Editorial [Hot topic:Food Addiction & Obesity Treatment Development (Executive Guest Editors: Mark S. Gold and Noni A. Graham)]

Obesity has become a global public health problem. Disability, illness, and deaths produced by overeating and lack of exercise have been the subject of study [1] and debate, as cigarette smoking advocates and researchers contest the suggestion that obesity is overtaking cigarette smoking as the nation's number one public health problem and underlying cause of death [2,3,4]. However, in the period of 1990-2000, poor diet and inactivity were considered the number 2 actual cause of death [5]. Other major problems, like breast, or colon or prostate cancers may be caused or enabled by obesity [6,7].

Considerable efforts have been made to reduce cigarette-smoking initiation and increase interventions and quit attempts, while reducing harm to those in second or third-hand contact with this environmental toxin. Overeating and obesity, long under the radar, has emerged as equally formidable and without effective public health, legal, and medical intervention and treatment strategies. Currently, obesity treatment is primarily medical, or loved one's admonitions, or self-help. Like the case of the alcoholic in the 1950s, this approach is limited and increases shame and stigma. We are told to eat less, eat better, eat slower, and exercise more, almost until the day that we are referred for a lap band or bariatric surgery. Hypertension, hyperlipidemia, joint and bone problems, type 2 diabetes, and a host of other diseases are treated while the underlying disease of continued compulsive overeating despite consequences goes unabated. Again, this is not unlike what occurred during the height of the cigarette-smoking epidemic. Smokers were treated for cough, hoarseness, polyps, upper respiratory infections, cancers, and other tobacco smoking related diseases while they continued to smoke or tried to quit on their own. A combination of physician re-education, making smoking status one of the medical vital signs, availability of nicotine OTC and newer pharmacological agents helped the smokers receive an intervention, stage of change assessment, and a quit attempt. At the same time, the public was protected by clean air laws and a reduction in marketing to potential long-term users - children. Smoking initiation rates decreased by changes in access (e.g., vending machines) and taxation. In retrospect, these medical approaches successfully “treated” the chronic recidivist smoker and prevented and “treated” the most smokers.

The same comprehensive approach should apply to obesity. We must address the environment in which this epidemic has been allowed to occur, which means taking a tough look at food marketing, taxation of palatable foods, lifestyle, and the genetic effects. It has been postulated that a ‘thrifty’ genotype predisposes our generation to diabetes - what worked well for the hunter/gatherer i.e., quick efficient depositing of fat in the body during times of food abundance to sustain their lives through times of food scarcity - is now our enemy in the 21st century [8]. We have more food available than any society before us. Thus, the genotype manifests as widespread obesity and diabetes, which is passed from generation to generation and is especially risky in the maternal-child relationship. Women have a higher prevalence of obesity and it is now commonplace to birth an oversized infant out of an environment of maternal insulin resistance, hyperglycemia and preeclampsia [9]. Unfortunately, many of these infants grow to develop obesity and diabetes and the cycle repeats. We need therapeutic targets to help flip the switch. The intrauterine and postnatal environments are the foundation for a large portion of our overall taste preferences and life habits. Although women are encouraged to gain weight for healthier pregnancies, this is a risk factor for maternal obesity, birthing oversized infants in subsequent pregnancies, and childhood obesity.

Cigarette smoking is an addiction and disease of the brain that was studied in the lab using nicotine implants and smoking rat models. Nicotine and newer treatments based on these translational models have been life saving for patients around the world. In obesity treatment development, most treatments have been drugs of abuse (e.g., amphetamines, fen-phen) and many new treatments have been proposed which suppress appetite, an unlikely and unfortunate target for psychopharmacological therapies. Rather than appetite, treatments like those developed for alcohol dependence and relapse, which interfere with reinforcement, are the translational goal of our work here at the University of Florida and at Princeton. Indeed, the obesity problem may be due to a pathological attachment to food as have been observed in cigarette smoking, gambling, and sex. Binge eating disorder is currently the most prevalent eating disorder [10]. However, having ‘food addiction‘ become a widely accepted diagnosis is yet to be determined. In the meantime, diet education, overeating prevention, early intervention and exercise adherence and augmentation are likely to be important interim measures against the obesity epidemic [11]. For the morbidly obese and those with significant obesity and co-morbidities, bariatric surgery remains the safe, effective, treatment of choice [12,13]. All will be reviewed in detail, in this issue of Current Pharmaceutical Design.