Tag Archive for: obesity

The Price of Obesity

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Continuing with comments made by Bill Maher, he suggests that the prevailing thought is that we can be healthy at any weight. Companies have embraced that thought with workout gear and other products featuring oversized models. Maher then goes on to talk about the ill health associated with being obese. Type 2 diabetes, cardiovascular disease, and cancer are associated with excess body fat. He says being overweight can compromise the immune system and cites statistics on the impact of COVID-19 on people who are obese. I checked them out, and he’s correct as it relates to hospitalizations, ICU placement, and mortality.

Fat and Fit Updated

I have repeatedly made the case that a person could be fat and fit if they exercise at a high level. That’s what the data from the Cooper Clinic demonstrated, and so did my doctoral research. I then add that it doesn’t matter—because very few people could or would do the work necessary. And that was correct, too.

But at 71, I think I was too optimistic in my recommendation even though that’s what the data suggested. The reason is that it’s difficult to maintain a high fitness level the older that you get. What’s possible at 30 years old is not at 50, 60, or 70 years old. The aging body changes.

The Price of Obesity

The cost of obesity is high. You may not have high blood pressure at 250 pounds while you’re younger and fitter, but you’re taxing your heart and cardiovascular system to sustain it. You may delay pre-diabetes and have perfect blood work—for now. And there’s a cost to your joints that may not be realized for decades, but when it hits you, you’ll find your world has shrunk because there are things you simply can’t do any longer.

I’ve been a runner for decades, but those days are over. I wonder if I had decided a decade or so earlier to lose weight and sustain 175 pounds instead of 225 whether my knee would have sustained less damage. Carrying 50 extra pounds generates forces up to ten times greater; that certainly has an impact on hips, knees, ankles, and feet.

Life Is a Struggle

Maher talks about how difficult it is to lose weight. There’s no question that it’s a struggle, but that’s no different than any worthwhile goal. It’s hard to get the weight off and difficult to keep it off. Even as the expert, I know that one well. Life is a struggle.

There is a commercial that we see repeatedly with an overweight woman in her 20s who is walking out her front door to go jogging. I think it’s powerful because she asks herself “What if a sprain my ankle?” and closes with her finishing her run. She’s at the perfect age to add the other components of eating better, eating less, and getting to a weight that is less taxing to her body. That’s aging with a vengeance in action.

The Bottom Line

I’m completely in favor of fat acceptance when it means loving and accepting those around you no matter their size. But if you see people you love trying to exercise and eat healthier, you can quietly let them know you’re rooting for them and will help in any way you can. Let’s not kid ourselves: it’s not the healthiest way to live, and sooner or later, we’ll pay the price.

Maher is a keen observer of the human condition and can be caustic in his commentary. But I think he’s got the tone and tenor just about right in his close:

“And that’s the saddest part. We can do this—I think. But by lying about it and making excuses, psychologically it’s telling ourselves that letting ourselves go is the best we can do. And I gotta believe that as Americans, we can still do better than that.”

What are you prepared to do today?

        Dr. Chet

Reference: https://www.youtube.com/watch?v=yfiWjnStE3w

Feast Mode!

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Comedian and political satirist Bill Maher has been one of my favorites since his first show Politically Incorrect aired over 20 years ago. He is also an outspoken critic of our nation’s health: it’s poor and getting worse. On a recent show, he used the term Feast Mode and explained why it’s a problem.

Feast Mode used to be going on vacation and eating whatever you wanted. It also used to be reserved for holidays such as Thanksgiving where you intended to overeat and then went back to a healthier way to eat, if not in the types of food, at least in the quantities. He suggests that Feast Mode now extends all year long for most Americans. I agree and have the numbers to prove it: close to 70% of us are overweight with 41.9% now classified as obese.

He goes on to talk about the politics of obesity, comparing the psychology of fat shaming to celebrating our fatness. No one should be shamed for being overweight, but that doesn’t mean that it’s healthy to be fat. He suggests that science gets re-written to support what you want it to be instead of reality. I would correct one thing: social science might get re-written, but hard science is based on hard numbers—and however we may feel about it, the number on the scale is the number on the scale. We’re not quibbling about five pounds here; we’re talking about 50 or 100 pounds or more beyond a normal weight.

The question is what does Feast Mode cost? I’ll cover that on Saturday.

Tomorrow night is the monthly Insider Conference call. I’ve got a couple of topics related to dietary supplements to cover and then I’ll answer Insider questions. Become an Insider before 8 p.m. tomorrow and join the discussion.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.cdc.gov/nchs/fastats/obesity-overweight.htm

It’s All About the Calories

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The paper advocating the carbohydrate-insulin model (CIM) for explaining the obesity pandemic, not only in the U.S. but throughout the world, was written by the leading experts in endocrinology and nutrition. There were experts who’ve conducted some of the major nutritional studies that you’ve heard about over the years, from the Women’s Health Initiative to studies on the ketogenic diet. This is an expert group.

I agree with their desire for more research in this area. They’re trying to find out what would constitute their definition of cause: what increases appetite? Does palatability drive food choices? What hormones impact how much a person eats? And more. Where I disagree is in their lack of acknowledgement of the energy balance model (EBM) as valid. I outlined a written response to send to the journal that would have been about five pages long. Here are my two primary arguments.

Prior Research on Weight Loss

The authors talk about prior research showing that a low-fat diet doesn’t work long term; one of the authors was heavily involved in the weight loss study on a low-fat diet in the Women’s Health initiative. Their analysis was incorrect. The objective of that study was to compare a group of normally fed women eating the typical American diet of close to 40% fat with a group who was going to lower their fat intake to 20%. In the analysis, there were no differences in weight loss over the course of the study. The results suggested that a low-fat diet doesn’t work.

Here’s the problem: looking at the data from that study, what you see is that the women who were supposed to achieve a 20% fat intake couldn’t get below 28%. That doesn’t meet the goals of the study and thus doesn’t support their conclusion.

The Minnesota Starvation Experiment

My primary argument goes back to the research done on conscientious objectors during World War II. I’ve talked about this fascinating study many times, but here’s the short version: for a period of six months, 36 men who were conscientious objectors had their caloric intake cut by 25%. Their physical activity was also increased; they had to walk up to 22 miles per week.

What was unique was that they were weighed every week and their caloric intake adjusted based on weight loss or weight gain. If they did not lose the required amount, they were given less food. If they lost too much, they were given more food.

What makes that study even more consequential is the types of food that they were given to eat. The menu was very low fat and had virtually no protein; it consisted of breads and starches from root vegetables. In the CIM, that would be just about the worst types of food to eat to lose weight. But remember, the purpose of that study was to feed people foods that would be available after the end of the war. Every subject lost weight and lost it on a linear basis; most emerged looking emaciated. That’s the only study I’ve ever seen where people lost weight in a linear fashion over that period of time, and they did it eating an almost 100% carbohydrate diet.

The Bottom Line

There are many other aspects of the paper that I could comment on, but those are my two strongest points. I do believe that insulin is the most powerful hormone in the body; it does help store food as fat if someone overeats for an extended period of time. That makes it more difficult to sustain weight loss until the body is retrained to lose weight and keep it off.

But let me be clear: it always was, it is, and it always will be about the calories regardless of the source. Eat too many and you gain weight. Eat fewer and you lose weight. For sure, make better choices on the selection of the food that you eat and move more. But it’s all about the calories. Period.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN. 2021. doi: https://doi.org/10.1093/ajcn/nqab270.

The Weight Loss Battle: Carbs vs Calories

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As a member of the American Society of Nutrition, I get a news feed that lets me know what’s being published in their journals. A recent article talked about the carbohydrate-insulin model (CIM) as a cause of the obesity pandemic. The debate surrounded the question of whether the energy balance model (EBM) that says calories in should equal calories out is adequate to explain the 70% overweight population in the U.S. Instead, a large group of researchers suggested that it’s time to research insulin as it relates to the highly refined carbohydrate intake of the population as the actual cause of obesity.

But that’s not all. The article suggested that insulin causes the body to store excess carbs as fat. More than that, to maintain blood sugars, it forces people to eat more carbs because they’re actually being starved, which drives hunger and is actually responsible for obesity. They went on to explain the fallacy of the EBM model and to deal with the criticism of the CIM model. In actuality, the researchers want to study the CIM approach, and this was a call for research to find out what really causes obesity.

To say it didn’t sit well in the nutrition and medical community is an understatement. Over 100K responses were generated in a couple of weeks, and I guess the nutrition Twitter world went nuts. Why? This is actually a battle over the ketogenic diet and everything else that focuses on counting calories. I’ll give you my opinion and why I believe what I do on Saturday.

The Insider Conference call is tomorrow night at 9 p.m. Eastern. If you have questions about your health or products, become an Insider before 8 p.m. and you can participate. Even if you only want to listen, you’ll learn something new to improve your health and the health of others you know.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN. 2021. doi: https://doi.org/10.1093/ajcn/nqab270.

Addressing the Systems of Health and Disease

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A systems approach to dealing with diseases and conditions is not what we currently do: if you have pain, you want to relieve the pain. That approach may fix the symptom, but it also may not fix the failure of a complex system that caused the problem. If you’ve broken a bone or had a torn ligament surgically repaired, that was not a system failure, but the approach to get things back to normal would be the same. Multiple systems would be involved, not just pain control.

To illustrate the point, I’m going to talk about one of the most complicated conditions: carrying too much body fat. It affects 70% of the population of the U.S. and is a growing problem around the world. My advice for dealing with it goes like this: Eat less. Eat better. Move more. Those recommendations really don’t change, but to permanently lose the weight and keep it off, the number of systems involved is staggering.

A Systems Overview of Obesity

Here are some of the questions yet to be answered about organs and systems that are involved in weight reduction:

  • What will happen to fat cells? The fat cells manufacture hormones that can impact appetite and hunger. At this point, there’s no research to suggest they’re ever reabsorbed.
  • The pancreas produces digestive enzymes and insulin. How will less food or different foods along with more exercise impact their involvement in digestion and metabolism?
  • Our taste buds have developed over the years. Will they change to reduce the taste and feel of sugar, fat, salt, and umami we may crave?
  • Can the impact of insulin on the liver change? Your liver develops a process to convert carbohydrate to fat and store it. Will that be reversed?
  • Will the adrenal gland respond to the decrease in fat intake and cholesterol production to reduce the production of cortisol and lower inflammation?
  • What happens to the microbiome in the long term? Does it adapt? Does it stimulate hunger or decrease it?

I could go on and on, but I think you get the point. It’s complicated to deal with complex systems. We don’t have the answers yet because we haven’t been asking the right questions.

The Impact of Aging on Complex Systems

We know as people age, we lose muscle mass, gain body fat, and lose bone density among many other changes. What we don’t know much about is the specific changes in every type of cell, organ, or system. If we don’t have that, we may not be able to address the correct cog in the system. That doesn’t mean we shouldn’t try; we can take what we currently know about how our bodies change over a lifetime and use that as a starting point. The earlier in life the better, but we still have to deal with individuals and the bodies they have right now.

We live a lot longer than we did 100 years ago. It’s time we began making those years better in every way rather than simply managing pain and other infirmities.

The Bottom Line

This challenge lies before us: Find a way to manage complex systems in order to not just survive but thrive throughout our entire lives. That’s where I’m headed in developing Aging with a Vengeance. We have to deal with the changes from aging that contribute to where we are today, regardless of age. Along the way, we’ll find out the optimal age for preventing some of those issues or at least slowing them down. I’m pumped for this journey to be the best version of ourselves, regardless of our current age or physical state. We just have to keep our heads in the game.

What are you prepared to do today?

        Dr. Chet

Metabolically Healthy and Obese

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The researchers in Germany continued to determine which factors associated with being obese were the most predictive of mortality from any cause and from cardiovascular disease. While not explicitly stated, it seems to me that they attempted to use variables that were simple to assess. With that in mind, here are the variables which demonstrated whether someone was metabolically healthy or not, regardless if they were normal weight, overweight, or obese.

Criteria for Metabolic Health

  • Systolic blood pressure less than 130 and no use of blood pressure lowering medication
  • Waist-hip ratio less than 0.95 for women and less than 1.03 for men
  • No prevalent diabetes

These criteria are simple enough for most people to determine for themselves, no doctors necessary. People usually know whether they’re diabetic, and they also know whether they’re taking medication to lower their blood pressure. Most people have a home BP cuff to assess systolic blood pressure or have access to one in a store.

The waist should be measured at its widest point and hip should be measured at the bony process of the femur. Divide the second number into the first, and that gives you the waist hip ratio.

The Results

The subjects who were considered metabolically healthy and obese had no greater risk of mortality from all causes or from cardiovascular disease then did normal weight, metabolically healthy subjects. This study examined only the death rate, not the rate of disease. Still, I think that if someone is working towards becoming a healthier version of themselves, intermediate goals can be very motivating.

I like this study for two reasons. First, it confirms what I thought for many years: people who are overweight or obese can be metabolically healthy. Second, it means that instead of trying to lose all the weight a person needs to lose, there can be intermediate steps on the way to becoming the best version of yourself; in fact, you don’t even need to be trying to lose weight to start being healthier.

The study also found that some people who were metabolically unhealthy and normal weight or slightly overweight were at higher risk for cardiovascular disease and total mortality. Could it be that the reason for the reduced risk was exercise? It was not considered, but it would be interesting to see further analysis on the data to determine if fitness was a contributing factor in metabolic health.

The Bottom Line

This study provides a basis for assessing risk of mortality on more than just BMI. What it shows is that even though you may be carrying too much weight, that doesn’t mean that you’re automatically at risk for death due to cardiovascular disease or other causes. I believe regular exercise is critical to achieve metabolic health and thus reduce your mortality risk, so that’s your first step to becoming and staying metabolically healthy.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Net Open. doi:10.1001/jamanetworkopen.2021.8505

Can You Be Obese and Healthy?

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The research question that was most interesting to me as a graduate student was this: could you be overweight, even obese, and still be healthy? That question still interests me today, and for good reason: 70% of the U.S. population is overweight or obese, and we’ve just passed 40% of the entire population falling into the obese category. And it’s not just the U.S.; we’ve exported our poor fitness and diet habits around the world.

Research done decades ago from by Cooper Institute, most often under the direction of Steven Blair, demonstrated that you could be fat and fit. Their research showed that people who were obese, meaning they had a BMI greater than or equal to 30.0, were no more at risk for death from cardiovascular disease or all-cause mortality if they were in the high fitness category.

That’s not the same question as this: could you be metabolically healthy and at no more risk for death from cardiovascular disease or all-cause mortality than someone with a normal BMI (18.5-24.9 kg/m2)? Researchers from Germany decided to examine that question. They used data collected from the National Health and Nutrition Education Survey III, which included over 12,000 subjects, and the U.K. Biobank, which contained over 374,000 subjects. Then they examined the statistical relationship between many different variables such as triglycerides, total cholesterol, hemoglobin A1C, C-reactive protein, systolic blood pressure, and on and on. Once they had a series of statistical relationships between obesity and mortality, then they sought to derive as simple an algorithm as they could to develop a profile of someone who would be metabolically healthy and obese. I’ll tell you more about that in Saturday’s memo.

Meanwhile, have you examined that map that was part of the CDC atrial fibrillation primer? Here’s what I saw: I’ll call it the I-75 Corridor of A-fib. Starting in Flint, MI, if you follow the pattern of the deepest red, it follows I-75 through Detroit to Toledo, OH, then Cincinnati, OH, and all the way down through Georgia to Florida. That’s the I-75 Corridor of A-Fib. What does it mean? Nothing, as far as I know; it doesn’t correspond to race or income or temperature. It’s an observation, nothing more, but maybe some epidemiologist or statistician somewhere will look into in more deeply.

What are you prepared to do today?

        Dr. Chet

Reference: JAMA Net Open. doi:10.1001/jamanetworkopen.2021.8505

Obesity Game Changer?

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Obesity is a serious issue in the U.S. and around the world; type 2 diabetes, hypertension, CVD, and other diseases associated with obesity have significant health costs. That’s why a real game changer would be important to help people lose weight and maintain their weight loss. The latest candidate is semaglutide, an anti-diabetic medication used for the treatment of type 2 diabetes by increasing insulin secretion. In my opinion, the results of this study do not achieve game-changing status. Let’s take a look at the details.

There Was Limited Weight Loss

The mean weight loss was 14.9% which translated to 34 pounds in 68 weeks. That’s really not impressive; most people can lose a half pound a week by paying more attention to their diet and increasing their activity level. The rate of weight loss in the placebo group stabilized at about 20 weeks, and that’s where it stayed for the rest of the study. In the experimental group, the rate of weight loss declined twice; first at about 20 weeks and then again at 52 weeks. By 60 weeks, the experimental subjects did not appear to be losing any more weight.

The Lifestyle-Change Program Was Ineffective

With 35 years of experience in weight loss programs, my hunch is that by 20 weeks, both the placebo and the experimental group had reverted to their prior eating patterns. We don’t know for sure because no nutritional data were presented, but that would explain the lack of continued weight loss in the placebo group and slowing weight loss in the experimental group. The drug may be game-changing, but without permanent lifestyle changes, it’s just another weight loss drug.

The medication was effective in continuing weight loss in the experimental groups, but we don’t know how. Insulin is the most powerful hormone in the body, but we don’t know exactly how semaglutide helped these subjects lose weight. Did it influence appetite? Did it impact insulin levels alone?

At What Price?

The lowest price I could find with insurance coverage was $800 per month. This would be cost-prohibitive for most people. Another way of looking at: it cost $376 per pound of weight lost. I’m not sure that’s worth the price because we still don’t know if the drug will help maintain the loss for a significant period.

And besides the monetary cost, what physical cost did the drug have? Every drug has side effects. That’s why in most cases I recommend trying lifestyle changes before adding a medication; if unhealthy habits helped create the problem, changing those habits is the best place to start. Even if a healthier diet and increased activity don’t solve the problem, those changes may mean you can take a lower dose of the med, thus reducing side effects. Except in urgent cases, most doctors will give you some time to try lifestyle changes before adding a medication.

The Bottom Line

I consider the study a failure because the subjects in both groups never learned how to change their food intake and exercise behaviors. Yes, those people taking the pharmaceutical did better related to weight loss, and because of that, some metabolic factors improved. But the rate of weight loss slowed down as the study progressed and eventually appeared to stop. Maybe this drug will give some people an edge with initial weight loss and thus improve their odds of long-term success, but if they don’t permanently change their behaviors, they won’t permanently lose weight.

We have to quit thinking of a healthier diet as a temporary change. The challenge is not losing weight; the challenge is in maintaining the lost weight. If you go back to your old eating habits, you’ll go back to your old weight; if you won’t commit to changing your diet and activity, taking a pill isn’t going to help you for very long.

While interesting, this study doesn’t change the game. The game was, is, and always will be eat better, eat less, and move more. For life.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2021. DOI: 10.1056/NEJMoa2032183

“Game-Changing” Treatment for Obesity!

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If ever a health headline gets your attention, it’s one that proclaims there’s a better way to lose weight. “A game changer” said one of the principle authors of the study in a news release about the study. The results of any study that suggests “game-changing results” just has to be reviewed, and that’s what I’ll do in this week’s Memos.

The study was a trial of 1,961 subjects conducted at 129 sites around the world. The subjects were randomly assigned to the experimental group and placebo group in a 2:1 ratio. The experimental group received once-weekly injections of semaglutide, currently approved as a diabetes treatment, while the controls were injected with a placebo. Both groups received individual counseling sessions every four weeks to help them adhere to a reduced-calorie diet and increased physical activity. The study was 68 weeks long.

After 68 weeks, the mean change in body weight from baseline to week 68 was 14.9% or 34 pounds in the semaglutide group as compared with 2.4% in the placebo or about six pounds. Anthropometric measures, BMI, and cardiovascular and metabolic measures were better in the semaglutide group compared to the controls.

The results of the trial have already caused the manufacturer to apply for a rapid approval review as a weight loss drug. The question is this: is it really a game changer in the treatment for obesity? I’ll talk about that on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: NEJM. 2021. DOI: 10.1056/NEJMoa2032183

How the Quality of Your Diet Changes Your Mycobiome

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In the experiment I told you about on Tuesday, the researchers established that environment—exposure to light, temperature, and other environmental factors—affects the microbiome, including the fungi or mycobiome. The researchers then tested the changes in the mycobiome (the fungus part of the microbiome) after feeding the mice a highly processed diet compared with mice eating conventional mice chow. They also monitored changes in body composition, triglycerides, and other hormones related to obesity.

After eight weeks on the highly processed diet, there were differences in the quantity of fungi. Some groups of related organisms increased while others decreased. Because not every group has known roles in digestion and metabolism, the researchers examined metabolic changes in response to the dietary change; they found an increase in body fat and triglycerides in the male mice along with concurrent changes in hormones that signified a move toward prediabetes. (For some reason, the female mice in this species are protected from those effects.)

After examining the composition of the highly processed chow, I’d like to have seen one more group of mice in the experimental group. Because the highly processed chow had no fiber, it would have been helpful to see what would happen to the entire microbiome if the amount of fiber was the same in the processed chow as the conventional chow. Maybe it wouldn’t have impacted the fungi at all, or the change could have been significant.

The Bottom Line

What lessons can we learn from this study? We’re not mice after all. I think it means that a highly processed, highly-refined carbohydrate diet may cause undesirable changes in our microbiome, including the fungal levels as well. For example, Candida albicans is a primary fungus in our digestive system, but it can cause all kinds of problems if it gets out of control. Reducing refined carbohydrates has a beneficial impact on keeping that fungus at beneficial levels.

Regardless of your current age, a better diet is part of Aging with a Vengeance. Reducing processed food, especially carbohydrates, can benefit your microbiome and all that it impacts. Time to start now.

What are you prepared to do today?

        Dr. Chet

Reference: Comm Bio (2021).4:281 https://doi.org/10.1038/s42003-021-01820-z