OBESITY T. Anthony Don Michael, M.D.
Obesity is the classical American paradox. We live in a culture that watches the Olympic Games, sport activities, and spends billions of dollars on cosmetology to create the body beautiful and even more effort to create the ageless man and woman. Coincidentally, extreme overweight obesity has galloped away in an untrammelled fashion such that one-third of all Americans over the age of 20 and one-fifth under this age are overweight. Obesity isn't just an American phenomenon, it is internationally and nationally an epidemic. Predictions are that at its rate of increase that over 90% of Americans will be overweight in the third decade of the next century. The medical history of obesity dates back to the stone age with primary approaches to treatment from the time of Hippocrates involving changes in diet and exercise. The anthropologist, Margaret Mead, astutely observed that man who had developed genes to survive food depletion, lived into the urban era in which there was food repletion and sedentariness. This led to obesity. More recently, the nature vs. nurture hypothesis has become hot and furious. While it is known that the obesity gene is a reality and that genetic engineering is attempting to alter its expression, the increased incidence of obesity is not related to this but is attributable to behavior. Scientific researchers have shown that the hormone Leptin, produced by the body, produces a sense of satiety in the hypothalamus and that as weight gain occurs, sensitivity to this hormone is lost. This leads to uncontrolled overweight, associated with a resistance to insulin, leading to diabetes and to sex hormones resistance causing sexual dysfunction and cancer in both males and females. Side effects of obesity are thus high blood pressure, nonfatal heart attacks, strokes, diseases of blood vessels, accident proneness, orthopedic injuries, a proclivity to trauma, diabetes mellitus, elevation of cholesterol, gout, prostate cancer and hypertrophy, breast and uterine cancer, gallstones, hernias, colon cancer, complications associated with surgery due to blood clots, thickening of the blood, bluish skin, infections, disfigurement, depression, and above all a loss of self-esteem. Charles Dickens described the Pickwickian boy, a somnolent individual, who tended to fall asleep during the day and snored at night. Obese patients may develop a condition called sleep apnea in which they stop breathing and in which their heart stops, another side effect associated with obesity. This is the Pickwickian sleep apnea syndrome. Detection of obesity is commonly done by measuring the body mass index, which is the ratio of weight to the square of the height. A body mass index of 22-24 is ideal, over 27 indicates overweight; however, over 30 defines obesity. Being 100 pounds overweight is usually characterized as malignant obesity. Measurements, such as the waist-hip ratio, was doubted at one time as being an important index for risk for heart disease. The large hips of the ladies in paintings by Reubens and the other Dutch Masters, however, do not protect from heart disease as there is a recognized relationship with elevated triglycerides, a form of blood fat. Obesity is also more accurately measured by impedance techniques in which the body fat and lean mass are separately measured and added together to comprise the weight. This determination takes a few minutes and is a more sophisticated way of looking at overweight. Cultural studies have shown that Asians who return to their countries lose weight and that "pot belly" or upper truncal obesity in these people in their own countries carries a high risk of diabetes and heart disease, although their overall weight is normal. Similar studies have been shown in Puma Indians. Overweight in postmenopausal females is associated with upper truncal obesity or a "pot belly," a tendency to diabetes, high uric acid and gout, high triglycerides, low HDL cholesterol, heart disease. This is characterized as the so-called syndrome X and is responsible for heart attacks, strokes, and vascular disease in these patients. In classic studies of Mason, carried out on nurses over several decades, overweight and overall mortality were closely related. These nurses between the ages of 30 and 55 had twice the risk of mortality in the overweight group and three times the risk in those who were obese. Similar results were obtained with high blood pressure. In analyzing these studies, it is not facetious to recall the Shakespearean aphorism that "old men are lean," highlighting the relationship of leanness to longevity. Mason showed this clearly in her studies. In approaching obesity, there has been a great deal of partial solutions motivated by economic factors. Thus, diets of different types have emerged as panaceas and are heavily invested in. Although highly effective over the short haul, most of these techniques have led to the phenomenon of cycling or relapses. While drugs were used in the past, such as thyroid, amphetamines, and ephedrine, these have been shown to be ineffective and dangerous. Exercise alone has had a long history which is reputable and knowledge about behavior modification and stress management has been scanty. In this day and age, it is believed that a multifaceted approach to obesity is the only valid method to lose weight and that this approach needs to be carried out over a period of years allow it to evolve into a lifetime change in order to achieve weight reduction. This multipronged approach is based on scientifically FDA approved drugs of which there are two classes: the thermogenic group which increase energy consumption and reduce appetite but are not habit forming, such as phentermine (Fastin) and the serotonin antagonist which prevent the uptake of serotonin in the brain, examples of which are fenfluramine (Pondimin, Redux) and drugs that prevent absorption of fat, such as Xenical. A safe approach to weight therapy has also been the use of a drug called "mazindol," which is a tricyclic thermogenic drug. The appropriate treatment of patients with drugs is to catch periods during which they eat the maximum amount of their food and use the drug to reduce this intake. An understanding of their side effects and safety profiles, contraindications, in patients at risk and in precisely patients in whom they are likely to cause problems. The obese should be discouraged from going to "pill in the mill," surreptitious, economically driven practitioners for providing weight loss. These drugs, however, effectively used have produced a dramatic effect in initiating weight loss and in maintaining it. Diet is a cornerstone of therapy. Appropriate diets have to recognize that the undernutrition can result and needs to be combined. This applies particularly to the recently revived very low calorie diets which had gained publicity as being dangerous. We know now that with appropriate monitoring, these can be safely used. The prescription of a diet by a registered dietitian or nutritionist is essential in a weight management program. Diets that have specific formulations and are expensive have not been shown controlled scientific studies to be beneficial. The recommendations of the American Bariatrics Association on Dieting need to be strictly adhered to. Exercise is a cornerstone of weight loss. Without exercise, weight loss is seldom possible. While exercise improves stress with the production of encephalins and endorphins, it also reduces diet in some cases and expends energy. Modes of exercise vary, ranging from walks in the mall to aerobic exercises, games, underwater exercises, jogging, walking, and rehabilitation programs which have been enormously successful. There are innumerable exercise tapes and videos that are available which are motivational. Exercise is very much an individual matter and has to be organized. Frequently individuals think they get adequate exercise at work, but this is disorganized and seldom consistent. The fourth component of weight loss is behavior modification. While this has been handled by formation of groups, classes, talks, and the elaboration of more advanced societal bodies akin to those that deal with other forms of addiction, behavior modification is in my view best achieved concomitant with successful weight loss. While many of the techniques of weight loss will produce a 15% decrease in weight over a six month period, none of them have been successful in maintaining this weight loss. Thus, behavior modification without the protracted use of the other three techniques, drugs, diet, and weight loss, is rarely effective. Studies by Weintraub have used four-year periods of drugs and diet to induce behavior modifications that plan to induce lifetime habits. Stress management is important in patients as frequently extreme stresses induce excess of eating. A variety of techniques, such as biofeedback, psychological counseling, techniques for reducing stress include exercise, positive reenforcement, and evaluation of stressors are important. In the malignantly obese patient, previous operations, such as the ileal shunt, gastric balloons have been found to be not only ineffective but dangerous. Currently, gastric bypass has been shown to be relatively simple especially with laparoscopy and effective in inducing losses of 100 pounds which other techniques may not be able to allow. One of the least considered factors in weight loss relate to the stresses of modern living. Namely, the obese patients who wakes up, goes to work with a scanty or no breakfast, has infrequent meals, and ends the day consuming 5,000 calories in front of a computer or television. Indeed there is a documented case of a lady sleep walker who consumed food all night! It is important to tailor drug therapy to periods of time in which hyperphagia or overeating occurs. This allows conservation of drugs and a reduction in the cost of treatment. In contrast, retired persons tend to eat either throughout the day or during the day. Drug therapy for these patients needs to be tailored to their requirements and their times of eating. It is considered that a combination of drugs, diet, exercise, behavior modification and stress can cause 15-30% of weight loss in six months and that the persistence of these techniques to induce a change in lifestyle is the only effective way of treating obesity. The advantages of doing this certainly are dramatic, both short and long-term. Patients are energized, optimistic, often euphoric, enthusiastic, improve their sense of well-being and social skills, increase their insurability, reduce modality and morbidity, and thereby reduce medical bills and know that they will live longer. This positive effect on both the soma and the psyche can serve as important stimulants to recognize, identify, and motivate individuals to improve their overall quality of life. This can only be done by dedication to a long-term lifestyle change, avoidance of panaceas provided by dedication to an altered better life. Only then can they like "Humpty Dumpty" avoid being put back together again in the form that they were! The beast indeed can become a beauty.
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