Vivienne Matalon, MD, Moderator,
David Heber, MD, PhD;
John W.C. Johnson, MD;
Frank Kane, MD;
John Foreyt, PhD
Forum on Obesity
Clinician Intervention

Matalon: Obesity is among the most serious health problems in the United States, second only to cigarette smoking. Data from the US Department of Health now classifies 97 million Americans as having a weight problem; 58 million of these persons are obese.' Research has also shown that women are more affected by weight problems than men.' Clinicians providing health care to women should be aware that 55% of the obese population is female.' The reason for this may be physiological, because women have a higher percentage of essential body fat (about 12%) than men.

Obesity has been identified as a risk factor in more than 30 illnesses, including cardiovascular disease, gallstone formation, diabetes, osteoarthritis, gastrointestinal disorders, breast inflammation, sleep apnea, and even malignancy.' Our discussion today will focus on this widespread disease entity.

Heber: Indeed, we are currently in the midst of an obesity epidemic. I have been treating

obese patients for more than 20 years, over 80% of whom have been women. The reasons why obesity is much more prevalent among women than men involve physiological, psychological, and cultural considerations. Physiologically speaking, body fat is a secondary sex characteristic in women-that is, the deposition of fat around the hips and thighs during puberty is a part of normal development in adolescent girls. For many women, accumulation of fat occurs with postpregnancy weight gain, and the location of fat deposits shifts during the life cycle. After menopause, women often accumulate upper-body fat, which increase their risk for several chronic diseases, such as heart disease, hypertension, diabetes, and some cancers

I suggest that patients being treated for obesity keep a diary of food, physical activity, and their feelings.

(including breast cancer).' Also, muscle mass decreases after menopause because of loss of estrogen. As for the psychological component, much has been written about the impact of excess body fat on selfimage and emotional well-being in women. As physicians, we need to develop the skills that will allow us to address these important issues.

Matalon: Which aspect plays a greater role in obesity, psychology or physiology?

Heber: It is difficult to separate the two. Nutrition involves both behavior and physiology. Food intake obviously has a behavioral side, whereas food itself has a biochemical element. Therefore, the reasons for eating, which are often emotional, as well as food compositions-percentages of fat, carbohydrate, and protein-a contribute to obesity

Foreyt: The psychological aspect of obesity is often overlooked, yet its costs can be devastating. We know that as weight increases, self-esteem is often affected negatively. To treat obesity, we must treat the psychological aspect concomitantly with the physiological.

Heber: From a motivational standpoint, health enhancement is a more successful approach than illness prevention in motivating patients to change their behavior patterns.

Heber: It is clearly psychosocial. On average, Americans are eating 200 more calories per day than they did just 10 years ago. The reasons include portion sizes, fast food, and lack of physical activity and exercise. From the psychosocial point of view, some people work hard, then they come home and use food to relieve their stress.

Matalon: I agree with Dr Heber about the correlation between fast food and obesity, even between feeding patterns in children and obesity. The first solid food often given to infants is rice cereal, a starch. This type of high- carbohydrate diet prevails throughout infancy, childhood, and adulthood.

Dr Heber, you mentioned diabetes earlier; diabetes and hyperlipidemia have been linked. Could you elaborate on this?

Heber: These commonly occurring diseases are frequently seen in obese patients. Metabolic syndromes such as hyperinsulinemia, hyperlipidemia, hypertension, and glucose intolerance often occur along with abdominal obesity, challenging the paradigm of care for the primary care physician. In cases such as hypertension, heart disease, and diabetes, we have all been taught to triage to different specialties. However, the focus in treating type 2 diabetes, which affects 30 million Americans, should be on weight control and weight management. hi many patients, hypertension can also be controlled by losing about 10% of body weight. The recent guidelines that were set by the American Heart Association suggest that the primary approach to hypertension and hyperlipidemia should be changes in diet and lifestyle. This, however, is not common in clinical practice.

Foreyt: Many physicians never even mention the patient's obesity; instead, they focus on the other health issues and neglect the very one that is the cause. We also need to emphasize that patients do not have to lose 100 lb to benefit their health; as little as 10 to 20 lb is often beneficial.

Kane: Many of my patients, predominantly the postmenopausal women, are frustrated because they cannot lose weight-despite their efforts, which are not just for cosmetic reasons. The American Academy of Family Physicians has recently passed a resolution urging insurance companies to classify obesity as a medical illness. As primary care physicians, we have to consider obesity as more than just a triage. We must treat the patient as a whole; weight is often the central problem causing the other medical conditions. At present, two things limit our ability to treat obesity effectively-lack of proper training, and time constraints. Managed care has put a tremendous burden on the practicing physician in terms of patient care; nutritional counseling, which is extremely important, requires more time than we currently have.

Heber: The good news is that meal replacements and portion-controlled meals currently enable patients to embrace those diet and lifestyle changes that actually work. We also understand, more than ever before, the physiology of exercise and the role of regular activity in weight maintenance. In addition, two new drugs have been approved by the US Food and Drug Administration (FDA) for weight loss- sibutramine (Meridia') and orlistat (Xenicall). With all of these treatment options, it is up to us, physicians, to recommend them to our patients.

Matalon: Indeed, even as little as a 5% weight loss can make a difference, by reducing the patient's diabetic, hypertensive, or thromboembolic profile.

Foreyt: And let's not forget the psychosocial profile.

Heber: Thousands of patients have been prescribed either a satiety agent (e.g., sibutramine) or a lipase inhibitor (e.g., orlistat) and have experienced significant weight loss. In a study we, performed at our center, we combined meal replacements with a satiety agent and got significant weight losses-up to 35 lb in 24 weeks This was also accompanied by a major amelioration of secondary risks.

Matalon: We are seeing a growing number of medical consequences associated with obesity. How do we treat obese patients with comorbid conditions such as gallbladder disease, sleep apnea, or respiratory conditions?

Kane: Obese patients are at greater risk for cholelithiasis because when people 'go on a diet, 'their gallbladder contracts less, which in turn causes stone formation in the bile. We currently have effective prophylactic treatments that prevent both formation of gallstones and the need for surgery.

Matalon: What about sleep apnea?

Heber: We frequently find ourselves in a vicious circle with obese patients who have symptoms of sleep apnea. Patients often overeat to keep themselves awake during the day after a sleepless night. If we do not identify the sleep apnea and treat it appropriately, it becomes very difficult to manage the obese patient.

Matalon: Sleep apnea has been shown to be associated with a interruption to rapid- eye - movement (REM) sleep; this contributes to a deficiency in REM sleep, which results in daytime fatigue. Has that been your experience too?

Kane: Indeed, this is the "catch-22" problem we face. We ask the patient to exercise, but she is too fatigued.

Heber: When advising on exercise or nutritional changes, it is important to adhere to whatever is practical. First, I try to get the patient to walk, and then I initiate some aerobic activities. Anybody can walk, or maybe garden; patients can take on simple physical activities in their leisure time.

Matalon: Obesity hyperventilation syndrome also plays a role in patients with low oxygen- carrying capacity, shortness of breath, fatigue, andlor noncardiac chest pain. Promyelocytic leukemia has also been linked to obesity. What do we know about malignancy in patients with obesity?

Heber: The American Cancer Society has studied over 750,000 persons and found that obesity is a risk factor for many kinds of cancers, including that of the breast, prostate, colon, kidney, ovaries, uterus, and gallbladder.' The culprits are not only excess fat or calories, but also the absence of fruits and vegetables- important phytonutrients and fiber-from the diet, and the lack of exercise. Therefore, when we talk about obesity, we are really talking about the entire picture of the patient who is concomitantly overnourished and malnourished.

Matalon: What can we add about clinical depression in this context, Dr Kane?

Kane: The obese patient who tends to be depressed turns to food for comfort. Such a person does not have strong self-esteem. This is why obesity and clinical depression often coexist; however, the question of what came first is often very difficult to answer.

Johnson: Many of my obese patients are depressed, and this interferes with their compliance to some extent. They lack the enthusiasm to get into any weight- reduction program.

Matalon: In conclusion, we can clearly say that obesity management has finally come to the forefront of medicine. The etiology of this condition is both genetic and acquired through a variety of coexisting metabolic conditions and physiologic, psychosocial, and socioeconomic changes. Understanding the morphology of this illness is essential to selecting a safe, physiologically based treatment protocol. As our panelists have poignantly illustrated, respect for this condition as a medical entity begins with the education of the treating physician