COVER

THE OBESITY EPIDEMIC

About half of all adult Canadians are overweight or obese—and the bill for treating the resulting diseases comes to an estimated $15 billion a year

MARK NICHOLS January 11 1999
COVER

THE OBESITY EPIDEMIC

About half of all adult Canadians are overweight or obese—and the bill for treating the resulting diseases comes to an estimated $15 billion a year

MARK NICHOLS January 11 1999

THE OBESITY EPIDEMIC

COVER

About half of all adult Canadians are overweight or obese—and the bill for treating the resulting diseases comes to an estimated $15 billion a year

MARK NICHOLS

CHRISTINE BLYTHE HAS been overweight for much of her life. For many years, she says, she shrugged off sneers and insults and accepted the fact that she had a hard time finding jobs because few employers wanted to hire a fat person. Now, Blythe, who lives in Trenton, Ont., where her husband, Mark, is an airframe technician at the Canadian Forces base, runs her own secretarial and desktop publishing business. And she weighs more than she ever has—Blythe guesses she is carrying more than 225 lb. on her five-foot frame, but does not know the exact figure because she has stopped weighing herself. And she has run out of patience with the jibes. The reason: her children, Erin, 6, and four-year-old Stuart, are taking the heat—other kids and even their parents ridicule the Blythes be cause of their mother’s size. “I’m always having to explain and excuse my weight to my children,” she says. So instead of accepting the slurs, Blythe, 39, has taken to confronting adults and children about their attitudes. “I think I’m OK the way I am, and my children have a lot to be proud of in their mother,” she says, “if only society would let them see beyond my physical size.”

Angry though she is, Blythe is also bemused by the fact that she is scorned for her size in a world where being overweight is an increasingly common condition. Health officials point with alarm to an epidemic of obesity they say is sweeping the world’s industrialized nations. Though international data are sketchy, Canada appears to have one of the worst problems—along with the United States and Britain—with about half the population weighing too much. The ranks of the overweight include a distressingly large number of chubby children, with statistics showing that obesity among young people is growing even faster than in adults.

And physicians warn that the growing ranks of overweight and obese Canadians carry a costly price tag. Treating a formidable array of obesity-related medical problems, experts say, costs somewhere in the region of $15 billion a year. “We are facing an epidemic of gigantic proportions,” says Claude Bouchard, an obesity expert at Quebec City’s Laval University, who estimates that obesity may be the underlying cause of one out of every five deaths in Canada. Health officials estimate that obesity causes at least three-quarters of diabetes cases, and a third of cardiovascular problems, including many strokes. In fact, U.S. researchers say the seriously overweight have a 75-per-cent greater risk of having strokes than those of normal weight. Being overweight can also \ lead to numerous other problems including gall I bladder disease and joint problems (page 57).

7 To combat the growing public health problem I posed by obesity, a group of experts plans to inauÉ gurate a Canadian obesity network in March, linking

doctors and medical organizations. The goal, says Dr. David Lau, chief of endocrinology and metabolism at The Ottawa Hospital, is “to mobilize health professionals and ordinary Canadians to begin fighting this expensive and expanding problem.”

Faced with the gloomy news from their bathroom scales—and chiding from their physicians—Canadians are sweating in gyms and signing up for weight-loss programs, or at least trying to abide by New Year’s resolutions to do something about their weight. But a survey suggests that while close to half of North Americans vow each year to lose weight or change their eating habits, only 14 per cent keep to their resolutions through the year. A random survey of 1,000 adults by TOPS (for Take off Pounds Sensibly) Club, Inc., a Milwaukee-based non-profit support organization, found that about 59 per cent of women make weight-related resolutions, compared with 32 per cent of men, but that men are more likely to follow through. Meanwhile, many of the overweight turn to self-help organizations such as Overeaters Anonymous, gathering regularly to share their feelings of being powerless in the presence of food. Some of the fleshiest are desperate enough to try extreme solutions, including costly liposuction procedures that vacuum unwanted fat from bloated bodies (page 60).

Some people of size are waging a different kind of war—campaigning against the bigotry they say fat people routinely encounter in North American society (page 62). Heléna Spring, head of the Torontobased Canadian Association for Size Acceptance, says her group—which has attracted a membership of about 500 since its founding last October—wants to make Canadians more tolerant of fat people. “I’ve had total strangers grab things out of my supermarket cart,” says Spring, who will not give her current weight but says she once tipped the scales at nearly 400 lb. “They tell me: You don’t need this— you’re too fat.’ ”

Sally Smith, executive director of CASA’s much larger American counterpart, the 29-year-old Sacramento, Calif.-based National Association to Advance Fat Acceptance, argues that negative attitudes towards fat people are fostered by North America’s $55billion-a-year weight-loss industry and by ubiquitous images in the media of pencil-slim women and washboardbellied men. “We’re tired of being discriminated against,” says Smith, who says she weighs about 350 lb. ‘We feel we should be accorded the same dignity as average-sized people.”

These days, surveys show, “average” in Canada means overweight. Separate polls published in 1997 by Health Canada and the Toronto-based research firm Pollara showed that more than half of adult Canadians are overweight. Many are close enough to an ideal weight that they can deal with the problem with a little extra effort to eat well and keep active. But many others are facing a much more difficult challenge.

Health risks

Being overweight or obese can lead to serious medical and psychological consequences,including:

• DIABETES

• HEART DISEASE

• HIGH BLOOD PRESSURE « STROKE

• RESPIRATORY PROBLEMS

• GALLSTONES

(especially in women)

« OSTEOARTHRITIS

• CANCER

prostate and colon in men; breast, endometrial, ovarian and gall bladder in women.

• PSYCHOLOGICAL RISKS

depression, social isolation, low self-esteem.

Defining degrees of fatness in terms of the Body Mass Index, a widely used computation based on height and weight, the drug company-sponsored Pollara survey—which was based on more up-to-date data than Health Canada’s—found that while 17 per cent of Canadians were merely overweight, 29 per cent were obese (above 167 lb. for anyone at a height of five feet, six inches) and five per cent severely obese (216 lb. or more).

The numbers are borne out by what Canadian physicians see daily in their offices. “Between 30 and 50 per cent of my patients are overweight or obese,” says Oshawa, Ont., general practitioner Dr. Paul Whitsitt. “And I see the complications that come with being overweight.” Whitsitt estimates that perhaps 80 per cent of patients suffering from Type II diabetes, a slow-developing form of the disease that usually strikes people over 40 and often can be controlled without insulin injections, are too fat.

Why are so many people packing on pounds? Most experts blame the sedentary habits and high-calorie diets prevalent in industrialized nations—or as Dr. David Jenkins, a University of Toronto professor of medicine and nutrition sciences, puts it, “sloth and gluttony.” Much of the problem stems from the

The body is designed to store fat for periods of scarcity

ATTITUDES TOWARDS SIZE: Blythe with her son, Stuart, and her daughter, Erin (top); Birmingham in his St. Paul’s Hospital office holding a plastic model of a pound of fat

fact that modern humans are equipped with biological systems adapted for survival in the feast-or-famine world of humankind’s hunter-gatherer forebears. Cells in nearly every part of the body are designed specifically to store fat as an energy source for periods of scarcity—when their owner overeats, fat cells can swell to many times their normal size. Overweight and obesity problems develop when the body consistently consumes too much fuel in the form of food for the amount of energy expended. And it matters what kind of food is consumed: because it takes less effort for the body to store energy from fat, a gram of it counts for nine calories, compared with only four calories per gram of carbohydrates or proteins.

According to Bouchard, an exercise physiologist who has become an internationally recognized authority on obesity, physical inactivity is probably the single most important part of the equation. Abundant food supplies and urban lifestyles built around cars and transit systems, elevators and escalators are at the core of the crisis. “Mankind’s war on muscular effort over the centuries has been largely won,” says Bouchard. “Most of us expend about 300 to 400 fewer calories in energy output each day than we did half a century ago.”

Rather than urging patients to go in for rigorous dieting, the mantra of doctors and obesity experts today is lifestyle change built around moderate eating habits and a stepped-up level of physical activity. “It’s fundamental that we don’t put people on diets as such,” says Dr. Laird Birmingham, an internist who

runs a weight-loss clinic at Vancouver’s St. Paul’s Hospital. “We want people to eat three meals a day and a couple of snacks—with the emphasis on moderate quantities, low-fat food and plenty of fruit and vegetables. Eating is a learned behaviour, and if you can change your eating habits for a few weeks, the body will adapt.” As for exercise, while doctors encourage patients to stay fit with regular workouts, they also make the point that even light exercise can help to control weight. “I ask patients to aim at 30 minutes of increased physical activity a day,” says Whitsitt, “which they can get in ordinary ways— climbing stairs instead of taking the elevator, working in the garden, walking to work instead of driving.” The moderate approach centred on lifestyle changes rather than draconian diets is shared by most commercial weight-loss businesses. “There’s no magic bullet,” says Marguerite Neri, general manager for southern Ontario at Weight Watchers, a Woodbury, N.Y.-based chain that has about 40,000 paid-up members who attend weekly meetings across Canada. ‘We try to get people to eat balanced meals, cut down on fatty foods and be more active, by walking more or riding bikes. You don’t have to go to a gym.” (Average cost for a six-month Weight Watchers program: about $350.) Jenny Craig, another U.S.-based chain with about 30 outlets in Canada, follows a similar weight-loss recipe, but adds another ingredient: clients can buy their food from Jenny Craig, paying around $72 a week for packaged and frozen low-fat, low-calorie meals.

The scheme worked for Doris Barkley, a Vancouver insurance consultant. Barkley had been battling weight problems for most of her life, but it was during the early 1990s, when a job promotion increased on-the-job stresses, that her weight really took off. “When I’m stressed or angry,” she says, “I tend to reach for food.” For years, Barkley avoided weighing herself. But she learned the nasty truth in April, 1995, when she signed on with Jenny Craig. “I weighed in at 263V2 lb.,” she recalls. Since then, Barkley says she has become more physically active than she ever was before, and she eats a good deal less. Now a relatively svelte 171 lb. on a five-foot, five-inch frame, Barkley, 53, hopes to lose another 10 lb.—and is determined not to become severely obese again. “If I’m not vigilant,” she broods, “all that weight could come back again—and I don’t ever want that to happen.”

The fact remains that for many people, attempts to get rid of unwanted weight seem doomed to failure—or, at best, a temporary improvement that soon disappears. The problem, experts explain, is that even the most user-friendly weightcontrol systems result in the body getting fewer calories than it is accustomed to—and it reacts by slowing its metabolic activities to save energy. When that happens, weight loss levels out—and, in despair or disgust, many people go back to their old eating habits. It happened to Laura (not her real name), a 36-year-old Halifax mother of two who has struggled with weight since high school. During the early 1990s, Laura relates, she repeatedly joined a weight-control program and each time lost between 10 and 15 lb. before succumbing to food cravings. “It’s like someone who’s decided to break off an affair,” she says, “but you think you can go back once a month for a quickie.” For Laura, each lapse led to another weight gain. Now, the five-foot, five-inch woman, who regards herself as a compulsive eater, weighs about 180 lb.

For many of the overweight, diets based on severe calorie restriction lead inexorably to the yo-yo cycles of shedding and regaining pounds. “We think of dieting as the first step towards an eating disorder” such as bulimia or anorexia, says Margaret

WEIGHT AND HEALTH

Most physicians today are aware of the serious medical problems that can result from being overweight. But it was different a generation ago. Dr. James Brooks, a general practitioner in Toronto, recalls that when he was a medical student in the 1960s, “We weren’t taught very much about weight control and obesity.” Even so, he adds, a doctor of that period confronted by a seriously obese patient might be alarmed. In which case, the physician could consult a set of tables distributed by the Metropolitan Life Insurance Company, which set out desirable weights for men and women based on actuarial data on mortality. MetLife still publishes the tables, but doctors are now equipped with more sophisticated ways of assessing healthy weights. The current guidelines are based on the Body Mass Index, a system originally developed by Belgian statistician and astronomer Adolphe Quételet in the 1840s. Adopted by Health Canada as a national standard in 1988, the BMI uses a simple calculation of weight and height to arrive at a desirable weight range for each individual—and points to the health risks that can come with unacceptably high weights.

Some experts argue that doctors need to look beyond the BMI. Because abdominal fat concentrations can increase the risk of diabetes and heart disease, says Jean-Pierre Després, a researcher and professor of nutrition and medicine at Quebec City’s Laval University, physicians should check waistlines. For men and women under 40, he adds, a waist measurement of 39 inches or more, regardless of height, can indicate a significant fat accumulation. Although it is natural for abdominal fat to increase with age, adds Després, people should try to prevent that from happening. “It is bad news,” he says, “when your waistline goes up over time.”

USING THE BMI CHART

The Body Mass Index uses height and weight to de termine how close a person is to a desirable weight. Extend a straight line from your height through your weight and into the BMI column. The results:

30 AND OVER You may be at risk of serious weight related problems.

BETWEEN 25 AND 30 You may be at some risk of weight-related problems.

BEWJEEN 20 AND 25 You are in the ideal zone for good health. A BMI under 20 can be linked to health risks.

Beck, acting director of the Torontobased National Eating Disorder Association, “because they create such a physical and mental preoccupation with eating.” And there is some evidence, says Donna Ciliska, an associate professor of nursing at McMaster University in Hamilton, that yo-yo dieting can sometimes permanently turn down the body’s metabolic rate so that fewer calories are burned, “and you actually wind up heavier than when you started.”

Dr. Moe Lerner, a Winnipeg physician who specializes in emergency and family medicine, thinks the psychological profile of many fat people makes it difficult for them to slim down. “All their lives,” he says, “fat people feel that they are physically and emotionally starving. I don’t think anyone who is obese enjoys food, but they need it.” Lerner, 45, has had plenty of experience with obesity: as a lonely medical student at the University of Manitoba during the 1970s, he began gaining weight and currently carries about 450 lb. on his six-foot frame. A frequent talkshow guest and something of a celebrity in North American obesity circles, Lerner is skeptical of medical theories about obesity. “It’s all very well to talk about lifestyle changes,” he says. “But 95 per cent of those who lose weight wind up putting it on again.”

Most orthodox physicians are similarly unimpressed by the current crop of fad diets trumpeted in best-selling books like Sugar Busters! and Mastering the Zone, which point to carbohydrates as a dangerous source of insulin-raising sugar and extol high-protein diets built around meat and animal fats. Such diets, says Toronto’s Jenkins, may help some people lose weight, but they fly in the face of evidence that diets rich in fruit and vegetables promote good health. “There is very good data showing that eating fruit and vegetables correlates with less heart disease, diabetes and some types of cancer,” he says. “But where are the long-term studies showing that meat can do that? I haven’t seen any.”

For some people, a propensity for putting on weight comes with their genetic inheritance. Doctors estimate that only a fraction of one per cent of the obese are afflicted by any of 30 or so rare genetic diseases, including several that result in mental and behavioural problems, along with obesity. Scientists also suspect that some fat people have mutations of genes connected with the hormone leptin and its receptor, which play a crucial role in obesity control. But last year, a research team under Bouchard turned up another genetic problem that may affect up to 40 per cent of Canadians. The problem crops up in a gene that is needed for the functioning of the hormone cortisol, which helps control the body’s energy balance.

People who inherit flawed copies of the gene, but eat moderately and keep active, will probably not be greatly affected. But among those who

eat too much and exercise too little, the faulty gene ca speed fat accumulation, particularly in the abdominal are; As it happens, many experts regard waistline fat as th most dangerous kind. Jean-Pierre Després, another Lav; researcher, says that an overly fleshy belly, by channellin too much fat into the liver, can increase the risk of cardie vascular disease and diabetes.

Some physicians believe that many of the obese nee pharmaceutical help. Yet effective anti-obesity drugs hav been in short supply since Redux and Pondimin, key ir gredients in the appetite-depressing “fen-phen” drug con bination, were pulled off the market in the fall of 1997 afte doctors linked them to potentially fatal heart problem; Fen-phen became wildly popular in the mid-1990s, wit! North American doctors writing millions of prescription for Redux (dexfenfluramine) or Pondimin (fenfluramine « along with the amphetamine-like drug phentermine. Thei withdrawal leaves no prescription weight-loss drugs on th

4 Canadian market. Proponents of natural remedies say th; g some herbal products, such as ephedrine, a plant extrae

5 that reputedly can stem hunger pangs, can help.

I Now, new drugs are on the horizon, including Meridi; 1 a Prozac-like appetite control capsule that has been aval ® able in the United States for over a year, but has yet to wii I approval from Health Canada. Another promising medic; Ö tion is awaiting clearance by U.S. and Canadian regulator;

All their lives, fat people feel that they are physically and emotionally starving'

THE RISKS AND FALLACIES OF DIETING: Lerner in his Winnipeg office (top); Ciliska in Hamilton

orlistat, a drug designed to prevent the body from brea! ing down and absorbing fat. Clinical studies in Europe showed that participants lost 10 per cent of body weigh after using orlistat for a year. The drug can have nast side-effects in the form of abdominal pains and oil; stools—but some doctors think those very qualities wii help to keep people who use the drug from eating fatt foods, which make those problem worse.

In another approach, U.S. researchers are trying to de termine whether leptin injections can help take of pounds. Because fat people develop resistance to the hoi Î mone—which signals the brain about the state of th d body’s fat reserves—researchers reasoned that a leptii J boost might make them less prone to overeating. In trial £ involving 127 obese and slim patients, doctors reporta I that some—but not all—obese patients who had daily lep g tin injections lost up to 40 lb. over a six-month period.

5 A pill to cure obesity is the kind of thing Arlene Lind, aí Edmonton hospital receptionist, dreams about. “I’ve tried pretty wel every diet there ever was,” she laments. “I’ve lost weight and then pu it on again dozens of times.” She has tried drugs and even intestina bypass surgery. But despite all her efforts, the five-foot, four-inch Lint now weighs about 180 lb. “I still keep thinking I’ll find a way someda; to lose weight,” she says. But in the meantime, she has reluctanti; come to terms with her size. Like Christine Blythe and other ovei weight women, she resents “being snubbed by people who feel supe rior to me—I’d like to give them a swift kick.” But she is no longe struggling to get slim. “I’m just trying to enjoy life,” she says, “and kee] my weight stable—that would be an accomplishment in itself.” And ; worthwhile first step for the growing number of Canadians who kee] piling on unwanted pounds.

With SHAUNEMacKINLAYin Halifax

SHAUNE MacKINLAY