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Cost of Obesity 'Will Wipe Out Healthcare'

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Cost of Obesity 'Will Wipe Out Healthcare'

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Obesity weighs heavily on American health and wealth.

Carrying extra pounds undermines several major weight-bearing pillars of value-based healthcare, including disease prevention, population health management, and cost control. In interviews and email exchanges over the past week, a trio of obesity experts helped me gauge the crisis and suggested ways to slash obesity rates.

Jay H. Shubrook Jr., DO, a diabetes specialist and professor at Touro University College of Osteopathic Medicine in Vallejo, CA, says the societal costs of obesity are becoming too great to bear.

"Our public health is at stake," he says. "We will not make meaningful headway on the prevention and treatment of chronic disease until we change the infrastructure that supports unhealthy habits. An immigrant from almost any other country who moves to the U.S. becomes at higher risk for diabetes once they live here. We have a sedentary lifestyle with an abundance of high caloric foods at our disposal."

Shubrook has been witnessing the impact of historically high obesity rates in his patients for nearly two decades.

Before moving to California this year, he served in several clinical, leadership, and academic positions at OhioHealth O'Bleness Hospital, a 132-bed acute care facility in Athens, Ohio. In 2013, O'Bleness identified obesity and poor dietary infrastructure in Athens County as "areas of concern" in the organization's Community Health Needs Assessment. In addition to pegging the adult obesity rate in Athens County at about 31%, the O'Bleness health needs assessment sounds an alarm over limited access to healthy foods in low-income areas and an overly high percentage of fast food restaurants among the area's eateries.

"Obesity is a crisis for two reasons," Shubrook says. "We are seeing lower life expectancy rates among our children, and we already know we can't handle the economic impact of diabetes. It will wipe out healthcare."

Otis Brawley, MD, chief medical officer at the American Cancer Society, says obesity is one of the top cancer risk factors in the United States.

"The combination of high caloric intake, obesity, and lack of physical activity will surpass tobacco as the leading cause of cancer death within the next two decades. It is already a leading cause of heart disease, diabetes, and orthopedic injury," he says.

Poor dietary habits and high obesity rates threaten to cripple the healthcare industry and the broader economy, Brawley says. "It is imperative that we reverse the trend, as healthcare costs associated with [the obesity] epidemic are already dragging our economy down and eventually will collapse our economy if it continues over the next several decades."

Justin Noble, a certified nutrition coach, children's book author, and co-founder of MyBodyVillage.com, says the healthcare industry will be unable to "move the needle" on cost of services as long as obesity and other lifestyle-related health risk factors remain out of control.

"The main issue with healthcare in America is that it is focused on treatment instead of prevention. Eighty-six percent of all healthcare spending in 2010 was for people with one or more chronic medical conditions. The gross majority of these conditions are brought about by lack of exercise, poor diet, stress, smoking, and alcohol consumption. In a nutshell, these ailments are brought on by the choices people make. If we put more effort into giving people the tools and the resources they need to make healthy choices, we will find ourselves paying less for the diseases associated with these poor choices. Until that happens, I only see the needle moving up."

The data demonstrating the dire health effects of obesity is distressing:

More than one third of adults and about 17% of youths are obese, the Centers for Disease Control and Prevention (CDC) reported in February 2014.

Obesity-related conditions include heart disease, stroke, Type 2 diabetes, and several types of cancer, according the CDC's Division of Nutrition, Physical Activity, and Obesity website.

In 2008, the estimated annual medical cost to treat obesity-related diseases was $147 billion, the CDC reported.

Many peer-reviewed studies have identified obesity as a high-risk factor for diabetes. A study published in 2000 concluded size definitely matters in the relationship between obesity and diabetes: "Relative to overweight people with stable weight, each kilogram of weight gained annually over 10 years was associated with a 49% increase in risk of developing diabetes in the subsequent 10 years."

A half century ago, Americans rose to another public health-related crisis with immediate actions and a long-term commitment to change.

Beginning in the 1960s, polluted river infernos, overflowing landfills, and other environmental calamities sparked a societal shift in American attitudes about natural resources. The country's collective nest had been fouled. A coalition of powerful institutions -- including government agencies, public schools, and the entertainment industry -- teamed up with communities to protect the environment.

Counter marketing was part of the immediate response to environmental degradation, including one of the most memorable public service announcements of the 20th century, the Keep America Beautiful campaign " Crying Indian" ad in 1971.

Shubrook says similar public service announcements and high-shock-value communication techniques need to be deployed as soon as possible to help reduce obesity. He cites a spoof of Coca-Cola's polar bear ad campaign that features ursine cartoon characters becoming obese on sugary drinks, then developing several related health problems such as diabetes and erectile dysfunction.

"It takes the sexiness of commercials and puts out a different message," he says. "When I show this spoof ad to my medical students, they see the power of marketing. There has to be some counter marketing [to offset advertising of high-calorie foods]."

The American obesity crisis poses more challenges than the healthcare industry can address on its own, Shubrook says, urging the formation of community coalitions to promote healthier lifestyles. In Athens, OH, and surrounding towns, healthcare professionals, political leaders, and business owners have banded together, creating a "critical mass" of activism to reduce obesity in their communities. "In each community, that [coalition] is going to be different. In some cases, youth groups will be crucial. That's the trick: You have to identify the key mass."

Brawley and Nobles say education, particularly for children, will play a decisive role in whether the country can contain the obesity epidemic.

"I do have some hope that we can change our eating practices," Brawley says. "I have more hope for preventing obesity in younger generations. Very few obese adults over 50 are successful with weight loss. European patterns of obesity have not risen over the past forty years as American patterns have. This tells us that populations can eat responsibly. I believe an aggressive education effort can prevent obesity."

Health and nutrition education should be a top public health priority, Nobles says. "First and foremost, the easiest way to get us on the right track is to start at an early age. Healthy children make healthy adults, which make a healthy society. The earlier we teach children about making healthy choices the better. It's much easier to stop a bad habit before it starts than it is to break a bad habit."

Last week I reached out to these food industry companies and associations, but did not receive responses to my requests for comment: the American Beverage Association, Coca-Cola, The Food Institute, and Little Caesar Enterprises Inc.
This article is brought to you by our partners at HealthLeaders Media.

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Cost of Obesity 'Will Wipe Out Healthcare'

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Obesity weighs heavily on American health and wealth. Carrying extra pounds undermines several major weight-bearing pillars of value-based healthcare, including disease prevention, population health management, and cost control. In interviews and email exchanges over the past week, a trio of obesity experts helped me gauge the crisis and suggested ways to slash obesity rates.

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AMERICA’S OBESITY CRISIS. THE HEALTH AND ECONOMIC COSTS OF EXCESS WEIGHT

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AMERICA’S OBESITY CRISIS. THE HEALTH AND ECONOMIC COSTS OF EXCESS WEIGHT

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This is why people with obesity are more likely to die from coronavirus

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This is why people with obesity are more likely to die from coronavirus

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This is why people with obesity are more likely to die from coronavirus

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There is a concerning trend surfacing in the medical literature: high rates of obesity in groups of patients with severe or life-threatening COVID-19.

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The coronavirus is particularly unkind to those who are obese

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The coronavirus is particularly unkind to those who are obese

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America's obesity epidemic appears to be making the coronavirus outbreak more dangerous - and potentially more deadly - in the United States, new research suggests. For younger and middle-aged adults in particular, carrying excess weight may significantly boost the likelihood of becoming severely ill with COVID-19.

The evidence for this comes from thousands of COVID-19 patients who sought treatment in emergency departments in New York, and it's prompting alarm among doctors and other health experts. In the U.S., 42.4% of adults have obesity, which means their body-mass index, or BMI, is 30 or more.

In one of two new studies released this week, COVID-19 patients who were younger than 60 and had a BMI between 30 and 34 were twice as likely as their non-obese peers to be admitted to the hospital for acute care instead of being sent home from the ER. They were also 1.8 times more likely to require critical care in a hospital's intensive care unit.

More severe obesity posed an even greater risk to COVID-19 patients in this under-60 age group. When these patients had a BMI of 35 or higher, they were 2.2 times more likely than their non-obese peers to need standard hospital care and 3.6 times more likely to end up in the ICU.

"Obesity appears to be a previously unrecognized risk factor for hospital admission and need for critical care," wrote the authors of the study published this month in the journal Clinical Infectious Diseases. But that only applies to relatively younger patients; among those ages 65 and older, there was no link between obesity status and hospital care.

The authors, from New York University's Grossman School of Medicine, suggested that the country's high prevalence of obesity might be nudging rates of severe illness and death higher in the U.S. than in South Korea, China and Italy, where obesity rates are lower.

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The results also give doctors a new way to predict which COVID-19 patients who are not yet senior citizens run a higher risk of hospitalization and critical illness.

"Unfortunately, obesity in people <60 years is a newly identified epidemiologic risk factor," wrote the researchers, who included 3,615 patients in their study.

In a second report, a different team of NYU doctors and researchers examined the factors that appeared to predispose 4,103 COVID-19 patients of all ages to hospitalization. That study was posted Saturday to the website MedRxiv, a forum for sharing work that has not yet been peer-reviewed and published in a medical journal.

Consistent with virtually all research on the coronavirus, this study found that being older than 75 was the most potent predictor of hospitalization for COVID-19, followed by being between the ages of 65 and 75.

The third-best predictor was having a BMI over 40, a condition doctors call "severe obesity."

When all other factors were held equal, COVID-19 patients with severe obesity were more than six times more likely to be hospitalized than were patients who were not obese. Even a history of heart failure was less likely to land a COVID-19 patient in the hospital, the researchers found.

Almost 10% of U.S. adults have a BMI of 40 or more.

To make matters worse, the authors of the study found that elevated levels of inflammation upon hospital admission was one of the four top signs that a patient's condition would become critical. Because stored fat is a powerful driver of inflammation, that measure tends to be higher in people with obesity.

"We find particularly strong associations of older age, obesity, heart failure and chronic kidney disease with hospitalization risk, with much less influence of race, smoking status, chronic pulmonary disease and other forms of heart disease," the researchers wrote.

Obesity is linked to higher rates of many disorders affecting the respiratory system, including obstructive sleep apnea and asthma. So people carrying extra weight may be more susceptible to infections that affect the lungs.

But there's also good reason to expect that people with obesity might suffer more from a respiratory infection, said William Dietz, an obesity researcher at George Washington University . Since they typically carry more fat around their midsections, people with obesity tend to have reduced lung volume to begin with. For the same reason, they need to expend more effort with each breath, Dietz said.

That is a particular burden when an infection compromises the lungs' ability to take in oxygen for transport to the blood. And when patients are immobile and lying flat on their backs, as is often the case in a hospital bed, excess weight in the midsection is a force that works against even the power of mechanical ventilation, he said.

For that reason, patients with obesity who are mechanically ventilated are often laid on their stomachs, a practice that has been widely observed in ICUs caring for COVID-19 patients.

"This is not reassuring for the United States," said Dietz of the new findings.

Vulnerability to lung infections is further compounded by many of the social factors that are also linked to obesity, said Steven Gortmaker of Harvard's Chan School of Public Health. African Americans, low-wage workers, those in poverty and people with poor access to healthcare have higher rates of both obesity and of respiratory illnesses, he said.

That these groups appear to be disproportionately affected by COVID-19 is probably not a coincidence, Gortmaker added.

Nor is the new coronavirus the first novel pathogen to afflict those with obesity, he added. A 2011 study found that half of California adults who were hospitalized with the H1N1 "swine flu" virus in 2009 and 2010 had obesity, and those with extreme obesity were more likely to die.

The finding prompted researchers to recommend that adults with obesity be given priority for vaccines and for antiviral medications that could treat the infection.

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The coronavirus is particularly unkind to those who are obese

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America's obesity epidemic appears to be making the coronavirus outbreak more dangerous - and potentially more deadly - in the United States, new research suggests. For younger and middle-aged adults in particular, carrying excess weight may significantly boost the likelihood of becoming severely ill with COVID-19.

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Childhood obesity increases your kids' risk of chronic disease

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Childhood obesity increases your kids' risk of chronic disease

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Type 2 diabetes is becoming more common in children

Obesity can help cancer progress

We have long known that the American lifestyle with our high-fat and high sugar diet and sedentary existence promotes chronic diseases like heart disease, stroke, diabetes and cancer. What is changing is how fast the negative impact of our lifestyle is taking hold, plus we now know that problems at an early age can set the stage for disaster later in life.

The key is the rise in the rate of obesity in youngsters, resulting in an alarming trend in which diseases that once were assumed to strike older adults, are now occurring much earlier. A perfect example is Type 2 diabetes.

Type 2 diabetes in kids

Obese children are susceptible to Type 2 diabetes. I have written about this in the past, and from responses I received, there is some confusion. Let me provide some basics.
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There are two types of diabetes. Type 1 diabetes is a genetic malfunction in which the body's immune system attacks the pancreas gland and destroys insulin-producing cells. Without insulin, sugar (glucose) cannot gain entrance to cells and it will linger and accumulate in the bloodstream. Type 1 diabetes typically is diagnosed early in life, and it makes up only a small portion of total diabetics in the U.S. Of the 30.3 million total diabetics in the U.S., only 1.25 million have Type 1.

Type 2 diabetes is quite different from Type 1. In Type 2 diabetes the pancreas gland is intact and able to produce insulin. However, the cells of the body resist the effects of insulin and it cannot do its job of escorting glucose into the cells. Therefore, glucose accumulates in the bloodstream just like in Type 1, but for a different reason.

Most Type 2 diabetics are overweight, and the excess body fat, especially around the waist, is related to insulin resistance. In the past, this usually meant that Type 2 diabetes came on in middle age from years of adding excess body fat, and thus it was called maturity-onset diabetes.
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Today, because of the increasing incidence of obesity in youngsters, Type 2 diabetes is becoming more common in children as young as 10 years of age. That's really bad news for many reasons, including the fact that diabetes combined with obesity greatly increases the risk of heart disease.

Risk of cancer

Recently, research studies report that childhood obesity not only promotes Type 2 diabetes at an early age, it also sows the seeds for increased risk of several kinds of cancer. Cancers typically found in adults over age 50 are now showing up in young adults in their twenties. For example, when it comes to breast cancer, one in ten new cases are in young adults 20 to 40, and the trend is moving downward in age.

So, how does childhood obesity increase the risk of cancer? Several ways. Obesity can over-stimulate the immune system to produce harmful byproducts that can mutate DNA. This means if you are obese at a young age, it can alter DNA in a bad way, sustaining cancer risk even when weight is lost.
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In addition to damaging the DNA of cells, there are other pathways. Obesity can upset the body's metabolism resulting in hormone imbalances that help cancer progress. Obesity may change the microbiota (bacteria in the intestinal tract), favoring species that promote tumors. And, if the esophagus is damaged by acid reflux in obese individuals, it can open the door to cancer.
Reach Bryant Stamford, a professor of kinesiology and integrative physiology at Hanover College, at stamford@hanover.edu.
This variety of pathways arising from childhood obesity suggests that if the body is able to successfully block one pathway, cancer may find an alternative way to gain a foothold. For example, multiple myeloma, a very aggressive blood cancer, is twice as likely in adults with a history of childhood obesity. And regarding colon cancer, in a research study of more than a million Israeli men, those who were overweight at ages 16-19 had a 1.5 fold increased risk of developing colon cancer by age 48.

The bottom line

Before things get too far out of hand, it's time we woke up to the threat. If you have influence over a youngster who is overweight, please don't ignore it. The old way of thinking is wrong. Assuming that the child will grow out of it is a mistake, because even if they do (which is highly unlikely), the residual effects from being overweight at a young age can destroy health later on.

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Don't call 'baby fat' cute. Childhood obesity increases your kids' risk of chronic disease

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Type 2 diabetes is becoming more common in children Obesity can help cancer progress We have long known that the American lifestyle with our high-fat and high sugar diet and sedentary existence promotes chronic diseases like heart disease, stroke, diabetes and cancer.

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The High and Rising Costs of Obesity to the US Health Care System

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The High and Rising Costs of Obesity to the US Health Care System

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The papers in this special issue examine behavioral, pharmacotherapy, and surgical interventions for weight loss, based on a 2016 conference on state-of-the-art weight management hosted by the Veterans Health Administration. The purpose of this editorial is to provide new information on the medical care costs of obesity that help motivate those interventions.

In this editorial we re-estimate our IV models of the impact of obesity on medical care costs using MEPS data for 2006-2013, that is, after adding 3 more years of data (2011-2013) and removing older years of data (2000-2005) from our sample. Table below indicates that we estimate that obesity raises the medical care costs of obese adults by an average of $3429 (in 2013 dollars); this is slightly less than the point estimate for 2010 ($3748 in 2013 dollars), but the difference is not statistically significant.

Those statistics describe the difference in average expenditures for obese and non-obese individuals, adjusted for sociodemographic factors. However, there may be interesting nonlinearities in how medical care costs vary along the range of body mass index (BMI). To explore this, we estimate an IV model in which medical care costs are regressed on BMI and BMI squared. Fig. plots predicted medical care costs over BMI for men and women in the MEPS 2006-2013 as the solid line; the dashed lines indicate the 90 percent confidence intervals. The figure shows that expenditures have a J-shape over BMI, i.e., expenditures fall with BMI through the categories of underweight (BMI ≤18.5) and healthy weight (18.5 < BMI < 25), are relatively constant with BMI in the overweight range (25 ≤ BMI < 30), and then rise slowly with BMI through the range of obese class I (30 ≤ BMI < 35) and then rise rapidly in the range of obese class II (35 ≤ BMI < 40) and especially obese class III (40 ≤ BMI).

These estimates of the medical care costs of obesity are useful for several reasons. First, they are necessary to calculate the cost-effectiveness of various anti-obesity treatments, interventions, and policies. Our causal estimates of the effect of obesity on medical care costs tend to be larger than estimates of the correlation of obesity with medical care costs that are estimated using models that do not correct for the endogeneity of weight. Cost-effectiveness studies that use estimates of the correlation of obesity with medical care costs, rather than the causal effect, may underestimate the benefits of preventing and reducing obesity, which could result in suboptimal investment in obesity prevention and treatment.

Third, this information is useful for public policy. The second set of columns in the table lists the medical care costs of obesity that are paid by third-party payers, which include health insurance companies and public health insurance. These represent "external" costs of obesity-costs paid by society as a whole, as opposed to obese individuals. According to the Table, $3210 out of the $3429, or 93.6 percent, of the increase in medical expenditures due to obesity is incurred by third-party payers and thus represents negative externalities of obesity. These external costs represent an important economic rationale for government intervention to prevent and reduce obesity.

The results we present are subject to the following caveats and limitations. As with any application of IV, one must be cautious that the instrument is valid; that is, the instrument should not affect the outcome (here, medical care costs) except through the endogenous regressor (here, BMI). In our IV model, the instrument for adult BMI is the BMI of their biological child. A potential threat to the validity of this instrument is pleiotropy: the genes that affect weight may also affect things that affect residual medical care costs; however, a study of the genes linked to obesity found that they tend to only be related to obesity-related outcomes. Still, one can never prove the null hypothesis of no correlation between the instrument and unobserved factors. A second limitation of the analysis is that the MEPS contains only self-reported and not measured weight and height, and reporting error can lead to bias in coefficient estimates.

Despite these limitations, these new, updated estimates of the medical care costs of adult obesity have important implications, for both the Veteran's Administration (VA) specifically and the health care sector more broadly. The VA manages the health care of individuals at all points in the BMI distribution; for example, for certain overweight and obese veterans it offers the MOVE! weight management program, weight loss medications, and bariatric surgery. Based on Fig. , those transiting into class II obesity (BMI ≥35) are expected to incur rapidly escalating health care costs with BMI. The VA could identify individuals approaching this threshold and prioritize them for interventions that prevent further weight gain. The expected benefits of implementing such interventions can be estimated using Fig. . The VA can compare these expected benefits to the cost of weight loss drugs to evaluate their criteria for use, and the VA could also use these estimates to determine BMI cutoffs for bariatric surgery based on its cost-effectiveness at different points in the BMI distribution.

These estimates of the medical care costs of adult obesity also have implications beyond the VA. For example, the high external costs represent an economic rationale for government intervention to prevent and reduce obesity, and Fig. , displaying estimated medical care costs by BMI, can be used by health insurers, employers, and government agencies to determine the cost-effectiveness of, and business case for, interventions that prevent and reduce obesity.

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The High and Rising Costs of Obesity to the US Health Care System

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The papers in this special issue examine behavioral, pharmacotherapy, and surgical interventions for weight loss, based on a 2016 conference on state-of-the-art weight management hosted by the Veterans Health Administration. The purpose of this editorial is to provide new information on the medical care costs of obesity that help motivate those interventions.

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Obesity in the U.S. is a deadly epidemic

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Obesity in the U.S. is a deadly epidemic

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Obesity in the U.S. is a deadly epidemic.

It causes about 300 thousand deaths each year. About 100 million adults are obese, so are twelve million children.
From 1971 to 2000 obesity rates increased from 14 to 31 percent. A grossly overweight person has a body mass index, a comparison of weight and height, of over 30 kilograms/meters squared. People with a body mass index greater than 40 are morbidly overweight.
The condition increases the risk of type 2 diabetes, hypertension, heart disease and cancer. In 2010, no state had a prevalence of obesity less than 20%. In twelve states, 30 percent or more of the population was obese.
In the United States the condition costs $150 billion per year in direct medical outlays, which is about nine percent of all medical spending.

The average adult American consumes about 657,000 calories a year, or 1,800 a day. The body, through a balancing mechanism called homeostasis, knows when it should eat and and when to stop eating.
Increased calorie int

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Obesity in the U.S. is a deadly epidemic. 100 million adults are obese

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Obesity in the U.S. is a deadly epidemic.It causes about 300 thousand deaths each year. About 100 million adults are obese, so are twelve million children.From 1971 to 2000 obesity rates increased from 14 to 31 percent. A grossly overweight person has a body mass index, a comparison of weight and height, of over 30 kilograms/meters squared.

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Targeting Obesity With Health Care Reform

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Targeting Obesity With Health Care Reform

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OP-ED

The Medicare Board of Trustees just released its latest report on the program's finances and the results are terrifying. Despite a decline in health care costs, the Medicare Trust Fund will be bankrupt in 2026.

For the program to survive for future generations, innovation will be essential. The old medical paradigm of diagnosing and treating diseases must give way to a more holistic approach aimed at eliminating risk factors that lead to disease. The best place to start is by addressing the growing problem of adult obesity.

In the past 30 years, the percentage of American adults who are obese has doubled, driving a sharp rise in such chronic conditions as diabetes, heart disease and hypertension.

The ramifications for health spending are significant. Annual health costs for obese individuals are more than $2,700 higher than for non-obese people. That adds up to about $190 billion every year. And many of these costs are borne by Medicare, which will spend a half-trillion dollars over the next decade on preventable hospital readmissions alone.

We cannot afford to wait until patients are on Medicare to fight obesity. Rather, we need to encourage weight control over the course of patients' lives.

Fortunately, we now have an ideal opportunity to implement reforms. The new health insurance exchanges created under the Affordable Care Act can establish effective care coordination strategies to identify and treat chronic conditions earlier, addressing not just the immediate conditions but the underlying ones as well. Obesity is one of the most common. Medicare, in turn, can adopt these strategies, and the benefits for both patients and taxpayers will be substantial. We may not be able to "cure" obesity, but even making small amounts of progress can yield big results. A 5%-10% loss of body weight can lower risk for heart disease and other killers. For obese patients, even a modest weight reduction can have significant health benefits. An 11-pound reduction in weight leads to a 58% decreasein the chance of developing diabetes. Even just losing two pounds reduces the risk of diabetes by 16%.

Currently, there is no obesity care coordination in Medicare services. Medicare generally covers bariatric surgery for morbidly obese patients, but the program offers little for those whose weight problem is not yet so severe. For example, it does not cover obesity medicines, despite clinical evidence that pharmaceutical treatment can result in significant weight loss.

Comprehensive care coordination must entail extending Part D coverage to include weight loss drugs. We know that these drugs are effective at helping patients shed extra pounds.

In both the health care exchanges and among Medicare recipients, we need to give physicians and patients as many tools as possible to combat obesity.

Some patients can lose weight and keep it off just by changing their diet and increasing their exercise. Others respond to a combination of pharmaceuticals and lifestyle management. Still others need surgical options to conquer obesity. Widening the range of effective treatment options could save Medicare $15 billion annually.

By 2020, half of all Americans are likely to suffer from one or more chronic diseases, a majority of them weight-related. We simply cannot "bend the cost curve" to control health care spending without addressing Americans' weight. To do that, we need all treatment options on the table.
Tommy Thompson, a former governor of Wisconsin, served as the U.S. secretary of Health and Human Services from 2001-2005. Kenneth Thorpe, Ph.D. is professor and chair at the Rollins School of Public Health at Emory University. Both serve on the Partnership to Fight Chronic Disease. This originally appeared in USA Today on June 15, 2013.

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Targeting Obesity With Health Care Reform

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By TOMMY THOMPSON & KENNETH THORPE The Medicare Board of Trustees just released its latest report on the program's finances and the results are terrifying. Despite a decline in health care costs, the Medicare Trust Fund will be bankrupt in 2026. For the program to survive for future generations, innovation will be essential.

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Mr. Downey talked about obesity, health care costs incurred as a result of high levels of obesity, and whether the federal government should spend more on... read more

Mr. Downey talked about obesity, health care costs incurred as a result of high levels of obesity, and whether the federal government should spend more on combating obesity. He also talked about an article in the journal Health Affairs titled "National Medical Spending Attributable to Overweight and Obesity: How Much, And Who's Paying?" This research was underwritten by the Centers for Disease Control. (The article can be found on the website www.healthaffairs.org.) He responded to viewer comments and questions. close

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Mr. Downey talked about obesity, health care costs incurred as a result of high levels of obesity, and whether the federal government should spend more on combating obesity. He also talked about an article in the journal [Health Affairs] titled "National Medical Spending Attributable to Overweight and Obesity: How Much, And Who's Paying?"

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Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates

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Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates

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The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists

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The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists

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Abstract

Obesity is the next major epidemiologic challenge facing today's doctors, with the annual allocation of healthcare resources for the disease and related comorbidities projected to exceed $150 billion in the United States. The incidence of obesity has risen in the United States over the past 30 years; 60% of adults are currently either obese or overweight. Obesity is associated with a higher incidence of a number of diseases, including diabetes, cardiovascular disease, and cancer. Consumption of fast food, trans fatty acids (TFAs), and fructose-combined with increasing portion sizes and decreased physical activity-has been implicated as a potential contributing factor in the obesity crisis. The use of body mass index (BMI) alone is of limited utility for predicting adverse cardiovascular outcomes, but the utility of this measure may be strengthened when combined with waist circumference and other anthropomorphic measurements. Certain public health initiatives have helped to identify and reduce some of the factors contributing to obesity. In New York City and Denmark, for example, such initiatives have succeeded in passing legislation to reduce or remove TFAs from residents' diets. The obesity epidemic will likely change practice for gastroenterologists, as shifts will be seen in the incidence of obesity-related gastrointestinal disorders, disease severity, and the nature of comorbidities. The experience gained with previous epidemiologic problems such as smoking should help involved parties to expand needed health initiatives and increase the likelihood of preventing future generations from suffering the consequences of obesity.

Keywords: Obesity, body mass index, central adiposity, exercise, health initiatives

Obesity has been defined as a body mass index (BMI) greater than 30 kg/m ², with extreme obesity defined as a BMI greater than 40 kg/m ². Obesity is rapidly becoming the leading cause of preventable death in the United States, with obesity-related deaths projected to soon surpass deaths related to tobacco abuse. The incidence of obesity has doubled in the United States since 1960, with one third of the adult population currently obese. Perhaps more alarming is the increase in overweight children; over the past 25 years, this rate has risen from 6% to 19%.

Numerous comorbid conditions have been associated with obesity, including type 2 diabetes, hypertension, hypercholesterolemia, hypertriglyceridemia, and nonalcoholic fatty liver disease. As a result of these comorbidities, the medical costs directly related to obesity are difficult to determine, but a conservative estimate would place the healthcare burden for obesity at approximately $150 billion per year in the United States. The increase in mortality among obese individuals is likely related to comorbid conditions, rather than obesity per se; because of their various obesity-associated conditions, obese patients present challenging and complex issues in medical and surgical intensive care units. In the current debate over healthcare reform in the United States, no proposed solution can reasonably ignore or minimize the role that obesity plays with regard to economic and health consequences.

This article will give an overview of the epidemiology of obesity, provide measures of defining obesity, and discuss the impact of public health and environmental factors associated with the marked increase in obesity. Potential health initiatives that might be successful in preventing obesity and its associated consequences in future generations will also be discussed. Finally, this article will address the implications that obesity has for gastroenterologists.

Obesity Epidemiology

In 2001, the US Surgeon General released a report raising concerns about the growing obesity epidemic; this report was the first to note that obesity and obesity-related diseases might soon overtake smoking as the leading cause of preventable death in the United States. The number of overweight (BMI >25 kg/m ²) and obese (BMI >30 kg/m ²) adults has increased dramatically in recent years. The rate of adults between the ages of 20 and 74 years who were classified as either obese or overweight has risen from 44.9% in 1960-1962 to 66.2% in 2003-2004, with similar trends for both men and women. The rate of individuals who were overweight but not obese ranged between 31.5% and 33.4% over the same time period. The major shift in the prevalence of obesity occurred between 1980 and 2004, effectively doubling in just 25 years (from 15.0% in 1980 to 32.9% in 2004). The number of people who were classified as extremely obese (BMI >40 kg/m ²) increased from 0.9% in 1960 to 5.1% in 2004.

More concerning than the rise in obesity among adults is the increased prevalence of obesity among chil-dren. In the United States, the prevalence of obesity in children has tripled in just 30 years; not surprisingly, rates of dyslipidemia and type 2 diabetes among children have shown a corresponding increase over the same time period. In children, obesity is defined based on growth charts from the Centers for Disease Control and Prevention. For children aged 19 years or younger, obesity is defined as a weight at or above the 95th percentile for age; overweight children are those whose weight is between the 85th and 95th percentiles for age. In 1974, 5.1% of children were considered obese and 10.4% were considered overweight by these definitions. In 2008, 14.6% of children were considered obese.

The prevalence of obesity shows striking disparities with regard to race and ethnicity in both adults and children. Between 1999 and 2004, the prevalence of obesity in non-Hispanic white adult women was 30.5%, compared to 39.8% in Mexican American women and 50.6% in non-Hispanic African American women. Obesity rates in adult men showed no significant differences between ethnic groups. The distribution of obesity among children aged 2-19 years with regard to race showed trends similar to those seen in adults. The prevalence of obesity was lower among non-Hispanic white children (13.9%) compared to non-Hispanic African American children (18.8%) and Mexican American children (19.7%). When gender and race were considered, significantly higher rates of obesity were seen in Mexican American boys (22.7%) than in non-Hispanic white boys (14.8%) or non-Hispanic African American boys (16.1%). Non-Hispanic African American girls had significantly higher rates of obesity (21.6%) than non-Hispanic white girls (13.0%).

While obesity is clearly a major public health issue in the United States, the increased prevalence of obesity is not limited to this country; indeed, obesity is now a global epidemic. Over the past 10 years, the World Health Organization (WHO) has recognized the increasing number of people who are overweight or obese, and attention is now being given to the global implications associated with this trend. In an analysis of the leading causes of global mortality and burden of disease, obesity and being overweight were among the top 10 causes for each. The presence of a worldwide epidemic is suggested by the fact that in various regions of the world-North America, Central America, South America, most of Western Europe, the Middle East, and Eastern Europe-the majority of countries report that at least 40% of their population between the ages of 45 and 59 years are overweight or obese. East Asian countries such as China, Japan, Vietnam, and India report lower rates of obesity, but the use of BMI alone may be problematic due to cultural and ethnic variability in adipose proportion and distribution. In the latter geographic areas, rates of diabetes and cardiovascular disease (CVD) are increased at BMIs below the WHO cutoff for being overweight (25 kg/m ²), a phenomenon most likely linked to proportionate increases in body fat in these populations.

Body Mass Index as an Estimate of Obesity and Mortality

Using BMI alone to define obesity has been problematic in some settings, given differences in genetics, fat distribution, and percentage of body adiposity among various countries. Because Asian populations have a higher proportion of body fat, for example, lower BMIs have been proposed to identify individuals in these populations who are overweight or obese. A cross-sectional study looking at 3 different ethnic groups in Singapore (Chinese, Malays, and Indians) demonstrated the limitations of using BMI alone to estimate body fat percentage. Compared to white subjects, BMI underestimated body fat percentage in Chinese, Malay, and Indian subjects, with the error ranging from 2.7% to 5.6%. Furthermore, Asians had a higher risk of developing diabetes and CVD and had increased mortality at normal BMIs compared to other ethnic groups.

Further problems occur when epidemiologic studies use self-reported data to calculate BMI. Many of the larger international studies used to estimate the number of overweight and obese individuals in foreign countries have used surveys involving self-reported heights and weights. However, the use of self-reported data often results in inaccurate estimations of weight and height and, subsequently, inaccurate BMI values. A study of 16,000 individuals examined the validity of self-reported data for BMI calculation. In this study, subjects were asked to report their weight and height, after which these estimates were compared to measured values. On average, BMIs in older individuals were 1 unit lower when calculated using self-reported values compared to BMIs calculated using measured values. Furthermore, this self-reporting bias worsened as true BMI values increased. In a subsequent study of 6,000 individuals in the National Health and Nutrition Examination Epidemiological Study (NHANES), researchers found that every 1-unit increase in BMI correlated with a 2-lb underestimation of weight. When gender was considered, men were found to overestimate their weight by 5.0 lbs, and women underestimated their weight by 1.8 lbs, on average. In an earlier French study of 7,250 individuals, values for both self-reported weight and height were inaccurate. Weight was significantly underestimated (by a mean of 0.54 kg among men and 0.85 kg among women). In contrast, height was significantly overestimated (by a mean of 0.54 cm among men and 0.40 cm among women). This combination of errors led to an underestimation of BMI- by 0.29 kg/m ² in men and 0.44 kg/m ² in women-and an underestimation of the rate of individuals who were overweight, by 13% in men and 17% in women.

Large cohort studies have shown that elevated BMI has been associated with an increased risk of future cardiovascular events. In the largest of these studies, over 1 million adults were prospectively followed for 14 years, and the cause of mortality was evaluated. When other risk factors such as smoking were removed from the analysis, higher BMIs were associated with an increased risk of mor-tality. Among white men and women with a BMI above 40 kg/m ², the relative risk (RR) for mortality was 2.58 and 2.0, respectively, compared to individuals with a BMI in the normal range (22.9-24.9 kg/m ²). In a similar group of African American subjects with BMIs above 40 kg/m ², no increase in mortality was seen compared to normal-weight controls. When death from cardiovascular causes was evaluated, men with BMIs greater than 40 kg/m ² had an increased risk of mortality compared to their lean counterparts (RR=2.90; 95% confidence interval [CI] 2.37-3.56).

In a subsequent large prospective cohort study of 527,265 US men and women between the ages of 50 and 71 years, researchers evaluated the association between BMI and death from any cause over a 10-year period (1996-2005). Obesity was associated with an increase in mortality across all races and both genders. When individuals without preexisting cardiovascular conditions (including smoking) were isolated, overweight individuals still showed an increase in mortality. In a subcohort analysis of 50-year-old individuals who had never smoked, those who were morbidly obese (BMI >40 kg/m ²) had an increased risk of mortality (RR=3.82; 95% CI 2.87-5.08) compared to individuals with a BMI in the normal range (23-24.9 kg/m ²). While BMI is thus a useful predictor in some settings, how BMI compares to other anthropo-metric measurements in terms of accurately determining obesity, associated comorbid diseases, and respective mortality has been a topic of recent debate.

Central Adiposity

While the WHO still uses BMI to identify individuals who are overweight or obese, mounting evidence suggests that a pattern of central adiposity is more accurate in predicting obesity-related cardiovascular consequences. In a large case-control study of 27,000 people in 52 countries, the correlation between myocardial infarction (MI) and either waist-to-hip ratio (WHR) or BMI was evaluated. WHR, waist circumference (WC), and hip circumference were individually associated with an increased risk of subsequent MI independent of other risk factors, including BMI. When other cardiovascular risk factors and WHR were taken into account, there was no significant association between MI and BMI (odds ratio 0.98; 95% CI 0.88-1.09). The attributable risk for MI in the top 2 quintiles for WHR was 24.3% (95% CI 22.5-26.2%), compared to 7.7% in similar quintiles for BMI (95% CI 6.0-10%).

A recent cohort study examined the possibility of using WC, WHR, and BMI in conjunction with Framing-ham risk scores to predict coronary heart disease (CHD) and CVD mortality. A total of 4,175 Australian men who were free of CVD, CHD, diabetes, and stroke at baseline were followed for 15 years. Baseline Framingham risk scores were calculated, and WC, WHR, and BMI measurements were taken. Initial Framingham scores were strong predictors of CVD and CHD deaths 15 years later. WHR was found to be an independent predictor of CVD and CHD deaths, and WC predicted CVD deaths. BMI did not predict mortality due to either CVD or CHD.

Two different meta-analyses evaluated measures of abdominal adiposity and their relationship to cardiac events, as well as their ability to predict the development of associated cardiac risk factors. In the first of these meta-analyses, BMI was compared to measures of central adiposity-including WHR, WC, and waist-to-height ratio (WHtR)-to determine the best predictor for development of hypertension, type 2 diabetes, and hyperlip-idemia. A total of 10 studies met the inclusion criteria, and a total of 88,514 adult subjects (54% female) in 9 countries were included in the meta-analysis. WHtR was found to be the best discriminator for development of all 3 cardiovascular risk factors, while BMI was the worst. The majority of the patients included in this study were from Asia and the Middle East.

The second meta-analysis, which examined the association between WC or WHR and the incidence of CVD, included 258,114 patients from 15 randomized controlled trials (RCTs) or prospective cohort studies. For every 1-cm increase in WC, the RR of a cardiovascular event increased by 2% (95% CI 1-3%). WHR and WC were both associated with an increased risk of future cardiovascular events (WHR RR=1.95, 95% CI 1.55-2.44; WC RR=1.63, 95% CI 1.31-2.04).

In comparing these different measures of central adiposity, it is important to note that technical limitations can make it difficult to measure WHtR consistently. Although visceral adipose stores can be directly measured by computerized axial tomography, magnetic resonance imaging, or dual energy x-ray absorptiometry, the high cost of these tests limits their applicability in large epidemiologic studies. In contrast, WC and WHR can be measured easily in the clinical setting and are not limited by cost or technical issues.

Health Burden and Obesity-associated Diseases

Several studies have shown a relationship between elevated BMI and chronic medical conditions such as diabetes mellitus, hypertension, hyperlipidemia, and obesity-related cancers. Epidemiologic studies have also shown an association between adult obesity and premature death from all-cause mortality. One study found that obesity was associated with a 7-year decrease in life expectancy for women and a 6-year decrease for men, which is similar to findings from past studies on smoking. Furthermore, pediatric obesity is associated with many of the same cardiovascular risk factors as adult obesity, including hypertension, diabetes, metabolic syndrome, and hyperlipidemia.

Conversely, other studies have shown reduced mortality due to cardiovascular causes in obese patients compared to lean controls. These latter studies appear to reflect an increase in the diagnosis and early treatment of cardiovascular risk factors in this high-risk group more so than a decreased incidence of obesity-related comorbid conditions such as diabetes, hypertension, and hyperlipidemia. These clinically significant outcomes are not restricted to medical fields, but also complicate surgical outcomes. Postoperative complications occur more frequently in obese patients than lean controls, with an increased incidence of MI, peripheral nerve injury, wound infection, and cardiac arrest.

In addition to the potential impact on mortality, the overall morbidity seen in this growing patient population remains a key issue contributing to decreased quality of life in overweight and obese individuals. Impairment in activities of daily living-such as eating, dressing, and transferring to and from a bed or wheelchair-occur at a younger age in obese patients compared to nonobese controls. If overall mortality decreases but the diagnosis and treatment of obesity-related conditions continue to increase, the cost of managing the obese patient population could be overwhelming.

While the hazards of obesity have long been known, the benefits of weight loss and exercise have only recently become more apparent. One study investigated 3,234 nondiabetic patients with elevated fasting glucose levels and randomly assigned them to treatment with placebo, metformin, or lifestyle modification (including weight loss and exercise). Metformin reduced the likelihood of developing diabetes by 31%, whereas lifestyle modification reduced the chance of developing diabetes by 58% (with weight loss >7%). A subsequent meta-analysis examining the effect of weight loss on blood pressure showed that for every 1 kg of weight lost, blood pressure dropped by 1.1 mmHg systolic/0.9 mmHg diastolic. Additional meta-analyses have also demonstrated improvements in cardiovascular risk factors related to weight loss. Loss of only 1 kg was shown to be associated with improvement in serum cholesterol (-1.0%), low-density lipoprotein cholesterol (-0.68%), triglycer-ides (-1.9%), and high-density lipoprotein cholesterol (+0.2%). Furthermore, loss of 5 kg was associated with a decrease in fasting plasma glucose levels of 18 mg/dL, an improvement similar to that achieved from treatment with current oral hypoglycemic agents.

Fast Food and Trans Fat

The parallel between the national and international expansion of fast food companies over the past 50 years and the growth of the obesity epidemic is no coincidence. The United States now has approximately 250,000 fast food restaurants, and total fast food consumption has risen from 2% to 10% of total energy intake per person over a 20-year period. Surveys have revealed that the top 3 reasons US consumers choose fast food over healthier alternatives are: fast food is quick (92% of respondents), restaurants are easy to visit (80%), and the food tastes good (69%). There remains debate about the degree to which fast food companies, with their provision of high trans-fat foods, are responsible for the obesity epidemic. In a large, multicenter, prospective cohort study, 3,031 adults between the ages of 18 and 30 years were followed for 15 years to evaluate their fast food habits, development of insulin resistance, and changes in body weight. Participants were drawn from 4 major US cities, included an equal number of African Americans and whites, and had variable levels of education. This study found a strong positive correlation between visits to fast food restaurants and weight gain with development of insulin resistance. The average frequency of fast food intake was 1.3 times per week among white women and 2.0 times per week among other ethnic/gender groups. Higher baseline consumption of fast food was associated with increased weight gain after 15 years. Increased fast food consumption was also associated with significantly increased insulin resistance in all ethnic/gender groups. Other cross-sectional studies have shown similar associations between fast food intake and increased body weight.

The specific aspect of fast food consumption that contributes most to obesity and insulin resistance is currently the subject of much debate. One possibility is that the high caloric density of fast food is the sole culprit, but there may also be a specific component in fast food that contributes to the increased risk for obesity and diabetes. Fast food is indeed characterized by a high caloric density (energy content/food weight ratio), and the total caloric content of a typical fast food meal exceeds that of the average meal by 65%. In addition to high caloric density, fast food has historically had higher amounts of industrially produced trans fatty acids (TFAs). Compared to other fats, TFAs have higher melting points, better taste, and longer shelf lives. The lower rates of CVD in countries such as France, where use of TFAs is limited but total fat consumption remains high, has led to observational studies evaluating the link between TFAs and heart disease. In the United States, an average daily intake of 5 g of TFAs has been estimated to increase an individual's risk of heart disease by 25%. The Nurses Health Study found that intake of TFAs was directly related to risk of CHD, and a subsequent observational study of 21,930 Finnish men who were followed for 6 years found a positive correlation between TFA intake and risk of death from CHD. Individuals in the top quintile of TFA intake (6.2 g/day) had a multivariate RR of 1.39 (95% CI 1.09-1.78) for death from CHD, compared to those in the lowest quintile of TFA intake (1.3 g/day).

The Expert Committee of the American Medical Association recently concluded that there is strong evidence that eating away from home, specifically consumption of fast food, is a risk factor for childhood obesity. Fast food children's meals were first introduced in the late 1970s and have been very popular with toddlers and adolescents. In terms of nutrient composition, fast food children's meals are high in total fat and TFAs, have high caloric density, and offer very little nutritional value. A recent study examined the nutrient quality of fast food meals marketed to young children. Criteria from the National School Lunch Program (NSLP) were used to analyze these meals in terms of their percentage of energy from fat and carbohydrates, overall energy density, and vitamin composition. Only 3% of the fast food children's meals met the NSLP criteria for healthy meals; those meals were offered with milk and fruit, and the majority were deli sandwich-based meals. Children's meals are often offered with toys, which promotes brand recognition and repeated visits to the restaurant. Given the nutritional composition of children's fast food meals, it is not surprising that obese and overweight children consume more meals away from home than normal-weight children.

In addition to children's fast food meals and the early brand recognition they build, children are bombarded with television advertising from fast food companies. Branding involves developing recognition and positive associations with a product. Studies have found that children aged 3-6 years view, understand, and remember advertising when cartoon characters are used. One study examined the content of advertising contained in children's television programs on 3 popular networks (Public Broadcasting Service, Disney, and Nickelodeon) using randomly selected 4-hour blocks from 9 am to 1 pm. In 96 half-hour blocks, there were 130 food-related advertisements (1.4 per half hour). Half of these advertisements were specifically aimed at children, with most from fast food companies. The fast food advertisements seemed to focus on building brand recognition and positive associations through the use of logos and cartoon characters.

In addition to fast food advertising directed at children, some evidence suggests that a disproportionate number of fast food restaurants are located in close proximity to schools. Using the California Healthy Kids Survey of over 500,000 children, data were analyzed for specific questions about high-risk behaviors such as fast food consumption and proximity of fast food restaurants to home. The primary outcome in this study was BMI. Students with fast food restaurants within 0.5 miles of their home were more likely to be overweight or obese. These children also consumed more soda and ate less fruits and vegetables. Other studies have shown similar findings, demonstrating a link between increased rates of obesity in urban areas with a predominately poor, African American population and a high density of fast food restaurants, versus lower rates of obesity in white neighborhoods with large chain grocery stores.

Portion Distortion, Soft Drinks, and Fructose

The high caloric density and trans-fat content of fast food are only some of the factors contributing to the obesity epidemic. In the past 30 years, the portion sizes of many foods have increased, leading to increased energy intake. Fast food companies have increased portion sizes 2- to 5-fold since the items were originally introduced over 50 years ago. In response to the 2004 documentary Super Size Me, McDonald's announced plans to phase out their "Super Size" items. Despite this action, items on McDonald's current menu still dwarf the portion sizes introduced in 1955. These items include French fries (increased by 250%), soda (increased by 457%), and hamburgers (precooked weight increased by 500%). Despite dropping the "Super Size" name, a large order of French fries in 2006 (6.0 oz) was only slightly smaller than the "Super Size" French fries served in 1998 (6.3 oz). Wendy's followed suit and dropped the "Biggie" label from its largest-portioned items, but this change was only in name. The "Great Biggie" French fries served in 2002 (6.7 oz) became large French fries in 2006 (6.7 oz), and the 2002 "Biggie Soda" (32 oz) increased in size to become the 2006 large soda (42 oz). The largest increase in portion sizes has come with the ever expanding size of hamburger options. In 2003, Hardee's introduced the "Monster Thickburger," with 1,420 calories, and Burger King's "Angry Triple Whopper" is the highest-calorie item on the restaurant's menu, with 1,360 calories.

Consumption of soft drinks has been linked with metabolic syndrome and cardiovascular risk based on the Framingham study. The number of calories consumed in sodas and fruit juices has increased significantly over the past 30 years. The largest study to show this trend examined beverage consumption in the United States among 73,335 individuals over the age of 2 years. Overall energy intake from sweetened beverages increased by 135% from 1977 until 2001, increasing average daily caloric intake by 278 calories. During the same time period, milk consumption decreased by 38%. These trends coincided with the expansion of the obesity epidemic. Prospective studies have linked increased intake of sweetened beverages directly with increased weight gain. The first of these studies enrolled 548 ethnically diverse students (average age of 11.7 years) from public schools in 4 Massachusetts communities and followed their consumption of sugar-sweetened beverages over 19 months. For each additional serving of sweetened beverage consumed on a daily basis, BMI and the incidence of obesity were significantly increased. A second prospective study examined the effect of sucrose and artificial sweeteners on weight gain in a population of overweight adults. Subjects were randomized to receive sucrose supplements (152 g sucrose/day) or artificial sweeteners (0 g sucrose/day) for 10 weeks. The change in weight differed significantly between groups, with the sucrose-supplement group gaining a mean of 1.6 kg, while the artificial-sweetener group lost a mean of 1.0 kg. A recent systematic review of prospective studies reached similar conclusions, finding that increased sugar-sweetened beverage consumption was associated with weight gain and obesity and proposing that strategies to reduce consumption of these beverages would likely help reverse the obesity epidemic.

The consumption of high fructose corn syrup (HFCS) has also been evaluated as a possible independent risk factor for the development of obesity. Fructose typically comes from 3 main sources: sucrose, HFCS, and fruit. The amount of fructose in fruit, which is relatively small compared to that in soft drinks, seems to serve the function of enticing individuals to consume other nutrients. In contrast, the HFCS added to soft drinks contains much higher concentrations of fructose and has no other nutritional benefits. Beyond adding excess calories to an individual's diet, fructose has also been linked to central adiposity, gout, and hyperlipidemia. In 1 study, high fructose intake for 6 weeks was found to increase postprandial serum triglycerides by 32% compared to a similar diet of isocaloric high glucose intake. These findings have been confirmed by other studies.

The amount of fructose consumed in the United States has increased over the past 30 years. An analysis of the NHANES database showed that in 1977 the average estimated daily intake of fructose was 37 g/day (8% of total daily calories). Approximately 15 years later, the average daily intake of fructose had increased to 54.7 g/day (10.4% of total daily calories). Not surprisingly, adolescents have the highest daily consumption of fructose (72.8 g/day; 12.1% of total daily calories), and 25% of adolescents receive more than 15% of their total daily calories from fructose. The correlation between obesity and soft drink consumption alone warrants limiting the amount of HFCS in an individual's diet.

Physical Inactivity

Physical activity (PA) has been suggested as an essential requirement for decreasing the incidence of obesity and reducing the number of overweight individuals. Certainly, PA in any form helps to tip the balance of energy consumption versus energy expenditure in a favorable direction. A study using the NHANES database found that adults who reported low levels of PA were more likely to have gained significant weight over the previous 10-year period. Self-reported levels of PA (low, medium, or high) were compared to change in weight after 10 years. Individuals who reported low PA at the follow-up visit were more likely to have experienced major weight gain (greater than 13 kg). The study found no significant correlation between baseline PA and subsequent weight gain. Looking at this relationship prospectively, another study measured 24-hour energy expenditure and future weight gain in 95 people. Individuals with low 24-hour energy expenditure (200 kcal below predicted values) were 4 times more likely to gain at least 7.5 kg over a 2-year period compared to individuals with high 24-hour energy expenditure (200 kcal above predicted values).

The role that PA has played in the rise in adolescent obesity over the past 20 years has been the subject of considerable debate. A recent analysis of PA showed no clear decline in PA among adolescents over the past 20 years. This analysis examined 7 large studies from the Youth Risk Behavior Surveillance Surveys from 1991 to 2007. Vigorous PA was defined as any activity that caused increased sweating and a sensation of breathing hard for more than 20 minutes during 3 of the previous 7 days. The amount of vigorous PA reported by adolescents did not differ significantly between 1993 (65.8%) and 2005 (64.1%). Furthermore, the adolescent attendance rate for physical education class and the amount of exercising for over 20 minutes during class has significantly increased in recent years, and the amount of television viewing has significantly decreased. These data call into question the role that PA has played in the increase in obesity among adolescents.

One of the factors thought to be responsible for decreased PA is the increase in time spent watching television. A recent study examined the role of increased television viewing on all-cause and cardiovascular mortality. A total of 8,800 adults followed for a median of 6.6 years were evaluated for numerous cardiovascular risk factors. This study found a significant positive linear relationship with both BMI and WC as hours of television increased, when adjusted for age and sex. Even after adjusting for age, sex, WC, and exercise, an increase in television viewing was still associated with a significant increase in all-cause and cardiovascular mortality.

Probably the most important role for exercise and increased PA in individuals with obesity is the prevention of recidivism after successful weight loss from dieting and the maintenance of lean body mass as body fat mass is reduced. A meta-analysis examined the effect of exercise, exercise plus diet, and diet alone on weight gain. Over the course of 15 weeks, weight loss in the exercise-only group was 2.9±0.4 kg, compared to 10.7±0.5 kg in the diet-only group. The weight loss that occurred by combining diet with exercise was not significantly different from that seen with diet alone. At the 1-year follow-up visit, however, the diet-plus-exercise group had maintained the weight loss better than the diet-only group (mean 8.6±0.8 kg total weight lost compared to 6.6±0.5 kg, respectively). Other studies have confirmed that exercise alone usually incurs only a small amount of weight loss and that the more important role of exercise is maintaining weight loss after a successful diet program.

Health Initiatives to Prevent Obesity

Obesity is the next major epidemiologic battle for physicians, public health experts, government officials, and the general population. By many estimates, obesity has already surpassed smoking as the most pressing public health threat. In much the same way that antismoking campaigns were developed, health initiatives must now be developed to effectively prevent obesity and its associated diseases. While smoking and obesity share many similarities from a public health perspective, obesity is potentially more problematic since adequate nutrition is essential to survival; therefore, abstinence from food is not an option. Also, what constitutes good nutrition as opposed to harmful food choices is often not clearly understood by the general public. As changes to the healthcare system in the United States are discussed, plans should be offered that directly and aggressively target obesity through health initiatives and prevention programs.

Food Labeling

Labeling the nutritional content of food products and fast food has been proposed as a way to allow consumers to make informed choices about the types of foods they consume. Beginning in the 1960s, the government required tobacco products to have labels from the US Surgeon General stating that smoking may be hazardous to one's health. These labeling requirements have since progressed to more specific statements, ie, that smoking causes lung cancer and emphysema and that quitting smoking may reduce the risk for serious health concerns. The problem with these labels is that they appear in small print and people often do not read them. Indeed, there are little data to suggest that this labeling has been effective in preventing smoking. Ironically, these labels have been used by tobacco manufacturers in litigation against patients with smoking-related diseases to claim that patients were properly warned about the dangers of smoking.

In a similar fashion, little data exist to show that labeling food products has improved eating habits. In a recent RCT from Germany, a variety of food labeling strategies were compared, including no labeling, food labels with daily recommended levels for specific nutrients, labels with healthy choice designations, and traffic light labels indicating the level of healthiness. No significant differences were found in consumption habits between the different labeling strategies. In a study evaluating a similar "stop light" labeling technique, adolescents at 3 different high school cafeterias were found to purchase more items deemed to be high calorie (red) compared to lower calorie options (green and yellow), despite being given a higher percentage of healthier options.

One of the main problems with the current strategy for labeling nutritional content is that this information is very difficult for consumers to comprehend. Most consumers are unaware of the dietary content of restaurant foods. A recent RCT was conducted to evaluate whether providing calorie information influenced the types of foods purchased at fast food restaurants. After randomization, half of the 594 participants were provided with menus containing calorie information, while the other half were given menus without this information. The number of calories consumed was not statistically different between the 2 groups. However, some data suggest that providing calorie information does influence consumption patterns, at least for females.

The Nutrition and Education Labeling Act of 1994 specifically exempted restaurants from providing nutritional labeling of their products. Recently, however, New York City mandated that fast food companies provide nutritional labeling for all of their products. Initial data suggested that 1,156 customers had perceived a change in consumption because of the labeling, but comparison to a similar population in New Jersey (where labeling is not mandated) showed that there was no difference in actual calories consumed. Nonetheless, having nutritional labeling on restaurant food should lead to more informed decisions about consumption. Overall, there may be a role for nutritional labeling, but use of this technique without other strategies or regulation of nutritional content should not be expected to significantly alter eating habits or prevent obesity-related consequences.

Eliminating Trans Fat in New York City, Denmark, and Beyond

The average daily per capita intake of TFAs in the United States has been shown to increase heart disease risk by 25%, and most leading health organizations have advocated the complete removal of TFAs from foods. To achieve this objective, however, consumers would need to read labels and become educated about the TFA content of food, and healthcare providers would need to provide counsel on TFA-free options. In 2003, the US Food and Drug Administration required all packaged goods to reveal the amount of TFA if it exceeded 0.5 g. However, the food industry has circumvented these labeling requirements. For example, fast food companies have reduced serving sizes to keep the amount of TFA below 0.5 g, allowing them to continue using TFA without having to report it on labels. Furthermore, restaurants are not required to report the amount of TFA in the food they serve. In addition to such roadblocks, educating patients about healthy food options is often frustrating and time-consuming for healthcare providers. Therefore, the best option is to eliminate the use of industrially produced TFAs and shift toward the use of safer fats in both packaged goods and restaurant food.

In 2006, the New York City Department of Health and Mental Hygiene put forth a bold proposal to eliminate all artificial TFAs from restaurant food. The response from the restaurant and food industry was not surprising, with critics calling the ban a threat to the flavor of food and saying that the increased cost of converting to TFA-free food would be an economic burden. The first phase of the ban involved restricting TFAs in cooking oils and spreads only, as this goal was more easily obtainable than the complete elimination of TFAs. By the summer of 2008, 99% of restaurants had successfully changed to oils and spreads low in TFAs. The second phase of the ban involved the complete elimination of artificial TFAs from other foods and ingredients. Approximately 6 months after the second phase was initiated, the use of artificial TFAs had been reduced from 50% to 1.6%. By using healthier replacement oils, the amount of saturated fats was also reduced. Outcome data regarding the impact of this measure will not be available for several years, but previous studies suggest that the elimination of TFAs should reduce the risk of heart disease and hyperlipidemia among residents of New York City.

Denmark has been monitoring artificial TFAs in the diets of its residents for over 30 years. Authorities there determined that labeling was not an effective way to reduce the consumption of foods high in TFAs, such as fast food (especially children's meals), and in March 2003, Denmark became the first country to restrict the use of TFAs in food products. The consumption of food potentially high in TFAs was analyzed before and after this ban, and researchers found that the amount of TFA in the same representative food (such as a large order of French fries and chicken nuggets) was reduced from 30 g to less than 1 g. Over the same period, the same meal in countries without a ban (such as Hungary, Poland, and the United States) still contained 36-42 g of TFAs.

As a result of the successful efforts in New York City and Denmark, legislation to ban artificial TFAs from restaurants has been passed by 1 state legislature, 10 local city governments, and Puerto Rico, and 17 more states are considering similar legislation. While these programs are encouraging, a complete ban on TFAs in all states may be necessary to optimize the health of the US population.

Taxation of High Calorie Beverages

Large portion sizes and increased consumption of soft drinks and fruit juices are partially responsible for the obesity epidemic. These beverages are prevalent in schools, which may place children at an increased risk of diabetes. The current debate is how to limit the consumption of these beverages in the US school system. Two ideas that have been proposed are to increase taxation on high calorie beverages and to restrict their availability in vending machines in schools. While the volume of soft drinks consumed by adolescents that comes from vending machines in schools is much smaller than the volume purchased in commercial stores or restaurants, much of the legislative effort has focused only on restricting vending machine sales.

The current level of taxation on high calorie beverages is probably insufficient to decrease consumption. A recent study used multivariate linear regression analysis to determine how state taxes on soft drinks affect adolescent obesity. Self-reported BMI data were obtained from students in the 8th, 10th, and 12th grades between 1996 and 2007. The BMI data were compared to differences in taxation for vending machine products from various states. No significant correlation was found between the rate of adolescent obesity and the level of taxation in the various states involved in the study. The most obvious explanation for this finding was that these taxes were all very small and thus were unlikely to have an effect on consumption or long-term consequences such as weight gain. The average state tax on a $1.00 bottle of soda sold in a store is approximately $0.04.

Newly proposed legislative strategies have suggested raising the tax on nondiet soda, fruit drinks, and flavored milk. The governor of New York recently included an 18% tax on nondiet sodas in his proposed budget. Others have suggested placing a per-ounce excise tax of $0.01 on non-diet sodas. Such a strategy would add a tax of $0.20 to a 20-oz bottle of soda (normally sold for approximately $1.00), thus increasing the total cost by 20%. When offered options of diet sodas or other healthier beverages costing 20% less than the nondiet beverages, consumers may be more likely to choose the lower calorie alternatives. Such behavior has been seen when tobacco products have been taxed at higher rates. Adolescents aged 12-18 years in states with a cigarette tax in the highest quartile ($0.60-$1.00 per pack) were less likely to experiment with tobacco and become established smokers than adolescents in states with a tax in the lowest quartile.

Implications for Gastroenterologists

In addition to the many consequences already mentioned, the growing obesity epidemic is also expected to impact the morbidity and mortality associated with certain gastroen-terologic disease processes, the performance of endoscopic procedures, and the complexity of patient management. When evaluating patients in a clinic setting, therefore, gastroenterologists should calculate BMIs and determine whether patients are overweight or obese, as well as determine their WCs and make a determination regarding central versus peripheral adiposity. Determining the degree of obesity (normal weight, overweight, obese, and so on) and the distribution of adiposity will help to identify patients at increased risk for complications from certain gastrointestinal disorders.

The incidence of cholecystitis and choledocho-lithiasis will likely increase as the obesity epidemic continues to affect more individuals. A recent prospective observational study found that obese patients with acute cholecystitis were more likely to be admitted to the hospital and spent more days in the hospital than nonobese patients. The incidence of gastroesophageal reflux disease (GERD) is also increased in overweight and obese individuals. Increased WC (>80 cm), but not greater BMI, has been shown to correlate with an increased incidence of Barrett esophagus. Obesity alone is associated with increased severity in acute pancreatitis. Similar to the data for GERD, umbilical WC was shown to be better than BMI for predicting the development of severe acute pancreatitis in obese patients. Additionally, central adiposity is a driving factor in nonalcoholic steatohepatitis (NASH). Increases in the incidence of NASH and cirrhosis will likely occur as a result of this obesity epidemic. Eventually, NASH cirrhosis may become the most common indication for liver transplantation.

Obesity increases morbidity for critically ill patients compared to their lean counterparts. In trauma patients in a surgical intensive care unit, obesity may also increase mortality. Potentially, the observed increase in mortality among obese trauma patients could be explained by obesity-associated decreases in hepatic blood flow. In these critically ill obese patients, gastroenter-ologists may increasingly be called upon to achieve enteral access and manage enteral feeding. Optimal nutritional therapy in this situation is controversial and involves high protein, hypocaloric "permissive" underfeeding. In the near future, nutritional formulas may involve phar-maconutrition with specific formulas for obese patients that are designed to reduce oxidative stress, remove fat from the liver, and promote microvascular perfusion.

Gastroenterologists will also increasingly be called upon to manage complications in patients who have undergone bariatric surgery. The anatomic alterations from these surgical procedures can result in myriad micronutrient deficiencies that require the skills of a clinical nutritionist for long-term management. Severe nutritional deficits can be avoided with aggressive supplementation following bariatric surgery. Endoscopy is often required in the evaluation of such patients when nausea, vomiting, gastrointestinal bleeding, or anastomotic ulceration complicates the postoperative course. Obesity may increase the complexity of such endoscopic procedures. Obese patients are also at risk for restrictive lung disease as well as central or obstructive sleep apnea. Thus, clinicians may have greater difficulty when performing conscious sedation, as obese patients may have a greater likelihood for oxygen desaturation. As a result, a larger number of endoscopic procedures may need to be performed under medical anesthesia care.

Finally, endoscopic therapies to promote weight loss in obese patients are already on the horizon. Gastric inflat-able balloons, one of the earliest endoluminal concepts to treat obesity by promoting early satiety, are being reevalu-ated as a weight loss technique and potential bridge to later bariatric surgery. Two new strategies to achieve gastric restriction using endoscopic suturing or stapling devices are also being investigated. Endoluminal vertical gastroplasty utilizes the EndoCinch Suturing System (C. R. Bard), which was previously used for the treatment of GERD, to apply a running suture line from the fundus to the antrum, effectively reducing gastric luminal capacity. Similarly, transoral gastroplasty utilizes an endoluminal stapling device to achieve a full-thickness tissue plication and pleating of the gastric folds from opposing stomach walls to create a similar restriction of the gastric lumen. Finally, the duodenojejunal bypass sleeve is a temporary, removable stenting device that is anchored in the duodenal bulb and extends beyond the ligament of Treitz; this sleeve is designed to promote a variable degree of malabsorption.

Conclusion

Obesity is the next major public health challenge facing the United States. Currently, over 60% of the US population is overweight or obese. The health consequences of obesity include increased rates of diabetes, hyperlipidemia, heart disease, and cancer. BMI is a useful epidemiologic tool that can approximate body adiposity for large groups of people, but clinicians may need to combine BMI with WC in the office setting in order to more accurately identify patients at risk for CVD. Currently, health initiatives to address obesity need to be developed and promoted. Based on previous experience with the smoking epidemic, allowing the food industry to control the rate and direction of such measures will result in inadequate or suboptimal programs. Instead, artificial TFAs should be completely banned, as was done in Denmark and New York City, and the number of high calorie beverages consumed on a daily basis should be limited; increased taxation and restricted access to vending machines in schools may help decrease the number of calories consumed from soda and other high calorie beverages. Finally, a renewed emphasis on PA in the school curriculum may help to prevent children from becoming overweight or obese. The obesity epidemic will undoubtedly affect gastroenterologists, whether through obesity-related gastrointestinal disorders, the emerging need for endoscopic therapies to treat obesity, or the greater complexity of patient management in this population. The obesity epidemic must be fought using a wide range of strategies, as initiatives that address only certain portions of the problem at any given time have been shown to be ineffective.

Contributor Information

Ryan T. Hurt, Dr. Hurt serves as an Assistant Professor of Medicine in the Division of General Internal Medicine at the Mayo Clinic in Rochester, Minnesota, and as Assistant Clinical Professor in the Department of Medicine at the University of Louisville School of Medicine in Louisville, Kentucky.

Christopher Kulisek, Dr. Kulisek is a Gastroenterology Fellow in the Department of Medicine at the University of Louisville School of Medicine in Louisville, Kentucky.

Laura A. Buchanan, Dr. Buchanan serves as a Resident in the Department of Medicine at the University of Louisville School of Medicine in Louisville, Kentucky.

Stephen A. McClave, Dr. McClave is a Professor of Medicine in the Division of Gastroenterology, Hepatology, and Nutrition at the University of Louisville School of Medicine in Louisville, Kentucky.

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The Obesity Epidemic: Challenges, Health Initiatives, and Implications for Gastroenterologists

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Obesity is the next major epidemiologic challenge facing today's doctors, with the annual allocation of healthcare resources for the disease and related comorbidities projected to exceed $150 billion in the United States. The incidence of obesity has risen in the United States over the past 30 years; 60% of adults are currently either obese or overweight.

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The Effects Of Obesity On Medical Problems And Costs

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The Effects Of Obesity On Medical Problems And Costs

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If the address matches an existing account you will receive an email with instructions to reset your password

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Obesity is a major public health problem. It is directly associated with several health conditions including diabetes, heart disease, stroke, hypertension, gallbladder disease and fatty liver disease as well as some cancers. Nearly 1 billion individuals worldwide are overweight or obese and the numbers are on the rise.

Aims of obesity management

Management of obesity and overweight revolves around some basic aims that include:-

Reduction of body weight

Maintenance of the lost body weight and prevention of recurrence or regaining the lost weight

Maintenance of nutrition and preventing dietary deficiencies

Management of obesity

For most people, losing a small amount of weight to the tune of 5% can have benefits. This may be sufficient to reduce the risk of developing diabetes or lowering the blood pressure.

This is an achievable target that most patients can aim for and achieve by adopting a healthy life style of a healthy low calorie balanced diet and increasing physical activity. People should not be expected to lose more than 0.5-1 kg (1-2 lb) a week.

If management of obesity of a member of the family is the concern, the whole family may adopt healthy lifestyle measures. This is especially effective for obese children. Parents need to take responsibility for making changes to their child's diet and improving their physical activity especially for children under 12 years of age.

Exercise to lose weight

For an average adult at least 30 minutes of moderate physical activity is recommended on 5 or more days a week to lose weight and maintain the weight loss.

Moderate activity usually means activities that make the person feel warm and raises their heart rate and breathing rate. These are termed cardio-exercises and prevent development of diabetes and heart disease.

Most obese individuals however need to target a 45 to 60 minutes of moderate activity a day to stop them gaining weight. After losing the weight 60 to 90 minutes a day of moderate activity is needed to prevent putting on the weight again. This activity can be in a single session or several lasting 10 minutes or more.

Children should do 60 minutes of moderate activity each day. Activities suggested include cycling, brisk walking, climbing stairs, gardening, swimming or exercises in gyms.

Apart from improving physical activity, obese and overweight individuals need to reduce the time spent sitting down and inactive. This includes idle time before the television or the computer.

Management of diet

The calorie intake is usually reduced for obese individuals along with increased physical activity. Adults should usually be advised to follow a low-fat diet.

The patient is advised about 600 kilocalories (kcal) less than what he or she needs to stay the same weight. A low calorie diet provides only 1000 to 1600 kcal a day. Along with decrease in calories, vitamins and vital nutrients are ensured in diet to prevent deficiencies.

For those with a body mass index (BMI) of over 30 and those who have stopped losing weight before reaching their target, a very low calorie diet may be recommended. However, this cannot be followed for more than 12 weeks continuously.

Alternatively this very low calorie diet can be followed for 2 to 4 days a week. Very low calorie diet provides less than 1000 kcal a day. Diet should never be designed to provide less than 600 kcal a day unless the patient is monitored closely.

Ideal diet should avoid sweets, sugary drinks, foods rich in saturated and trans fats and be low of sodium (salt). Reducing the temptation to overeat may include avoiding situations that lead to overeating, eating slowly, eating small and healthy meals, drinking adequate amounts of water, avoiding alcohol etc.

Medications for weight loss

There are two medicines - called orlistat and sibutramine - that are sometimes prescribed for weight loss. They are not suitable for everyone and are not commonly used due to their risk of serious side effects. The medicines are normally recommended only for people with a BMI over 30.

The WHO defines an adult who has a BMI between 25 and 29.9 as overweight - an adult who has a BMI of 30 or higher is considered obese - a BMI below 18.5 is considered underweight, and between 18.5 to 24.9 a healthy weight .

Surgery for weight loss

Sometimes surgery may be suggested to lose weight. There are several different types of surgery that may help lose weight. They involve reducing the size of the stomach to induce early satiety and result in smaller meals and lower calorie intake.

An operation is only recommended for people with morbid or severe obesity, and those who have failed with other methods of weight reduction.

Further Reading

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Obesity is a major public health problem. It is directly associated with several health conditions including diabetes, heart disease, stroke, hypertension, gallbladder disease and fatty liver disease as well as some cancers. Nearly 1 billion individuals worldwide are overweight or obese and the numbers are on the rise.

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Disease of Obesity

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American Society for Metabolic and Bariatric Surgery

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Defining Obesity

Obesity is no longer considered a cosmetic issue that is caused by overeating and a lack of self-control. The World Health Organization (W.H.O.), along with National and International medical and scientific societies, now recognize obesity as a chronic progressive disease resulting from multiple environmental and genetic factors.

The disease of obesity is extremely costly not only in terms of economics, but also in terms of individual and societal health, longevity, and psychological well-being. Due to its progressive nature, obesity requires life-long treatment and control.

Measuring Obesity

The disease of obesity is characterized by an excessive accumulation of body fat. A variety of instruments are available for assessing the amount of fat versus lean tissue in the body. However, due to the expense of these instruments and the time required for body fat assessments, obesity is clinically defined by measures that 'estimate' adiposity from body weight, body build and height.

Ideal Body Weight (IBW)

One of these estimates for body size is ideal body weight (IBW), a number that is obtained from the Metropolitan Life Insurance Company Table. The IBW table is based upon mortality data and requires knowledge of body weight as well as body frame, a measure that is considered by many experts to be arbitrary. Using this table, overweight and obesity are defined by percentage of weight in excess of IBW.

Body Mass Index (BMI)

The body mass index (BMI) is another measure used to define overweight and obesity and is considered a more accurate estimate of body fatness than IBW. Large population studies find that the BMI generally reflects the amount of excessive body fat an adult has, although there are certain exceptions, such as the BMI of a woman who is pregnant, an athlete, a body builder or the elderly. BMI does not necessarily take into account a persons distribution of fat (abdominal vs. peripheral), however, and is not a good measurement of the metabolic activity of a person's fat tissue.

BMI takes into consideration an individual's height and weight can be determined by using a BMI chart or can be calculated according to one of the following formulas:

​(1) Weight in kilograms divided by Height in meters squared (BMI = kg/m2)

Or

​(2) Weight in pounds divided by Height in inches squared and this value multiplied by 705 (BMI= [(lbs/in2) x 705])

Body size categories using BMI have been based upon the ranges of BMI associated with a certain risk for mortality1-2. The categories and respective BMI categories are:
Calculate your BMI Here
Obesity Prevalence and Rate of Occurrence

According to the W.H.O., 65 percent of the world's population lives in countries where overweight and obesity kills more people than underweight. Approximately 500 million adults in the world are affected by obesity and one billion are affected by overweight, along with 48 million children.

In the United States, epidemiological data from an ongoing study that measures the actual body size of thousands of Americans, show that 34 percent of adults more than 20 years old are affected by obesity and 68 percent are overweight (2007-2008 data). Obesity affects 10 percent of children between two and five years of age, 2 percent of those between 6 to 11 years old, and 18 percent of adolescents.

Throughout the last 20 to 25 years, the prevalence of obesity has been increasing at an alarming rate. Since 1985, the Center for Disease Control (CDC) has supported an ongoing study, conducted on a yearly basis by state health departments, to examine changes in obesity prevalence state-to-state, and has found the following:

In 1990, the obesity prevalence for most of the states was 10 percent or less.

By 1995, more than half the states had a prevalence of 15 percent.

By 2000, nearly half the states had a prevalence of 20 percent or higher.

Five years later (2005), all but three states had a prevalence greater than 20 percent and nearly a third had a prevalence of 25 percent or more.

By 2010, the data show that most of U.S. states had a prevalence of 25 percent and many had a prevalence of 30 percent or higher.

For view of yearly changes in prevalence, view the CDC's online data.

Not only has the obesity epidemic increased in number throughout the past two decades, but also in severity. Data obtained from the yearly ongoing CDC-supported U.S. study found that between the years 1987 to 2005 the prevalence of severe obesity increased by 500 percent and super severe obesity (BMI greater than 50) increased by nearly 1,000 percent. According to the 2007-2008 NHANES findings, 5.7 percent of American adults, or nearly 14 million people, are affected by severe obesity.

Progressive Nature of the Disease of Obesity

Obesity is considered a multifactorial disease with a strong genetic component. Acting upon a genetic background are a number of hormonal, metabolic, psychological, cultural and behavioral factors that promote fat accumulation and weight gain.

Positive Energy Balance

A positive energy balance causes weight gain and occurs when the amount of calories consumed (energy intake) exceeds the amount of calories the body uses (energy expenditure) in the performance of basic biological functions, daily activities, and exercise. A positive energy balance may be caused by overeating or by not getting enough physical activity. However, there are other conditions that affect energy balance and fat accumulation that do not involve excessive eating or sedentary behavior. These include:

1. Chronic sleep loss

2. Consumption of foods that, independent of caloric content, cause metabolic/hormonal changes that may increase body fat. These include foods high in sugar or high fructose corn syrup, processed grains, fat, and processed meats

3. Low intake of fat-fighting foods such as fruits, vegetables, legumes, nuts, seeds, quality protein

4. Stress and psychological distress)

5. Many types of medications

6. Various pollutants

Weight Gain

Weight gain is yet another contributor to weight gain or, in other words, obesity 'begets' obesity, which is one of the reasons the disease is considered 'progressive'. Weight gain causes a number of hormonal, metabolic and molecular changes in the body that increase the risk for even greater fat accumulation. Such obesity-associated biological changes reduce the body's ability to oxidize (burn) fat for energy, increase the conversion of glucose (carbohydrate) to fat, and increase the body's capacity to store fat in fat storage depots (adipose tissue). This means that more of the calories consumed will be stored as fat. To make matters worse, obesity affects certain regulators of appetite and hunger in a manner that can lead to an increase in meal size and the frequency of eating. Weight gain, therefore, changes the biology of the body in a manner that favors further weight gain and obesity.

Obesity-related Conditions

A number of other conditions associated with obesity contribute to the progression of the disease. Obesity reduces mobility and the number of calories that would be burned in the performance of activity. Weight gain may also cause psychological or emotional distress which, in turn, produces hormonal changes that may cause further weight gain by stimulating appetite and by increasing fat uptake into fat storage depots.

Sleep duration is reduced by weight gain due to a number of conditions that impair sleep quality such as pain, sleep apnea and other breathing problems, a need to urinate more frequently, use of certain medications, and altered regulation of body temperature. Shortened sleep duration, in turn, produces certain hormones that both stimulate appetite and increase the uptake of fat into fat storage depots.

Weight gain also contributes to the development of other diseases such as hypertension, diabetes, heart disease, osteoarthritis and depression, and these conditions are often treated with medications that contribute to even further weight gain. In all of these ways and more, obesity 'begets' obesity, trapping the individual in a vicious weight gain cycle.

Diets

A low calorie diet is the primary treatment for overweight and obesity, but, dieting is also a contributor to obesity progression. Dietary weight-loss causes biological responses that persist long-term and contribute to weight regain. One of these responses affects energy balance. When a person loses weight, the body 'thinks' it is starving and energy expenditure is reduced in order to conserve calories. The reduction in energy expenditure with dietary weight-loss requires that, in order to maintain weight-loss, the dieter eat even fewer calories than someone of equal body size who has never been on a diet. However, eating less is difficult following a diet because there are long-term changes in regulators of appetite that increase the desire to eat and the amount of food that can be consumed. Such diet-induced changes favor a positive energy balance and weight regain and, because the conditions responsible for the reduction in energy expenditure and increased drive to eat persist long-term, an individual will often not only regain all of their lost weight, but even more.

Another biological response that occurs with dieting involves changes in fat metabolism that reduce the body's ability to burn fat and increase the capacity for fat to be stored in adipose depots (fat storage depots). With dietary weight-loss, the amount of dietary fat the body burns is reduced by approximately 50 percent. In addition, dieting reduces the amount of fat the body burns for fuel during low-grade activity such as walking, cleaning the house, fixing dinner, or working on a computer. The reduction in the amount of fat that is burned for fuel following a dietary weight-loss makes more fat available to be taken up by fat storage depots, and dieting increases the capacity for fat depots to store even more fat than before a diet. Altogether dietary weight-loss reduces the use of fat for fuel and increases the capacity for the fat that is not utilized to be stored. These changes lead to a progressive increase in fat accumulation even if the individual is not overeating.

Summary

Multiple factors acting upon a genetic background cause weight gain and obesity. Conditions associated with weight gain and biological changes in the body that occur as a result of weight gain contribute to progression of the disease, often trapping the individual in a vicious weight gain cycle. If you are concerned with your weight, please speak to your primary care physician to learn more about how to improve your weight and health.

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Obesity is no longer considered a cosmetic issue that is caused by overeating and a lack of self-control. The World Health Organization (W.H.O.), along with National and International medical and scientific societies, now recognize obesity as a chronic progressive disease resulting from multiple environmental and genetic factors.

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The Impact of Obesity on Your Body and Health

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The Impact of Obesity on Your Body and Health

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More than two-thirds of American adults are overweight and obese, making this an important topic for people living with cancer. When a person is overweight or obese, it means that they have too much body fat in relation to lean body tissue, such as muscle.

Many factors can cause people to become obese. These include genetic, hormonal, environmental, emotional, and cultural factors. People who are overweight have a higher risk of many serious health conditions, including type-2 diabetes, high blood pressure, and heart disease. Being overweight is also associated with an increased risk of many types of cancer.

Understanding weight gain and cancer risk

Several studies have explored why being overweight or obese may increase cancer risk and growth. The possible reasons that obesity is linked with cancer include:

Increased levels of insulin and insulin growth factor-1 (IGF-1), which may help some cancers develop

Chronic, low-level inflammation, which is more common in people who are obese and is linked with an increased cancer risk

Higher amounts of estrogen produced by fat tissue, which can drive the development of some cancers, such as breast and endometrial cancers

Fat cells may effect processes that regulate cancer cell growth.

How your weight changes throughout your life may also affect your risk for cancer. Studies have shown that the following factors can affect your cancer risk:

Research suggests that maintaining a healthy weight is associated with a lower risk of cancer and of the cancer returning in survivors.

Types of cancer linked with an increased weight

Being overweight or obese has been linked to these cancers:

Measuring weight gain

Obesity is often measured with body mass index (BMI) and waist measurements. BMI is the ratio of a person's weight and height. A healthy BMI is usually between 18.5 and 24.9. A BMI between 25 and 29.5 is considered overweight, while a BMI of 30 or higher is obese.

Also, people with larger waist measurements have a higher risk of various diseases, such as heart disease. A healthy waist measurement is under 40 inches for men and under 35 inches for women.

Weight management tips

To control weight gain, pay attention to what you eat and how much you exercise. You should also make healthy choices about what you eat and drink. This can be challenging because eating a high-calorie diet is typical in the United States. The reasons for this include a complete, relatively low-cost food supply and large portions. Here are some tips to help:

Eat more vegetables, fruits, lean protein, and whole grains. Some types of food, such as broth-based soups, also help a person feel "full" faster.

Avoid foods and beverages that are high in sugar, such as juice and soda.

Eat and drink only as many calories as you need to maintain a healthy weight and support your level of physical activity.

Aim for 30 to 60 minutes per day of moderate to intense physical activity on most days. But even a small increase in physical activity has benefits.

Suggestions for people who are overweight or obese

If you are currently overweight or obese, it is best to start by taking steps to lose weight through nutrition and exercise. Aim to lose 5% to 10% of your body weight as your first goal. Although this amount may seem small, research shows that even losing 5% to 10% of your weight is beneficial. Most hospitals and health care organizations have professionals such as dietitians who can provide weight management counseling and treatment.

Sometimes nutritional changes and increasing physical activity are not enough. But there are other steps you can take. The National Institutes of Health approach to obesity treatment includes:

A change in lifestyle behaviors. First, change behaviors to reduce the amount of food you eat and increase physical activity. A registered dietitian, exercise physiologist, clinical psychologist, or doctor who specializes in weight loss can help.

Behavior change support. For many, being overweight or obese is more complex than simply eating too much and exercising too little. It is important to get support when you are trying to lose weight. Most weight loss programs include sessions with a dietitian or weight loss specialist to help you make healthy lifestyle changes and stick with them over time.

Medication. Weight loss drugs are usually only recommended when a combination of diet, exercise, and behavior change support have not worked. Or, if you have other serious health conditions from being obese.

Surgery. A variety of procedures can make a person's stomach smaller. This is called weight loss surgery or bariatric surgery. This may be an option for people with a BMI of 40 or higher. Or for those with a BMI of 35 or higher who have another serious health condition related to obesity.

Questions to ask a medical professional about weight loss

Talk with your health care team about your weight. They can provide guidance and help you find resources. Consider asking these questions:

Is my weight unhealthy?

How is my extra weight harming my health?

How will losing weight improve my health?

How much weight do I need to lose?

How much weight should I lose each week?

What programs and treatments are available to help me lose weight?

Can you recommend professionals who can help me develop a weight loss program?

Where can I find information on healthy eating?

Where can I find information on exercise?

Related Resources
Physical Activity and Cancer Risk Changes People Can Make to Lower Their Cancer Risk Food and Cancer Prevention
More Information
Academy of Nutrition and Dietetics: Your Health and Your Weight National Cancer Institute: Obesity and Cancer Risk Society of Gynecologic Oncology: A Patient's Guide to Losing Weight to Reduce Your Risk of Endometrial Cancer

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Read a full-text transcriptMore than two-thirds of American adults are overweight and obese, making this an important topic for people living with cancer. When a person is overweight or obese, it means that they have too much body fat in relation to lean body tissue, such as muscle.

# data[].attributes.attachment_link.readable_text
Obesity is a major public health problem. It is directly associated with several health conditions including diabetes, heart disease, stroke, hypertension, gallbladder disease and fatty liver disease as well as some cancers. Nearly 1 billion individuals worldwide are overweight or obese and the numbers are on the rise.

Aims of obesity management

Management of obesity and overweight revolves around some basic aims that include:-

Reduction of body weight

Maintenance of the lost body weight and prevention of recurrence or regaining the lost weight

Maintenance of nutrition and preventing dietary deficiencies

Management of obesity

For most people, losing a small amount of weight to the tune of 5% can have benefits. This may be sufficient to reduce the risk of developing diabetes or lowering the blood pressure.

This is an achievable target that most patients can aim for and achieve by adopting a healthy life style of a healthy low calorie balanced diet and increasing physical activity. People should not be expected to lose more than 0.5-1 kg (1-2 lb) a week.

If management of obesity of a member of the family is the concern, the whole family may adopt healthy lifestyle measures. This is especially effective for obese children. Parents need to take responsibility for making changes to their child's diet and improving their physical activity especially for children under 12 years of age.

Exercise to lose weight

For an average adult at least 30 minutes of moderate physical activity is recommended on 5 or more days a week to lose weight and maintain the weight loss.

Moderate activity usually means activities that make the person feel warm and raises their heart rate and breathing rate. These are termed cardio-exercises and prevent development of diabetes and heart disease.

Most obese individuals however need to target a 45 to 60 minutes of moderate activity a day to stop them gaining weight. After losing the weight 60 to 90 minutes a day of moderate activity is needed to prevent putting on the weight again. This activity can be in a single session or several lasting 10 minutes or more.

Children should do 60 minutes of moderate activity each day. Activities suggested include cycling, brisk walking, climbing stairs, gardening, swimming or exercises in gyms.

Apart from improving physical activity, obese and overweight individuals need to reduce the time spent sitting down and inactive. This includes idle time before the television or the computer.

Management of diet

The calorie intake is usually reduced for obese individuals along with increased physical activity. Adults should usually be advised to follow a low-fat diet.

The patient is advised about 600 kilocalories (kcal) less than what he or she needs to stay the same weight. A low calorie diet provides only 1000 to 1600 kcal a day. Along with decrease in calories, vitamins and vital nutrients are ensured in diet to prevent deficiencies.

For those with a body mass index (BMI) of over 30 and those who have stopped losing weight before reaching their target, a very low calorie diet may be recommended. However, this cannot be followed for more than 12 weeks continuously.

Alternatively this very low calorie diet can be followed for 2 to 4 days a week. Very low calorie diet provides less than 1000 kcal a day. Diet should never be designed to provide less than 600 kcal a day unless the patient is monitored closely.

Ideal diet should avoid sweets, sugary drinks, foods rich in saturated and trans fats and be low of sodium (salt). Reducing the temptation to overeat may include avoiding situations that lead to overeating, eating slowly, eating small and healthy meals, drinking adequate amounts of water, avoiding alcohol etc.

Medications for weight loss

There are two medicines - called orlistat and sibutramine - that are sometimes prescribed for weight loss. They are not suitable for everyone and are not commonly used due to their risk of serious side effects. The medicines are normally recommended only for people with a BMI over 30.

The WHO defines an adult who has a BMI between 25 and 29.9 as overweight - an adult who has a BMI of 30 or higher is considered obese - a BMI below 18.5 is considered underweight, and between 18.5 to 24.9 a healthy weight .

Surgery for weight loss

Sometimes surgery may be suggested to lose weight. There are several different types of surgery that may help lose weight. They involve reducing the size of the stomach to induce early satiety and result in smaller meals and lower calorie intake.

An operation is only recommended for people with morbid or severe obesity, and those who have failed with other methods of weight reduction.

Further Reading

# data[].attributes.attachment_link.description
Obesity is a major public health problem. It is directly associated with several health conditions including diabetes, heart disease, stroke, hypertension, gallbladder disease and fatty liver disease as well as some cancers. Nearly 1 billion individuals worldwide are overweight or obese and the numbers are on the rise.