Obesity

Technically, what is obesity?

Obesity is technically measured through a formula called the body mass index (BMI). If your BMI is 30 or higher, you are considered to be obese.

What causes it?

The causes of obesity are complex and include genetic, biological, behavioral and cultural factors. Basically, obesity occurs when a person eats more calories than the body burns up. If one parent is obese, there is a 50 percent chance that the children will also be obese. However, when both parents are obese, the children have an 80 percent chance of being obese. Although certain medical disorders can cause obesity, less than 1 percent of all obesity is caused by physical problems. Obesity in childhood and adolescence can be related to: " poor eating habits

  • overeating or binging
  • lack of exercise (i.e., couch potato kids)
  • family history of obesity
  • medical illnesses (endocrine, neurological problems)
  • medications (steroids, some psychiatric medications)
  • stressful life events or changes (separations, divorce, moves, deaths, abuse)
  • family and peer problems
  • low self-esteem
  • depression or other emotional problems

Nowadays, gone is the simplistic notion that obese people don't have willpower or they are too lazy to exercise. Although the basis of obesity is not only fully understood, the condition has been recognized since at least 1985 as a chronic disease caused by a complex set of factors.

Genes

Studies show that obesity runs in families. If one or both of your parents are obese, your obesity risk is higher because genes determine your body shape and, to some extent, your weight. Just because you are vulnerable to obesity, however, doesn't mean your fate is sealed. You can defy Mother Nature by learning to control your diet and by exercising regularly. In certain cases, medication or surgery also can help.

Fatty foods

Hot dogs, Big Macs, French fries, macaroni and cheese, nachos, potato chips, ice cream -- all these high-fat American favorites are cheap, accessible and delicious. Is it any surprise that fatty foods are contributing to the soaring obesity rates in this country?

Lifestyle

If you spend most of your time at a desk or on a sofa, your risk for obesity is higher. Likewise, the risk is higher for people whose fat intake makes up more than 30 percent of their daily calories. Studies show people who get 20 to 30 minutes of exercise most days are less likely to be obese. Your obesity risk is even lower if you combine an active lifestyle with a low-calorie diet.

Metabolic rate

This term refers to the rate at which your body uses food. If your metabolism tends to be slow, you are more likely to store excess calories in the form of fat. A slow metabolism means you probably need to work harder at losing weight. However, your efforts may ultimately increase your metabolic rate. Muscle burns more calories than fat, even at rest. So reducing fat and building muscle through weight-bearing exercise can help you burn calories more efficiently.

Psychology

Some people overeat (binge) when they feel stressed out or depressed. Research shows that about 30 percent of obese people are binge eaters. According to psychotherapist Shelia Harbet, Ph.D., binge eating temporarily relieves the stress of negative feelings. Unfortunately, binging is usually followed by feelings of guilt, shame, disgust and depression.

"Often, binge-eating episodes are followed by resolutions by the compulsive overeater to stop bingeing and adhere to diets," says Harbet, a professor in the department of health sciences at California State University, Northridge. "These resolutions are eventually broken, filling compulsive eaters with guilt and depression, leading them back to binge eating again."

Why is obesity such a concern?

Some of the possible health problems stemming from obesity include type 2 diabetes, coronary heart disease, high blood triglycerides, high blood pressure and stroke. Obesity also raises your risk of certain types of cancer. Obese men are more likely than normal-weight peers to die from cancer of the colon, rectum and prostate. Obese women are more likely than non-obese women to die from cancer of the gallbladder, breast, uterus, cervix and ovaries. Death from some cancers may be more likely because obesity makes the cancers harder to detect in the early stages (for example, the initial small lump of breast cancer may not be felt in an obese woman). Recent studies show obesity increases the risk of Alzheimer's-type dementia.

Other disease and health problems linked to obesity include:

  • Gallbladder disease and gallstones
  • Osteoarthritis, back, hip and knee joints deteriorate, partly a result of excess weight on the joints
  • Gout, or joint pain, caused by deposits of uric acid crystals in the joint space; most often experienced as arthritis in one joint
  • Sleep apnea, a disorder characterized by loud snoring and multiple short periods when breathing stops during sleep
  • Psychological and social problems - see Ward Halverson personally to discuss these, as they can be quite destructive, especially with children and teenagers.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, if you are 40 percent overweight, you are twice as likely to die prematurely as an average-weight person. The more obese a person is, the more likely he or she is to have health problems.

Emotional aspects of obesity

One of the most painful aspects of obesity may be the emotional suffering. People often equate attractiveness with thinness, especially in women. This message, intended or not, makes many overweight people feel unattractive. Many assume that obese people are gluttonous, lazy or both. However, more and more evidence contradicts this assumption.

Obese people may face prejudice or discrimination at work, at school, while job hunting and in social situations. Feelings of rejection, shame or depression are common. Founded in 1969, the National Association to Advance Fat Acceptance has been striving to eliminate discrimination based on body size and to provide fat people with the tools for self-empowerment through public education, advocacy and member support.

We eat to live, yet our eating habits are often hazardous to our health. In America, where food is plentiful, many eat too much.

Americans have obsessions with food and obsessions with diets and thinness. We're hooked on supersized foods, yet we spend billions on diet plans and products, some of which are questionable or downright dangerous.

Today, more than 70 million Americans are overweight, accounting for 300,000 preventable deaths each year and $100 billion in health care costs, according to the American Obesity Association. In the past decade, the proportion of the population that is obese has increased from 25 percent to 32 percent - a near epidemic rise.

Complicated challenges remain to help people eat their way to health. Physicians and health educators need to continue to clarify healthy dieting. Government agencies and consumer health watchdogs need to continue to guard against the dangers of certain food supplements, which aren't magic bullets for weight loss.

"The health bureaucracy in Washington is very concerned about the increase in obesity and the risks of obesity," says Frances M. Berg, editor of Healthy Weight Journal, M.S., L.N., and an adjunct professor at the University of North Dakota School of Medicine. "However, they should also be warning us about hazardous weight loss products, eating disorders, dysfunctional eating and size prejudice."

Statistics show that 95 percent to 97 percent of people who lose weight, gain it back, and often they gain back more than they lost, Berg says. She believes doctors and health educators should be a part of the solution and should encourage their patients to eat normally, live actively and to keep a stable weight. Doctors should also warn against diets, which only cause more weight gain in the long run.

"We need to focus on changing habits," she says.

Berg says the key to weight loss is to eat enough food to nourish and satisfy and to exercise most days of the week. However, Berg says, while many people lose weight successfully by good eating habits and exercise, most people cannot work themselves down to that lean, mean body weight.

What can be done about obesity?

Each year, Americans spend more than $33 billion on weight-reduction programs and diet foods and beverages, most of which fail to provide long-term results. Losing weight and keeping it off can be extremely difficult. Most people who lose weight only gain it back again. Permanent weight loss may seem elusive, but is by no means impossible.

If you are obese, see a doctor before launching into any weight-loss program. Also, consult your doctor before taking any over-the-counter diet pill or supplement. This is particularly important if you have high blood pressure or another medical condition, or if you are severely obese. Be wary of fad diets and rapid weight-loss programs because they may provide dramatic short-term results but can be hazardous to your long-term health. Also, don't feel pressured to conform to an official weight chart. Scientific evidence suggests strongly that dropping even small amounts of weight - 10 percent to 15 percent of initial body weight - can reduce your risk of diabetes and other illnesses.

On any non-medically supervised weight-loss program, women should get at least 1,200 calories a day and men at least 1,600 a day. If you eat too few calories, your metabolism slows down and weight loss becomes even more difficult. This is vital to remember.

The most successful weight-loss strategies include calorie reduction combined with increased physical activity, and behavior-modification therapy designed to improve eating and exercise habits. These changes should be permanent so you can keep the weight off, which means recognizing the process as a lifestyle change rather than just a temporary fix.

Here are some tips to get you started:

  • Cutting back on dietary fat can help reduce calories and is heart-healthy. There is much talk about "good" fats, such as olive and canola oils, and "bad" fats, such as palm oil and butter. Remember that these differences are more important for controlling cholesterol than they are for controlling weight. French fries have the same number of calories, no matter what kind of fat they are fried in.
  • Reducing dietary fat alone -- without reducing calories -- won't cause weight loss. Some fat-free food products actually contain more calories than their fat-containing counterparts because manufacturers replace fat with sugar to make the product more palatable.
  • Most regular sodas contain 150 calories or more. So a six-pack of cola may contain as many as 1,000 calories. The same is true for 12 ounces of some juices. Learning to drink "diet" or sticking to water may reduce calories if you drink large amounts of sodas or juices.
  • Try to keep your fat intake to less than 30 percent of total calories.
  • Don't give up just because you reached a plateau or ate too much at a party last night.
  • Keep junk food out of your house. Instead, keep fruit or a bowl of washed carrots or celery front and center in your refrigerator.
  • If you've been sedentary for years, don't go overboard with exercise. Doing too much too soon can lead to burnout and injuries. Begin by walking outdoors or on a treadmill for 10 minutes a day. After a few days, increase your walking session to 15 minutes, then 20, and eventually to 30 minutes or more. Try to get in a total of at least 150 minutes of walking or other physical activity a week.
  • After you can walk 30 solid minutes without feeling winded, begin to pick up the pace or find a hilly place to walk.
  • Continue to step up the pace of your exercise program and add some other forms of low-impact exercise, such as cycling or low-impact aerobics. Varying your exercise routine prevents boredom and burnout.
  • If your schedule seems too jammed for exercise, give up something else. Wake up a half-hour early to exercise. Say no to the next person who asks you to volunteer somewhere. Or, take a walk or go to the gym during your lunch hour, then eat at your desk afterward.
  • Set a series of short-term weight loss goals, such as 1 to 2 pounds a week or 8 pounds a month.
  • Set your long-term goal at about 10 percent over ideal weight. That is enough to significantly reduce your risk factors for obesity-related diseases. With success, and if warranted, you can attempt further weight loss.


Behavior modification

The Institute of Medicine at the National Academy of Sciences offers these behavior modification tips to keep weight off for good and stay healthy:

  • Self-monitoring. Track your eating and exercising habits by recording them in a diary.
  • Stimulus control. Eat only at specific times and places, go food shopping when you are not hungry, and lay out your exercise clothes to remind you about physical activity.
  • Contingency management. Reward yourself for changes such as reducing grams of fat or increasing minutes of exercise.
  • Stress management. Reduce or cope with stress by exercising regularly, meditating or learning relaxation techniques.
  • Cognitive-behavioral strategies. Identify unrealistic expectations, and focus on changing your attitudes and beliefs. Talk about yourself positively. Imagine yourself eating well and exercising regularly.
  • Social support. Use family and friends as a source of support for encouragement and positive reinforcement of your goals.


Ward V. Halverson, LCSW-R, M.Ed. is an expert at helping people make major life changes using these types of approaches. Work closely with him but prepared to be honest and flexible - remember about confidentiality, that Ward can't share your diet and exercise successes or failures with anybody without your permission (unless someone's life is in danger). He also recognizes that such major lifestyle changes take time for adaptation and accommodation; few people are as patient, open-minded, or caring as Ward - you will get through it and find success.

Here are some tips to keep in mind:

  • Get at least 30 minutes of exercise most days of the week. This can be a great calorie burner. Aim for cardiovascular exercises, which get your heart pumping. Walking and running are great activities. Be sure to check with your doctor before starting an exercise program.
  • Watch your weight loss. Safe weight loss is about 2 pounds a week.
  • Eat plenty of fruits and vegetables, which are low in calories and rich in fiber. Fiber makes you feel full.
  • Skip the magic diet pills and save your money. They don't work.


What are some other issues to be considered, particularly with children?

Obese children need a thorough medical evaluation by a pediatrician or family physician to consider the possibility of a physical cause. In the absence of a physical disorder, remember: the only way to lose weight is to reduce the number of calories being eaten and to increase the child's or adolescent's level of physical activity. Lasting weight loss can only occur when there is self-motivation. Since obesity often affects more than one family member, making healthy eating and regular exercise a family activity can improve the chances of successful weight control for the child or adolescent.

Specifically with children and adolescents:

  • start a weight-management program
  • change eating habits (eat slowly, develop a routine)
  • plan meals and make better food selections (eat less fatty foods, avoid junk and fast foods)
  • control portions and consume less calories
  • increase physical activity (especially walking) and have a more active lifestyle
  • know what your child eats at school
  • eat meals as a family instead of while watching television or at the computer
  • do not use food as a reward
  • limit snacking
  • attend a support group (e.g., Weight Watchers, Overeaters Anonymous)
  • Parents: focus on your child's strengths and successes; make it fun!


Obesity frequently becomes a lifelong issue. The reason most obese adolescents gain back their lost pounds is that after they have reached their goal, they go back to their old habits of eating and exercising. An obese adolescent must therefore learn to eat and enjoy healthy foods in moderate amounts and to exercise regularly to maintain the desired weight. Parents of an obese child can improve their child's self esteem by emphasizing the child's strengths and positive qualities rather than just focusing on their weight problem.

When a child or adolescent with obesity also has emotional problems, a child and adolescent psychiatrist can work with the child's family physician to develop a comprehensive treatment plan. Such a plan would include reasonable weight loss goals, dietary and physical activity management, behavior modification, and family involvement.

What about taking medication or undergoing surgery?

Many supplements are on the market for weight loss. These are often a mixture of different substances and herbal extracts. Most of them contain stimulants such as ephedrine (Ma Huang extract), in addition to chromium salts (often chromium picolinate), and sometimes a substance called hydrocyctric acid (HCA - from Garcinia cambogia). The stimulants work in a manner similar to Dexatrim® and there is much debate over whether chromium picolinate or HCA work at all. To date, no published studies have supported their use in weight reduction, and unpublished studies that have shown benefits in weight reduction were mostly done by their manufacturers. Chitosan is another common supplement that is derived from shellfish. It is said to bind fats and increase their elimination in the stool. Individuals taking this supplement may wish to consider supplements of vitamin A, D and E.

The best advice is to avoid weight loss supplements, which generally do not work and may be dangerous. The Food and Drug Administration banned the sale of dietary supplements containing ephedra (ephedrine alkaloids) because of their harmful cardiovascular effects, including increased blood pressure, stroke and irregular heart rhythm. About 100 deaths have been reported.

Many supplements should not be used by people with certain medical problems or pregnant and nursing women, and some may interact with medications. Tell your doctor about any supplements you are taking. Chitosan should not be taken by anyone with a shellfish allergy. While some people may feel more comfortable with "natural" products as opposed to prescription drugs, keep in mind that the 1994 Dietary Health Supplement Education Act states that herbal products do not have to be proven safe and effective to be sold. Additionally, patents can be issued for these products without proof of their claims of health benefits. The best course is to exercise and watch your calorie intake.

Weight loss medications

If you have been unable to lose weight or maintain weight loss after six months of diet and exercise alone, your doctor may recommend adding drug therapy if your body mass index (BMI) is 30 or greater (or 27 or greater if you have additional risk factors for disease). All medications to assist with weight loss should be taken only under direct medical supervision. Anti-obesity drugs are designed to be part of a comprehensive weight-loss program that includes regular exercise and a low-calorie diet.

According to the National Institute of Diabetes and Digestive and Kidney Diseases, medications most often used to fight obesity are appetite suppressants, several of which have gained U.S. Food and Drug Administration (FDA) approval. These medications decrease appetite by increasing the availability of serotonin or catecholamine -- two brain chemicals that affect mood and appetite.

In general, appetite suppressants lead to an average weight loss of 5 to 15 pounds above that expected with non-drug obesity treatments. Studies suggest that if you don't lose at least four pounds over four weeks on a particular drug, then that medication is unlikely to help you achieve significant weight loss in the long run.

Several weight-loss drugs have fallen into disfavor. The original appetite suppressants, introduced in the 1970s, were amphetamines. Experts now consider amphetamines, or "speed," to be more dangerous than being overweight. Amphetamines have a number of potentially dangerous side effects, mainly physical and psychological addiction.

Two other popular appetite suppressants were removed from the market in 1997 after studies strongly suggested that they could damage the heart's mitral valve. These drugs -- Pondimin® (fenfluramine) and Redux® (dexfenfluramine) -- were often prescribed in combination with phentermine ("fen-phen"). Phentermine increases the body's metabolism and decreases appetite by enhancing the availability of two brain chemicals, dopamine and norepinephrine. Phentermine has not been associated with heart valve disease and the drug is still available by prescription.

Other FDA-approved anti-obesity drugs include:

  • Meridia® (sibutramine hydrochloride monohydrate). Sibutramine is the first in a new class of anti-obesity drugs known as "neurotransmitter uptake inhibitors." It works by manipulating the appetite-control centers in the brain. In clinical studies involving 6,000 obese people, sibutramine resulted in an average five percent to 10 percent weight loss over one year. People who have a history of stroke, heart disease, congestive heart failure or uncontrolled high blood pressure should not use sibutraine. Although this drug was not associated with heart-valve abnormalities, it can cause significant elevation in blood pressure in some people. The drug manufacturer, Knoll Pharmaceutical Co., is urging physicians to carefully monitor the blood pressure of all patients taking subutratmine.
  • Xenical® (orlistat). Orlistat is the first drug in a new class of anti-obesity drugs that blocks the absorption of dietary fat. Orlistat works in the gastrointestinal tract, blocking enzymes needed to digest fat. Instead of being absorbed from the intestine, up to one-third of the fat that a person consumes is excreted in the stool. Orlistat also blocks the absorption of needed fat-soluble vitamins A, D, E, and K, as well as beta-carotene. So daily vitamin supplements must be taken. Orlistat's most commonly reported side effects are bloating, diarrhea and oily stools. In one clinical trial, patients who took orlistat and followed a weight-loss diet for one year lost an average of 19 pounds, while those who followed the diet and took a placebo lost 13 pounds, on average. Patients who took orlistat also showed improvements in high blood pressure, high cholesterol and diabetes, according to the drug's manufacturer, Hoffman-La Roche.


Sibutramine and orlistat have different mechanisms of action. Several studies have shown that weight loss with sibutramine plus orlistat are no greater than with sibutramine alone.

Weight loss drug on the horizon

Cholecystokinin boosters. Cholecystokinin is made in the intestine but also is present in the brain where it is believed to produce a feeling of fullness. If drugs could be manufactured to boost cholecystokinin's effect, people who take the medication would feel full quicker and presumably eat less. Research into this treatment approach is in the early stages; results, if any, are probably years away.

Risks of drug therapy

Before taking any appetite suppressant medication, ask your doctor or pharmacist about all the known risks and side effects. Taking more than one diet drug at the same time can be dangerous. Certain prescription medications have the potential for abuse or dependence. Also, keep your expectations realistic; most studies of appetite suppressants show that a patient's weight tends to level off after four to six months.

Also bear in mind that most appetite suppressants are approved only for short-term use (a few weeks or months). Sibutramine is the only appetite suppressant medication approved for longer-term use in significantly obese patients, although the safety and effectiveness have not been established for use beyond one year.

Obesity surgery

Surgical treatment is the only proven way to achieve long-term weight control for the severely obese -- those with a BMI of 40 or greater or a BMI of 35 to 40 with other health problems. Surgery is indicated only after less invasive methods have failed and the patient is at high risk for obesity-associated illness.

Obesity surgery involves creating a small pouch in the stomach and a small outlet at the bottom of the pouch. The two approved operations are called Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass. Studies show that a new surgical procedure involving elements of both has yielded excellent results thus far.

Depending on the type of operation used, food passes from the pouch to the remaining part of the stomach or directly to the small intestine. The surgically created pouch is so small that it limits ingestion of food before you feel full.

Typically, patients lose 48 percent to 74 percent of their excess weight in the first year after surgery -- if they follow diet and behavior recommendations. The rate of weight loss slows over time, and eventually weight stabilizes. Bariatric surgery has been associated with improvements in type 2 diabetes.

Risks of bariatric surgery

Between 10 percent and 20 percent of patients develop complications following surgery. These include wound infections, leaks or narrowing at connection to the pouch, ulcers, hernias, breathing problems (such as post-operative pneumonia) and blood clots.

After bariatric surgery, you must remain under medical surveillance for the rest of your life. Bariatric surgery is expensive - about $15,000. And not all insurance plans cover it.