Weighing In on the Obesity Epidemic

Publication Date May 7, 2018

By Brooks Jackson, MD, MBA
Dean, UI Carver College of Medicine
Professor of Pathology

Seventy to 80 percent of adult Americans are now overweight or obese, with the nation’s adult population in 2015-2016 approaching an obesity rate of 40 percent [1]. Approximately 21 percent of children between 12-19 years of age are obese [1]. Iowa had the 13th highest adult obesity rate in the nation in 2016, with an adult obesity rate currently at 32 percent—up from 21 percent in 2000 and from 12 percent in 1990 [2].

The risks of being overweight have been well documented and include hypertension, diabetes and its complications, liver disease, heart disease, sleep disturbance, some forms of cancer, and chronic joint disease [3]. Few people know that an extra 10 pounds of body weight add approximately 48,000 pounds of stress on the knee joint per mile walked [4]. Adults with diabetes are two to four times more likely to die from heart disease than adults without diabetes [5].

Obesity is one of the biggest drivers of preventable chronic diseases and health care costs in the U.S., with the total estimated cost of the obesity epidemic ranging from $147 to $210 billion per year, including the cost of absenteeism and reduced productivity [6].

Sixty years ago, people were remarkably thinner. Data from 1960 show that 13 percent of adult Americans were obese, compared to 39 percent today [1,7].

The gene pool of humans has not changed. So, what accounts for this difference? First, our lifestyles have become increasingly sedentary. In the past, day-to-day activities required more energy. For example, people pushed a lawn mower to cut their grass as opposed to self-propelled and tractor mowers. People raked their leaves and shoveled snow instead of using air/snow blowers. A greater percentage of people walked to work. Children usually walked to school and spent hours running around outside. Today’s children are more likely to be indoors on their computers or smart phones. In addition, the average American now watches approximately five hours of television per day, which often entails concurrent snacking [8].

In addition, we are also confronted with the temptation of unending overnutrition that includes increased portion sizes, calorie-dense processed foods, and sugar-sweetened drinks [9].

Rarely mentioned as contributors to the obesity epidemic are two major differences among the American population from 60 years ago. The prevalence of cigarette smoking in 1955 was 37 percent (52 percent among adult males), compared with 15 percent in 2016 [10, 11]. Adult smokers weigh, on average, 10 pounds less than nonsmokers, are less likely to be overweight or obese, and tend to gain weight when they quit smoking [12]. Second, the use of psychiatric medications—such as antidepressants and medications for anxiety and bipolar disorder—has soared in the past 50 years, with one in six adults reporting filling one or more prescriptions of these drugs in 2013 [13]. A number of these and other types of medications have been associated with weight gain [14].

Obviously, urging people to take up smoking or stop the use of psychiatric medications for mental illness is not the answer. A better solution is daily exercise, which has been shown to be one of the best predictors in achieving a longer life expectancy and reducing stress. It can also be effective in treating mental illness [15, 16].

While there have been advances in treating adult obesity in recent years, major challenges remain, particularly in the treatment of childhood obesity and in prevention. Dietary and behavioral therapy remains the cornerstone of treatment, but the body’s biologic adaptations during dieting decrease metabolism and increase appetite, thereby promoting weight regain over time in the majority of patients.

In the past 10 years, several anti-obesity drugs or combinations have been approved by the FDA and are providing a beneficial adjunct to dietary therapy in some patients, but there is yet no anti-obesity drug that is uniformly effective and without side effects.

Bariatric surgery, which was pioneered at University of Iowa Hospitals and Clinics by Dr. Edward Mason in the 1970s, has been documented in clinical trials to be effective in improving obesity and its complications in patients with morbid or extreme obesity. Bariatric surgery is now substantially safer with minimally invasive surgical techniques, but it is not applicable to a majority of obese people.

While the prevention and treatment of obesity remains a challenge, there is reason for cautious optimism. The rate of obesity among children ages 2–5 has declined slightly in some cities and states [17], and the emergence of the specialty of obesity medicine is promoting increasingly effective treatment.

Recent studies have shown that while our genes have not changed, a large proportion of the population has a genetic predisposition to obesity due to an environment that leads to sedentary lifestyles and over nutrition [18]. Recognition that some individuals are genetically predisposed to obesity while others are genetically resistant should promote understanding that obesity is not simply caused by lack of willpower [18]. This finding should minimize stigmatization of patients with obesity. Understanding the regulation of these genes is important for developing interventions to maintain a healthy weight.

The University of Iowa takes the obesity epidemic seriously and is committed to helping Iowans achieve a healthy weight. We have established an Obesity Research and Education Initiative that is focusing on the causes and consequences of obesity that may help inform programs and education aimed and preventing and treating obesity.

At the UI Carver College of Medicine, we’ve implemented an ambulatory practice model for medical students that includes workshops on nutrition, pharmacotherapy, bariatric surgery, and lifestyle factors. We also are one of nine medical centers around the country participating in a National Cancer Institute-funded study (called MSWeight) comparing the efficacy of two approaches to teaching weight management counseling so that future doctors may better understand obesity and be better prepared to help patients.

As physicians, we can and should take the lead on this important public health issue in addition to treating patients with obesity-related medical conditions and serving as knowledgeable, trusted resources in terms of nutrition, exercise, and other lifestyle factors. We also have a responsibility to make sure that obesity remains at the forefront of public consciousness and discussion.

Obesity is a public health issue that’s also closely connected to our state’s economy, educational system, legislative priorities, and cultural affairs. And it’s also one that many patients still feel reluctant to admit or talk about. Let’s use our expertise as care providers, science and policy experts, and health communicators to take the weight off patients and communities.

References

  1. Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. "Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016." JAMA 2018. Published online March 23, 2018. E1-E-3.
  2. "The State of Obesity: Better Policies for a Healthier America" released August 2017, Robert Wood Johnson Foundation.
  3. Billington CJ, Epstein LH, Goodwin NJ et al. "Overweight, obesity, and health risk." Arch Internal Med 2000;160:898-904.
  4. Messier SP, Gutekunst DJ, Davis C, DeVita P. "Weight loss reduces knee‐joint loads in overweight and obese older adults with knee osteoarthritis." Arthritis and Rheumatism 2005; 52: pp 2026-2032.
  5. "Cardiovascular disease and Diabetes" American Heart Association. Accessed Jan 29, 2018.
  6. Cawley J, Meyerhoefer C. "The Medical Care Costs of Obesity: An Instrumental Variables Approach."  J of Health Economics 2012; 31: 219-230. And Finkelstein, Trogdon, Cohen, et al.  "Annual Medical Spending Attributable to Obesity."  Health Affairs 2009.
  7. Ogden CL, Carroll MD. "Prevalence of overweight, obesity, and extreme obesity among adults: United States, Trends 1960-1962 through 2007-2008."
  8. John Koblin. "How Much Do We Love TV? Let Us Count the Ways." New York Times. June 30, 2016.
  9. Piernas C, Popkin BM. "Food Portion Patterns and Trends among U.S. Children and the Relationship to Total Eating Occasion Size, 1977–2006." J Nutr 2011; 141: 1159–1164.
  10. Office of Smoking. "Cigarette smoking in the United States 1950-1978."
  11. CDC. "Current Cigarette Smoking Among Adults — United States, 2016." MMWR 2018; 67(2);53–59.
  12. Audrain-McGovern J, Benowitz NL. "Cigarette Smoking, Nicotine, and Body Weight." Clin Pharmacol Ther. 2011 Jul; 90(1): 164–168.
  13. Moore TJ, Mattison DR. "Adult utilization of psychiatric drugs and differences by sex, age, and race." JAMA Intern Med 2017; 177:274-275.
  14. Dent R Blackmore A, Peterson J, et al. "Changes in body weight and psychotropic drugs: A systematic review of the literature." PLoS One 2012;7:1-13. e36889
  15. Gremeaux V, Gayda M, Lepers R, Sosner P Juneau M, Nigam A. "Exercise and longevity." Maturitas 2012; 73:312-317.
  16. Richardson CR, Faulkner G, McDevitt J. "Integrating physical activity into mental health services for persons with serious mental illness." Psychiatric Services 2005;56:324-331.
  17. Ogden CL, Carroll MD, Kit BK, Flegal KM." Prevalence of childhood and adult obesity in the United States, 2011-2012." JAMA 2014;311:806-814.
  18. Mark AL. "Dietary therapy for obesity: an emperor with no clothes." Hypertension 2008;51:1426-1434. (A review)

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