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Written by an international group of leading experts on obesity and related disorders, this volume is the first to address the clinical aspects of obesity. The contributors review the latest clinically relevant findings on the etiology and pathophysiology of obesity, examine the full spectrum of comorbid conditions and complications, and discuss the role of drugs, behavioral interventions, exercise, and surgery in treatment of obesity.
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Economic globalization is associated with a worldwide rise in the incidence of obesity. If the United States and United Kingdom can be considered the first "fat lands," most ethnic groups in other parts of the world, especially in the developing countries of South America and Central Europe, are experiencing the same trend toward an obese population. The number of overweight persons -- 1 billion -- now exceeds the number of malnourished persons -- 850 million. However, even though any report of a new discovery related to obesity instantly appears in the media, physicians are not really interested in the condition. But is obesity a disease? Ironically, in this multifaceted new book, several authors suggest that obesity might be a logical adaptation for survival. In their view, the epidemic of obesity might be not the result of abnormal physiology but, rather, given the human genetic and metabolic profile, a natural response to the modern world. This is an important nuance, and it could modify the views of health care professionals and opinion leaders about obese patients. If environmental factors that most people face from infancy to death "force" them to eat excessively and badly, and to exercise less than they should, then attempting to modify human physiology could well be a hopeless means of fighting obesity. As junk foods add an excess of 300 kcal per person every day, the body's reaction -- to increase its weight until a new, steady state of energy balance is achieved -- is less pathologic than it at first seems. In this scenario, there would not be any "set point" for body weight, but instead a "settling point," dictated by a close interaction between our genes and the environment. Indeed, the role of the genes in the variation of body mass seems surprisingly important, as demonstrated by studies of twins and of populations that have different degrees of ethnic admixtures, which can help explain the prevalence of obesity. The former showed that nutrient partitioning in a situation in which food intake is tightly controlled is genetically determined. The latter suggested that in the Pima Native American population, the degree of admixture is inversely correlated with obesity and diabetes. Molecular genetics has shown that mutations in genes that modulate satiety, such as the melanocortin 4 receptor gene, can lead to childhood obesity. Surprisingly, the nature of the environmental changes that affect energy intake or expenditure is still being debated. Are people actually consuming more calories and fat than they were 15 years ago, or less? Are they really exercising less? Classic observational epidemiology so far has failed to reach definite conclusions. Since genetic factors could make people more or less susceptible to increased adiposity, this points to the need for large-scale, multiethnic studies of genetic interaction with the shared environment in the expression of obesity at different ages. Obesity is clearly associated with a number of illnesses and with premature death. The economic impact of obesity is estimated at 6 percent of U.S. health expenditures; modest weight loss could lead to huge savings, and this alone should persuade physicians and health insurance companies to support weight-reduction programs. The principal merit of Obesity: Mechanisms and Clinical Management is that it gives the most complete picture to date of complications associated with obesity. If sleep-disordered breathing is a well-known complication, its pathogenesis, clinical effects, and treatment should be widely disseminated. The same is true for hypertension and renal disease, and for hepatobiliary and orthopedic complications, which have a severe limiting effect on the life of obese patients. What is new in obesity treatment? Readers expecting a strong statement about the merits (or risks) of the low-carbohydrate Atkins diet will be disappointed. This book advocates a long-term combination of behavioral, nutritional, and pharmacologic treatment of obesity, which is a chronic disorder. The chapter on the surgical treatment of obesity is comprehensive and well balanced. Although perioperative complications are now infrequent, there is concern about long-term complications, including nutritional problems. These may be more prevalent than expected, as Europeans are now experiencing, since the follow-up for patients treated by bariatric surgery is longer in European countries than in the United States. Multidisciplinary teams are needed for the follow-up of patients treated surgically. What is missing from this book? Possibly a unifying view of the effects of obesity on pathophysiology. Apart from the intriguing chapter related to obesity-linked cancers, discussion of adipocyte biology is almost absent, even though the hypertrophic adipocyte itself is a driving force behind most metabolic complications of obesity. Furthermore, the book does not mention the recently demonstrated role of adipocytes in recruiting significant macrophage infiltration into the adipose tissue of severely obese subjects; this process seems to be a key factor in the highly deleterious state of inflammation associated with excess adiposity. The uncovering of mysteries in obesity is still in progress. Philippe Froguel, M.D., Ph.D.
Copyright © 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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