Monday, April 28, 2014

An Epidemic of Obese Proportions

Abstract

Obesity is becoming one of the most common diseases to date.  There is a lot of information stating why and how, but the current methods of prevention and treatment are not slowing the rise in this epidemic.  Through the use of medical texts and peer reviewed journals, this paper looks at the reasoning behind the upward trend in obesity in conjunction with epidemiologic observations, nutritional intake and activity levels, metabolic syndromes, socio-demographics, and psychosocial affects.  Review of the current and proposed means of prevention and treatment as well as the role that other disease plays in obesity and vice versa.



An Epidemic of Obese Proportions

Obesity is possibly one of the hardest issues to combat.  It is not caused by a virus or bacteria and cannot be cured with medication.  Obesity is defined as a condition when an individual having an excessive proportion of their body weight as accumulated fat such that it poses a health risk. What are the underlying causes that have made obesity such an overwhelming global epidemic?  What are the risks involved for further disease brought on by obesity?  Obesity is a challenging health issue that has a multifaceted cause and effect factor that needs to be understood in order for it to be treated and prevented.    Our behaviors and socioeconomic outlook on ourselves and our place within society have dictated our need for more –of everything- in order to feel full or fulfilled, yet the changes we have made to our foods and activities has left us empty; if changes on all levels –behavior, socioeconomic, psychological- are not made, the obesity epidemic will continue to grow.

Behavioral causes of obesity

There are many agreed-upon factors influencing why an individual becomes overweight or obese (let alone the global population), but negative behavior choices are at the top of the list.  Some of these behaviors are learned from parents, some are a part of the negative environment we as a global society have created, and some are unknowingly induced at the psychological level through the media, advertising industry, and the concept of food security.
These negative behaviors that perpetuate an obesogenic lifestyle include: eating habits, sedentariness, and sociodemographics.  Eating habits are typically defined as the increased consumption of poor yet highly energy-dense foods outside of the home.  Sedentariness is a decrease in physical activity such that it creates health risks. And sociodemographic variables of gender, age, and education levels determine access to and understanding of food choice, financial and health costs associated with negative health behaviors, and food security that stipulates affordability, physicality, and social needs of healthy foods versus cheaper energy-dense and fast food choices.
            These behaviors combined with the increase in convenience availability and the increased demand of conveniences, such as, transportation, cooking, cleaning, and communication have only made these behaviors have become a perceived social norm.  While the stigmas around being obese include stereotypes like being lazy or lacking self-control we have created an environment for ourselves through our demands for more convenience that have perpetuated the stereotypes into phenotypes.

Clinical Causes of obesity

Not all obesity causes are the result of poor health behaviors. “There are over 600 genes, markers, and chromosomal regions identified as being associated with human obesity phenotype” (Ulijaszek, 2007).  In the United States obesity is considered the most common nutritional disorder costing more than $100 billion a year in health-related expenses.  Research has shown that mutations at the genetic level have been found to be associated with obesity; thus showing that environmental factors that play roles in gene mutation have a greater potential to become more prevalent with successive generations.
Most clinical causes of obesity are termed secondary causes and can be brought about by medications, other diseases, and psychosocial aspects.  There are a number of medications that have weight gain as a side effect.  Thankfully, for some of these medications, there are alternatives that offer either less weight gain, no weight gain, or promote weight loss.  These medications fall into the pharmaceutical classes of psychiatric/neurologic, steroid hormones, anti-diabetic agents, antihistamines, antihypertensive agents, and highly active antiretroviral therapies.  As for obesity being a comorbid diagnosis of another underlying disease, the average among obese individuals falls below 1%.  Those diseases that have a greater potential for causing obesity as a secondary disease fall under endocrinopathies which include: Cushing’s syndrome, hypothalamic damage, insulinoma, and hypothyroidism.  Psychosocial aspects of obesity include: sexual, physical, and emotional abuse –especially when it occurs in women or during childhood or adolescence.

Society’s impact on obesity

Society’s impact on obesity may not be very recognized or readily acknowledged.  The move from agrarian to industrialized life-styles and the implementation of the 7-day work week has changed not only the access to physical activity and food but the structure of these same daily activities. Combined with the increase in low cost transportation, the decline of physical activity in highly industrialized nations these associations have been well documented as being a part of the obesogenic societal creation.  The spiral continues downward as the need to reduce time constraints on daily living creates greater deficits in physical activity.  “Convenience in food is also expressed in the emergence of fast food.  Eating at fast-food restaurants is positively associated with having children, a high-fat diet, and high BMI, but negatively associated with vegetable consumption and physical activity” (Ulijaszek, 2007).
Within the United States the goal of improving test scores of standardized tests (No Child Left Behind Act) has done little to impress upon our nation’s growing children the value and need for physical activity.  Physical education programs and sports programs (along with programs in the arts) have had funding and time reduced, if not cut altogether.   With schools held accountable for improved testing scores, many states developed rewards and penalties for those schools that showed improvement and for those that didn’t.  As an unrecognized side effect, schools and school districts reacted accordingly cutting time from those activities and educational necessities like physical education, the arts, and even recess which offered a chance of fresh air and sunshine if not some form of physical activity, as a way to compensate for poor test scores.   “In a nationally representative sample, the presence of school accountability and years of exposure to accountability laws significantly increase students’ BMI” (Schnider, 2013).
Thanks to government subsidies unhealthy food has become abundant and inexpensive as the costs of these products (sugar, corn, wheat, soybeans, and dairy) decrease they become more readily available and easier to obtain while the cost of whole foods (fruits and vegetables) have increased.  These cost differences affect most those in the poorer sectors indicating that food security is one culprit in the obesity epidemic.  It is no surprise that these same crops are used in some of the most energy-dense foods containing high combinations of sugar, fat, and salt and are some of the most accessible to all income levels.
Eating, especially, has a historical social context.  When comparing those who eat alone versus those who eat in groups, consumption of food in these social environments increases dramatically the more individuals there are at the table. 

“Obesity spreads through social networks in adults.  Individuals ate 35% more when eating with one other person, 75% more with three other people, and 96% more with a group of seven or more.  Furthermore, an individual’s chance of becoming obese increased by 57% if he or she had a friend who became obese and 37% if his or her spouse became obese.  These studies point to effects of environment and cultural influences on obesity.”
(Swencionis, 2012)
Holidays, especially, only perpetuate this group socialized eating setting and have been shown to have become more food centered over the years and less religious centered over the years.
            Advertising of food is currently under scrutiny to see if there is a deeper correlation between the number of advertisements an individual sees regarding food per day and their risk of becoming obese.  Marketing of food appears everywhere, billboards, television, social media; sporting events (think the recent Winter Olympics), mail flyers, magazines… the list goes on.  It has been proven time and time again that advertising works in the promotion of products as is shown by marketing expenditures, and it has been shown that “industry marketing campaigns can even counter the effect of health promotion messages” (Lesser, 2013).  Surveys taken in middle and lower income neighborhoods have shown that for every 10% increase within the neighborhood of outdoor food advertising there is a 1% change, and in areas with 30% increase in outdoor food advertising there is a 2.6% increase in the risk of becoming obese.

Obesity’s dark side –disease caused by obesity

The epidemiology/pathophysiology behind obesity is anything but simple.  Excess body weight is defined as a BMI of 25 to 28 for overweight and a BMI of 30 or more for obese and has long been recognized in association to type 2 diabetes and an increased risk factor for cardiovascular disease, but more recently through the literature review done by the World Cancer Research Fund, there appears to be “convincing evidence that body fatness is associated with an increased risk” of cancer (Renehan, 2008).  Obesity has also been linked to an increased likelihood of metabolic complications, insulin resistance, hypertension, dyslipidemia, endocrine manifestations, obstructive sleep apnea, and gastrointestinal disorders.
Obesity’s havoc on the human body starts out small.  Metabolic complications occur when there is a greater concentration of fat distribution in the upper body or in those with enlarged fat cells.  Concentrations of fat like this result in the release of free fatty acids and glycerol through the process of lipolysis, which is regulated by insulin and catecholamines.  This metabolic complication leads to insulin resistance.  Insulin in a healthy body promotes the uptake of glucose, oxidation, and storage; when an individual becomes insulin resistant the ability of these processes becomes reduced.  Insulin resistance initially can lead to hyperinsulinemia –a high risk factor in cardiovascular disease- and type 2 diabetes.  Hypertension occurrence in obesity is the result of decreased vascular relaxation caused by hyperinsulinemia and its effects on renal sodium absorption.  Dyslipidemia, like metabolic complications, is associated with upper-body obesity and type 2 diabetes.  The affects of dyslipidemia are an increase in triglycerides, a decrease in high-density lipoprotein (the good cholesterol), and high proportions of dense low-density lipoproteins (the bad cholesterol). 
Of the abnormalities of endocrine function that occur in obese individuals one of the most common abnormalities in obese women is polycystic ovarian syndrome.  The most common mechanical complications brought on by being obese are an increased risk for lower extremity degenerative joint disease and venous stasis which can be aggravated by right heart failure.  Obstructive sleep apnea is more common in obese men and more common in women with the upper-body obese phenotype.  The cause is due to the collapse of the upper airways during sleep due to the enlargement of upper airway soft tissues and is associated with an increased risk of hypertension, right heart failure, and sudden death.  Obesity-caused gastrointestinal disorders are associated with gastroesophageal reflux disease, gallstones, fatty liver, and nonalcoholic steatohepatitis which can lead to cirrhosis of the liver and death.
            Obesity’s role in cancer is still being researched, but the findings thus far have revealed connections between body fatness and an increased risk of “oesophageal adenocarcinoma, and cancers of the pancreas, colorectum, post-menopausal breast, endometrium and kidney, and evidence of a probable association with risk of gall bladder cancer” (Renehan, 2008).  Obesity-cancer caused mechanisms include insulin resistance (insulin, C-peptides, insulin-like growth factors), sex steroids (oestrogen and androgens), and adipokines (polypeptide hormones, adipocytes, and leptin), though insulin resistance is considered to be at the heart of the obesity-cancer associations.  Other biological obesity-related candidates include abnormal cytokine production which is often seen in chronic inflammatory responses.  These pro-inflammatory factors increase as the fat mass increases.  Pro-inflammatory factors are secreted from adipocytes, meaning as the amount of fat accumulation increases so does the amount of pro-inflammatory factors.  Not only are these pro-inflammatory factors recognized in connection with cancer, but also, in connection to the development of insulin resistance, type 2 diabetes, and obesity-related atherosclerosis. 
            When looking at the diseases caused by obesity it is easy to see that there is a vicious cycle of cause and effect.  As each stage in the cycle is obtained it appears as though it is only easier for transition to the next stage of disease.  Recognition of obesity’s dangerous health affects is important at the earliest possible stage in order to make any attempt to keep the cycle from going forward toward death.

Combating Obesity

According to Callahan “Most of the 67 percent who are overweight or obese will remain so for the rest of their lives” (2013); thus the first line of defense in the fight against obesity lies in keeping children from the same fate.  Programs similar to those against smoking are proposed as possible weapons in the arsenal against obesity: taxation on sugared drinks and unhealthy highly processed foods, reducing or even banning advertising of unhealthy foods to children, posting nutritional information on restaurant menus, and reducing the cost of healthy foods.  But these proposals run into major barriers: marketing practice and the potential impact on shareholder wealth.  The World Health Organizations report on Diet and Nutrition, as quoted by Ghani, state that the “the marketing practices targeting children as ‘causative,’” allow for the potential targeting of marketers for interventions (2007).  While proposals are good, test data have shown negative impacts that reflect abnormal stock price reactions when companies are exposed as “obesity related costs in marketing, consumer education, and increased regulation” (Ghani, 2007).  The forecasts for shareholders potential losses make forcing changes in marketing and potential legal implementation against companies who produce obesogenic-type foods and products very difficult.
While it has been clearly shown that negative environmental factors that influence individuals to eat outside of the home has a high correlation to obesity, the contrast exists for those who take a more conscious path in eating.  Consumption of four or more meals per day, eating whole foods and skim dairy products, trimming visible fat from meats or choosing leaner meats, and avoidance of eating while otherwise distracted (watching television) have proven to help with weight control.  “Perceived barriers can have a negative effect on commitment to a behavior; situational or environmental influences affect commitment to and engagement in a given behavior; persons are more likely to engage in a behavior if they have positive role modeling and support; and that families, peers, and health care providers are important sources of support for promoting a given behavior” (Moore, 2014; quoting Pender et al., 2002).
            Taking a threefold support concept of family, peers, and health professionals it should be possible to come up with steps to promote better behavior patterns while simultaneously recognizing the negative behaviors which promote the obesogenic lifestyle in the first place.  “Behavior condition therapy for obesity consists of self-monitoring, stimulus control, and behavior modification.  Self-monitoring is usually by diary. Stimulus control consists of restricting eating locations, not engaging in other activities while eating, restricting quantities, leaving the table soon after finishing, shopping only from a list and restricting shopping to that list, and making snack foods unavailable or difficult to obtain” (Swencionis, 2012).

Conclusion

            Clearly, obesity has become a disorder of convenience.  Acceptance of the global dependence upon the convenience of energy-dense and highly accessible foods that have been proven to increase our susceptibility to obesogenic living; acceptance of our dependence upon those convenience making devices (cheap transportation, entertainment); and acceptance of our psychosocial changes in our views on food and physical activity have driven us down a dangerous path.  Obvious and not-so-obvious changes need to be made. Stopping the epidemic of obesity will take the global effort of everyone and of many generations; but we need to start now.




Reference

Callahan, D. (2013). Obesity: Chasing an Elusive Epidemic. Hastings Center Report, 43(1), 34-
40. DOI:10.1002/hast.114
Ghani, W. I., Childs, N. M., & Szewczyk, S. H. (2007). Food Marketing Practices and Anti-
Obesity Policy: Impact on Shareholder Wealth. Marketing Management Journal, 17(1), 123-135.  Retrieved from: http://eds.b.ebscohost.com.lib.kaplan.edu/eds/pdfviewer/pdfviewer?sid=eb81aab8-fc67-43d0-b6b5-e378e0b8f6b7%40sessionmgr115&vid=4&hid=104
Goldman, L. and Auseillo, D (ed).  (2004). Cecil Textbook of Medicine 22nd Edition.
Philadelphia, PA: Saunders.
Lesser, L. I., Zimmerman, F. J., & Cohen, D. A. (2013). Outdoor advertising, obesity, and soda
consumption: a cross-sectional study. BMC Public Health, 13(1), 1-7. DOI:10.1186/1471-2458-13-20
Mesas, A.; León-Muñoz, L.; Guallar-Castillón, P.; Graciani, A.; Gutiérrez-Fisac, J.; López-
García, E.; et al. (2012). Obesity-related eating behaviours in the adult population of Spain, 2008-2010. Obesity Reviews: An Official Journal of the International Association for the Study of Obesity, 13(10), 858-867. DOI:10.1111/j.1467-789X.2012.01005.x
Moore, M.M.; Robinson, J.C.; Rachel, M.M.; and Boss, B.J. (2014). Barriers to Physical Activity
and Healthy Diet Among Children Ages 6 Through 13 in a Mississippi Elementary School.  Journal of Pediatric Nursing, 29(2014), 74-82. DOI:10.1016/j.pedn.2013.08.010.
Renehan, A., Roberts, D., & Dive, C. (2008). Obesity and Cancer: Pathophysiological and
Biological Mechanisms. Archives of Physiology and Biochemistry, 114(1), 71-83. doi:10.1080/13813450801954303
Schneider and Zhang. (2013). School Accountability and Youth Obesity: Can Physical
Education Mandates Make a Difference? Educational Research International, 2013(2013). DOI: 10.1155/2013/431979
Swencionis, C. and Litman Randell, S. (2012).  The Psychology of Obesity.  Abdominal
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of the International Association for the Study of Obesity, 8(Suppl. 1), 183-187.
DOI: 10.1111/j.1467-789X.2007.00339.x


Tuesday, April 22, 2014

Friday, April 18, 2014

Appetite vs Hunger

As I drove home in my sun-warmed car post acupuncture treatment, I realize that I may have a need to be clearer with my acupuncturist regarding my appetite as the sharp painful pressure in my ear and jaw slowly dissipated.  We all define words slightly different based on our personal perception and experience and typically not that far from the actual meaning of the word (s).  For me appetite has always meant my desire for certain foods with or without hunger; whereas, hunger was the desire to eat for nourishment or to replenish drained energy stores.  

According to Google; appetite (noun) is a natural desire to satisfy a bodily need, especially for food and hunger (noun) is a feeling of discomfort or weakness caused by lack of food, coupled with the desire to eat.  So when asked this morning how my appetite was during the past week, I said I hardly ever have an appetite; which is true.  I rarely desire certain foods over others, and I certainly have a preference for some foods more than others, but my perception of appetite clearly did not fit.  What I should have probably said was that typically I get very hungry just before lunch and only slightly hungry toward the end of the day.

Why the confusion between these two synonymous words?  Finding answers to this strange dilemma of mine is not easily done.  Google searches of course pull up millions of topics mostly on appetite control and even searching EBSCOhost (an academic paid search engine) pulls up scientific based research on appetite control and hunger satiety through various methods of food intake and meal portioning or timing. A glance through search results on the psychology of hunger appear to create a negative image of hunger, i.e. that when we hunger we lose control over our thought processes and ability to choose, as in choose healthy good-for-us things versus the alternative bad-for-us things.  A search on the psychology of appetite results in how behaviors affect eating habits and appetite control methods for the prevention of ill-health effects.

When did we place such negative meanings on these two so very natural words?  What happened to our hunger for life or our appetite for adventure?  Clearly I am not the only one at a loss in how to interpret these words in a practical manner, let alone in a medical-like setting where an incorrect interpretation means the difference between a painful pressure in my ear and the reduction of stress –which was my intention.


“Appetite has really become an artificial and abnormal thing, having taken the place of true hunger, which alone is natural. The one is a sign of bondage but the other, of freedom.” 
~ Paul Brunton, The Notebooks of Paul Brunton


“Whether sixty or sixteen, there is in every human being's heart the lure of wonder, the unfailing child-like appetite of what's next, and the joy of the game of living. In the center of your heart and my heart there is a wireless station; so long as it receives messages of beauty, hope, cheer, courage and power from men and from the infinite, so long are you young.”
~Samuel Ullman

“Hungry man, reach for the book: it is a weapon.” 
~ Bertolt Brecht


“If you take responsibility for yourself you will develop a hunger to accomplish your dreams.”
~Les Brown



Stay Happy! Stay Healthy!