Cover Story 2/9/04
Rethinking Weight
Hey, maybe it's not a weakness. Just maybe. . .it's a disease
http://www.usnews.com/usnews/issue/...th/9obesity.htm
By Amanda Spake, US NEWS
Maria Pfisterer has never in her life been skinny. The Arlington, Texas, mother of three was at her slimmest at age 18, when she married Fred, an Air Force sergeant. But she was plump, not seriously fat. She first became seriously overweight at age 21, when she gained about 70 pounds during her first pregnancy. By the time she delivered her daughter Jordan, now 14, she was carrying over 200 pounds on her 5-foot, 2-inch frame.
Over the past 14 years, Pfisterer has tried every weight-loss strategy imaginable: She has taken the (now banned) appetite-suppressing drug combo fen-phen (she lost 60 pounds only to regain it during her second pregnancy). She went on a doctor-prescribed and -supervised low-calorie diet (she lost 10 pounds but regained it). She has been enrolled in Jenny Craig, Weight Watchers, Curves, and a variety of quick-weight-loss fads. All resulted in a little lost and more regained. She has taken antidepressants, reputed to have weight loss as a side effect. They didn't for her. She would love to get into one of those intensive medical weight-loss programs, but she can't afford the $4,000-plus price tag. So she does what she can. "If I lose weight, it seems like I always go back up to that same 197 to 202 range," she says. "I just don't know how to keep it off."
Pfisterer isn't alone. A majority of Americans--now 64 percent--are overweight or obese and struggling to conquer their expanding waistlines before their fat overtakes their health and makes them sick or kills them. At the heart of this obesity epidemic is a debate over whether obesity is a biological "disease" and should be treated like any other life-threatening illness--cancer, heart disease--or whether it is simply a risk factor for those killers. The stakes are high because the answer may determine who gets treated for obesity, what treatments are available, who pays for treatment, and, ultimately, who stays healthy.
New understandings of the biology of obesity are driving the debate. "I think there's enough data now relating to mechanisms of food intake regulation that suggest obesity is a biologically determined process," says Xavier Pi-Sunyer, director of the Obesity Research Center at St. Luke's-Roosevelt Hospital in New York City. And many national and international health organizations--from the National Institutes of Health (NIH) to the World Health Organization--agree. The WHO has listed obesity as a disease in its International Classification of Diseases since 1979. In fact, the organization recently called on member states to adopt programs to encourage a reduction of fat and sugar in the global diet. The recommendation did not sit well with the U.S. food industry or with some within the Bush administration, who still maintain the obesity epidemic can be reversed by individuals taking more personal responsibility and making better lifestyle choices. Many health insurers agree. "For a wide number of people in this country the question is: How do you motivate people to make changes in diet and increase physical activity?" says Susan Pisano of the Health Insurance Association of America.
The reason governments, insurance companies, and others still take such positions, says Pi-Sunyer, is that "they are worried they will have to reimburse doctors and patients for treatment. And now, you have such a huge number of people needing treatment." On any given day, about 29 percent of men and 44 percent of women are trying to lose weight, and presumably a large percentage of those would love to be offered medically supervised treatment if it were covered in their health insurance plan.
Instead, they pay out of pocket for a $33 billion commercial diet industry--and keep getting fatter. The number of people who are severely obese--that is, those with a body mass index of 40 or above or who are more than 100 pounds overweight--is growing two times as fast as is obesity generally. From 1986 to 2000, the prevalence of Americans reporting a BMI of 40 or above quadrupled, from about 1 in 200 adults to 1 in 50. People who are severely obese generally have more weight-related illnesses and require more expensive treatments than do those who are merely "too fat."
Fat's high price. A new study by RTI International and the Centers for Disease Control and Prevention, published this month in the journal Obesity Research, shows that the nation is spending about $75 billion a year on weight-related disease. Type II diabetes, heart disease, hypertension, high cholesterol, gallbladder disease, osteoarthritis merely top the list. Almost 80 percent of obese adults have one of these conditions, and nearly 40 percent have two or more.
Healthcare costs for illnesses resulting from obesity now exceed those related to both smoking and problem drinking. About 325,000 deaths a year are attributed to obesity. The trend lines are only expected to get worse, since childhood obesity is also increasing rapidly (Page 56).
Researchers are encouraged by the stance taken by the WHO and NIH, as well as the American Medical Association, the National Academy of Sciences, and the CDC. Says Yale psychologist Kelly Brownell: "The ramifications could be enormous--for opening up better treatments, and to some extent for social attitudes toward people with this problem. When alcoholism was declared a disease, it changed attitudes and reduced the stigma of blame."
And to be sure, there is no shortage of stigma and blame when it comes to obesity. Weight discrimination dates back to the early Christian church, which included "gluttony" as one of the seven deadly sins. Obesity was viewed as the outward manifestation of the "sin" of overindulgence. Most overweight adults have suffered ridicule, self-consciousness, or depression, particularly if they were obese as children or adolescents. Severely obese patients frequently report workplace discrimination. One woman told researchers: "They put my desk in the back office where no one could see me."
Prejudice against the obese stems from the widely held belief that getting fat--and certainly staying fat--results from a failure of willpower, a condition that could be remedied if obese people simply made a personal choice to eat less. But to most obesity experts this notion of personal choice is downright nutty. "Who would choose to be obese?" asks Rudolph Leibel, a Columbia University geneticist and a noted obesity researcher. "Telling someone they've decided to become obese is like saying, `You've decided to give yourself a brain tumor.' "
Increasingly, researchers are demonstrating that obesity is controlled by a powerful biological system of hormones, proteins, neurotransmitters, and genes that regulate fat storage and body weight and tell the brain when, what, and how much to eat. "This is not debatable," says Louis Aronne, director of the Comprehensive Weight Control Program at New York-Presbyterian Hospital and president-elect of the North American Association for the Study of Obesity. "Once people gain weight, then these biological mechanisms, which we're beginning to understand, develop to prevent people from losing weight. It's not someone fighting `willpower.' The body resists weight loss."
This wonder of natural chemical engineering evolved over centuries to protect humans against famine and assure reproduction of the species. "The idea that nature would leave this system to a matter of `choice' is naive," says Arthur Frank, director of George Washington University's Weight Management Program. "Eating is largely driven by signals from fat tissue, from the gastrointestinal tract, the liver. All those organs are sending information to the brain to eat or not to eat. So, saying to an obese person who wants to lose weight, `All you have to do is eat less,' is like saying to a person suffering from asthma, `All you have to do is breathe better.' "
When Maria Pfisterer looks at her family, she sees her future--and it is frightening. Her father, a diabetic with congestive heart failure and hypertension, weighs nearly 400 pounds, and at age 60 he can scarcely move. Her older sister is also obese and suffers from hypertension. Both Maria and her sister worry they will eventually develop diabetes like their dad.
"My daughter Jordan is very heavy. She's struggling already with weight, and if she gets any more sedentary, I worry what will happen to her," says Pfisterer. "I'm trying to teach her to eat better and keep active. She's into dance, but she'll say, `I'm the fattest kid there.' It breaks my heart."
Pfisterer herself says she does not eat a lot and is always on the go. "I don't eat half gallons of ice cream or bags of chips. But if I lose a little, I regain. I think genetics have a lot to do with it."
Studies of twins. Leibel, director of the division of molecular genetics at Columbia University College of Physicians and Surgeons, has spent a career documenting what Pfisterer knows intuitively. He says, "I believe there are strong genetic factors that determine susceptibility to obesity." Obesity does not result from a single gene, he explains, but rather a variety of genes that interact with environmental influences to increase one's chance of becoming obese. In studies of adult twins, who share many or all of the same genes, BMI, body composition, and other measures of fatness appear to be 20 to 70 percent inherited.
Still, biology is not destiny. Overweight results from one thing: eating more food than one burns in physical activity. Genes simply facilitate becoming fat. "I think the primary problem is on the food intake side," Leibel adds. "There are multiple genes involved in that intake process, and there is good reason to believe that nature and evolution have selected for ingestion of large amounts of food."
But even when limitless food is available, not everyone gets fat. In a series of studies of adult twins in Quebec who ate a high-calorie diet designed to produce weight gain, results between sets of twins were vastly different. Some twin pairs gained three times as much weight and fat as others. "We know there are genetic factors," says Jules Hirsch, professor emeritus at Rockefeller University, "but obesity may be a multistep process." Hirsch says an overabundance of fat cells leading to obesity may be the result of gene-environmental interactions that occur in infancy or in utero, leading to vastly different responses to food in adulthood. The story of the offspring of women who survived the Dutch winter famine of 1944-45 may be a case in point. Babies born to women who suffered severe undernutrition early in their pregnancies tended to have more fat and become obese more readily as adults. But the offspring of women who were undernourished late in pregnancy tended to be leaner and have less fat as adults. Clearly, says Hirsch, there is a great deal more to learn about how obesity develops.
Even scientists who basically accept that obesity is a sophisticated biological problem feel that treatment has to consider the powerful roles of social organization and psychology. Take the case of the bottomless soup bowls.
University of Illinois nutrition and marketing professor Brian Wansink sat student volunteers in front of bowls of tomato soup in his lab and told them they were involved in a "taste test." Some of the students' bowls were normal. The others had bowls that automatically refilled from a hidden tube in the bottom. The students with the bottomless bowls ate an average of about 40 percent more soup before their brain told them they were full. "Biology has made us efficient at storing fat," says Wansink. "But obesity is not just biology; it's psychology. We're not good at tracking how much we eat. So we use cues--we eat until the plate is empty, or the soup is gone, or the TV show is over."
Indeed, research shows that people eat more in groups and with friends than they do when dining alone. Simply eating with one other person increases the average amount eaten at meals by 44 percent. Meals eaten with large groups of friends tend to be longer in duration and are as much as 75 percent bigger that those eaten alone. Eating with someone, suggests John DeCastro, the author of these studies, probably leads to relaxation and a "disinhibition of restraint."
Viewing obesity principally as a biological disease worries Wansink because he fears it will remove personal control and shift blame to someone else. But doctors who treat overweight patients say that thinking of obesity as a disease would simply make more treatment available. Most obesity programs rely on personal responsibility to put into action behavioral techniques designed to achieve greater control over biology. "Most of our treatment is still based on modifying choice," says GWU's Frank. "But underneath it all you've got to recognize why it is so difficult to eat less and lose weight. It doesn't make it easier, but it takes it out of the world of willful misconduct."
Frauds. The biggest dilemma overweight people face is the world of largely mediocre, misleading, useless, or downright dangerous devices, diet programs, supplements, and drugs promoted to reduce fat. "The treatment of obesity is littered with a history of abuses," says NAASO's Aronne. "Every infomercial out there about weight is damaging people because it's giving them an unrealistic view of what can be done." Most university- and hospital-based weight-loss programs produce a 10 percent loss of body weight in six months. This is more than enough to reduce the incidence of Type II diabetes by 58 percent and lower blood pressure in borderline hypertensives. But it is not enough to make a fat person as thin as a Hollywood celebrity. Coverage of obesity by health insurers might bring science and sanity to the chaos of weight loss, where, as Aronne puts it, "ethical treatments are competing in an unethical marketplace."
But clinicians acknowledge that weight-loss successes are modest. "To be frank, a lot of the treatment has not been very effective," says Pi-Sunyer. He points out that there are currently two drugs approved for long-term treatment of obesity, sibutramine and orlistat. Their effect is modest, and their cost is high, about $100 a month. "So for people to pay that amount, they would like to see more impressive results." Two drugs approved for treating epilepsy, topiramate and zonisamide, are being tested to treat obesity, but the jury is still out on them. "So that's an out for the insurers," says Pi-Sunyer. They can say, `Unless you have a treatment that takes weight off and keeps it off, then why pay for it?' It would be a much stronger argument if we had a more proven treatment."
What's standing in the way? Basically funding for research. The American Obesity Association reports that NIH funding for research on obesity is less than one sixth that spent on AIDS. "Given the nature of the problem and the side effects," says Pi-Sunyer, "we're spending a pittance."
The health insurance industry argues that obesity treatments can't be covered because there is no evidence of effectiveness. Critics counter that the same argument could apply to a lot of complicated diseases. "We don't have a good way of treating Alzheimer's disease," says GWU's Frank, "and we don't have a particularly good way of treating AIDS either. We have a health insurance system based on illness, not treatment effectiveness. Why should obesity be the one disease that's subjected to this cost-effectiveness standard?"
About half of the $75 billion yearly price tag for obesity is covered by taxpayers in Medicare and Medicaid funds. These government health plans are debating right now whether the plans should cover obesity treatment. Currently, only in cases of severe obesity will government and some private insurers reimburse doctors for surgery to reduce girth.
But not always. Samantha Moore, a 26-year-old Maine woman who weighs nearly 400 pounds, was recently turned down a third time for gastric bypass surgery. Even though she has been dieting all her life, her insurer denied surgery because she has not made enough "medically supervised" attempts at weight loss. Does the insurer pay for medically supervised weight loss? "No," says Moore. "It's shocking to me that the insurance company keeps saying, essentially, `You're not sick enough to get this surgery.' I think they're putting off a decision because if I wait much longer, I'll be too sick to get the surgery."
Fat or fit? Not all scientists agree that labeling obesity "a disease" will improve the situation for people like Pfisterer or Moore. Stephen Ball, an exercise physiologist at the University of Missouri, says, "If we call obesity a disease, then anything that reduces one's fatness or lowers BMI would be a successful treatment, such as liposuction or a very low-calorie diet, where we know these are not healthy. By the same token, if you don't lose weight with an exercise program but your blood glucose becomes normal, cholesterol improves, then that could be considered a failure, because it didn't reduce weight. Fitness is a more important indicator of health outcomes than fatness."
Indeed, Steven Blair at the Cooper Institute in Dallas has shown that cardiovascular fitness as measured on a treadmill test is a better predictor of mortality and illness than BMI. "I'm convinced . . . that people who are active or fit but in a high BMI group have lower death rates from all causes--cancer, heart disease, diabetes--than the sedentary and unfit in the normal or lean BMI category. Even among women in our study with BMIs of 37, 20 percent did well enough on the treadmill test to be considered fit. We're obsessed with weight, but where has that gotten us?"
Ultimately, if better and more accessible treatments are not offered to obese Americans, the cost not only of obesity but of treatment and health insurance will escalate. The number of people undergoing surgery doubled from 2001 to 2003, in part because people are becoming more obese but also because many want medical help with weight loss and can't find any other treatment health insurers will cover.
Frustrated with her options and limited ability to pay for treatment, about six months ago Maria Pfisterer began to explore the possibility of gastric bypass surgery. She is not 100 pounds overweight, and her BMI is not over 40--generally the criteria physicians use for evaluating candidates who would benefit from surgery. Gastric bypass surgery is an irreversible procedure in which the size of the stomach is reduced and the small intestine is bypassed to produce rapid weight loss in people whose fat is putting their lives in danger. Recovery is long, complication rates are high, side effects are bothersome, and it's major surgery--people die from it. But Pfisterer learned through obesity-help.com, a Web site offering advice to the obese, that her insurer might pay for surgery, given her family history.
"For people like me, who are considered on the low end for surgery, there are other options that might be better," she says. "But I can't take advantage of them unless health insurance starts to pay for them."
US News: "Rethinking Weight"
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