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By Patricia B. Gatbonton, MD
It’s been said that the three words a woman is most happy to hear
are not “I love you,” but “You’ve lost weight.”
Nourishment, or the lack of it, is an obsession with most Filipinos.
For instance, mere acquaintances are forthright enough to comment,
“You’ve gained [or lost] weight,” sometimes even before asking
how you are.
National vital statistics
From the Food and Nutrition Research
Institute’s (FNRI) 5th National Survey of 1998, the prevalence of
obesity among Filipinos was 3.3 percent with female adults having a
prevalence rate (4.4 percent) twice than that of the males (2.1
percent). Obesity was more prevalent among adults 40-59 years.
Obesity is a predisposing factor in the
development of heart and vascular diseases such as congestive heart
disease, hypercholesterolemia and hypertension. The Department of
Health (DOH) 1993 Philippine Health Statistics ranked diseases of
the heart and the vascular system as first and second, respectively,
among the ten leading causes of death in the country. The prevalence
rates of these diseases have steadily risen over the seven-year
period from 1988 to 1994. By 1994, the prevalence rate for
cardiovascular disease was 73.3 percent and accounted for 15.7
percent of total deaths.
Diet is one of the risk factors for
cardiovascular diseases that play a key role in determining
cholesterol production in the body. Elevated cholesterol levels are
also a risk factor for hypertension, atherosclerosis and stroke.
Fat and fatter?
Most of us have a general idea about sizing up
how heavy a person is by just eyeballing them. How are the degrees
of fatness defined in scientific terms?
The National Heart, Lung, and Blood Institute (nhlbi)
of the United States and the World Health Organization (WHO) have
provided uniform definitions of overweight and obesity.
Overweight-technically refers to an excess of
body weight, defined as a BMI of 25 to 29.9 kg/m2
Overweight refers to a weight above the
“normal” range. This is often determined from life insurance
tables or by calculating the body mass index.
Obesity is a state of excess adipose tissue (fat
cell) mass, a BMI of greater than 30 kg/m2. Obesity is defined by
the presence of excess body fat.
Measure of a man (and woman)
Of the several ways to measure degree of obesity
available to us, the simplest would be a body mass index (BMI), the
waist circumference and the waist/hip ratio.
Although not a direct measure of adiposity, the
BMI is most widely used method. It is calculated from the height and
weight as follows:
BMI = body weight (in kg)
÷ square of stature (height, in meters)
Table 1 shows us the definitions from the nhlbi
report. More recent classifications redefine class III and add class
IV and class V.
Recently, the WHO has suggested much lower
standards of obesity for the Western Pacific Region, seen in Table
2. This is because studies on the Hong Kong Chinese population
project that risks for cardiovascular events are much higher than
Western counterparts at the same BMI. Why this is so is still not
clear. What greatly concerns epidemiologists is the obesity epidemic
is increasing exponentially in the Asia Pacific region alongside
other lifestyle diseases like Type 2 diabetes and hypertension.
BMI defines the degree of risk for
cardiovascular morbidity. A BMI between 25 and 30 kg/m2 is low risk,
above 30 kg/m2 is moderate risk. A BMI between 25 and 30 is
significant and requires therapeutic intervention when other risk
factors like hypertension and glucose intolerance co-exist.
Tale of the tape
Body fat distribution in different anatomic
depots also has substantial implications for morbidity. A large
abdomen, with the fat centrally located around the paunch (nowadays
referred to as a “beer belly”) is medically more significant
than subcutaneous fat in the buttocks and lower extremities.
You can measure abdominal obesity in 2 ways,
through the waist-to-hip ratio or by getting the waist
circumference.
The waist is not at the level of the umbilicus
unless you had absolutely flat abdominal muscles. For the rest of us
who are not so lucky, take a tape measure to the level of the
natural waistline or the narrowest part of the torso if viewed from
the front. Measure the hip at its widest circumference, including
buttock extension.
For instance the ratio for woman whose waist
measures 37 inches and hip is 40 inches 0.925. A WHR>0.9 in women
and a WHR >1.0 in men is abnormal.
A waist circumference (WC) > 88 cm (35
inches) in women and > 102 cm (40 inches) in men carries a
greater risk for cardiovascular problems. A man who claims to wear a
size 36 Levi’s but has his paunch spilling over his belt suffers
from the low waist gang syndrome. His true waist size is not 36
inches!
Apples or pears
Android (or apple shape, or male pattern)
obesity is highly associated with the insulin resistance syndrome.
Also known as “Syndrome X,” it is a clustering of cardiovascular
and metabolic problems that includes: elevated insulin levels, high
blood pressure, abnormal blood sugars (may not yet reach diabetic
levels), high total and bad cholesterol levels, and high uric acid
levels among others.
The reason for this association is unknown but
may be because intra-abdominal fat cells are more metabolically
active than those from other depots. The initial BMI risk needs
further adjustment because of the additional risk conferred by a
large waist.
This is in contrast to gynecoid (or pear shape,
or female pattern) obesity where fat deposits at the buttocks and
hips, annoying though that is, and has no association with finely
tuned balance.
The hypothalamus tightly regulates weight with
caloric intake and energy expenditure to within 0.15 percent.
Obesity results from the failure of this sensitive and sophisticated
regulatory mechanism. Even a small imbalance between total energy
intake and expenditure can lead to massive weight gain.
We maintain our weight around a physiologic set
point. A sensing system in adipose tissue keeps tabs on peripheral
fat stores. We also have a central monitoring system, a hypothalamic
receptor, or “adipostat.” When we lose weight, regulatory
mechanisms drive us to conserve energy (decreased expenditure) and
eat more (increase calorie intake). When we gain weight the
hypothalamus responds by decreasing hunger and increasing energy
expenditure.
The recently discovered ob- gene, and its
product leptin, provides a molecular basis for this physiologic
concept. Leptin, a hormone fat cells produce, signals body energy
stores. The gastrointestinal tract feeds the brain information
about food intake; the cerebral cortex contributes behavioral
information and regulation. The hypothalamus regulates food intake,
metabolic activity and energy expenditure (primarily in muscle and
fat tissue). Among the many mediators of these systems are
neuropeptide Y, insulin and the sympathetic nervous system.
Couch potatoes
We are growing couch potatoes, both young and
old. Physical activity is largely supplanted by sedentary indoor
activity. Today’s kids are victims of Nintendo-ization—a novel
concept from the eminent epidemiologist Dr. Paul Zimmet. In this
millenium of video and computer games, the only body parts that get
any exercise are the child’s fingers and thumbs.
Our sedentary lifestyles lower energy
expenditure and promote weight gain. Data from the National Health
and Examinations Survey (nhanes) prove that low levels of physical
activity and recreation are responsible for weight gain in both men
and women.
In this 10-year study of weight change, subjects
aged 25 to 74 were divided into two groups: those who gained more
than 13 kg and those who gained less; and into three activity
levels: low, medium, and high. The more a person exercised, the less
weight they gained and vice versa. Men and women in the low activity
category were 3 to 4 times more likely to have significant weight
gain than the more active subjects.
“Jack Sprat would eat no fat
His wife would eat no lean,
And between the two of them
They licked the platter clean.”
In this classic “Mother Goose” nursery
rhyme, marital harmony comes to a Laurel and Hardy-ish couple who,
because of their opposite food preferences, manage to finish all the
food on the plate. Horrors! Eating fat and cleaning out your plate
is no longer politically correct or healthy.
A high fat diet, which actually makes food
palatable, leads us to overeat to obtain enough carbohydrate to
maintain glycogen stores, which are much smaller than our fat
stores.
Studies on normal volunteers shows that eating
several small meals a day helps to keeps serum cholesterol and sugar
levels lower than when they eat a few large meals each day.
The adage “Eat like a King at breakfast, a
Prince at lunch and a pauper at supper” is scientifically sound.
Obese persons tend to consume 25 percent (and usually more than 50
percent) of energy between the evening meal and the next morning.
Many binge eaters tend to have uncontrolled episodes of eating at
night.
Warning: Too much fat is dangerous to your
health.
The degree of obesity and overweight has a
direct bearing on the metabolic, anatomic, degenerative, neoplastic
and psychological complications of obesity.
Metabolic abnormalities result from changes in
nutrient handling and distribution and include high cholesterol
levels, diabetes mellitus, gallstones, fatty liver disease, high
blood pressure, and central sleep disturbance.
Changes in physical structure and pressure
relationships result in anatomic complications like heartburn,
obstructive sleep apnea, stress incontinence, varicose veins and
higher risk for accidental injury.
Long-standing heavyweight bearing causes
degenerative complications like arthritis, and vertebral disc
disease.
Obese persons are also at risk for
obesity-related tumors that occur in the gastrointestinal tract or
reproductive organs. They include endometrial, ovarian, breast and
prostate carcinoma, as well as adenocarcinoma of the colon,
gallbladder, pancreas and esophagus.
Being obese also weighs heavy on the mind. Many
fat persons suffer from depression, anxiety disorders, binge eating
disorders and some forms of bulimia.
Why lose weight?
Increasing body weight increases health risks;
the lowest mortality rate is associated with a BMI of 22 kg/m2. A
weight loss of 5 to 10 percent from baseline has tremendous
metabolic payoffs, not to mention the psychologic boost to a
person’s self esteem. When you look better, you feel better.
Weighing the risks
The initial evaluation of overweight patients
should address several issues:
• What is the degree and type of
overweight?
• Is there a treatable cause of
overweight?
• What is the individual risk of
morbidity and mortality associated with overweight?
A thorough medical history starts from birth,
childhood, adolescence and adulthood. Any illnesses, medication
intake, menstrual and obstetric history, food preferences and eating
habits are important to the evaluating physician. A thorough
physical examination will include not only measurement of height,
weight, blood pressure, but also waist circumference and a hunt for
peripheral clues to possible treatable causes of obesity.
For example, finding acanthosis nigricans a
condition characterized by pigmentation in the folds of the neck,
the armpit and over the knuckles is a clue to insulin resistance, a
component of Syndrome X.
Patients in the highest risk require the most
aggressive treatment approaches.The patient, however,
must be ready to make these changes and the physician must consider
individual peculiarities, ethnicity, and other differences when
using these guidelines.
Therapeutic approaches
The primary approach to the treatment of
obesity include:
Dietary modification
Exercise
Behavioral therapy
Pharmacotherapy
Weight loss surgery
All treatments of obesity entail some risk. The
initial approach to the treatment of overweight or obese subjects
must consider the following questions:
• Is treatment appropriate?
• What are the risks of treatment?
• What is the most appropriate treatment
regimen?
Is treatment appropriate?
Some subjects may wish to lose weight, even if
they are not “overweight.” For this group, exercise is the first
recommendation. In addition, behavior modification techniques and a
lower fat diet can be helpful.
What are the risks of treatment?
Most of the currently available drugs have minor
side effects that diminish with treatment; there are also a few
serious side effects. Patients who wish to lose small amounts
of weight (the majority of the overweight population) should not
take these drugs over the short term. Patients whose obesity carries
high risk take the drug under strict medical supervision.
What is the most appropriate treatment
regimen?
Treatments for obesity influence either nutrient
intake or energy loss. Those that reduce energy intake are better at
causing acute weight loss than those that increase energy
expenditure.
For initial weight loss the goal is to eat less
and, when possible, burn more energy. Dieting, with or without the
anorectic drugs can help reduce food intake.
Weight loss goals
• To ameliorate or reverse the complications
of obesity.
• To improve cardiovascular fitness and muscle
strength.
• To improve physical and psychological
well-being.
The first goal for any overweight subject is to
prevent further weight gain and keep body weight stable (within 5
percent of its current level).
The physician needs to identify a realistic
weight-loss goal. Most patients have a “dream” weight loss of
more than 30 percent, which is not realistic.
A successful program will lead to a weight loss
of more than 5 percent of initial weight. A 5 to 15 percent weight
loss reduces the risks of most disorders associated with obesity.
The overweight subject must understand that
achieving and maintaining weight loss is difficult because it
triggers energy conservation.
Dietary therapy
Approximately 22 kcal/kg is required to maintain
one kilogram of body weight in a normal adult. Thus, the expected or
calculated energy expenditure for a woman weighing 100 kg is
approximately 2200 kcal/day. The variability of ± 20 percent could
make energy needs as high as 2620 kcal/day and as low as 1860
kcal/day. No adult needs fewer than 1200 kcal/day for weight
maintenance. Most people will lose weight on a diet of 800 to 1200
kcal/day. More severe caloric restriction can induce weight loss
more quickly. The minimum caloric intake to maintain adequate
nutrition is approximately 500 kcal/day.
Thirty mg 1 tablet ODTake once daily in am. Have
blood pressure and pulse checked regularly.Take one capsule TID with
each meal. If meal is lean or contains no fat, it can be skipped.
Take multiviatmins daily 2 hours before or after dose.CostP 23/day
for 15 mg P 27 for 30 mgP 85/day for 10 mg tabP 120/day .
Going under the knife
Only patients who are morbidly obese, either 45
kg (100 lb), or 100 percent, above ideal body weight are candidates
for surgery. Potential benefits of surgery include major weight loss
and improvement in hypertension, diabetes, sleep apnea, CHF, angina,
hyperlipidemia, and venous disease. Two procedures in common use
today are the vertical-banded gastroplasty and the Roux-en-Y gastric
bypass. (Please refer to article, “Tinkering with the digestive
tract,” in this issue.)
The National Institutes of Health Consensus
Conference on Gastrointestinal Surgery for Severe Obesity in 1991,
recommends that suitable patients be selected using the following
criteria:
• The presence of 45 kg (100 lb), or 100
percent, above ideal body weight, or one or more severe medical
conditions related to refractory obesity.
• Repeated failures of other therapeutic
approaches.
• At eligible weight for 3 to 5 years.
• Capability of tolerating surgery.
• Absence of alcoholism, other addictions, or
major psychopathology.
• Prior clearance by a psychiatrist.
The decision to have surgery for obesity is one
not made lightly. An appropriately experienced surgeon, together
with nutritionists, psychologists and other support personnel should
evaluate the patient and following surgery, provide continuous care.
Heavy cross
Obesity is a chronic illness, a lifetime burden
and a heavy cross to carry. Weight issues are complex and many
factors, psychologic, societal, interpersonal and metabolic,
interact in the heavy individual. Desirable body weight may be an
illusive goal and tolerance, understanding and a little
encouragement goes a long way in helping the vertically challenged
someday reach not for the sky, but for their toes.
US says it will contest WHO plan to fight
obesity
but claim of faulty science is rejected by
nutritionists
The Bush administration announced it will demand
significant changes to a major World Health Organization initiative
to battle obesity globally, saying the plan is based on faulty
scientific evidence and exceeds the U.N. body’s mandate.
The move prompted intense criticism from US and
international health and nutrition experts, who charged that the US
objections are a thinly veiled attempt to placate the food and sugar
industries and derail a vital international assault on one of the
world’s biggest health problems.
The WHO plan, which outlines strategies that
nations can use to fight obesity, has been widely applauded by
public health advocates but bitterly opposed by some food
manufacturers and the sugar industry because it includes some
controversial options, such as restricting advertising aimed at
children and increasing junk food prices through taxes and
adjustments in farm subsidies.
The US delegation plans to seek significant
revisions when WHO’s governing board considers the proposal next
week in Geneva, a key official said.
“There have been approaches that WHO has taken
that we do not consider to be based on the best practices and the
best science,” said William R. Steiger, special assistant for
international affairs at the Department of Health and Human
Services. “What we want is a strategy that WHO can trumpet that is
the product of the best possible scientific evidence.”
Steiger said the revisions the United States
will seek are still being finalized, but the goal will be to place
much greater emphasis on the role of “personal responsibility”
instead of government regulation.
“We have a whole series of potential changes
we’d like to see,” Steiger said in a telephone interview. “One
overarching example is that any strategy that deals with this
subject has to deal with individual responsibility. What’s lacking
is the notion of personal responsibility as opposed to what the
government can do.”
Steiger denied that industry concerns are behind
the administration’s position. The Grocery Manufacturers of
America (GMA) and the Sugar Association acknowledged they oppose
parts of the plan, but denied influencing the US position.
However, GMA spokesman Michael E. Diegel echoed
the administration’s criticism. “There is no mention of what we
consider to be the fundamentally important issue of individual
responsibility,” he said.
Although the report could not compel nations to
act, international health experts said the comprehensive approach
outlined in the draft version would provide a powerful weapon to
governments and public health advocates seeking action against one
of the most pressing public health problems.
“This document is fantastically important,”
said Philip James, chairman of the International Obesity Task Force,
an independent London-based public health think tank. “It should
have a big impact, unless it’s sabotaged. And we know it’s being
sabotaged.”
WHO estimates that perhaps 1 billion adults are
overweight and at least 300 million are obese. In the United States,
more than two-thirds of adults are overweight, and nearly one in
three is obese. Researchers have blamed the skyrocketing rates
largely on a combination of people getting less exercise and
consuming more inexpensive, high-calorie junk foods.
In 2002, WHO’s governing body, the World
Health Assembly, voted to develop a strategy for combating the
problem along with other chronic health problems influenced by
lifestyle, such as heart disease. WHO issued a scientific report in
June 2002 that provided the basis for the 18-page strategic plan,
which would come before the assembly for final approval in May if
the executive board endorses it next week.
“It essentially establishes a new standard
with which all doctors and public health interest can now challenge
the governments and say, ‘What are you doing about this?’ “
said James, who is also vice president of the International Union of
Nutritional Sciences.
On January 5, Steiger sent a letter to WHO
Director-General Jong-wook Lee with a stinging 28-page critique
outlining “where the US government’s policy recommendations and
interpretation of the science differ from those” of WHO.
---Washington Post
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