‘Emotional hunger’ vs. ‘hungry gut’: The attempt to subtype obesity and tailor treatments

This is part of a series about new obesity drugs that are transforming patients’ lives, dividing medical experts, and spurring one of the biggest business battles in years. Read more about The Obesity Revolution.

“Anne” is sitting in a small, wood-paneled consultation room, at the Mayo Clinic in Rochester, Minn., about to embark on yet another weight loss journey. Except this one might be different from all the others — the tours of Weight Watchers, Jenny Craig, and dietitian-led programs. Her doctor, Andres Acosta, is probing her struggle at a depth that’s new to Anne.

Acosta begins today’s appointment by telling Anne — a pseudonym we’ve used to protect her patient confidentiality — that he wants to understand the “root cause” of her obesity. An hour-long interview about her life, health history, and nutrition and physical activity patterns follows, along with an interrogation of what she feels might trigger her to overeat or indulge in the wrong foods. Stress eating emerges as a major theme — but the doctor also notes that her weight piled on following her pregnancies, when she was diagnosed with a thyroid-attacking autoimmune disorder, Hashimoto’s disease. She went from being an “alarmingly thin” 120 pounds in college, to having obesity by age 41. Now age 68, and 183 pounds, her knees ache with arthritis, which makes it difficult to walk; she has high blood pressure, obstructive sleep apnea, and high cholesterol. The extra weight is not a cosmetic concern; she says it’s slowly eroding her health.

At the end of the appointment, Acosta tells Anne about the battery of tests he wants her to go through next — a thyroid workup, surveys about her emotional eating, and checks of her resting metabolic rate, body composition, and “gastric emptying” (to determine how quickly food empties out of her stomach and whether this might be a cause of excess hunger). He suspects that, instead of the shortage of willpower many people — clinicians included — still associate with obesity, Anne’s case might be caused by a sluggish metabolic rate related to her Hashimoto’s, in combination with her apparent emotional eating. She’ll need more than the standard issue “eat less, move more” prescription many patients with obesity get.

With the tailored approach, Acosta is trying to reflect a truth obesity researchers and clinicians have known for years but rarely tackle in the clinic: obesity is not one thing, it’s many. “Obesity is a complex and heterogeneous disease,” Acosta said. The causes of weight gain differ among people, and excess fat is linked with a diversity of health consequences — cancer or heart disease in some, type 2 diabetes in others, while still others are spared metabolic problems.

Yet patients are typically given “one size fits all” solutions — even though researchers also know individual responses to the same weight loss interventions vary widely. Clinical trials of just about every lifestyle program — from diets and exercise programs, to weight loss counseling — show some patients gain weight, some lose a lot, and most cluster around an unimpressive average, often regaining lost weight in the long term.

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