Posts Tagged ‘smoking’

Obesity Costs Exceeding Smoking

April 19th, 2012

Researchers at the Mayo Clinic have found significantly higher costs associated with obesity, especially morbid obesity, than smoking. Smokers had average health costs $1,275 higher than non-smokers but the added costs for persons with morbid obesity were $5,500 per year.

Full study appears at:


NIH Disses Physical Activity as Cure of Childhood Obesity

November 23rd, 2011

The National Heart, Lung and Blood Institute has issued guidelines endorsed by the American Academy of Pediatrics. They are directed to all primary pediatric care providers to address the known risk factors of cardiovascular disease, including obesity, blood pressure, cholesterol, tobacco and lipids.

The report notes that longitudinal data on non-white populations are lacking and that “Clinically important differences in prevalence of risk factors exist according to race and gender, particularly with regard to tobacco-use rates, obesity prevalence, hypertension, and dyslipidemia.”

The report notes, “Obesity tracks more strongly than any other risk factor, among many reports from studies that have demonstrated this fact…Tracking data on physical data is more limited.”

Regarding overweight and obesity, the report states,

“The dramatic increases in childhood overweight and obesity in the United States since 1980 are an important public health focus. Despite efforts over the last decade to prevent and control obesity, recent reports from the National Health and Nutrition Examination Survey show sustained high prevalence: 17% of children and adolescents have a BMI at the >95th percentile for age and gender. The presence of obesity in childhood in childhood and adolescence is associated with increased evidence of atherosclerosis at autopsy and of subclinical measures of atherosclerosis on vascular imaging. Because of its strong association with many of the other established risk factors for cardiovascular disease, obesity is even more powerfully correlated with atherosclerosis; this association has been shown for BP, dyslipidemia, and insulin resistance in each of the major pediatric epidemiologic studies. Of all of the risk factors, obesity tracks most strongly from childhood into adult life.”

Given that physical activity is a primary prescription for preventing childhood and adolescent obesity, it is interesting to read what the expert panel has to say about its utility:

“A moderate number of RCTs (randomized controlled clinical trials) have evaluated the effect of interventions that addressed only physical activity and/or sedentary behavior on prevention of overweight and obesity. In a small number of these studies, the intervention was effective. It should be noted that these successful interventions often addressed reduction in sedentary behavior rather than attempts to increase physical activity. In a majority of these studies there was no significant difference in body-size measures. Sample sizes were often small and follow-up was often short (frequently < 6 months). ..Overall, the expert panel concluded that on the basis of the evidence review, increasing activity in isolation is of little benefit in preventing obesity. By contrast, the review suggests that reducing sedentary behavior might be beneficial in preventing the development of obesity.”

The report identifies populations at special risk for obesity: children with a BMI between the 85 and 95th percentiles;children in whom there is a positive family history of obesity in 1 or both parents; early onset of increasing weight; excessive weight gain during adolescence; children who have been very active and become inactive. See Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents- NHLBI, NIH

Will Wal-Mart Hit Overweight Workers Next?

October 21st, 2011

The New York Times reports that Wal-Mart is cutting some health care benefits. Among the changes is a requirement for smokers to pay a substantial penalty…an extra $260 to $2,340 a year…if they want health care coverage. Wal-Mart Cuts Some Health Care Benefits –

The change raises the specter of when this kind of penalty will be applied to persons who are overweight or obese. A major failing of the Affordable Care Act was the ‘Safeway’ provision to allow imposition of such penalties (there called ‘employer incentives’)  on workers whose health metrics did not improve. As the nation’s largest employer, this move by Wal-Mart does not bode well as it could be applied to overweight and obese workers.

Obesity Undercutting Life Expectancy Gains

December 3rd, 2009

A study published December 3, 2009 in the New England Journal of Medicine indicates that the negative effects of the increasing rates of obesity in the US will overwhelm the positive effects of declines in smoking rates. The researchers from Harvard University used multiple scenarios which came to similar conclusions.  The authors believe that life expectancy itself is likely to continue to improve due to improvements in medical care but the improvements will be less rapid than otherwise due to obesity. They conclude, “ Efforts to improve health should focus on stabilization or reversal of trends in BMI, continued reductions in tobacco use, and better control of the clinical risk factors associated with obesity and smoking. Inadequate progress in these areas could result in an erosion of the pattern of steady gains in health observed in the United States since the early 20th Century.” NEJM — Forecasting the Effects of Obesity and Smoking on U.S. Life Expectancy

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, “ 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.

Employer Incentives

September 27th, 2009

Employer Wellness Programs

In recent years, employers, mainly large ones, have developed wellness programs designed to promote healthier lifestyles among their employees while at the same time reducing their health care expenses. Recently, questions have arisen addressing how much of an incentive can an employer provide before it becomes a punitive measure. The National Business Group on Health has proposed as part of health care reform that the tax code be amended so that the expense of the employer-sponsored program is not taxed as income to the employee when provided off-site. Likewise, employees would be able to use their own health spending accounts for fitness and weight management.

Others have sought to change current laws to allow employers to provide significant financial rewards to persons with certain conditions under control or, from the other viewpoint, penalize workers who cannot bring such conditions, under control.

New research from the National Bureau for Economic Research indicates that financial rewards for weight loss simply do not work. Outcomes in a Program that Offers Financial Rewards for Weight Loss

Safeway, for example, has been promoting their plan called Health Measures. This plan gives employees reduction in their insurance premiums if they are, and stay, within certain limits on four medical risk factors: smoking, obesity, blood pressure and cholesterol. Rebates for achieving the goals total nearly $800 for an employee or $1,600 for a family. People who test within the limits get lower health premiums at the outset of the year. An employee who fails the obesity test can get a retroactive payment if he or she loses 10% of his or her body weight by the end of the year. But if the person’s BMI is still over 30 at the beginning of the following year, the payment is withheld until the employee reaches the permanent goal of under a BMI of 30. (See, Bensinger Gail, Corporate Wellness, Safeway style,, accessed May 24, 2009)

Legally, the Safeway program may be pushing the envelope. Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), no person can be denied or charged more for coverage than other similarly situated person (e.g. full time, part time) because of health status, genetic history, evidence of insurability, disability or claims experience. HIPPA “makes it easy for health plans to reward members for participating in health-promotion programs but difficult to reward them for achieving a particular health standard, “ according to Mello and Rosenthal. In one allowable category for wellness programs, employee rewards are based solely on participation. The second category allows rewards based on attainment of a specific standard, such as losing a specific amount of weight, but the financial incentive is limited to less that 20% of the cost of the employee’s coverage. If the person cannot meet the standard if it is unreasonably difficult or medically inadvisable, that person must be offered a reasonable alternative standard. Other federal and state laws also apply to this situation. (Mello MM, Rosenthal MB, Wellness Programs and Lifestyle Discrimination – The Legal Limits, NEJM July 10, 2008; 359: 192-199) Wellness programs and lifestyle discrimination–th…[N Engl J Med. 2008] – PubMed Result

Safeway President Steven Burd has called for overturning the HIPPA 20% rule and the provisions of the Americans with Disabilities Act which prevent companies from being more aggressive about pushing employees reaching specific personal targets.

This is a highly sensitive issue for several reasons:

  1. Obesity is caused by a multitude of factors a few of which are under an individual’s control. By the time a person enters the workforce, the number of fat cells (adipose tissue) has been established and will not change no matter what the intervention, including bariatric surgery. Genetic predisposition and an environment overwhelming favoring the easy availability of food are two extremely strong factors for an individual to try to overcome. Eating and exercise habits are ingrained. It is therefore of some concern that the person who designed the Safeway program, Ken Shaclmut, Senior VP for Strategic Initiatives, indicated, “I want to be clear – we were adamant about designing this program to cover only those things for which our employees had control and which were clearly behavioral in nature. We do not differentiate for genetics and we did everything prospectively and transparently so that everyone had equal opportunity to improve their behaviors.” ( Emphasis added. Accessed May 24, 2009).

A few things about this statement. First, obesity has a strong genetic basis. See, Understanding Obesity.

Second, Mr. Shaclmut may overstate the level of individual control over the three other factors – smoking, blood pressure and cholesterol. What makes these risks controllable has little to do with behavior and more to do with a variety of prescription and over-the-counter drugs for their control. Obesity is, unfortunately, lacking the number and variety of such products.

Three, employers already discriminate against persons with obesity in firing, promotion and hiring decisions. A recent paper addressed 32 experimental studies in weight discrimination in employment. The findings demonstrated that overweight and obese individuals are disadvantaged in workplace interactions, evaluations, and employment outcomes as a result of negative weight stereotypes. (Roehling MV, Pilcher S, Oswald F, Bruce T, The effects of weight bias on job-related outcomes: a meta-analysis of experimental studies. Academy of Management Annual Meeting, Anahiem, CA, 2008 )

Fourth, another recent study for the negative association between BMI and wages is larger in occupations requiring interpersonal skills with presumably more social interactions. This wage penalty increases as employees get older. This study demonstrates that being overweight and obese penalizes the probability of employment across all race and gender groups except for black men and women. (Han E, Norton ED, Stearns SC, Weight and Wages: Fat Versus Lean Paychecks, Health Econ 2009; 18:535-548 Weight and wages: fat versus lean paychecks. [Health Econ. 2009] – PubMed Result)

Fifth, obese employees in firms which provide employer paid health care are paid less than their peers for the same work. This indicates that employers are offsetting the higher health care costs of obese employees with lower wages. Bundorf MK, Bhattacharya J. The Incidence of the Health Care Costs of Obesity, Abstr AcademyHealth Meeting 2004;21: No. 1329. Available at – 17k – 2005-05-02)

Sixth, the difficulties of weight loss and maintenance of weight loss need to be understood. About 1/3 of American adults are engaged in weight loss efforts at any given time. Yet, obesity increases. Why is that? Some dieters do succeed in weight loss but few, 5-10%, manage to keep the weight off over the long term. (See, Freedman MR, King J, Kennedy E, Popular Diets: A Scientific Review. 2001, Obesity Res. 9 Suppl.1: 1S-40S. Popular diets: a scientific review. [Obes Res. 2001] – PubMed Result Maintaining weight loss is extremely difficult. As soon as weight starts to decrease, energy expenditure also drops in obese individuals. Not only is resting metabolic rate decreased; non-resting energy expenditure is also less because less mass is being moved. Take the situation with persons with type 2 diabetes, a common chronic disease highly correlated with obesity. Weight loss in this population is very difficult. Typically, patients lose weight over 4-6 months then plateau. Patients generally lose about 4-10% of their baseline weight. Hypothalamic signals in defense of body weight increase and intervene to prevent further weight loss. This initiates a regain of the lost weight. Neurotransmitters are activated to such an extent that the signal levels of increased hunger and decreased satiety become extremely difficult to ignore. Also, most diabetic patients are on anti-diabetes medications, many of which, like insulin, actually cause weight gain. (See, Pi-Sunyer, FX, Weight Loss in Type 2 Diabetic Patients, Diabetes Care, June 2005, 28;6:1526-7 Weight loss in type 2 diabetic patients. [Diabetes Care. 2005] – PubMed Result )

Seventh, employer wellness programs, as they apply to obesity, are not precisely defined. At present they encompass a variety of approaches and do not have a standardized format. It does appear that they provide advice on nutrition and physical activity and perhaps the ill effects of obesity. As such, they would be similar to the behavioral format used as standard therapy for control groups in randomized clinical trials, usually of pharmacological compounds. Such interventions have not been particularly effective. (See, Poston WS, Haddock CK, Lifestyle Treatments in Randomized Clinical Trials of Pharmacotherapies for Obesity. Obesity Research 2001 9;9:552-563. Lifestyle treatments in randomized clinical trials…[Obes Res. 2001] – PubMed Result) However structured, it is impossible to think that an employer wellness program would be as intense and well-funded as the Diabetes Prevention Program (DPP). In this study over 3,000 non-diabetic persons with elevated fasting and plasma glucose concentrations ( but not diabetes) were assigned to placebo, metformin (a drug to treat diabetes) or an intensive life-style modification program with the goal of at least a 7% weight loss and at least 150 minutes of physical activity per week. “The lifestyle modification intervention reduced the incidence of diabetes by 58% compared to 31% in the metformin group. The advantage of lifestyle intervention over metformin was greater in older persons and those with a lower body-mass index than in younger persons and those with higher body-mass index.” The weight loss difference between the lifestyle group and the metformin group was barely 4 pounds after 4 years. Only 10 million persons in the United States resemble the participants in the DPP. (Diabetes Prevention Program Research Group, Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin, New England Journal of Medicine, 2/7/2002 346:393-403. Reduction in the incidence of type 2 diabetes with…[N Engl J Med. 2002] – PubMed Result)

Eight, employer wellness programs do have adequate evidence of their effectiveness at long term weight loss and maintenance. A CDC Report evaluating such programs reported, “The Task Force determined that insufficient evidence existed to determine the effectiveness of single-component worksite interventions focused on nutrition, physical activity, or other behavioral interventions among adults.” (Katz DL, et al, Public Health Strategies for Preventing and Controlling Overweight and Obesity in School and Worksite Settings, A Report on Recommendations of the Task Force on Community Preventive Services, MMWR, Oct. 7, 2005 Public health strategies for preventing and contro…[MMWR Recomm Rep. 2005] – PubMed Result) More recently, Goetzel and Ozminkowski looked at the health and cost benefits of work site health-promotion programs. Commenting on a 2007 systematic literature review they observed, “Health and productivity outcomes from these interventions were reported from 50 studies qualifying for inclusion in the review. The outcomes included a range of health behaviors, physiologic measurements, and productivity indicators linked to changes in health status. Although many of the changes in these outcomes were small when measured at an individual level, such changes when measured at an individual level were considered substantial.” 38 38 (Goetzel RZ, Ozminkowski RJ, The Health and Cost Benefits of Work Site Health-Promotion Programs. Annu. Rev. Public Health 2008;29:303-23 The health and cost benefits of work site health-p…[Annu Rev Public Health. 2008] – PubMed Result)

Ninth, wellnessand prevention programs also may actually be working at cross purposes. It is not uncommon to see programs stress smoking cessation and weight loss. Rarely, however, do they seem to address the perception that smoking cessation will lead to weight gain. A 1991 study by the Centers for Disease Control published in the New England Journal of Medicine found mean weight gain after smoking cessation was 2.8 kg for men and 3.8 for women. Major weight gain of over 13kg occurred in 9.8% of the men and 13.4% of the women. (Williamson DF, Madans J, Anda RF, Smoking Cessation and severity of weight gain in a national cohort. NEJM, 1991 Mar.14;324 (11):739-45. Smoking cessation and severity of weight gain in a…[N Engl J Med. 1991] – PubMed Result) Smoking creates insulin resistance and is associated with central fat accumulation. As a result, smoking increases the risk of the metabolic syndrome and type 2 diabetes. ( Chiolero A, Consequences of smoking for body weight, body fat …[Am J Clin Nutr. 2008] – PubMed Result ) Weight control advice was not associated with reduction in weight gain after cessation. (See, Parsons AC, Shraim M, Inglis J, Interventions for prevention weight gain after smoking cessation. Cochrane Database Syst. Rev. 2009 Jan. 21;(1):CD006219 Interventions for preventing weight gain after smo…[Cochrane Database Syst Rev. 2009] – PubMed Result

Tenth, to the extent that wellness programs which shift costs to employees create stress, they may actually lead to weight gain. We know that chronic stress is a contributor to obesity and the metabolic syndrome. (See, Kyroou I, Tsigos C Chronic stress, visceral obesity and gonadal dysfunction, Hormones 2008 7(4):287-293. Chronic stress, visceral obesity and gonadal dysfu…[Hormones (Athens). 2008 Oct-Dec] – PubMed Result) Overweight women experience more stressful lives events than normal women. Obese and extremely obese men and women are more likely to report several specific stressful life events and more stressful life events overall compared to normal weight individuals. ( See, Gender differences in associations between stressf…[Prev Med. 2008] – PubMed Result

Twelfth, more punitive employer wellness programs are likely to operate like a tax on overweight employees. Compliance with any weight loss regimen involves both time and money. While employers may bear some of this in their programs, the economic burden is likely to fall mainly on overweight/ obese employees, who have already paid a penalty in their wages for their largely inherited status.

Successful maintainers who have lost at least 30 lbs. for an average of five years expended and average of 1.5 hours a day on exercise and consume less that 1,400-1, 500 calories. (See, Klem, ML, Wing RR, McGuire MT, Seagle HM, Hill JO, A descriptive study of individuals successful at long-term maintenance of substantial weight loss. 1997 Am J Clin Nutr 66;239-246 A descriptive study of individuals successful at l…[Am J Clin Nutr. 1997] – PubMed Result))

A recent collaborative position paper explains the issues of money, place and time stated:

The Role of Money

One hypothesis linking SES variables and childhood obesity is the low cost of widely available energy-dense but nutrient-poor foods. Fast foods, snacks, and soft drinks have all been linked to rising obesity prevalence among children and youth. Fast food consumption, in particular, has been associated with energy-dense diets and to higher energy intake overall. Calorie for calorie, refined grains, added sugars and fats provide inexpensive dietary energy, while more nutrient-dense foods cost more, and the price disparity between the low-nutrient, high-calorie foods and healthier food options continues to grow. Whereas fats and sweets cost only 30% more than 20 years ago, the cost of fresh produce has increased more than 100%. More recent studies in Seattle supermarkets showed that the lowest energy density foods (mostly fresh vegetables and fruit) increased in price by almost 20% over 2 years, whereas the price of energy-dense foods high in sugar and fat remained constant.

Lower cost foods make up a greater proportion of the diet of lower income persons. In U.S. Department of Agriculture (USDA) studies, female recipients of food assistance had more energy-dense diets, consumed fewer vegetables and fruit, and were more likely to be obese. Healthy Eating Index scores are inversely associated with body weight and positively associated with education and income .

The Importance of Place

Knowing the child’s place of residence can provide additional insight into the complex relationships between social and economic resources and obesity prevalence. Area-based SES measures, including poverty levels, property taxes and house values, provide a more objective way to assess the wealth or the relative deprivation of a neighborhood. All these factors affect access to healthy foods and opportunities for physical activity.

Living in high-poverty areas has been associated with higher prevalence of obesity and diabetes in adults, even after controlling for individual education, occupation, and income. In the Harvard Geocoding Study, census tract poverty was a more powerful predictor of health outcomes than was race/ethnicity. Childhood obesity prevalence also varies by geographic location. The California Fitnessgram data showed that higher prevalence of childhood obesity was observed in lower income legislative districts. In Los Angeles, obesity in youth was associated with economic hardship level and park area per capita. Thus, the built environment and disadvantaged areas may contribute in significant ways to childhood obesity.

The Poverty of Time

The loss of manufacturing jobs, the growth of a service economy and the increasing number of women in the labor force have been associated with a dramatic shift in family eating habits, from the decline of the family dinner to the emerging importance of snacks and fast foods. The allocation of time resources by individuals and households depends on socioeconomic status.

The concept of “time poverty” addresses the difficult choices faced by lower income households. When it comes to diet selection, the common tradeoff is between money and time. One illustration of the dilemma is provided by the Thrifty Food Plan (TFP), a recommended diet meeting federal nutrition recommendations at the estimated cost of $27 per person per week. While this price is attractive, it has been estimated that TFP menus would require the commitment of 16 hours of food preparation per week. By contrast, a typical working American woman spends only 6 hours per week, whereas a non-working woman spends 11 hours per week preparing meals . Thus, TFP may provide adequate calories at low cost, but requires an unrealistic investment in time. ( See, Caprio S, Daniels SR, Drewnowski A, Kaufman FR, Palinkas LA, Rosenbloom AL, Schwimmer JB Influence of race, ethinicity, and culture on childhood obesity: implications for prevention and treatment: a consensus statement of Shaping America’s Health and the Obesity Society. Diabetes Care 2008 Nov;31(11):2211-21. Influence of race, ethnicity, and culture on child…[Obesity (Silver Spring). 2008] – PubMed Result)

It is useful to consider that weight management is not the only thing people have to do. Time taken for physical activity and nutritional improvement is going to be time taken away from other activities, such as care for self and others, self-improvement, community activities and volunteering, time with children and family members, and recreation (including television viewing and using a computer/Internet)

Intrusive wellness programs have the potential to interfere with the employees’ right to privacy and complicate the doctor-patient relationship. Under the Safeway plan, for example, an employee can request an exception on recommendation of a physician. To whom the employee can request this is not clear. Nor is it clear under what circumstances the exception would be granted. Look at two common scenarios:

1. The employee has a disease like HIV/AIDs or cancer in which weigh loss is common and his or her physician does not want the employee to lose any weight if they can help it. Would the employee have to reveal this condition?

2. The employee has common diseases like type 2 diabetes or depression. The physician has recommended drugs which actually cause weight gain. Does the employee have to disclose this? What if the employer decides that another medication could be used? Does now the doctor, patient and often managed care plan have to discuss medical alternatives with Human Resources? In other words, will the employees health be endangered by the effort to live a healthy lifestyle?

Who is disadvantaged by employer wellness program? Programs such as Safeway’s may have unintended discriminatory effects. The biometrics used in such programs, to the extent they include obesity, elevated triglycerides and blood pressure, are part of what is known as the metabolic syndrome. Approximately 34% of adults meet the National Cholesterol Education Program’s criteria. Older males and females from 40-59 years of age are about 3 times as likely as those 20-39 to meet the criteria for the metabolic syndrome. Males and females over 60 were more than 4 and 6 times respectively to meet the criteria. Overweight and obese males were 6 and 32 times as likely as normal weight males to the meet the criteria and overweight and obese females were 5 and 17 times as likely to meet the criteria. (See, Ervin RB, Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003-2006. National Health Statistics Reports; No. 13.National Health Statistics metabolic syndrome – PubMed Results )

Therefore, we can expect that such programs deliver little in the way of improvements in individual’s body weight, while having a disproportionate impact on minorities, the elderly and those with serious health conditions. To the extent that these employees see a reduction in their health insurance (possibly to the point of zero if the 20% limitation is totally removed), they will only increase the ranks of the uninsured, thereby frustrating the whole purpose of health care reform.

For further information, see;

Insurance coverage and incentives for weight loss …[Obesity (Silver Spring). 2008] – PubMed Result

Effects of a reimbursement incentive on enrollment…[Obesity (Silver Spring). 2007] – PubMed Result

Worksite Opportunities for Wellness (WOW): Effects…[Prev Med. 2009] – PubMed Result

The Working Healthy Project: a worksite health-pro…[J Occup Environ Med. 1999] – PubMed Result

LEAN Works: About CDC’s LEAN Works | DNPAO | CDC

Public Health Strategies for Preventing and Controlling Overweight and Obesity in School and Worksite Settings </P><P>A Report on Recommendations of the Task Force on Community Preventive Services

Financial incentive-based approaches for weight lo…[JAMA. 2008] – PubMed Result


September 26th, 2009


Research is fundamental to understanding, preventing and treating obesity. And yet research reports are often not accepted by the public or policy-makers. One reason is that almost every adult is their own self-study of weight control. A study might have the most precise protocol, a powerful sample size and control for a variety of factors but if it does not comport with what “I” experience, I am not likely to believe it. But research itself in obesity is not without its difficulties. Many studies are ‘underpowered”, i.e. they have too few subjects to draw a conclusion from. That is why many preliminary studies do not pan out in larger tests. Also, in many cases, especially in drug trials, researchers try to remove “confounders” from the test subjects so they can see if there is an effect of the drug. That means that many patients who are sick, smoke, take other drugs, etc. are excluded from the trial. When the drug, for example, gets used by a more ‘real-world’ sample, the effects sometimes vanish. Studies that rely on self-reported weights or dietary recall or physical activity diaries are sometimes less reliable than studies where a more objective measurement is needed. Self-reported weight and height — Rowland 52 (6): 1125 — American Journal of Clinical Nutrition and COMPARISON OF SELF-REPORTED AND MEASURED HEIGHT AND WEIGHT — PALTA et al. 115 (2): 223 — American Journal of Epidemiology

There also may be a bias from the funding source (See Conflict of Interest in Medical Research, Education, and Practice – Institute of Medicine, Relationship between funding source and conclusion…[PLoS Med. 2007] – PubMed Result, Scope and impact of financial conflicts of interes…[JAMA. 2003 Jan 22-29] – PubMed Result) or a selection of participants which may skew the results one way or another. Currently, there is a lot of concern about ghost written scientific articles. Ghostwriting Widespread in Medical Journals, Study Says –

What’s a reader to do? The first is to read skeptically. The second is to go to several different papers or research articles. If different authors appear to agree upon key points, chances are that they are on to something. Remember, extraordinary claims require extraordinary evidence. Research is a communications process among researchers and it should be thought of as a dialogue to which we can all listen.

Many readers may find useful this site, The Little Handbook of Statistical Practice. It is a handy guide to understanding some of the statistical issues involved…like association is not causation.

Research is key. If you are interested in furthering research, you should look into participating in a clinical research activity. To see what clinical trials are underway in obesity research, see of: Open Studies | “Obesity” – List Results –

A major NIH initiative is support for Obesity and Nutrition Research Centers. In addition to the research they carry out, these centers are critical training facilities for new investigators exploring obesity. Most have their own websites which can provide additional, valuable information. Their sites may provide you with helpful information. Also included are their annual reports.

  1. University of Alabama Nutrition & Obesity Research Center | Nutrition & Obesity Research Center Annual report at
  2. University of Colorado at Denver and Health Science Center. No website. Annual report at
  3. Pennington Biomedical Research Center PBRC – Nutrition Obesity Research Center. Annual report at:
  4. University of Maryland, Annual report at
  5. Boston, MA  Boston Obesity Nutrition Research Center Annual report at:
  6. Harvard,MA,  no website. Annual report at:
  7. University of Minnesota. Minnesota Obesity Center | College of Food, Agricultural and Natural Resource Sciences | University of Minnesota Annual Report at
  8. Washington University, Missouri
  9. Columbia/Cornell, New York, NY Annual Report at:
  10. University of North Carolina at Chapel Hill. No website. Annual report at:
  11. University of Pittsburgh. No web site. Annual Report at:
  12. University of Washington. Annual Report at:


New Studies , updated October 16, 2009

Obesity driven GERD drives up health care visits Trends in Gastroesophageal Reflux Disease as Measu…[Dig Dis Sci. 2009] – PubMed Result

Psychiatrists survey on attitudes to obese patients Psychiatrists’ perceptions and practices in treati…[Acad Psychiatry. 2009 Sep-Oct] – PubMed Result

More evidence for role of FTO gene in obesity via loss of control and selecting diet high in fat The FTO gene rs9939609 obesity-risk allele and los…[Am J Clin Nutr. 2009] – PubMed Result

AHRQ summarizes evidence on breast-feeding, finds reduced risk of obesity, type 2 diabetes A Summary of the Agency for Healthcare Research an…[Breastfeed Med. 2009] – PubMed Result

Weight loss after bariatric surgery may be explained by changes in gut hormones controlling appetite. The Gut Hormone Response Following Roux-en-Y Gastr…[Obes Surg. 2009] – PubMed Result

Inheritance Factors

September 26th, 2009

Genes are not the only way characteristics may be passed from generation to generation. Researchers are actively pursuing what is called epigenetics. Epigenetics refers to changes in appearance, or phenotype, which is not due to changes in the DNA, which regulates genes and their expression.

Intrauterine Environment

The intrauterine environment (the womb) has been shown to affect the child’s disposition to obesity. Fetal origins of obesity. [Obes Res. 2003] – PubMed Result and Programming of body composition by early growth an…[Proc Nutr Soc. 2007] – PubMed Result Maternal and child obesity: the causal link. [Obstet Gynecol Clin North Am. 2009] – PubMed Result Gestational weight gain may predispose offspring to obesity and high blood pressure Associations of gestational weight gain with offsp…[Circulation. 2009] – PubMed Result and Gestational weight gain and risk of overweight in …[Am J Clin Nutr. 2008] – PubMed Result

Multiple factors are probably at work leading to an increased risk of developing obesity. Developmental origins of childhood overweight: pot…[Obesity (Silver Spring). 2008] – PubMed Result and Early determinants of overweight at 4.5 years in a…[Int J Obes (Lond). 2006] – PubMed Result

The question is to what extent the genes or the intrauterine environment influence the progression to adult obesity. The influence of birthweight and intrauterine envi…[Int J Obes Relat Metab Disord. 2003] – PubMed Result

One way in which the fetus might be affected in his or her development is by enhanced nutrition in the womb

Intrauterine changes are thought by some to contribute to the increase in obesity in India. Obesity epidemic in India: intrauterine origins? [Proc Nutr Soc. 2004] – PubMed Result

Maternal weight gain during pregnancy may affect the baby’s birth weight and long term risks Gestational weight gain and child adiposity at age…[Am J Obstet Gynecol. 2007] – PubMed Result

Detrimental influences in the womb, such as smoking Maternal smoking during pregnancy and child overwe…[Int J Obes (Lond). 2008] – PubMed Result, Association of maternal lifestyles including smoki…[Obesity (Silver Spring). 2007] – PubMed Result, Associations of maternal prenatal smoking with chi…[Obes Res. 2005] – PubMed Result, and famine The Dutch Famine of 1944-1945: a pathophysiologica…[Curr Opin Clin Nutr Metab Care. 2006] – PubMed Result or harmful chemicals Developmental exposure to endocrine disruptors and…[Reprod Toxicol. 2007 Apr-May] – PubMed Result and Role of nutrition and environmental endocrine disr…[Mol Cell Endocrinol. 2009] – PubMed Result

An unique, new study found that maternal weight loss from bariatric surgery may improve cardiometabolic  risks in infants which is sustained into adulthood.Effects of Maternal Surgical Weight Loss in Mother…[J Clin Endocrinol Metab. 2009] – PubMed Result


Early infancy

Weight status in the first 6 months of life and ob…[Pediatrics. 2009] – PubMed Result

Predictors of body size in infancy Predictors of body size in the first 2 y of life: …[Int J Obes Relat Metab Disord. 2004] – PubMed Result

Parental feeding styles

Children from obese parents were more likely to have a preference for fatty foods, lower liking for vegetables and a more overeating type eating style than children with lean parents as well as a greater preference for sedentary activities. Food and activity preferences in children of lean …[Int J Obes Relat Metab Disord. 2001] – PubMed Result The picture of the obese mother using food for non-nutritive purposes may be a myth but there obese mothers may exercise less control. Parental feeding style and the inter-generational …[Obes Res. 2002] – PubMed Result Infants of overweight/obese mothers have higher energy intake Relationship between maternal obesity and infant f…[Nutr J. 2005] – PubMed Result Infants born to overweight/obese mothers have lower resting metabolic rate, higher BMI Lower energy expenditures in infants from obese bi…[Nutr J. 2008] – PubMed Result


Breastfeeding has long been considered protective against the development of obesity Association between infant breastfeeding and overw…[JAMA. 2001] – PubMed Result

But not everyone is convinced.Critical review of the World Health Organization’s…[Obes Rev. 2008] – PubMed Result and Breastfeeding and the risk of childhood obesity. [Coll Antropol. 2007] – PubMed Result

How breastfeeding might be protective has not yet been determined. Mechanisms underlying the association between brea…[Int J Pediatr Obes. 2009] – PubMed Result

Overweight/obese mothers may be less likely to breastfeed their children than normal weight mothers. A systematic review of maternal obesity and breast…[BMC Pregnancy Childbirth. 2007] – PubMed Result