Public Health Enemy No. 1
Tackling America’s Growing Obesity Epidemic

By Amy Meadows

    The statistics are chilling. A recent study by Johns Hopkins Hospital revealed that nearly 300,000 children ages 1 to 6 are too heavy to fit into standard car seats, which are designed to hold children weighing up to 40 pounds. Their plight has prompted some manufacturers to begin producing larger, hefty-model safety seats that can accommodate children weighing up to 80 pounds. While terribly disturbing, this story is just one of many that underscore
the serious crisis Americans of all ages are facing today.
     According to the 1999-2000 National Health and Nutrition Examination Survey conducted by the Centers for Disease Control and Prevention (CDC), more than 64 percent of adults are classified as either overweight or obese, which means they have a body mass index (BMI), or standard ratio of weight to height, that is over 25 (overweight) or 30 (obese). That staggering figure represents a 36 percent increase in just over two decades. In Georgia alone, more than 22 percent of adults are considered obese. Even more alarming is the fact that these astonishing statistics have trickled down to the country’s youth. The American Obesity Society (AOS) reports that more than 30 percent of children ages 6 to 11 are overweight and more than 15 percent of children in the same age group are obese; the numbers are similar for adolescents ages 12 to 19. That’s double the percentages from 30 years ago.
     The CDC defined the obesity crisis as a growing epidemic in 1999 because of the unprecedented increase in obesity statistics across the board. And while the numbers have continued to rise, that announcement brought to light an important subject and an imperative dialogue about how to elicit a change within society. Now, people are trying not only to understand how America has gotten to this point, but also what the overriding effects of obesity are and how individuals can lose weight and get healthy once again. Every day, organizations that are dedicated to obliterating the obesity epidemic are conducting research and publishing reports about obesity and its consequences, leading many overweight and obese citizens to seek out treatment options. It’s clearly an uphill battle, but America is beginning to confront public health enemy No. 1.

Super-Sizing a Nation
     For some people, genetics do play a major role in determining whether or not they will become overweight or obese. However, for
a majority of the population, poor nutrition and lack of physical activity are the key culprits.
    “It’s the environment we’ve created that interacts in a negative way with our genes that causes weight gain,” explained James Hill, director of the Center for Human Nutrition at the University of Colorado and past president of NAASO, The Obesity Society, the leading scientific organization dedicated to the study of obesity. “For example, food is available everywhere; it’s very cheap, it’s high in calories and it’s served in large portions. All of this feeds into our physiology, which is geared up to eat. At the same time, we’ve created an environment where you don’t have to be physically active anymore, and our physiology doesn’t drive us to be active if we don’t have to be. So the environment says eat and be inactive — and our genes are fine with that.”
     Today’s Americans are always on the go, and eating on the run has turned the country into a fast food nation. Unfortunately, the food available at most fast food establishments is brimming with calories. For instance, a McDonald’s Quarter Pounder with Cheese yields 510 calories, while a Whopper with cheese from Burger King is a whopping 760 calories. Those numbers don’t include sides like French fries and a sugary soda. Moreover, not only are the portion sizes bigger than they used to be, but people are given the opportunity to “value size” their meals, practically doubling their caloric intake. And this trend is found everywhere, even in the grocery store or sandwich shop. According to the National Institutes of Health, 20 years ago, a standard bagel measured 3 inches in diameter and provided 140 calories; nowadays, the standard bagel is 6 inches in diameter and offers 350 calories. When it only takes 3,500 calories to produce a pound of weight, it’s easy to see how people’s BMI scores have skyrocketed.
     Furthermore, people are not burning off the calories they take in each day. The CDC has stated that more than 50 percent of American adults do not get enough physical activity, and 25 percent of adults get no activity at all during their leisure time. It’s the same with children. While contemporary kids always seem to be on the go, they’re actually living more sedentary lives than ever before. In 2005, the Kaiser Family Foundation reported that American children 8 years and older spend 6.5 hours each day watching television, sitting in front of the computer and playing video games. And physical activity during school has decreased dramatically; not only is recess being eliminated around the country, but the National Association for Sports and Physical Education also says that one in four children does not participate in any school physical education. Moreover, physical activity decreases as children become adolescents, and the CDC reveals that almost half of today’s teens are not regularly active. Now kids, as well as adults, are paying for it with their health.

Running the Risk
     The list of health risks associated with obesity is at once long and unnerving. In adults, obesity can lead to stroke, heart disease, hypertension, Type II Diabetes, osteoarthritis, sleep apnea, liver disease, pancreatitis, Gastroesophageal Reflux Disease and that’s just the beginning. Obesity can also cause some cancers, such as kidney cancer, colorectal cancer, gall bladder cancer, endometrial cancer and postmenopausal breast cancer. In addition, overweight and obese people can suffer from urinary stress incontinence, chronic pain and even infertility.
    “In a way, you go down this path from being a normal weight to obese to having Type II diabetes to having heart disease to having cancer,” Hill said. “It seems to be that whole cascade. And if we could prevent obesity, we could prevent almost all diabetes. We could also probably prevent a lot of heart disease, which has been estimated to contribute to 20 to 30 percent of all cancers.”
     Sadly, overweight children experience the same negative health effects, from hypertension to sleep apnea. They often must contend with the early onset of puberty as well. Additionally, diabetes has always been an issue, but now the stakes are much higher, as children are beginning to develop Type II diabetes, once considered an adult disease. And since overweight children run a 70 percent risk of becoming obese adults, they’ll carry these co-morbidities, or illnesses associated with severe obesity, throughout their lives, which may be cut short.
     And even if obese individuals live long lives, their quality of life will certainly suffer because of their condition, which itself is being classified as a disease by many organizations. “This is something that people debate right and left,” Hill continued. “Here’s what I believe. Obesity develops not because of a disease, but once you have the excessive body fat, it affects all of your organs. So, at that point, it is a disease because your organs have changed, your fat cells have changed, and the excess fat negatively affects all of your body processes.”
     The multitude of health issues overweight and obese people face undoubtedly reduces quality of life, as do the psychological effects of being heavy, including poor body image, low self-esteem and depression. These consequences cross all age and gender boundaries and are a very real by-product of a condition that has become the country’s second leading cause of preventable death.

Expensive Effects
     A society laden with obese individuals experiences a wide range of ramifications as a whole, starting with the impact obesity has on basic economics. Overweight and obese people often find themselves paying more than the average lean American just to live. Larger clothes are more expensive, the cost of purchasing numerous prescriptions to treat their co-morbidities is high, and some people may have to buy an additional seat to travel on an airplane. Even children are seeing the effects; parents who have to buy hefty-model car seats can shell out as much as $250.
     The costs associated with obesity also affect the healthcare industry and employers. According to a report in “Issue Brief,” a publication of The John F. Kennedy School of Government, just eight years ago, 9 percent, or $78 billion, of the nation’s total medical spending was “attributable to overweight and obesity.” That kind of spending directly affects employers, who must deal with medical care costs, increased health insurance premiums, and other expenses like paid sick leave, life insurance and disability insurance.
     Even other industries, like the airlines, are being touched by obesity. According to the CDC, because Americans weigh more than they did decades ago, airplanes must use more fuel to transport them, resulting in higher fuel costs. In 2000, airlines spent $275 million to burn 350 million more gallons of fuel than in previous years.
     The numbers don’t lie, and the obesity epidemic proves Americans have to tighten their belt.

Popular Options
     The customary advice for losing weight is to exercise and eat right. For some people, though, that’s easier said than done. If it were that simple, then the industry that has sprouted up around the issue of obesity would not exist. An evening in front of the television reveals the many treatment options that are now available for overweight and obese individuals. From meal plans like Jenny Craig and Weight Watchers to medical weight loss programs to a wide range of in-home exercise equipment and specials on gym memberships, there seems to be an answer for everyone. Furthermore, a number of popular diets have swept the nation in recent years. The Atkins Diet and the South Beach Diet are two of the most favored, with the first being a low-carbohydrate diet and the latter offering information about how to eat the “right carbs.”
     Some of these methods may work, and some may not. And some may work temporarily. It really depends on the individual and his or her commitment to sticking with a chosen plan. Unfortunately, many meal plans are not meant to be followed in perpetuity, so people tend to gain weight back when they end their diet. That’s often when they turn to pharmaceutical interventions to try to get the weight off — sometimes under a doctor’s supervision and other times with over-the-counter pills. However, several medications, like Fen-Phen, have been taken off the market after research indicated that they can have negative side effects like heart valve damage. So, individuals must weigh the pros and cons of any new program and figure out what’s best for them.

Time to Take Drastic Measures
     Many of today’s popular options, particularly the meal plans, result in yo-yo weight loss and weight gain over time. Some people lose 50 pounds, only to turn around and gain back 75 pounds. And this can go on for years. According to Kym Carter, R.N. and Bariatric Surgical Weight Loss Center coordinator at North Fulton Regional Hospital (NFRH) in Roswell, “When someone is on a diet for years in and out, your body adjusts as well as it possibly can, but your metabolism gets a glitch in it.” Typically, the body seems to stop notifying the brain that the stomach is full. “A lot of people think it’s just lack of self-control, but it’s not lack of self-control or just being lazy — it is a lack of satiety. After you’ve gone on this roller coaster for so long, your body is not as sharp as it could be, and that hunger mechanism breaks down.”
     It’s at this point, when everything else has seemed to fail, that people turn to bariatric surgery, a treatment option that has grown in popularity over the last several years as physicians have perfected the procedure. “We want patients to use us as a last resort,” Carter continued. “And the patients we see have been fighting obesity most, if not all, of their lives.”
     Patients who are eligible for weight loss surgery must meet certain requirements set forth by the National Institutes of Health; they must either be more than 100 pounds over their ideal weight, have a BMI of 40 or greater, or have a BMI of 35 or greater with co-morbidities, such as diabetes or hypertension. Once they are accepted as a surgical candidate, they have three options in regards to the type of bariatric surgery they want to have done: restrictive, malabsorptive or a combination.
     One restrictive procedure known as the Lap-Band System is the newest option available and does not require any reconstruction of the digestive system. Instead, the surgeon creates a false pouch using an adjustable silicone band device, which is placed around a portion of the stomach to make it smaller. A bladder located on the inside of the device is inflated with an injection of saline, making the pouch smaller. Adjustments, however, can be made to the device throughout a patient’s life. Yet, the downside of this procedure is that it only restricts the amount of food that can be consumed — not the amount of calories that is absorbed by the body. Therefore, patients must follow a physician-appointed eating plan and exercise regimen to ensure weight loss. “You have a tool you’ve been given, but you still have to work the tool,” Carter explained. “There is no automatic anything, even with bariatric surgery. This is not a quick fix.”
     The same is true for malabsorptive procedures like the Biliopancreatic Diversion and the Biliopancreatic Diversion with Duodenal Switch, which are also restrictive but do require major changes to the digestive tract. In these cases, part of the stomach is removed or the stomach is stapled, while the small intestine is rearranged to reduce the number of calories it can absorb. It is extremely effective for morbidly obese individuals, because it helps them lose the initial weight quickly.
     According to Carter, though, the “gold standard” of bariatric surgeries is the combination procedure known as the Roux-En-Y Gastric Bypass. This procedure is the most widely used technique and incorporates the best characteristics of the restrictive and malabsorptive options. “These people lose up to at least 85 percent of their excess body weight in the first 12 months,” Carter noted. Then again, they do run the risk of becoming deficient in certain vitamins and minerals, because some of the important nutrients that are usually absorbed in a portion of the stomach do not make it there. Henceforth, these patients have to take multivitamins and calcium every day for the rest of their lives, and some may even need B12 supplements.
     Carter does state that every surgery has its risks. One critical factor is the use of general anesthesia, which can present a problem for an obese person, who is already considered a high-risk patient; the anesthesia can hide in the fat stores and potentially cause an overdose if the patient is under for too long. Fortunately, many of today’s bariatric surgeons, including those at NFRH, have helped refine these procedures, which can often be done laparoscopically and more quickly than ever before. The key, she said, is to find a surgeon who is a certified member of the American Society for Bariatric Surgery and understands how other disease processes can affect the body during surgery.
     Some insurance providers will cover bariatric surgery, as it is now seen as a health issue instead of a cosmetic one. Others, however, have chosen to remove that option from their plans. For patients who must pay for the surgery out of pocket, they need to be aware that, on average, it costs between $20,000 and $30,000.

Weighing Options
     Before deciding to pursue this course of action, Kevin Munley suggests that individuals spend months conducting research about the surgery and their options so they can make educated decisions. That’s what he did before having the Lap-Band procedure in August of 2004. He went online to find a community of people who had undergone the surgery and attended sessions at the NFRH Bariatric Surgical Weight Loss Center, which offers pre-, intra- and post-operative support. “This is not something to be taken lightly,” he asserted. “It’s stressful, and you should give yourself at least six months to prepare for it.” After completing his research, Munley, who weighed 350 pounds, had the surgery and has lost 152 pounds to date.
     Virginia Rock, Bariatric Program Assistant at NFRH and a bariatric surgery patient in 2001, agrees and goes on to say that patients must be compliant before and after the surgery to make it work. “People need to educate themselves,” she declared. “They need to talk to people who’ve had the surgery and they need to start going to support groups six months before they have the surgery. And they need to continue to attend after surgery. Many people think this is the magic pill, that the weight falls off and you never have to worry about it again. But there is no magic pill. You have to change you. You’ve got to do the work beforehand and after.” Through a precise eating plan and regular exercise, Rock went from 398 pounds to 160 pounds, losing almost all of that in the first year after surgery.
    “This is a lifetime commitment,” Carter reiterated. “But it’s saving people’s lives and giving them a better outlook on their future.”

The Big Picture
     Of course, many people want to avoid surgery, but they don’t know where to turn if they have been unsuccessful with other treatment
options. In Metro Atlanta, there’s now another alternative — Verto, Inc., the city’s only comprehensive, medically supervised, non-surgical weight management clinic for adults and adolescents. Opened in August of 2005 and located in Norcross, Verto takes a different approach to the weight loss process.
    “We are interested in reducing your total body weight, but our main focus is to alter your body composition because there’s another line of research that clearly shows that your health and longevity is dependent upon the amount of lean muscle that you have,” explained Michael O’Grady, the doctor who founded Verto with Vincent K. Ramsey, Ph.D. after conducting extensive research in the areas of rehabilitation, bariatrics and obesity through the National Institutes of Health. That research, which looked at 400 older adults over a four-year period and the effects of pharmacological and nonpharmacological interventions on muscle mass, revealed that for every pound of muscle a person builds, he or she loses three pounds of fat. That evidence paved the way for a new method of approaching the treatment of obesity.
     Verto addresses five components in its standard six-month program: medical evaluations, nutritional counseling, functional exercises, behavioral modification and patient education. A patient’s first visit to the clinic involves a thorough medical exam, including a blood test, an EKG, a DEXA-scan to measure bone density and more. It also includes a functional evaluation to test strength, agility and flexibility so a customized exercise regimen can be created. Then, each subsequent visit begins with a check of the patient’s vital signs. Those visits also include a personalized workout with an exercise scientist and a dietary check with a nutritionist to ensure that the patient is following the meal plan designed for him or her (which does not focus on depriving oneself, but on making good choices). Each patient is expected to visit the clinic twice a week and also work out at home using tips provided by Verto’s highly educated and experienced staff to get enough physical activity throughout each week. There is even a psychologist on staff if a patient feels that he or she needs to deal with the emotional side of being obese.
    “What we realize is that it takes about six months if you want to do it right,” observed Rich Hilmer, executive director of Verto. The goal is not to help patients lose 30 pounds in three months; it’s to take the weight off gradually and safely. And after the initial six months, patients are asked to visit once a month for the next year so the doctors and staff can track their progress. “Sustainability is our other uniqueness,” he added. “We don’t just get the weight off quickly and then you’re on your own.”

One Step At A Time
     For James Hill, the beginning of the end of the obesity epidemic is within Americans’ reach. “What everybody can do as a first step is stop gaining weight,” he opined. “The average adult in the U.S. gains one to two pounds per year every year. By making small changes, you can stop gaining weight. Then, if you continue making small changes, you’ll lose weight.”
     He suggests finding ways to cut 100 calories a day and burn 100 calories a day — advice that has become the mantra of America On The Move, a program Hill helped found through the America On The Move Foundation. Taking these small steps each day will add up in the end and ultimately bring about a big change.
    “The obesity epidemic didn’t happen overnight. It happened with those one to two pounds a year,” he added. “The good news is that we can prevent that [weight gain] if people would start with small changes. And, over time, we can get rid of this epidemic.”

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