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George A. Bray, Claude Bouchard, "Handbook of Obesity: Clinical Applications, 3 Ed"

From The New England Journal of Medicine

Obesity, the stepchild of American medicine, may be the only remaining medical condition in which patients are stigmatized and their physicians disparaged. Few members of the medical profession profess to treat obesity, and many of those who do are marginal "diet doctors" or proprietors of pill mills. Treatment has always had limited effectiveness, and for some time it has largely been out of the hands of physicians. Psychologists, for example, developed the first systematic treatment for obesity -- behavior therapy -- and commercial weight-loss organizations have used this method to dominate the treatment of obesity in America. Most Americans who underwent treatment for obesity in the recent past did so under the auspices of these organizations, as obesity was progressively demedicalized. The recent entry of the pharmaceutical industry into the field has changed this picture for the better, but there is still a distressing disjunction between research and practice.

This schism is the more distressing since research on obesity has been extraordinarily productive. The book reviewed here is a celebration of this research and can take its place alongside the standard textbooks on diabetes and other metabolic diseases.

The Handbook of Obesity "has been designed to provide up-to-date coverage of the range of subjects that make up the field of obesity research," and it does this unusually well. Its 88 authors constitute a pantheon of obesity research, and it would be hard to find a topic that they have not covered, usually very well. The 49 chapters are divided into four parts.

Part I deals with the history, definition, and prevalence of obesity and is notable for the outstanding section on history, a special interest of its author, George Bray, who is one of the editors. Part II focuses on the causes of obesity and is, appropriately, the longest, constituting nearly half the book. It is introduced by a magisterial chapter entitled "The Genetics of Human Obesity," which, reflecting the explosion of research on the topic, is followed by chapters on animal models of obesity and molecular genetics of obesity. The role of energy intake and expenditure and their integration into the regulation of energy balance is then covered in great detail.

Part III deals with the ill effects of obesity, which transform a benign biologic variant into a disorder that contributes to 5 percent of national health care costs. The broad coverage of this area extends to 10 different disorders and will be a valuable resource for physicians dealing with any of the numerous conditions that are affected by obesity. Part IV discusses prevention and treatment. In addition to its authoritative treatment of the field, this book is unusually interesting. Almost every chapter contains information that was new to me and left me intrigued with all that we know about human obesity.

I see two limitations of the Handbook of Obesity, one inherent in the nature of the enterprise, one in its application. By the time a book on a topic of great interest is published, much of it is already outdated. An example is the chapter on pharmacologic treatment of obesity, which is introduced as "an up-to-date guide to the use of currently available medications for obesity." It was written, however, before the fen-phen debacle -- the sudden widespread appearance of valvular heart disease brought about by the appetite suppressants fenfluramine and phentermine -- and the uncertainties it has evoked. The other limitation reflects the disjunction between research and practice noted above. This is a book about research, written by researchers for researchers, and it has little to offer busy clinicians in this era of managed care. Desperate for help with the patients whom they can see for only brutally short periods of time, they need clinical pathways and practice guidelines. The scholarly chapters on treatment in this book provide superb reviews of the literature for use in research on obesity, but they do not substitute for practical guidance in the care of obese patients. For this, the clinician must look elsewhere.

Reviewed by Albert J. Stunkard, M.D.

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