someone of “normal” weight. The problem is the co-morbidities that develop – everything from diabetes to cancer, to joint problems – despite the “plus size” lobby that claims being big is not only healthy, but a valid lifestyle choice that should, among other things, be supported by free extra seats on airlines.

Fat phenotypes

Among all this madness, it’s revealing to see the Mayo Clinic’s world authority on the topic talking about the need to individualise treatment for obesity.

“Individualised medicine initiatives mainly focus on rare diseases or cancer”, says Andres Acosta, MD, PhD, a gastroenterologist and obesity expert. “Little has been attempted to individualise treatment for noncommunicable chronic diseases such as obesity – a chronic, relapsing disease, and a primary cause of Type 2 diabetes, fatty liver disease, cardiovascular disease and cancer. There are many obesity interventions, such as diets, devices, surgery and medications. However, not much is known about the predictors of response to these obesity interventions.

“Sustained weight loss with current treatment options remains a challenge in the clinical practice”, he says.

Acosta and his team have studied anti-obesity medications based on obesity phenotypes to enhance weight loss. In early research published in the journal Obesity, they showed a phenotype-guided approach was associated with 1.75-fold greater weight loss after one year; the proportion of patients who lost more than 10% at one year was 79%, compared with 34% whose treatment was not phenotype-guided.

The team stratified obesity into four phenotypes that regulate body weight:

• Hungry brain – mainly controlled by the brain-gut axis, and abnormal calories are needed to reach fullness.

• Emotional hunger – desire to eat to cope with positive or negative emotions.

• Hungry gut – abnormal duration of fullness.

• Slow burn – decreased metabolic rate.

Key drivers for intake are fullness, duration of fullness and emotional eating. Key drivers for energy expenditure are resting energy expenditure, non-exercise physical activity, exercise and the thermogenic effect of food and exercise.

These phenotypes hold sway whether people take weight-loss drugs or not. To keep off excess fat long-term, there’s still no escaping the fact that clients are going to need intensive coaching to change habits, change what they eat and change their daily level of activity (doesn’t have to be formal exercise).

“WeightWatchers’ nutrition and behaviour-change program can provide the support needed to help people build liveable healthy habits for the long term and manage the dietary-induced side-effects often felt while taking chronic weight management medications, such as glucagon-like peptide-1s (GLP-1s)”, said Dr Gary Foster, PhD, their chief scientific officer. So even WeightWatchers (to give them SOME credit) get this; their clients won’t.

SIMON MARTIN, EDITOR

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