An update on OBESITY

Conway McLean, DPM

Obesity is a growing epidemic in the United States — it has been for decades — and it continues unabated. If anything, it has grown alarmingly. Severe obesity was extremely rare before the early 1970s but has since increased faster than obesity, with no evidence of slowing. The epidemic has been fueled by economic growth and industrialization, an ever-more mechanized culture, and an increasingly sedentary lifestyle. Perhaps most consequential has been the transition to processed foods and high calorie diets. Anywhere this diet has become popular, obesity reliably follows.

Obesity is a complex, multifactorial, and largely preventable disease. Gender plays a role in who is more likely to become obese, with women being disproportionately affected. Ethnicity does as well. Clearly, it is a critically important issue. The consequences of being overweight, and the associated health care costs, have serious health and cost consequences for individuals, their families and our nation.

The psychology of body image is a part of this topic. Shaming people for their weight has proven an ineffective means of stimulating weight loss. Healthcare workers have done it for decades, although no study indicates fat shaming helps. Many people still link obesity to a lack of willpower, an erroneous concept. Perhaps most harmful about shaming is obese individuals have a harder time losing excess weight when this societal bias against obesity is taken to heart.

What makes someone obese? It’s typically defined simply as excess body weight, measured as BMI (body mass index), calculated as weight divided by height. It turns out to be much more complicated than that, with central adiposity, fat build-up around the middle, to be a much better gauge of what is obese. In both clinical and research settings, waist circumference, a measure of abdominal fat, has become an increasingly important evaluator of what is overweight and who is obese.

Should we review the consequences of obesity to health and well-being? Do we need to list the many effects of carrying this extra weight? The morbidity resulting from being overweight, especially “middle adiposity”, this fat around the waist, goes beyond heart disease and extends to nearly every organ system in the human body.

Most of us know that obesity greatly increases the risk of numerous chronic diseases. Diabetes maybe one of the most severe and yet most common complications. This disease has dramatic effects on many organ systems, like obesity itself. Obesity also seriously increases the risk for high blood pressure, stroke and many types of cancers. Various disabilities, depression, cardiovascular disease, and even mortality, all are significantly more common in the obese. The association with most of these ailments is inarguable.

The health care costs and psychosocial costs of obesity are tremendous. When coupled with the varied and numerous maladies associated with obesity, controlling this growing epidemic is of critical importance to the health and welfare of all citizens of the world. Obesity is estimated to increase national healthcare spending by $149 billion annually. Being overweight or obese is the most common reason young adults are declared ineligible for the military.

The most startling development in the science of public health has to be the latest projections for the future incidence of obesity. The current data reveals 40% of American adults now have obesity, while 18% have severe obesity, at least according to the New England Journal of Medicine. This works out to one in three Americans, regardless of age, having obesity (which totals more than 100 million people). Studies as recent as 2012 predicted a leveling-off of obesity rates. Unfortunately, this does not appear to be the case.

In the U.S., based on state-to-state figures, the latest projections reveal something dramatic and unexpected. Earlier projections were inaccurate. A new, exhaustive study indicates that by 2030, half of the American population will be obese. Just as concerning, 85% of adults are going to qualify as overweight. These figures are based in part on newly released data from the CDC, the Centers for Disease Control.

Childhood obesity results in some of the same conditions as adult-onset, except with earlier occurrence, or increased incidence in adulthood. Environmental factors, one’s socio-economic surroundings are important in the likelihood of developing obesity. Things like the parent’s diet, lifestyle, parental obesity, smoking, and others, have been implicated in the risk to one’s offspring.

Given all the myriad complications and morbidity associated with obesity, what is our health care system doing for it and about it? Contrary to the data, one third of healthcare providers do not consider obesity to be a disease state. Less than ten percent of primary care providers believe obese patients receiving interventions can succeed at long-term weight loss, so why try?

Many interventions have been developed. One of the first treatment goals is to stabilize body weight. Monitoring weight loss and waist circumference should be done regularly when any plan is instituted. Guidelines reveal that even a modest reduction of body weight, a 3-5% decrease from initial measurement, can have health benefits. Earliest management should have a specific focus, like physical activity or nutrition. Establishing realistic goals, set for a specific length of time, is best and should concentrate on waist circumference or loss of fat mass. Bariatric surgery, although costly, has demonstrated clear and significant benefits. Prevention is even more effective, with some prevention programs likely able to reverse these obesity trends.

How the many risk factors for obesity interact with one another to produce the so-called “globesity” epidemic is multifactorial, and not well understood. Genetics and environment are both critical. Simply put, obesity is the result of an energy imbalance between calories consumed and the calories expended. This creates an energy surplus resulting in excess body weight. But how and why this occurs is the result of multiple components of “nature vs nurture”. This is a branch of medicine about which we must know more.

If not, could we end up like the humans aboard the spaceship in the movie “Wall-E”, where the inhabitants never leave their mobile recliner, never walking or exercising. Everyone on this ark of a spaceship is obese. Does this seem far-fetched? And yet, if you look at the trends, it is one of progressive increase. The numbers are alarming, and portend dire times for our health care system. To take action sufficiently dramatic to change this arc would require unbelievable energy and financial expenditures, fighting the gigantic food industry. It’s hard for me to see these changes taking place.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.