Obesity Takes Center Stage in Health Debate

By Suria Santana

It's a bitter pill to swallow. Despite the wealth of weight-loss supplements available in pharmacies, numerous fad diets and intense debate on whether low fat or "low carb" is best, America's waistline has widened over the past several decades.

Current estimates count two out of three Americans as overweight, and the costs of being a hefty nation are severe. A recent study published in Health Affairs predicts that one out of five healthcare dollars spent by adults 50 to 69 years of age will go toward obesity treatments by 2020 should trends continue. According to the Department of Health and Human Services (HHS), the cost for obesity-related medical expenses and lost productivity amounts to more than $117 billion per year.

Even more alarming is the fact that the rising obesity rate is poised to overtake tobacco as the leading cause of preventable deaths in the United States. A recent Centers for Disease Control study shows that while tobacco killed an estimated 435,000 people in 2000, poor diet and physical inactivity resulted in 400,000 deaths in America in the same year. Since 1990, obesity-related deaths have increased by 33 percent.

With such facts in mind, the HHS launched a national education campaign against the obesity epidemic this year.

"Americans need to understand that overweight and obesity are literally killing us," HHS Secretary Tommy Thompson said. "We need to tackle America's weight issues as aggressively as we are addressing smoking and tobacco."

The campaign, titled "Healthy Lifestyles and Disease Prevention," encourages Americans to take manageable steps to ensure long-term weight control. It urges people to make small lifestyle adjustments, such as taking the stairs instead of an elevator.

"We know that gloom and doom messages warning against weight gain don't work," Secretary Thompson said. "These messages are provocative and attention-getting, but they are also empowering and achievable."

Following up on the HHS campaign, the Food and Drug Admin- istration (FDA) issued a report focusing on the message that "calories count." It recommends better food labeling and encourages restaurants to provide calorie and nutrition information on their menus. It also calls for strengthening coordinated scientific research to create effective anti-obesity drugs and develop foods that are healthier and contain fewer calories.

Environmental Influences

Such recommendations are not unreasonable in a world where the largest and fastest meals are also the cheapest. But are McDonald's super-sized menu options to blame? Experts say the answer is not so simple.

Lifestyle changes that have led to greater caloric intakes and less physical activity on the part of most Americans are contributing to the epidemic. As George Blackburn, M.D., Ph.D., associate director of nutrition at Harvard Medical School, explained, consuming an additional 300 calories a day and burning 300 less calories can lead to a 30-pound weight gain in only a year. In order to beat the rapidly rising obesity rate, Americans will need to burn a few more calories and reduce the amount of food they consume by approximately 10 percent, he said.

The government's current focus on the importance of caloric intake is right on target in Dr. Blackburn's view.

"The FDA has hit a home run by emphasizing caloric intake in its latest campaign," he said. "Calorie control is an excellent place to start educating the public." Controlling caloric intake is not as easy as it might sound, however.

"Nowadays, you can find snack food items in a much greater number of venues," said Josephine Connolly, assistant clinical professor of family medicine at Stony Brook University School of Medicine. "Almost any place you take your kid to has vending machines. The snack food industry knows it can't increase the number of consumers, but it can certainly try to influence the frequency with which its consumers snack."

With the accelerated pace of living today eating habits changed substantially. Traditional sit-down meals have almost disappeared from the family routine.

"There's no time to go home and cook dinner anymore," Connolly said. "People are snacking more and finding less time for meals because there's a trend to be more involved in activities. From the adult perspective, this might include volunteering in more organizations or spending your time taking care of children who are also more likely to be involved in more structured activities."

This is exemplified by the predicament of the soccer mom - someone who finds herself having to stop by a fast food restaurant to feed her children so they can make it in time for practice, according to Connolly.

Although some children get to burn excess calories in soccer practice, the average American does not use his muscles as much as he should, according to Jarol Boan, M.D., Ph.D., assistant professor of medicine and surgery at Duke University Medical Center.

"We have a number of labor-saving devices in our environment that are very useful for us, but they decrease our energy expenditure," Dr. Boan said.

Exercising is the only way to compensate for living in a country where electric car windows, automatic sliding doors and even rolling airport walkways are commonplace.

Interestingly enough, climbing obesity rates are not only a first-world concern, according to the International Obesity Task Force. This health problem is rising to epidemic proportions elsewhere and is affecting developing nations. One-third of all deaths in the globe are now attributable to obesity, lack of exercise and smoking.

Halting the Epidemic

The international scope of the obesity epidemic indicates that combating this public health problem will not be an easy task. Many medical educators think that it will take more than national campaigns to tackle America's growing girth.

"The FDA tends to make very reasonable recommendations for the public, but they do it in a way that is broad based, so that the general public can understand them," said Dr. Boan. "I think that in that way they miss the individualization treatment that is required to effectively deal with the obesity problem. Their strategy for encouraging restaurants to put caloric intake in their menus is probably a drop in the bucket."

Connolly also finds the FDA's recommendation problematic.

"Unless a restaurant is part of a chain, it is not going to know the nutrition content of the food it is providing," she explained. "Restaurants are not going to chemically analyze every ingredient in their foods and put them through a database. They simply cook as they cook without following a standardized recipe as in most chain restaurants."

In addition, she believes that the government should first attempt to provide the public with easy-to-understand nutritional recommendations before requiring restaurants to provide nutritional content to the public.

"It's difficult for us to pass on this role to industry when we are not as a government providing very clear nutritional recommendations to begin with," Connolly said.

To compensate for the limitations of the government's nutritional recommendations, Connolly teaches Stony Brook medical students about how the guidelines are generated, urging them to think critically before using such blanket recommendations as a reference in their medical practice.

"The nutritional recommendations from the government come from the U.S. Department of Agriculture, which has a primary mission to protect the agricultural industry and facilitate food production," Connolly said. "The nutritional recommendations are really a secondary mission, and there might be some conflict with that."

She emphasizes the need for practicing doctors to become well versed in nutritional matters or at least have expert assistance when offering dietetic advice to their patients.

"Doctors need to have a very deep understanding of the food supply when they make nutritional recommendations to patients," Connolly said. "There are limitations to how much they can really understand, so it's helpful to either have a registered dietitian in their practice or someone they can refer patients to."

Ending Prejudice

In addition, future physicians must learn to be more compassionate toward the obese.

"The current paradigm in thinking among medical students and the general population is that weight control is an individuals choice," said Connolly. She teaches students that the current environment leads individuals to make unhealthy choices, which in turn is resulting in rising obesity rates.

Dr. Boan notices a problem with how the obese are viewed by many practicing doctors. "There's a great deal of discrimination against the obese in the medical profession," she said.

She has developed a month-long clinical course at Duke that aims to sensitize medical students to issues affecting obese patients. The course's curriculum outlines the underlying causes of obesity and effective ways of treating it. Students learn how to manage overweight and obese patients without prejudice and to counsel adults to make healthy lifestyle choices through their various clinical interactions with patients.

Harvard's medical school also reinforced its curricular obesity content. Last month, the school sponsored a symposium co-directed by Dr. Blackburn, titled "Obesity Medicine: Emergence of a New Discipline." Topics included obesity medicine and practice management, risk assessment and identification of co-morbidities and strategic use of pharmacotherapy for obesity.

Dr. Blackburn thinks that medical schools are in the position to create a solution to this health problem, something that can only be accomplished with a shift in curricular focus.

"Students must be skilled in a new doctor-patient interaction called 'motivation intervention,'" he said. "Under this approach, doctors actively engage their patients to get a healthier lifestyle, eat less and exercise more. This new focus on doctor-patient communication is the No. 1 skill that needs to be built into medical school education."

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