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January 7, 2010 – Vol. 4 • No. 5
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Losing extra weight reduces health risks

Sadie B. King, a 62-year old retired school teacher, was taken aback.

A cancer specialist actually used the word “obese” in explaining why King might have developed uterine cancer.

“Of course I was offended,” King said. “I always considered myself pleasingly plump. I never considered myself obese. In my mind, I was still the slim person I had always been. It never dawned on me that I was obese.”

And that’s part of the problem with obesity: There is a significant gap between the medical definition and human perception. It all depends on who is in the mirror. “It’s hard to look at them [very heavy people] and think you’re in the same category,” King said. “I’m skinny compared to them.”

But the scale doesn’t lie. King had become one of “them” and in the process put herself at risk for serious medical complications. In King’s case, that meant the risk for developing uterine cancer.

Constance Brown-Riggs, a national spokesperson for the American Dietetic Association, said the problem goes beyond the use of words. When obese people insist they are healthy, Brown-Riggs shoots back a question. “What does healthy mean to you?” she asks.
Even if an overweight person has normal blood pressure and cholesterol, she points to the quality of life. “Can you walk up a flight of stairs without puffing?” she asks. “Can you bend down and tie your shoe?”

As a weight loss specialist at Brigham and Women’s Hospital Dr. Malcolm K. Robinson has a different approach. “Being obese does not mean a person will become unhealthy,” he said. “But the risk of that happening is very high. It’s all about risk reduction.”

Part of the confusion lies in fat mythology.

“Years ago when man went from feast to famine, he would eat more calories than needed and store the extra as fat,” Robinson explained. “When times were lean, he’d dip into the storage department.”

In other words, Robinson said, fat was a good thing.

But nowadays people are eating way more than required for basic survival. As it is now, obesity is the third leading cause of preventable deaths in America, and the numbers of those defined as obese continue to swell.

Between 1995 and 2008, those defined as obese by the Centers for Disease Control (CDC) skyrocketed by 69 percent, from 16 percent to 27 percent of all U.S. adults. The nation’s weight has gotten so bad that about two-thirds of all U.S. adults are either overweight or obese.

The problem is worse in people of color. The CDC has reported that the prevalence of obesity in blacks is more than 50 percent higher than whites. Nationwide, almost 36 percent of blacks are considered obese; in five states that percentage climbs to more than 40 percent. Black women have a higher prevalence of obesity than any other group.

Part of the problem is the different perceptions of weight among the races.

A 2006 study published in the International Journal of Behavioral Nutrition and Physical Activity found that even when blacks and Hispanics were told by their doctor that they were overweight or obese, when queried later, they reported that their weight was about right.

The state of denial can be found in the words and phrases often used by African Americans to describe excess weight. “Pleasingly plump” is one phrase. “Big boned” is another. Ironically, one of the most popular words is “healthy.”

According to Dr. Gina N. Duncan, chief resident of psychotherapy at Massachusetts General Hospital, African Americans have a higher acceptance of being overweight or obese. That is not entirely bad, Dr. Duncan explained, pointing out that blacks have a lower rate of eating disorders than whites.

But the tolerance comes at a price. “We’re not looking at what’s going on inside,” she said. “We tend to focus on external appearance. We convince ourselves that you can look good at any size. We need to focus on health instead.”

Medical experts use two major determinants of obesity – the body mass index (BMI) and waist size. Obesity is defined as having a BMI of 30 or greater. That number is a measure of body fat based on a person’s height and weight.

While the BMI is a fairly reliable measure of healthy weight, it has its drawbacks. Athletes and those with well-developed muscles will have higher readings since muscle weighs more than fat. However, those who shun exercise and lack muscle definition can safely assume that their BMI is on target.

An even more reliable measure of obesity is waist size. Fat in the abdominal area is generally a combination of subcutaneous – fat underneath the skin that can be grabbed - and visceral – internal fat surrounding abdominal organs. It’s been found that visceral fat is metabolically active, and in excessive supply, can trigger cardiovascular disease and diabetes. The classic “beer belly” is not just the layers of fat accumulating around the abdomen; it generally marks the presence of the more dangerous visceral fat.

It is recommended that women maintain a waist size of 35 inches or less and men 40 inches or less.

The good news is that visceral fat – and the resultant health risks – can be reduced through exercise and healthy eating. Losing just 5 to 10 percent of current weight can help deter the threat of cardiovascular disease.

Many doctors are now examining the psychological links to obesity. Anxiety and depression are not talked about as much as lack of exercise or eating smothered pork chops but they are clearly contributing to the problem.

According to Dr. Duncan, overeating can be a symptom of depression. Stress can also play a role, as can self-esteem and self-perception. “Eating right and exercising are things people do when they care,” she explained.

About themselves.

And that’s when King started to pay attention.

She recently joined a clinical trial called SUCCEED – Survivors of Uterine Cancer Empowered by Exercise and healthy Diet – designed for obese women with Stage one or Stage two uterine cancer to determine if lifestyle change can have an impact on the quality of life.

She started in April 2009 and lost 22 pounds by December. She’s doing it the right way. Slowly – one pound at a time.

“It’s a lifestyle change,” she said. “It’s the little things that work.”

For years, King said her doctor told her that she needed to lose ten pounds to avoid serious health problems. But King now admits that she never quite got the message.

Even when she was diagnosed as pre-diabetic.

Every six months she visited her primary care physician to monitor her blood sugar levels. And every six months she got the same sermon. “You really need to lose ten pounds,” the doctor would tell her. But the advice began and ended right there in the doctor’s office. No referral to a nutritionist was made; no hints on how to proceed were ever offered.

Quite naturally, her weight kept increasing. Though her doctor diligently asked what she was eating, she never asked what she was drinking.

King finally realized that her many trips to McDonald’s for the 230-calorie sweet ice tea was doing a number on her diet.

Fortunately, those days are in the past.

King says she is committed now. “Before, I had no energy, so I would sit a lot,” she said. “Now I move.”

It took a diagnosis of uterine cancer for Sadie B. King to come to terms with her problem of obesity.

Gina N. Duncan, M.D.
Chief resident of psychotherapy
Massachusetts General Hospital

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