One of the striking and discouraging features of the obesity epidemic is the inverse relationship to socioeconomic status.  Put another way, obesity is disproportionately a disease of the poor.  Many people have commented on the higher costs associated with eating well, but is this true?

First, it’s indisputably true that it is very easy to eat high calorie, high carbohydrate foods, meals, drinks and snacks very cheaply.  The cheap cost of ingredients combined, in some cases with government subsidies and the proliferation of low cost store options means that many people in a low income household find that the most cost effective way to feed a family is to eat high carb processed foods.  Bulk items of sweets, sugar laden treats, high fructose corn syrup, packed sodas and products, breads, rice and cereals can combine to make for high calorie meals.  And, as we know, meals derived from high proportional carbohydrates not only lead to excess calorie consumption, but they tend to increase a cycle of hunger and overeating.  This is the perfect formula for obesity.

But what about eating “well”?  Does it really have to cost more?  Well, when compared to the bulk food sugar and snack options, it does cost a bit more, but it is definitely possible to eat fresh fruits and vegetable, whole grains and mixture of dairy, legumes and other protein sources very inexpensively.

A number of studies have described the association between skipping breakfast and weight gain and obesity.  It has been postulated that the reason for weight gain stems from the fact that we tend to eat more food and higher calories foods later if we skip breakfast in the morning.  There is also a belief that calories consumed early in the day are more likely to be burned by the body, whereas the calories consumed late in the evening are more likely to be stored as fat.

A study out of the Institute of Population Health at the University of Ottawa, uncovers some of the reasons why children gain more weight when they skip breakfast.  Published in the Public Health Nutrition Journal in January of 2009, the study by Dubois et al, provided some detailed analysis of the 1,549 children who were previously studied in their 2006 paper on breakfast skippers.

The detailed study examines the association between breakfast skipping and the intake of daily calories, nutrients and food in the preschool children.  Interviews and eating behavior questionnaires were used to develop the data.

One of the key findings was that skipping breakfast was associated with the consumption of snacks in the afternoon and evening, which were higher in calories and higher in carbohydrates.  Skipping breakfast was also associated with weight gain and being overweight, having a higher BMI.  A specific correlation was found between overweight/obesity and the dinner time consumption of higher calories and higher carbohydrates among the breakfast skippers.

Interestingly, the total daily calorie consumption was not significantly different between the breakfast skippers and the breakfast eaters, even though the body mass index was higher in the breakfast skippers.  These findings support the idea that a more even distribution of calorie intake throughout the day is healthier and less likely to lead to weight gain.  Skipping breakfast leads to behavior in which children eat more calories and more carbohydrates late into the afternoon and night, a pattern associated with weight gain and obesity.

It is one more study that demonstrates there is more to metabolism than “calories in = calories out” while the overriding principal of calories in = calories out is roughly true, it can differ significantly when the calories are consumed at different times of day.  Consuming the same amount of calories late into the evening and night is associated with weight gain and obesity, and this is one more study illustrating that principal.  And it helps explain why breakfast skipping is a behavior to be avoided and discourage in children (and adults too!).

Published in the Journal of the American Dietetic Association in June 2010, a Baylor College of Medicine and US Department of Agriculture study reports interesting data about the association between breakfast skipping and obesity.  The study examined 4,320 children age 4-13 years in addition to 5,339 children age 14-18 years.  The data is an analysis of data collected from what is called the National Health and Nutrition examination survey, which ran from 1999 -2006.  It involved a type of survey using 24 hour dietary recall and then some sophisticated statistical analysis using multivariate analysis.

Interestingly, 20% of the children age 9-13 and 31.5% of the adolescents were breakfast skippers.  This number is quite a bit higher than the percentages reported for preschool age children.  It probably more closely approximates that of adults who are known to develop behaviors of breakfast skipping as the demands of more advanced education and work become paramount.

Additionally, the study found that approximately 36% of the children and 25% of the adolescents consumed what were called “ready-to-eat” cereals, the kind of breakfast that comes in a box with lots of nice illustrations on the outside.  While those “ready-to-eat” or RTE cereal consumers were taking in higher levels of helpful micronutrients and dietary fiber, they were also taking in higher amounts of total carbohydrates.  They did have lower intakes of total fat and cholesterol.

The key finding was that the breakfast skippers had a higher body mass index and higher waist circumference than the breakfast eaters who ate boxed cereal.  Obesity was higher in the breakfast skippers.

So what this study tells us, from examination of nearly 10,000 young people in the United States, is that while the ready-to-eat boxed cereals may not be perfect, eating them for breakfast every day is probably far better than skipping breakfast.  We’ve seen that skipping breakfast is associated with higher waist circumference, poorer eating behaviors later in the day and greater changes of obesity.  Studies from Fiji, to Canada to the United States support this finding.  And while the boxed breakfast cereals may not be the ideal nutrition, they are clearly better than the eating behavior of skipping breakfast altogether.

In searching for clinical evidence linking eating behaviors and weight gain among children, I recently read a study out of Ottawa, Canada published by a group of epidemiologists in the Public Health Nutrition Journal, June 2006, entitled Breakfast Eating and Overweight in a Preschool Population: Is There a Link. The study was designed as a population based study involving nutritional interviews with parents of preschool age children between four and five years old.  The study is part of a longitudinal study of child development and included 1,549 children.  And a pretty strong link was found between skipping breakfast and being overweight.

9.8% of the children did not eat breakfast every day.  Many of the children who did not eat breakfast had immigrant mothers and less educated mothers (no high school diploma).  Additionally, a higher percentage of the breakfast skippers came from low income families.

Analysis of the study data found that skipping breakfast nearly doubled the chances that the preschool child would be overweight when the authors controlled for the other variables involved.  Using what is called an odds ratio, a common statistical method in describing the increased chances of obesity, the authors reported an odds ratio of 1.9 for breakfast skippers, meaning a nearly doubled chance of being overweight stemming from breakfast skipping.

In this large, well designed study, the evidence associating breakfast skipping with overweight status among preschoolers is pretty strong.  In fact, it is a bit startling that the association with breakfast skipping emerges in such a young age group.  The study also identifies groups that are more likely to have breakfast skippers among their toddlers, groups that may be better targets for educational outreach.

In a recently published study out of the Asian Pacific Journal of Clinical Nutrition, epidemiologists from Harvard Medical School showed a significant correlation between breakfast skipping and being overweight or obese among a study population of 523 adolescent girls.  One of the theories in the study was that specific behavior s could be measured and then correlated with weight gain, overweight and obesity.  It is hoped that this kind of measure would lead to some specific behavioral interventions and teachings that might improve the epidemic of adolescent weight gain and obesity.

The study was conducted among Fijian adolescent girls and published in volume 19 in the 2010 journal.  The various behaviors were assessed and among them, skipping breakfast was found to have a high correlation to the adolescent girls who were overweight and obese.  In this study population, 41% of the adolescent girls were considered overweight and 15% were considered obese.  A more sophisticated analysis, which involved a multivariate analysis technique, found frequent breakfast skipping associated with a higher odds ratio of overweight and obesity.  The association was considered statistically significant, but the odds ratio was around 1.15, not an especially strong correlation.  A further, even more sophisticated statistical analysis called regression modeling that adjusts for other types of eating problems and pathology lead to the breakfast skipping being found to have a non-significant influence on overweight and obesity.

So what we might take from this study is that breakfast skipping is associated or correlated with weight gain and obesity among adolescent girls.  It may not however be causative and may not be the specific behavior that needs to be targeted, but may be one of several different abnormal eating behaviors that lead to weight gain and obesity.

At the split, a mere 13.1 miles, I had run 1:38, a fast time for me and one that ought to allow good finish.  At this point I was not feeling even a trace of fatigue, but that would soon change…

Around mile 15 the thought definitely had crept into my mind that I was no longer feeling so wonderful.  The tailwind that I had enjoyed for a number of miles was definitely no longer blowing in the same direction I was running.  And the scenery had changed a bit as well.  We were now navigating along a coastal road that offered a number of rolling hills.  I’ll be the first to admit I am no great fan of hills, mainly because of the pain that I experience in my knees when running up and down them.  I have studiously avoided hills in all of my training runs despite the purported helpfulness to the training cause.  I find that the need for ice packs and ibuprofen afterwards diminish some of my enjoyment, which is the whole point of running after all.

The race also took a decided turn for the worse on a section of road that no longer offered a nice secluded area for running, but instead had about a ten foot wide path demarcated by orange cones that ran right next to the highway.  Since the hour was getting later, commute traffic was in full swing so cars and trucks zoomed past at high speed with lots of buffeting wind shear and noise.  By mile 17 my walk breaks at the aid stations were, by necessity becoming much longer.  It’s hard to put a finger on what exactly was the nature of the misery I was experiencing.  It was not pain per say.  I tried to take inventory of all my body parts.  My feet were a little sore, sure.  Ankles and knees were feeling it, but not too bad.  I really was having trouble breathing, my chest didn’t hurt.  I really couldn’t point to any one single thing except that globally in the entirety of my being, I knew that was beginning to suffer.  I knew in my heart I had not trained for this race and, in fact I was supposed to be viewing the race itself as a “training run”.  Yet the competitor within me who wants to beat my last times had to go out fast and run the first half at a good pace and it wasn’t until around mile 15 that I gave up the idea of running this race in 3:30.  By mile 18 though I was seriously considering the idea I would not finish in under four hours.

My daughter and I were playing a board game, but I had the baseball game on in the background.  And one phrase caught her attention the pitcher had “good stuff” today.  What did this mean she wanted to know?

I found myself describing that sometimes pitcher’s have “good stuff” and other times they don’t have “good stuff”.  What’s meant by this is that some days, even though it’s the same pitcher with the same training, the same experience and expertise, the same baseball, same dimensions of the baseball yard and the pitching mound, he nails the strike zone, feels good, has a sharp breaking curveball and basically has everything he needs to be successful and accomplish his goal that day of striking out hitters and winning the game.  Other days, even though he’s the same person, he can’t hit the strike zone to save his life and his curveball has no snap.  The opposing team jumps all over pitchers on those days and you see the pitchers leave the game early and usually they wind up on the losing end.

I found myself going on to say this is a lot like life for the rest of us.  Some days we have it and some days we don’t.  I brought it around to her own experiences such as doing school work, practicing music or doing sports.  Most of the time she has “good stuff” and can play and practice, study and thrive.  Other days she feels tired and her heart is not fully in it.

This is an awful like what we all face as we age past our thirties and forties and face a challenging goal of maintaining fitness and avoiding weight gain.  Some days you’ve got the right stuff, and this means you’re motivated to exercise and avoid excessive calorie intake.  You have the willpower to stay away from the snacks and treats, monitor your calories, take note of grams of carbohydrates that you need to avoid and you do so successfully.  You make plans and stick with them.  But other days when you don’t have the good stuff, you’re motivation may be lacking and the willpower to avoid temptations is just not as strong.  Those are the tough days.

One of the real keys to successfully maintaining weight and successfully losing weight is to maintain the long view.  For example, keep in mind that cutting out just 96 calories per day results in about 10 pounds of weight loss over the course of a whole year.  Now think of the opposite, giving in and consuming an extra 96 calories per day results in a 10 pound weight gain over the course of a year.  So as much as weight loss success and weight maintenance success are a product of careful calorie counting and exercise, they are also a product of avoiding major lapses and downturns when you don’t have the right stuff, when you don’t feel motivated, when you don’t feel strong, when you feel like you are going to give into the temptations of the calories and desserts and treats, those days count just as much as all the rest.  So you need a battle plan to combat those days when you don’t have the right stuff.  You need to have successful ways to limit calorie intake even when you don’t feel motivated and you don’t feel tremendous willpower to resist eating and drinking more calories.  You also need a plan to find ways to exercise and burn calories even when you don’t feel motivated to do so.  So I suggest two main strategies:

1. When you don’t have the “right stuff”, make sure the conditions in your house do not allow for a major lapse.  This means getting rid of all your favorite tasty treats, high calorie snacks and desserts.  Do not, I repeat, do not stock the pantry with your favorite desserts and treats.  Quite the opposite in fact, make it so that when you are padding around in your pajamas and have absolutely no willpower and find yourself wandering into the pantry, there should be absolutely nothing that remotely tempts you.  This will save you.
2. Even when you don’t have the “right stuff” make yourself do a tiny, tiny, tiny, itsby, bitsy bit of exercise.  That’s right, take the first baby step.  Commit to walking outside your front door and maybe to the mailbox and no further.  Make just that much of a commitment.  And if that’s all you do for that day then I commend you because you kept your end of the bargain.  I suggest to you though that once you’ve reached the mailbox, your brain is likely to have changed and your attitude is likely to have improved to the point where you can then commit to walking a block and then let’s see what happens, maybe you’ll end up walking a few miles and turning a lousy day into a great one.

All of us have days when we don’t have the right stuff.  The trick is to find a way to win anyway, just like the best pitchers.

When speaking to parents about overweight children I occasionally encounter some resistance by the parents that seems based on what is “the norm”.  And what I sometimes come to understand is that many parents, like many kids, see the peers of children and do not see themselves or their kids standing out as being obese.

This phenomenon in which parents and kids look around and see that they stand out from “the norm,” has the effect of decreasing the sense of importance or urgency to medical recommendations to lose weight.  After all, if you weight just a little bit more than all your friends and peer group then how serious a problem could it really be?

The real problem is the norm has changed, but health statistics for body mass index have not.  What this means is our aesthetic of what looks normal or what looks healthy even, may wax and wane over time (remember the Rubinesk artistic renderings of the human form), but this aesthetic sensibility does not change the fact that increasing BMI is closely correlated with rapidly increasing diabetes respiratory problems, bone and joint abnormalities and shorter life expectancy.

The challenge for all of us who are aiming at preventing obesity among young people is to elevate the sense of urgency and convince parents, teachers, community leaders and kids that weight gain is in fact unhealthy and needs to be addressed with a serious plan of attack.  The slow motion nature of health deterioration with obesity tends to discourage a sense of urgency.  But the shifting standard of the aesthetic norm further weakens the resolve of parents and kids to take on a weight problem with some urgent seriousness.

The Fight for Air half marathon run proved to be a beautiful course on a stunning day.  I had brought a heavy sweatshirt that I could discard after the first mile or so expecting there might be cold morning weather, but I never needed it.  The sun had risen and the 8:15 start time allowed for perfect temperatures for a nice run.

The start at Damonte Ranch High School was kicked off by our popular Mayor, Bob Cashell.  I dialed up Pandora to stream in some good running tunes and prepared for a nice race moving toward the front of the starting line.

For reasons I can’t explain, the first mile for me was utter misery.  I felt like I was gasping for breath myself with my heart rate way above anything it should have been.  My Garmin said I was running about a 7:10 mild pace, typical for the start of races when everyone is moving out quickly, but for some reason it felt like I was doing an all out sprint.  I slowed down and tried to regroup, but it took a couple of miles for me to find any sense of a running groove.  Someday it would be nice to know why these things happen, but I think for most runners we know that some days we’ve got it and some days we don’t.

Into the long, flat, lovely course from miles 4 through 10, I felt pretty comfortable running around 8 minutes miles, not blowing the doors off certainly, but at least no longer feeling like I would need CPR imminently.  One section of the course takes the racers onto a nice hard packed trail and most of the course winds through very nice walking trails or neighborhood streets, a most pleasant morning.  At the finish, I passed the mile 12 marker and checked my Garmin, which confirmed the distance.  Then at about 12.5 miles, where we made a turn toward the high school once again, inexplicably a race monitor was yelling to each racer going by that we all had “one more mile” holding up one finger.  I imagine it through us all off a little bit, but made for a very nice and very short remaining “mile”.

All in all the race organizers did a fantastic job and the course was nicely laid out, even and pretty flat, making for a pleasant experience.  At one transition from the trail section back to the road there was a little bit of rough terrain to traverse, but nothing serious and I didn’t hear any reports of ankle sprains or other troubles as I left the course.

It’s great to see so many participants in a growing number of events in and around Reno and Lake Tahoe.  And the stunningly beautiful Reno September blue sky and sunshine ought to make for a great future for this race.

As if things weren’t bad enough, recent reporting tells us something that many of us already suspected: clothing manufacturers have been making larger and larger clothes for any given size.  So adding to our own self delusion that we in fact might be staying relatively fit, numerous clothiers now sell pants labeled as “36” that are actually 37, 38 or 39 inches in the waist!

What does it mean that we as Americans now need to be caudled in this way?  We shop, try on and buy clothes presumably by the way they fit, yet it makes us feel better to know that my dress size is an 8 or my pants size is a 34, despite all evidence to the contrary.

As the years go by our metabolism slows approximately 1% per year meaning that if we are to maintain our weight we must decrease our calorie count by at least this much every single day.  Most of us however increase our calorie intake as the years go by, as we can afford tastier cuisine and as the food industry continues to find more efficient ways of packing additional calories into our every purchase.  And we know from numerous data sources that we are, as a nation, continuing to become increasingly overweight and obese.  Yet, the clothing manufactures help us feel better about it all by simply renaming the sizes that we now must wear and choosing our old sizes reminding us of our smaller, healthier selves.

So here is a question for all of us: be truthful now, would you rather have all your favorite clothiers simply tell you the bad news that in fact your waist has gone from a 34 to a 38 and now you must buy something that actually says 38 on it or it won’t fit?  Or, would you rather that they continue to be your enabler, allowing you to delude yourself in thinking you are still a 34-inch waist despite the fact that it truly measures 38?