Extreme Obesity, And What You Can Do About It

Too much weight can take a toll on your body, especially your heart. The good news is that there are steps you can take to get healthier — and even losing a little body weight can start you on the right path.

Why lose weight?
If you’re extremely obese, losing weight can mean “less heart disease, less diabetes and less cancer,” said Robert Eckel, M.D., past president of the American Heart Association. “Metabolic improvements start to occur when people with extreme obesity lose about 10 percent of their body weight.”

Losing weight can reduce your risk of heart disease and stroke; risk factors like high blood pressure, plasma glucose and sleep apnea. It can also help lower your total cholesterol, triglycerides and raise “good” cholesterol — HDL.

Understanding Extreme Obesity
A healthy BMI ranges from 17.5 – 25 kg/m2. If your body mass index is 40 or higher, you are considered extremely obese (or morbidly obese.) Check out the American Heart Association’s BMI calculator for adults to determine if your weight is in a healthy range. (Note: BMI in children is determined using a different BMI calendar from the CDC.)

A woman is extremely obese if she’s 5 feet, 4 inches tall and weighs 235 pounds, making her BMI 40.3 kg/m2. To reach a healthy BMI of 24.8, she would have to lose 90 pounds to reach a weight of 145 pounds.

A man is extremely obese if he’s 6 feet, 2 inches tall and weighs 315 pounds, making his BMI 40.4 kg/m2. To reach a healthy BMI of 25.0, he would need to lose 120 pounds to reach a weight of 195 pounds.

Doctors use BMI to define severe obesity rather than a certain number of pounds or a set weight limit, because BMI factors weight in relation to height.

How to Get Healthier
If you’re extremely obese, taking action to lose weight and improve your health may seem overwhelming. You may have had trouble losing weight or maintaining your weight loss, been diagnosed with medical problems and endured the social stigma of obesity.

“The key to getting started is to find a compassionate doctor with expertise in treating extreme obesity,” said Dr. Eckel, who is also professor of medicine and Charles A. Boettcher II Chair in Atherosclerosis at the University of Colorado Anschutz Medical Campus in Aurora, Colo. “Bonding with your physician is the best way to get past first base and on the path to better health.”

If you’re extremely obese, Dr. Eckel recommends that you become more active, but not to start a vigorous workout program without getting physician advice and not until you’ve lost about 10 percent of your body weight.
“You can continue the level of physical activity that you’re already doing, but check with your physician before increasing it,” Dr. Eckel said. “Some people with extreme obesity may have health issues like arthritis or heart disease that could limit or even be worsened by exercise.”

Treatment Options
Talk to your doctor about the health benefits and the risks of treatment options for extreme obesity:

  1. Change your diet. You may be referred to a dietician who can help you with a plan to lose one to two pounds per week. To lose weight, you have to reduce the number of calories you consume. Start by tracking everything you eat.

    “You have to become a good record-keeper,” Dr. Eckel said. “Reduce calories by 500 calories per day to lose about a one pound a week, or cut 1,000 calories a day to lose about two pounds a week.”

  2. Consider adding physical activity after reaching a minimum of 10 percent weight-loss goal.
  3. Medication. Some people can benefit from medication to help with weight loss for extreme obesity. Keep in mind that medication can be expensive and have side effects.
  4. Surgery. If changing your diet, getting more physical activity and taking medication haven’t helped you lose enough weight, bariatric or “metabolic” surgery may be an option. The American Heart Association recommends surgery for those who are healthy enough for the procedure and have been unsuccessful with lifestyle changes and medication. Risks can include infections and potentially dangerous blood clots soon after the operation, and concerns about getting the right amount of vitamins and minerals long-term.

Get The Social Or Medical Support You Need
Although some people can modify their lifestyle and lose weight on their own, many need extra help. A social support system can help encourage your progress and keep you on track. Decide what support best fits your needs — either a weight-loss support group or one-on-one therapy.

Some people with extreme obesity suffer from depression. Talk to your doctor about the best treatment, as some anti-depressant medications can cause weight gain.

Learn more:

  • BMI Calculator
  • BMI in Children
  • 5 Goals to Losing Weight
  • Losing Weight With Life’s Simple 7 Infographic
  • Preventing Childhood Obesity: Tips for Parents and Caretakers

Local Researchers Make Link Between Night Shift Work & Diabetes

PITTSBURGH (KDKA) — If you regularly worked the night shift, even if you’re retired now and keep a normal daytime schedule, you’re at higher risk of a common disease: diabetes.

Researchers at the University of Pittsburgh interviewed 1,000 retired night shift workers, classified them into 0 to 7 years, 8 to 14 years, 15 to 20 years, and more than 20 years.

“Our definition was any non-overtime work that fell within the midnight to 6 a.m. window,” says University of Pittsburgh’s Dr. Timothy Monk.

Both body mass index, or BMI, and diabetes rates were higher for night shift retirees compared to day workers.

Even when BMI was taken into account, the risk of diabetes was 1.4 to 2 times greater and there was no difference among the groups, suggesting that any time on night shift might be associated with a higher risk.

The way the body processes energy and uses the hormone insulin can be affected by sleep deprivation and disrupted circadian rhythms, which is your internal clock.

Just about everyone works the night shift at some point in their career, and many jobs are crucial in the overnight hours.

So eliminating night shift is impractical. But it could be made more sensible.

“In many cases, there are situations where it is not always vital that people work through the night. There are ways of having them, for example, work in the evening, or share the work, rather than have them do an overnight. Because there is a cost,” Monk says.

And just because you’ve worked a night shift doesn’t mean diabetes is a done deal.

“Even with this increased likelihood of getting diabetes, 75 percent of the retired shift workers did not get diabetes. So that gives us hope.” Monk said.

If you work night shift, you might want to pay attention to this risk.

Watch your diet, get regular exercise, and ask your doctor about testing your blood sugar at check-ups.

More Diabetes News
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The Five Stages Of Living With Obesity | Dr. Sharma's Obesity Notes

stages-of-grief-300x282Some readers may be well aware of the five stages of grief, the natural process of grieving, which, according to Kubler-Ross, move from denial to anger to fear to grief and finally to acceptance.

As others have pointed out, the same five stages apply to virtually every serious life event, including being diagnosed with a chronic or severe illness.

Now that we have come to appreciate that obesity is a chronic disease (for which we have no cure!), it should come as no surprise that these five stages also apply to obesity.

First comes denial: not denial that I am gaining or have put on weight – that is obvious enough. Rather, denial that this may be a real problem or may have serious consequences down the road. A normal response in this stage is to not want to know about it. I don’t see a doctor because I don’t want to hear that I have a problem. I don’t listen to advice because it doesn’t apply to me. I don’t weigh myself because I don’t want to know. Pseudoacceptance – it may be as it may, but if that’s the case, then that’s the case – don’t tell me I have a problem and don’t tell me I need to do something about it – leave me alone!

Second comes anger: often it is the anger that fuels the denial. Anger at my body. Anger at myself. Anger at the people around me (including those offering help or understanding). Anger at life in general. Why me? Why this? Why can I not stop myself? Why can I not stick with my diet or exercise plan? Nothing works!

Third comes depression: this phase is characterized by sadness, a sense of loss, despair, anxiety, fear of what is to come. What if this weight gain continues? What if my health problems get worse? I don’t want to be the “fatty” that people make fun of. I don’t want to be ridiculed in public. I don’t want my pains to get worse. I don’t want to end up in a wheelchair or have diabetes or sleep with a CPAP machine. There will be restrictions – giving up things I love. It will mean effort – doing things that I don’t care for. No longer can I live like I used to or like others continue to – lucky them!

Fourth comes bargaining: OK, I get that I have a problem but really, there must be some simple way out of this. If I can only find the right diet or right exercise or maybe cut my carbs or go vegan or get myself tested for food allergies. How about I just give up the white stuff, or the fat, or the pop? What if I buy a treadmill and religiously used it every day? How about I just share my story ? May be someone will help me – or I will find the strength. I have been successful in every other aspect of my life – so really – how hard can this be?

Fifth we reach acceptance: This is where I finally accept that I have this problem and reach the point where I am ready to move on. Once I accept that this problem is not simply going to go away, nor will it be fixed by another quick diet or weight-loss supplement, I reach the stage where I accept that I need to become more realistic about the solutions. I am now ready to find and accept the help I need (and fight for it if I have to) or I am ready to accept that this is what I will have to live with for the rest of my life – so let’s make the best of it and move on.

Research shows that these stages are not perfectly sequential – often they occur in parallel and even regress or sometimes flip-flop from one stage into another. That is perfectly natural. Some folks may never move beyond denial or anger, some may be stuck forever in depression or bargaining. Even those, who have accepted their situation may occasionally regress (e.g. the surgical patient who is in denial having to take his vitamins).

At this point it is important to point out that acceptance does not simply mean accepting the status quo.

Rather, acceptance means accepting the fact that I need to now deal with this problem the best I can. If I need to become a marathon runner to conquer this weight, so be it. If I need to open my soul to a psychologist to work through my childhood trauma, then that’s what I have to do. If in the end the only solution is bariatric surgery – bring it on. If this is what it will take – I am now ready to accept it, embrace it, use it to my advantage. I am now ready to stand up to bullies and the “wise guys” who have all the answers.

As health professionals, it is important that we recognise what stage our patients is at. The denial and anger stage are not the best time to discuss diet plans. Nor is the depression or bargaining stage the best time to bring up the topic of surgery or lifelong medication.

With true acceptance comes hope and a positive change that sets the foundation of whatever is to come next. This is no longer the time to point fingers, assign blame, nurse regrets,  hide in shame, dissolve in despair.

Things are as they are and I accept them. But, as they say, when life throws you lemons, reach for the tequila!

If you have experienced or can relate to these stages – I’d love to hear your story.

Edmonton, AB

The Five Stages Of Living With Obesity , 10.0 out of 10 based on 4 ratings

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25 Responses to “The Five Stages Of Living With Obesity”

  1. EC says:

    I am slightly confused on the denial part where you say “that this may be a real problem or may have serious consequences down the road.” Do you consider it denial if someone is overweight or obese (by the BMI chart), is weight-stable, has good health measures, exercises and eats a mostly healthful diet? Or are you specifically referring to someone a little higher on the Edmonton Obesity Scale by this? That would be more in line with my understanding of your general message, but it’s not clear to me here.

    I guess I feel a little touchy on this one, because this smacks of the “Vague Future Health Threat” a lot of people get hit with by their doctors and pretty much all of society the instant they get above BMI 25.0. Any argument that says “really, I’m healthy,” is countered with the idea that we’re in denial.

  2. Nanette says:

    You hit the nail on the head every single time. This blog is full of win. Thank you!

  3. Arya M. Sharma, MD says:

    EC – if your weight is not really a problem then this is not a question of denial – after all there is nothing to deny. But, let us be honest, the vast majority of people with excess weight do have a problem – people who don’t, make up a rather small healthy minority of fat people. If this is where you belong, good for you.

  4. Dagny Kight says:

    I’ve gotten a lot of response to a section in my book where I write about how going on a diet takes a person through stages of struggling with a sense of control.

    You pick a day to start a new diet and make a plan. The planning gets you all motivated and excited.

    At first, you stick to the plan very specifically and it makes you feel proud of yourself. You have a sense you’re “doing something” to solve a problem and you’re being good at it.

    The diet plan imposes changes on your regular routine and lifestyle that are difficult to maintain so little by little, it starts to break down. The breakdown usually begins with a temptation to eat something off the diet plan so you bargain with yourself that you’ve “been good” up to this point so you deserve a treat and it’s OK.

    The diet plan becomes more difficult to maintain over time so the bargaining gets bigger. You fall off the diet one day so you consider that day a total loss, you might as well eat whatever you want. You do it because you bargain with yourself to be back “on” the diet tomorrow.

    Eventually you consider the diet a complete failure. You bargain with yourself to be “off” the diet and decide it’s over. You eat whatever you want in an “off” a diet manner until the day that you decide you will start your new diet. You feel OK about what you’re eating as long as you stick to the terms of the bargain you make with yourself.

    You start the cycle over again.

    People have written to me that they do this all the time and they realize they’ve used up months and years of their lives living like this. I know I did.

  5. DebraSY says:

    I would like to share a little correction to your premise, based on my limited time as a lay chaplain. These are the Kubler-Ross stages of death. They are what people go through from diagnosis to final chapter of life as they confront their own mortality (and, as you rightly point out, the order is not set — though bargaining is usually listed before depression). The stages of death are frequently confused with stages of grief, and often misapplied, especially in early grief. The first stage of grief — when one learns that someone dear has died — is chaos. The grieving person may bounce back and forth from feeling numb to feeling profound sadness to feeling uncharacteristic emotions. Often friends see the numb stage or an uncharacteristic emotion and inform the poor griever that he or she is in denial and must move on. This is unhelpful. It makes the grieving person feel guilty for something that is natural.

  6. Kelly. Proulx says:

    This is awesome Dr Sharma. Thank you for putting this together. As a Dietitian I see people battling with their weights all the time and some days I struggle to help them. I use the stages of change, but this is excellent. Thank you.

  7. Linda Fair says:

    I wrote this a couple of years ago and your article reminded me of it:
    The Many Layered Cake of Obesity

    1. The bottom layer is the pain that started it all. Whatever drove us to seek comfort, solace, numbness in food, over and over again. Most of this probably started very early in our lives and was not our fault.

    2. The next layer contains the real physical effects of being obese: diabetes, cholesterol, heart disease, fatigue, joint deterioration, etc.

    3. The next layer contains the self-loathing that we cannot control this thing that eats at us.

    4. Another layer is all the unkind judgmental things that others have said to us, well intentioned or not.

    5. …all the times and ways that others have tried to “help” or “fix” us by controlling us.

    6. …all the misinformation and unhelpful advice that we have received directly or indirectly.

    7. …the isolation we seek in order to avoid being hurt again.

    8. …all our other needs, wishes and desires that cannot be fulfilled because of our obesity and/or others’ attitudes.

  8. Melinda Munro says:

    I’m with EC. I am super healthy and fit but with a BMI over 30. So am I in denial? No, actually bargaining, most of the time and sometimes acceptance. But EC is right, there is a constant pushback to doctors that the BMI does not mean I have any illness which I am denying.

    But I am curious about your comment about numbers, Dr. Sharma. What is the percentage of EOSS 0 or 1 in the population of people who have BMI’s over 30? Are we a tiny minority or are we sizable enough to warrant attention to what genetic factors drive our ability to be fit, strong and fat?

  9. Pierre Trudel says:

    Pierrette I live with these steps everyday.We have “been there,done that”.When we talk to others that are still in denial we no longer try to convince them.
    Until they reach the other factors, we are talking for nothing.
    I know of “no” people that are obese and exercise regularly and eat properly.
    Those that say they do are full of it and are in real strong denial.
    People that are obese simply eat all the time because they are always hungry.I know.I did also.
    When I changed my lifestyle and realised that I can eat healthy foods and be totally satisfied, then and only then did I really join “my fight” to become healthy.
    My wife is 62 and I am 61 and we are both in the best health of our lives…..Wow
    Pierre Pierrette Trudel

  10. Arya M. Sharma, MD says:

    Melinda: The exact numbers based on NHANES III for population with BMI 30 to 35 is Stage 0 = 8%, Stage 1 = 19%. For BMI greater than 40, the numbers are Stage 0 = 5% Stage 1 = 14%

  11. Arya M. Sharma, MD says:

    Linda: The Layered-Cake of Obesity – interesting idea!

  12. Arya M. Sharma, MD says:

    DebraSY: You make an important point – all of these stages are “natural” and even “healthy” as part of the process. Thus, for e.g., although it sounds negative, “denial” is a very healthy initial response, so is “depression”. The problem is when people get stuck in one of the other stage or fail to eventually progress to acceptance. The notion of thinking of this as a staged process (not always linear) is for the professional to recognise where your patient is at and counsel appropriately. As I said, trying to talk someone, who is in the denial stage into addressing the problem will only create defensiveness.

  13. Arya M. Sharma, MD says:

    Dagny – you perfectly describe someone stuck in the bargaining stage. This person has not yet fully accepted that changes have to lifelong and that the expectations have to be realistic. I know hundreds of people (probably most people trying to lose weight), who are stuck in the bargaining stage and never make it to full acceptance.

  14. Valerie X Armstrong says:

    This is so much like a blog post I made on 11/13/12…great minds, you know


  15. Elina Josephson says:

    As usual, I find myself offering a contrary voice. I believe from experience, that these stages are better understood as interwoven threads. Rather than experiencing them one at a time, a person who is gaining weight cycles through them often on a moment by moment basis. All the threads exist in the same time and space but the person is more focused on one or the other. This is not nearly as true for grief, but it is true for weight management. What this means for a qualified and caring CBT is that you are not required to wait for the client to transition into acceptance, you can help the client shift focus and change perspective. You can help the client find motivation, strength and purpose. We are complicated and powerful. Within each one of us, at every single moment,lives the potential to simply make another choice.

  16. Arya M. Sharma, MD says:

    Elina – you are bang on that these stages are interwoven (which is why I chose the image of the ribbon for the illustration). I also agree all all these stages can co-exist from minute to minute, from day to day. A skilled CBT counsellor will recognise this and provide the necessary support.

  17. DebraSY says:

    Pierre: you no of NO ONE who is obese and exercising regularly and eating properly? All obese people are “full of it” and “in real strong denial”? Wow, that’s harsh. Is Diana Nyad in denial? What about 75% of the Kansas City Chiefs (my team) or, for that matter, 75% of other people’s football teams. What about Oprah (also proof positive that no amount of accountability and resources can assure permanent weight-loss maintenance). What about Janet Cook, the first person to swim the Berring Straight? There are also many non-famous obese people who quietly exercise and eat well with no fanfare. I knew quite a few when I belonged to the YMCA.

    Please reconsider your judgments. Weight bias hurts people.

  18. Dagny Kight says:

    I don’t deal with weight because of “pain that started it all.” I don’t allow people to treat me like I am some weak, broken emotional wreck or to label me in that way. Some of us can have bodies that manage energy very efficiently and brains that want to think about food and connect it to everything in our lives. Fighting that to manage your weight in an intensely obesogenic environment is VERY DIFFICULT. Even if you think certain situations triggered certain habits, the struggle with weight itself becomes the difficulty.

    We have to get rid of this paradigm that says every fat person is a screwed up mess of emotional issues and “pain that started it all.”

    Food is its own driver.
    Weight is its own stressor.
    Fighting to control your body and mind is immensely difficult and can feel endless

  19. Benedetta says:

    Dagny, well said. Thank you!

  20. Sharon says:

    Very wise words. So how can one move on to that stage of acceptance, or help a client or loved one to do so? I find myself cycling between denial, depression and bargaining–and would love to be able to move to acceptance, so I can fix my weight and my life.

  21. Arya M. Sharma, MD says:

    Sharon – that’s a great question. I am not a counsellor but there are many who read this – they may wish to chip in with some advice.

  22. Elina Josephson says:

    This is at Sharon- You might just not be done cycling yet. Acceptance often comes when all the other possible versions of reality have been exhausted. When you get tired of running in circles and the reward of one more bite does not seem worth it. When the payoff from the denial and the depression and the bargaining no longer works for you. When that times comes, find a great CBT counselor, come in with a willing heart and and an open mind. Walk in to work, do not expect to be fixed, but rather to be empowered to fix yourself. When that day comes, your counselor will help you open the door and you will have found acceptance.

  23. EC says:

    Pierre’s comment is exactly why I brought up the “denial” issue, because this is the kind of thing I hear over and over. Thank you, Debra and Dagny, for pointing out the flaws in assuming that every fat person is an emotional wreck, or a lazy glutton, or “in denial” — an attitude I find frustrating and insulting.

    While the numbers of obese in EOS 0 or 1 are small, it is still enough that it’s not a total anomaly. I would guess that for people in overweight BMI (where I am — high side of it), those numbers are a bit higher. It needs to be addressed instead of doctors having the knee-jerk reaction of prescribing intentional weight loss to everyone above BMI 25, even if those folks are healthy and weight-stable with good enough habits.

  24. Melinda Munro says:

    You go Dagny!

    If we aren’t being judged as being lazy and deceitful (Pierre), we are judged as being broken emotional wrecks with childhoods laden with abuse.

    The reality is our bodies are hyper efficient and in some of our cases, due to external drivers to be thin, we engaged in behaviours, like yo-yo dieting, that made our bodies even more efficient.

    However, thin friends of mine face some of the same labels – if you are skinny, you must be anorexic with an unaccepted history of abuse.

    How about we agree that we can be healthy people whose genetics and body morphs are different from someone else’s.

    If we are struggling with mental illness that impacts our physical health, then focus on that and not make stereotypical judgements.

  25. Diane says:

    Dr. Sharma, I have bounced back and forth through all of these stages, spending lots of time in denial. It took a lot of work with an addictions counsellor to get me to the stage in which I was willing to go to any lengths to get healthy again. I am on the waitlist for surgery in BC and have been for 4 1/2 years. I don’t have a date yet but I have reason to believe I will have one soon. I appreciate that you recognize that it is sometime a battle to get what we need to get healthy. Thank you for all the work you do on our behalf.

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Pregnancy Weight Gain Linked to Childhood Obesity | WebProNews

Pregnancy Weight Gain Linked to Childhood Obesity

Though recent data has shown that childhood obesity numbers are falling in a number of U.S. states, health officials in the country are still referring to obesity as an epidemic. This week, a new study has shown that expectant mothers may have more direct, biological influence on the size of their children than previously thought.

The study, published Monday in the journal PLoS Medicine, shows that high weight gain during pregnancy is directly linked to an increased risk of obesity for the children up until age 12. The study’s authors believe that helping women limit their weight gain during pregnancy could have an impact on the fight against obesity in the U.S.

“From the public health perspective, excessive weight gain during pregnancy may have a potentially significant influence on propagation of the obesity epidemic,” said Dr. David Ludwig, lead author of the study and the director of the Boston Children’s Hospital’s Obesity Prevention Center. “Pregnancy presents an attractive target for obesity prevention programs, because women tend to be particularly motivated to change behavior during this time,”

The study looked at 41,133 mothers and children in the state of Arkansas over 12 years, cross-referencing birth records and school BMI records. Statistical comparisons were then made between siblings, ruling out demographic, genetic, and environmental influences. Excessive weight gain in the study was defines as 40 or more pounds, which correlated to an 8% increase in the risk of a child being obese.

Though the difference in BMI from mothers who gained the least weight during pregnancy to those who gained the most is only one-half of a BMI unit, Ludwig and his colleagues believe this effect could contribute to hundreds of thousands of obesity cases nationwide.

Overweight and healthy: the concept of metabolically healthy obesity …


Carrying too many pounds is a solid signal of current or future health problems. But not for everyone. Some people who are overweight or obese mange to escape the usual hazards, at least temporarily. This weight subgroup has even earned its own moniker—metabolically healthy obesity.

Health professionals define overweight as a body-mass index (BMI) between 25.0 and 29.9, and obesity as a BMI of 30 or higher. (BMI is a measure of weight that takes height into consideration. You can calculate your BMI here.)

Most people who are overweight or obese show potentially unhealthy changes in metabolism. These include high blood pressure or high cholesterol, which damage arteries in the heart and elsewhere. Another harmful metabolic change is resistance to the hormone insulin, which leads to high blood sugar. As a result, people who are overweight or obese are usually at high risk for having a heart attack or stroke, developing type 2 diabetes, or suffering from a host of other life-changing conditions.

But some people who are overweight or obese manage to avoid these changes and, at least metabolically, look like individuals with healthy weights. “Obesity isn’t a homogeneous condition,” says Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard School of Public Health. “It appears that it doesn’t affect everyone in the same ways.”

Dr. Hu and three colleagues wrote a “Personal View” article in Lancet Diabetes and Endocrinology reviewing what is known about metabolically healthy obesity. They identified several characteristics of metabolically healthy obesity. These include a high BMI with

  • a waist size of no more than 40 inches for a man or 35 inches for a woman
  • normal blood pressure, cholesterol, and blood sugar
  • normal sensitivity to insulin
  • good physical fitness

BMI isn’t perfect

BMI is not a perfect measure of weight or obesity. It often identifies fit, muscular people as being overweight or obese. That’s because muscle is more dense than fat, and so weighs more. But muscle tissue burns blood sugar, a good thing, while fat tissue converts blood sugar into fat and stores it, a not-so-good thing.

“Further exploration of metabolically healthy obesity could help us fine-tune the implications of obesity,” says Dr. Hu. “It supports the idea that we shouldn’t use BMI as the sole yardstick for health, and must consider other factors.”

Genes certainly play a role in how a person’s body and metabolism respond to weight. Some people may be genetically protected from developing insulin resistance. Others are genetically programmed to store fat in the hips or thighs, which is less metabolically hazardous than storing fat around the abdomen.

The concept of metabolically healthy obesity could be used to help guide treatment. Currently, exercise and a healthy diet are the foundation for treating obesity. When those efforts aren’t enough, weight-loss surgery (bariatric surgery) is sometimes an option. Such surgery is appropriate for people with metabolically unhealthy obesity, the authors suggest, but for people with metabolically healthy obesity it might make more sense to intensify the lifestyle approach rather than have surgery. This idea, however, needs to be tested in clinical studies, says Dr Hu.

Don’t rest easy

Metabolically healthy obesity isn’t common. And it may not be permanent, warns Dr. Hu. Just because a person has metabolically healthy obesity at one point doesn’t it will stay that way. With aging, a slowdown in exercise, or other changes, metabolically healthy obesity can morph into its harmful counterpart.

It’s also important to keep in mind that obesity can harm more than just metabolism. Excess weight can damage knee and hip joints, lead to sleep apnea and respiratory problems, and contributes to the development of several cancers.

Bottom line? Obesity isn’t good, even if it’s the metabolically healthy kind.




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New Inquiries into Eating Disorders and Obesity



Last week, there was some media coverage of a new study, published in Pediatrics (the journal of the American Academy of Pediatrics), that highlights the concurrence between obesity/overweight and eating disorders. The study sheds light on the fact that a significant number of young people who seek clinical treatment for eating disorders come from a history of overweight or obesity. At the Mayo Clinic Children’s Center, where Dr. Leslie Sim, one of the authors of the study, works, 45% of adolescents seen for ED treatment in the last year came from a history of obesity. The study makes a case for recognition of obesity as a common precedent to disordered behaviors. It also illuminates the very tendency of primary care providers to overlook symptoms of disordered eating in people with history of obesity. It highlights two case studies: a fourteen-year-old boy and an eighteen-year-old girl whose eating disorders were misdiagnosed in large part because they had previously been obese.

As I read this article, I felt an enormous sense of disappointment at the way both obesity and eating disorder treatment are failing young people in this country. Because our emphasis is on weight loss at all costs (rather than the fostering of healthy habits), obese adolescents often transition directly into anorexia, bulimia, binge-eating, and EDNOS. At least half of the men and women I know who have struggled with eating disorders were overweight or obese growing up, so it comes as no surprise that what I’ve observed is borne out in the 45% statistic. Still other individuals who have shared their stories with me say that the eating disorder began when they were advised to lose weight by a health care provider or school nurse. In their dutiful attempts to obey that mandate, they quickly turned to extreme forms of restrictive eating or exercise.

Sim, Lebow, and Billings’ study details the history of a fourteen-year-old boy who had lost over 87 pounds. Possessed of a significantly higher than average BMI through childhood, he’d begun dieting at the age of 12, first by eliminating sweets, fats, and carbohydrates, and ultimately resorting to eating 600 calories per day. He developed hallmark symptoms of an eating disorder: difficulty concentrating, low moods, bloating, constipation, social withdrawal, fatigue, and intolerance to cold. His health care providers tested him for a number of GI disorders (celiac sprue, GiardiaH. pylori), and thyroid abnormalities. In spite of the fact that he began to show heart irregularities and dehydration, eating disorders weren’t suggested.

The study states,

In spite of having lost over half of his body weight, the medical documentation associated with the evaluation stated, ‘there is no element to suggest that he has an eating disorder at this particular time.’ At the request of his mother, however, Daniel was referred for an ED evaluation. Of note, Daniel’s weight was a focus of discussion at all medical appointments throughout his childhood. However, during the 13 medical encounters that took place when he was losing weight, there was no discussion of concerns regarding weight loss.

Italics are mine.

The next case study is equally disturbing. An eighteen year old girl was sent to an ED evaluation because she was demonstrating extreme fear of weight gain, amenorrhea, intolerance to cold, stress fractures, excessive exercise, food restriction, and binge eating. She, too, came from a history of obesity. She had begun dieting at the age of fourteen, ultimately going from 97th percentile for weight to the 10th percentile in only three years. After the first year of her weight loss, she developed amenorrhea, but the suggested explanations were PCOS or her long distance running, and she was put on birth control pills. She was referred to a dietitian after her stress fractures developed. The dietitian didn’t suggest ED treatment or express concern over her severely low fat diet, even when the girl’s mother suggested that she might have an ED. According to the study, the girl’s physician noted, “‘given that her BMI is currently appropriate, it is reasonable to do a trial off the birth control pill and see if her menses resume.’”

Italics are mine again.

In our green recovery discussions, we have often touched on how flawed BMI is as a marker of health. The USA Today coverage of the new study discusses this problem. It notes that many of the people who need ED treatment aren’t immediately identified as being at risk because they aren’t underweight:

It’s a “new, high-risk population that is under-recognized,” says Hagman, medical director of the eating disorders program at Children’s Hospital Colorado, who was not involved in the new report.

The kids she sees in this condition “are just as ill in terms of how they are thinking” as they are in terms of physical ailments, she says. “They come in with the same fear of fat, drive for thinness, and excessive exercise drive as kids who would typically have met an anorexia nervosa diagnosis. But because they are at or a even a little bit above their normal body weight, no one thinks about that.”

These cases are no surprise, says Lynn Grefe, president of the National Eating Disorders Association. “Our field has been saying that the more we’re pushing the anti-obesity message, the more we’re pushing kids into eating disorders” by focusing on size or weight instead of health and wellness.

Medicine is not a perfect science. BMI can help physicians to quickly identify someone who is very overweight or underweight, but like any diagnostic tool, it has limitations. One way to circumvent these limitations is to use multiple diagnostic criteria when it comes to complex conditions like EDs. Weight may be telling, but it doesn’t tell the whole story. Listening to a patient’s symptoms, history, and habits is equally, if not more, crucial. It’s time for treatment providers to stop equating eating disorders with the state of being underweight. People who are not underweight by the books can have eating disorders, and–as one of my commenters noted–people who are underweight don’t necessarily have them.

What struck me most about this study was the bias it unearthed. It is the idea that there are two types of people– people who have been overweight, and people who are, or could become, restrictive– and that those two types of people are not and cannot be one in the same. This is the bias that leads a primary care physician to miss overwhelmingly evident ED symptoms in a kid who used to be obese. It is the bias that, left uncorrected, may allow countless adolescents and adults who are in need of care to go unnoticed.

US News and World Report interviewed Dr. David Katz as a part of its coverage. Katz is the Editor-in-Chief of the journal Childhood Obesity, President-Elect of the American College of Lifestyle Medicine, founder and President of the non-profit Turn the Tide Foundation, and the founding director of Yale University’s Prevention Research Center. He has devoted much of his career to combating childhood obesity through education about healthy eating and a comprehensive approach to patient care. He echoed the dangers of treating obesity and disordered eating as mutually exclusive phenomena, and underscored the fact that there is quite a bit of fluidity between them:

“First, obesity itself is a risk factor for eating disorders,” Katz said. “This link is well established for binge-eating disorder, where obesity is potentially both cause and effect…Second, while weight loss in the context of obesity may appear beneficial, there is a point at which the methods used — or the extremes reached — may indicate an eating disorder,” Katz said.

“Effective treatment of obesity cannot simply be about weight loss — it must be about the pursuit of health,” Katz said. “An emphasis on healthful behaviors is a tonic against both obesity and eating disorders. By placing an emphasis on diet and activity patterns for health and by focusing on strategies that are family based, we can address risk factors for both eating disorders and obesity.”

Just as weight restoration alone cannot remedy anorexia, neither is weight loss, in and of itself, an adequate treatment for obesity. In both cases, changes in weight should be accompanied by an emphasis on the importance of nourishing foods and an attempt to foster lasting, positive body image.

✵          ✵          ✵

Between the ages of eight and ten, right after my parents’ divorce and during a turbulent moment in my childhood, I gained some weight. My pediatrician remarked on it during an annual checkup when I was eleven–he wasn’t overly worried, he said, but a diet might help me get back to a more “appropriate” weight for my frame. He left it at that, and I took matters into my own hands. This was that summer that I discovered rules and restriction. It was the summer I realized that I could make my body “behave” itself. It was also the year that my weight took its first major plunge, and the roller coaster in and out of my ED began.

In bringing up my own story, I don’t mean to draw a direct or easy comparison between what I remember and what the two individuals profiled in the study experienced. Nor am I putting all of the blame on my physician, because he was acting in good faith, and there were many, many factors involved with my ED. But I couldn’t help but feel a sense of recognition as I read, an empathy that having comes from having once felt as if someone–someone who was supposed to be taking care of my health–had given me the message that I ought to reject my body. While I recognize the seriousness of childhood obesity, and support all healthful measures undertaken to treat and prevent it, I believe that the onus is upon health care practitioners to do so in a way that will encourage children to embrace their bodies, rather than renounce them. I’m hopeful that it can be done.

As always, I’d love to hear your thoughts on the study, which can be found here (Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Pediatrics. 2013 Sep 9. [Epub ahead of print]).

In the meantime, I wish you a happy Sunday, and a great start to the week ahead.


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China 'Catastrophe' Hits 114 Million as Diabetes Spreads

China’s diabetes epidemic is worse than previously estimated — much worse.

The most comprehensive nationwide survey for diabetes ever conducted in China shows 11.6 percent of adults, or 114 million, has the disease. The finding, published yesterday in the Journal of the American Medical Association, adds 22 million diabetics, or the population of Australia, to a 2007 estimate and means almost one in three diabetes sufferers globally is in China.

Chinese are developing the metabolic disease at a lower body mass index than Americans, the researchers found, meaning that changes in diet and physical activity stoked by rapid economic development are resulting in an earlier onset of the obesity-linked disease. The epidemic will worsen with 40 percent of 18-to-29-year-olds on the verge of developing diabetes, which increases the risk of stroke, heart attack and kidney failure.

“Diabetes in China has become a catastrophe,” said Paul Zimmet, honorary president of the International Diabetes Federation and director emeritus of the BakerIDI Heart and Diabetes Institute in Melbourne. “The booming economy in China has brought with it a medical problem which could bankrupt the health system. The big question is the capacity in China to deal with a health problem of such magnitude.”

Eclipsing U.S.

Yesterday’s report is based on a survey of a nationally representative sample of 98,658 Chinese adults in 2010. A similar survey in 2007 pegged diabetes prevalence at 9.7 percent, or 92.4 million adults. The latest results means diabetes is now more common in China than in the U.S., where 11.3 percent of adults are diabetic.

The Brussels-based International Diabetes Federation estimates there are 371 million people worldwide with the disease, including 92.3 million in China.

The increase in the prevalence of diabetes in China, estimated at about 1 percent in 1980, has been “unparalleled globally,” Zimmet said in a telephone interview.

“China is now among the countries with the highest diabetes prevalence in Asia and has the largest absolute disease burden of diabetes in the world,” wrote authors led by Guang Ning in the laboratory for endocrine and metabolic diseases at the National Health and Family Planning Commission. “Poor nutrition in utero and early life combined with over-nutrition in later life may contribute to the accelerated epidemic of diabetes in China.”

Measuring Disease

The study incorporated measurements of glycated hemoglobin A, or HbA, into its diagnosis, adopting updated guidelines from the American Diabetes Association, in addition to tests used in earlier studies: glucose readings taken after patients fasted for a period of time, and a measurement of the amount of sugar in the blood two hours after patients consumed a sweet drink.

The added criteria may have partly contributed to the increased prevalence, Guang and colleagues wrote. The scientists estimate half of adults in China, or 493.4 million people, have higher-than-normal blood glucose levels, which put them in a pre-diabetic state.

“These data document a rapid increase in diabetes in the Chinese population,” according to the study’s authors, who include researchers from Beijing’s Chinese Center for Disease Control and Prevention and Johns Hopkins University in Maryland. “Diabetes may have reached an alert level in the Chinese general population, with the potential for a major epidemic of diabetes-related complications, including cardiovascular disease, stroke, and chronic kidney disease.”

Cases Undiagnosed

Almost two-thirds of patients treated for diabetes didn’t have adequate blood-sugar control, the authors found. For every person in China diagnosed with diabetes, at least two more will be unaware they have it.

Study participants were weighed and measured to calculate their body mass index, or BMI, calculated as weight in kilograms divided by height in meters squared. For example, a 5-foot, 4-inch (1.63 meter) woman weighing 175 pounds (79 kilograms) has a BMI of 30. BMI of 30 or more is considered obese, while a BMI of 25 to 29.9 is considered overweight, according to the National Institutes of Health.

The average BMI in yesterday’s study was 23.7, compared with 28.7 in the U.S. population.

“Rapid lifestyle changes in China have caused rising trends in obesity, and that is now bringing out the abnormality of a people biologically more vulnerable to diabetes,” Juliana Chan, a professor of medicine and therapeutics at the Chinese University of Hong Kong, said in a telephone interview.

As in the rest of Asia, the burden of diabetes is falling disproportionately on the young and middle-aged, the authors said. Pre-diabetes was present in 40 percent of adults ages 18 to 29, and 47 percent among those 30 to 39.

‘Very Scary’

“The alarmingly high figures for prediabetes are very scary,” said Chan, who wrote an editorial accompanying yesterday’s study and is also the founding director of the Chinese University of Hong Kong’s Institute of Diabetes and Obesity. “A lot of people think diabetes is a disease that mainly affects the elderly, but we have a very unhealthy young population that may lose their ability to work in the prime of their lives, and this would also have an impact on their families and on society,” Chan said.

China’s rising prevalence of diabetes has strained its health services and helped fuel a 20 percent-a-year growth in drug sales, stoking the need for newer and costlier medications from companies including Merck Co. (MRK), Novo Nordisk A/S (NOVOB) and Sanofi. (SAN)

China’s government is trying to fight the scourge by expanding basic medical coverage, buying more medicines in bulk to lower costs, and conducting a corruption probe of international drugmakers, including GlaxoSmithKline Plc.

To contact Bloomberg News staff for this story: Daryl Loo in Beijing at dloo7@bloomberg.net

To contact the editor responsible for this story: Jason Gale at j.gale@bloomberg.net

China's Diabetes ‘Catastrophe’ Afflicts 114 Million

Sept. 4 (Bloomberg) — The most comprehensive nationwide survey for diabetes ever conducted in China shows 11.6 percent of adults, or 114 million, has the disease. The finding, published yesterday in the Journal of the American Medical Association, adds 22 million diabetics, or the population of Australia, to a 2007 estimate and means almost one in three diabetes sufferers globally is in China. Stephen Engle reports. (Source: Bloomberg)

Enlarge image
Obesity  Diabetes

Obesity Diabetes

Obesity  Diabetes

Mark Ralston/AFP via Getty Images

A reflection of overweight patients exercising is seen at a weight loss facility in Tianjin. “Rapid lifestyle changes in China have caused rising trends in obesity, and that is now bringing out the abnormality of a people biologically more vulnerable to diabetes,” said Juliana Chan, a professor of medicine and therapeutics at the Chinese University of Hong Kong.

A reflection of overweight patients exercising is seen at a weight loss facility in Tianjin. “Rapid lifestyle changes in China have caused rising trends in obesity, and that is now bringing out the abnormality of a people biologically more vulnerable to diabetes,” said Juliana Chan, a professor of medicine and therapeutics at the Chinese University of Hong Kong. Photographer: Mark Ralston/AFP via Getty Images

Fat But Fit: Metabolically Healthy Obesity

Suzanne Tucker/Shutterstock

Can you be fat and healthy at the same time? Apparently so, according to a new study by University of Pennsylvania physicians and obesity researchers who say that there are people with “metabolically healthy obesity.”

Many obese people are classified as such when their body mass index or BMI reaches a certain value. BMI, a formula based on a person’s weight and height, was invented by Belgian mathematician Adolphe Quetelet in the early 19 century and has garnered wide acceptance as a simple way to measure “fatness.” It’s quick and easy to administer – requiring only a scale and a ruler – and allows for comparison for broad populations, taking in age and country-by-country variations. Indeed, BMI is a good statistical measure of the obesity of a whole population of people.

Doctors have noted, however, that some people with BMI in the obese range are actually quite healthy and that in many cases, fat people fare better than thin ones with the same ailments. In the “obesity paradox,” researchers noted that diabetic patient of normal weight are twice as likely to die than those who are obese. Others have pointed out that thin dialysis patients are more likely to die than heavier ones.

In recent years, the medical field has began to accept that BMI is not a reliable measure of health in individuals, and that some people who are obese do not have nor are they in any danger of developing obesity-related diseases.

But how many people are actually “fat but fit” and “not fat but not fit”? The answer may surprise you. For 1 in 5 Americans, BMI may actually tell the wrong story:

– 8% of normal-weight adults in the United States are actually metabolically unhealthy
This translates to 19.2 million people whom doctors may not currently worry about but should.

– 10% of obese adults
are actually metabolically healthy
This means that 24 million chubby Americans are not in any danger of dying because of obesity-related illnesses, but are probably badgered by their family, friends and employers to lose weight.

BU School of Medicine Review Calls for New Criteria for Identifying …

in 2013, Health Medicine, News Releases, School of Medicine

August 30th, 2013


Contact: Gina Orlando, (617) 638-8490, gina.orlando@bmc.org

(Boston) – With soaring obesity rates in the U.S., the American Medical Association has classified obesity as a disease. This major shift in healthcare policy brings much needed medical attention to obese patients. However, this definition of obesity focuses on a single criterion of Body Mass Index (BMI), which includes a large group of persons with high BMI who are metabolically healthy and not at high risk for type 2 diabetes, cardiovascular disease or obesity-associated cancers.


In a review article published online in Endocrinology, Gerald V. Denis, PhD, professor of pharmacology and medicine and James A. Hamilton, PhD, professor of physiology and biophysics at Boston University School of Medicine (BUSM), discusses the importance of eliminating healthy obese persons from unnecessary pharmaceutical treatments of the disease.


Previous studies have shown that the total volume of fat around the heart in obese persons is detrimental to some organ functions, but that total pericardial fat is not predicted by BMI. Thus, noninvasive imaging, such as magnetic resonance imaging (MRI), of pericardial fat could help to identify cardiovascular risks that are not clearly coupled with BMI. In addition, this could provide an opportunity to find blood biomarkers, which are the best indicators of relative metabolic status.


“These insights strongly suggest that BMI alone is insufficient to classify patients as obese and unhealthy; metabolism, body composition, fat deposition and inflammatory status must be part of a comprehensive health evaluation,” said Denis.

Certain non-obese individuals may also benefit from a noninvasive imaging approach, as well. Although not apparent physically, many lean people experience significant risks for these same diseases because of chronic low-level inflammation and fat deposition in or around vital organs. Where BMI alone would exclude this group from screenings, weighing more factors that contribute to pericardial fat could save lives.

“By using a more individualized approach, some obese persons can be relieved of the additional stigma of classification in a major disease category. In addition, unnecessary medical interventions and costs can be reduced,” added Hamilton.


The work was supported in part by grants from the National Institutes of Health (NCI and NIDDK; R56 DK090455 –GVD) and a subcontract from the Boston Area Diabetes Endocrinology Research Center (BADERC; P30 DK057521). G.V.D. is Chair-Elect of the Obesity and Cancer Section of The Obesity Society.

'Fat Letters' Take the Stage in Childhood Obesity Debate – WebMD

‘Fat Letters’ and the Childhood Obesity Debate

Teens whose parents harped about weight gain

By Alan Mozes

HealthDay Reporter

WEDNESDAY, Aug. 21 (HealthDay News) — If their kids are frequently tardy, truant or failing to turn in homework, parents of U.S. schoolchildren expect to be notified. And in some districts, they might be contacted about yet another chronic problem: obesity.

The “fat letter” is the latest weapon in the war on childhood obesity, and it is raising hackles in some regions, and winning followers in others.

“Obesity is an epidemic in our country, and one that is compromising the health and life expectancy of our children. We must embrace any way possible to raise awareness of these concerns and to bring down the stigmas associated with obesity so that our children may grow to lead healthy adult lives,” said Michael Flaherty, a pediatric resident physician in the department of pediatrics at Baystate Medical Center in Springfield, Mass.

About 17 percent of U.S. teens and children are obese — three times the number in 1980, according to the federal Centers for Disease Control and Prevention. And one in three is considered overweight or obese. Being overweight or obese puts kids at risk of developing serious health problems, such as heart disease. Too much weight can also affect joints, breathing, sleep, mood and energy levels, doctors say.

Massachusetts — which has had a weight screening program since 2009 — is one of 21 states that have implemented statutes or advisories mandating that public schools collect height, weight, and/or BMI (body mass index) information. Some states further require that parents receive confidential letters informing them of the results, advising that they discuss the findings with a health care provider.

But some parents in the Bay State and elsewhere consider such policies an unwelcome intrusion into private family matters. Other objectors say “fat letters,” as they are sometimes called, have the potential to trigger bullying or eating disorders among the very children they’re trying to help.

In Massachusetts, where parents are letter-informed of BMI results for students in grades 1, 4, 7 and 10, the state department of public health is currently debating a possible repeal of the letter portion of its screening protocol.

This would be a grave mistake, Flaherty believes. “The growing number of children and adolescents seen day in and day out in our clinics with hypertension, high cholesterol, diabetes, and musculoskeletal issues secondary to weight do not lie,” he said.

Flaherty, a clinical associate at the Tufts University School of Medicine, outlines his thoughts in a “perspective” piece published online Aug. 19 in Pediatrics.

While acknowledging that the effectiveness of such programs remains to be determined, Flaherty notes that school screenings are nothing new, with many states having done so for many years. And in 2005, the U.S. Preventive Services Task Force determined that calculating a child’s BMI — a calculation of body fat based on height and weight — should be considered the “preferred measure” for tracking weight issues.