The Obesity Code

From the Introduction

The art of medicine is quite peculiar. Once in a while, medical treatments become established that don’t really work. Through sheer inertia, these treatments get handed down from one generation of doctors to the next and survive for a surprisingly long time, despite their lack of effectiveness. Consider the medicinal use of leeches (bleeding) or, say, routine tonsillectomy.

Unfortunately, the treatment of obesity is also one such example. Obesity is defined in terms of a person’s body mass index, calculated as a person’s weight in kilograms divided by the square of their height in meters. A body mass index greater than 30 is defined as obese. For more than thirty years, doctors have recommended a low-fat, caloriereduced diet as the treatment of choice for obesity. Yet the obesity epidemic accelerates. From 1985 to 2011, the prevalence of obesity in Canada tripled, from 6 percent to 18 percent.1 This phenomenon is not unique to North America, but involves most of the nations of the world.

Virtually every person who has used caloric reduction for weight loss has failed. And, really, who hasn’t tried it? By every objective measure, this treatment is completely and utterly ineffective. Yet it remains the treatment of choice, defended vigorously by nutritional authorities. As a nephrologist, I specialize in kidney disease, the most common cause of which is type 2 diabetes with its associated obesity. I’ve often watched patients start insulin treatment for their diabetes, knowing that most will gain weight. Patients are rightly concerned. “Doctor,” they say, “you’ve always told me to lose weight. But the insulin you gave me makes me gain so much weight. How is this helpful?” For a long time, I didn’t have a good answer for them.

That nagging unease grew. Like many doctors, I believed that weight gain was a caloric imbalance—eating too much and moving too little. But if that were so, why did the medication I prescribed—insulin—cause such relentless weight gain?

Everybody, health professionals and patients alike, understood that the root cause of type 2 diabetes lay in weight gain. There were rare cases of highly motivated patients who had lost significant amounts of weight. Their type 2 diabetes would also reverse course. Logically, since weight was the underlying problem, it deserved significant attention. Still, it seemed that the health profession was not even the least bit interested in treating it. I was guilty as charged. Despite having worked for more than twenty years in medicine, I found that my own nutritional knowledge was rudimentary, at best.

Treatment of this terrible disease—obesity—was left to large corporations like Weight Watchers, as well as various hucksters and charlatans mostly interested in peddling the latest weight-loss “miracle.” Doctors were not even remotely interested in nutrition. Instead, the medical profession seemed obsessed with finding and prescribing the next new drug:

•You have type 2 diabetes? Here, let me give you a pill.
•You have high blood pressure? Here, let me give you a pill.
•You have high cholesterol? Here, let me give you a pill.
•You have kidney disease? Here, let me give you a pill.

But all along, we needed to treat obesity. We were trying to treat the problems caused by obesity rather than obesity itself. In trying to understand the underlying cause of obesity, I eventually established the Intensive Dietary Management Clinic in Toronto, Canada. The conventional view of obesity as a caloric imbalance did not make sense. Caloric reduction had been prescribed for the last fifty years with startling ineffectiveness.