Obesity

This past Father’s Day I shared some of my childhood photos with my son, including my eighth grade class photo.  The year was 1962.  There were 27 kids in my class, 12 boys and 15 girls.  What struck me was that none of us were overweight.  Some of us were “stocky”, but no one was what we would refer to as fat and none were obese.[1]  According to the CDC, about 4.5% of teens aged 12 – 19 were obese compared to 20% today.[2]  What is most startling is that the percent of teens who are obese doubled in just twenty-five years: in the late 1980s – early 1990s just 10% of teens were obese.

If we want to reminisce about the ‘good ole days’, the biggest difference is that today the majority of Americans are corpulent.  Two-thirds of Americans are either overweight, based on desirable body mass index (BMI), or obese.  Obesity is defined as being about 30 pounds above your BMI and like the data for teenagers, the number of Americans who are obese doubled in a little over two decades to 40%.  However, it’s not just a rise in the percent of teens and adults who are obese that is a concern.  Because the population of the United States has more than doubled in the past 60 years the number of individuals who are obese has increased as a percent of the population and in total numbers: currently 132 million Americans![3] 

Obesity is a major  concern for the health care system because it contributes to a number of health problems and diseases including: Type 2 diabetes, high blood pressure, stroke, heart attack, congestive heart failure, cancer, gallstones, degenerative arthritis, and sleep apnea (which in turn contributes to these diseases).  And being overweight is also believed to be a factor in your response to the COVID19 virus.  As a consequence, health care costs in the United States are higher than in countries with a lower incidence of obesity.

I have been overweight, but not obese much of my life.  I lost about twenty pounds through dieting when I was in college in the late 1960s and then lost even more weight when I was in my early twenties due to an upper respiratory illness.  I had to be hospitalized and the antibiotics I was given totally took away my sense of smell.  I remember that when I was recuperating, they served me a delicious looking steak, but when I took a bite, it tasted like shoe leather!  I’ve been able to maintain a fairly consistent weight most of my life, primarily through exercise and periodically cutting back on sweets, but like all seniors I’ve had the challenge of gaining weight due to a slowing metabolism.  So, personally, I appreciate how difficult it is to lose and maintain a healthy weight.

For much of the past fifty years, being overweight and particularly obese also comes with a social stigma – the assumption that you’re fat because you have no will power.  Being overweight is considered a failure of personal responsibility, e.g. you’re lazy and lack self-control.  However, in response to what is now considered a health crisis, science is beginning to unravel why it is so easy to gain weight and why it is so difficult to lose it. 

Like most things in life, weight gain is influenced by your genes and your environment.  For example, if your parents are overweight, they may have inherited and may pass on genes that influence metabolism, feelings of satiation, tendency to be sedentary, and the tendency for your body to store fat.  Also, through their own eating habits the household you grow up in may contain a lot of foods that contribute to overeating.[4]  The role of genetics in obesity is complex because genes and environment interact to influence weight.  For example, factors in the environment may influence how an inherited characteristic in a gene is expressed.  This doesn’t mean that behaviors influenced by our genes are set in stone, such as a tendency to be sedentary.  Rather, we should be conscious of our behaviors as they relate to weight gain and work to modify them, such as setting aside a specific time to exercise each day.

One of the ways that heredity and metabolism influences weight is based on the calories it takes to lose and maintain a desired lower weight.  Studies indicate that people who diet to lose weight have to eat fewer calories to maintain that weight compared to someone who is naturally at that weight.  For example, a man who weighs 190 pounds may be able to consume about 2200 calories a day and maintain that weight.  But if you got down to 190 pounds by dieting, you may have to limit your consumption to 1800 calories a day to maintain the weight.  Eating fewer calories will increase hunger and thus you’ll not only have a harder time maintaining the weight loss, you’ll likely gain some if not all of the weight back.  Losing weight at a slow rate may help because it allows your metabolism to adjust to the change in caloric intake.  Over time, your body should adjust; however, depending on the amount of calories you’ve had to cut, that may be difficult to do and your body will crave more food, which is why so many dieters gain back some or all of the weight they lost.  Will power helps but is probably not sufficient by itself to help maintain weight loss.

Aging is a natural process and one that also influences weight gain because as we age our metabolism slows down.  Unless we lower our intake of food/calories and/or increase the rate we burn calories we will, inevitably gain weight.  And as we age, we lose muscle tone and the discs in our vertebrae compress, thus we lose some height. So in addition to a few or more extra pounds, we don’t carry that weight in the same way we did when we were younger.

Another biologic factor, lack of sleep, also contributes to declining health by reducing the body’s ability to protect against disease and by reducing production of chemicals that regulate appetite.  Studies indicate that the majority of people who get less than eight hours of sleep on a consistent basis have higher rates of cancer, cardiovascular disease, age related dementia, and diabetes.  Interestingly, they also tend to gain weight.  This makes sense when you realize you spend a third of your life asleep for a reason – it is when your body is restoring itself.  For example, one study found that lack of sleep increased production of ghrelin, a hormone that triggers food craving and also decreased production of the hormone leptin, which helps signal satiation.  Unfortunately, this creates a vicious cycle because a lack of sleep contributes to weight gain and being overweight contributes to a lack of sleep, such as through sleep apnea.[5]

Two environmental factors that have a significant impact on weight gain are our level of activity and the choice of foods available to us.  One of the saving graces for many people during the COVID19 pandemic is that they can work from home.  They can do this because they have an office job, where a computer can connect them to the people and resources they need to complete their work.  However, this signifies that many contemporary professions are sedentary in nature and unless people make the time to move around and commit to a higher level of energy expenditure, they gain weight.  This is especially true of children who spend much of the time sitting in a classroom.

Like most kids I enjoyed candy.  My wife and I like to wax nostalgically about the junk food we had as kids that are no longer (in most cases, thankfully) available to the current generation of youngsters.  For example, there were: chocolate cigarettes (that had a nasty habit of melting all over your hands), pure sugar cigarettes (obviously tobacco manufacturers were trying to hook us early), Mary Jane hard candy with a peanut butter filling (still being made but in my time it didn’t also refer to marijuana), miniature wax bottles with colored sugar water in them, Fizzies tablets (sugary fruit flavored tablets with sodium bicarbonate that when added to water created a carbonated drink), Squirrel Nut Zippers (caramel covered nuts), and an innumerable variety of sugar coated bubble gums. 

So why weren’t kids of my (baby boomer) generation fat?  Back then candy was not something you ate every day.  For 15¢ you could buy a small bag of popcorn and a small cup of soda (not a 12 oz. bottle or can) when you went to the Saturday matinee movie and Halloween was a candy bonanza, but otherwise most homes did not have a lot of what we now consider junk food, including potato chips, taco chips, pretzels and the like.  Additionally, high fructose corn syrup was not introduced into the American diet until 1967.  In fact, much of the increase in the rate of obesity correlates with the increase in the use of high fructose corn syrup in prepared foods[6] and access to foods made with simple carbohydrates, i.e. cookies and pastries.  Not only are these foods high in calories they also activate the pleasure centers in our brain, the same parts of our brain activated by addictive drugs.  And they influence our blood sugars levels, which can create cravings for more sugars.  Consequently, will power alone is often insufficient to fend off signals from the brain seeking another dose of sugar or simple carbohydrates.  

Given the prevalence of obesity in the United States it has at times been called a pandemic.  However, unlike COVID19, which is contagious and spreads quickly, illness and mortality due to obesity is slow and insidious.  It is reflected in the increase in diabetes, cardiovascular disease, and cancer.  Someone who is morbidly obese and dies at a young age probably won’t have obesity listed as the cause of death, rather it will be due to a heart attack.  But obesity will be the underlying cause.

Throughout The Case for Universal Health Care I’ve tried to connect disease with the cost of treatment.  One study funded by the National Institutes of Health found that between 2005 and 2010, “the aggregate costs of obesity in the adult, noninstitutionalized population of the US rose from $212.4 billion to $315.8 billion (both in 2010 dollars), an increase of 48.7 percent; this large increase is due to three factors: (1) an increase in costs per obese individual; (2) an increase in the population, so even if the prevalence of obesity remained constant there would be more obese individuals; (3) an increase in the prevalence of obesity.”[7] 

In response to the obesity epidemic, researchers are trying to understand the biological mechanisms that control hunger, satiation, and the body’s tendency to either gain or lose weight.  It is a complex process involving neurological signals between our gut and brain, organs related to metabolism, and chemicals in our brains.[8]  While this research holds much promise, such as a medication to help us lose and maintain weight, it is still in the future and obesity remains a significant health problem for our country.

Among industrial nations, the United States has the highest rate of obesity, which is one of the reasons our country’s health care costs are also among the highest.[9]  The national health care program I advocate for can address obesity in a number of ways.  For example, it can fund campaigns and initiatives to educate Americans about good food choices and ways to increase levels of activity.  It can pay for comprehensive medical evaluations and provide individual counseling and support, such as referral to a dietitian, sports medicine specialist, or clinician specializing in cognitive behavior theory or mindful mediation.  If necessary, it can pay for gastric bypass surgery.  And perhaps most importantly, a national health care program would expand research funding to address the problem.

Finally, my proposal for universal health care has multiple sources of funding including a tax on goods and services.  The tax on healthy foods is lower than the tax on foods high in sugar, simple carbohydrates, and high fructose corn syrup.  This might curtail consumption of these foods.  This has worked in lowering tobacco use and it might help in changing people’s diets. 

Several years ago I asked a friend, a clinical counselor who teaches mindful meditation and uses mindful meditation in her practice, for information about mindful eating.  In part, it is about savoring what you eat.  It involves eating slowly and thinking about the taste, smell, and texture of the food.  There is scientific evidence that after taking a few bites of food the taste receptors on our tongues are “overwhelmed” and don’t distinguish taste as well as when we took our first bites.  By eating mindfully, we give the taste receptors time to “recharge” which creates two benefits: we enjoy our food more and by eating slowly, it takes less food to feel satiated.  I found that it takes practice and concentration to eat this way, which is why I still struggle at it.  But it does demonstrate that we can change our behaviors and that obesity, while not a failure of will power, is something Americans can and need to address.  The health of a nation is based on the health of its people and right now, with two thirds of Americans overweight or clinically obese, we are not a healthy nation.


[1] As an aside, we were all white.  I attended a Washington D.C. school.  The school system was integrated but the neighborhoods were still segregated.  We had some African-Americans students in our school, but not in my class.  By the time I got to high school, it was fully integrated.

[2] https://www.cdc.gov/nchs/data/hestat/obesity_child_15_16/obesity_child_15_16.htm#table2

[3] https://www.cdc.gov/nchs/data/hus/2018/021.pdf

[4] https://obesitymedicine.org/obesity-and-genetics/

[5] Walker, Matthew (2017).  Why We Sleep.  Scribners.  New York, N.Y.

[6] Over the past 20 years, consumption of high fructose corn syrup has gone down by about 40% as people have become more aware of what they eat and due to switching to foods and beverages made with artificial sugars. 

https://www.statista.com/statistics/328893/per-capita-consumption-of-high-fructose-corn-syrup-in-the-us/

[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5359159/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2710609/

[9] https://worldpopulationreview.com/country-rankings/obesity-rates-by-country

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