Obesity prevention is a continuum

I read with interest Dr Havrankova’s assertion that the treatment of obesity is futile, which emphasized that prevention is most important.¹ It is refreshing to see an emphasis on prevention rather than cure in a clinical argument. In fact, the paper correctly advocates for primary prevention of obesity through the tenets of the Ottawa Charter for Health Promotion—improving population health by reorienting health services, developing personal skills, strengthening community action, creating supportive environments, and building healthy public policy.² From a long-term societal change perspective, this holds the most hope for the greatest effect at the lowest cost.

However, we know that prevention is a continuum, involving primary, secondary, and tertiary prevention aimed at preventing the disease, preventing morbidity, and mitigating morbidity, respectively.³ We further know that obesity is not an issue on its own, but is a risk factor for cancer, cardiovascular disease, and diabetes. It is related to other chronic disease intermediates such as hypertension and hyperlipidemia, and it is associated with decreased mental health, osteoarthritis, and endocrine disruption.⁴

The author correctly points out that the “individual and collective cost of obesity is astronomical.”¹ This cost does not arise from obesity itself, but from the chronic diseases associated with it.^5–7 As such, making the argument for prevention means not solely arguing for primary prevention of obesity but, more important, recognizing the important role obesity treatment has in the primary and secondary prevention of chronic disease outcomes.

Further, we know that the prevention of obesity is an incredibly complex phenomenon, requiring the interplay of different sectors, from government to industry to primary care providers. Based on existing evidence, the United States Preventive Services Task Force recommends screening for obesity and intensive counseling as a preventive service.⁸ Treatment of obesity by health care providers surely represents one important piece to solving this puzzle.

Then, there is the critical issue of childhood obesity.⁹ The arguments put forward by both discussants do not address this growing epidemic.^1,10 While our research base continues to develop, it stands to reason that obese children become obese adults. We know that this is a generation that could potentially see a lower life expectancy than that of its parents.¹¹ For many of these children, it is too late for primary prevention. However, that does not condemn them to a lifetime of obesity and resultant chronic disease. Treatment of obesity as a risk factor must be a mainstay of chronic disease prevention throughout their life course.

There is unfortunately a non sequitur in negating the need to treat obesity with an argument for the importance of prevention. The two simply cannot be separated: any argument for obesity and chronic disease prevention must consider counseling, education, and treatment opportunities. Otherwise, our chronic disease prevention efforts will indeed be doomed to futility.

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