Obesity is Not Just a Word

Obesity is considered by many to be one of the gravest health threats of our generation. Rates of overweight and obesity in the U.S. have risen at epidemic proportions over the past two decades. Medical complications of obesity are significant and deaths attributable to obesity approach the number attributable to tobacco abuse. Despite this, we have yet to find a “cure” or a consistent treatment that successfully addresses more than a minority of obese patients.

Obesity is neck and neck with cigarette smoking as the most important modifiable medical risk factor, and affects risk of diseases of virtually every organ system, including certain cancers

Approximately 66% (percent )of Americans are either overweight or Obese. That's roughly 110 million people. If current trends continue, it has been estimated that nearly all American adults will be overweight or obese by 2030. The rate of childhood obesity and extreme obesity has increased dramatically. And now, even developing nations are seeing an increase in obesity and obesity−related complications, partly because they have adopted a Western diet and lack of exercise.

There are significant ethnic disparities in rates of overweight and obesity. Rates of overweight in African−American and Mexican−American women are approximately 35% greater than age−adjusted rates for Caucasian women; rates of obesity in African−American and Mexican American women are approximately 50% greater than the rates for Caucasian women of the same age.

Obesity is the most important risk factor in the development of type 2 diabetes, the sixth leading cause of death in the United States. Hypertension and high cholesterol levels are significantly higher risks in patients who are overweight, compared with normal weight patients, and in patients who are obese, compared with overweight patients. Obesity also increases overall mortality, and has recently been shown in Framingham and other populations to shorten life expectancy by a mean of at least several years.

No other field of medicine is as subject to fads and hype, as well as to unreasonable patient expectations, as is obesity treatment. Part of the reason lies in the inherent difficulty of reconciling a society whose main fuels are high caloric density and tasty with an ideal “Barbie doll” body type.

In addition to the medical risks of obesity, obese patients face unfortunate emotional, psychological and social consequences (though the desire to avoid these psychosocial factors strongly motivate many people to try to lose weight). There is widespread prejudice against obese individuals, even among young children. People who are overweight and obese often experience social and job discrimination. This negative feedback from their world often contributes to low self−esteem and the high rate of depression among obese people who seek treatment. In American society, obese women, compared to obese men, bear much greater social stigma.

No other field of medicine is as subject to fads and hype, as well as to unreasonable patient expectations, as is obesity treatment. Part of the reason lies in the inherent difficulty of reconciling a society whose main fuels are high caloric density and tasty with an ideal “Barbie doll” body type.

The cigarette smoker need never smoke again; the obese person, however, must learn to coexist with the offending substances in order to live. As such, we cannot expect many complete cures and we will need to be constantly on the alert for relapses in those who appear to be in remission.

If weight loss is defined as losing weight and keeping most of it off for five years, the success rate for weight loss is low, perhaps 5 to 15% from the limited data provided by published studies. This low rate must be viewed in context and compared with our similarly poor success in treating other chronic conditions and addictions (such as cigarette smoking and drug abuse). In fact, if you look at the chronic pleasurable overconsumption of food energy as a kind of addiction, an instructive distinction between food and other reinforcing substances appears. The cigarette smoker need never smoke again; the obese person, however, must learn to coexist with the offending substances in order to live. As such, we cannot expect many complete cures and we will need to be constantly on the alert for relapses in those who appear to be in remission.

The first step in treating the obesity is often a medical evaluation. Obesity is defined as having an excess of body fat rather than an excess of body weight. Men are considered to be obese when body fat makes up at least 25% of body weight, and for women, it is 30%. However, the measurement of percent body fat is harder to obtain and not as intuitive a measure as body weight. For this reason, one’s relative weight can stand in as a reasonable measure of body fat (which is defined as the percent of body weight that is made up by fat).

In the case of mid-section, or central, obesity, even mild adiposity may lead to medical problems... Fortunately, abdominal fat is usually the first fat depot to shrink with weight loss.

The risk of developing medical conditions related to weight problems typically increases in proportion to how overweight a person is. , And for some weight-related complications – in particular, coronary artery disease, type 2 diabetes and stroke – the risk is very much dependent upon how fat is distributed throughout the body. . Fat concentrated in the mid-section or gut (i.e., the “apple-shape” pattern), which is more common in men, increases the risk for these diseases. In contrast, excess fat in the lower body (thighs, hips and buttocks: is associated with a lower risk of complicating conditions (and this “pear-shape” pattern is more typical in women)

In the case of mid-section, or central, obesity, even mild adiposity may lead to medical problems. It should be noted that central obesity can exist even when the individual has a BMI in the normal range. A waist circumference of more than 40 inches for men and more than 35 for women suggests abdominal obesity(this can be measured with a tape measure around the widest point above the navel). Fortunately abdominal fat is usually the first fat depot to shrink with weight loss.

In addition to a standard medical history, a patient’s weight history may be useful to doctors in identifying the factors involved in a patient’s weight gain. The weight history may also lead to ways to treat weight problems as well as ways to avoid them. For example, a change in job leading to a reduction in physical activity may be detected. Also important is whether the onset of obesity was in childhood or later in life. Although only one−fifth of obese adults were obese children, about four−fifths of obese children go on to become obese adults. Obesity in childhood can result not only in an increase in the number of fat cells but in their size as well. Increases in the number of fat cells (hyperplasia) occur less frequently in adults and usually only when rapid weight gain occurs. Treatment of this form of obesity is more difficult for both children and adults because weight loss does not generally reduce the number of fat cells, only their average size.

Other information that can be learned from a person’s weight history includes postpartum weight gain (the average woman weighs about 10 lbs more two years postpartum compared to her pre−pregnancy weight, but this is extremely variable) and weight gain after smoking cessation (here, the average weight gain is about 6 pounds, but again this highly variable and it’s the most common reason women give for not wanting to quit smoking). It is also important for doctors to find evidence of yo−yo dieting and eating disorders such as binge eating or bulimia nervosa (bingeing plus purging, either by vomiting, use of diuretics, or excessive exercise).

The history should also try to uncover any symptoms that might be suggestive of diseases that complicate obesity, such as type 2 diabetes, coronary artery disease, hypertension, and sleep apnea. Doctor should especially be on the lookout for signs and symptoms of depression, since it often accompanies severe obesity and may require additional treatment. Childhood or adult sexual and physical abuse is a common factor involved in weight problems. Because patients may be uncomfortable volunteering painful histories doctors often need to ask specific questions, after a good, trusting, relationship is established with the patient. The family history is of particular interest regarding endocrine (hormone) disorders, as well as extreme obesity and its complications.

One’s expectations about what changes are really likely to occur with successful weight loss are also important for a physician to understand. Although it may be motivating to believe that life will improve vastly with weight loss, disappointment (and the risk of regaining weight) may follow unless the changes likely to occur have been discussed with a doctor and placed in proper perspective.

It is important that a person to help his or her doctor understand the impact of the obesity itself on his or her level of functioning and quality of life. Some very important aspects of one’s weight problem may only become clear if a doctor asks specific questions, or if the person takes the lead and brings up such issues. Take the following example: the patient may have withdrawn from social interactions; or may no longer be able to enjoy certain activities or interests because of weight gain; or he or she may have suffered job discrimination. One’s expectations about what changes are really likely to occur with successful weight loss are also important for a physician to understand. Although it may be motivating to believe that life will improve vastly with weight loss, disappointment (and the risk of regaining weight) may follow unless the changes likely to occur have been discussed with a doctor and placed in proper perspective.

There are clearly many medical benefits that can accompany weight loss, especially for those suffering from the medical complications of obesity. For example, some patients with type 2 diabetes may be able to discontinue insulin or other diabetes medications, blood pressure medications may become unnecessary, and sleep apnea can disappear with a weight loss as little as 10 to 15% of one’s initial weight. But psychologically-speaking, there are other things to take into account. Although self−confidence often increases, the “wallflower” does not always become the life of the party, and the average, competent worker does not get a promotion upon losing weight. Doctors can encourage obese patients to have a realistic view by reminding them that prejudices about body weight and character are in no way based in fact, and that they are the same good people whether they weigh 300 or 150 lbs.

Most obese individuals are not hungrier than lean people. The difference is that they may fall back on old or learned habits and situations that lead to eating, and interpret these feelings as “hunger.” A major breakthrough in controlling unnecessary eating can result when a person learns to accurately tell the difference between real, physiological hunger from learned forms of “hunger,” and respond to each appropriately.

As mentioned, it is important for doctors to help patients identify and understand their specific triggers for eating. These eating cues are situations or feelings that lead to eating, often in an inappropriate way. In our society, physical hunger is rarely a significant part of life, even for those in lowest socio-economic class. In fact, physical hunger is not an important eating cue for many people at all, in part because they rarely let themselves get to the point of true hunger. Instead, people often eat in response to a host of other cues, most of which are unrelated to real hunger.

Underlying some of these cues is the fact that many people associate food with love, caring, and comfort. This association may begin in early childhood, and often persists into adult life. Many people fall victim to it, which makes it difficult for many to have a healthy “relationship” with food. An overweight patient should, with his or her doctor’s help, try to recognize that using food to deal with stress, boredom and emotions is, at best, an ineffective method.

The most common eating cues are: habit (“It’s noon so I guess I’ll have lunch” or “I always have a jelly doughnut and coffee in the car on the way to work”), stress (“I’ve got to finish this paper and eating while I write helps me concentrate”), boredom (“There’s nothing else to do”), emotions (“I eat when I’m depressed or upset”) and food as a reward (“After a hard day, I deserve a rich dessert”). Underlying some of these cues is the fact that many people associate food with love, caring, and comfort. This association may begin in early childhood, and often persists into adult life. Many people fall victim to it, which makes it difficult for many to have a healthy “relationship” with food.

An overweight patient should, with his or her doctor’s help, try to recognize that using food to deal with stress, boredom and emotions is, at best, an ineffective method. The stressful situation does not resolve with eating, boredom does not disappear, and the emotions that one is trying to ignore by eating will still be present on some level. In fact, eating may actually worsen the problem by distracting a person from dealing directly with the situation.

Restrained eaters may be superb dieters but they may also be equally superb overeaters once the diet has been “broken.” Although a certain amount of control and monitoring are necessary to maintain a healthy weight, in the long run, a high level of dietary restraint may lead to more problems than it solves.

The results of a food diary can be tricky for a doctor to interpret for a couple of reasons. First, obese patients may underreport their food intake if they are being asked to recall what they have eaten in the past. Second, if they are asked to begin keeping a food diary starting at the present time, he or she may begin restrained eating as a result. (These two facts may explain some of the tendency towards obesity if the person is less aware of the foods and quantities he or she chooses.) Despite these potential problems, the information gathered from a food diary can be very useful to doctor and patient. The clinician can often learn, for example, that the person's diet is too heavy in fats and low−fiber carbohydrates, like write rice and potatoes. By cutting fat and increasing high-fiber carbohydrates, especially fruits and vegetables, some patients can considerably increase the volume of food they consume, while feeling less hungry in the weight loss process.

If a doctor simply tells a patient not to eat when under stress, given the habit of many obese patients to use food inappropriately, it is not likely to work. Instead, the following 3−step approach is usually a better bet.

First, a doctor may recommend a period of observation and recording to encourage the patient to recognize the specific cues that trigger the inappropriate eating. For instance, a person might be asked to wear his or her watch upside−down as a reminder of “Why am I reaching for the food at this time?” If the patient is not physically hungry, it’s likely that he or she is simply responding to an inappropriate eating cue and the nature of this cue should be considered.

While losing a large amount of weight in a reasonable amount of time does require a fairly aggressive diet routine, maintaining a new lower weight does not.

Second, a doctor may suggest that the patient substitute other responses for inappropriate eating. For example, for stress eating, this might be writing down what the stress is, formulating a plan for doing something about it, doing something (besides eating) to relieve the stress on the spot or, at the very least, substituting the food with a walk around the block or a call to a friend.

The third step is repetition — the patient practices making better, more appropriate responses to the cue or cues that originally triggered the eating response. The rewards of substituting a new behavior for an old one include the positive responses of others to the change that the patient makes—not just to eating, but to life.

Although a person must change his or her behavior in certain ways, not every “bad” behavior must be completely eliminated and not every tasty food replaced with bland, “healthy” ones. While losing a large amount of weight in a reasonable amount of time does require a fairly aggressive diet routine, maintaining a new lower weight does not. If a person can learn to partially control even a few of his or her inappropriate eating behaviors and shift to a diet to one that’s lower in calories than the old one, these changes are often enough to maintain weight loss.

It’s often a good idea to scour the supermarket aisles (at a time when one is not hungry!) for tasty, low−fat, low−calorie alternatives to one’s favorite foods. It is important to explore the wide variety of foods now available and to focus on the good taste of the new choice rather than comparing it to the “real thing.”

Changing one’s diet gradually is a helpful method that can alter the make-up of a person’s diet over time. For example, a patient who is reluctant to switch from whole milk to skim milk could, for example, first try 2% milk, get used to this for a month or so, then move on to 1% fat milk for another month. At this point, one usually notices that the whole milk that was once seemed so difficult to give up will now taste too rich. At some later date, the final move to skim milk can be made without too many feelings of deprivation. This actually allows a person to see that taste preferences are acquired and are very changeable, even in later life.

It’s often a good idea to scour the supermarket aisles (at a time when one is not hungry!) for tasty, low−fat, low−calorie alternatives to one’s favorite foods. It is important to explore the wide variety of foods now available and to focus on the good taste of the new choice rather than comparing it to the “real thing.” The presentation of nutritional information on food labels is very useful, because it lists not just grams of fat, for example, but also the percentage of the daily dietary fat that those grams represent. Learning to read labels and to stay within the calorie “budget” is an important part of losing and maintaining weight.

It is important to be somewhat skeptical of commercial weight−control diets and weight-loss products. Many commercial diets are based on very limited menus, the rationale being that eating the same foods over and over again will curb consumption. Some over-the-counter dieting agents have diuretic actions (making the body shed its much-needed fluids), which may lead to dehydration rather than real weight loss. In fact, any substantially reduced−calorie diet will initially cause the body to shed some water, but the fluid−based weight loss will be regained as soon as the period of severe calorie restriction ends.

Overweight people usually need to cut calories by about 500-750 calories/day in order to lose 1 to 1.5 pounds per week. It may be necessary to speak to a dietician, who can help design an effective “calorie-deficit” diet. There are a couple of ways to do this: a diet can be “balanced−deficit” (meaning that the total number of calories is reduced, but the proportions from carbohydrate, fat, and protein stay the same), or the diet may be “fat−deficit” (in which most of the caloric reduction comes from restricting fat intake). The ”fat-deficit” diet is often preferable because the typical American diet is too high in fat, especially saturated and trans fats, and simple sugars. Also, another benefit of a low-fat diet is that a greater volume of food can be eaten since a large part of it is fiber−rich, complex carbohydrates, often from vegetable sources. Usually a fat-deficit diet reduces fat to 30% of the total calories one consumes.

It is important to be somewhat skeptical of commercial weight−control diets and weight-loss products. Many commercial diets are based on very limited menus, the rationale being that eating the same foods over and over again will curb consumption. Some over-the-counter dieting agents have diuretic actions (making the body shed its much-needed fluids), which may lead to dehydration rather than real weight loss.

Obese patients may benefit from a diet that reduces both fat and calories. A highly restricted diet should be administered only under a trained physician's supervision. It is important to understand that even at this level of caloric restriction it will take more than a year to attain a weight−loss of 50 to 70 pounds. Few people can sustain this degree of restriction for such a long time; for that reason, a physician−supervised, low−calorie diet of fewer than 1200 calories per day may be appropriate for a short amount of time. More restrictive diets are sometimes necessary, particularly if the patient already suffers from serious weight-related problems that are likely to be reduced with significant weight loss.

Low−calorie diets (LCD) can consist of regular food, commercially available meal replacements, or a combination of both. If a person follows the LCD diet fully, the amount of weight loss to be expected can range from 1.5 to 4 pounds per week, depending on the person’s body mass and level of physical activity. A highly restricted diet should be administered only under doctor supervision and with full attention given to the behavioral changes that are necessary to maintain the weight loss.

Despite the laundry list of health benefits of exercise, exercise alone will not produce weight loss if a person does not reduce his or her calorie intake at the same time. This may be due to the fact that exercise increases hunger and may lead to extra eating, which might completely counteract the number of calories burned in the exercise.

Exercise is, however, an excellent way to maintain a lower weight after one has lost it, which allows a person to eat somewhat more than a non−exerciser and still maintain the new weight. Regular aerobic exercise and strength training will also improve cardiovascular fitness, reduce fat stores, promote muscle growth (which burns more calories than fat, even at rest), and exercise often results in significant improvements in mood and overall well-being.

A good first step in adding exercise to one’s routine is to increase the amount of everyday physical activity (or so−called “lifestyle” activity), rather than to immediately add a formal exercise regimen. Lifestyle activities could include taking the stairs instead of the elevator, parking the car farther away from one’s destination, and taking the dog for a longer walk than usual.. Making some of these small changes to one’s daily routine can double the level of physical activity in a very sedentary person.

Studies show that an hour of exercise is best for weight control and 90 minutes for weight loss. The intensity of the exercise is not critical to the burning of calories: walking at a leisurely pace for one hour is roughly equal to walking briskly for half an hour.

In general, a person should try to make at least 20 to 30 minutes available for each session of exercise. Studies show that an hour of exercise is best for weight control and 90 minutes for weight loss. The intensity of the exercise is not critical to the burning of calories: walking at a leisurely pace for one hour is roughly equal to walking briskly for half an hour. You can set your own pace. Initially, it may be quite slow, but if one is basically healthy, most people can build up to a faster pace fairly quickly and find that exercise becomes easier overall. Setting goals can strengthen this process. Keeping a log of time spent walking and distance covered after each session is a good idea. Then one can see the progress he or she is making and regularly set the goal a bit higher.

Medications may be useful for obese patients, either in the early stages of weight loss to increase the likelihood of sticking to the plan, or later, when motivation begins to waver or hunger becomes more of a problem. Some medications are effective in increasing weight loss during the period in which they are used, and they may help maintain some weight loss over time (although regaining weight tends to occur even with continued use of these medications). Commonly used weight-loss drugs are phentermine and sibutramine. One somewhat effective medication, ephedra, is no longer available because it has been linked to heart problems in those taking the drug.

It is important to know that herbal agents are drugs and can be as toxic as synthetic or prescription drugs. Moreover, few herbal “remedies” are subjected to the degree of scientific scrutiny that pharmaceuticals undergo, their effects are much less understood than other, prescription medications.

An additional prescription drug for weight loss is orlistat, which is sold as Xenical,^® and in an over-the-counter form as Alli^®. This is the only obesity medication currently available, which works specifically in the digestive system, rather than affecting the whole body. It acts in small intestine by reducing the amount of fat that is metabolized by about 25−30%, depending on dosage. However, these medications also block the absorption of cholesterol and fat−soluble vitamins, so if one is taking orlistat he or she will also need to take a multivitamin. While orlistat and Alli^® have no appetite−curbing effects, they often have other, unwanted side-effects: for example, consuming more than a moderate amount of fat in one sitting can result in unpleasant GI consequences. The drug may be more suitable for people who are having a hard time avoiding junk food and other fats than for people who feel increased physical hunger.

Herbal medications are also widely used for weight control. Those that are less effective include fiber supplements, ephedra−like agents (e.g., citrus aurantium) and conjugated linoleic acid (CLA). Many other agents have been advertised for weight loss (for example, DHEA, chromium picolinate, hoodia gordonii, chitin/chitosan) but do not appear to have a significant effect on weight loss. It is important to know that herbal agents are drugs and can be as toxic as synthetic or prescription drugs. Moreover, few herbal “remedies” are subjected to the degree of scientific scrutiny that pharmaceuticals undergo, their effects are much less understood than other, prescription medications.

Treating morbid obesity with surgery has come a long way in recent years, but is reserved for special circumstances only. Generally, a patient is referred for bariatric surgery only if his or her BMI is over 40 (or over 35 if there are significant medical complications stemming from obesity) and they have failed to lose or maintain weight loss from the options discussed earlier in this article.

Many may be familiar with gastric bypass surgery, which is typically the most successful of the surgical interventions. This procedure combines “stapling” of the stomach to make it smaller, along with a bypass of the small intestine which decreases the absorption of some of the food the person consumes.. Though short−term results are significant in many patients, the long−term outcomes, as with all methods of weight loss, depend largely on the patient’s ability to make long-term changes to one’s lifestyle. Therefore, aside from the surgery itself, , a patient has the best chance at long−term success if he or she has access to a hospital that offers thorough preoperative evaluation as well as long−term therapy to help maintain the weight loss.

Obesity is a serious medical problem that is made worse by pervasive social prejudice. Evaluation and treatment by a healthcare professional is often helpful to address underlying causes of weight gain and create a strategic approach toward weight loss and maintenance. Patients should be wary of unnceessary, and potentially harmful, commercial weight loss schemes and supplements.