Influence reimbursement policies for effective early intervention and prevention strategies for obesity * Reevaluate policies for use of drugs in the treatment of obesity Recommendations for Education Programs

Toward a New Conceptualization of Treatment and Prevention of Obesity Obesity is a prevalent, serious, and refractory public health problem. Recent long-term results from treatment studies have shown discouraging rates of relapse. These findings, combined with a growing antidieting movement, have called into question whether weight loss is possible with current methods and whether obesity should be treated at all. An important issue in this debate is whether efforts to lose weight can be successful. A frequently cited statistic, that 95% of overweight persons regain lost weight, is based on surprisingly weak data. What little is known about long-term results comes entirely from specialty research clinics, where subjects are heavier, display more psychopathology, and are more likely to be binge eaters than overweight people in general. These are negative prognostic factors, so extrapolating these subjects' results to people who lose weight by any method may be a serious mistake. Research is clearly needed to test the effectiveness of weight loss efforts of all types. Even if sustained weight loss occurs more often than expected, there is a desperate need to improve treatments for obesity.1-3 A "conceptual house-cleaning" is in order and bold, innovative perspectives are needed. One means of advancing conceptually is to place past, current, and future research into a generational model. To propose such a model, four generations of research may be considered. The first generation of treatment studies on obesity consisted of atheoretical research with small samples, minor weight loss, short follow-up periods, and controlled studies in which the challenge was to find a single best treatment. The second generation spanned the mid-1970s through the mid-1980s, and although weight losses were more impressive and follow-up periods longer, relapse appeared nearly universal if subjects were followed up for long enough, and the search continued for a best treatment. We are now early in a third generation of research. There is some recognition of heterogeneity in the obese population, especially now that binge eating has been identified as a problem requiring special treatment. Theory is playing a more prominent role, and there is more attention to targeted populations (eg, diabetics and binge eaters). This paper argues for a fourth generation of research to begin immediately. This generation would involve a strong connection with theory, integration with basic research, increased focus on smaller but better-maintained weight losses, greater emphasis on heterogeneity, more research on weight maintenance, and, above all, an effort to match individual patients to treatments. To successfully undertake this fourth generation of research, we must consider specific questions to be priorities: 1. Who should lose weight? 2. Who can lose weight? 3. How much can be lost? 4. What is the best approach for an individual? 5. How can weight maintenance be enhanced? With any problem as resistant to treatment as obesity, the prospect of prevention is appealing. The likely targets of prevention efforts, according to most discussions, would be children with early signs of excess weight gain and children of overweight parents. However, these may be the very people with a genetic tendency to gain weight, and interrupting this process may create serious problems. Animal research suggests that such individuals may preserve body fat at the expense of lean body mass, even if weight is reduced. Increased problems with body image disturbances and eating disorders would be expected if children become the focus of even more concern about weight and dieting, particularly if their biology creates strong opposition to efforts to lower weight. Therefore, discussion of prevention should be undertaken with careful consideration of methods for intervention and appropriate target groups. -Kelly D. Brownell, PhD Yale University