Archive for October, 2009

The Obesity Society Meeting-Day Two

October 26th, 2009

Today’s sessions of the Obesity Society’s annual scientific meeting covered a lot of ground.  I think the most interesting  was the session on the relationship of cancer and obesity organized by Ruth Ballard-Barash of the National Cancer Institute and Ted Adams of the University of Utah School of Medicine. Christine Friedenreich, Ph.D. of the Alberta Health Services presented a comprehensive overview of the association between specific cancers and obesity, reviewing the published literature for each cancer. At the end, she proposed that obesity was responsible for about 20% of all cancers. If (in an ideal world) obesity levels could be resolved to normal BMIs, she speculated 1.6 million deaths due to cancer could be saved, 2.2 million new cancer cases could be avoided and we could avoid having 5 million persons living with cancer.

Other key presentations addressed the powerful influence of sleep and circadian rhythms, or the lack thereof, on rising rates of obesity. This led one presenter to suggest that we should have our biggest meals at breakfast and gradually reduce caloric input throughout the day to a light salad at dinner. Rena Wing reported on the 4 year results of the Look Ahead Trial which provided persuasive information for intensive lifestyle counseling over less intensive interventions in reductions in body fat and related metabolic indicators.

Sometimes these meetings morph into abstract, perhaps irrelevant, discussions of minutia   among researchers.  At other times, you feel you are witnessing an emerging new insight into obesity and its effects. So it was today in a session, Is There Good and Bad Body Fat? chaired by Richard Bergman, editor of Obesity, and including prominent researchers, Tamara Harris, Michael Jensen (who readers may remember from our conference at the 2008 Republican National Convention) and Sam Klein. Their task was to unravel which fat was bad and which was good. Their presentations covered detailed, precise research into these tangled issues.  Why are there some obese individuals who were, nevertheless, metabolically normal? Why did bariatric surgery resolve diabetes in some cases but not others?  Why does weight loss resolve some metabolic disorders but not others? For many in the audience, these are the cutting edge questions – today – to understand the metabolic sequela of weight gain, insulin resistance, diabetes and cardiovascular disease. The presenters provided exciting new data interspersed with a camaraderie and jocularity which is the realm of highly accomplished and competitive scientists who admire each other’s works but are not going to give them an inch. Bottom line: adipose cell build up in the liver may explain many of the inconsistencies in present views of the obesity-insulin resistance-metabolic disorders axis. But, build up of adipose cell in the liver is hard to measure given today’s technology and bio-statistical resources. On the other hand, there may well be another factor, not yet identified (kind of like dark matter in astrophysics), which modulates the effects of obesity, insulin resistance and metabolic disorders. The large, enthusiastic audience no doubt left with many possible research proposals in mind to unravel this conundrum. Stay tuned, as they say, “we wait with bated breath,” for the next insight.

The Obesity Society Meeting, Day One

October 25th, 2009

This Saturday, October 24 is the “pre-meeting” day which means it is outside the constraints of the Continuing Medical Education limitations on corporate participation. Most participants head right for the Pharmacology update section. This section involves presentations by mainly pharmaceutical company researchers as to where their compounds are on the tortuous path to approval by the Food and Drug Administration (FDA). To researchers, it is a tip-off as to where their research should be going; to competitors, it is an indication of how their compounds may fare. There are not a few investment advisors in the audience looking to where their clients should place bets as to which company’s products may get approved or not.
A cautionary note: This Saturday show is not unlike the paddock at the Kentucky Derby. Some horses look just beautiful; some are not so handsome but have great records; some are nags but just keep moving along. Over the next few days, more details on these compounds eke out in oral and poster presentations. Sometimes the beautiful horses stumble; sometimes the nags win. It’s a horse race.
Today, however, presentations by three pharmaceutical companies and one researcher for a device manufacturer focused on their products in Phase II or Phase III of development. The companies were Arena, Vivus, Orexigen and Amylin. The one device company was represented on the platform by Lee Kaplan of Harvard, commenting on GI Dynamics’s EndoBarrier system.
I was seated among several highly experienced, knowledgeable obesity researchers and, frankly, keyed off their reactions. The Arena information was impressive but not inspiring. The Vivus presentation showed real promise and indicated a good bet for approval. The Orexigen data was impressive but not overwhelming. Amylin’s products were at an earlier stage of development and should not be compared with those at later stages of development. However, they seem to have a good track on products which may not have the side effects of the other compounds. The GI Dynamics data involved a new surgical intervention which, while promising, had a number of issues around delivering the product.
In short, a lot more needs to be discussed about these compounds. However, these presentations were inspiring to the audience of researchers and clinicians that a new generation of therapies are closer than we think. The Devil is, alas, in the details and over the next few days more details on these and other products will emerge. Stay tuned.

The War on the Obese – The Ohio Front

October 23rd, 2009

In 2003, a prestigious  researcher, Jeffrey M. Friedman, called for a ‘War on Obesity, not the Obese.” A war on obesity, not the obese. [Science. 2003] – PubMed Result We seem, six years later, not able to make the distinction.

Elsewhere we have addressed various attacks on persons with obesity, rather than obesity itself. Medical experts, it seems, appear particularly unable to tell what is a war on obesity and what is a war on persons with obesity.

A ‘War on Obesity’ includes the same elements that have guided other, successful, approaches to health care problems, whether infectious diseases or chronic conditions. The elements are straight-forward: (1) educate the public and health professionals, (2) focus research on finding both the causes and effective interventions, (3) promote prevention, when possible, (4) intervene and treat those affected, (5) if relevant, strongly combat stigmatization and discrimination, as they are impediments to effectively treating and preventing the disease, and (6) consumer protection to stop the exploitation of worried people and their diversion into unproductive avenues of recourse. With obesity, in general, the federal government has only focused on educating the public and promoting prevention (although we still lack proven prevention strategies). All the other strategies have been not totally, but largely, neglected.

Identifying a “War on the Obese” requires a little work. It requires work because stigmatizing overweight/obese people is so ingrained in our culture. It starts early and does not stop. Shunning, embarrassing, ridiculing and penalizing persons with obesity is so ingrained in our society, we take it for granted. How do we recognize it?

Lets take Dr. Toby Cosgrove, CEO of the Cleveland Clinic, statements about hiring obese persons.

1.       On August 12, 2009, David Leonhardt of the New York Times, wrote, “Cosgrove says if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent conversation, I told him many people might consider it unfair. He was unapologetic.”

2.       On September 6, 2009, Dr. Cosgrove was interviewed by Guy Raz on NPR:

RAZ: And you have argued that you would not hire people who are obese. Is that fair?

Dr. COSGROVE: No, I think that that was a quote that was taken out of an hour-and-a-half interview. And what I said was that we are concerned about the obesity problem, not about people who are obese.

3.       September 9, 2009, Cleveland .com carried the story, “Clinics Dr. Delos ‘Toby’ Cosgrove defends remarks about not wanting to hire obese people.” Asked at an obesity summit at the Cleveland Clinic, organized by the clinic’s bariatric surgery program by Walt Lindstrom, founder of the Obesity Law and Advocacy Center in California, if he wished ‘he hadn’t said it.” The Dr. Cosgrove demurred and said his comment was meant “to stimulate discussion on the growing costs of obesity.” He said, “I think a lot of people misunderstood what the point was…I never considered not hiring obese people, but I think we have to do something bold to address the problem.” The article goes on, “Cosgrove opened his remarks at the Obesity Summit by highlighting the Clinics health and wellness initiatives. On the obesity front, the hospital has eliminated fried foods, removed soda and candy from vending machines and subsidized Weight Watchers and fitness programs for its 40,000 employees, he said. “In nine months, we’ve lost 110,000 pounds across the organization, which I think is an amazing tribute to the program.”

4.       September 12, 2009: On a Wall St. Journal Health Blog, Dr. Cosgrove said, “it would be illegal to apply a similar standard (not hiring smokers) to people who are obese, because they’re protected by the Americans with Disabilities Act (ADA). He said, “I can’t decide that I’m not going to hire somebody because they are 400 pounds. We don’t hire smokers and that’s perfectly legal.” According to the blog entry, “Cosgrove questioned that rule, suggesting it could hinder efforts to lower the nation’s obesity rate. Dr. Cosgrove said, “We are protecting people who are overweight rather then giving people a social stigma.”  The blog reports that the Department of Justice said that only morbid obesity can be protected by the ADA but only “if it substantially limits a major life activity in the past or is regarded as substantially limiting.”

5.       On September 13, 2009, Connie Schultz, a Cleveland Plain-Dealer Pulitzer-prize winning columnist for her focus on blue-collar families and economics, wrote, “Apparently, it is now fashionable to bash the obese. For the sake of health care, you understand. Nothing personal.” Quoting Dr. Cosgrove remorse that “We are protecting people who are overweight rather than giving people a social stigma” Schultz states, “What, Oh, he must mean all those obese people bragging about the compliments from strangers, the big, welcoming grins on the faces of fellow airline passengers. Not to mention the parade of size-20 models on fashion runways. Yup, obesity is really popular in America. Who wouldn’t want to be called fat. Punishing obesity compounds the problem.”

6.       September 14, 2009, Dr. Cosgrove apologized to employees of the Cleveland Clinic for any “hurtful” comments, stating, “My objective was to spark discussion about premature causes of death, but some of my comments were hurtful to our community. That was certainly not my intent, and for that I apologize.”

In Cleveland, 70% of adults are over their recommended weight. Obesity is more prevalent among women than men, greater among black adults and higher among older persons than younger ones as well as more prevalent among lower income persons.

The picture of obese persons in Cleveland is intriguing. According to the Center for Health Promotion Research, “Obese and non-obese Clevelanders did not differ in the reporting of adequate fruit and vegetable consumption.” The difference appears to be in physical activity with obese persons reporting less adequate moderate or vigorous physical activity. More than half of all Clevelanders reported not getting adequate weekly amounts of moderate physical activity. BUT, as the report notes, “Clevelanders who were obese were more than twice as likely to report having diabetes (17% vs. 7%) and nearly twice as likely to report having asthma (15% to 8%).”  They also report more hypertension and high cholesterol that non-obese Clevelanders. Therefore, the reports notes, lower levels of physical activity were related to diabetes, hypertension, high cholesterol and heart attacks.

The report goes on to note that obese Clevelanders reported more use of nutrition classes and organized health promotion activities compared to non-obese residents. Fully 75% of obese Clevelanders are trying to lose weight. Of the 76% of Clevelanders who reported seeing a doctor in the past 12 months, only 16% were given advice about their weight! Obese Clevelanders reported using both diet and exercise compared to those who were not obese. And more obese persons used a diet- only approach, “a possible reflection of the mobility issues related to obesity, and the additional need for diet modification.” http://www.case.edu/affil/healthpromotion/Publications/Publications/Steps%20BRFSS%20Data%20Brief%20OBESITY%203.27.08%20FINAL.pdf

Dr. Cosgrove has apologized to his current employees saying he only wanted to talk about premature deaths due to obesity. If he is concerned about premature deaths due to obesity, he might address why does his health plan for employees cover bariatric surgery after a two year waiting period (http://www.clevelandclinic.org/healthplan/plan-cchs-caremanagement.htm#MedBenefitsCoverClarification), one of the longest in the country, and, for which, there is no medical justification?

Even though Dr. Cosgrove has apologized to his employees, does anyone in the hiring process at Cleveland Clinic not understand the boss doesn’t want to see so many fat people on staff? Would you hire an obese Clevelander and take them to meet the boss for the ‘Welcome aboard’ gesture? Not likely.

At the end of the day, there is no evidence that stigmatizing obese persons reverses or resolves the problem. Stigma and discrimination does not work and only increases the sum of human unhappiness. We need new therapies and we need physicians who want to help their patients, and, Dr. Cosgrove, we need positive leadership.

October 12th, 2009

October 21, 2009

FDA plans revision to nutrition label. FDA seeks to improve nutrition labeling on food products – washingtonpost.com

October 20, 2009

Women with obesity at risk for in vitro fertilization failure The Press Association: Obesity cuts IVF success – study

October 19,2009

Can anyone get insurance? Now an underweight girl is excluded. Underweight Girl Denied Insurance Coverage – Denver News Story – KMGH Denver

October 14, 2009

Dr. Bernandine Healy hits punitive steps against the obese The Obesity Epidemic Isn’t Just About Willpower – US News and World Report

October 18, 2009

Washington Post columnist Robin Givhan address the Fashion industry and thinness in the culture.Robin Givhan on Fashion: Size of the Model vs. Size of the Customer – washingtonpost.com

Great Idea: solve obesity by making people taller. Idea Lab – Should a War on Shortness Be One of the Goals of Health Care Reform? – NYTimes.com

October 17, 2009

NYT reports on prospects for new drugs for obesity Arena, Orexigen and Vivus Are Chasing an Effective Diet Drug – NYTimes.com

Why can’t CDC find obese swine flu patients? Pneumonia, Susceptibility of Young Among Traits of Swine Flu – washingtonpost.com

Rational Irrationality

October 4th, 2009

October 4, 2009

Rational Irrationality and the Obesity Epidemic

In the October 5, 2009 issue of The New Yorker there is an interesting article on the global financial meltdown by John Cassidy,” Rational Irrationality.” Cassidy, author of the upcoming book, “How Markets Fail: the Logic of Economic Calamities,” has an intriguing theory. The market crashes, he argues, were as much the product of rational decision-making as corporate greed or failure of regulators.

He sees individuals making sensible, rational choices…when to get the most affordable mortgage, when a financial institution invests in them, when to sell them. These immediate choices are rational for each actor but can become catastrophic in the aggregate. For example, pedestrians on a bridge adjust their footsteps to walk across, the crowd grows and every step forward carries a small, lateral movement. The lateral movements start the bridge swaying and then dangerously so. The rational choice of each walker becomes nearly catastrophic. Or, it is rational for a family to save more money and cut back on its purchases. But when everyone starts doing the rational thing, the economy starts freezing up. Goods not sold are not manufactured. People lose their jobs. More people cut back their spending. More layoffs and the economy starts going into a free fall. Investors pull back, unwilling to take  new risks. New businesses can’t get started. The savers become unemployed and unable to get credit.

Could this apply to obesity? Cassidy doesn’t address this although the field of behavioral economics is paying more attention to obesity. But one could see the argument. Each individual has choices to make every day on whether to eat or not, whether to expend calories or not. It is rational to enjoy a dessert with co-workers, to have a second slice of your mother’s pie, to finish the kid’s sandwich, to reward yourself after a hard day with another glass of wine.( Once, I turned down a favorite aunt’s offer of a big breakfast. She almost never forgave me. Won’t do that again!) A half pound is gained here, another there. The net change in weight comes just gradually, almost below our perception, a result of small steps which make sense at the time.

But eating and exercising are not the only choices people have to make. People spend large parts of their time caring for themselves and others, engaged in self-improvement, volunteering, spending time on family and community projects and, also, relaxing. (See Obesity A-Z – Time studies)

Cassidy notes that in the bridge metaphor, actually The Millennium Bridge in London, engineers, figuring out the problem, installed dozens of shock absorbers.  (If this were about obese people, we probably would blame them for hurting the bridge and tax them for the repairs, then ban them from using it.)

Nevertheless, Cassidy reminds us that with the economic meltdown, “The first step (in fixing the problem) is simply to recognize that they aren’t aberrations, they are the inevitable results of individuals going about their normal business in a relatively unfettered marketplace.”

What are the implications for obesity? Well, much of the educational and prevention activity assumes that people are making the wrong choices and they need guidance and direction, maybe a push, to make right choices. But what if folks feel they are making the right choice? Why change? How can we motivate people who believe that they are doing the right thing…’individuals going about their normal business in a relatively unfettered marketplace?

The End of Summer

October 4th, 2009

September 22, 2009, 5:18 EDT

Thank Goodness. The mean summer of 2009 is finally over. Not only did we see an ugly side of America in the town hall meetings across the country and observe a Congressman insult the President of the United States in a joint session of Congress, it was mean season for persons with obesity.

Alabama has decided to impose a tax on overweight state employees; President Obama’s nominee for Surgeon General was attacked for her weight; the American Medical Association adopted as official policy that persons with obesity should not be eligible for disability payments and the CEO of the Cleveland Clinic, Dr. Toby Cosgrove, told his people to stop hiring overweight persons.

Dr. Cosgrove is a major leader in health care and in the health care reform debate. No doubt he sees the Cleveland Clinic, which already bars smokers from employment, as a leader not only in Cuyahoga County, Ohio but in the nation as well. Good solutions to the obesity epidemic? Make the overweight unemployed so they can’t get health insurance or disability payments if they are disabled? How does a leader like Dr. Cosgrove believe overweight/obese people will live? How will they preserve their families? Pay the rent? Clothe the kids? Not enough people unemployed in Ohio?

As reported by the Cleveland Plain Dealer, Cosgrove is slyly honing his message, trying to tamp down ire from obesity advocates while sending a clear signal to everyone at Cleveland Clinic: the boss doesn’t want to hire fat people. But there is another reason: The Cleveland Clinic is launching a for-profit “wellness” program and this attack on obese people keeps Cosgrove in the limelight. Does Cleveland Clinic’s Toby Cosgrove really hate fat people? : MedCity News Perhaps Dr. Cosgrove’s business strategy is to scare Clevelanders into paying to go to his ‘wellness’ clinic. Cleveland Clinic’s Lifestyle 180 promotes better health through better living | Health and Fitness – cleveland.com – – cleveland.com

Is the Cleveland Clinic plan mere discrimination? Perhaps we underestimate the good Dr. Cosgrove. Perhaps it is just a way to gin up business on the income side while cutting personnel expenses. What great health care reform!

The summer also brought the deaths of two Kennedys – Senator Ted Kennedy and his sister, Eunice Kennedy Shriver. We were in Massachusetts at the time of Eunice’s funeral and watched it on television and then watched Senator Kennedy’s a few weeks later. It doesn’t take much to see how dedicated these two were to the elimination of discrimination in whatever its form…persons with mental illness, persons denied health care, gays, women and the disabled. Senator Kennedy said, “Every American should have the opportunity to receive a quality education, a job that respects their dignity and protects their safety, and health care that does not condemn those whose health is impaired to a lifetime of poverty and lost opportunity.” Ending Segregation and Discrimination Against Disabled Americans | In His Own Words | Edward M. Kennedy

Where Dr. Cosgrove and the AMA would throw the sickest Americans under the bus, the Kennedys would pick them up. We can’t say how the intentional discrimination promoted by the good Dr. Cosgrove will work out. We do know he’s no Ted Kennedy. Thank Goodness the summer is over.

The Markup

October 4th, 2009

September 23, 2009

Watching the Senate Finance Committee markup of the health care reform bill is a fascinating experience…if your eyes don’t glaze over too quickly. For all those who want to see how sausages, err, laws, are made, this is the main show. What I’m looking for is how reform efforts will avoid crashing on the shoals of previous efforts. When I first started lobbying on health care some 30 years ago, an aide to a prominent Senator told me that there are only three things you can do in health care legislation: expand access, improve quality and control costs. But, he stressed: You can only do two of the three in any one piece of legislation.

Jonathan Cohn seems to have it right in his new “Truman Scale” which weighs three variables: expand coverage, cost and quality. Read about it at What Would Harry Do? | The New Republic

The old staffer’s insight has always seemed to me to be right. Previous reformers never seemed to understand its basic wisdom. But it does seem that Senator Baucus and the others are giving it a good try and may actually do it. However, the three principles are not equal. The Democrats are as committed to expanding access as the Republicans are to controlling costs. Both say they want quality care but there frankly isn’t that much of a constituency for quality.

Book Reviews

October 4th, 2009

THE WORLD IS FAT by Barry Popkin (Aver, New York, 2009)

Barry Popkin is a highly respected obesity researcher and professor of Global Nutrition at the University of North Carolina, Chapel Hill. In this book has given us all an insight into his life’s work – understanding the spread of obesity throughout the world.

Popkin’s work is a reader-friendly effort to tackle our persistent, modern problems of obesity: How did we get to this state? What’s the role of the food and beverage industry? What are the influences of evolution and our genes on obesity, as well as food marketing. Specifically, how did the world so quickly change its consumption patterns from long-standing local cuisines to foreign, highly-packaged, highly processed foods. Where other authors have dealt with some of these topics in great detail, Popkin’s humanizes the issues by looking at four typical families in different parts of the world and observe the change in consumption and activity.

His statistics are staggering: the average American drinks sugar-sweetened beverages about 2.5 times a day. More than 450 of a person’s daily calories come from beverages – 40% from soft drinks or fruit juices and 20% from alcohol; a slice of pecan pie, about 500 calories, would take an average adult 2.5 hours of walking or an hour of vigorous aerobics to work off.

Reading Popkin, one wishes for more international studies as countries vary in areas such as TV viewing, food advertisements. He writes, “It isn’t possible to link changes in fast-food intake in these (developing) countries with increases in obesity. However, the shift toward on-the-go eating as opposed to the slower eating of the past is a profound change. The lack of conclusive research on how Western or local fast-food chains are affecting the quantity and quality of food and the overall weight gain is a sharp contrast to the very large number of studies on this topic in the United States.”

The entire world is experiencing what is called “nutritional transition” which involved changes in occupational, lifestyle, transportation as well as nutritional factors. However, there are definite social , cultural, racial and ethnic differences. Disentangling this complex web may well be beyond any one book and it is a shame that international research organizations have not done more to explore these differences. They represent a natural laboratory which is perhaps no longer feasible within the United States because we have so many confounding factors.

This nutritional transition is of nearly unprecedented dimensions, second maybe only to the discovery of cooking or the beginning of agriculture. No wonder Gina Kolata, in her book, Rethinking Thin, The New Science of Weight Loss and the Myths and Realities of Dieting (Farrar, Straus and Giroux, New York, 2007) observed, “Some scientists, including obesity researchers like Jules Hirsch and Jeff Friedman, suggest an intriguing hypothesis. The origin of people’s recent weight gains may have little to do with their current environment or with their willpower or lack of it, or with today’s social customs to snack and eat on the run or with any other popular belief. Instead, they say, we may be a new, heavier human race and our weight may have been set by events that took place very early in life, maybe even prenatally.”

Popkin is active not only in research but in numerous governmental and non-governmental agencies across the globe trying to find strategies to affect global obesity. He offers numerous anecdotes on the efforts of these groups to find solutions. But one comes away with the view of our genetic preferences for sweet and salty foods combining with a vast industrial agricultural process fueled by aggressive and effective marketing creating a tsunami of obesity which is engulfing the world. In the end, one wishes Popkin will go on and explore the development of obesity around the world in even more depth to help us find a way out.

THE EVOLUTION OF OBESITY by Michael. L Power and Jay Schulkin, (Johns Hopkins University Press, Baltimore, 2009)

If Popkin’s book is for the general reader, this tome by Power and Schulkin is for the serious student of evolutionary biology. Popkin gives a chapter to the evolution of the modern diet; these authors give 13. They, senior researchers at the American College of Obstetricians and Gynecologists, take the long view.

Some may wonder why researchers at the home of obstetricians and gynecologists should be addressing obesity. They should not wonder. Body weight is highly regulated to be ‘just right.” Either extreme – underweight or obesity – creates problems for reproduction and survival. As a species, our bodies are interested in surviving to pass on our genes to the next generation and extreme variations in weight impede this genetic imperative.

For those confused about stories on mortality and overweight, the authors clarify that human babies are among the fattest of all mammals and this may have conferred a key support to our survival. Extra fat confers some benefits for mortality but increases other risks. But the authors definitely do not argue that obesity per se was adaptive. They argue, convincingly in my view, that “human obesity is an inappropriate adaptive response to modern living conditions.” And, “Adipose tissue is an endocrine organ whose natural function allows it to greatly increase in size; adipose tissue is meant to be variable. However, the extent of adiposity that is possible in today’s world exceeds the normal adaptive range of endocrine and immune function.”

For those who think that there is a simple answer to obesity …eat less, exercise more…this book will not provide support. The authors note, “Energy intake and energy expenditure are simple concepts in principle but very complex in actual physiology. The simple solution for weight loss, eat fewer calories and expend more, can be very difficult to achieve, for good metabolically adaptive reasons.”

But their main thesis is that fat is important both in our diets and in our bodies which likely arose in order to support the development of larger brains. “This hypothesis, “ they aver, “explains our fat babies, which explains the tendency for women to put on more fat than men do. “

The general reader may find this book too detailed but for the serious student of obesity it is a unique resource of research on every aspect of obesity in both human and animal subjects.

My only problem with the book is that they minimize the chances for drugs to treat obesity given the complexity and redundancy of the biological system to preserve body weight. They note and, given the history of obesity medications it is hard to refute them, that, “ The complexity of an evolved biological system suggests that most simple molecular interventions will have multiple unintended consequences and may trigger compensatory metabolic systems.” Fair enough. But don’t medications for blood pressure control, control of blood glucose or many other drugs have similar complexities to deal with? Why would a drug to decrease excess adiposity seem infeasible when we have several s drugs which increase adiposity? And if bariatric surgery apparently results in long term and significant weight loss without the expected unintended consequences why can’t we find the mechanism and build a drug to do the same thing?

The science is changing so fast in this area that we only hope that this is the first of a series of books allowing us to understand what is happening in our world, and our bodies.

THE END OF OVEREATING by David A. Kessler, MD (Rodale, 2009)

David Kessler’s tenure as the commissioner of the Food and Drug Administration (under Presidents George H.W. Bush and Bill Clinton), where marked by great leadership in the efforts to combat tobacco smoking.

The book should be looked at, as with Caesar’s description of Gaul, as coming in three parts. In the first part, Dr. Kessler explores the evolutionary preference humans have for sweet, fatty and salty foods.

In the second part, he deals with the food industry’s ability to take advantage of these natural likings now part of our brain patterns. The skilled, finely honed marketing machines are derided and blamed for forcing us into what Dr. Kessler calls, “conditioned hypereating” resulting in obesity.

Before you know it, the weight has piled on and your diets have all failed. Just before you throw up your hands in surrender at the nearest Cinnabon, the good Dr. Kessler has a remedy…his trademarked Food Rehab tm diet – the third phase of the book.

On page 207, the good Dr. Kessler states, “The elements of the Food Rehab tm program here have been used and tested in other contexts and still need to be rigorously evaluated for the treatment of “conditioned hypereating. “Nonetheless, I believe they can offer you some help.” The help the Food Rehab tm diet provides is “to change the way you eat.”

Let’s stop here. First, does Dr. Kessler have a reference for ‘tested in other contexts?” Well, no. Even the food companies first test a product in the lab. Shouldn’t a respected physician do the same?

For the statement “change the way you eat,” there is a citation to an abstract by Gary Foster, Ph.D, which states that, “cognitive behavioral therapy achieves about a 10 percent weight loss over twenty to twenty-four weeks with patients regaining one-third of their weight at the one-year mark.” This is left out of the main text. Isn’t this the same failed diets he just decried?

By going down the path of a “new” diet plan, Dr. Kessler has forgone the opportunity to make a real contribution to exert the kind of leadership he showed with smoking for the obesity issue. Many people feel smoking and obesity are parallel conditions and many believe that the tools which were successful in smoking cessation can work in obesity. Others note profound differences between the two problems and doubt that all of the solutions to smoking are likely to work in obesity.

Although he doesn’t know it, Dr. Kessler and I crossed paths on this topic – at least on paper. In 1999, the Internal Revenue Service reversed position and allowed the costs of smoking cessation programs to be deducible as a medical expense. In my position at American Obesity Association, I wrote a letter to the IRS asking that they also reverse their policy on not allowing the costs of weight loss to be deductible which had been issued about the same time as the smoking cessation ruling.

The IRS wrote back and said what evidence they would need to reverse their ruling. But they also said that we could not rely on their smoking cessation ruling because nicotine was addictive and cited an extremely influential study Dr. Kessler had written on the subject. (Kessler, DA, et al, The Legal and Scientific Basis for FDA’s Assertion of Jurisdiction Over Cigarettes and Smokeless Tobacco, JAMA, 1997;277:405-409)

In this paper, Dr. Kessler established that nicotine is a psychoactive (mood-altering) product and that nicotine “plays a role in weight regulation, with substantial evidence demonstrating that cigarette smoking lead to weight loss.” So I told the IRS that, on the basis of this argument, we were not going to argue that eating was addictive, but they could not argue it isn’t. (At the end of the day, we got the IRS to reverse its policy.)

Since then there has been a new research on the brain activity in smoking, obesity and alcohol consumption. Brain serotonin 2A receptor binding: relations to …[Neuroimage. 2009] – PubMed Result. Another study found, in rats, the nicotine exposure prenatally affected endocrine development and led to obesity. Prenatal nicotine exposure alters early pancreatic…[Endocrinology. 2008] – PubMed Result

There are so many questions relating to our understanding of smoking, nicotine addiction and obesity that it is a shame not to have Dr. Kessler’s expertise help lead us out of this quagmire.

CATCHING FIRE: HOW COOKING MADE US HUMAN by Richard Wrangham (Basic Books, New York, 2009)

This brilliant and readable book offers a new hypothesis about evolution of humans and the role of cooking and meal preparation. Wrangham is a professor of biological anthropology and this book shows his facility with the biological evolution of animals in general and primates in particular. More importantly, this book has several important insights into the evolution of obesity.

Briefly, Wrangham argues, pretty successfully in my opinion, that the shift from raw to cooked foods was the key factor in human evolution. Briefly, when early man began using fire, humanity started.

The process he lays out is fascinating. Once Homo Habilis (a chimpanzee like primate) evolved in to Homo Erectus, the species could shrink its digestive system, allowing humans to grow greater brains. Getting the gut to shrink depends on moving from raw food to first pounded meat and then to cooked food which were more pleasurable and digestible. This let early humans to lose tree climbing skills but gain speed in running. Speed in running allowed these first humans to run off predators who quickly overheated because of their body fir. Humans could lose body hair because fire helped them keep warm. Cooking also brought on the division of labor between men and women but promoted male-female bonding, created the household, and even led to the development of nicer people.

There are a couple of interesting aspects of this anthropological view of obesity. Wrangham devotes a fair bit of space to taking on the raw-food advocates. This movement tries to urge people to ‘return’ to the Paleolithic diet which stresses eating raw fruits and vegetables and less grain, beans and potatoes as well are refined or processed foods. Wrangham points out that, in the three studies of raw food consumption, a significant amount of body weight was lost. But there was a price. Constant feeling of hunger was one. The other was such serious energy depletion that fully half of the women in the studies stopped menstruating. Wrangham argues that a primitive society could not have sustained such depletions of energy. Further, he points to studies showing that most animals prefer cooked over raw foods.

Another interesting aspect of the authors work is that soft foods lead to an increase in obesity because fewer calories are burned in the digestive process than is the case with harder foods. (p.77)

He also express support for a more rapid change in evolution than many believe. He notes, “ ..in response to a major change in diet, species tend to exhibit rapid and obvious changes in their anatomy. Animals are superbly adapted to their diets, and over evolutionary time the tight fit between food and anatomy is driven by food rather than by the animal’s characteristics.” (p.89) Later, he cites the Grants studies of finches in the Galapagos to indicate that, if the ecological change is temporary, the changes in the species’ anatomy are also temporary. But if the ecological change is permanent, “the species also changes permanently, and again the transition is fast.” (p.93) (The work of the Grants was brilliantly described in the Pulitzer Prize winning book, “The Beak of the Finch: A Story of Evolution in our Time” by Jonathan Weiner.) He goes on to state, “The adaptive changes brought on by the adoption of cooking would surely have been rapid. “(p.94)

Further, he describes that shrinking the gut increases the size of brain and therefore intelligence. But some animals do not evolve into larger brains. Why? He answers, “Diet provides a major part of the answer…For an inactive person, every fifth meal is eaten solely to power the brain. Literally, our brains use up around 20% of our basal metabolic rate – our energy budget when we are resting – they though they make up only about 2.5 percent of our body weight. “ (p.109)

In his last chapter, Wrangham has some disquieting news for calorie-counters, the foundation of most all weight loss strategies. Wrangham goes through in some detail how Wilbur Olin Atwater came up with the caloric content of protein, fats and carbohydrates and then specific foods. And he documents the refinements in the Atwater system. The formula attributes protein with 4 calories, fats 9 and carbohydrates 4 per gram.

Wrangham spots two problems. First, the Atwater system does not recognize the energy-cost of digestion. Although humans pay less in calories for digestion than other species, it is still significant and can be reduced or increased depending on the food type: protein costs more to digest than carbohydrates and fat has the lowest digestive cost of all. He cites a 1987 study in which people eating a high-fat diet had the same weight gain as others eating almost 5 times the number of calories in carbohydrates. Also, he notes, “ Based on animal studies, we can expect that the costs of digestion are higher for tougher or harder foods than softer foods; for foods with larger rather than smaller particles; for food eaten in single large meals rather then in several small meals; and for food eaten cold rather than hot. Individuals vary too. Lean people tend to have higher costs of digestion than obese people. Whether obesity leads to a low cost of digestion or results from it is unknown. Either way, the variation is important for someone watching his or her weight. For the same number of measured calories, an obese person, having a lower digestive cost, will put on more pounds than a lean person. Life can be unfair.” (p.203) (Thanks doc, we needed that.)

Take away: nutrition scientists know the current calorie information is wrong; but it is too expensive and difficult to fix it. Net for dieters: You’re screwed – even the most rigorous calorie counter is doomed to a high error rate. Wrangham concludes, “The data in standard nutritional tables assume that particle size does not matter and that cooking does nothing to increase the energy value of foods, when abundant evidence shows the opposite to be true…We become fat from eating food that is easy to digest. Calories alone do not tell us what we need to know.”(p.205)

Overall, this is an exciting read. I know of only one other book by anthropologists on obesity (Fat, The Anthropology of an Obsession edited by Don Kulick and Anne Meneley, Jeremy P. Tarcher/Penguin, 2005) . These works show the valuable contributions to obesity we can look forward to from the work of many disciplines.