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The new england journal of medicine puzzling that the authors repeatedly state that Two new books offer long answers for the obesity is a biologic rather than a behavioral char­ treatment of obesity, and each comes from a dif­ acteristic, that adolescents and young women are ferent perspective. Treatment of the Obese Patient, a vulnerable to the psychosocial impact of nega­ well­referenced book, is a detailed review of the tive body image, and that unlike tobacco, food is various systems that regulate eating behavior and a necessity. I doubt that portraying obese people body weight. It includes discussions of neurobi­ negatively in a stereotypical visual context will ology, gut peptides, adipokines, and ectopic fat. An entire chapter deals with the endocannabi­ noids; it is a timely chapter given the expected Rollins School of Public Health of Emory University approval by the Food and Drug Administration of rimonabant, which blocks endocannabinoid recep­ tors. The first section concludes with carefully written chapters on how to measure body com­ position and energy expenditure. The only flaws I found in this book were its poor index and its (Contemporary Endocrinology.) Edited by Robert F. Kushner lack of a discussion of epigenetics in the chapter and Daniel H. Bessesen. 440 pp., illustrated. Totowa, NJ, on perinatal programming for obesity in adults.
Humana Press, 2007. $129. ISBN 978-1-58829-735-8.
The second half of the book offers clinically useful tools for stepwise management. How should we assess the obese patient? What about Pathophysiology, and Prevention polycystic ovarian disease? The chapter in which F. Xavier Pi­Sunyer translates the successful Dia­ (CRC Series in Modern Nutrition Science.) Edited by Debasis betes Prevention Program into clinical practice Bagchi and Harry G. Preuss. 569 pp., illustrated. Boca Raton, FL, CRC Press, 2007. $149.95. ISBN 978-0-8493-3802-1.
makes the book worth purchasing. Separate chap­ ters provide comprehensive reviews of energy den­ I s obesity a treatable disease? The short sity, the glycemic index, and low­carbohydrate answer is no. Clinicians who have been in prac­ tice for more than 20 years are aware of the facts. Despite the lip service that has been paid to health­ ful lifestyles, people of all ages, geographic origins, and nationalities have been steadily increasing their girth. Data from the Centers for Disease Control and Prevention (CDC) (www.cdc.gov/nchs/data/ad/ ad347.pdf) show that from 1960 to 2002 the aver­ age weight of men in the United States increased by nearly 24 lb, resulting in an increase in the aver­ age body­mass index (the weight in kilograms divided by the square of the height in meters) from 25.1 to 27.8. Similar increases have occurred among women. The largest increase has been among the ranks of the obese and extremely obese.
Obesity is an appropriate target for interven­ tion, and one would have thought that almost any weapon would help to make us a worthy op­ ponent of the enemy. But clinicians have been humbled by obesity. Each new inroad researchers have made into understanding the mechanism of obesity appears to be met with yet another Portrait of Daniel Lambert by Benjamin Marshall,
battalion in the enemy’s army. Our efforts to 19th Century.
manage obesity have been soundly defeated. We At the time of Lambert’s death, in 1809 in Stamford, need new perspectives if we are to regroup and England, he was 39 years of age and weighed 739 pounds.
reenergize our treatment of this disease.
n engl j med 357;24 www.nejm.org december 13, 2007 Downloaded from www.nejm.org at CREIGHTON UNIVERSITY on December 19, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved. diets. The chapter on motivational interviewing failure to devote enough time to rest. Sleep dep­ as a tool to assist change puts an interesting twist rivation induces changes in ghrelin secretion, on the “stages of change” paradigm of behavioral thus promoting weight gain. Committing to few­ therapy. The chapters on the use of drugs and er things, doing less, and sleeping more may be surgery for weight loss include a practical review part of the answer.
of the micronutrient deficiencies that are caused Margo A. Denke, M.D.
by bariatric surgery. The book concludes with two University of Texas Health Science Center important chapters; one is a discussion of the San Antonio, TX 78229 National Weight Control Registry, established by denke@att.net James O. Hill and Rena R. Wing, and the other is a discussion of the evaluation and management of obesity in children. In summary, this book provides new tools for immediate application in The second book, Obesity, takes a broader per­ (Global Environmental Governance.) Edited by Andrew F. Cooper, spective. We are treated to short reviews of neu­ John J. Kirton, and Ted Schrecker. 296 pp. Aldershot, England, robiology, leptin, and ghrelin as well as chapters Ashgate Publishing, 2007. $99.95. ISBN 978-0-7546-4873-4.
on environmental estrogens as endocrine disrupt­ ers, smoking and inflammation, and other oxi­ Governing Global Health admirably ad- dative stressors that may be contributing to the dresses the rapidly escalating global war with obesity epidemic. Regarding therapies, this book disease that is currently being lost. It focuses on has solid chapters on diet and exercise but many the major global health challenges of the 21st cen­ more on specific “neutraceuticals” — foods with tury, including HIV–AIDS, malaria, tuberculosis, purported therapeutic benefits. These chapters avian influenza, cancer, polio, obesity, cardiovas­ fit well in this book, but the enthusiastic reader cular disease, asthma, severe acute respiratory must be warned that the benefits of many of the syndrome (or SARS), and bioterrorism. It then treatments that are discussed are unproved. The provides analysis of how well existing institutions authors offer thoughts, theories, and treatments and ideas have responded to these challenges and that are “outside the box,” and they do so majesti­ what innovations will be required if we are to prevail. The book consists of contributions from The treatment of obesity remains a troubling 18 experts from the University of Waterloo (in On­ challenge. I was particularly struck by observa­ tario), the University of Ottawa, the University of tional data that are cited in Treatment of the Obese Toronto, and other organizations that are involved Patient that show increases in self­reported leisure in governing global health. It reads seamlessly as time and time engaged in physical activity. This it places the challenge in historical perspective is not what I hear from patients in my clinic, who and makes the case for the critically needed re­ are rushed and distracted and complain of not sponse.
having the time to devote to lifestyle changes. There is no question that disease is riding on I am also struck by comparisons from successive the back of globalization and has thus far been databases of dietary recall — which are somewhat outpacing our response to it. Global health is in flawed because of different methods but are none­ crisis, and as the editors state in their introduc­ theless intriguing. Americans are consuming tion to the book, “the war for global health is more calories, according to a recent report of self­ being waged and lost on many fronts. The already reported data from the CDC (www.cdc.gov/mmwr/ massive body count is mounting fast.” preview/mmwrhtml/mm5304a3.htm) — 7% more The editors explain that our existing lines of defense against this onslaught are “an ever more The challenges we face are our caloric intake elaborate edifice of intergovernmental global and lifestyle choices. Food is often eaten as an health institutions, . . . regional organizations, afterthought, on the run, with little concern for . . . informal, plurilateral bodies, . . . [and] its ability to nurture us. Labor­saving devices may a growing array of multistakeholder networks, have given us more leisure time, but we are not public­private partnerships, and committed action spending this time wisely, and this includes our by civil society actors.” These institutions and n engl j med 357;24 www.nejm.org december 13, 2007 Downloaded from www.nejm.org at CREIGHTON UNIVERSITY on December 19, 2007 . Copyright 2007 Massachusetts Medical Society. All rights reserved.

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