology of a novel anti-obesity agent. Int J Obes Relat Metab Disord 1997; 21 (Suppl 1): 25-29.
13. Wirth A: Obesity. Berlin, Heidelberg: Springer, 1997.

Address for the authors
Dr. med. Andreas Hamann
Department of Internal Medicine I
Medical clinic and polyclinic
University of Heidelberg
Bergheimer Strasse 58
69115 Heidelberg

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