Although it is conceptually easy to treat obesity: exhort the patient to 'push away from the table' decreasing calorie intake and to adopt a healthy program of physical activity increasing energy expenditure, it is notoriously difficult to achieve sustained medically significant weight loss. Without extraordinary measures such as prison-like conditions or surgical methods, the failure rate is in excess of 90% after 1 year. Diets, exercise and behavior modification, all 'difficult methods', fail miserably over the long term.88
In the food industry, it is cheaper to use low-cost fillers such as fats and oils in food processing, than reducing fat content, which could affect profits. Furthermore, fat is palatable, which is exploited by restaurants, cafeterias and fast-food establishments. The image of 'healthy' food being unpleasant, bad tasting or no fun to eat is deeply rooted in the American psyche.89'90 It is of interest that snack foods with reduced calories and/or saturated fat are usually eaten in greater quantities, to compensate for the reduction, in part because the consumer believes the food is healthy. This behavior thus cancels out any benefit of using these low-fat products. There are many reasons why weight gain is easy, and also why weight loss is difficult. Thus, people are forever looking for the 'easy way out'. Hypnotherapy, acupuncture, vibrators, creams, massage and even liposuction have not been demonstrated to achieve lasting weight loss in clinical trials.87,88
Since obesity is so difficult to treat, it is impossible to study the impact of weight loss on the initiation or progression of cancer in a clinical setting. In fact, most 'beneficial' practices, whether adherence to a low-fat diet, exercise, reduction of total energy intake or increased consumption of 'healthy' nutrients are so difficult to maintain for a sufficient number of individuals over a sufficiently long period of time that conclusive evidence (requiring an intervention study), is not available. Any data are circumstantial at best and are derived from observations of cohorts differing in their healthful practices within well-characterized populations.
These caveats notwithstanding, based on the circumstantial evidence presented earlier, a case can be made for treating obesity and for adopting reductions in dietary fat, increases in consumption of fruits and vegetables, and a physically active lifestyle with the goal of reducing the prevalence of cancer and improving survival of patients with cancer. Over the last 20-30 years, cardiovascular mortality, hypertension and hypercholesterolemia have decreased, in part from the success of public health intervention. This is encouraging because it demonstrates the feasibility of achieving populationwide changes in unhealthy behavior. However, massive investments, both public and private, are necessary to curb the trend of increasing prevalence of obesity in industrialized nations.
Dietary modification has been increasingly gathering momentum in the medical community. Medical school curricula now include courses on nutrition and diet. Many urological surgeons now routinely give their patients dietary guidelines after radical prostatectomy.90 Patients are generally more satisfied when family members and physicians give them guidance, such as dietary counselling.91-93 Thus, there are an increasing number of physicians and surgeons who encourage dietary changes in their patients after cancer surgery has been performed, giving the patients a sense of well-being.92,93 Moreover, it has been shown that spouses respond positively to the other's dietary modification. Therefore, two people in a household may mutually benefit from proper nutrition, dietary modification and/or lifestyle changes.
In addition to public health efforts, it is also important to recognize the contribution of improved pharmacotherapy and the increased awareness of the medical profession for identifying and treating these diseases. Only recently have government drug-regulating agencies understood the need for chronic, indeed, lifelong medication for obesity in analogy with hypertension or diabetes. Not surprisingly, this change in policy coincides with the development of new drugs for treating obesity. Unfortunately for obese subjects, one of these drugs, d-fenfluramine, was inappropriately and 'off-label' combined with phentermine ('fen-phen'), giving rise to a rash of cases with valvular heart disease, resulting in the withdrawal of this otherwise promising and relatively innocuous drug.94
Two other drugs have recently been approved: sibutramine, a centrally acting transmitter blocker, and orlistat, an intraluminal lipase inhibitor preventing absorption of fat calories.95 The effects of both these drugs are modest and they are only recommended for use within programs for lifestyle changes.
Progress has also been made toward identifying predictors of success in behavioral weight programs. Lavery and Loewy described eight characteristics of individuals successful in reducing their weights: (1) feeling in control of eating habits; (2) moderate excess weight at enrollment; (3) early weight loss response (first 8 weeks); (4) frequency of weight measurement; (5) increase in physical activity; (6) absence of emotional eating; (7) recent weight gain; and (8) occupation.96 The optimal strategy would be to prevent rather than treat obesity. Unfortunately, there are only few studies on this topic and very little is known about preventing obesity. Childhood obesity is extremely difficult to manage. Success requires the participation of the whole family.97
The most successful methods for treating obesity to date are surgical. Candidates are individuals with a BMI in excess of 35
in the presence of comorbidity. Exclusion criteria include serious psychopathology, inability to cooperate with treatment plans in follow-up, and lack of understanding of the rationale and methods for treatment after failure of non-surgical approaches.98 Urologists treating obesity-related benign conditions should consider referring patients for surgical management of obesity prior to operating.
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A time for giving and receiving, getting closer with the ones we love and marking the end of another year and all the eating also. We eat because the food is yummy and plentiful but we don't usually count calories at this time of year. This book will help you do just this.