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 personnel, as well as their families, said it would cover gastric banding, retroactive to February 2007.

Childbearing

Women of childbearing age who elect to have weight reduction operations must use secure birth control methods during the period of rapid weight loss. They should be informed that maternal malnutrition may impair normal fetal development. This is particularly important to those who may have previously failed to conceive, since fertility may increase following weight loss. Indeed, failure to conceive in the face of morbid obesity is yet another positive indication for weight loss surgery. Women who become pregnant after these surgical procedures need specific attention from the surgical care team. However, there are several reports in the literature of pregnancy outcomes following gastric bypass without evidence of fetal impairment.

Nutritional Consequences of Gastric Restrictive Surgery

Gastric restrictive surgery in the motivated, cooperative patient, who has been educated in the nutritional requirements to maintain adequate protein/calorie/mineral/vitamin intake, routinely results in a smooth post-operative course, with some protein deficit in the first 3 postoperative months, which is completely restored 18 months after surgery, by which time the patient will have re-established a lean body mass appropriate to the total body weight.

Pure gastric restrictive procedures such as vertical banded gastroplasty (VBG), silastic ring gastroplasty (SRG) and adjustable silastic gastric banding (AGB) all achieve weight loss by restricting volume of intake. Intake becomes a function of the patients motivation to chew well and eat slowly. Failure to do so may result in repeated vomiting and isolated cases of protein and vitamin deficiency have been reported in these circumstances. Careful patient follow up is therefore mandatory, with particular emphasis on the first three postoperative months. Adjustable silastic gastric banding (AGB) approved in 2001 for use in the USA following FDA trials can be considered functionally similar to vertical banded gastroplasty.

Gastric bypass with Roux-y (RGB) results in ingested food bypassing the gastric fundus, body, antrum, duodenum and a variable length of proximal jejunum. In consequence, these patients are at risk to develop iron deficiency secondary to lack of contact of food iron with gastric acid and consequent reduced conversion of iron from the relatively insoluble ferrous to the more absorbable ferric form. In addition, vitamin B12 deficiency may result in consequence of food no longer coming in contact with gastric intrinsic factor. Vitamin D and calcium absorption may also be reduced since the duodenum and proximal jejunum, which are the preferential sites of absorption, are bypassed by this procedure. Life long supplements of multivitamins, vitamin B12 iron and calcium are mandatory following this procedure. A corollary of this is the need for long term follow up for physical, nutritional and metabolic evaluation and counseling.

The National Institute of Health reports that there are two reasons for pre-operative psychological testing prior to bariatric surgery. One is to identify those with significant psychopathology in whom surgery would be contra-indicated, the other to pre-select those in whom the surgery is likely to be a success.

Studies of severely overweight persons conducted before their undergoing anti-obesity surgery show:

• There is no single personality type that characterizes the severely obese
• The population does not report greater levels of psychopathology than do average-weight control subjects
• Complications specific to severe obesity include body image disparagement and binge eating

Studies conducted after surgical treatment and weight loss show that:

• Self esteem and positive emotions increase
• Body image disparagement decreases;
• Marital satisfaction increases, but only if a measure of satisfaction existed before surgery
• Eating behavior is improved dramatically. The results of surgical treatment are superior to those of dietary treatment alone

Practitioners should be aware that severely obese persons are subjected to prejudice and discrimination and should be treated with an extra measure of compassion and concern to help alleviate their feelings of rejection and shame.

When a patient is considered for bariatric surgery, The American Society for Metabolic & Bariatric Surgery recommends that their general health, with the idea of identifying those for whom surgery is too risky and those who have conditions that need to be treated, stabilized, or managed for surgery to be worth its risk is ascertained.

Patients are typically faced with initial dietary restrictions, permanent changes in eating and dietary habits, altered body sensations and experiences, shifting body image and self care behaviors, new cognitions and feelings, and an emerging and different lifestyle. In addition, they may realize sometimes unexpected and significant changes in relationships that may result in marked stress. Bariatric surgery is a highly effective procedure that not only reconfigures and/or restricts a patient's stomach, but significantly affects their psyche as well. Generally patients will need a secure identity, sound psychological resources, resiliency, effective coping strategies, and willingness to access meaningful support from others.

Previous Attempts at Weight Management

It is well documented that non-surgical attempts at weight management for patients with morbid obesity have little if any long-term efficacy. Nonetheless, a thorough weight and diet history can provide valuable information regarding the psychological, behavioral, and physiological contributors to the progression of morbid obesity. Patterns of loss and regain provide information regarding eating habits and lifestyle as well as behavioral and emotional factors that have contributed to past successes or failures-and may be relevant post surgery.

Eating and Dietary Styles

The assessment of dietary habits and eating styles provide the clinician with vital information that not only points to the client's readiness for surgery but may indicate issues that will either support or interfere with issues of post surgical compliance and adherence. Tracking eating behaviors over time and across situations (e.g., stressful situations or holidays) can offer valuable insights and information regarding these issues. If the candidate demonstrates difficulties in one or more of these areas, make an effort to identify these areas of vulnerability, help the client predict and prepare for these situations, and propose appropriate interventions.

Assessing how a particular mindset influences eating can also provide important information. For example, it may be useful to track changes in eating and drinking habits prior to the time the client made the decision to pursue a bariatric surgical procedure, those habits at the time of making the decision to become a surgery candidate, and after attending the information (or orientation) seminar for surgery. Documenting the candidate's efforts over time to modify eating behavior and fluid intake and to cultivate a healthy lifestyle can serve to capture the degree to which the candidate understands the basic principles of healthy eating, reveal whether the candidate is motivated to modify behavior, and suggest the extent to which unhealthy eating (and other unhealthy lifestyle habits) is ingrained.

Accurately distinguishing between different types of maladaptive eating behaviors serves many purposes. Primarily it helps delineate maladaptive patterns of eating that are subsequent to dieting and restriction versus those styles of eating that are clearly emotionally driven.

• Binge eating: Studies suggest that approximately 30% of individuals presenting for the treatment of obesity engage in binge eating.1 It is important to distinguish between binge eating that is driven by psychological factors and binge eating that is driven by physiological factors. The direct biological consequences of semi starvation and restricted eating include preoccupation with food, increased pressures to eat, and the likelihood of binge eating. Other types of physiologically driven binge eating may be triggered if eating is initiated in an intense state of hunger (reactive overeating) or if restrained eating is disrupted via disinhibition or counterregulation.
• Overeating: Overeating may represent a lack of interoceptive awareness and an inability to discern internal cues such as hunger, appetite, satiety, or fullness. Alternatively, overeating may represent a conscious decision to eat "just because" or eating that is more emotionally driven. Many times early incidences of binge eating convert to discrete periods of overeating that are no longer hallmarked by the indicators of control associated with binge eating.
• Grazing: Grazing may stem from habit and mindlessness or may be compulsive or emotional in nature.
• " Night eating syndrome: This is defined as skipping breakfast more than 4 days per week, consuming more than 50% of calories after 7 PM, and difficulty falling asleep or staying asleep more than 4 days per week. The prevalence of night eating syndrome in presurgical bariatric candidates has been reported to be as high as 26% and as high as 27% in a bariatric sample 32 months after surgery.

Physical Activity and Inactivity

Physical activity and fitness are related to improved health and quality of life, while physical inactivity is related to increased risk for cardiovascular disease and has been implicated in the development of obesity. Some candidates report having a moderate activity program in place that is appropriate to their body size, shape, and physical limitations. Others may describe an almost entirely sedentary lifestyle. All candidates should understand the relationship between physical activity and lifelong management of morbid obesity and optimal states of physical and psychological health. Some patients seem more amenable to incorporating body movement into their daily lives when: it is fun, and/or it is done for the purpose of disease management (to improve cardiovascular fitness), it is used as a stress releaser, it improves sleep, or it becomes a social outlet, and not engaged in simply for "weight loss" or as an antidote to eating. By operating from this mindset, patients may be more likely to sustain their activity program.

Whether or not a candidate is currently engaging in appropriate activity, it is important to assess his/her plan (if any) to incorporate meaningful exercise post surgery. How reasonable is their plan? What will be necessary for them to maintain physical activity after surgery? Work schedules and family commitments may make it difficult to initiate a consistent plan. Some communities are more exercise-friendly than others and it is important to ascertain what barriers to sustained post surgery exercise the patient's home environment and neighborhood community may pose.

Coping Skills, Emotional Modulation, Boundaries

Some bariatric surgery patients are especially susceptible to weight regain when faced with adversity that distracts them from attending to self-management guidelines. Clinically, maladaptive eating behavior (whether stress eating, emotional eating, binge eating or night eating) is associated frequently with poor stress management and with an inability to effectively self-modulate intense emotions or internal sensations of arousal (whether positive or negative). A careful assessment of the candidate's coping strategies will reveal whether coping skills training is indicated. Such an assessment includes asking about coping both with negative stressors (uncertainty, frustration, deadlines, depressed mood, anger, anxiety or tension, or boredom) and with positive stressors (a raise, a promotion, a party, or vacation). A person who engages in one maladaptive coping behavior (e.g., stress eating) is at higher risk for ineffectual life stressor resolution and/or substituting another maladaptive coping behavior (e.g., compulsive shopping or alcohol abuse) if he/she has not learned more adaptive options for managing the stressor.

The assessment may also explore how a candidate copes with the emotional and physical strain imposed on him/her by the disease of morbid obesity. For example:

• If the candidate has experienced social discrimination or ridicule associated with morbid obesity, at what intensity has this occurred and for how long? What effect has it had on the candidate and how has he/she handled it?
• To what extent is the candidate demoralized over "failed" non-surgical attempts to manage morbid obesity? How does he/she handle this demoralization?
• Does the candidate equate morbid obesity to a "personal defect" or a "behavioral problem"? If so, does he/she compensate for this by over-extending oneself at home, at work, or with friends? Does the candidate have a tendency to take care of other people at the expense of his/her own health and well being? Is he/she a "caretaker" and puts the needs of others above his or her needs? Is the candidate able to ask for what he/she needs?
• Finally, to what extent does the candidate have control over his/her environment? Feeling helpless (or without control over one's environment) increases the risk for depression and for treatment non-adherence.

Current Life Situation

A chaotic lifestyle is negatively related to eating balanced meals and to following a regular program of physical activity, and that a chaotic home life is known anecdotally to interfere with postoperative adjustment. The assessment needs to clarify the stability of the candidate's current living situation - with respect to home, work and/or school, immediate, extended family, and close friends.

Motivation and Expectations

Patient motivation and reasons for pursuing surgery are critical variables to assess. The evaluation should query what is motivating the candidate to pursue a bariatric surgical procedure at this time. Most patients will state the obvious medical benefits. It is also important to have them discuss their more private motivations, if any, for having weight loss surgery. What expectations does the patient have concerning psychosocial, emotional and lifestyle challenges and adjustments post surgery, both short and long-term? Are they committed to actively and permanently following post-surgical guidelines for health and success? Patients may have unrealistic expectations concerning the effect of weight loss on their physical condition, as well as on their social and professional lives. They may believe that everything in their life would be great "if only they'd lose weight." Unrealistic expectations may lead to the perception of failure when those expectations cannot be met. This failure may then become linked to "throwing in the towel" and to giving in to old habits and unhealthy choices.

Section X. Guide to Behavioral Change

Behavioral Changes to Maintain and Reduce Weight

Over the past few years it has become clear that weight is an important health issue. Being overweight is a risk factor for health problems such as diabetes, high blood pressure, high cholesterol and triglycerides, arthritis, gallbladder disease, gynecologic problems, some cancers, and even lung problems. Some people who need to lose weight for their health don't recognize it, while others who don't need to lose weight want to get thinner for cosmetic reasons. However, in some ways weight is different from, for example, cholesterol level or blood pressure, because you can't see these by looking at someone.

Weight can affect a person's self-esteem. Excess weight is highly visible and evokes some powerful reactions, however unfairly, from other people and from the people who possess the excess weight. There are however, behavioral changes that can make a difference in the battle against obesity and overweight.²⁸

Set the Right Goals

Setting the right goals is an important first step. Most people trying to lose weight focus on just that one goal: weight loss. However, the most productive areas to focus on are the dietary and exercise changes that will lead to that long-term weight change. Successful weight managers are those who select two or three goals at a time that they are willing to take on, that meet the following criteria of effective goals:

Effective goals are 1) specific; 2) attainable; and 3) forgiving (less than perfect). "Exercise more" is a commendable ideal, but it's not specific. "Walk five miles everyday" is specific and measurable, but is it attainable if you're just starting out?" Walk 30 minutes every day" is more attainable, but what happens if you're held up at work one day and there's a thunderstorm during your walking time another day? "Walk 30 minutes, five days each week" is specific, attainable, and forgiving. In short, a great goal!

Behavioral Technique

Shaping is a behavioral technique in which you select a series of short-term goals that get closer and closer to the ultimate goal (e. g., an initial reduction of fat intake from 40% of calories to 35% of calories, and later to 30%). It is based on the concept that "nothing succeeds like success." Shaping uses two important behavioral principles: 1) consecutive goals that move you ahead in small steps are the best way to reach a distant point; and 2) consecutive rewards keep the overall effort invigorated.

Success and Rewards

Rewards that they control can be used to encourage attainment of behavioral goals, especially those that have been difficult to reach. An effective reward is something that is desirable, timely, and contingent on meeting their goal. The rewards that one administers may be tangible (e. g., a movie or music CD or a payment toward buying a more costly item) or intangible (e. g., an afternoon off from work or just an hour of quiet time away from family). Numerous small rewards, delivered for meeting smaller goals, are more effective than bigger rewards, requiring a long, difficult effort.

Self-monitoring

Self-monitoring refers to observing and recording some aspect of behavior, such as calorie intake, servings of fruits and vegetables, exercise sessions, medication usage, etc., or an outcome of these behaviors, such as weight. Self-monitoring of a behavior can be used at times when the person is not sure how they're doing, and at times when they want the behavior to improve. Self-monitoring of a behavior usually changes the behavior in the desired direction and can produce "real-time" records for review. For example, keeping a record of all exercise can let the person and their provider know how they are doing, and when the record shows that their exercise is increasing. This will act as encouragement to help the person keep it up. Some patients find that specific self-monitoring forms make it easier, while others prefer to use their own recording system.

While they may or may not wish to weigh themselves frequently while losing weight, regular monitoring of their weight will be essential to help maintain a lower weight. When keeping a record of ones weight, a graph may be more informative than a list of the weights. When weighing yourself and keeping a weight graph or table, however, remember that one day's diet and exercise patterns won't have a measurable effect on the fat weight the next day. Today's weight is not a true measure of how well you followed your program yesterday, because your body's water weight will change much more from day to day than will the fat weight, and water changes are often the result of things that have nothing to do with weight-management efforts.

Avoid Cues for Unplanned Eating

Stimulus (cue) control involves learning what social or environmental cues seem to encourage undesired eating, and then changing those cues. For example, the patient may learn from reflection or from self-monitoring records that they are more likely to overeat while watching television, or whenever treats are on display by the office coffee pot, or when around a certain friend. They might then try to sever the association of eating with the cue (don't eat while watching television), avoid or eliminate the cue (leave coffee room immediately after pouring coffee), or change the circumstances surrounding the cue (plan to meet with friend in non-food settings). In general, visible and accessible food items are often cues for unplanned eating.

Feel Fuller

Changing the way we go about eating can make it easier to eat less without feeling deprived. It takes 15 or more minutes for your brain to get the message you've been fed. Some suggested methods for eat less but feeling fuller include:

• Slowing the rate of eating can allow satiety signals to begin to develop by the end of the meal.
• Eating lots of vegetables can also make one feel fuller.
• Another trick is to use smaller plates so that moderate portions do not appear meager.
• Changing eating schedules, or setting one, can be helpful, especially if the person tends to skip, or delay meals and overeat later.

The claim that drinking water before a meal will reduce hunger was studied at Pennsylvania State University. Their findings don't support that idea. Those people who drank extra water (or other beverages) before and during meals were found to eat just as much as those who drank less. One exception concerns certain beverages such as vegetable juice and milk, which act more as food than liquid in the body. In separate studies, the researchers found drinking such beverages before meals reduced total calories consumed.²⁹

Exercise & Dieting Limitations

It takes an enormous amount of energy to burn a meaningful number of calories. A woman who walks 30 minutes a day, six days a week will burn only 850 calories. At this rate it would take her more than four weeks to expend the 3,500 calories needed to lose one pound.

In a study presented at the American College of Sports, over-weight college students were put on a treadmill for 45 minutes, five days a week, for 16 months. At the end of the study, women participants had gained more than a pound. Men lost about ten pounds but they had to burn the caloric equivalent of 60 pounds to do it.

People who combine diet with exercise will lose weight but that is because they are dieting. At best, exercise will help them lose a few extra pounds more than they would have otherwise. While exercise won't make you thin it's generally the only way to keep from getting fat again. That is because we make daily overeating mistakes such as a handful of potato chips. Even a 100 calories daily mistake adds up to ten pounds per year. Regular exercise allows the body to correct those small over-eating mistakes and will keep people from gaining the unwanted pounds.

Exercise also helps redistribute the percentage of lean mass and fat mass in the body, which can lower the risk for a number of health problems. Lean mass also has a higher metabolic rate, but for most people, the difference won't be noticeable because they will still need fewer calories than when they were fat.

A Duke University study found that overweight adults who aren't on a diet need only a small amount of exercise - the equivalent of a half-hour of brisk walking a day - to prevent further weight gain. The fact that small amounts of exercise alone can prevent weight gain is significant. Samuel Kline, Director of the Center for Human Nutrition at Washington University School of Medicine in St. Louis said that it is "important because on average we gain about a pound of fat a year from age 25 to 55 in this country."³⁰

Social Network

The National Institute of Aging recent study found that obesity can spread from person to person, much like a virus.. When one person gains weight, close friends tend to gain weight too. The study involved a detailed analysis of a large social network of 12,067 people who had been closely followed for 32 years, from 1971 until 2003. The investigators knew who was friends with whom, as well as who was a spouse or sibling or neighbor, and they knew how much each person weighed at various times over three decades. They found that people were most likely to become obese when a friend became obese. That increased one's chances of becoming obese by 57 percent.³¹

To explore whether obesity spreads from person to person within social networks, the research team gleaned weight, height and other data from the records of 5,124 Framingham Study participants at up to seven time points between 1971 and 2003. In addition, they analyzed similar information from the Framingham records of these key participants' parents, spouses, siblings, children and close friends. Together, these individuals formed a large, intertwined social web totaling 12,067 people. The average age of key participants at the inception of the study was 38 years, with a range of 21 to 70 years.

"We were able to reconstruct a large network of individuals who had been repeatedly weighed over time as part of the Framingham Heart Study, and we could see that as one person gained weight, those around him or her gained weight," says Christakis. "We didn't find that people who were overweight simply flocked together. Rather, we found what seemed to be a spread of obesity and that the likelihood of a person becoming obese depended on the nature of the relationship."

"The rising rate of obesity threatens to reverse the decline in disability in the older population, with major implications for the health care system," says Richard Suzman, Ph.D., director of the NIA's Behavioral and Social Research Program. "This seminal study breaks important new ground in showing how social networks may amplify other factors and help account for the dramatic increase in obesity across the population."

Findings include:

• A key participant's chances of becoming obese increased by 57 percent if he or she had a close friend who became obese.
• In same-sex friendships, a close friend becoming obese increased a key participant's chance of becoming obese by 71 percent. However, no such association was found in opposite-sex friendships.
• The perception of friendship also was an important factor. When two people identified each other as close friends, the key participant's risk of becoming obese increased by 171 percent if his or her friend became obese. In contrast, a key participant was not likely to become obese if someone claimed a close friendship with him or her but the key participant did not report the friendship.
• Among pairs of siblings, one's becoming obese increased the other's chance of becoming obese by 40 percent. This finding was more marked among same-sex siblings than opposite-sex siblings.
• In married couples, one spouse's becoming obese increased the likelihood of the other spouse becoming obese by 37 percent. Husbands and wives appeared to affect each other equally.
• Obesity spread across social ties, despite geographic distance from one person to another. Further, social distance--the degree of social separation between two people in the network--appeared to make more of a difference than geographic distance in the spread of behaviors and norms associated with obesity.
• An immediate neighbor's becoming obese did not affect a person's risk of becoming obese.
• Smoking behavior was not associated with the spread of obesity from person to person.

"We identified distinct clusters of obese people within social networks, and the clusters spread about three people deep," Christakis says. "People who were only one degree removed from each other socially, such as siblings or close friends, influenced one another twice as much as people who were two degrees removed from each other."

Their analysis was unique, Christakis said, because it moved beyond a simple analysis of one person and his or her social contacts, and instead examined an entire social network at once, looking at how a friend's friends' friends, or a spouse's siblings' friends, could have an influence on a person's weight. The effects, Christakis said, "highlight the importance of a spreading process, a kind of social contagion, that spreads through the network." Their research has taken obesity specialists and social scientists aback. But many say the finding is path-breaking and can shed new light on how and why people have gotten so fat so fast.

Social-Ecological Model

The CDC reports that changing multiple levels of society to promote health and prevent/control obesity and other chronic diseases requires several approaches. Rather than focusing solely on personal behavioral change interventions with groups or individuals, a blend of individual and environmental strategies are required. Whether the targets of interventions are individual students, employees, community citizens, corporate presidents, or legislators, each is surrounded by interpersonal social networks comprising families, friends, colleagues, and acquaintances.

Each layer of social structure (whether individual, interpersonal, organizational, community, or societal) affects the others above and below it, from the inside outward or the outside inward. Change one level and multiple levels may experience change. Each of the five major levels of social structure calls for a blend of intervention strategies and methods. For interventions to be most successful, many levels of social structure must be supportive of the change. Perhaps the most effective and comprehensive interventions occur when individual and environmental strategies are directed at several levels of social structure simultaneously. Increasingly, health promotion professionals are recognizing the dynamic interplay, which exists between individuals and their environments. Although lifestyle choices are ultimately personal decisions, they are made within a complex mix of social and environmental influences, which affect health behaviors by making healthier lifestyle options more readily accessible, affordable, comfortable, and safe.

The CDC concludes that research has shown that behavior change is more likely to endure when both the individual and the environment undergo change simultaneously. Together, the two approaches create synergy, having a far greater influence on individuals, organizations, communities, and society as a whole than either individual or environmental strategies could alone. Therefore, interventions, which address not only individual intentions and skills, but also the social and physical environmental context of a desired behavior, considering as well all social networks and organizations that share that environment, have the potential for population-wide impact.³²

Binge Eating Disorder

Eating a lot of food does not always mean that a person has binge eating disorder. The National Institute of Diabetes & Digestive & Kidney Diseases (NIDDK) reports that doctors generally agree that most people with serious binge eating problems often:³³

• Feel their eating is out of control
• Eat what most people would think is an unusually large amount of food
• Eat much more quickly than usual during binge episodes
• Eat until so full they are uncomfortable
• Eat large amounts of food, even when they are not really hungry
• Eat alone because they are embarrassed about the amount of food they eat
• Feel disgusted, depressed, or guilty after overeating

Binge eating also takes place in another eating disorder called bulimia nervosa. Persons with bulimia nervosa, however, usually purge, fast, or do strenuous exercise after they binge eat.

• Purging means vomiting or using a lot of diuretics (water pills) or laxatives to keep from gaining weight.
• Fasting is not eating for at least 24 hours.
• Strenuous exercise, in this case, means exercising for more than an hour just to keep from gaining weight after binge eating. Purging, fasting, and over exercising are dangerous ways to try to control your weight.

Binge Eating Prevalence

Binge eating disorder is probably the most common eating disorder. Most people with this problem are either overweight or obese, but normal-weight people also can have the disorder. The NIDDK reports that about 2 percent of all adults in the United States (as many as 4 million Americans) have binge eating disorder. About 10 to 15 percent of people who are mildly obese and who try to lose weight on their own or through commercial weight-loss programs have binge eating disorder. The disorder is even more common in people who are severely obese.

Binge eating disorder is a little more common in women than in men; three women for every two men have it. The disorder affects blacks as often as whites. No one knows how often it affects people in other ethnic groups.

People who are obese and have binge eating disorder often became overweight at a younger age than those without the disorder. They might also lose and gain back weight (yo-yo diet) more often.

Causes

No one knows for sure what causes binge eating disorder. The NIDDK reports that as many as half of all people with binge eating disorder have been depressed in the past. Whether depression causes binge eating disorder or whether binge eating disorder causes depression is not known.³⁴

Many people who are binge eaters say that being angry, sad, bored, or worried can cause them to binge eat. Impulsive behavior (acting quickly without thinking) and certain other emotional problems can be more common in people with binge eating disorder.

It is also unclear if dieting and binge eating are related. Some studies show that about half of all people with binge eating disorder had binge episodes before they started to diet.

Researchers also are looking into how brain chemicals and metabolism (the way the body uses calories) affect binge eating disorder. This research is still in the early stages.

Binge Eating Health Complications

People with binge eating disorder can get sick because they may not be getting the right nutrients. They usually eat large amounts of fats and sugars, which don't have a lot of vitamins or minerals.

People with binge eating disorder are usually very upset by their binge eating and may become very depressed.

People who are obese and also have binge eating disorder are at risk for:

• Diabetes
• High blood pressure
• High blood cholesterol levels
• Gallbladder disease
• Heart disease
• Certain types of cancer

Most people with binge eating disorder have tried to control it on their own, but have not been able to control it for very long. Some people miss work, school, or social activities to binge eat. Persons who are obese with binge eating disorder often feel bad about themselves and may avoid social gatherings.

Most people who binge eat, whether they are obese or not, feel ashamed and try to hide their problem. Often they become so good at hiding it that even close friends and family members don't know they binge eat.

Dieting Recommendation

The NIDDK recommends that people who are not overweight should avoid dieting because it sometimes makes their binge eating worse. Dieting here means skipping meals, not eating enough food each day, or avoiding certain kinds of food (such as carbohydrates). These are unhealthy ways to try to change your body shape and weight. Many people with binge eating disorder are obese and have health problems because of their weight. These people should try to lose weight and keep it off. People with binge eating disorder who are obese may find it harder to stay in a weight-loss program. They also may lose less weight than other people, and may regain weight more quickly. (This can be worse when they also have problems like depression, trouble controlling their behavior, and problems dealing with other people.) These people may need treatment for binge eating disorder before they try to lose weight.³⁵

Binge Eating Treatment

People with binge eating disorder, whether or not they want to lose weight, should get help from a health professional such as a psychiatrist, psychologist, or clinical social worker for their eating behavior. Even those who are not overweight are usually upset by their binge eating, and treatment can help them. There are several different ways to treat binge eating disorder.

• Cognitive-behavioral therapy teaches people how to keep track of their eating and change their unhealthy eating habits. It also teaches them how to change the way they act in tough situations.
• Interpersonal psychotherapy helps people look at their relationships with friends and family and make changes in problem areas.
• Drug therapy, such as antidepressants, may be helpful for some people.

Researchers are still trying to find the treatment that is the most helpful in controlling binge eating disorder. The methods mentioned here seem to be equally helpful for people who are overweight. A weight-loss program that also offers treatment for eating disorders might be the best choice. According to the NIDDK most people do well in treatment and can overcome binge eating.

Section XI. Healthy People 2010

Healthy People 2010

Healthy People 2010 builds on initiatives pursued over the past two decades. The Surgeon General's Report, Healthy People, and Healthy People 2000: National Health Promotion and Disease Prevention Objectives, both established national health objectives and served as the basis for the development of State and community plans. Like its predecessors, Healthy People 2010 was developed through a broad consultation process, built upon the best scientific information, and designed to measure programs over time.

Healthy People 2010 represents a set of health objectives for the Nation to achieve over the first decade of the new century. The overarching goals of the program are to:

1. Increase quality and years of healthy life
2. Eliminate health disparities

Healthy People Focus Areas

The 28 focus areas of Healthy People 2010 have been developed by leading Federal agencies with the most relevant scientific expertise. The development process was informed by the Healthy People Consortium-an alliance of more than 350 national membership organizations and 250 State health, mental health, substance abuse, and environmental agencies.

    Healthy People 2010 Focus Areas

The two focus areas that have a direct impact upon overweight and obesity are the sections on Nutrition and Overweight and Physical Activity and Fitness.

Nutrition and Overweight

The list of objectives for the Nutrition and Overweight focus are as follows:³⁶

Weight Status and Growth

• 19-1 Healthy weight in adults - Increase the proportion of adults who are at a healthy weight.
• 19-2 Obesity in adults - Reduce the proportion of adults who are obese
• 19-3 Overweight or obesity in children and adolescents - Reduce the proportion of children and adolescents who are overweight or obese.
• 19-4 Growth retardation in children - Reduce growth retardation among low-income children under age 5 years.

Food and Nutrient Consumption

• 19-5 Fruit intake - Increase the proportion of persons aged 2 years and older who consume at least two daily servings of fruit.
• 19-6 Vegetable intake - Increase the proportion of persons aged 2 years and older who consume at least three daily servings of vegetables, with at least one-third of them being dark green or orange vegetables.
• 19-7 Grain product intake - Increase the proportion of persons aged 2 years and older who consume at least six daily servings of grain products, with at least three being whole grains.
• 19-8 Saturated fat intake - Increase the proportion of persons aged 2 years and older who consume less than 10 percent of calories from saturated fat.
• 19-9 Total fat intake - Increase the proportion of persons aged 2 years and older who consume no more than 30 percent of calories from total fat.
• 19-10 Sodium intake - Increase the proportion of persons aged 2 years and older who consume 2,400 mg or less of sodium daily.
• 19-11 Calcium intake - Increase the proportion of persons aged 2 years and older who meet dietary recommendations for calcium.

Iron Deficiency and Anemia

• 19-12 Iron deficiency in young children and in females of childbearing age - Reduce iron deficiency among young children and females of childbearing age.
• 19-13 Anemia in low-income pregnant females - Reduce anemia among low-income pregnant females in their third trimester.
• 19-14 Iron deficiency in pregnant females - Reduce iron deficiency among pregnant females.

Schools, Worksites, and Nutrition Counseling

• 19-15 Meals and snacks at school - Increase the proportion of children and adolescents aged 6 to 19 years whose intake of meals and snacks at school contributes to good overall dietary quality.
• 19-16 Worksite promotion of nutrition education and weight management - Increase the proportion of worksites that offer nutrition or weight management classes or counseling.
• 19-17 Nutrition counseling for medical conditions - Increase the proportion of physician office visits made by patients with a diagnosis of cardiovascular disease, diabetes, or hyperlipidemia that include counseling or education related to diet and nutrition.

Food Security

• 19-18 Food security - Increase food security among U.S. households and in so doing reduce hunger.

Many of the Healthy People 2010 objectives that address nutrition and overweight in the United States measure in some way the Nation's progress toward implementing the recommendations of the Dietary Guidelines for Americans 2005. The recommendations for food and nutrient intake are not intended to be met every day but rather on average over a span of time. Although the Healthy People 2010 dietary intake objectives address the proportion of the population that consumes a specified level of certain foods or nutrients, it is also important to track and report the average amount eaten by different population groups to help interpret progress on these objectives. Other objectives target aspects of under nutrition, including iron deficiency, growth retardation, and food security.

• Improving accessibility of nutrition information, nutrition education, nutrition counseling and related services, and healthful foods in a variety of settings and for all population groups.
• Focusing on preventing chronic disease associated with diet and weight, beginning in youth.
• Strengthening the link between nutrition and physical activity in health promotion.
• Maintaining a strong national program for basic and applied nutrition research to provide a sound science base for dietary recommendations and effective interventions.
• Maintaining a strong national nutrition monitoring program to provide accurate, reliable, timely, and comparable data to assess status and progress and to be responsive to unmet data needs and emerging issues.
• Strengthening State and community data systems to be responsive to the data users at these levels.
• Building and sustaining broad-based initiatives and commitment to these objectives by public and private sector partners at the national, State, and local levels.

Physical Activity and Fitness

In addition, Healthy People 2010 objectives for Physical Activity and Fitness are:³⁷

Physical Activity in Adults

• 22-1 No leisure-time physical activity - Reduce the proportion of adults who engage in no leisure-time physical activity.
• 22-2 Moderate physical activity - Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day.
• 22-3 Vigorous physical activity - Increase the proportion of adults who engage in vigorous physical activity that promotes the development and maintenance of cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion.

Muscular Strength/Endurance and Flexibility

• 22-4 Muscular strength and endurance - Increase the proportion of adults who perform physical activities that enhance and maintain muscular strength and endurance.
• 22-5 Flexibility - Increase the proportion of adults who perform physical activities that enhance and maintain flexibility.

Physical Activity in Children and Adolescents

• 22-6 Moderate physical activity in adolescents - Increase the proportion of adolescents who engage in moderate physical activity for at least 30 minutes on 5 or more of the previous 7 days.
• 22-7 Vigorous physical activity in adolescents - Increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness 3 or more days per week for 20 or more minutes per occasion.
• 22-8 Physical education requirement in schools - Increase the proportion of the Nation's public and private schools that require daily physical education for all students.
• 22-9 Daily physical education in schools - Increase the proportion of adolescents who participate in daily school physical education.
• 22-10 Physical activity in physical education class - Increase the proportion of adolescents who spend at least 50 percent of school physical education class time being physically active.
• 22-11 Television viewing - Increase the proportion of adolescents who view television 2 or fewer hours on a school day.

Access

• 22-12 School physical activity facilities - Increase the proportion of the Nation's public and private schools that provide access to their physical activity spaces and facilities for all persons outside of normal school hours (that is, before and after the school day, on weekends, and during summer and other vacations).
• 22-13 Worksite physical activity and fitness - Increase the proportion of worksites offering employer-sponsored physical activity and fitness programs.
• 22-14 Community walking - Increase the proportion of trips made by walking.
• 22-15 Community bicycling - Increase the proportion of trips made by bicycling.

Key Challenges and Current Strategies

The first of the progress reviews for the Healthy People 2010 were held in 2004. In the discussion of data, the principal discussants were Murray Lumpkin, Principal Associate FDA Commissioner; Allen Spiegel, Director of NIH's National Institute of Diabetes and Digestive and Kidney Diseases; and Barbara Alving, Acting Director of NIH's National Heart, Lung, and Blood Institute. Participants in the review identified a number of obstacles to achieving the objectives which included the following:³⁸

• Americans live in an environment that promotes obesity. Food is abundant and portion sizes have increased, while opportunities for physical activity have diminished. Because the contributing factors to overweight and obesity are complex-including genetic, metabolic, behavioral, environmental, cultural, and socioeconomic components-reversing the epidemic will take concerted action by all sectors of society.
• The amount of advertising dollars spent to encourage people to eat large quantities of less healthful food far exceeds the amount spent to promote healthy eating and other healthy lifestyle choices.
• The public is besieged by claims and counterclaims for the benefits of faddish diets (e.g., low or high carbohydrate, low fat, high protein) that are not based on sound scientific evidence.
• For evolutionary reasons, human physiology is predisposed to conserve and store weight, not to shed excess amounts.
• Lack of acceptance of obesity as a disease by a large part of the public, healthcare providers, and third-party payers limits the success of some approaches to prevent and decrease overweight and obesity.
• Most schools do not require daily physical education classes at all grade levels. State standards for physical education vary widely, including time requirements, curricula, and educator qualifications and training. In addition, the recess break has been eliminated or shortened in many systems.
• Overweight and obese children are often ridiculed and bullied by their peers, which may lead to even less physical activity on their part.
• Technological advances have tended toward engineering physical activity out of daily life in the industrialized world and have promoted sedentary behavior, especially in choices of entertainment (e.g., computers and video games).
• A Memorandum of Understanding between ED, USDA, and HHS establishes a framework of cooperation for the three departments to work together to encourage youth to adopt healthy eating and physical activity behaviors.
• The 5 A Day for Better Health Program is a partnership between the fruit and vegetable industry, USDA, the HHS CDC and National Cancer Institute (NCI), and several nonprofit community-based health organizations. By providing information about the health benefits to be gained, the program seeks to increase Americans' consumption of fruits and vegetables to five to nine servings daily.
• The FDA Obesity Working Group will recommend an action plan directed at achieving a number of goals-including enhancement of food labels to assist consumers in preventing weight gain and reducing obesity; facilitation of the development of therapeutics for treating obesity; and collaboration with a range of public and private organizations and Federal agencies, including the Federal Trade Commission, to provide better nutrition information to consumers.
• Health care practitioners are now able to consult evidence-based guidance for treating overweight and obesity presented in the NIH report Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report.
• Through its Consumer Health Information for Better Nutrition initiative, FDA is seeking ways that food labels can provide consumers with more information about dietary guidance and emerging diet-disease relationships. For example, in cooperation with NCI/NIH, the agency is encouraging dietary guidance messages on fruit and vegetable products that meet the 5 A Day for Better Health Program criteria.
• The Department of Education will invest $70 million in fiscal year 2004 to encourage lifetime fitness activities and healthy eating habits. In that funding cycle, the Department of Education has extended grant periods from 1 year to up to 3 years to enhance continuity and sustainability.
• The NIH Obesity Research Task Force was established by the NIH Director in April 2003 to develop a strategic plan to include short-term and long-term goals for basic, clinical, and population research. The plan builds on research advances from previous efforts and is based on identification of future areas of greatest scientific opportunity and need. The proposed research will concentrate on lifestyle modification, biological/medical approaches to preventing and treating obesity, and breaking the link between obesity and associated diseases.

Healthy People 2010 Midcourse Review

Healthy People 2010 provides a vision for achieving improved health for all Americans. Developed through a national process, Healthy People 2010 identifies a set of 10-year health objectives to achieve during the first decade of the 21st century. It has two overarching goals:

1. Increase quality and years of healthy life
2. Eliminate health disparities

The midcourse review is the process through which HHS, Federal agencies, and other experts across the Nation assessed the data trends during the first half of the decade, considered new science and available data, and made changes to ensure that Healthy People 2010 remains current, accurate, and relevant, while concurrently assessing emerging public health priorities.

Goal 1: Increase Quality and Years of Healthy Life

Healthy People 2010: Understanding and Improving Health highlighted the importance of increasing and maximizing both years and quality of healthy life. Progress toward this goal is currently assessed by measuring life expectancy and healthy life expectancies. These assessments result in the following conclusions:

• Life expectancy continues to improve for the populations that could be assessed in the midcourse review.
• Women continue to have a longer life expectancy than men, and the white population has a longer life expectancy than the black population.
• Three different measures of healthy life expectancy demonstrate gender and racial differences: expected years in good or better health, expected years free of activity limitations, and expected years free of selected chronic diseases.
• Expected years in good or better health and expected years free of activity limitations increased slightly, and expected years free of selected chronic conditions decreased.

Goal 2: Eliminate Health Disparities

The second goal of Healthy People 2010 stems from the observation that there are substantial disparities among populations in specific measures of health, life expectancy, and quality of life. The second goal is to eliminate health disparities that occur by race and ethnicity, gender, education, income, geographic location, disability status, or sexual orientation. As discussed in the section on Healthy People objectives, there has been widespread improvement in objectives for nearly all of the populations associated with these characteristics. However, progress toward the target for individual populations and progress toward the goal to eliminate disparities are independent of each other. Improvements for individual populations - even improvements for all of the populations for a characteristic - do not necessarily ensure the elimination of disparities. This section focuses specifically on relative disparities between populations and changes in these relative disparities over time, regardless of whether the rates for specific populations are moving toward or away from the targets for each objective.

Disparities between populations and the persistence of disparities over time have been well documented. Unlike previous Healthy People initiatives, Healthy People 2010 calls for monitoring objectives for an extensive array of specific population characteristics. All population-based objectives and subobjectives were monitored by race and ethnicity, by income or education, and by gender (if applicable). Monitoring for other characteristics (that is, geographic location and disability status) was optional. Healthy People 2010, therefore, provides the basis for a broad examination of disparities among populations and changes in disparities over time. Findings for specific objectives and populations are presented in 27 of the 28 focus area chapters. None of the objectives in Public Health Infrastructure (Focus Area 23) call for data according to population characteristics. The findings concerning disparities among populations are summarized below. The following conclusions are based on this summary:

• Substantial disparities between populations were evident for many Healthy People 2010 objectives.
• Both increases and decreases in relative disparities were evident for individual populations for specific objectives and subobjectives; however, there was no change in disparity for most of the objectives and subobjectives with data for any group.

For specific population characteristics:

• Among 195 objectives and subobjectives with trend data for racial and ethnic groups, disparities decreased for 24 and increased for 14.
• Among 238 objectives and subobjectives with trend data for males and females, disparities decreased for 25 and increased for 15. Females more often had the best group rate, and reductions in disparity were more frequent among males.
• Among education groups, disparities decreased for 3 objectives and subobjectives and increased for 14.
• Among income groups, among geographic groups, and between persons with disabilities and persons without disabilities, there were few changes in disparities.

Report Summary

Full achievement of the goals and objectives of Healthy People 2010 depends on a health system reaching all Americans and integrating personal health care and population-based public health. The vision of Healthy People in healthy communities involves broad-based prevention efforts and moves beyond what happens in physicians' offices, clinics, and hospitals-beyond the traditional medical care system-to the neighborhoods, schools, workplaces, and families in which people live their daily lives. These are the environments in which a large portion of prevention occurs.

Section XIII. Footnotes