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- Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
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Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
While browsing through potential reading material recently, my attention was unexpectedly drawn to a “Special Report on Obesity” in the journal The Economist (1). As physicians, and particularly cardiovascular specialists, we are well aware of the enormous health care burden currently imposed by overweight and obesity. However, in reading the article I was impressed with the many economic and societal aspects of the condition, especially in regards to potential remedies. In fact, in many respects government and industry may have been more active in pursuing solutions than have we in medicine. Therefore, I thought that I might share some of the thoughts that were provoked in reading the article.
Although I have heard or read the statistics regarding overweight/obesity many times, they still serve to startle me. Data indicate that two-thirds of people in the United States are overweight (body mass index [BMI] >25 kg/m2), while 36% of adults and 17% of children are obese (BMI >30 kg/m2). Excessive fatness is also rapidly becoming prevalent worldwide. At least 24% of adults in Great Britain are obese, as are more than 20% of adults in countries such as Brazil, South Africa, and the United Arab Emirates. Obesity is even increasing in developing countries, such as China and India, and it is estimated that roughly one-third of the population of the world is overweight. It is likely that this has been a major contributor to the transition from infection to chronic diseases as the predominant cause of death in the developing world. Approximately 44% of diabetes and 23% of ischemic heart disease cases have been attributed to corpulence by the World Health Organization, and several years ago obesity-related illness was estimated to be responsible for up to 20% of total health-care costs.
In large measure the increasing prevalence of overweight/obesity has been related to changing culture, lifestyles, and economics. Increasing wealth has increased the availability of (often highly-refined) foodstuffs, and decreased the need for physical exertion. Soft drinks and fast food that are frequently highly caloric have become more accessible and affordable. It is not surprising, therefore, that enlarging body mass has increased more rapidly as a cause of disease since in the last 2 decades than any other disease cause.
The cause of obesity seems deceptively obvious; it occurs if you eat more calories than you burn. In fact, the size of the portion served and the speed with which it is consumed have been shown to influence weight. However, it is well documented that obesity is less prevalent among highly educated and wealthy individuals than those with lower income and less education, although the reasons are not precisely defined. Physiology also plays an important role in the process. The interaction of hormones, such as ghrelin and leptin impact appetite, as does the central nervous system. To some extent, these mechanisms seem to be influenced by genetic factors, although the strength of the role of genes is uncertain. These physiologic mechanisms appear to have been designed to protect our primitive ancestors for whom long intervals without food made it important to store extra calories when they were available. Unfortunately, in our current socioeconomic environment these mechanisms can have significant adverse effects.
The pathophysiology by which obesity leads to disease is also not simple. Of course there is the clear association of obesity with hypertension, hyperglycemia, and hyperlipidemia, all of which predispose to a variety of disorders. In addition, obesity is often accompanied by insulin resistance and diabetes, with the associated complications of these conditions. However, complications seem to be more closely related to abdominal adiposity and an increased waist-to-hip measurement. It has also now been well documented that there is a subset of fat individuals who are metabolically normal (healthy or fit fat), typically exercise regularly and are well conditioned, and do not seem to experience an increased morbidity or mortality. These individuals often exhibit an increased lean body mass. Moreover, a number of studies have established the relationship between visceral adipose tissue, inflammation, and subsequent adverse conditions. Thus, the BMI does not tell the whole story when it comes to predicting the effects of overweight/obesity.
Given the increasing prevalence and detrimental effects of obesity, it is stunning that few medical interventions are available. Agents that have proven to be of some benefit have also been shown to have severe side effects. Several newer drugs have been approved, but remain to be evaluated in general practice. Perhaps the most effective intervention at present is bariatric surgery, which has shown the ability to produce weight loss and reduce secondary abnormalities. It is perhaps a strong statement concerning the current state of overweight that a surgical procedure is increasingly being performed as the best therapy for morbid obesity. While it is easy to say that the obvious answer to fatness is to eat less and exercise more, and that weight is subject to choices made by a patient, many of the physiological mechanisms discussed earlier can conspire to make weight loss more difficult than weight gain.
In response to the epidemic of obesity, the lack of effective medical therapy, and the costs of complications, governments are increasingly seeking legislative approaches to prevent or reverse the condition. Much attention focuses, of course, upon the food industry. Fast food, including soft drinks, has been felt to be responsible for much of the fat gain in the United States, and the companies involved are rapidly expanding in the rest of the world. Obviously, a reduction in the size and/or caloric content of their products could be of benefit in reducing obesity. The perception of the major role of the food merchants in the current epidemic has been such that the industry is attempting to be proactive in providing healthier food choices. In the United States, 16 companies have promised to cut 1.5 trillion calories from their products, and 21 English companies have entered a “Responsibility Deal” with the Department of Health to help people reduce their caloric intake. However, as public companies, these entities have a responsibility to stockholders to achieve profits. In the past, stockholders have rallied against abandoning very profitable foods that are tasty but not necessarily nutritious. An additional consideration is that it is not always clear what constitutes healthy food, nor is such fare always well received by customers. The classic example is the reduced fat McLean Deluxe hamburger marketed by McDonald's several years ago that was a failure in the marketplace. Industry is responsible for making nutritious food that is appealing, but the public must be accepting of such offerings even if they are less tasty.
Governments have several options for addressing the obesity epidemic: they can conduct public health campaigns, use the mechanism of taxes, or eliminate the sale of products. Legislative action can be directed to the food suppliers or to the public. Considerable public health campaigns are ongoing as exemplified by the increasing requirements to provide information about the caloric content of products. Thus far, the response of industry to potential regulatory action has primarily been to increase education and emphasize the role of personal responsibility. The potential exists for the government to increase taxes on food that is deemed to be unhealthy. This was done in New York City for cigarettes with excellent success. However, data indicates that the tax must be a minimum of 20% to be effective, an amount that would be politically unpopular. Perhaps the boldest governmental intervention has been in New York City where Mayor Bloomberg has obtained the Health Department agreement to ban giant size portions of soft drinks with high sugar content. Not surprisingly, this action has been very controversial, with opponents maintaining that this is the introduction of the “nanny state” where the freedom to make lifestyle choices is taken from the individual by the government. Opponents argue that if the government can decide what kind of soft drink you can have in the name of good health, what else can it decide, and where does the authority stop. Clearly it is in the purview of the government to strive to eliminate products or conditions that compromise good health. The way in which the government pursues this activity will likely depend upon the growth of the obesity epidemic and its cost to society.
It is of some interest to me that the medical profession has been a bit less active in regard to control of obesity than I might have expected. Although I may be unaware of specific activities, I have not seen the same kind of organized effort for corpulence that was apparent for smoking. While we no doubt counsel our patients in regard to the deleterious effects of obesity and the need to lose weight, perhaps we could achieve more if we organized with a common voice to express our concerns about the danger of having excess weight.
There is little question that overweight/obesity represents an enormous and increasing problem for our health care system, particularly in regard to cardiovascular disorders. The remedy for this problem is likely multifactorial. Education, encouragement, and assistance in losing weight certainly should be the cornerstone of our action with patients. Perhaps as a profession we can take a more public role about the need for a concerted effort against the epidemic. Given the difficulties in losing weight, strong efforts must be directed to preventing obesity to begin with. Industry must be incentivized to make appealing, nutritional foods, and the public must be convinced that foregoing an acquired taste for better health is important. It appears clear that financial incentives would be most effective in changing the eating habits, but these would be very difficult to implement in the form of taxes. Perhaps smaller, more individual incentives could be implemented by insurers or employers to achieve a reduction in weight. The process of banning products seems to be a bit of a slippery slope in regard to food; how do you determine which products to ban? Nevertheless, the challenges presented by obesity to health care costs and the requirement to provide adequate foodstuffs to a more populous and overweight world could provoke society to take more drastic measures. Interestingly, although the consequences of overweight/obesity are primarily medical, economic and regulatory agencies appear to be playing the major role in seeking a solution. Surely the time has come for the medical community to become more organized and proactive in engaging the public and the food industry to emphasize the health hazards associated with obesity and seek solutions to the problem.
- American College of Cardiology Foundation
- Howard C.