Throw us a bone

by Caroline Cederquist, MD

Obesity and overweight are big problems in our society. More than one third of U.S. adults—more than 72 million people—and 16% of U.S. children are obese. Since 1980, obesity rates for adults have doubled and rates for children have tripled. Obesity rates among all groups in society—irrespective of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region—have increased markedly. Early signs of success in the prevention and control of obesity—at both state and national levels—are now emerging. Major CDC surveys have found no significant increase in obesity prevalence among children, adolescents, women or men between 2003–2004 and 2005–2006. Also, obesity rates appear to be leveling among children in some states such as Arkansas. We still have a long way to go.

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The percentages of overweight people in our population have taken a dramatic upswing since the early 1980's. Prior to that time, the rates of overweight were stable and had not increased much from those at the turn of the century. Weight experts have looked at the data and tried to understand why the rates have taken such a dramatic turn upwards. We found that several important environmental changes have occurred.

First, we are surrounded by an abundance of delicious, inexpensive and convenient food. Great advances in the technology of growing food have made it less expensive. The average family now spends 11 percent of its income on food compared to 22 percent in 1950. Since our dollar now buys more food, it is easier to have more of it around.

Couple this with the increasing frequency of restaurant dining in America. In the late seventies, less than 20 percent of our calories were eaten outside of the home. Currently, 34 percent of our calories are eaten away from home. Restaurant and fast food meals are notorious for being much higher in sugar, fat and calories. The faster, more convenient and inexpensive the meal is, the worse it usually is nutritionally. For example, at many fast food restaurants we can “supersize” a meal for a few extra cents (a real bargain!) and turn an already high fat, high sodium, junk food meal into a super sized feast that often contains more calories than the average person should be consuming in the whole day.

In addition, our eating opportunities have greatly increased. We can eat full meals just about anywhere—at sporting events, airports and gas stations. According to the U.S. Department of Agriculture there has been an average increase in food consumption of 500 calories per person per day from 1984 to 2000. Since it takes 3500 extra calories to gain a pound, this increase of 500 daily calories could be responsible for a gain of fifty pounds a year to an individual.

The foods we consume in greatest quantities are also the worst ones for us. Our intakes of simple carbohydrates, fats and sugars have seen the greatest increases. One 12-ounce can of soda, for example, contains the equivalent of ten teaspoons of sugar. Many children, teens and adults slug down several 20-ounce or larger servings of these pure sugar and empty calorie beverages every day. Researchers have shown that calories taken in as liquids do not register in the satiety centers of the brain (the part of the brain that makes us feel full.) Because we don’t feel full after drinking a calorie-rich beverage, we tend to eat as much solid food (and calories) as we might have without the drink. By contrast, eating a calorie-rich snack does make us feel full and we tend to eat less at a following meal. Accordingly, adding one soda a day to a child’s daily caloric intake has been shown to be a contributing factor for child obesity.

Furthermore, because foods and beverages like soda, chips, candies, cookies and baked goods have a relatively long shelf life at the supermarket and are very profitable, food manufacturers have a lot of money to spend on advertising. Food advertising, in terms of dollars spent annually, is now second only to automobile advertising in this country.

On the other side of the calorie intake equation is energy expenditure. We are becoming less active in our daily lives. Great technological advances save us steps during our activities of daily living and the layouts of our communities have also changed. Children walking to school and adults walking or biking to work have become increasingly rare as our population moves out to suburbia. Television must be mentioned, as well, because when we sit and watch television we are not active. While we sit and watch, we are also bombarded with colorful commercials that showcase junk foods. Many Americans consume the majority of their daily calories during primetime television viewing. An important study done with adolescent girls showed that their metabolism while watching television was lower than if they were sleeping. Our increase in television and computer use must also be recognized as a factor in our rising overweight rates. Obviously, our culture is making it very easy for us to gain weight. To avoid weight gain and to lose weight takes major effort for most of us.

Being overweight has long been considered a cosmetic concern. However, the thinking about excess weight has changed significantly over the past several years as physicians see more and more health problems directly related to how much extra body fat a person carries. The rate of diabetes, a disorder of blood sugar, has reached epidemic proportions. Its growth is directly attributed to the increase in cases of adult onset diabetes, which is usually caused by excess weight. Actually, excess body weight is felt to contribute to 61 percent of all cases of diabetes. Being overweight has been shown to contribute to significant numbers of cases of many serious conditions: 25 percent of high blood pressure, 17 percent of heart disease, 30 percent of gallbladder disease, 11 percent of breast, uterine and colon cancers each and 95 percent of sleep apnea.

Many public health officials feel that the increase in obesity and obesity-related conditions will start to undo the gains in life expectancy that we have enjoyed over the last century, largely as a result of improvements in treating infectious diseases with immunizations and antibiotics. Along with a large increase in childhood obesity rates, we will see these chronic conditions affect people at younger and younger ages. This trend has already begun. Most new cases of diabetes in teenagers are diagnosed as the adult onset, weight-related type* and not the juvenile onset type** where the body stops producing insulin for a reason unrelated to body weight.

Along with this bleak news comes good news for those who struggle with their weight. The heightened awareness of the problem has prompted physicians and pharmaceutical companies to look into the causes and treatment of excess weight and obesity. As a result, important new information is coming to light. The excitement in the mid-nineties about the weight loss results in people who were taking a combination of old appetite suppressants together (called phen-fen) has pushed treatment forward. Unfortunately, one of the medications was found to produce a rare heart valve abnormality and was prudently removed from the market. The sheer numbers of people who sought help with medication when the phen-fen combination was available ignited new interest in the field of metabolism and the regulation of appetite.

Two new weight loss medications entered the market after 1997 and approximately fifty new pharmaceutical compounds are in various stages of clinical trials and development. Most likely, however, these discoveries will not lead to a magic bullet medication for weight control. All of the studies on compounds in development show that the control of appetite and the processes by which humans hold onto body fat are highly regulated. Of course, this makes sense when we consider that our ancient ancestors lived in a time of periodic food scarcity. Survival of the fittest would favor those who can eat when not hungry and store fat easily. Our bodies and our metabolic processes do not change as rapidly as our environment has. I find it very heartening now when I hear discussions about the "thrifty gene" and metabolism instead of only that people who are overweight are self-indulgent and lazy. Many overweight people suffer shame and guilt about their condition because they feel that they have caused it to happen. There certainly is an environmental contribution to obesity that those who are overweight must address. Yet, there is also a real chemical and metabolic abnormality that occurs in the overweight person, which also must be treated.

One breakthrough in the field of overweight management is the discovery and recognition of the Metabolic Syndrome, which is diagnosed conditional to a person exhibiting three of the five following risk factors:

• A waist circumference of greater than thirty-five inches for a woman or forty inches for a man
• High serum triglycerides of 150 or above
• A low HDL or "good" cholesterol of below 50 in women or below 40 in men
• Blood pressure of 130/85 or higher
• A fasting blood sugar level of 110 or higher.

People with Metabolic Syndrome have what is called abdominal adiposity or the "apple" distribution of body fat. When excess fat is stored in the abdomen it causes changes in the rest of the body. Most notably, the muscle cells of the body develop insulin resistance. This means that the body still produces insulin but the cells of the body are insensitive to it and act like it is absent. Insulin is a hormone that is necessary for blood sugar (glucose) to enter a cell. If a cell is insulin resistant, then more and more insulin is secreted in order to overcome the resistance and transfer the sugar into the starving cell. These high levels of insulin cause symptoms such as cravings for sugar and ravenous hunger. The high circulating insulin levels also help aid in the deposition of fat because insulin is an important fat storage hormone. A person with Metabolic Syndrome will find that they easily gain weight despite trying to work on diet and exercise. Weight management physicians (bariatricians) have been working with patients with Metabolic Syndrome for years and have been able to successfully treat them. A January 2002 article in the Journal of the American Medical Association found the incidence of Metabolic Syndrome in the United States to be:

• For ages 20-29   6.7%
• For ages 30-39   14%
• For ages 40-49   23%
• For ages 50-59   34%
• For ages 60-69   43.5%
• For ages >70     42%

This means that one quarter to slightly less than one half of the population has the Metabolic Syndrome. In my medical practice, which specializes in weight management, the levels are even higher. Every day I am able to see patients with this disorder lose weight and see improvements in all of the associated parameters like blood pressure, triglycerides, and HDL levels. An understanding of what is happening metabolically in these patients is critical in helping them lose weight, and research in this area continues to move forward.

Comprehensive treatment of weight problems works best. Treating the metabolic issues, controlling appetite through dietary changes or by utilizing medications, increasing physical activity, and changing behavioral patterns that relate to eating and self esteem are all very important. This Weight Control Center was designed to give comprehensive and medically sound information regarding problems with excess weight and weight control. Utilize it in good health.

*Type 2 diabetes is a condition characterized by high blood glucose levels caused by either a lack of insulin or the body's inability to use insulin efficiently. Type 2 diabetes develops most often in middle-aged and older adults but can appear in young people.

**Type 1 diabetes is a condition characterized by high blood glucose levels caused by a total lack of insulin. It occurs when the body's immune system attacks the insulin-producing beta cells in the pancreas and destroys them. The pancreas then produces little or no insulin. Type 1 diabetes develops most often in young people but can appear in adults.

Posted October 2002
Updated December 2009