Return to Weight Management
Why We Are Fat and What We Can Do About It
Dennis B. Kottler, MD
This is the first part in a series looking at major health concerns that affect our society in epidemic proportions and the likely reasons these problems have become so common. This current monograph deals with the epidemic of obesity in adults and offers practical suggestions to combat this major health threat. Innovative self-treatment approaches are discussed that have proven effective in large numbers of people. The author also addresses impediments to weight loss that involve relationships with other people and personal psychological and psychiatric roadblocks.
Dimensions of the Problem: Defining Obesity and Overweight
Recent guidelines on obesity published by the National Heart, Lung, and Blood Institute of the National Institutes of Health (June 1998) give an indication of the scope of the weight problem and suggest meaningful ways in which to assess the degree of overweight. According to these guidelines, an astounding 55% of American adults fall into the combined categories of obese and overweight.
There are many ways to assess degree of obesity. Two of the ones proposed by the National Heart, Lung, and Blood Institute involve BMI or body mass index and measurement of waist circumference.
Body Mass Index
This measurement is defined as follows:
BMI = weight [kg]/height [m]2 (weight in kilograms divided by height in meters squared).
The easiest way to determine your BMI is to use the table displayed at the conclusion of this monograph.
Note that the BMI guideline is independent of gender. A BMI of 25 to 29.9 is considered overweight and one 30 or above is considered obese.
Waist Circumference Measurement
The other measure of obesity recommended by the NHLBI is a simple waist circumference measurement. This measure does vary with gender. It is best used in combination with the BMI guideline. According to the National Heart, Lung, and Blood Institute, a waist circumference of over 40 inches in men and over 35 inches in women signifies increased risk in those who have a BMI of 25 to 34.9 (or greater).
Another measure of obesity is total body fat which can be measured by means of a device which measures the bodys resistance to an electrical current. Finally, total body fat can also be measured by total immersion in a tank of water and calculation of body density based on the amount of water displaced compared to the persons weight. However, the measures discussed above, particularly body mass index, correlate well with this latter measurement and are easier to obtain, since they do not require special equipment.
Dangers of Excess Weight
According to the National Heart, Lung, and Blood Institute:
Obesity and overweight substantially increase the risk of morbidity from hypertension; dyslipidemia; type 2 diabetes; coronary heart disease; stroke; gallbladder disease; osteoarthritis; sleep apnea and respiratory problems; and endometrial, breast, prostate, and colon cancers. Higher body weights are also associated with increases in all-cause mortality.
We may add to this list of health risk dangers the lifestyle impediments introduced by excess weight. Some of these include: Decreased mobility, decreased ability to participate in many recreational activities, discomfort caused by ill-fitting clothes, difficulty accommodating to the environment such as sitting in narrow airplane seats, and impaired social effectiveness as a result of the social bias against obesity. This latter problem can be subtle and may take the form of failure to make a good impression in a job interview, lack of effectiveness while on the job, as well as the more obvious decreased odds of meeting someone for a romantic involvement.
Finally, people who are obese are often food-centric planning their activities with the focus on eating. This can limit the inclination to pursue other means of gratification, since food becomes a very strong self-reward mechanism. Of course, this pattern only leads to further obesity.
Technology: Outrunning the Human Genome
There is one overwhelming reason why our Western, American society has fallen victim to a rapidly increasing problem with overweight and obesity. In fact, most of the fattening of our population has occurred in the last 40 years and especially in this past decade. The reason for this dangerous trend lies in the fact that our modern technology is progressing incredibly faster than our poor poky human genome (the genetic endowment each generation inherits from its parents). Human evolution is indeed a very slow process, measured in millions of years. Lifestyle change brought about by technological evolution, or should we say revolution, has been astonishing over this last several decades.
Two obvious inventions, which have impacted our lifestyle to an immeasurable degree, are the automobile and the television, the latter being to some degree supplanted for many of us by the computer. The increase in sedentary lifestyle afforded by these two inventions alone is probably enormous. We have even created a word for the chronic television viewer, couch potato.
Now we are beginning to experience the effects of another major invention, the internet. We no longer have to leave the sedentary comfort of our sofa to obtain anything, from information to any number of things we can shop for on the web and have delivered to our door. We can even order food without having to get up and use the telephone. We can cyber-travel to anywhere on the globe, experience sexual stimulation through vivid images, and chat with a huge number of other cyber-people. We can substitute the virtual world for the real world and think this is a great favor of modern technology. (Before I get too caught up in my criticism of this lifestyle, I must remind myself that this monograph is published courtesy of this very same world wide web technology, so Ill stop here, but you get the point.)
Unfortunately, our genome is still geared to a much more active lifestyle than modern technology supports. Think of the caveman who spent many hours hunting and gathering food. The energy expenditure of the food-seeking probably consumed most of the calories ingested. The challenge was to prevent starvation.
In fact most of the million or so years humans have existed in roughly their current anatomical form, avoiding starvation was the key to survival. This starvation threat remains a critical challenge in much of the third world. In this regard, it is interesting to note that the government of India has a law which prohibits beverages being sold with a sugar content of less than 5%! It is extremely difficult to find diet drinks in India.
To adapt to the challenge of starvation, evolution developed a stomach which can be distended to accommodate huge quantities of food. Anyone can attest to this who has frequented an all-you-can-eat buffet. Other adaptations include a feeding behavior which tends to be calibrated for eating calories far in excess of that required to maintain normal weight (in modern society). In primitive times this voracious appetite served man well, since one never new when the next meal would be hunted down. The excess energy is stored in glycogen reserves in the liver and, of course, in the form of fat deposits. This was not a problem for the very active primitive man, but it is a major problem for the largely sedentary modern homo sapiens.
Another problem that we inherited from our primitive ancestors is the overwhelming appetite many of us have for sweet, salty and fatty food. It is no coincidence that we crave food high in calories and salt. The idea was to prevent starvation, and the salt helped retain fluid to avoid dehydration. In our present society of abundant food, these propensities come back to haunt us and tempt us into further and further weight gain.
An obese patient of mine recently remarked regarding her food intake: I only eat till I am full and than I stop. Isnt that what you are supposed to do. Unfortunately, her appetite is geared to a much more active lifestyle than the one she currently lives.
Curiously, the people who probably would have been the best survivors in primitive days or under famine conditions in the present, are most prone to accumulate excess fat in our current high tech society. These individuals possess a so-called thrift-engine metabolism. They store energy well and get many miles to the gallon, using their fuel at a snails pace. If they were automobiles they would meet Federal Standards for the next 100 years. Unfortunately, they are not automobiles, they are just fat humans.
Bringing the Environment into Synch with the Genes
We cant change our genes. At least not yet. But we can create an environment, a personal micro-environment, that more closely resembles the environment that our genes were originally designed for. I speak of the primitive environment of the hunter and gatherer. What would this micro-environment be? For one thing we can simulate the calorie-burning hunting and gathering by walking to the store; cavemen did not have cars. We can spend more time stalking the prey, more time shopping, less time consuming. We can make more careful use of our modern technologies, such as the internet, and not let ourselves replace real life with virtual life. We can space out our big meals, treating ourselves to the big meal out monthly instead of weekly. After all the caveman most likely did not have the luxury of a sumptuous repast on a daily basis.
What We Must Do to Lose Our Excess Weight
After an initial physical examination by a physician to rule out undiagnosed specific medical problems, which may contribute to the obesity or contraindicate the recommendations below, the fundamentals of losing weight are well known. They essentially revolve around the joint concepts of restricting calories and increasing exercise. A good approach is to plan on losing approximately 1 to 2 pounds per week, perhaps setting an initial goal of losing 10% of current body weight, depending on the degree of initial obesity. Even though the obesity may require further weight reduction, it is important to set a realistic initial goal. Once this 10% reduction is attained, the over-weight condition can be re-evaluated (using, for example the BMI) and a further goal of another 10% or so can be planned if this is appropriate. For those dealing with extreme amounts of excess fat, this slow approach may seem hopeless. However with patience and persistence eventually a goal of reasonable weight can be achieved. Furthermore, the methods suggested can evolve into a long-term healthy lifestyle.
Dont Count Calories Eaten, Count Calories Not Eaten
The traditional diet has involved counting calories. While this works and may not be a problem for some, for many people it is onerous to focus on the caloric cost of each food ingested. Rather, one should develop a general and approximate knowledge of the relative calories of various foods one usually encounters and substitue the less fattening options. Much of this knowledge is common sense. For example, one could substitute fruit for the cake or pie dessert, eat lean meats or fish in modest portions of 4 ounces or so, and snack on carrots and celery versus cookies, crackers, or pretzels. Just making a series of such substitutions and keeping everything else the same will most likely result in some weight loss over time.
Food preferences seem to some degree to be acquired tastes. True there is some evolutionary pre-programming to like high calorie foods and salty foods, but there is still wide latitude in the ability of the individual to modify these proclivities. In general, avoid sweet and mushy foods and salty and oily foods. Get accustomed to crunchy foods involving whole grains, vegetables, nuts (in moderation), and fruits. By all means try to avoid adding salt in food preparation and avoid foods that already have a lot of salt, check labels. Substitute spices for salt. Use herbs to add distinctive flavors to food. Use skim milk and low-fat cottage cheese as opposed to whole milk or milk fat products. If these suggestions are followed, over a period of time food preferences will change and the old foods will start tasting too rich or fatty.
A concept that has proven useful is the calorie deficit model of weight loss. It is based on the fact that a pound of fat represents approximately 4000 calories (actually kilocalories or food calories). The 4000 calorie figure is arrived at by multiplying the caloric value of fat, 9 calories per gram, by the 454 grams equivalent to one pound.
Armed with this knowledge that one pound of fat equals 4000 calories, if one cheats oneself of approximately this number of calories a week, on average one will lose one pound of fat a week, keeping all other things the same. This breaks down to approximately 500 to 600 calories per day, the approximate caloric price of a slice of that rich pie or cake or several handfuls of the crackers, cookies, or pretzels one is snacking on. So figure out where you can cut that approximately 500 to 600 calories daily and you are well on the way to trimming the fat. To many people, this approach of eliminating calories is much easier than counting all the calories ingested. Each temptation becomes an opportunity. The pie not eaten is a major achievement.
Of course a more aggressive weight loss program would require trimming perhaps 1000 calories daily to give a weight loss of approximately 2 pounds a week. The NIH (National Institutes of Health) recommends weight loss of 1 to 2 pounds per week.
Now add to this calorie deficit approach the synergistic effects of increasing activity and the weight will dissolve ( in slow motion of course) it does take patience. The main object is to plan for a long, slow process of weight loss which will then seamlessly merge into a greatly healthier lifestyle. The rewards will accrue over the course of the rest of ones life in greatly expanded possibilities for a whole host of lifestyle choices which may have been relatively unavailable as a result of the encumbrance of excess weight.
Think of Increasing Activity Level, Not Just Doing Exercise
Exercise to many is a bad word. To other people it is a pure joy. Usually a person falls into one or the other category. Those who exercise just to control weight without any real enjoyment of the process, usually give it up after variable periods of time, depending on the degree of masochism involved. For those who enjoy exercise it is easy to keep it going. Sometimes exercise can become an addiction, but that is another problem that will be addressed at another time under the general category of compulsive behaviors and lifestyles.
The point is, if exercise is appealing by all means do it. Even if it doesnt come easily give it a try. The NIH guidelines suggest 30 minutes or so of exercise (moderate exercise) daily if possible. Of course, depending on level of physical unfitness, one might have to work up to this goal. On the other hand, 45 minutes of daily exercise is better yet, if that is feasible for a given individual.
Now for those who spurn the E-word (were not talking e-commerce here), try to concentrate at the very least on increasing the level of daily activity. Take the steps as opposed to the elevator when possible, give up trying to find the closest parking space, walk on short errands rather than driving, offer to help a friend do a chore, help the spouse with his/her chores, and on and on. As these unplanned activities increase, ones energy level and motivation to be active also increase, and the weight loss benefits continue to accrue.
Remember inactivity begets inactivity and activity begets more activity. People who spend much of their leisure time on the couch find it ever harder to get up and do something. They not only get fat they often get less and less motivated if not outright depressed. Reversing the process takes effort at first but soon becomes easier and easier.
Tempo Increase Speed Ahead
Regarding unplanned activity it is helpful to try to increase the tempo of the activity. In planned exercise, one tends to walk faster and faster on the treadmill, for example. Similarly, try to increase the rate at which you move about your daily life. Often people with a tendency to be overweight move slowly. Consciously try to increase the rate of movement, whether it be walking into the kitchen to get the carrot sticks, or doing a chore. In the latter case, it is a pleasant surprise to end up with more leisure time to do other active, fun activities.
Remember slowness of movement, aside from its frequent relationship to obesity, also crops up in a number of other undesirable settings. People with a common form of depression often are slowed up in all activities. As we age, we lapse into slower movements. People even drive slower as they get older. Some of this slowness is the result of physical impairment or severe neurotransmitter abnormality in the case of certain depressions. However, at least some of this slowing is reversible when one becomes conscious of it and makes an effort to move faster. The faster tempo eventually becomes the norm. And the contribution to weight loss is an important benefit. Of course some people are naturally fast and usually not obese in the first place; other people are, as the ancient Greeks said, phlegmatic by nature. Even though these may be genetic temperaments, there is some room for change, but first one must recognize the problem.
One should adopt an attitude to the weight loss challenge that recognizes the strong positives involved. Some of these positives include:
1. Weight is something potentially under ones control with the rare exceptions of relatively infrequent specific medical causes of obesity. Thus if one is to have a physical problem, obesity is certainly one of the most hopeful.
2. Weight loss is something one can usually do on ones own (after an initial recommended medical examination).
3. Weight loss progress is easily measured and monitored by use of an accurate scale and calculation of BMI and Waist Circumference Measures, as discussed above. No fancy and expensive laboratory tests are required as is the case with many other medical problems.
4. Weight loss is self-reinforcing as one sees not just the results on the scale, but the benefits which start to accrue in the form of more active lifestyle, less tendency to get winded (climbing steps or uphill walks), more comfortable fitting clothes and more clothing choices, compliments from others, and increased likelihood of a healthier and longer life.
5. Weight loss often can be an inspiration to friends and family to do likewise.
6. The whole process can be thought of as a challenge that with some dedication can be won.
Ok, Big Shot, I Tried It All and I Still Cant Lose Weight
At this point, when nothing is working as it should and the scale seems stuck on the same number, look for things that might be interfering with your best attempts at weight loss. I group these interferences into four categories: Environmental, psychological, psychiatric, and physical.
Environmental Impediments to Weight Loss (Especially Other People)
Look for an enabler. Perhaps a spouse or roommate is unwittingly helping to maintain your overweight condition. For example, this person may be filling the house with fattening foods for themselves and then encouraging you to join them, not wanting to eat alone. Or the mere availability of such foods may prove irresistible. Deal with this enabler tactfully but firmly, explaining that you have a weight problem that endangers your health and that it is very important to you to lose the weight. Most people understand this, although they may need to be reminded periodically.
In some cases, more subtle dynamics may be at work. An enabler may have an unconscious desire to keep you overweight for more complicated reasons. Some of these motivations might include competitive feelings. For example, the enabler may have been unsuccessful in weight loss himself and has difficulty seeing you win the weight battle. Or perhaps, the enabler is in denial of your obesity as a way of denying his own obesity. In another scenario, the prospect of weight loss poses the fear for the enabler that you might leave the relationship, especially in the case of a romantic attachment. Other dynamics are also possible. Subtle reminders to the enabler regarding your need to lose weight may not be all that effective, since the enabler is driven by his own motivations and self interest, and thus may have an investment in your being fat, for reasons of which he is not even aware. One possible solution to this weight-loss impediment may involve seeking professional psychological help for this dysfunctional relationship. If this is not feasible, it may be necessary to resist the pressures of the enabler with ones full determination, often quite a challenge. Finally, in very extreme cases, a separation may have to be considered.
Then of course there is the food equals love phenomenon wherein a loving parent or spouse literally feeds the other person to slow death. This is often a learned behavior which the perpetrator has acquired from an equally loving parent. Whole families of fat people can be formed this way, in the name of love. Some spouses, traditionally the female although this is changing, feel guilty if they do not prepare a nutritious and often calorie-laden meal. When the person trying to lose weight insists, I would be happy with a vegetarian meal tonight, or even a bowl of oats and some fruit, the feeder announces, I couldnt do that to you. Horses eat better. But if you really cared about me ..., and the futile dialog continues.
One way, perhaps, to address the above enabler issues would be for both the person trying to lose weight and the significant other to read this monograph together and then discuss it. Often having a third party point things out is more acceptable than hearing the same things from one of the parties engaged in the conflict. Opening up a nice, calm dialog about these issues is a necessary first step to creating lasting change.
Psychological Impediments to Weight Loss
Prepare for periods of being discouraged. Weight loss does not proceed in linear fashion. Weight often seems to come off in a series of stages, interspersed with plateaus. Nothing seems to be happening for a while, than for some reason, a few more pounds come off. Then another plateau. There will also be times that weight seems to go up a pound or two. Have patience, this is just how it works. Daily variations are not important. Weigh yourself weekly or bi-weekly.
To avoid giving up, stay motivated by keeping an eye on long-term goals as well as the scale. Think of the long-term health benefits of weight loss. Think of how good it will feel to be lighter and more agile and quicker in movements. Think of the improvement in the tennis game or other physical activity. Think of the clothes not binding around the waist. Think of all the other activities that will be possible once the hindrance of a fat, unfit body is no longer a problem.
Other areas of psychological impediment are more subtle. An individual may harbor unconscious motivations to stay fat. He may fear the possibilities that might open up once the weight is lost. For example, obesity may have been an excuse to avoid seeking romantic attachments. Also, large size may imply self-importance and power, thinness frailty. Weight loss may also arouse the fear of looking older with more pronounced wrinkling and sagging skin. These fears, often unconscious, may require the skills of a therapist to uncover and treat.
The reliance on food as a primary reward activity is also a major psychological impediment to weight loss. Some individuals rationalize, life sucks, I might as well enjoy my food. This attitude might reflect an underlying chronic depression. Eating is also an easier activity with which to reward oneself as opposed to playing a sport or leaving the house to attend a play, or to pursue some other interest. Finally, eating can be done by oneself without having to deal with another person. These advantages are very short-lived gratifications as opposed to the long-term gratification that can be obtained by achieving and maintaining a normal and healthy weight. Keep the mind focussed on the long-term goals as numerated above.
Psychiatric Impediments to Weight Loss
Numerous psychiatric, medical conditions can complicate weight loss. For example, if one has some forms of clinical depression, especially the so-called atypical depressions, it is not unusual to gain weight. The weight gain can be related to a general loss of interest and avoidance of activities as well as to metabolic changes, which can result from the depression. In one such form of depression, the individual tends to crave carbohydrates, sleep excessively, and suffer from feelings of low energy. This particular depressive state is often more common in the winter season and it has been theorized that it bears some resemblance to the hibernation state observed in some animals. It is obvious how this disorder can derail any attempt at weight loss and professional help should be obtained.
Various eating disorders can also play havoc with weight. Examples of these disorders are compulsive eating patterns, bulimia (the binge-purge disorder), and anorexia nervosa, although this latter disorder is associated with excessive weight loss, by definition. Under no circumstances should bingeing and purging be used as a means to control weight and laxative use or regular diuretic use is also not recommended, unless it is prescribed by a physician for a particular medical condition.
Physical Impediments to Weight Loss
The books all recommend aerobic exercise as a weight loss adjunct. However, what about the disabled individual who cannot bear weight on his legs? There are many physical impairments which can make traditional exercise difficult, harmful, or even impossible. In these cases one must be creative. Upper body aerobic exercise can be just as effective as lower body exercise and actually can often burn more calories. Some examples of upper body aerobic exercise are rapid twirling of the arms in large and small circles with the arms outstretched and rowing exercises. Consult with a health professional for medical clearance and other suggestions. And, of course, if one has any of a number of serious medical conditions, including such things as cardiovascular disease, diabetes, or respiratory problems, the advice of a physician is mandatory before beginning a weight-loss program.
Finally, obesity when severe, is itself a major impediment to weight loss since it limits physical activity. For the very obese it might be an effort, or even impossible, to get out of bed. Nonetheless even these individuals can usually do something to increase their activity, even if the activity has to progress very gradually. For example, if it is impossible to mobilize the entire body, at least limb exercises are a possibility. Professional counseling by a physical therapist might be very helpful to design an incremental activity program. The main point is to GET MOVING...even a little.
Alternative Weight Loss Strategies
For the sake of completeness, I will touch on various weight loss approaches other than those recommended above. In general, these techniques are reserved for the more severe cases of obesity where the calorie-restriction and increased-activity approach has not produced significant results over a period of say 6 months or more and there is serious danger to ones health. These techniques include surgical intervention, such as gastric stapling and jejunal (intestinal) bypass, and the use of medication. Various medications have been used to help control weight. These include amphetamines, amphetamine-like drugs, such as phentermine, thyroid, and antidepressants such as fluoxetine/Prozac (although not approved for this usage by the FDA). These drugs have also been used in creative combinations, such as PhenPro (phentermine and Prozac). None of these medications produces consistent weight loss results and in the case of amphetamines, a potentially habituating drug, the weight loss is usually transient.
Just recently, a drug that prevents fat absorption, orlistat, has been FDA approved and is being marketed under the brand name of Xenical. This drug causes much of the fat ingested to pass through the body unabsorbed and thus not contribute to weight gain. Problems with this latter drug include abdominal pain and bloating as well as oily diarrhea, particularly when one ingests fatty foods. This side effect suggests that the drug may work quite successfully for some people as a kind of Antabuse for obesity. Antabuse, when taken before alcohol consumption, results in a very nasty physical reaction to the alcohol, thus making a person think twice before drinking while on this drug. Likewise, Xenical may perform the same aversion therapy for someone used to ingesting large amounts of fatty foods.
One of the most creative weight loss approaches tried several years ago was the gastric balloon. Much as one would put a brick in the toilet tank to displace water and lower the water bill, the gastric balloon, would be lowered into the stomach and then inflated to take up space. Thus, a person would feel full with only a modest food intake. The idea sounded like a winner until several serious complications occurred, including death, when the balloon would dislodge and cause an intestinal obstruction, a medical emergency.
Various health store remedies involving herbs have been tried with limited success. And of course many people have placed themselves on pre-formulated diets, sold under various proprietary names. The problem with these methods is that they are not conducive to maintaining weight loss, since one usually gets bored with the limited foods supplied. On the other hand, sensible calorie restriction and increased physical activity can become part of a normal lifestyle.
Finally, hope may yet be on the horizon. Various biotech companies are working on understanding the various mechanisms the body uses to regulate weight. One interesting theory involves a peptide (a series of amino acids) called leptin. The theory states that fat cells normally trigger leptin release into the bloodstream. Theoretically, when there is more fat cell mass, more leptin is released. The leptin then interacts in the brain with receptors in the hypothalamus to turn off eating behavior. Obese people are thought by some to produce either insufficient leptin, defective leptin, or to possess defective leptin receptors in the hypothalamus, all of which would interfere with regulation of feeding behavior and weight regulation. Thus it would seem that the ability to supply exogenous leptin, in the form of a drug, would also turn off eating behavior and could be given to obese individuals to help them lose weight.
Two features have complicated the leptin picture. First, leptin has to be injected, since the drug is broken down in the stomach and thus cannot ever get to the hypothalamus intact when taken by mouth. And second, there are apparently various troublemaker mice which are both obese and have excessive leptin all in the same mouse! So for now it is back to the drawing board for leptin.
I have attempted to provide an overview of the obesity problem as we experience it in our modern technological society. In addition, I have offered what I believe to be practical suggestions that can be applied to the individual who wishes to combat the forces which strive to make us fat. It is my hope that the reader of this monograph will look back in 6 months or so and feel that the time and expense involved was well worth it and a total loss of pounds that is.
Dennis B. Kottler, MD
Please e-mail the author with your feedback at: email@example.com
To use the BMI table below, first find height in inches in the column on the left and then go across the table to locate weight in pounds. Finally locate the BMI by going up to the top of the column.
This table has been created using the following formula (converts kilograms to pounds and meters to inches):
BMI = Weight in pounds divided by 2.2/ (Height in inches divided by 39.37) squared.
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