Obesity has risen at an epidemic rate during the past 30 years. The rapid rise in the prevalence of overweight and obesity among all segments of the U.S. population is of grave concern as the health and quality of life of those afflicted plummets and health care costs and societal burdens continue to increase. Obesity is a serious condition that affects people of all ages and socioeconomic groups. Obesity is the second leading cause of preventable death in the United States, after smoking.

The Centers for Disease Control and Prevention (CDC) in its People 2010 program has announced that one of the national health objectives for the year 2010 is to reduce the prevalence of obesity among adults to less than 15%.¹

After completing this course, the dietetics professional will be able to:

1. Describe obesity terms and measurements
2. Identify the prevalence and cost of overweight and obesity in the US
3. Describe the Global impact of obesity
4. Identify the health consequences of obesity
5. Identify the factors contributing to overweight and obesity
6. Describe the six types of diets to consider in the development of a nutritional plan
7. Describe the benefits of the "Mediterranean" diet
8. Describe the CDC Weight Management Recommendations
9. Describe the types of obesity related surgery
10. Identify behavioral changes that affect obesity and overweight
11. Describe government efforts to promote healthy lifestyles

Measurements

To most people, the term "obesity" means to be very overweight. The Institute of Health definitions are:²

• "Overweight" as an excess amount of body weight that includes muscle, bone, fat, and water.
• "Obesity" specifically refers to an excess amount of body fat. Some people, such as bodybuilders or other athletes with a lot of muscle, can be overweight without being obese.

Everyone needs a certain amount of body fat for stored energy, heat insulation, shock absorption, and other functions. As a rule, women have more body fat than men. The Dietary Guidelines for Americans 2005 and the CDC defines "Obese" as adults with having a body mass index (BMI) of 30 or greater.

Measuring the exact amount of a person's body fat is not easy. The most accurate measures are to weigh a person underwater or to use an X-ray test called Dual Energy X-ray Absorptiometry (DEXA). These methods are not practical for the average person, and are done only in research centers with special equipment.

There are simpler methods to estimate body fat. One is to measure the thickness of the layer of fat just under the skin in several parts of the body. Another involves sending a harmless amount of electricity through a person's body. Both methods are used at health clubs and commercial weight loss programs. Results from these methods, however, can be inaccurate if done by an inexperienced person or on someone with severe obesity.

Because measuring a person's body fat is difficult, health care providers often rely on other means to diagnose obesity. Weight-for-height tables, which have been used for decades, usually have a range of acceptable weights for a person of a given height. One problem with these tables is that there are many versions, all with different weight ranges. Another problem is that they do not distinguish between excess fat and muscle. A very muscular person may appear obese, according to the tables, when he or she is not.

In recent years, body mass index (BMI) has become the medical standard used to measure overweight and obesity.

Body Mass Index and Terms

BMI uses a mathematical formula based on a person's height and weight. BMI equals weight in kilograms divided by height in meters squared (BMI = kg/m2). The BMI table that follows has already calculated this information.³

Although the BMI ranges shown in the table are not exact ranges of healthy and unhealthy weight, they are useful guidelines.

• A BMI of 25 to 29.9 indicates a person is overweight.
• A person with a BMI of 30 or higher is considered obese.

Like the weight-to-height table, BMI does not show the difference between excess fat and muscle. BMI, however, is closely associated with measures of body fat. It also predicts the development of health problems related to excess weight. For these reasons, BMI is widely used by health care providers.

Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. Then look to find your weight group.

According to the CDC, as Americans age, the tendency to be overweight (BMI > 25) and/or obese (BMI > 30) increases. The age group with the highest prevalence of overweight and obesity among men is 65 to 74 years, and among women, 55 to 64 years.

Body Fat Distribution: "Pears" vs. "Apples"

Health care providers are concerned not only with how much fat a person has, but also where the fat is located on the body. Women typically collect fat in their hips and buttocks, giving them a "pear" shape. Men usually build up fat around their bellies, giving them more of an "apple" shape.

Of course some men are pear-shaped and some women become apple-shaped, especially after menopause. If you carry fat mainly around your waist, you are more likely to develop obesity-related health problems. Women with a waist measurement of more than 35 inches or men with a waist measurement of more than 40 inches have a higher health risk because of their fat distribution.

Calorie Count

One problem in losing weight is the calorie count. Once a person starts losing weight they become a smaller person and smaller people need fewer calories to maintain body function so the starting point of the individual's diet has changed. A person with a caloric (or energy) requirement of 2,000 calories can lose weight on a 1,500-calorie diet. But once they've lost 10 pounds their resting metabolic rate may fall to 1,900 calories so they need to move to 1,400 calories a day to get the same 500-calorie-a-day deficit. This is the reason that once one starts to lose weight it becomes harder and harder.⁴

However, if the person is dieting then it doesn't matter if they consume fat calories or carbohydrate calories or protein calories as long as the person is in caloric deficit. In theory the body sheds one pound for every 3,500 calories cut from the diet.

Section III. U.S. Obesity Trends and Cost

U.S. Obesity Trends

The Dietary Guidelines for Americans 2005 found that between 1999 and 2002, 65% of U.S. adults were overweight, an increase from 56% in 1988-1994. Data from 1999-2002 also showed that 30% of adults were obese, an increase from 23% in an earlier survey. During this same period there were also dramatic increases in the prevalence of overweight have occurred in children and adolescents of both sexes, with approximately 16% of children and adolescents aged 6 to 19 years considered to be overweight (1999-2002).⁵

According to the CDC, during the past 20 years there has been a dramatic increase in obesity in the United States. Following dramatic increases in overweight and obesity among U.S. adults between 1976-1980 and 1999-2000, obesity has reached epidemic proportions; nearly 59 million adults are obese.⁶

Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults as part of the CDC's Behavioral Risk Factor Surveillance System (BRFSS). At the state level, in 2003, the CDC reported the following increases in obesity:

• In 1991, 4 states had obesity prevalence rates of 15-19% and no states reported rates at or above 20%.
• In 2003, 15 states had prevalence rates of 15-19%, 31 states had rates of 20-24%, and 4 states had rates more than 25%.

The following map of the US shows the prevalence of obesity for each state.

It should be noted that the statistics about overweight and obesity may differ depending upon the source. However, when comparing all the available studies and research regarding overweight and obesity, the combination of the data tends to shows the same trends and supports the same conclusions. The National Institute of Diabetes and Digestive Kidney Diseases (NIDDKD) reports that definitions or measurement characteristics for overweight and obesity have varied over time, from study to study, and from one part of the world to another. The varied definitions affect prevalence statistics and make it difficult to compare data from different studies.

Prevalence refers to the total number of existing cases of a disease or condition in a given population at a given time. Some overweight- and obesity-related prevalence rates are presented as crude or unadjusted estimates, while others are age-adjusted estimates. Unadjusted prevalence estimates are used to present cross-sectional data for population groups at a given point or time period. For age-adjusted rates, statistical procedures are used to remove the effect of age differences in populations that are being compared over different time periods. Unadjusted estimates and age-adjusted estimates will yield slightly different values.⁷

The recent increases in the prevalence of overweight and obesity are reflected across all ages, racial and ethnic groups, and education level in the U.S. In reviewing the following three charts, for instance, one can see that the "average" obese American is aged 50-59, Black/non-Hispanic with less than a high school diploma.

The following charts outline generalizations about the demographics of the obese population of the US.

Although the rates of obesity have increased across all races, the Black non-Hispanic group has the highest rates of obesity.

Obesity prevalence has increased across all education levels, although it tends to skew higher for persons with less education.

Relationships between place of residence (i.e., size of metropolitanstatistical area), age and body mass index (BMI) are illustrated in the following chart.

Obesity Economic Cost

Obesity is costing not only lives but dollars, too. A study by the Journal of Health Affairs found that $93 billion per year goes to treat health problems of overweight people. About half this expense is paid by the government through Medicare which provides care to the elderly, and Medicaid, which serves the poor.

The differences in spending on people who are overweight and those who weighed less were, for the most part, not statistically significant, by themselves. But major differences appeared for those who were obese. Altogether, medical spending attributable to extra weight totaled $78.5 billion in 1998, or $92.6 billion in inflation-adjusted 2002 dollars. This financial burden rivals the expenses attributable to smoking.⁸

In the CDC's estimates that the annual cost of obesity and overweight in the United States to be about $117 billion.⁹

In 2004, disability insurer UnumProvident Corp reported that disability claims from certain weight-related problems have doubled since 1996, and the nation's largest disability insurer says that those claims are partly to blame for increases in the premiums it charges. UnumProvident, in a recent study of 1.3 million disability claims, found that claims for hypertension and diabetes have increased 100% since 1996, while musculoskeletal-disorder claims rose 78%. About 1% of the claims filed are specifically for obesity. But if related conditions are included the total is 5.6%. The total number of days employees are absent from their jobs because of these claims is 1.97 million. The company says that claims in which obesity is a contributing factor amount to an average annual cost of $51,023 per claimant.¹⁰

The Centers for Medicare & Medicaid Services eliminated terminology that previously restricted Medicare coverage of obesity as a disease in 2004. According to the American Dietetic Association (ADA) this represents a significant step toward providing high-quality treatment of obesity and its related conditions to millions more people in the United States. ADA's official position has been that obesity is a complex, chronic disease state with genetic, physiological, psychological, metabolic and environmental influences.

Obesity Treatment Benefits

The CDC listed the following economic and personal benefits of reducing obesity:¹¹

Nutrition

• Each year, over $33 billion in medical costs and $9 billion in lost productivity due to heart disease, cancer, stroke, and diabetes are attributed to diet.

Physical activity

• In 2000, health care costs associated with physical inactivity were more than $76 billion.
• If 10% of adults began a regular walking program, $5.6 billion in heart disease costs could be saved.
• Every dollar spent on physical activity programs for older adults with hip fractures results in a $4.50 return.

Weight loss

• A 10% weight loss will reduce an overweight person's lifetime medical costs by $2,200-$5,300.

The lifetime medical costs of five diseases and conditions (hypertension, diabetes, heart disease, stroke, and high cholesterol) among moderately obese people are $10,000 higher than among people at a healthy weight.

Personal Costs and Discrimination

According to the American Obesity Association, the social consequences of being overweight and obese are serious and pervasive. Overweight and obese individuals are often targets of bias and stigma, and they are vulnerable to negative attitudes in multiple domains of living including places of employment, educational institutions, medical facilities, the mass media, and interpersonal relationships.

The position of the American Obesity Association is that persons with obesity are frequently the victims of discrimination. Obesity is often described as the last 'acceptable' form of discrimination based on physical appearances.

Weight Stigma

Stigma and bias generally refer to negative attitudes that affect interpersonal interactions and activities in a detrimental way. Stigma may come in several forms, including verbal types of bias (such as ridicule, teasing, insults, stereotypes, derogatory names, or pejorative language), physical stigma (such as touching, grabbing, or other aggressive behaviors), or other barriers and obstacles due to weight (such as medical equipment that is too small for obese patients, chairs or seats in public venues which do not accommodate obese persons, or stores which do not carry clothing in large sizes). In an extreme form, stigma can result in both subtle and overt forms of discrimination, such as employment discrimination where an obese employee is denied a position or promotion due to his or her appearance, despite being appropriately qualified.

Weight stigma occurs in multiple settings by a range of individuals. For example, in employment settings, overweight people may face bias from several sources. Experimental studies have found that when a resume is accompanied by a picture or video of an overweight person (compared to an "average" weight person), the overweight applicant is rated more negatively and is less likely to be hired. Other research shows that overweight employees are ascribed multiple negative stereotypes including being lazy, sloppy, less competent, lacking in self-discipline, disagreeable, less conscientious, and poor role models. In addition, overweight employees may suffer wage penalties, as they tend to be paid less for the same jobs, are more likely to have lower paying jobs, and are less likely to get promoted than thin people with the same qualifications.

In school settings, students who are overweight or obese can face harassment and ridicule from peers, as well as negative attitudes from teachers and other educators. At the college level, research shows that qualified overweight students, particularly females, are less likely to be accepted to college than their normal weight peers.

In medical facilities, biased attitudes toward obese patients have been documented among physicians, nurses, psychologists, dieticians, and medical students, and include perceptions that obese patients are unintelligent, unsuccessful, weak-willed, unpleasant, overindulgent, and lazy. One alarming consequence of negative attitudes by health care professionals is that obese patients may avoid obtaining medical care because of these negative experiences. Research has demonstrated that heavier patients are more likely to cancel and delay appointments and preventive health care services, particularly among women who are overweight or obese.

Wages and Benefits

Several studies have found that women with obesity earned less than non-obese women. In a study by Rothblum and colleagues, of persons who were 50 percent or more above their ideal weight, 26 percent reported they were denied benefits such as health insurance because of their weight and 17 percent reported being pressured to resign or fired because of their weight.

Legal Issues

The Civil Rights Act of 1964, (Title VII, 42 U.S.C. §2000 et seq.) established basic federal law on employment discrimination. It does not identify weight as a protected characteristic, and as a result does not provide direct protection for obese individuals who have been discriminated against by their employer due to their weight.

The differential application of weight standards, formal or informal, to members of protected classes may constitute disparate treatment discrimination.

In Gerdom v. Continental Airlines Inc., the court determined that the airline's weight restriction program treated employees differently based on sex because it was designed to apply only to females, and "it was not merely slenderness, but slenderness of female employees which the employer considered critical." The airline argued that it had a competitive strategy featuring attractive flight attendants and that a slender female was a Bona Fide Occupational Qualification (BFOQ). The court rejected this argument holding that customer preference unrelated to the ability to do the job cannot justify discriminatory policies.

Disparate treatment may also be found if weight policies designed to apply to all groups are enforced at a significantly higher rate against a protected group. Union of Flight Attendants v. Pan American World Airways, Inc.

An employer's use of formal or informal weight standards may involve illegal discrimination if, though neutral on its face, the rule has a significant disparate impact on a protected class. In other words, if a claimant established that the weight rule was having an adverse impact on African Americans, Title VII would require an employer to justify its weight rules by showing that it is job-related and consistent with business necessity.

Rehabilitation Act and the Americans with Disabilities Act (ADA)

The Rehabilitation Act and the ADA provide protection against employment discrimination. Under both acts, a person must establish that he or she is an individual with a disability within the meaning of the acts. This includes anyone who has a physical or mental disability that substantially limits one or more major life activities of the individual, a record of such impairment or who is regarded as having such impairment.

Equal Employment Opportunities Commission (EEOC)

Personal Costs of Obesity

The "personal cost of obesity" adds up to $15,568 a year, including medications and food according to a June 2005 published study in the online version of the journal Health Affairs. Per person health care spending for obese adults was 56 percent higher than for normal-weight adults in 2002. In 1987, obese adults with private health insurance spent $272 more per year on healthcare than did normal-weight adults. By 2002, that difference had increased to $1,244 per person per year.

Obese persons also must purchase plus-size clothing which costs more on average than clothing for those of normal weight due to less selection, and use of more yardage of fabric and more inches of labor-intensive stitching Increasing, the obsese are being hit with extra expenses like the requirement to buy two airline seats.

Children & Adolescents

Obese children rate their quality of life with scores as low as those of young cancer patients on chemotherapy. Teasing at school, difficulties playing sports, fatigue, sleep apnea and other obesity linked problems all severely affect obese children's well-being. In a study conducted at the University of California in San Diego, overweight children were found to have at least one medical complication and miss four times as much school as normal weight children. They are also more likely to report feeling socially isolated.¹²

In a study released in October 2003 by the Medical College of Georgia, a child's socioeconomic status was found to play a direct role in whether their genetic susceptibility to obesity is expressed or controlled. Researchers studied the genotypes of almost 500 black and white American children, aged 5 to 25, and found those from lower socioeconomic backgrounds were more likely to display the negative effects of genes that are known to be involved in causing obesity.

These findings were presented at the American Physiological Society conference in Augusta, Ga. "Some gene effects were dependent on socioeconomic status. If you are a carrier of the 'bad gene,' so to say, and you are also in a lower socioeconomic class, then you will show the effect of the gene and are obese," researcher and genetic epidemiologist Dr. Harold Snieder stated in a news release.¹³

• "If you are in the middle or higher socioeconomic class, you don't show any effects of the gene. So that means only in a bad environment do the effects of these genes come out," Snieder said "We don't know which part of the socioeconomic status is responsible for children being obese, but physical activity and diet are likely to play a role."
• Risk factors for heart disease, such as high cholesterol and high blood pressure, occur with increased frequency in overweight children and adolescents compared to those with a healthy weight.



• Type 2 diabetes, previously considered an adult disease, has increased dramatically in children and adolescents. Overweight and obesity are closely linked to type 2 diabetes.
• Overweight adolescents have a 70% chance of becoming overweight or obese adults. This increases to 80% if one or more parent is overweight or obese.
• The most immediate consequence of overweight, as perceived by children themselves, is social discrimination.

Section IV. Global Obesity Epidemic

World-Wide Issue

On every continent on the globe, even including where malnutrition is rife, the number of people who are either overweight or obese is rising at an alarming rate. The same combination of high-calorie diets and sedentary behavior fuels the epidemic of fat in the US and internationally.

The International Obesity Task Force, a coalition of researchers and institutions, released a report on obesity in 2005 as the European Union began an initiative with the food and marketing firms to address the growing obesity problem in Europe. The Task Force found that at least seven European nations have higher rates of obesity among men than in the United States. These include Cyprus, the Czech Republic, Finland, Germany, Greece, Malta, and Slovakia.

The situation in Africa reflects the differences in how economic status is associated with obesity world-wide. In the U.S. and other developed countries obesity is more prevalent among the poor while in poor countries the well-to-do are more likely to be fat.

The biggest worry associated with obesity is the concurrent surge in diabetes. Experts predict the number of diabetics world-wide will triple in the next 15 years to about 320 million - a number exceeding the population of the U.S. Diabetes is a major risk factor for cardiovascular disease and a leading cause of blindness, kidney disease, and amputations. It is a very expensive disease for developing nations to fund.¹⁴

The worldwide incidence of obesity is increasing. In fact a new word - "globesity" has now been coined to reflect the escalation of global obesity and overweight. In 1998, the World Health Organization (WHO) published a report entitled "Obesity: Preventing and Managing the Global Epidemic", which classified obesity as a growing epidemic. According to WHO, if immediate action is not taken, millions will suffer from an array of serious weight-related disorders.

Global Obesity Levels

For the first time, the number of overweight individuals around the world rivals the number who are underweight. Developing nations have also joined the ranks of countries troubled by obesity. A United Nations (UN) survey found obesity growing in all developing regions, even in countries beset by hunger. In China, the number of overweight people rose from less than 10 percent to 15 percent in just three years. In Brazil and Colombia, the figure of overweight is about 40 percent - comparable with a number of European countries. Even sub-Saharan Africa, where most of the world's hungry live, is seeing an increase in obesity, especially among urban women. In all regions, obesity appears to escalate as income increases.

The following chart shows the percentage of obese adults in Europe and Australia.

Percentage of Obese Adults in Europe and Australia

International Obesity Reports

London - BBC: Child obesity due to poor nutrition and lack of exercise is a "ticking time bomb" for life expectancy levels, the UK's food watchdog has warned. The Food Standards Agency (FSA) chairman, Sir John Krebs, said the trend meant young people today would not live as long as their parents. The FSA, whose own research shows advertising influences children's eating habits, wants some food packaging to carry health warnings. It is concerned that popular entertainers and cartoon characters are promoting foods that contain dangerously high levels of fat or salt.

Beijing - Xinhua News Agency (government-owned): Experts have called for increased awareness of and concern about the rising numbers of obese children in China, a highlighted balanced diet, and rational nutrition and physical exercises to help control the weight of kids. Official statistics show that 10 percent of the children in China suffer from obesity and the number is increasing by eight percent per year. In big cities like Beijing and Shanghai, there is an average of one obese child in every five. Taking less outdoor exercises and indulging in watching TV and playing games at home are the main reasons behind the child obesity, said experts. Experts warned that obese children are vulnerable to weakened intellectuality, autistic personality, unhealthy sexual development, and high incidence of chronic diseases like arteriosclerosis, hepatocirrhosis, diabetes, and hypertension.

Chennai - The Hindu : Obesity is spreading at an alarming rate, not just in industrialised countries but also in developing countries, where obesity often sits next to malnutrition. In developing countries, it is now estimated that more than 115 million people suffer from obesity-related problems, including Type II Diabetes, heart disease and obesity-related cancers. Among poorer nations, adoption of industrialized foods and food preferences, together with drastically decreased physical activity levels are the basic ingredients for accelerating obesity, especially among children and adolescents. Within developing countries, shifts to urbanization, non-manual labour, high calorie foods, and higher levels of sedentary living are all contributing to this growing problem, often in conjunction with undernourished segments of the population.

Melbourne - The Age : Tips on which foods children should eat and how much exercise they need will be sent to parents as part of a $100 million push to tackle childhood obesity. And 150,000 children - about 10 per cent of those with a weight problem - will get after-school exercise sessions up to three times a week…With an estimated 1.5 million under-18's overweight or obese, Prime Minister John Howard recently announced the four-pronged strategy at a child obesity meeting in Launceston. Mr. Howard said Australia could overcome the "huge problem" of childhood obesity by encouraging more exercise and better eating at all ages. "In the end, it's a challenge to parents because it's parents who determine and set the eating habits of their children and... we'll be encouraging parents to set the example to their children," he said. "It's a paradox in this country. We love sport and pride ourselves on our sporting prowess and yet more and more of us are watching sport and not exercising ourselves."

London - Middle East Online: Obesity ratio in Saudia Arabia, Kuwait, Bahrain, Qatar, the United Arab Emirates, the Sultanate of Oman and the Republic of Yemen has reached 60 per cent and is more common among women, a Gulf study revealed. Director of the environmental and biological research program at Bahrain Center for Studies and Research Dr. Abdul Rahman Mosaiqer pointed out that his study, along with other studies, proved that obesity is more common in women than men in GCC countries compared to some European countries. Mosaiqer noted that these reasons lie in the lack of sport and physical activities, over quantities of fatty food as well as the repetition of pregnancy among women without having enough intervals between giving birth and pregnancy.

Glascow - The Scotsman: The largest international study carried out into teenage behaviour has found that children in Scotland have among the highest consumption of sugary soft drinks in the world. The survey of 162,000 youngsters from 35 countries revealed that Israel was the only country whose children consume more sugary drinks. The new research, published by the World Health Organisation (WHO), will fuel already grave concerns about Scotland's growing obesity problem. Scotland's chief medical officer, Dr. Mac Armstrong, has described the report as "an international alarm bell." Public-health experts have pointed to the consumption of sugary drinks as a key factor in the rise of obesity, and last year Dr. Armstrong called for a ban on the sale of carbonated sugared drinks in schools. A study in the British Medical Journal also found that rates of obesity were much lower among children actively discouraged from such beverages.

Section V. Obesity Health Consequences

Health Risks

Obesity is more than a cosmetic problem; it is a health hazard. In testimony before the Senate Health, Education, Labor and Pensions Committee, The American Dietetic Association urged that obesity be designated a disease by federal agencies and institutions with all of the attendant ramifications that such a designation implies -- including sanctioned insurance coverage for obesity treatment. Coverage will facilitate the timely provision of health services to treat obesity and its attendant comorbidities such as hypertension, lipid abnormalities, diabetes mellitus.

The Dietary Guidelines for Americans 2005 found that one of the major causes of morbidity and mortality in the United States are related to poor diet and a sedentary lifestyle. A new study by researchers at the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) published in JAMA concludes that obesity kills 112,000 Americans each year.

The study indicates that being overweight, as opposed to obese, actually saves 86,000 lives. When the authors add their obesity and overweight deaths, they write: "Thus, for overweight and obesity combined, our estimate was 25,814 excess deaths."¹⁵

Several serious medical conditions have been linked to obesity, including type 2 diabetes, heart disease, high blood pressure, and stroke. Obesity is also linked to higher rates of certain types of cancer. Obese men are more likely than non-obese men to die from cancer of the colon, rectum, or prostate. Obese women are more likely than non-obese women to die from cancer of the gallbladder, breast, uterus, cervix, or ovaries.

Health care providers generally agree that the more obese a person is the more likely he or she is to develop health problems.

Identifying Other Complications

Obesity Related Diseases Complications

Overweight and obese people are at an increased risk for developing the following conditions (in no particular order).

• Type 2 (non-insulin dependent) diabetes
• Cardiovascular disease
• Stroke
• Hypertension
• Dyslipidemia
• Hyperinsulinemia, insulin resistance, glucose intolerance
• Congestive heart failure
• Angina pectoris
• Cholecystitis
• Cholelithiasis
• Osteoarthritis
• Gout
• Fatty liver disease
• Sleep apnea and other respiratory problems
• Polycystic ovary syndrome (PCOS)
• Fertility complicationso Pregnancy complications
• Psychological disorders
• Uric acid nephrolithiasis (kidney stones)
• Stress urinary incontinence
• Cancer of the kidney, endometrium, breast, colon and rectum, esophagus, prostate and gall bladder
• Death

Obesity and Hypertension

The Departments of Epidemiology and Biostatistics at the, University of Michigan found the relevance of both hypertension and obesity, as important public health challenges, is increasing worldwide. Compared with the year 2000, the number of adults with hypertension is predicted to increase by 60% to a total of 1.56 billion by the year 2025. The growing prevalence of obesity is increasingly recognized as one of the most important risk factors for the development of hypertension. This epidemic of obesity and obesity-related hypertension is paralleled by an alarming increase in the incidence of diabetes mellitus and chronic kidney disease.

Obesity and in particular central obesity have been consistently associated with hypertension and increased cardiovascular risk. Based on population studies, risk estimates indicate that at least two-thirds of the prevalence of hypertension can be directly attributed to obesity.

Obesity-related metabolic abnormalities and impairment of cardiovascular function may be present even at a young age, and progress asymptomatically for decades before clinical manifestations set in. It is conceivable that these early abnormalities found in young obese subjects might facilitate the future development of hypertension and atherosclerosis independently of other traditional risk factors. This hypothesis is supported by recent findings which link obesity to accelerated progression of coronary artery calcification as a marker of atherosclerosis in apparently healthy individuals with an otherwise favorable cardiovascular risk profile.

Metabolic Syndrome Associated with Obesity

In an article appearing in The Journal of the American Medical Association, researchers at the Centers for Disease Control and Prevention (CDC) estimated that as many as 47 million Americans may exhibit a cluster of medical conditions (a "metabolic syndrome") characterized by insulin resistance and the presence of obesity, abdominal fat, high blood sugar and triglycerides, high blood cholesterol, and high blood pressure.

The syndrome was first defined in the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, released 2001. Because the root causes of the metabolic syndrome for a majority of individuals may be poor diet and insufficient physical activity, the high prevalence of the syndrome underscores an urgent need to develop comprehensive efforts directed at controlling the U.S. obesity epidemic and improving physical activity levels within the U.S. population.

The following chart outlines the age-adjusted prevalence of high blood cholesterol (> 240 mg/dL) in overweight U.S. adults, male and female.

The CDC reports that among people diagnosed with Type 2 diabetes, 85 percent have a BMI > 25 (classified as falling within the overweight range) and 55 percent have a BMI > 30 (classified as obese).

Carrying extra body weight and body fat are associated with the development of type 2 diabetes. People who are overweight are at much greater risk of developing type 2 diabetes than normal weight individuals. Being overweight puts added pressure on the body's ability to properly control blood sugar using insulin and therefore makes it much more likely to develop diabetes. Almost 90% of people with type 2 diabetes are overweight.

A weight gain of 11 to 18 pounds increases a person's risk of developing type 2 diabetes to twice that of individuals who have not gained weight.

Reproductive Complications

Obesity during pregnancy is associated with increased risk of death in both the baby and the mother and increases the risk of maternal high blood pressure by 10 times.

In addition to many other complications, women who are obese during pregnancy are more likely to have gestational diabetes and problems with labor and delivery.

• Infants born to women who are obese during pregnancy are more likely to be high birthweight and, therefore, may face a higher rate of Cesarean section delivery and low blood sugar (which can be associated with brain damage and seizures).
• Obesity during pregnancy is associated with an increased risk of birth defects, particularly neural tube defects, such as spina bifida.
• Obesity in premenopausal women is associated with irregular menstrual cycles and infertility.

Life Expectancy and Obesity

The National Institute on Aging, a component of the National Institutes of Health found that over the next few decades, life expectancy for the average American could decline by as much as 5 years unless aggressive efforts are made to slow rising rates of obesity. The U.S. could be facing its first sustained drop in life expectancy in the modern era, the researchers say, but this decline is not inevitable if Americans-particularly younger ones-trim their waistlines or if other improvements outweigh the impact of obesity.¹⁶

The new analysis suggests that the methods used to establish life expectancy projections, which have long been based on historic trends, need to be reassessed. This re-evaluation is particularly important, as obesity rates surge in today's children and young adults.

Unlike historic life expectancy forecasts, which rely on past mortality trends, the study based their projection on an analysis of body mass indexes and other factors that could potentially affect the health and well-being of the current generation of children and young adults, some of whom began having weight problems very early in life. Unless steps are taken to curb excessive weight gain, younger Americans will likely face a greater risk of mortality throughout life than previous generations. Obesity may already have had an effect. The sharp increase of obesity among people now in their 60s may be one explanation why the gains in U.S. life expectancy at older ages have been less than those of other developed countries in recent years.

To estimate the overall effect of obesity on life expectancy in the U.S., the study calculated the reduction in death rates that would occur if everyone who is currently obese were to achieve the difficult goal of losing enough weight to reach an "optimal" BMI of 24. The calculation was based, in part, on age, race, and sex-specific prevalence of obesity in the United States from the Third National Health and Nutrition Examination Survey. Based on these calculations, the researchers estimated that life expectancy at birth would be higher by 0.33 to 0.93 year for white men, 0.30 to 0.81 year for white women, 0.30 to 1.08 year for black men, and 0.21 to 0.73 year for black women if obesity did not exist.

The overall reduction in life expectancy of one-third to three-fourths of a year attributed to obesity in this analysis exceeds the negative effect of all accidental deaths combined, and could deteriorate over time. These trends suggest that the relative influence of obesity on the life expectancy of future generations could be markedly worse than it is for current generations. The life-shortening effect of obesity could rise…to two to five years, or more, in the coming decades, as the obese who are now at younger ages carry their elevated risk of death into middle and older ages.

Obesity and Cancer

As an example of how Americans are eating themselves to death, a landmark study concludes that one of every five cancer deaths in women and one of every seven in men are due to excess pounds. The study, by the American Cancer Society, is by far the largest on the subject and the first to quantify the risk for all forms of cancer.

More than 900,000 people were followed for 16 years to see how their weight at the start of the study affected their risk of later dying of the disease. The heaviest women had cancer death rates 62% higher than those of normal weight, and overweight men had rates 52% higher.

Like obesity, cancer is a major health problem in the United States and in other countries as well. Based on the American Cancer Society's 2002 estimates for cancer incidence, cancers linked to obesity among women comprise approximately 51% of all new cancers diagnosed among women in 2002: 2% thyroid cancers (15,800 new cases), 6% uterine cancers (39,300 new cases), 12% colorectal cancers (75,700 new cases), and 31% breast cancers (203,500 new cases). Among men, cancers linked to obesity comprise approximately 14% of new cancers: 3% kidney cancers (19,100 new cases) and 11% colorectal cancers (72,600 new cases). In terms of mortality, for women, obesity-related cancers are estimated to comprise 28% of cancer-related deaths in 2002: 15% breast cancers (39,600 deaths), 2% uterine cancers (6,600 deaths), and 11% colorectal cancers (28,800 deaths). Among men, obesity-related cancers are estimated to comprise 13% of cancer-related deaths in 2002: 10% colorectal cancers (27,800 deaths) and 3% kidney cancers (7,200 deaths).

The study found that overall, fat was more of a cancer hazard for women than men. Extra pounds mean extra hormones, estrogen and insulin, which are produced in fatty tissue and which spur cell growth, setting the stage for the overgrowth that is typical of tumors.

Overall, while the mechanisms underlying the obesity-carcinogenesis relationship are not fully understood, sufficient evidence exists to support recommendations that adults and children maintain reasonable weight for their height and ages for multiple health benefits, including decreasing their risk of cancer.

Obesity is especially important as a cancer risk factor because it's so common. Carrying around too many pounds has long been known to raise the risk of heart disease and diabetes, but there's less awareness of its cancer hazard.

Obesity is also linked to gastro esophageal reflux, the eruption of stomach acids into the esophagus. That, in turn, has been shown to increase the rate of various esophageal cancers, whose incidence has grown tremendously over the past two years. Smoking remains the biggest cancer risk, accounting for 30% of all such deaths. Diet accounts for almost another 30%.

Strokes and Obese Women

The University of Southern California study on women and strokes found that strokes have tripled in recent years among middle-aged US women. Almost 2% of women ages 35 to 54 reported suffering a stroke from 1994 to 2004. Only about half a percent did in the previous survey, from 1988 to 1994.

The percentage is small because most strokes occur in older people but the sudden rise in middle age and the reasons behind it are ominous because it happened even though more women in the recent survey were on medicines to control their cholesterol and blood pressure.

Women's waistlines are nearly two inches bigger than they were a decade earlier, and that bulge corresponds with the increase in strokes. No other traditional risk factors such as smoking, heart disease or diabetes changed enough between the two surveys to account for the increase in strokes.¹⁷

Psychological and Social Effects

Emotional suffering may be one of the most painful parts of obesity. American society emphasizes physical appearance and often equates attractiveness with slimness, especially for women. Such messages make overweight people feel unattractive.

Many people think that obese individuals are gluttonous, lazy, or both, even though this is not true. As a result, obese people often face prejudice or discrimination in the job market, at school, and in social situations. Feelings of rejection or depression are common.

The nature of the relationship between obesity and psychological distress continues to be debated by researchers and clinicians alike. Studies of nonclinical samples of obese persons have consistently shown that obese individuals do not differ from their nonobese counterparts in psychological symptoms, psychopathology, or personality overall. However, studies do indicate that subgroups within the obese population, such as obese individuals presenting for clinical weight-loss treatment and obese binge-eaters, show elevated psychopathology. Individuals seeking treatment for weight loss have consistently demonstrated a higher prevalence of distress then their nontreatment--seeking counterparts. A Duke University study explored the hypothesis that the relationship between degree of obesity and depression/global self-esteem is mediated by body-image evaluation in obese individuals seeking weight-loss treatment.

The study followed 177 obese men and women, self-referred to a residential weight-loss facility for weight control and lifestyle change. This study was based on the 110 participants (80 women and 30 men, 98 percent white) who completed a battery of questionnaires at the onset of treatment. Body-image satisfaction was measured by evaluation toward appearance, health, and fitness.The overwhelming majority of research investigating body image is conducted on women and, therefore, less is known about body image among men. As a result, it was not known whether the relationships among the variables of interest would vary as a function of gender.

There were four major findings of the study:

1. Body-image evaluation was related to both depression and self-esteem
2. Degree of obesity was correlated with body-image evaluation
3. Degree of obesity was associated with depression and self-esteem
4. The relationship between weight and depression/self-esteem was partially mediated by body image. Consistent with the findings of others, body-image evaluation was significantly and moderately correlated with both depression and self-esteem.

Those with more negative evaluations of their appearance reported higher levels of depression and lower levels of self-esteem. Degree of obesity was found to be related to body-image evaluation. Heavier participants reported less satisfaction with their appearance. The degree of obesity was also found to be associated with psychological distress. Heavier participants reported higher levels of depression and lower levels of self-esteem. The fourth key finding supports the hypothesis that the relationship between weight and depression/self-esteem is partially mediated by participants' body-image evaluation. In this sample, body-image evaluation accounted for a portion of the correlations of BMI with both depression and self-esteem.

This study demonstrates that body-image dissatisfaction not only partially mediates the relationship between degree of obesity and psychological distress in treatment-seeking individuals, but also is directly related to negative effect and low-self esteem. The researchers propose that body-image dissatisfaction may be a factor that should be evaluated with obese patients seeking residential weight-loss treatment, and when evident, should become one target of intervention efforts.

Section VI. Factors Contributing to Obesity

Overweight & Obesity Causes

The obesity epidemic covered on TV and in the newspapers did not occur overnight. Obesity and overweight are chronic conditions. Overall there are a variety of factors that play a role in obesity. This makes it a complex health issue to address. This section will address how behavior, environment, and genetic factors may have an effect in causing people to be overweight and obese.

The Dietary Guidelines for Americans 2005 found that overweight and obesity are a result of energy imbalance over a long period of time. The cause of energy imbalance for each individual may be due to a combination of several factors. Individual behaviors, environmental factors, and genetics all contribute to the complexity of the obesity epidemic.

• Overweight and obesity result from an energy imbalance. This involves eating too many calories and not getting enough physical activity.
• Body weight is the result of genes, metabolism, behavior, environment, culture, and socioeconomic status.
• Behavior and environment play a large role causing people to be overweight and obese.

The following are the National Center for Chronic Disease Prevention and Health Promotion's definitions for the terms use to quantify weight changes:¹⁸

• Energy imbalance - When the number of calories consumed is not equal to the number of calories used.
• Weight Gain: Calories Consumed > Calories Used
• Weight Loss: Calories Consumed < Calories Used
• No Weight Change: Calories Consumed = Calories Used

Genetics and the environment may increase the risk of personal weight gain. However, the choices a person makes in eating and physical activity also contributes to overweight and obesity. Behavior can increase a person's risk for gaining weight.

Unhealthy Eating Patterns

Although Americans are slowly adopting healthier diets, a large gap remains between recommended dietary patterns and what Americans actually eat. According to the CDC only about one-fourth of U.S. adults eat the recommended five or more servings of fruits and vegetables each day.

Poor eating habits are often established during childhood. More than 60% of young people eat too much fat, and less than 20% eat the recommended five or more servings of fruits and vegetables each day. The following chart developed by the CDC summarizes the percentage of adults who reported eating fewer than five servings of fruits and vegetables a day, by sex.

(Source: CDC, Behavioral Risk Factor Surveillance System)

Calorie Consumption

In the U.S., a changing environment has broadened food options and eating habits. Grocery stores stock their shelves with a greater selection of products. Pre-packaged foods, fast food restaurants, and soft drinks are also more accessible. While such foods are fast and convenient they also tend to be high in fat, sugar, and calories. Choosing many foods from these areas may contribute to an excessive calorie intake. Some foods are marketed as healthy, low fat, or fat-free, but may contain more calories than the fat containing food they are designed to replace. It is important to read food labels for nutritional information and to eat in moderation.

Portion size has also increased. People may be eating more during a meal or snack because of larger portion sizes. This results in increased calorie consumption. If the body does not burn off the extra calories consumed from larger portions, fast food, or soft drinks, weight gain can occur.

How do portions today compare to portions sizes 20 years ago? The National Institutes of Health has developed a Web site to inform people on the increasing portion sizes. Some of their questions include:¹⁹

Calories in a Bagel

Question 1. A bagel 20 years ago was 3 inches in diameter and had 140 calories. How many calories do you think are in today's bagel? Answer: Today's 6-inch bagel has 350 calories. This is 210 more calories than a 3-inch bagel 20 years ago.

Question 2. Now guess how long you will have to rake leaves in order to burn those extra calories? (Based on a 130 lbs person) Answer: If you rake leaves for 50 minutes you will burn approximately 210 calories.

Calories in a Cheeseburger

Question 1. A cheeseburger 20 years ago had 333 calories. How many calories do you think are in today's cheeseburger? Answer: Today's fast food cheeseburger has 590 calories. This is 257 more calories than a portion 20 years ago.

Question 2. Now guess how long you will have to lift weights in order to burn those extra calories? (Based on a 130 lbs person) Answer: If you lift weights for 1 hour and 30 minutes, you will burn approximately 257 calories.

Part of the problem is that the USDA and FDA used different methods and survey data when they each determined uniform serving sizes. The result is that serving sizes found on FDA-regulated labels tend to be larger than serving sizes used in the USDA's food pyramid. Even then both measures are smaller than amount typically consumed by the public.

Calories Used & Physical Activity

Our bodies need calories for daily functions such as breathing, digestion, and daily activities. Weight gain occurs when calories consumed exceed this need. Physical activity plays a key role in energy balance because it uses up calories consumed.

Physical activity is any bodily movement produced by skeletal muscles that result in an expenditure of energy with a range of activities such as:

• Occupational work - Carpentry, construction work, waiting tables, farming
• Household chores - Washing floors or windows, gardening or yard work
• Leisure time activities - Walking, skating, biking, swimming, playing Frisbee, dancing. Structured sports or exercise. Softball, tennis, football, aerobics

Regular physical activity is good for overall health. Physical activity decreases the risk for colon cancer, diabetes, and high blood pressure. It also helps to control weight, contributes to healthy bones, muscles, and joints; reduces falls among the elderly; and helps to relieve the pain of arthritis. Physical activity does not have to be strenuous to be beneficial. Moderate physical activity, such as 30 minutes of brisk walking five or more times a week, can have health benefits.

The Dietary Guidelines for Americans 2005 reports that regular physical activity and physical fitness make important contributions to one's health, sense of well-being, and maintenance of a healthy body weight. Physical activity is defined as any bodily movement produced by skeletal muscles resulting in energy. In contrast, physical fitness is a multi-component trait related to the ability to perform physical activity. Maintenance of good physical fitness enables one to meet the physical demands of work and leisure comfortably. People with higher levels of physical fitness are also at lower risk of developing chronic disease. Conversely, a sedentary lifestyle increases risk for over weight and obesity and many chronic diseases, including coronary artery disease, hypertension, type 2 diabetes, osteoporosis, and certain types of cancer. Overall, mortality rates from all causes of death are lower in physically active people than in sedentary people. Also, physical activity can aid in managing mild to moderate depression and anxiety.

Despite all the benefits of being physically active, most Americans are sedentary. Technology has created many time and labor saving products. Some examples include cars, elevators, computers, dishwashers, and televisions. Cars are used to run short distance errands instead of people walking or riding a bicycle. As a result, these recent lifestyle changes have reduced the overall amount of energy expended in our daily lives. According to the Behavioral Risk Factor Surveillance System, in 2000 more than 26% of adults reported no leisure time physical activity.

The Dietary Guidelines for Americans 2005 found that in 2002, 25% of adult Americans did not participate in any leisure time physical activities in the past month, and in 2003, 38% of students in grades 9 to 12 viewed television 3 or more hours per day.

The belief that physical activity is limited to exercise or sports, may keep people from being active. Another myth is that physical activity must be vigorous to achieve health benefits. Physical activity is any bodily movement that results in an expenditure of energy. Moderate-intensity activities such as household chores, gardening, and walking can also provide health benefits. Confidence in one's ability to be active will help people make choices to adopt a physically active lifestyle.

Environment

People may make decisions based on their environment or community. For example, a person may choose not to walk to the store or work because of a lack of sidewalks. Communities, homes, and workplaces each shape health decisions. With fewer options for physical activity and healthy eating, it becomes more difficult for people to make good choices. The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity identified action steps to prevent and decrease obesity and overweight. The following table lists the steps related to possible environmental factors.

Obesity Demographics

The CDC report Behavioral Risk Factor Surveillance System documents the demographics of obesity based upon age, income, and level of education. The following chart outlines the relationship between family income and obesity.²⁰

The following chart highlights the relationship between obesity and poverty level.

The following chart compares body mass index (BMI), age and health insurance coverage.

Genetic Role

Any explanation of the obesity epidemic has to include both the role of genetics as well as that of the environment. A commonly quoted genetic explanation for the rapid rise in obesity is the mismatch between today's environment and "energy-thrifty genes" that multiplied in the past under rather different environmental conditions. In other words, according to the "thrifty genotype" hypothesis, the same genes that helped our ancestors survive occasional famines are now being challenged by environments in which food is plentiful year round.

It has been argued that the thrifty genotype is just part of a wider spectrum of ways in which genes can favor fat accumulation in a given environment. These ways include the tendency to overeat (poor regulation of appetite and satiety); tendency to be sedentary (physically inactive); diminished ability to use dietary fats as fuel; and enlarged, easily stimulated capacity to store body fat. It is noticeable that not all people living in industrialized countries with abundant food are or will become obese; nor will all obese people suffer the same health consequences. The variation in how people respond to the same environmental conditions suggests that genes also play a role in the development of obesity. This diversity occurs even among groups of the same racial or ethnic background and within families living in the same environment. All of these observations are consistent with the theory that obesity results from the interaction of genetic variation with shifting environmental conditions.

The indirect scientific evidence for a genetic basis for obesity comes from a variety of studies. Mostly, this evidence includes studies of resemblance and differences among family members, twins, and adoptees. Another source of evidence includes studies that have found some genes at higher frequencies among the obese (association studies). These investigations suggest that a sizable portion of the weight variation in adults is due to genetic factors. Identifying these factors, however, has been difficult.

Progress in identifying the multiple genes associated with the most common form of obesity has been slow but is accelerating. As of October 2005 (the latest update of the Human Obesity Gene Map), single mutations in 11 genes were strongly implicated in 176 cases of obesity worldwide. Additionally, 50 chromosomal locations relevant to obesity have been mapped, with potential causal genes identified in most of those regions.

Recently, several independent population-based studies report that a gene of unknown function (FTO, fat mass and obesity-associated gene) might be responsible for up to 22% of all cases of common obesity in the general population. Interestingly, this gene also shows a strong association with diabetes. The mechanism by which this gene operates is currently under intense scientific investigation.

Rising rates of obesity seem to be a consequence of modern life, with access to large amounts of palatable, high calorie food and limited need for physical activity. However, this environment of plenty affects different people in different ways. Some are able to maintain a reasonable balance between energy input and energy expenditure. Others have a chronic imbalance that favors energy input, which expresses itself as overweight and obesity. According to the Office of Genomics and Disease Prevention the following factors are considered in accounting for these differences between individuals.

This means that for people who are genetically predisposed to gain weight, preventing obesity is the best course. Predisposed persons may require individualized interventions and greater support to be successful in maintaining a healthy weight.

1. Obesity is a chronic lifelong condition that is the result of an environment of caloric abundance and relative physical inactivity modulated by a susceptible genotype. For those who are predisposed, preventing weight gain is the best course of action.
2. Genes are not destiny. Obesity can be prevented or can be managed in many cases with a combination of diet, physical activity, and medication.
3. Drugs that will aid in losing weight or maintaining a healthy weight are being developed and are expected to be available in the next few years.
4. People who are affected with overweight and obesity are often victims of stigmatization and discrimination. It is time to stop blaming the victim. Many obesity researchers believe that people who struggle with their weight are pushing against thousands of years of evolution that has selected for storing energy as fat in times of plenty for use in times of scarcity. It is time to recognize their struggle, understand their challenges and support their need for lifelong efforts to achieve better health.

People can't change their genes, but they can change their behavior. Small victories in weight loss - often as little as 10% of total body mass - can result in positive effects on health and well-being, even if an ideal weight remains elusive. Also, the positive effects of regular physical activity include lower blood pressure and increased cardio respiratory fitness' even in people who are significantly overweight. In the longer term, understanding the genetic variations that influence energy metabolism may help us to understand the underlying biological factors that affect weight gain and energy expenditure and develop interventions that capitalize on these insights. Finally, to recognize that obesity may be due to a metabolic condition rather than a flaw in character is important both for the people who are affected and for society as a whole.

The public health messages to prevent overweight emphasize a nutritious diet and daily physical activity. Many who follow this advice from the outset are able to maintain a healthy weight, even with a genetic susceptibility to gain weight. However, these lifestyle interventions have a range of uptake and effectiveness, especially if obesity is already present. For people who are already overweight, the public health interventions aimed at the general population are not a complete solution. Insights from genetics and molecular biology in controlling appetite and activity may provide more effective drug therapies for treatment of affected individuals. As public policy continues to emphasize the importance of diet and exercise as major factors that affect long-term health, public health needs to also seek new approaches-such as considering genetic factors in risk factor assessment and intervention design--to more thoroughly address this complex problem.

Psychological Factors

Most overweight people have no more psychological problems than people of average weight. Still, up to 10 percent of people who are mildly obese and try to lose weight on their own or through commercial weight loss programs have binge eating disorder. This disorder is even more common in people who are severely obese.²¹

During a binge eating episode, people eat large amounts of food and feel that they cannot control how much they are eating. Those with the most severe binge eating problems are also likely to have symptoms of depression and low self-esteem. These people may have more difficulty losing weight and keeping it off than people without binge eating problems.

Those that are upset by binge eating behavior and think they might have binge eating disorder should seek help from a health professional such as a psychiatrist, psychologist, or clinical social worker.

Society has often blamed obesity on the individual feeling that an imperfect body reflects an imperfect person A primary cause of psychological issues for people who are obese is bias against obesity, says William J. Medick, Ph.D. a psychologist who works with morbidly obese patients in the LivLite Weight Management Program. "The prevailing misconception is that obese people are lazy, eat all the time, and lack self discipline," says Dr. Medick. "This can lead to self- blame, guilt, shame, depression and social withdrawal."

Many people eat in response to negative emotions such as boredom, sadness, or anger. It has been observed that women with the most severe eating problems are also likely to have symptoms of depression and low self-esteem. These women may have more difficulty losing weight, and keeping it off, than other people.

Some individuals use food to fill emptiness, provide good feelings, and sooth job pressures and family conflicts. Often eating has nothing to do with hunger. This is emotional eating and change takes energy, willingness and commitment to self- change.

Diseases and Drugs

Some illnesses may lead to obesity or weight gain. These may include Cushing's disease, and polycystic ovary syndrome. Drugs such as steroids and some antidepressants may also cause weight gain.

Weight gain is among side effects listed in official information sheets for some of the most frequently prescribed drugs in the United States. They include drugs taken by tens of millions of people for diabetes, clinical depression, high blood pressure, gastric reflux and heartburn, and serious mental disorders like schizophrenia and bipolar disorder.

"Weight-gain drugs" is how Dr. George A. Bray, an obesity expert at Louisiana State University, described such medications. Dr. Bray has studied why obesity skyrocketed in the United States between 1970 and the 1990s. The number of obese people remained fairly steady - about 20 per cent of men and 15 per cent of women - until the mid-1970s. Then it took off on an upward spiral that by 2000 meant a 100 per cent increase in obesity in men and a 50 per cent rise in women.

Use of prescription drugs rose during that period, and exploded in the 1990s. In 1993, the number of prescriptions written each year edged over the 2 billion mark for the first time. It reached 3 billion by 1999, and will top 4 billion by the end of 2004, according to the Association of Chain Drug Stores. Almost every person in the United States now takes at least one prescription drug a year. Factor in people who take multiple drugs, and doctors write an average 12 prescriptions annually for every person in the country.

Consumers who would never suspect to look in the medicine chest for the cause of their weight gain have few sources of information. Package inserts (which include the official description of a drug's side effects) usually give weight gain short shrift, including those for widely used weight-gain medicines like antidepressants.

Section VII. Weight Loss and Food Plans

Weight Loss Profile

Health care providers generally agree that people who have a BMI of 30 or more can improve their health through weight loss. This is especially true for people who are severely obese.

Preventing additional weight gain is recommended if the individual has a BMI between 25 and 29.9, unless they have other risk factors. Obesity experts recommend they try to lose weight if the individual has two or more of the following:

• Family history of certain chronic diseases. If they have close relatives who have had heart disease or diabetes, you are more likely to develop these problems if you are obese.
• Pre-existing medical conditions. High blood pressure, high cholesterol levels, or high blood sugar levels are all warning signs of some obesity-associated diseases.
• Apple" shape. If their weight is concentrated around the waist, they may have a higher risk of heart disease, diabetes, or cancer than people of the same weight who have a "pear" shape.

Fortunately, a weight loss of 5 to 10 percent can do much to improve health by lowering blood pressure and cholesterol levels. In addition, recent research has shown that a 5 to 7 percent weight loss can prevent type 2 diabetes in people at high risk for the disease.

Benefits of Weight Loss

Although obesity is associated with a number of sometimes serious medical conditions, for most people it is a treatable and manageable chronic condition. Weight loss is an essential part of managing and reducing obesity, as it provides many short and long-term health benefits. Physicians typically recommend that obese people lose approximately 10 percent of their weight to significantly decrease obesity related health risks13. According to recent research, the following health benefits are associated with weight loss:

• Losing five to 15 percent of total body weight can lower an individual's chances for developing heart disease or having a stroke
• Weight loss may improve blood pressure, triglyceride and cholesterol levels, and decrease inflammation throughout the body
• Weight loss of 10 to 15 pounds is likely to slow the development of, and halt the symptoms associated with, knee osteoarthritis
• Weight loss of five to 10 percent of total body weight can raise high-density lipoprotein cholesterol
• For every two pounds lost, low-density lipoprotein cholesterol levels are reduced by one percent

CDC Weight Loss Recommendations

The method of treatment depends on the level of obesity, overall health condition, and motivation to lose weight. Treatment may include a combination of diet, exercise, behavior modification, and sometimes weight-loss drugs. In some cases of severe obesity, gastrointestinal surgery may be recommended. The CDC notes that weight control is a life-long effort.

The CDC recommends that the safest and most effective way to lose weight is to reduce calories and increase physical activity. The CDC also recommends that it is best to consult with the individual's personal physician or health care professional for advice to meet their needs.²²

Government research and recommendations can provide the facts based on science so that people can make informed choices about appropriate weight loss. The fact is the majority of people who are attempting weight loss are not using the correct method to achieve or maintain positive results.

Types of Diets

The National Institute of Diabetes & Digestive & Kidney Diseases lists the following types of diets to consider in developing a nutritional plan. It is important to choose an eating plan that the individual can live with. The plan should also teach how to select and prepare healthy foods, as well as how the person can maintain their new weight. Many people tend to regain lost weight. Eating a healthful and nutritious diet to maintain their new weight, combined with regular physical activity, helps to prevent weight regain.²³

1. Fixed-menu diet. A fixed-menu diet provides a list of all the foods they will eat. This kind of diet can be easy to follow because the foods are selected for them. But, they may get very few different food choices, which may make the diet boring and hard to follow away from home. In addition, fixed-menu diets do not teach the food selection skills necessary for keeping weight off. If they start with a fixed-menu diet, they should switch eventually to a plan that helps them learn to make meal choices on their own, such as an exchange-type diet.
2. Exchange-type diet. An exchange-type diet is a meal plan with a set number of servings from each of several food groups. Within each group, foods are about equal in calories and can be interchanged as they wish. For example, the "starch" category could include one slice of bread or 1/2 cup of oatmeal; each is about equal in nutritional value and calories. If the meal plan calls for two starch choices at breakfast, they could choose to eat two slices of bread, or one slice of bread and 1/2 cup of oatmeal. With the exchange-type diet plans, they have more day-to-day variety and they can easily follow the diet away from home. The most important advantage is that exchange-type diet plans teach the food selection skills they need to keep the weight off.
3. Prepackaged-meal diet. These diets require them to buy prepackaged meals. Such meals may help them learn appropriate portion sizes. However, they can be costly. Before beginning this type of program, they should find out whether they will need to buy the meals and how much the meals cost. They should also find out whether the program will teach them how to select and prepare food, skills that are needed to sustain weight loss.
4. Formula diet. Formula diets are weight-loss plans that replace one or more meals with a liquid formula. Most formula diets are balanced diets containing a mix of protein, carbohydrate, and usually a small amount of fat. Formula diets are usually sold as liquid or a powder to be mixed with liquid. Although formula diets are easy to use and do promote short-term weight loss, most people regain the weight as soon as they stop using the formula. In addition, formula diets do not teach them how to make healthy food choices, a necessary skill for keeping their weight off.
5. Questionable diets. Individuals should avoid any diet that suggests that they eat a certain nutrient, food, or combination of foods to promote easy weight loss. Some of these diets may work in the short term because they are low in calories. However, they are often not well balanced and may cause nutrient deficiencies. In addition, they do not teach eating habits that are important for long-term weight management.
6. Flexible diets. Some programs or books suggest monitoring fat only, calories only, or a combination of the two, with the individual making the choice of both the type and amount of food eaten. This flexible type of approach works well for many people, and teaches them how to control what they eat. One drawback of flexible diets is that some don't consider the total diet. For example, programs that monitor fat only often allow people to take in unlimited amounts of excess calories from sugars, and therefore don't lead to weight loss.

Choosing a Weight Loss Program

Obesity is a chronic condition. Too often it is viewed as a temporary problem that can be treated for a few months with a strenuous diet. However, as most overweight people know, weight control must be considered a life-long effort. To be safe and effective, any weight-loss program must address the long-term approach or else the program is largely a waste of money and effort.

For many people who try to lose weight, it is difficult to lose more than a few pounds and few succeed in remaining at the reduced weight. The difficulty in losing weight and keeping it off leads many people to turn to a professional or commercial weight-loss program for help. These programs are quite popular and are widely advertised in newspapers and on television. What is the evidence that any of these programs are worthwhile, that they will help the individual lose weight and keep it off and that they will do it safely?

The National Task Force on Prevention and Treatment of Obesity, a subcommittee of the National Digestive Diseases Advisory Board, notes that almost any of the commercial weight-loss programs can work, but only if they motivate the person sufficiently to decrease the amount of calories they eat or increase the amount of calories they burn each day (or both). What elements of a weight-loss program should an intelligent consumer look for in judging its potential for safe and successful weight loss?

It is recommended that a responsible and safe weight-loss program should be able to document the five following features:

1. The diet should be safe. It should include all of the Recommended Daily Allowances (RDAs) for vitamins, minerals, and protein. The weight-loss diet should be low in calories (energy) only, not in essential foodstuffs.
2. The weight-loss program should be directed towards a slow, steady weight loss unless a doctor feels that the individual's health condition would benefit from more rapid weight loss. Expect to lose only about a pound a week after the first week or two. With many calorie-restricted diets there is an initial rapid weight loss during the first 1 to 2 weeks, but this loss is largely fluid. The initial rapid loss of fluid also is regained rapidly when the person returns to a normal-calorie diet. Thus, a reasonable goal of weight loss must be expected.
3. If they plan to lose more than 15 to 20 pounds, have any health problems, or take medication on a regular basis, they should be evaluated by their doctor before beginning any weight-loss program. A doctor can assess their general health and medical conditions that might be affected by dieting and weight loss. Also, a physician should be able to advise the individual on the need for weight loss, the appropriateness of the weight-loss program, and a sensible goal of weight loss. If they plan to use a very-low-calorie diet (a special liquid formula diet that replaces all food intake for I to 4 months), they definitely should be examined and monitored by a doctor.
4. The program should include plans for weight maintenance after the weight loss phase is over. It is of little benefit to lose a large amount of weight only to regain it. Weight maintenance is the most difficult part of controlling weight and is not consistently implemented in weight-loss programs. The program they select should include help in permanently changing the person's dietary habits and level of physical activity, to alter a lifestyle that may have contributed to weight gain in the past. The program should provide behavior modification help, including education in healthy eating habits and long-term plans to deal with weight problems. One of the most important factors in maintaining weight loss appears to be increasing daily physical activity, often by sensible increases in daily activity, as well as incorporating an individually tailored exercise program.
5. A commercial weight-loss program should provide a detailed statement of fees and costs of additional items such as dietary supplements.

Good Nutrition Plans

In developing a meal plan, the National Institutes of Health (NIH) recommends that a patient's diet contains all the essential nutrients for good health. Using the Food Guide Pyramid and the Nutrition Facts Label that is found on most processed food products can help the person choose a healthful diet. The Pyramid shows the kinds and amounts of food that they need each day for good health. The Nutrition Facts Label will help the individual select foods that meet their daily nutritional needs. A healthful diet should include:

• Adequate vitamins and minerals. Eating a wide variety of foods from all the food groups on the Food Guide Pyramid will help them get the vitamins and minerals they need. If they eat less than 1,200 calories per day, they may benefit from taking a daily vitamin and mineral supplement.
• Adequate protein. The NIH recommends that the average woman 25 years of age and older should get 50 grams of protein each day, and the average man 25 years of age and older should get 63 grams of protein each day. Adequate protein is important because it prevents muscle tissue from breaking down and repairs all body tissues such as skin and teeth. To get adequate protein in the diet, make sure they eat 2-3 servings from the Meat, Poultry, Fish, Dry Beans, Eggs, and Nuts Group on the Food Guide Pyramid every day. These foods are all good sources of protein.
• Adequate carbohydrates. At least 100 grams of carbohydrates per day are needed to prevent fatigue and dangerous fluid imbalances. To make sure they get enough carbohydrates, eat 6-11 servings from the Bread, Cereal, Rice, and Pasta Group on the Food Guide Pyramid every day.
• A daily fiber intake of 20 to 30 grams. Adequate fiber helps with proper bowel function. If you were to eat one cup of bran cereal, 1/2 cup of carrots, 1/2 cup of kidney beans, a medium-sized pear, and a medium-sized apple together in one day, you would get about 30 grams of fiber.
• No more than 30 percent of calories, on average, from fat per day, with less than 10 percent of calories from saturated fat (such as fat from meat, butter, and eggs). Limiting fat to these levels reduces your risk for heart disease and may help you lose weight. In addition, you should limit the amount of cholesterol in your diet. Cholesterol is a fat-like substance found in animal products such as meat and eggs. A diet should include no more than 300 milligrams of cholesterol per day (one egg contains about 215 milligrams of cholesterol, and 3.5 ounces of cooked hamburger contain 100 milligrams of cholesterol).
• At least 8 to 10 glasses, 8 ounces each, of water or water-based beverages, per day. People need more water if they exercise a lot.

Fad Diets

Quick-fix weight loss programs abound, making claims of easy, no-fail weight loss. Some are yo-yo diets where the individuals put the weight back on when they stop the diet, some severely restrict caloric intake, and still others proclaim the superiority of one particular food item or group.

Generally speaking, no "miracle diets" exist. Some dieting fads consider fluid loss equivalent to weight loss, but little actual fat is lost.

The American Dietetic Association has previously recommended that when considering one or more popular diets or exercise plans, the individual owes it to themselves and their health to make sure the claims are valid. The questions that should be asked are: Does the diet plan:

• Promise a quick fix?
• Encourage or require you to stop eating certain foods, food groups or products?
• Rely on a single study as the basis for its recommendations?
• Contradict recommendations of reputable health organizations?
• Identify "good" and "bad" foods?
• Just sound too good to be true?

If the answer is "Yes" to any of these questions, the ADA recommends that the person keep looking for a plan that is backed by solid science, lets the individual keep eating their favorite foods and allows for flexibility. The best source for help in making healthful changes to any diet is a dietetic professional with the training and expertise to help develop an eating plan that is right for the individual.

The "Mediterranean" Diet

Another diet that has become popular is the Mediterranean diet. The American Heart Association reports that there is no one Mediterranean diet. At least 16 countries border the Mediterranean Sea. Diets vary between these countries and also between regions within a country. Many differences in culture, ethnic background, religion, economy and agricultural production result in different diets.

The Mediterranean diet incorporates the basics of healthy eating, plus a splash of flavorful olive oil and perhaps a glass of good red wine, among other components characterizing the traditional cooking style of countries bordering the Mediterranean Sea.

Most healthy diets include fruits and vegetables, fish and whole grains, and limit unhealthy fats. While these fundamental parts of a healthy diet remain tried and true, subtle variations or differences in proportions of certain foods may make a difference in your risk of heart disease.

Benefits of the Mediterranean diet

According to the Mayo Clinic, the Mediterranean eating style significantly reduces the risk of further heart disease in individuals who had already had a heart attack. Remarkably, this benefit was not related to any significant difference in cholesterol levels - rather other components of the diet seem to work in concert to protect the body.²⁴

Key components of the Mediterranean diet include:

• Eating a generous amount of fruits and vegetables
• Consuming healthy fats such as olive oil and canola oil
• Eating small portions of nuts
• Drinking red wine, in moderation, for some
• Consuming very little red meat
• Eating fish on a regular basis

Fruits, vegetables and grains

The traditional diet among some Mediterranean countries includes fruits, vegetables, pasta and rice. For example, residents of Greece eat very little red meat and average nine servings a day of antioxidant-rich fruits and vegetables. This eating pattern has been associated with a lower level of low-density lipoprotein (LDL) oxidation - a change in LDL cholesterol (the "bad" cholesterol) that makes it more likely to build up deposits in arteries.

Grains in the Mediterranean region typically contain very few unhealthy trans fats, and bread is an important part of the diet there. However, throughout the Mediterranean region, bread is eaten without butter or margarines, which contain saturated fat or trans fats.

Healthy fats

The Mediterranean diet doesn't view all fat as bad. The focus of the diet isn't to limit total fat consumption, but to make wise choices about the types of fat.

The Mediterranean diet is similar to the American Heart Association's Step I diet, but it contains less cholesterol and has more fats that contain the beneficial linolenic acid (a type of omega-3 fatty acid). These fat sources include olive oil, canola oil and nuts, particularly walnuts. Fish - another source of omega-3 fatty acids - is eaten on a regular basis in the Mediterranean diet. Studies have shown that omega-3 fatty acids lower triglycerides and may provide an anti-inflammatory effect helping to stabilize the blood vessel lining. The Mediterranean diet discourages saturated fats and hydrogenated oils (trans-fatty acids), both of which contribute to heart disease.

Choosing oils and fats

Olive oil. All types of olive oil provide monounsaturated fat, but "extra-virgin" or "virgin" oil are the least processed forms, and so contain the highest levels of the protective plant compounds that provide antioxidant effects.

Nuts. Nuts are high in fat - up to 80 percent of their calories - but tree nuts, including walnuts, pecans, almonds and hazel nuts, are low in saturated fat. Walnuts also contain omega-3 fatty acids. Nuts are high in calories, so they should not be eaten in large amounts - generally no more than a handful a day.

Wine

The Mayo Clinic reports that the health effects of alcohol have been debated for many years, and some doctors are reluctant to encourage alcohol consumption because of the health consequences of excessive drinking. However, light intake of alcohol is associated with a reduced risk of heart disease.

Red wine has an aspirin-like effect, reducing the blood's ability to clot, and also contains antioxidants. The Mediterranean diet typically includes some red wine, but this should be consumed only in moderation. This means no more than one 5-ounce glass of wine daily for women (or men over age 65), and no more than two 5-ounce glasses of wine daily for men under age 65. Any more than this increases the risk of health problems, including increased risk of certain types of cancer.

If the individual is unable to limit their alcohol intake, they have a personal or family history of alcohol abuse, or they have liver disease, they should refrain from drinking wine or any other alcohol. Red wine may also trigger migraines in some people.

Putting it all together

• Eat natural peanut butter, rather than the kind with hydrogenated fat added.
• Use butter sparingly, and don't think that "low fat" or "cholesterol-free" on the label means a product is necessarily good for you. Many of these items are made with trans fats.
• Eat a variety of whole fruits and vegetables every day. Ultimately, strive for seven to 10 servings a day. Keep baby carrots, apples and bananas on hand for quick, satisfying snacks. Fruit salads are a wonderful way to eat a variety of healthy - and tasty - fruit.
• Use canola or olive oil in cooking. Try olive oil for salad dressing and as a healthy replacement for butter or margarine. After cooking pasta, add a touch of olive oil, some garlic and green onions for flavoring. Dip bread in flavored olive oil or lightly spread it on whole-grain bread for a tasty alternative to butter.
• Substitute fish and poultry for red meat. Avoid sausage, bacon and other high-fat meats.
• Limit higher fat dairy products such as whole or 2% milk, cheese and ice cream. Switch to skim milk, fat-free yogurt and low-fat cheese.
• Eat fish once or twice a week. Water-packed tuna, salmon, trout, mackerel and herring are healthy choices.. Avoid fried fish, unless it's sauteed in a small amount of olive oil.
• Keep walnuts, almonds, pecans and Brazil nuts on hand for a quick snack.

In January 1993, the Harvard University School of Public Health and Oldways Preservation & Exchange Trust (a Boston based educational organization) held a conference on the Mediterranean diet and its impact on public health. They reviewed data from a variety of epidemiological studies that described the dietary traditions of the people from the Mediterranean area (Crete, Greece, Southern Italy and Northern Africa) which may be responsible for the low rates of chronic disease. From this committee, the Mediterranean Food Guide Pyramid was developed.

This pyramid, representing a healthy, traditional Mediterranean diet, is based on the dietary traditions of Crete, much of the rest of Greece and southern Italy circa 1960, structured in light of current nutrition research.

The design of the pyramid is not based solely on either the weight or the percentage of energy (calories) that foods account for in the diet, but on a blend of these that is meant to give relative proportions and a general sense of frequency of servings, as well as an indication of which foods to favor in a healthy Mediterranean-style diet. The pyramid describes a diet for most healthy adults. Whether changes would need to be made for children, women in the reproductive years, and other special population groups is an issue that needs further consideration.

Section VIII. CDC Weight Management Recommendations

Weight Management Research to Practice Series

The Weight Management Research to Practice Series is designed to summarize the science on a weight management topic for health professionals. The series is developed by a collaborative multi-disciplinary workgroup consisting of DNPA behavioral scientists, epidemiologists, and communication specialists.²⁵

Energy Density

Energy density is the relationship of calories to the weight of food (calories per gram). For the same number of calories, people can eat foods with low energy density in greater volume than foods with high energy density. This helps people feel full and yet consume fewer calories. Limitation of intake need not be based on calories.

CDC research supports the conclusion that replacing foods of high energy density (high calories per weight of food) with foods of lower energy density, such as fruits and vegetables, can be an important part of a weight management strategy.

Extensive research has been conducted on the relationships between calories, amount of food eaten and body weight. The association of this information with the role of fruits and vegetables in weight management can be summarized as follows:

• To lose weight a person must eat fewer calories than what he or she expends.
• People may not limit what they consume based on calories alone. Feeling full is one reason that people stop eating. Short-term studies indicate that the volume of food people eat at a meal is what makes them feel full and stop eating, rather than the calorie content of the food.
• At the same calorie level, foods with low energy density provide a greater volume of food, which may help people feel full at a meal while consuming fewer calories.
• Water and fiber increase the volume of foods and reduce energy density. In their natural state, fruits and vegetables have high water and fiber content and thus are low in calories and energy density.
• Fruits and vegetables are good substitutes for foods of high energy density.

Foods high in energy density have a large number of calories relative to their weight or volume (4 to 9 calories per gram of weight). Foods high in energy density include low-moisture foods like crackers and cookies or high-fat foods like butter and bacon.

Foods with medium energy density range from 1.5 to 4 calories per gram of weight. Examples include hard-boiled eggs, dried fruits, bagels, broiled lean sirloin steak, hummus, grape jelly, whole wheat bread, and part-skim mozzarella

Foods low in energy density have 0.7 to 1.5 calories per gram; those very low in energy density range from 0 to 0.6 calories per gram. Examples of foods in these two groups include tomatoes, cantaloupe, broth-based soups, fat free cottage cheese, fat free yogurt, strawberries, broccoli, and turkey breast roasted with no skin. Most fresh fruits and vegetables fall into one of these two categories.

Fat increases the energy density of foods, while water and fiber decrease energy density. Water has the greatest impact on energy density because it adds weight to food without increasing calories, thus decreasing energy density. Most fruits and vegetables are low in energy density because of their high water and fiber content and their low fat content.

The popular term "comfort food" succinctly provides one reason: people eat foods that make them feel good, that give them comfort. The CDC reports short-term studies (mostly conducted over several days with limited food options) indicate that feeling full is more likely to make a person stop eating than is the total caloric content of the food consumed. Many people believe that consuming high-calorie foods will make them feel full, provided contrary evidence. In their study 20 obese and nonobese participants ate as much as they wanted over 5 days from a diet that alternated from low-energy-density to high-energy-density foods. On the low-energy-density diet, the participants felt full with just over half the calories (1570 kcal) they needed to feel full on the high-energy-density diet (3000 kcal).

Different aspects of the environment may act as cues to consume more food than people realize. It is important that people understand how their surroundings can influence their calorie intake so they can make simply changes within their environments.

• Package size may influence consumption. For some reason, the larger the package, the more people consume from it without realizing it. To minimize this effect, encourage patients or clients to
• Divide up the contents of one large package into several smaller containers to help avoid over consumption.
• Don't eat straight from the package. Instead, serve a reasonable portion in a bowl or container.
• Out of sight, out of mind. People tend to consume more when they have easy access to food. Advise patients or clients to make their home a "portion friendly zone."
• Get rid of the candy dish, or better yet, replace it with a fruit bowl.
• Place especially tempting foods, like cookies, chips, or ice cream, out of immediate eyesight, like on a high shelf or at the back of the freezer. Move the healthy fare to the front at eye level.
• When buying in bulk, store the excess in a place that's not convenient to get to, such as in a garage or basement.

The CDC recommends that practitioners who advise their patients or clients to substitute fruits and vegetables for foods of high energy density as part of a weight management strategy might consider including the information.

To lose weight, people must eat fewer calories than they expend. Adding fruits and vegetables to an existing eating plan that supplies sufficient calories or has more calories than needed can cause the person to gain weight. Fruits and vegetables should be substituted for foods high in energy density.

• To lower the energy density of foods, such as soups, sandwiches, and casseroles, substitute fruits and vegetables for some of the ingredients that have higher energy density, such as high-fat meat, cheese, and pasta. For example, vegetables such as carrots, broccoli, mushrooms, and celery can be added to a chicken noodle casserole, thereby lowering the energy density of a fixed amount (e.g., 1 cup) of the altered dish in relation to 1 cup of the original casserole. Lettuce, tomatoes, onions, and other sliced vegetables can be added to sandwiches while decreasing the amount of high-fat meat or cheese. Many different vegetables can be added to pasta sauce.
• The way fruits and vegetables are prepared and consumed makes a big difference in their effect on weight. Techniques such as breading and frying, adding high-fat dressings and sauces, and as part of a high-calorie dessert greatly increase the calorie and fat content of the dish even if it includes fruits and vegetables.
• Whole fruit is lower in energy density and more satiating than fruit juices. Pulp-free fruit juices lose their fiber content in the process of juicing. For weight control purposes, the whole fruit contains added fiber that helps make one feel full.
• Are canned and frozen fruits and vegetables just as good as fresh? Frozen and canned fruits and vegetables are good options when fresh produce is not available. Consumers should be careful, however, to choose those without added sugar, syrup, cream sauces, or other ingredients that will increase calories, thereby raising the energy density. Additionally, consumers should be aware that frozen and canned fruits and vegetables sometimes contain added salt, which is not in fresh produce.

Portion Size

Portion sizes, have increased significantly over the past 2 decades. Restaurant meals of all kinds have gotten larger with an emphasis on getting more food for the money. However, the rise of portion sizes is not limited to restaurants alone. Bags of snack foods or soft drinks in vending machines and the grocery store are offered in larger and larger sizes that contain multiple servings while a 1-ounce bag of snack food or an 8-ounce soft drink, which are the recommended single serving sizes, are very difficult to find. Americans are surrounded by larger portion sizes at relatively low prices, appealing to the consumer's economic sensibilities.

Eating in restaurants offers many opportunities to encounter large portion sizes. The CDC reports the number of eating establishments in the United States increased by 75 percent between 1977 and 1991. While Americans have many choices in restaurants, the food (especially from fast food restaurants) is often very cheap and available in large quantities. The frequency of eating out, particularly at fast-food restaurants, is associated with an increase in energy and fat intake and with a higher body mass index.

Even those who do not frequent restaurants are confronted with large portion sizes of prepackaged or convenience foods. The current weight of ready-to-eat foods was compared with past weights using data from manufacturers. Portion sizes of these foods began increasing in the 1970s and have continued to do so through today to the point where most exceed federal serving size standards.

Even though there is information available about appropriate serving sizes, people generally do not correctly assess the amount they are eating. Often people are unable to tell the differences in portion size when offered different sizes on different days. Although the ability to accurately determine appropriate amounts of food to eat is important, there is little research to suggest which methods would be most successful in helping people estimate appropriate serving sizes. The CDC states that characteristics of people (gender, age, body weight, level of education) cause differences in the way they estimate portion size, and error in estimating becomes greater as portions increase. In addition, physiologic satiety cues are readily overridden by food cues, such as large portions, easy access, and the sensory attractiveness of food.

In addition to food cues, other factors add to the effect of portion size, causing people to eat more than they need, particularly in a restaurant setting. Eating out can affect energy intake not only because of portion size, but also by convivial atmosphere, tendency to choose foods with high energy density, and alcohol consumption.

The research suggests that people inadvertently consume more calories when faced with larger portions. The CDC recommends that practitioners counsel their patients and clients with the following suggestions:

• Portion control when eating out. Many restaurants serve more food than is appropriate for one person. Encourage your patients or clients to control the amount of food that ends up on their plate by splitting an entrée with a friend, or asking the waiter to put half of the meal in a "doggie bag" before it's even brought to the table.
• Portion control when eating in. To minimize the temptation of second and third helpings when eating at home, people should serve reasonable portions on individual plates, instead of putting the serving dishes on the table. Keeping the excess food out of reach may discourage inadvertent overeating.
• Portion control in front of the TV. When eating or snacking in front of the TV, encourage people to put a reasonable amount of food into a bowl or container, and leave the rest of the package in the kitchen. It's easy to overeat when a person's attention is focused on something else.
• Controlling hunger between meals. Encourage patients or clients to eat a snack, like a piece of fruit or small salad, if they feel hungry between meals to avoid overeating during the meal.

Section IX. Obesity Related Surgery

Gastrointestinal Surgery

Severe obesity is a chronic condition that is difficult to treat through diet and exercise alone. Gastrointestinal surgery is the best option for people who are severely obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems. The surgery promotes weight loss by restricting food intake and, in some operations, interrupting the digestive process. As in other treatments for obesity, the best results are achieved with healthy eating behaviors and regular physical activity.

The concept of gastrointestinal surgery to control obesity grew out of results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine. Because patients undergoing these procedures tended to lose weight after surgery, some physicians began to use such operations to treat severe obesity.

Gastrointestinal surgery for obesity, also called bariatric surgery, alters the digestive process. The operations promote weight loss by closing off parts of the stomach to make it smaller. Operations that only reduce stomach size are known as "restrictive operations" because they restrict the amount of food the stomach can hold.

Some operations combine stomach restriction with a partial bypass of the small intestine. These procedures create a direct connection from the stomach to the lower segment of the small intestine, literally bypassing portions of the digestive tract that absorb calories and nutrients. These are known as malabsorptive operations.

Patient Selection

The option of surgical treatment should be offered to patients who are morbidly obese, well informed, motivated, and acceptable operative risks. The patient should be able to participate in treatment and long term follow-up. Some patients with manifest psychopathology that jeopardizes an informed consent and cooperation with long term follow up may need to be excluded. A decision to elect surgical treatment requires an assessment of the risk and benefit in each case. Increased abdominal fat or "central obesity" (apple shaped as opposed to pear shaped) is an important risk factor associated with the major complications of obesity.

Functional impairments associated with obesity are also important deciding factors for surgical treatment. An important conclusion of the 1991 National Institutes Consensus Development Conference Statement on the surgical treatment of obesity was that "patients judged by experienced clinicians to have a low probability of success with non-surgical measures, as demonstrated, for example, by failure in established weight control programs or reluctance by the patient to enter such a program, may be considered for surgical treatment".

The National Institute of Health reports that patients whose BMI exceeds 40 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. They must clearly and realistically understand how their lives may change after operation.

In certain circumstances, less severely obese patients (with BMI's between 35 and 40) also may be considered for surgery. Included in this category are patients with high risk co-morbid conditions such as life threatening cardiopulmonary problems (e.g. severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy, or severe diabetes mellitus). Other possible indications for patients with BMI's between 35 and 40 include obesity-induced physical problems that are interfering with lifestyle (e.g. musculoskeletal or neurologic or body size problems precluding or severely interfering with employment, family function and ambulation).

Some candidates for surgical treatment of severe obesity have such impaired health that they must be hospitalized pre-operatively and undergo treatment to improve their operative risk.²⁶

Weight-loss surgery remains rare, despite the fact that about a third of adult Americans are obese -- and despite evidence that the procedures improve overall health. Only an estimated 1% of the nation's 15 million morbidly obese people, typically those who are 100 pounds or more overweight, have undergone surgery. That may be partly due to the fact that the most popular weight-loss surgery to date has been gastric bypass, a more invasive procedure.

Restrictive Operations

Purely restrictive operations only limit food intake and do not interfere with the normal digestive process. To perform the operation, doctors create a small pouch at the top of the stomach where food enters from the esophagus. At first, the pouch holds about 1 ounce of food and later may stretch to 2-3 ounces. The lower outlet of the pouch is usually about ½ inch in diameter or smaller. This small outlet delays the emptying of food from the pouch into the larger part of the stomach and causes a feeling of fullness.

After the operation, patients can no longer eat large amounts of food at one time. Most patients can eat about ½ to 1 cup of food without discomfort or nausea, but the food has to be soft, moist, and well chewed. Patients who undergo restrictive procedures generally are not able to eat as much as those who have combined operations.

Purely restrictive operations for obesity include adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG).

Adjustable gastric banding. In this procedure, a hollow band made of silicone rubber is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the rest of the stomach. The band is then inflated with a salt solution through a tube that connects the band to an access port placed under the skin. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution. Improvements in surgical techniques and follow-up care have helped gastric banding become the dominant weight-loss operation in Europe and Australia.

Vertical banded gastroplasty. VBG uses both a band and staples to create a small stomach pouch, as illustrated in figure 3. Once the most common restrictive operation, VBG is not often used today.

Advantages: Restrictive operations are easier to perform and are generally safer than malabsorptive operations. AGB is usually done via laparoscopy, which uses smaller incisions, creates less tissue damage, and involves shorter operating time and hospital stays than open procedures. Restrictive operations can be reversed if necessary, and result in few nutritional deficiencies.

Disadvantages: Patients who undergo restrictive operations generally lose less weight than patients who have malabsorptive operations, and are less likely to maintain weight loss over the long term. Patients generally lose about half of their excess body weight in the first year after restrictive procedures. However, in the first 3 to 5 years after VBG patients may regain some of the weight they lost. By 10 years, as few as 20 percent of patients have kept the weight off. (Although there is less information about long-term results with AGB, there is some evidence that weight loss results are better than with VBG.) Some patients regain weight by eating high-calorie soft foods that easily pass through the opening to the stomach. Others are unable to change their eating habits and do not lose much weight to begin with. Successful results depend on the patient's willingness to adopt a long-term plan of healthy eating and regular physical activity.

Risks: One of the most common risks of restrictive operations is vomiting, which occurs when the patient eats too much or the narrow passage into the larger part of the stomach is blocked. Another is slippage or wearing away of the band. A common risk of AGB is breaks in the tubing between the band and the access port. This can cause the salt solution to leak, requiring another operation to repair. Some patients experience infections and bleeding, but this is much less common than other risks. Between 15 and 20 percent of VBG patients may have to undergo a second operation for a problem related to the procedure. Although restrictive operations are the safest of the bariatric procedures, they still carry risk-in less than 1 percent of all cases, complications can result in death.

Because combined operations result in greater weight loss than restrictive operations, they may also be more effective in improving the health problems associated with severe obesity, such as hypertension (high blood pressure), sleep apnea, type 2 diabetes, and osteoarthritis

Combined Restrictive-Malabsorptive Operations

Combined operations are the most common bariatric procedures. They restrict both food intake and the amount of calories and nutrients the body absorbs.²⁷

Roux-en-Y gastric bypass (RGB). This operation, is the most common and successful combined procedure in the United States. First, the surgeon creates a small stomach pouch to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This reduces the amount of calories and nutrients the body absorbs. Rarely, a cholecystectomy (gall bladder removal) is performed to avoid the gallstones that may result from rapid weight loss. More commonly, patients take medication after the operation to dissolve gallstones.

Biliopancreatic diversion (BPD). In this more complicated combined operation, the lower portion of the stomach is removed. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure leads to weight loss, it is used less often than other types of operations because of the high risk for nutritional deficiencies. A variation of BPD includes a "duodenal switch", which leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum in the digestive pathway. The larger stomach allows patients to eat more after the surgery than patients who have other types of procedures.

Advantages: Most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. With the Roux-en-Y gastric bypass, many patients maintain a weight loss of 60 to 70 percent of their excess weight for 10 years or more. With BPD, most studies report an average weight loss of 75 to 80 percent of excess weight. Because combined operations result in greater weight loss than restrictive operations, they may also be more effective in improving the health problems associated with severe obesity, such as hypertension (high blood pressure), sleep apnea, type 2 diabetes, and osteoarthritis.

Disadvantages: Combined procedures are more difficult to perform than the restrictive procedures. They are also more likely to result in long-term nutritional deficiencies. This is because the operation causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and related bone diseases. Patients must take nutritional supplements that usually prevent these deficiencies. Patients who have the biliopancreatic diversion procedure must also take fat-soluble (dissolved by fat) vitamins A, D, E, and K supplements, and require life-long use of special foods and medications.

RGB and BPD operations may also cause "dumping syndrome," an unpleasant reaction that can occur after a meal high in simple carbohydrates, which contain sugars that are rapidly absorbed by the body. Stomach contents move too quickly through the small intestine, causing symptoms such as nausea, bloating, abdominal pain, weakness, sweating, faintness, and sometimes diarrhea after eating. Because the duodenal switch operation keeps the pyloric valve intact, it may reduce the likelihood of dumping syndrome.

Bariatric Surgery for Adolescents

With rates of overweight among youth on the rise, bariatric surgery is sometimes considered as a treatment option for adolescents who are severely overweight. However, there are many concerns about the long-term effects of this type of operation on adolescents' developing bodies and minds. Experts in pediatric overweight and bariatric surgery recommend that surgical treatment only be considered when adolescents have tried for at least 6 months to lose weight and have not been successful. Candidates should be severely overweight (BMI of 40 or more), have reached their adult height (usually 13 or older for girls, 15 or older for boys), and have serious weight-related health problems such as type 2 diabetes or heart disease. In addition, potential patients and their parents should be evaluated to see how emotionally prepared they are for the operation and the lifestyle changes they will need to make.

Surgery Expense

Bariatric procedures cost from $20,000 to $35,000. Medical insurance coverage varies by state and insurance provider. Insurers are slowly loosening their purse strings. The federal agency that oversees the Medicare program instituted coverage for bariatric surgery in early 2006. That was followed by a favorable assessment on gastric banding last year from the BlueCross BlueShield Association, whose member health plans look to it for guidance. In September, the federal Tricare program, which provides coverage for 9.2 million active and retired U.S. military pers