Weighing In On Obesity

January 1, 2006 by Natalie Salat

ILLUSTRATION: Bernadette Lau

ILLUSTRATION: Bernadette Lau

Tammy Noble had tried every diet and weight loss method under the sun, including Weight Watchers, the Atkins Diet and Dr. Phil’s Ultimate Weight Solution, only to find that, after losing 10 or 20 pounds, “I’d gain it back, and then some.”Since beginning this cycle of dieting in her late teens, she edged up to 250 pounds by her late 20s. At more than 100 pounds over what was considered a healthy weight for her, Noble was “morbidly obese,” a category she did not want to belong to, not least because of the health risks. “I finally just said, ‘I have to do something.'”

Last August, on her 30th birthday, Noble went through with a drastic measure: gastric bypass surgery. “I knew that having bariatric surgery wasn’t like a magic potion, but it was the tool I needed to be able to take the weight off and keep it off.” Just two months after the procedure, she was down to 208.5 pounds and back at work as a customer service representative for Chrysler. As she acknowledges, the surgery is not a quick fix. And, once done, it requires a lifelong commitment, with careful attention to nutrition and regular exercise. As her stomach has been reduced to an egg-sized pouch, the most she can eat at one time is a cupful of food. If she eats any more, or surpasses her limit of two grams of added sugar at a sitting, she will feel sick.

Fortunately, Noble says, there are plenty of food options out there. And, she has a partner with whom to share the journey to a healthy lifestyle. Her husband, Adam, had bariatric surgery two weeks after she did.

The Nobles are by no means alone in their battle of the bulge. As a population, Canadians have hit critical mass, literally and figuratively. You do not need statistics to see that obesity has become much more common from coast to coast–you only need to visit the local mall. Meanwhile, defining obesity among seniors is more complicated, partly due to the fact that up until now the risks of obesity among this growing segment of society have not been studied nearly enough.

Overall, as of 2004, 23 per cent of the Canadian adult population is obese, up from the 14 per cent noted in a 1978-79 survey. The new percentage translates into 5.5 million people aged 18 or older. What is more, 60 per cent of Canadian adults are in a weight range that “increases their risk of developing health problems,” according to the survey. Childhood obesity has tripled since the 1970s. And obesity among the aboriginal population is much higher than the norm.

How did we get from there to here? “For the amount that we move, we eat way too much and not particularly well,” observes Dr. Mark Tremblay, a professor of exercise physiology at the University of Saskatchewan and the senior scientific adviser for health measurement at Statistics Canada. He also notes that our genetic makeup, which is geared to help us survive periods of starvation, also works against us in an environment where there is a fast food outlet or doughnut shop on every corner.

On the plus side, our plus sizes have started to shift momentum towards doing something about obesity. The federal, provincial and territorial governments have begun throwing resources into research and prevention, with efforts on both nutrition and physical activity. In July, Health Minister Ujjal Dosanjh and public health minister Carolyn Bennett “reaffirmed” the government’s commitment to combat rising obesity levels.

“There’s no question we have to do a better job in making the healthier choices the easier choices,” says Bennett, who was a family doctor before entering politics. “If we don’t do something, (this) will be the first generation of children who do not outlive their parents,” she adds, quoting the Ontario Medical Association’s report on childhood obesity: An Ounce of Prevention or A Ton of Trouble.

Recognizing that factors such as poverty and availability of fruits and vegetables play a major role, Bennett says the federal Public Health Agency, which was established in 2004, is working with provincial and territorial governments as well as other federal departments to turn the tide towards healthy living. She points to the $300 million the government included in the 2005 budget.

Examples of past, present and future efforts include Health Canada’s nutrition labelling regulations for food packaging, Action Schools B.C.–a program to make regular physical activity and nutritious eating habits part of children’s lives–and Drop the Pop, a campaign across the three territories to encourage people to reduce their intake of empty calories in soft drinks.

Health Canada is reviewing its soon-to-be released Canada’s Food Guide to Healthy Eating. The 1992 guide–with the rainbow design–has been criticized for bowing to the food industry and encouraging overeating with its increased number of food servings over the 1982 guide. “Canada suffers from exactly the same kind of lobbying pressures we do,” says Dr. Marion Nestle, the renowned New York City-based nutrition advocate. “It certainly did in the creation of the original rainbow graphic.”

However, Nestle says there has been a “huge change” in action and attitude in the last couple of years since the publication of her book and the popularity of documentaries such as Supersize Me. “Almost every food company is scrambling madly to try to make its products look healthy. Some of them have even examined their marketing practices. On the consumer side, there’s a huge grassroots movement to try to do something about this.”

While acknowledging that her own advice–“eat less, move more, eat more fruits and vegetables and don’t smoke”–is not very sexy, Nestle has no time for fad diets. “Well, they always have a grain of scientific truth to them–almost all of them. I think people are desperate for a way not to have to stop whatever it is they’re doing. Most people I know who are overweight don’t think they eat that much.” She points to the gigantic portions of food North Americans have become used to as one of the causes of our girth.

But not all girth is created equally. It is not so much the extra pounds as their location on the body that are important, explains Dr. Arya Sharma, a professor at McMaster University in Hamilton, Ont., and the head of the city’s obesity clinic at Hamilton General Hospital.

The traditional definition of overweight and obesity is based on the Body Mass Index. To determine your BMI, take your weight in kilograms and then divide it by the answer you get when you multiply your height by your height in metres. Weight ÷ (height x height). According to this definition, you are overweight if you have a BMI of 25 and over, and obese if you have a BMI of 30 and above. But, says Sharma, “The problem with that definition is that…it doesn’t give you two important pieces of information: How much fat there really is in your body and the location of that fat.”

He gives the example of a hockey player with a BMI of 35 and a body fat percentage of 10 per cent. “Obviously, he’s not obese because he’s a chunk of muscle.”

More critical than weight, is waist circumference and the measure of abdominal obesity. For women, a waist circumference of 88 centimetres or 34.3 inches or more is considered a health risk. For men, the crucial measure is 102 centimetres or 39.7 inches. “People with abdominal obesity also tend to store fat in other organs, including the liver, the heart, pancreas and the muscle. (This) storage of fat might be causing all the problems,” says Sharma.

And what are those problems? “Type 2 (adult-onset) diabetes, abnormalities in their fat metabolism that increase levels of bad (artery-clogging) cholesterol, lower levels of good cholesterol, increase blood pressure.” Besides putting people at risk for cardiovascular disease and ailments such as osteoarthritis and certain cancers, Sharma adds psychosocial problems and diminished quality of life to the effects of bearing excess weight. This is especially true for the 2.7 per cent of Canadians who are morbidly obese. “There’s huge discrimination against obese people in society in general, but also in the medical profession and among people who make decisions about access to care.”

Sharma says medical coverage for obesity treatments is difficult to get, and “drugs for treating obesity are not paid for by health insurance or provincial (health care). Everybody says they consider obesity a disease, but they don’t treat it like a disease.”

An analysis by Dr. Peter Katzmarzyk of Queen’s University in Kingston, Ont., indicated that the economic cost of obesity in Canada in 2001 amounted to $4.3 billion, with $1.6 billion in direct health care costs and $2.7 billion in indirect costs, including lost economic output.

Tremblay foresees an even greater burden on the health system to come. “There’s a much heavier prevalence of overweight and obesity in kids now than there used to be. We’re already seeing the chronic disease problems in adulthood, so it doesn’t take a rocket scientist to project that we’re going to have a very serious and early onset of chronic disease problems from a large proportion of kids. At the same time, our aging population is at its peak and will be placing demands on our health care system like we’ve never seen before.”

As far as older Canadians are concerned, Dr. Hélène Payette, a professor at the University of Sherbrooke in Quebec, says not enough data has yet been collected to define obesity among seniors. Payette specializes in nutrition and heads the research centre on aging at the university’s geriatric institute. She also says “the same premises for measuring obesity do not apply as (for younger adults). An ideal weight for seniors is higher than for younger adults.” This is because body composition changes as we age; we start to lose muscle mass, and with that loss comes a decrease in our metabolism, the body’s process of converting food into energy.

Payette is leading a five-year study on nutrition and aging with universities in Sherbrooke and Montreal. She anticipates it will provide answers to a range of questions, including the causes and consequences of changes in appetite, food preferences and hunger sensations among the elderly, and what role exercise plays in preventing the loss of muscle.

Above all, she emphasizes that seniors need to focus on muscle-building exercise rather than eating less to shape up. “Weight loss is an extremely important problem in seniors, especially the frail elderly who have lost their ability to function independently.”

What usually accompanies diminished food intake is an “extremely harmful” muscle loss, adds Payette. “Those who have a large percentage of body fat can no longer carry or move their bodies. (Seniors) must not lose weight rapidly.”

While their calorie requirements are lower–in the range of 1,300 a day–older folks need to ensure they are getting the nutrients they require. Tea and toast will not cut it. In fact, says Payette, many seniors, particularly those in long-term care, are not eating–or exercising–enough.

Though there are no firm recommendations on healthy body weights for seniors, Sharma offers a criteria that everyone can follow. “Once you find your body weight is affecting your ability to go about daily life, like bending down and crossing your legs, or affecting your self-esteem, or your blood pressure starts going up and you have back and knee pains, you’re not at a healthy weight.”

People reaching a BMI of 40 and above should look at surgical options, says Sharma. “Everything else can be a quick fix over a short period, but from virtually all the data that’s out there, the morbidly obese patients who lose weight without surgery are going to put that weight back on.”

McMaster University is working on setting up a comprehensive obesity treatment and training centre with its two teaching hospitals. Bariatric surgery would be one of its offerings. In Ontario alone, about 4,500 residents require such surgery each year; fewer than 300 have the surgery in Canada.

Noble had to apply twice for Ontario Health Insurance Plan approval to pay for her gastric bypass, as her first application got lost in the shuffle. She also chose to have her surgery in the U.S., as there was a years-long waiting list for the surgery in Ontario. “There’s a lack of doctors (with the expertise) here.” The clinic she went to specializes in the surgery, which costs up to $40,000 US.

Sharma sees a need for obesity centres across Canada; he also calls for medical schools to teach family doctors how to treat obesity–something that is lacking.

“There is a lot of humbug out there, and people providing unethical treatments that are ineffective.” Unfortunately, he says, patients are turning to these commercial options with their attractive promises because they are not getting the kind of service they should be getting within the health care system. “Anybody claiming 20 pounds of weight loss a week is a charlatan, and needs to be behind bars.”

Mary Bush would also like to see Canadians avoid losing weight in unhealthy ways. Bush, the director general for Health Canada’s office of nutrition and planning, says the department is committed to coming forward with a food guide that “will empower Canadians to understand the challenge at hand, and how to rise to that challenge.”

Glendora Boland, a community dietitian in St. John’s who is on the food guide advisory committee, is excited about the changes she is seeing. “I’m happy to say people have now made the connection that healthy eating and active living are actually linked to your health. It’s certainly been a long time.”

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