Obesity Drives Car Size?

The following quote is taken from a recent article in the ECONOMIST on the discontent of Americans with the economic state of their country:

Petrol prices, despite their recent retreat, hurt nearly everyone. Adam Julch, an enormous former college football star who is now a manager at a trucking firm in Omaha, Nebraska, complains that he had to trade in his pickup truck for a little Honda Civic. “I’m 350 pounds,” he says, “I feel like I’m in a clown car.”

Two aspects of this quote deserve comment:

1) Yes, larger people need larger cars to move them around - more larger people could mean more larger cars. This is not unlike the idea that it may not be the huge portion sizes in restaurants that lead to obesity but rather it is obesity that leads to larger portions sizes in restaurants (yes, large people need more calories and generally have bigger appetites than thin people) - so restaurants have to serve up portions large enough to feed even their hungriest customers.

2) The fact that this was a former athlete, as are many of my biggest patients, emphasizes that even being a highly successful competitive athlete does not protect you from severe obesity later in life.

Now there is food for thought. Feel free to comment.

AMS
Dushesnay, Quebec

Hat Tip to Michael Dwyer for bringing this quote to my attention

What's With the Guys?

So to finish this week on men's health let me pose a question:

According to the new numbers from the Canadian Community Health Survey released last week, men aged 25 to 44 were considerably more likely than their female counterparts to be obese. Even in the age group 45 to 64, men were slightly more obese than women.

So clearly, at least as many men as women should be worried about their weight and seeking help - especially since men, due to their greater likelihood to gain abdominal fat, are at much higher risk for weight-related diabetes and heart disease.

But when you look at any obesity program (including ours), the women seeking help by far outnumber the guys (probably by 4 to 1, if not more).

So the question is - how do you get the guys to realize that their increased weight is putting them at risk and that it is they rather than the women, who should be seeking help.

Any suggestions from my readers out there on how to increase "obesity-risk-awareness" amongst men would be most welcome.

I look forward to your thoughts on this,

AMS
Edmonton, Alberta

New Obesity Numbers for Canada

Yesterday, Statistics Canada released the latest data from the 2007 Canadian Community Health Survey (CCHS) for obesity.

Overall 4 million Canadians aged 18 or older, 16% of the total, reported data on weight and height that put them in the obese category. Another 8 million, or 32%, were overweight.

Although between 2005 and 2007, rates of both overweight and obesity generally changed little, during that period, there was a slight increase in the proportion of women aged 18 to 24 who were obese, and a decrease in the proportion of senior men who were overweight.

Self-reported obesity rates were generally highest among individuals aged 45 to 64. One-fifth (20%) of men in this age group were obese, as were 18% of women. The proportion who were overweight also tended to peak in middle-age.

Men aged 25 to 44 were considerably more likely than their female counterparts to be obese.

Among the provinces, rates of obesity were highest in Saskatchewan, Alberta and Atlantic Canada, ranging from 18% in Alberta to a high of 22% in Newfoundland and Labrador. The lowest rates were in British Columbia where only 11% of adults were obese.

Overweight and obese adults were less likely to rate their health as excellent or very good than were adults not carrying excess weight.

Obviously, because of the tendency of respondents to over-report their height and under-report their weight, it is likely that these figures from the CCHS underestimate the actual prevalence of obesity and overweight.

Clearly, the obesity epidemic is alive and kicking. Delivering appropriate obesity treatments to one-fifth of the population is likely to remain a challenge for the forseeable future.

AMS
Edmonton, Alberta

Taming the Obesity Giant

This rather "dramatic" slogan was the title of a presentation that I held last night at a public forum on obesity held at the Maclab Centre for Performing Arts in Leduc, a city just South of Edmonton.

The forum was organized by the Leduc health council and was well attended.

My main messages:

1) Obesity is a widespread chronic disease that needs to be resourced in the same manner as other chronic diseases.

2) Although not curable, we do have treatments that are highly effective in reducing morbidity and (at least in the case of bariatric surgery) mortality.

3) Unless we appreciate the tremendous impact that obesity is having as a driver of a wide range of acute and chronic diseases as well as short and long-term disability, and develop the same infrastructure and access to obesity treatments as we do for other chronic diseases, the (avoidable?) spending on obesity-related comorbidities and disabilities (e.g. hip and knee replacements, diabetes, etc.) will simply continue to skyrocket.

4) In the short term, nothing less than a catastrophic event (e.g. gas prices of $4/litre, food shortage, etc.) is likely to reverse the current epidemic.

5) While we discuss how to rebuild our cities and change our food supply, we cannot continue to simply ignore the plight of the Millions already suffering the consequences of this disabling and cruel disease.

Hard words, perhaps not what the audience was ready to hear or digest - nevertheless enthusiastic compliments on talking about these issues without mincing words or providing unrealistic rosy outlooks.

There is an obesity crisis out there and it's not going away anytime soon!

AMS
Edmonton, Alberta

Supersizing Pregnancy Care: the Dawn of Bariatric Obstetrics?

Last week's issue of the New England Journal of Medicine features an article by Susan Chu and colleagues from the US Centers for Disease Control and Prevention (Atlanta, GA) on the impact of obesity on health care during pregnancy.

Dr. Chu and colleagues examined 13,442 pregnancies (2000-2004) according to pre-pregnancy BMI. After appropriate corrections for confounders, hospital stay for delivery was significantly greater by approximately a full day among women with obesity than in normal weight women. Most of the increase in length of stay associated with higher BMI was related to increased rates of cesarean delivery and obesity-related high-risk conditions.

A higher-than-normal BMI was also associated with significantly more prenatal fetal tests, obstetrical ultrasonographic examinations, dispensed medications, telephone calls to obstetrics, and prenatal visits with physicians. Thus clearly, obesity during pregnancy is associated with increased use of health care services.

Obesity in pregnancy is not a topic that is discussed much in the media. I first became aware of the magnitude of this problem, when I was approached by the obstetrics folks from the McMaster University Hospital (Hamilton, Ontario) who found themselves looking after an increasing number of severely obese expecting mothers. This contact led to the initiation of a working group on bariatric nursing that devised protocols for looking after large and very large mothers.

I further realised the importance of this issue when I heard about the apparently close link between maternal obesity and the risk for both the mother and infant and the fact that obesity during pregnancy may set up the infant for future obesity through epigenetic programming. As I have blogged before, limiting weight gain during pregnancy in overweight and obese mothers may be a first step towards preventing childhood obesity.

Given that there are around 13,000 babies born in the Capital Health Region every year, about 10% of these to mothers with pre-pregnancy BMI>30, the finding of Dr. Chu et al., if translated to our region, could mean as many as 1,500 or so extra days in hospital for new mothers, much of this due to obesity-related risk. Obviously more screening tests, more frequent prenatal visits and more medications would add to the costs.

Clearly, the issue of increasing weights and weight gain in women of child-bearing age is a public health issue whose consequences and impact have yet to be fully appreciated.

As these issues affect both mothers and infants, it would not be a bad place to focus prevention measures for best impact.

AMS
Edmonton, Alberta

The Real Cost of Obesity May Not be in Health Care

When you follow the current public discussion on the consequences of obesity, the focus is most often on the potential costs for health care. This is not surprising, given that obesity is directly linked to a wide range of chronic diseases including hypertension, type 2 diabetes, sleep apnea, osteoarthritis and many forms of cancer.

But health risk are not the only cost of obesity. Even a cursory glance at the patients presenting in our clinic immediately makes it evident that a disproportionate number are on short or long-term disability, not working to their full potential or simply unemployed. If you take into consideration that the average age of patients in our clinic is in the lower 40s, it immediately becomes evident that there are economic losses to society here that go well beyond the simple costs of health care.

Numerous studies have in fact documented that obesity may have important economic consequences for individuals - and thus society.

This was once again demonstrated in the largest study on this issue to date. Nina Karnehed and colleagues from the Karolinska Institute in Stockholm examined social mobility in over 750,000 men born between 1951 and 1965. Subjects were studied at age 10 and again at age 30.

Men who were obese at age 18 were almost 30% less likely to be upwardly mobile (achieve a higher socioeconomic status than their fathers) and 30% more likely to be downwardly mobile (achieve a lower socioeconomic status than their fathers) compared to normal weight men. This finding was independent of childhood socioeconomic index (SEI), IQ or education, suggesting that societal factors (e.g. bias and discrimination) may be responsible.

This difference is substantial. Downward social mobility means less income and lower SEI with all its consequences. These costs to society may be far greater than any costs to health care.

I am no economist, but I don't find it difficult to imagine that when a substantial proportion of the population (currently 25% of all adults) are at risk of not realizing their full economic potential this could mean a huge loss for the overall economy.

Thus, apparently obesity not only affects mental or physical health but also socioeconomic health - an important consequence of the obesity epidemic that I have not heard much about in the media or elsewhere.

Perhaps the increased health care costs of obesity are the least of our worries.

AMS
Edmonton, Alberta

Counseling the Community Health Councils on Obesity

Last evening I gave a presentation to members of the Strathcona County Community Health Council (CHC). The CHCs are advisory bodies appointed by the Capital Health Board, to provide community perspectives that support Board business planning and strategic direction.

Council members are volunteers with strong community linkages. Most have been involved with local groups or organizations where they receive community input on various health issues.

Input from CHCs helps the Board to update its business plan and meet the health needs of people in the Capital Health region.

Thus, informing the CHC members about the importance of the Weight Wise program and its relevance to improving the health of their communities is of utmost importance.

As anticipated, the interest in Weight Wise was keen. Not only were they interested in learning about my vision for the program but also in the challenges and possible solutions to the obesity crisis.

I emphasized that Weight Wise is in fact not a single program but rather a whole suite of programs and initiatives addressing both obesity prevention and treatments in the Capital Health Region and beyond.

I spoke about the unique opportunities here in Edmonton, where we can indeed create a seamless obesity program that provides services across the continuum of care.

I spoke to the need of providing obesity care to the over 250,000 people in the region already clinically obese and the over 25,000 with severe obesity.

I also spoke about the many excellent researchers here at the University of Alberta already working on important issues relevant to obesity prevention and care.

My guess is that my presentation was well received - indeed, I hope it was.

It will take all the support we can get to create a climate in which spending money on obesity prevention and treatments is not the exception but rather the rule.

AMS

How Far Will You Travel for Obesity Treatment?

One consequence of the rapid increase in obesity is that the vast majority of Canadians cannot rely on local facilities or expertise for obesity treatments. As a result, patients often have to travel long distances or even across borders to seek obesity treatments.

For example, our program has over 300 patients from other provinces awaiting assessment and hoping for treatment.

This throws up a number of logistical but also practical issues: how do you provide cross-border management for a chronic disease?

It is one thing to fly across the country to consult an expert for a diagnosis of a rare condition or a one-time specialized procedure. But what do you do for a common condition that requires on-going lifelong management? How do you provide education, counseling, monitoring and support across 1000s of kilometers?

Sure there are telephones, internet and telehealth but this does not entirely replace the need to actually see and examine a patient face-to-face.

Remember, obesity is a complex and heterogeneous condition - patients may require 10s of visits with a whole array of health professionals to determine the best treatment plan. Successful obesity management requires continued intervention and monitoring to keep the patient in remission. Early signs of relapse need to be recognized and dealt with to prevent weight regain. Surgical patients need band readjustments, dietary counseling and psychological support.

Much of this is theoretically possible across distances with modern communication technologies but in reality often impractical and inefficient.

On the other hand, how do you refuse to see patients who are clearly in dire straits for whom no local help is available or forthcoming any time soon?

Frankly, I see no alternative to rapidly ramping up obesity care across Canada - this will take both time and resources but most of all a change in attitude: ignoring obesity is no longer an option - limiting efforts to prevention is not helping the millions already struggling with this condition.

AMS

The Faster the Food - the Greater the Risk?

This weekend, I was invited to participate in a panel discussion following a public viewing of the documentary Super Size Me.

The event was part of the University of Alberta's Centenary Celebrations and was co-hosted by the Faculty of Medicine and Dentistry's Arts & Humanities in Health & Medicine program and the Edmonton Public Library in their film series called "Good Medicine".

As a panelist, I had the opportunity to see the film again and to reflect on what the film is actually about.

Of course, given that the film shows how Morgan Spurlock super sizes himself by eating nothing but McDonald's for 30 days, this film can easily be interpreted to simply show how bad fast food is for you.

While there is no question that given its high content of fat, sugar and salt, fast food is certainly not the most nutritious food, to me, this is not what the film actually proves.

In fact, when you think about it, Morgan could have splurged on 5000 KCal a day of even the most nutritious and expensive foods for 30 days and probably have gained as much weight and felt as sick in the end. Yes, you can gain weight on healthy foods!

Even the most pricey restaurants, do not necessarily design their meals to be healthy and balanced and I am probably not the only one who has eaten over 2500 KCal in food and wine at a single meal even in restaurants featuring celebrity chefs - no shortage of fat, sugar and salt in those foods either.

So eating at McDonald's was just a cheaper way to make this film - no doubt, had Morgan eaten all his meals at a 3-star restaurant, he would have needed a much larger budget for his film. In other words - this was just a "cheap" shot at McDonald's.

Don't get me wrong - there is nothing healthy about McDonald's or most of the food you can get at any fast food chain. But the film does not prove this.

What the film does show though, is that eating 5000 KCal a day can lead to weight gain and make you feel pretty sick. What the film also shows is that this is quite easy to do on fast food. Part of this is because the food is so cheap (=affordable). But another important reason why it is so easy to overeat is because the food is designed to be eaten fast.

I have previously blogged about the notion that the problem with fast food is more the "fast" than the "food" (see my post No Time to be Thin). It is indeed very hard to significantly overeat on "slow" food. This is because, when you eat slow, you will be quite full long before you have managed to tuck away 2000 KCal at a single meal. In fact, the bulkier and greater the volume of the food (i.e. the lower the caloric density), the harder it is to eat 2000 KCal at a single meal.

In the film Morgan also criticizes McDonald's for offering to super size your order (which they have since stopped doing). This, however, is also not so different from what happens in any restaurant, where the servers are trained to offer an appetizer, salad, dessert and more wine if you don't remember to order these extra calories yourself. They will also be happy to "super size" your steak order by offering to add a lobster tail or extra cream or cheese on you baked potato.

So here is what I think the film does show:

a) eating 5000 KCal a day leads to weight gain, which in turn is likely to make you sick

b) McDonald's (and no doubt other fast food restaurants) make it easy and affordable for you to do so

c) McDonald's (and virtually every other restaurant I know of) wants you to eat more and will try any trick in the book to get you to do so

How do we deal with this - for one, we could begin by posting calories on ALL menus - hopefully a disincentive to overeating, no matter how fast or slow the food.

AMS

Don't Shoot the Messenger

Here is an interesting Editorial in the Globe and Mail on not being judgmental about people with obesity. The author is Irving Gold, Chairman of the Canadian Obesity Network's Board of Directors.

The editorial speaks for itself and there is little point in repeating it here.

The reason for my post is mainly to point out the interesting discussion with 100s of comments that were provoked by this Editorial. The range of comments very much reflects the nature of the current discussion on obesity by the general public and nicely shows how emotional people can get when discussing this subject (both on the pro and con side).

To me, the increase in obesity has always been just a symptom of living in an obesogenic environment.

The fact that this environment affects some people more than others is not different from other situations, where for the same level of exposure some suffer the consequences while others get home free.

Not every smoker gets a heart attack, not everyone who eats a ton of salt gets a stroke and not everyone who breathes in polluted air gets an asthma attack. But yes, more smoking means more heart attacks, more salt means more strokes, more pollution means more asthma.

Similarly, not everyone who indulges in junk food or lies on the couch becomes severely obese. In fact, we all know people (I call them the mutants), who can eat ridiculous amounts of food and never seem to gain a gram of fat. In fact, there is a whole "weight-gain" industry out there catering to young men who are tired of having sand kicked in their face by the jocks.

Obviously, the people likely to be affected most by our obesogenic environment are those that have familial, emotional, sociocultural or medical reasons for eating too much and not moving enough - the same people, who would have been the largest even 100 years ago. They are the magnifying glass through which we fully realise the profound impact of our environment on population weight.

The fact that we have more people with obesity is sending us a clear message: let's clean up our act and address the issues that are causing our obesogenic enviroment and provide help to those who are struggling the most.

Don't shoot the messenger!

AMS

Does the Focus on Obesity Prevention Promote Bias and Discrimination?

Imagine walking into an emergency room with chest pain and simply being sent away with a leaflet advising you to quit smoking.

Imagine arriving at a hospital with signs of stroke and simply being referred to a lecture on reducing sodium intake.

Imagine being diagnosed of colon cancer and just receiving well-meanining advise on the virtue of eating more fibre.

What is fundamentally wrong with the above scenarios? The simple fact that they are confusing prevention with treatment.

While giving up smoking, excessive salt and eating more fibre may be valuable in preventing heart disease, stroke and cancer, as treatments (at least in the short term) they are near to useless.

Once patients present with the disease, they need treatment.

This is not to say that lifestyle changes are not as important for secondary prevention - but they are rarely enough.

While many may agree with the above, they seem to have a hard time applying this knowledge to obesity.

While every politician, non-government organization and legions of health workers are campaigning for more efforts on preventing obesity, rarely do I hear the cry for more treatments - this is blatant discrimination!

When a quarter of the population or around 11,000,000 Canadians already have the "disease" focussing all available resources solely on prevention is a joke.

Not that efforts at prevention are not important - of course they are. Yet, even the most optimistic experts do not think that the current epidemic can be reversed in the forseeable future. It will take time to rebuild our cities, force people to abandon their cars, regulate our food chain, focus on calories and change our culture of overconsumption and sedentariness.

Even if any of these measures worked, no one expects them to have an immediate impact on those struggling with obesity today.

A 200 lb 17 year-old does not have 10 years to wait for "prevention" to kick in - he/she needs help today.

Even if treatment focussed only on providing minimal obesity treatments to those who most need them, i.e. those already experiencing the complications of diabetes, knee pain, sleep apnea, fatty livers, infertility - we would still need to provide obesity treatments for millions of Canadians.

Ignoring their plight and focussing all resources on "prevention" is not only demeaning and in-human, it also perpetuates the wide-held notion that obesity is entirely preventable and that anyone who has obesity has obviously "failed" at doing the right thing and therefore simply deserves no better.

The more we promote the idea that all it takes to prevent obesity is simply for individuals to eat less and move more - the more we can rest in our armchairs and blame people with obesity for just eating too much and not moving enough.

What message could be more powerful in cementing the already widespread bias and discrimination against individuals struggling with this condition?

Perhaps only worse is the message that anyone can become masters of their own weight if they only tried hard enough (as in Biggest Loser?). This idea is even more discriminating, because it implies that anyone who is too heavy is simply not making the effort.

All of this flies in the face of the fact that recidivism of obesity in our current obesogenic environment is almost 100%.

No matter how much weight people lose and irrespective of the weight-loss method (perhaps short of surgery) weight sooner or later comes back. In the exceptional few who do manage to keep the weight off, it remains nothing short of a daily obsession, where the slightest slip-up is punished with immediate weight re-gain.

Simply losing weight is not treatment for obesity - keeping it off is!

Continuing to channel all our efforts solely into prevention and ignoring the plight of the millions who have no where to turn for help except to commercial weight-loss scams is a direct reflection of and only promotes the bias and discrimination against people with obesity.

Fortunately, treating obesity is not more difficult or even more expensive than dealing with other chronic conditions - but it does require at least the same attention and commitment of resources as we devote to other chronic diseases. Not providing treatment is perhaps only a reflection of the bias and discrimination towards people struggling with this condition (they deserve no better!).

We cannot afford to simply write off a quarter of all Canadians. Health ministers, health authorities, NGOs and health professionals now have to step up to the plate!

AMS

The Six Natural Laws of Weight Gain

With all the talk of "thrifty genes" and how our "hunter-gatherer genome" is overwhelmed by the "obesogenic" environment, it may be time to revisit my favorite theories about the "Natural Laws of Weight Gain".

This is something I came up with almost 10 years ago and have used in a lot of talks over the years. I've always wanted to put these ideas into a book but somehow never got around to it.

Simply stated, my Six Natural Laws of Weight Gain are as follows:

1. Always eat when food is around
2. Always go for the gravy
3. Always eat as fast as possible
4. Always eat as much as possible
5. Don't move if you don't have to
6. When fuel runs short, turn down the furnace

If anyone is thinking, "hey, that's me", you're probably not alone (in fact it's me too!).

If you take a minute to think about it, you'll probably recognize just how deeply these Natural Laws are engrained in our biology and culture and may realize how we've actually designed much of our environment to accommodate these laws.

Suddenly terms like "mindless eating", "fast"food restaurants, "all-you-can-eat" buffets, "poutine", "super-size it" and "couch potato" take on a whole new meaning.

While through the millennia of evolution these Natural Laws guaranteed the survival of our species, in our current obesogenic environment, they also pretty much guarantee weight gain.

As I have often pointed out in my talks: "In today's obesogenic environment, people have to develop "abnormal" behaviors to avoid gaining weight".

Doing things that came "naturally" to most of us is a surefire recipe for weight gain - in today's enviroment, fighting obesity literally means going against our "nature"! No wonder it is so hard to do.

OK, I realize that by now some of you are screaming that this must be wrong, that I am grossly oversimplifying the complex psychosociobiology of obesity, and that I am just providing obese people with an easy "excuse" to blame it all on nature.

Of course I realize that in reality things are way more complex and that there are many paths that lead to obesity ranging from childhood molestation to antipsychotics or from genetic defects to endocrine abnormalities (the list of possible causes if far longer than you may think!).

Nevertheless, I do believe that perhaps with the exception of such "special causes" the Natural Laws do provide a reasonable and useful framework for thinking about the root causes of the current obesity epidemic.

So in the next couple of weeks, I will be occasionally revisiting this theme and hope to explore some of these laws and how they apply to our current dilemma.

Perhaps the title of my book should be: "The Six Natural Laws of Weight Gain and How to Break Them"!

I wish someday to actually find time to write it - I could probably have a lot of fun with this.

AMS