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ARE THERE PUBLIC HEALTH SOLUTIONS OUT THERE FOR CHILDHOOD OBESITY?

last edited: March 22nd, 2011

With the success of graduated driving licenses in reducing deaths involving teenagers behind the wheel, we try to think about ways in which other regulatory solutions might impact childhood obesity.  But obesity is immediately a much thornier problem isn’t it?  No licenses or government scrutiny generally involves itself in what food is put on the table in an American household.  No government agency regulates how much TV time a child gets or how much exercise a school offers.  We tend to want our governments to stay away from issues of person responsibility and home decisions and activities.

But yet the deadliness of childhood obesity forces us to think harder and give some real thought to the possibility of a public health solution.  What kinds of ideas might be crafted?

Well, some have posed financial incentives rather than direct regulations.   For example financial breaks and discounts on things like health insurance, automobile registrations and other fees. Companies, governments and schools consider reduced rates for people with a healthier BMI since it ultimately saves money to have healthier individuals in the group. Studies have shown that financial incentives do matter when people attempt to lose weight. But would widespread use of such incentives serve to further discriminate against overweight people, who, as a group, already face a good deal of discrimination?

And where does government fit in?  California waged a very successful campaign to reduce smoking with the use of funds from a tobacco tax. A University of California multivariate regression analysis showed that the rate of decline in smoking, fell more sharply after the campaign took on tobacco with clever billboards and a carefully crafted ad campaign that made fun of smoking and portrayed it as uncool, not sexy, and just plain dumb. Could something like this work to curtail obesity? Or would it end up appearing to single out overweight individuals for ridicule?

For now, there seems to be little controversy in the idea that public health experts and government can and should influence the lunch menu and food options at public schools. But how far should even this small step be taken? Eliminating high calorie snacks and drinks from the school also eliminates a source of precious funding for school extracurriculars.

The public health solutions are thorny. But the enemy we face is more deadly than cancer, and more destructive to the workforce, and to the longevity of individuals, than other enemies that we have previously faced. So it is worth taking some time to consider unconventional solutions as well as those that have proved successful in the past.

FATTY ACIDS AND LIPOPROTEIN LIPASE (LPL) MAY HOLD KEY TO OBESITY IN THE BRAIN

last edited: February 12th, 2011

Basic science researchers continue to examine the molecular and biochemical structure that controls metabolism.  Researchers are unlocking some of the mysteries as to the biochemical basis of obesity.  In one recent such study released in January of 2011, Dr. Hong Wang and a team of researchers from the University of Colorado School of medicine in collaboration with other institutions described a study of fatty acid metabolism in brain cells.  Their research involves a specific type of genetically modified mouse that has an impaired lipoprotein lipase enzyme in the brain cells or neurons.  Lipoprotein lipase is an important enzyme in the neurons that allows the breakdown of fats into its building blocks and allows the free fatty acids to be delivered to the brain.  What these researchers discovered was that impairing that enzymatic process led to the mice eating more and becoming more sedentary, and then becoming obese.

The area of the brain that was most affected appeared to be hypothalamus, one of the central regulatory centers of the brain.  It is hypothesized that the lipoprotein lipase allows delivery of fatty acids to these important brain cells in the sensitive hypothalamic brain nuclei that provide important signals to regulate body metabolism, body energy expenditure and body mass.

While these studies are at the level of the laboratory and the animal neurons, they appear to hold important clues for the future of improved understanding of metabolism and obesity.  One day it is hoped such research will lead to pharmaceutical interventions, which might promote improved delivery of free fatty acids to the hypothalamus and serve to re-institute proper metabolism and energy balance in people who are losing it and gaining weight.

THERE IS SOMETHING NOBLE ABOUT RUNNING IN SNOW AND RAIN

last edited: February 9th, 2011

Mind you, I don’t do this very often, in fact, truth be told, I go greatly out of my way to avoid doing even the most minimal training run when it’s raining and snowing. I don’t like to be cold. I realize this makes me weak and something less of a person in the eyes of everyone else I grew up with in Wisconsin, but I just can’t help it. When I must go out and the thermometer is below 40 °F, I start putting on clothes as though I were embarking on an Arctic expedition. My kids laugh at me.

But sometimes the running schedule, the work schedule, the kid’s schedule and the weather all conspire to make it unavoidable and today was one of those days. So I looked out at the foggy, 32 °F, according to my thermometer day and tried to think of every possible excuse for why I could skip this run that I had set aside time for. I was difficult. I had arranged coverage at the hospital, my kids had other activities going and I, for a few uncharacteristic hours, had no commitments and had nothing to do except what I was supposed to do: a 15-18 mile training run. I felt good physically. I wanted to run I just didn’t want to be outside in that weather.

But I bucked up, put the iPod on some jaunty music and covered my earphones with a wooly winter cap. Donned some long purplish leggings that I hoped didn’t look too bizarre. Three layers, gloves and my sunglasses. I seriously considered the idea of wrapping a scarf around my head and neck, but realized that crossed over into the ridiculous. No actual runner would have a scarf trailing behind them in the wind.

I felt surprisingly good. There was a certain nobility that kept me going. I felt like “Yeah, I can run in the snow and rain, that’s how great I am.” Never mind that I was considering turning back at just about every stride or that I was running a very, very slow pace or that I was preoccupied my iPod would become ruined if it got little droplets of water in it. I was doing it. So strange things carry you along. On this day it was a sense of purpose. A sense I so rarely have that I am committed enough to my mission to run the next race. That I didn’t opt out of a training run just because of a little cool temperature and a little bit of precipitation. In fact, after about six miles I was rewarded by a few rays of sunshine and the sensation of the rain, snow, sleet combination that had been striking my cheeks like unwelcome, little, tiny, frozen ice picks. In fact, it was downright pleasant there for a while. On the return leg, the temperature dropped noticeably. My fingers were downright cold and any notion of some sort of nobility had long since been replaced by a strong desire to be home in my warm house and to take a warm shower. A simple calculation told me if I kept running I would get there faster than if I stopped and walked.

So we rely on what we can. Most days it’s just fun, it’s nice to be outside, the sun is shining, it feels good to run and breathe in the fresh air and enjoy life. But on some days you find yourself carried along by some strange sensations and on this day it had something to do with a sense that running in the rain and snow is somehow good for me and I should be proud of it. Now that I’m home I’m not so sure any of that’s true, but I am glad I stuck it out. None of these sorts of notions are particularly explainable or have a whole lot of validity, but I say go with it. If that’s what is keeping you along propelling your legs forward then absolutely give into any sort of vanity, pride, competitiveness or whatever dark instinct is carrying you forward on your bid toward better fitness. It’s all too easy to give into a sense of comfort, warmth and well, yes, laziness.

ARE CHILDREN OF ALCOHOLICS DESTINED TO BECOME OBESE?

last edited: February 8th, 2011

A recent research study from the Washington University School of Medicine in St. Louis demonstrated that women with a family history of alcoholism were significantly more likely to become obese than women who did not have such a family history.  In their analysis of patients in an alcoholism survey study spanning two eras, 1991-1992 and 2001-2002, the researchers found that women with family history of alcoholism were 49% more likely to become obese.

There has been a good deal of speculation of obesity as a product of a “food addiction” and so by one line of reasoning a genetic predisposition might very well lead to a higher rate of obesity and other addictions.  This study tends to support the idea that there could possibly be an inherited propensity toward overconsumption of food or alcohol or substances.  On the other hand, such a study might play into psychological stress children of alcoholics experience and we know that consumption of food is a soothing mechanism by which people cope with psychological stress.

I am struck by many research studies which identify subgroups among us who are more likely than the rest of us to become obese.  This includes a great many people taking various medications, which are known to increase appetite, people whose own parents are obese, people whose social network and group of friends are obese, people who are less affluent, people with attention deficit disorder, depression or a host of other psychological conditions, and perhaps people whose parents were alcoholics.  While each of these subgroup studies might help in the wider effort to prevent and combat obesity, to some degree the focus on subgroups might detract a bit from the overarching conclusion that virtually everyone is at risk of obesity when placed in the type of environment that in which most of us live today in the developed world.

That is to say with most Americans now clinically overweight or obese, it stands to reason that solutions must be fairly universal and not too specifically aimed at narrower subgroups.  On the other hand, obesity prevention efforts in preschools, schools, homes, youth groups, clubs, churches, Scouts and other venues might well improve the odds of success by delivering even more potent messages and instituting more rigorous programs of obesity prevention for those of greatest risk.

THE FUTURE OF FOOD IN THE ERA OF OBESITY

last edited: February 7th, 2011

By many predictions, nearly all of us in this country will soon be overweight or obese.  We are certainly well on our way thanks to a complex set of conditions that collectively produce the “obesogenic environment”.  This certainly includes not only school, work and play lives that have deemphasized physical activity in favor or more sedentary paths and screen time.  It also however stems perhaps most clearly from increased consumption of increasingly delicious and inexpensive, high carbohydrate, high calorie obesogenic foods.  The purveyors of food have considerately catered to our burgeoning appetites and tastes, obliging us with ever-larger portions of focus group tested, perfectly delicious meals, snacks and treats that pack a wallop and deposit huge amounts of fat to our bellies and thighs to name a few places.

All of the science that has been applied to creating the obesogenic foods has been very successful.  Let’s face it, foods today are available more quickly, they seem “fresher”, they clearly taste better and we want more and more of them.  These foods have the advantage of science technology in their ingredients and preparation.  They also benefit from modern understanding of supply chain, preservation and fulfillment.  But what about the food of the future in the obese world in which we live?

I would like to advance the radical idea that the same background of scientific and technological innovation can and will supply foods that are aimed specifically at providing weight loss and weight maintenance while achieving goals of satiety, deliciousness and satisfaction in the consumer.  For example, an increasing array of rather tasty snacks, drinks and foods is slowly becoming available in corners of the food producing world like medically supervised weight loss programs.  The foods are scientifically based and effectively designed to suppress appetite rather than encourage it to promote less consumption of calories rather than more, and to help the consumer achieve success in the mission of losing weight and improving health rather than the mission of selling more burgers.

So will these “foods of the future” catch on?  One imagines a George Jetson-like household in which buttons are pushed and a dispensary offers up a nifty high metabolic protein shake and everyone smiles happily rubbing their skinny tummies.  This is likely to be the case for a tiny minority of people who see it as in their personal best interest to avoid overconsumption of calories and carbohydrates.  For the rest of us however, food is much more than nourishment for the body.  It is pleasure, it is comfort and so much more.  So while the foods will be there, the mindset that will allow the foods to work – that is help us become healthier individuals with trimmer waistlines – we must become more knowledgeable, more educated and more personally devoted to the cause.  And a cause, by necessity, involves giving up things like hot, crispy French fries and specialty ice cream, made-to-order sundaes is going to be a tough sell.

TREATMENT AND PREVENTION

last edited: January 4th, 2011

Modern epidemics and health crises have demanded vigorous and sweeping responses from healthcare practitioners.  But, they have also required vigorous responses from many other segments of society including everyone from teachers to political leaders.  Think of the complexity and relative effectiveness of the response to the AIDS epidemic.  Health researchers would now generally agree that the most effective response to the deadly virus has come from a combination of efforts that involve policy changes to enhance prevention efforts, combined with effective treatments for those already afflicted.

As horrific as the AIDS epidemic has been and continues to be on a worldwide basis, it is dwarfed by the obesity epidemic by any measure including the measure of premature deaths.  So how can we best formulate a response to the obesity epidemic that will minimize needless suffering, premature disease and premature deaths?

Clearly the lessons from the last major health crises are that we must respond with vigorous and sweeping efforts at all levels including those aimed at prevention and those aimed at treatment for those already afflicted.

Just like other major health crises, many factors in the obesity epidemic serve as distractions and undermine positive efforts toward prevention and treatment.  For example, debates about the degree to which obesity is a self-inflicted disease serve to undermine research efforts, treatment efforts and prevention efforts.  Although the complex nature of obesity is one that requires solutions that draw from many disciplines including those associated with mental health, the complex social, psychological and cultural aspects of obesity must not stand in the way of logical research, prevention programs and effective treatments.  At the end of the day, our response as healthcare providers, community leaders and stewards of our future generations must focus on health, wellness and longevity and nothing less.

Ultimately, the successful eradication of such a complex disease will need to happen through sweeping obesity prevention efforts.  We see the initiation of such efforts at many levels including public and private awareness campaigns, emphases on fitness and physical activity, community movements toward locally grown and produce based diets, school district efforts aimed at replacing high calorie meals for kids, legislative efforts that focus on calories, carbohydrates or fats and many more.  Undoubtedly during this process there will be measures that help the prevention cause and there will be missteps that hinder the cause and obfuscate the solutions or drown us in polemic.  Nonetheless, the driving force must be to prevent more kids from acquiring what is indisputably a deadly disease.

Treatment must also be a twin priority with prevention.  While the National Institutes of Health and the CMS have exhibited objectivity and fairness in endorsing bariatric surgery as early as 1991, many other advisory policies from professional societies and governmental agencies lag far behind the currently available data and they fail to appreciate the seriousness of obesity as a disease.  Newer and better treatments will continue to become available and these treatments are likely to include a mixture of medications, surgical procedures and implanted devices.  Eventually, a select number of these treatments will be excepted as superior interventions, which can help induce increasing correction of obesity and durable weight loss results.

To date, modest success has been achieved with structured medically supervised programs utilizing evidence based tools such as meal replacement, diet formulations low in sugar, psychological and dietary counseling, diet logs, support groups and regular exercise such as walking.  Surgical programs have achieved markedly greater success and increasingly, the most successful programs employ each of the proven elements from the non-surgical experience to boost outcomes and maintain their durability.

In the past, rather arbitrary guidelines have arisen from specialty societies that recommended very stingy use of obesity treatments only in the most severe of cases.  For example, many specialty societies and currently available references will recommend the use of the appetite suppressive drug, Phentermine or its analog, Tenuate only at certain body mass index thresholds.  Working on the theory that these “conservative recommendations” will be better for patient safety, they have served to deter practitioners from prescribing much needed obesity therapy and overemphasized the risk of very safe drugs while markedly underemphasizing the risks of the disease of obesity.

Our hope is that as we move forward such miscalculations will be eliminated and the seriousness of obesity as a health crisis will be appreciated, and the treatment and prevention efforts evaluated in their proper light.

SHOULD THE FDA APPROVE LAP-BAND FOR LOW BMI?

last edited: December 27th, 2010

The FDA Advisory Committee, which recently agreed to review the current criteria that Allergan Corporation and physicians and hospitals may use to promote the laparoscopic adjustable gastric band will soon be deciding to broaden these criteria.  Until now, the LAP-BAND has been approved under FDA guidelines for people with a body mass index of 35 and greater if an obesity related health problem is present.  The most common ones include diabetes, hypertension and obstructive sleep apnea, although the list is truly very long and includes nearly every organ system.  The proposal from Allergan Corporation would lower these criteria to a body mass index of 30 with an obesity related disease or 35 without documented disease.

Should the FDA grant this approval?

The recommendations should be grounded in data and should not take into account fears of excess costs, social implications and politics.  The recommendation should acknowledge the deadly seriousness of the obesity epidemic and the tragedy of the lives claimed by obesity.

To most of us working in the field of obesity treatment, obesity research and bariatric medicine, all too often it seems the media focus on sensational stories about unusual complications of weight loss treatments and weight loss surgery.  Most stories do not focus on the deadly effects of obesity, although it now ranks as the number one cause of early disease and death in the United States.

At least five longitudinal studies have examined weight loss surgery and compared surgical patients with similarly obese non-surgical patients over a period of time.  Each study demonstrated a profound disadvantage for people electing not to undergo weight loss surgery.  In studies by Flum and Christou, obese individuals undergoing weight loss surgery enjoyed a dramatic reduction in disease and mortality risk over the span of just a few years.  Other authors have confirmed these findings.

What these studies indicate, in my view, is less a commentary about the dramatic success of surgery, but more about the deadliness of obesity and disease.

More to the point on low BMI LAP-BAND, O’Brien and numerous other authors have examined and continued to examine the outcomes of low BMI patients who undergo LAP-BAND surgery.  The complication rate of this out-patient, thirty minute procedure is markedly low and pales in comparison to the deadliness of obesity as a disease.  The reductions in weight achieved with LAP-BAND surgery, and an associated weight loss program complete with counseling, weigh-ins, band adjustments and support groups are profound and significant.  And because obesity is such a deadly risk factor, even modest weight loss produces major gains in health status and longevity.

So whether the FDA committee will examine the data critically and without bias remains to be seen.  There are indeed major implications of a decision which would expand the recommendations to tens of millions of Americans.  But time and time again, healthcare providers, leaders and regulators have continued to overlook obesity as a serious disease and have continued to turn away from treatments and policies that would favorably impact obesity related disease and deaths.

In my view and in the view of most experts in the field of obesity treatment, the data for LAP-BAND approval for BMI 30 and over has been in for a long time.  Its approval is well overdue.

“I AM IN TRAINING”

last edited: December 18th, 2010

One of the best tools in your disposal to set the expectations for yourself and to those around you is to say “I am in training.”  For many of my patients they truly are “in training.”  Training for a first ever 5K run/walk, training for a first ever bike ride tour or training for a first ever half marathon.  For each person, no matter their experience level and their goals, such endeavors do require training.  They require preparation, practice, focus and determination well before the event itself.  And for people who are in the midst of a weight loss journey or those who are working to maintain lost pounds, the sense of being “in training” stands as an important notice to everyone that expectations are different than they are for other people or for other times of the year.

I think back to high school and college days when the athletes would sometimes use this phrase to describe their own status in preparation for the season.  It generally meant no alcohol no drug use and it also involved an understanding of a certain set of behaviors that were expected in order to maintain good standing with the team or with the sport.  So too does being in training connote certain expectations for the person losing weight and keeping it off.  It means no wild indulgences, no binge drinking no excessive consumption of desserts and treats.  No “throw caution to the wind,” eating a box of candy or a tub of ice cream.  It means dedicating oneself to valuable goals to maintain attitude of fitness and a focus on healthy eating.

So set a goal for yourself.  Make a fitness display such as a race one of your goals, make a plan to prepare and, yes, train for it.  Then when occasions arise that would pull you off your path toward a healthier weight and improve fitness, remind yourself and those around that you are in training.  It will feel good.

COOKING FOR THE HOLIDAYS

last edited: December 14th, 2010

As the holidays approach we are all of course thinking about the wonderful time spent around the table eating cookies and holiday treats as well as having some big, terrific dinners with family and friends.  So if you are cooking or in charge of some the main meals like I am, what should you be preparing so as not to burst the waistlines?

Here are a few ideas that may help you stay focused on your goals of losing weight or maintaining weight through the holidays.

  1. Focus on family and friends and social connection rather than the food itself.  Remember to take time to enjoy the people, environment and activities as these are more important than the food itself.
  2. Be active!  Family walks, making snowmen, going ice skating, skiing and tobogganing are all fantastic, fun, family holiday events and are even more wonderful than sitting around the couch, turning on a ball game and devouring a giant bowl of chips.
  3. Think about protein first and think about minimizing the carbohydrates.  Yes, I know this sounds a bit Scrooge-like, but it does mean that you can enjoy some wonderful meals and not give away all the fun by remaining mindful of the nutritional content.  Holiday birds, fish and poultry are very healthy meals.  Steamed vegetables, sweet potatoes, legumes, lots of wonderful things here kept in moderation.  And yes, many of the things you will want to be eating like Christmas cookies, mince pie and other holiday treats will be loaded with tons of carbohydrates.  So have a taste, but stay away from the mountains of goodies that will undoubtedly proliferate around the Christmas tree and dinner table.
  4. Have a plan.  So if the above paragraph sounds like great advice, but totally impractical, plan ahead.  You must be playing defense in order to succeed in avoiding weight gain during the holidays.  This means defend your body from all the wonderful temptations, the high calorie, high carbohydrate treats, snacks and desserts that will tempt you over the holidays.  Have a plan that you are going to taste one of mom’s cookies and no more.  Have a plan that you will have two bites of a pie and no more.  If you proactively create a plan and set an expectation in your mind, then you are much more likely to succeed in minimizing your calorie and carb intake than blowing your eating plan.  If you make no plan then you will very likely fail.  It’s far too tempting to simply have another cookie or enjoy that big, fat slice of pie when the alcohol and social environment is encouraging you to do so.  With a plan you stand to have a much better fighting chance.
  5. Limit alcohol.  Once again, easier said than done, but by preparing to limit your alcohol you are much more likely to succeed in limiting your alcohol.  Alcohol is a terrific social lubricant and something that many people enjoy with holiday social occasions.  It also tends to make us more receptive to temptations, increase our calorie intake and put off our serious fitness plan until the New Year.  Add to that the fact that every gram of alcohol contains seven calories, and you have a recipe for some serious weight gain.  So one glass of wine and that’s it.

POSSIBLE NEW CHOLESTEROL “MIRACLE DRUG”?

last edited: December 7th, 2010

Some of us live with tremendous hope that technology and drugs will lead us out of the darkness and suffering associated with obesity related disease.  Adding to that hope was a recent study examining and experimental drug called Anacetrapib, which appears to markedly lower bad cholesterol while raising good cholesterol.

The study, which was published in the New England Journal of Medicine, was led by Dr. Christopher Cannon out of Brigham and Women’s Hospital in Boston and carries a great deal of credibility.  The drug showed unexpectedly striking reductions of the LDL cholesterol while HDL rose.  After six months, the study reported that the LDL fell from an average of 81 down to 45 for the test subjects who were taking the new drug, whereas those given the placebo saw an insignificant drop from 82 to 77.  At the same time, the HDL-the good cholesterol- rose from 41 to 101 for those on the study drug, but changed from 40-46 on the placebo.

It is probably a couple of years before Anacetrapib might be widely available on the market.  And as we’ve learned from countless other drugs, sometimes serious side effects do not become evident until years later.  Nonetheless, this drug looks promising and more studies will continue to accrue.

The real exciting data will come if and when the studies can show a reduction in cardiovascular health events and deaths.  That may take time, but appears likely given these marked changes in the LDL and HDL.

Perhaps combinations of drugs will continue to emerge that not only reduce the late stage consequences of obesity, but perhaps help with obesity itself.   In other blog discussions I have talked about emerging and experimental pharmaceuticals and we’ll revisit this topic again periodically.


Dr. Kent Sasse, Medical Director | 75 Pringle Way Suite 804 Reno, NV 89502 | Phone: 775-829-7999

Dr. Kent Sasse serves the entire city of Reno and all the surrounding areas. Dr. Sasse is one of the nation's foremost medical weight loss and bariatric surgical experts.
Dr. Sasse has educated patients about food nutrition and weight loss for many years.

Copyright © 2007-2010 Kent Sasse, M.D. All Rights Reserved.

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