Weighty Matters: The Obesity Epidemic Keeps Advancing

A new federal analysis shows that the adult obesity epidemic in the United States keeps on getting worse.  Between 2007 and 2016, the percentage of the adult population that was obese increased from an already very high 33.7 percent to a staggering 39.6 percent.  And the rate of those severely obese increased from just under 6 percent to close 8 percent over the same time period (see figure).  Severe obesity is defined as a body mass index (BMI) of 40 or higher, which translates to someone 5'8" weighing 265 pounds or more.

The one silver lining of the new report is that obesity in youth appears to be staying relatively steady.  While rates of obesity in ages 2 - 19 years increased from 16.8 percent in 2007 to 18.5 percent in 2016, it was not to a degree that reached statistical significance.  

Still, the continuing trend in adult obesity remains extremely troubling - not only for individuals who suffer from increased risk of cancers, stroke, diabetes, heart disease, and lower quality of life but also for the nation as a whole that experiences higher health care costs and lost productivity. 

These numbers show us how important it is to keep up our efforts to address this issue - and in new and innovative ways.  We live in what many classify as an "obesigenic" society.  Technology, workplaces, and infrastructure are actively designed to cut down on physical activity. And ads and other cues that surround us encourage us to overeat - and often with unhealthy choices. 

Without diminishing the important innovations we've experienced as a society over the past decades, we need to harness our energy to address such unhealthy outcomes by making important changes at all levels of society - from schools and workplaces to neighborhoods and individuals to local and federal policies.  

Related posts:

Quick Nutrition Tips for Lowering the Risk of Colon Cancer

Eating to Lower Cancer Risk: Replacing Superfoods with Science

Large Study Further Confirms Overweight & Obesity Increase Risk of Premature Death

In Practice: What I Learned from Weighing Myself (Almost) Every Day

12 Little Things That Can Put a Hitch in Your Efforts to Keep Weight in Check - And Ways to Fix Them

by Hank Dart

Even in the middle of the roiling media cycle we're in, diet has still managed to break through and make headlines the past couple weeks. Probably the biggest recent story was the release of a paper in the Journal of the American Medical Association that found that around 40 - 50 percent of deaths in the United States from heart disease, stroke, and diabetes could be linked to unhealthy eating. Big culprits were eating too much sodium and processed meat, and not enough nuts, seeds, and fish rich in healthy fats.

Following on the heels of this was a paper in the journal Cancer Causes and Control by Isabelle Romieu of the International Agency for Research on Cancer (IARC), which detailed the key drivers of energy imbalance that lead to obesity. Energy imbalance, when it comes to weight gain, simply means consuming more calories than you need, which over time can lead to becoming overweight and possibly obese.

And, as many of us have frustratingly found, it doesn't take too many of these extra calories to put on weight, something Romieu and her co-authors highlight -

"Very small deviations from energy balance, on the order of 1 - 2% of daily energy intake, can result in large long-term change in body weight (~20kg)[Ed: ~44lbs]."

For a moderately active adult woman, for example, 1 - 2 percent is only about 20 - 40 extra calories a day. That's the splash of cream in a morning coffee, three ounces of sugary soda, or half a small cookie. Or looking at it from the other end, that's the calories burned by walking less than half a mile. Not much at all.

Clearly, the little things we do in relation to how we eat and how active we are can really matter, especially over time. So, let's take a look at some of the little things that can put a hitch in our best efforts to keep in energy balance.

 Most likely, we all have at least one or two -- and probably more -- that we do regularly. The good news: because they're little, or at least little-ish, they're sometimes not too hard to start to tackle. 

Why not begin today?

Eating too fast
It's a go, go, go world these days, and that mindset can transfer to our eating, too. But eating food fast can easily lead to overeating because our minds and stomachs need some time to synch up. You can quickly down two hot dogs, a shake, and large fries before your mind has had a chance to register the first hot dog and tell you you've had enough. Before you know it, you feel stuffed and may have eaten a 1,000 calories more than your body actually wanted.

The fix: Simply try to slow down at each meal. Take time between bites. Enjoy your food. This slower pace can put your stomach and mind in better synch and help you feel satisfied with less food.


Ordering "the works"
Steer clear of ordering anything with "the works." Along with "stuffed crust" and "extra whip," "the works" are two terrible words to utter when you're working to keep calories in check. Whether on a potato, hamburger, or dessert, "the works" is usually just a vehicle for extra calories you may not even enjoy all that much.

The fix: Try low-calorie toppings instead, like fresh fruit, tomatoes, or salsa.


Being swayed by advertising
Most food companies want to get us to eat and drink - and the more the better. And they spend billions of dollars a year on advertising to get us to do just that. So, it's important to try to develop a bit of media savvy when it comes to advertising, so we can make clear, objective choices about the food we eat.

The fix: When you see a food ad, just take a moment and ask yourself: Why is the company paying for this ad? Is the ad a true depiction of what buying and eating the food is like? Is the food a healthy choice for me and my family? Most of the time, the answers will speak for themselves.


Driving a lot
Many of us need to spend way too much time in cars -- or on buses or subways. It's just a fact of life. We have to get to and from work, pick up the kids, and run errands. But many times, we also take the car or other transportation when we could just as easily walk or ride a bike. And this cuts out a great opportunity to easily add some physical activity to our days.

The fix: If it's safe, try to do some errands on foot or by bike a couple times a week. Then, build from there.


Eating mindlessly
Most of us do some amount of automatic eating -- eating without really thinking about it because there's food in front of us, our favorite TV show is on, or it's a certain time of day. But such mindless eating, usually when we're not even hungry, can add a lot of extra calories to our days.

The fix: Just take a moment and think before you eat. Ask yourself: Am I actually hungry? If you're not, try to do something other than eating for while. Go for a quick walk, play a game, even do some chores or errands you've been putting off.


Throwing in the towel 
Set-backs are natural. We're human. But don't let set-backs frustrate you into abandoning your health goals - even for a day. Yes, you ate five pink cookies you hadn't plan to and missed your workout. That's OK. Keep the long view.

The fix: Stay positive and know that health is a journey. And journeys are rarely straight lines to a destination. There can be twists and turns. Just get back on track and keep moving forward -- knowing you can get where you want to be.


Drinking calories
A lot of beverages are packed with calories -- sugary soda, sweet tea, and many types of blended coffee drinks. On top of this, it's been shown that our bodies don't register these liquid calories as readily as those from food. So, we often don't compensate for beverage calories by eating fewer food calories. The result: extra calories in our day.

The fix: Choose water or unsweetened tea and coffee instead of sugary drinks. Start with just one or two days a week, but eventually try to get down to zero sugary drinks. It's probably not as hard as you think.


Being too refined
Being refined in life is wonderful, but eating too many refined grains is not. Refined grains -- which make up foods like white bread, white rice, and regular pasta -- have had most of their fiber and nutrients stripped out in processing. Diets rich in less-processed whole grains -- like, 100% whole wheat bread, brown rice, and old-fashioned oatmeal -- have been shown to help keep weight in check.

The fix: Try to start buying more whole-grain foods. There are a lot of options these days. Look for foods with "whole" or "whole-grain" as a first ingredient and not too much sugar (7grams/serving or less).


Avoiding the bathroom scale
Not many people enjoy stepping on the bathroom scale. But avoiding it for long periods can lead to unwelcome surprises. Weight gain has a way of sneaking up on people. An extra pound here and an extra pound there can really add up over time. Stepping on the scale weekly, even daily, can help us keep track of our weight and adjust how much we're eating and how active we are.

The fix: Set a date with your scale -- every Tuesday at 7am, say -- and keep it. Want to go a step further? Keep track of your weight with a paper log or smartphone app.


Ignoring calorie labels
One thing's clear by now: calories matter. And although it's not essential to painstakingly track how many calories are in the food we eat, it can be helpful to have a general idea. Some meals, especially when we're eating out, can have a surprisingly large number of calories, at times bordering on a whole day's worth.

The fix: Many restaurants and fast food places post calorie-counts on menus, so they're pretty easy to find. Given them a quick read before you order, so you know what you're getting, and adjust if you need to.

Eating out for lunch - a lot
Eating lunch out -- whether at a restaurant, fast-food place, or food truck -- is often fun, tasty, and easy. But there can be downsides, too. It can be unhealthy, expensive, and calorie-packed.

The fix: Try to brown-bag it more often. Packing your lunch with healthy foods, in modest portions, means you're more likely to keep calories in check.


Waiting 'til tomorrow
Trying to get on a healthier path -- whether it's walking more or eating more fruits and vegetables -- isn't always easy. So, it's natural to want to put things off. And a day here or a day there may not make much difference, but the more you put things off, the more likely you are to keep putting things off. The sooner you get started on a healthier path, the sooner it'll become second nature to you, and the sooner you'll start getting benefits.

The fix: Try a new healthy behavior today, no matter how small it may seem. It can be buying a banana at lunch or walking to a bus stop that's further away than usual. Then keep it up, building over time with other healthy changes. 

You've got this.

Photo: A Tall Glass of Water by Enid Martindale (CC License, CC BY 2.0)

Large-Scale Problem: Obesity Rates Still Increasing in Certain Groups

by Hank Dart

The course of the obesity epidemic in the United States has been so bad for so many years that even minor victories have been cause for celebration. But despite some bright spots in the most recent Centers for Disease Control and Prevention reports on national rates of obesity (on adults, on youth), there's little celebrating going on.  The reason?  Some striking milestones in the rates of obesity in both women and teenagers.

The rate of obesity in US women -- which for most of the past decade rested around 35 percent -- has now surpassed 40 percent -- rising from 35.7 percent in 2005/6 to 40.5 percent in 2013/14, the most recent years for which there are data. And this overall number doesn't tell the complete picture, as the burden of obesity isn't shared equally across all groups.  The rate of obesity is around 38.2 percent in white women, 46.9 percent in Hispanic women, and 57.2 percent in black women.  Asian women have the lowest rate, at around 12.4 percent.

While the numbers in men are concerning as well, they've stabilized somewhat over the past decade, bouncing around the mid-30s, with the most recent report finding that 35 percent of men in the United States are obese. As with women, the numbers for men vary by age, with Asians having the lowest rate (12.6%) and blacks the highest (38%).

The new numbers for youth are not quite as striking - but remain concerning as well.  They show that over the past 25 years the rate of obesity in adolescents and teenagers has nearly doubled -- from 10.5 percent to 20.6 percent -- with the overall rate of obesity in youth ages 2 - 19 years old now at 17 percent, up from 10 percent in 1988.

There are, however, two positive trends in younger kids, with rates of obesity dropping since 2004 in 2 - 5 year olds and leveling off since 2008 in 6 - 11 year olds.

The overall picture of obesity in America, however, can be quite discouraging, even for the optimists who tend to work in public health. The epidemic began over two decades ago, and no efforts so far have been able to make real strides in reversing it. And the health, quality of life, and fiscal implications are enormous.

In a recent Viewpoint in the Journal of the American Medical Association, David Ludwig, MD of Harvard Medical School and the New Balance Foundation Obesity Prevention Center writes that the latest evidence may support predictions that the obesity epidemic and its health consequences may begin to shorten life expectancy in coming generations. While advances in the treatment of obesity-related chronic diseases like heart disease, diabetes, stroke, and cancer have kept mortality rates of these disease relatively stable or on the decline, a new provisional report on death rates suggests that mortality rates may now be increasing for some diseases.  The obesity epidemic could be creating more disease, and more serious disease, that advances in treatment can no longer keep up with.

Making progress against the epidemic is going to be essential if we are to help prevent growing rates of disease in the years and decades ahead.

In addition to bolstering research on the causes and prevention of weight gain, we need to support efforts that help people make and maintain healthy food and activity choices.  As with the fight against tobacco, this means multi-pronged, multi-layered approaches - such as improved food and activity offerings in schools and workplaces, taxes on unhealthy foods, subsides for healthy foods, widespread communication campaigns, and infrastructure that allows people to easily and safely fit activity into their days.  The social, financial, and structural environment that surrounds us is key to making and sustaining healthy behaviors.

Stemming the tied of weight gain in the US will not be easy, but it's essential that as a society we garner the will to put in place a concerted effort that will benefit current and future generations.

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See also:

Other Cancer News in Context posts addressing cancer, chronic disease, and weight.

8 Ways to Lower Colon Cancer Risk in One Simple Graphic

by Katy Henke

Colon cancer is the third most common cancer in the United States. The good news is that 75 percent of cases could be prevented with healthy lifestyle choices. These eight simple tips can help you lower your colon cancer risk and improve your overall health (PDF). For more information and prevention tips, visit 8ways.wustl.edu.

(PDF)

Obesity shortening life among breast cancer survivors, national US data

Obesity is a strong driver for postmenopausal breast cancer. Consistent data from around the world show that overweight and obese women are at increased risk of breast cancer through their postmenopausal years. It is estimated that obesity causes more than 10% of postmenopausal breast cancer. Mechanisms for this include higher circulating estrogen levels among overweight and obese women compared to lean women, and insulin pathways. After menopause the ovaries are less active, and fat cells produce estrogen. Obesity is also related to mortality from many other causes (heart disease, stroke, diabetes, etc.). To put the breast cancer burden in context and evaluate the population health impact of breast cancer on lifespan Dr. Chang and colleagues draw on US National Health Interview Survey data and the linked mortality data. They then estimate life expectancy for women who are normal weight and obese, and the life years lost to breast cancer (see report).

The national data show that the life years lost among women diagnosed with breast cancer are greater for younger women than those diagnosed at older ages. This makes good sense. In addition, obese women with breast cancer had greater loss of life than non-obese women. For example, women who were obese and diagnosed with breast cancer before age 50 lost on the average 9.8 years compared to non-obese women who lost 7.8 years. For women diagnosed after age 70 obese women lost approximately 5 years and the nonobese 3.7 years. This pattern was also seen in analysis of African American women.

Choosing measures for evaluation of population level health remains an area that the National Academy of Sciences continues to address. They have recommended life expectancy and quality of life as appropriate measures for population health. This report, evaluating life years lost associated with breast cancer applies this framework. The data clearly support a greater emphasis on the prevention and control of obesity given its impact on this the second most common cause of cancer mortality in women.

Obesity Cuts Life Short

More than 15 yeas ago we showed conclusive evidence that obesity causes many chronic conditions in the US population1-3 -, that weight gain increases risk of diabetes 4-6, heart disease 7, breast cancer 8, and that this burden adds up quickly, even before we get to overweight, let alone obesity. In the New England Journal of Medicine (report) we summarized some of this evidence 9.

With a cut off of BMI at 25 defining overweight, we see that risk of diabetes, gall stones, and high blood pressure and heart disease are all elevated, and the risk continues to rise with higher levels of adiposity or BMI. This is true in the first figure – showing the relative risks for women, and in the second for men.

Relative Risk of Diabetes, and other chronic conditions by level of Body mass Index (BMI)

Women




Men




We recently completed and analysis of national data to predict life years lost associated with obesity-related diseases for U.S. non-smoking adults, and to examine the relationship between those obesity related diseases and mortality.10 We used data from the National Health Interview Survey, 1997-2000 (see report).

We analyzed these data to estimate the association between those obesity related diseases and mortality and used simulations to project life years lost associated with the diseases.

What did we find?

We found that obesity-attributable comorbidities are associated with early mortality that leads to large decreases in life years and increases in mortality rates. The life years lost associated with obesity related diseases is more marked for younger adults than older adults, for blacks than whites, for males than females. Furthermore, the magnitude of life years lost increases with increasing level of obesity.

Using U.S. non-smoking adults aged 40 to 49 years as an example to illustrate percentage of the life years lost associated with disease caused by obesity, we found that the mean life years lost for U.S. non-smoking black males aged 40 to 49 years with a body mass index above 40 kg/m2 was 5.43 years. This translates to a 7.5% reduction in total life years lived. White males of the same age range and same degree of obesity lost 5.23 life years on average - a 6.8% reduction in total life years. For black females the numbers are: 5.04 years, a 6.5% reduction in life years, and white females they are: 4.7 years, a 5.8% reduction in life years.

Overall, diseases caused by obesity increase the chances of dying and lessened life years by anywhere from 0.2 to 11.7 years depending on gender, race, BMI classification, and age. The effect of obesity related diseases on mortality is shown for each age group in the figure below.



The epidemic of obesity in the US continues to carry a heavy burden for society 11,12, on our health care system 13,14, our businesses 15, and on our families.

References

1.         Willett W, Dietz W, Colditz G. Guidelines for healthy weight. N Engl J Med. 1999;341:427-434.

2.         Colditz GA, Coakley E. Weight, weight gain, activity, and major illnesses: the Nurses' Health Study. Int J Sports Med. Jul 1997;18 Suppl 3:S162-170.

3.         Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. Oct 27 1999;282(16):1523-1529.

4.         Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes in women. Ann Intern Med. 1995;122:481-486.

5.         Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care. 1994;17:961-969.

6.         Colditz GA, Willett WC, Stampfer MJ, et al. Relative weight and increased risk of diabetes in a cohort of US women (abstract). Am J Epidemiol. 1987;126:750-751.

7.         Willett WC, Manson JE, Stampfer MJ, et al. Weight, weight change, and coronary heart disease in women: risk within the 'normal' weight range. J Am Med Assoc. 1995;273:461-465.

8.         Huang Z, Hankinson SE, Colditz GA, et al. Dual effects of weight and weight gain on breast cancer risk. JAMA. 1997;278(17):1407-1411.

9.         Willett WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med. 1999;341:427-434.

10.      Chang SH, Pollack LM, Colditz GA. Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults. PLoS One. 2013;8(6):e66550.

11.      Oster G, Thompson D, Edelsberg J, Bird AP, Colditz GA. Lifetime health and economic benefits of weight loss among obese persons. Am J Public Health. Oct 1999;89(10):1536-1542.

12.      Colditz G. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31:S663-667.

13.      Thompson D, Edelsberg J, Colditz G, Bird A, Oster G. Lifetime health and economic consequences of obesity. Arch Intern  Med. 1999;159:2177-2183.

14.      Thompson D, Brown JB, Nichols GA, Elmer PJ, Oster G. Body mass index and future healthcare costs: a retrospective cohort study. Obes Res. Mar 2001;9(3):210-218.

15.      Thompson D, Edelsberg J, Kinsey K, Oster G. Estimated economic costs of obesity to U.S. business. Am J Health Promot. 1998;13:120-127.

Transdisciplinary Energetics and Cancer (TREC)

Obesity and cancer?

Why are we meeting in Philadelphia?

These are question not commonly asked on our CNiC blog. Let me explain a little of our new center on obesity and cancer, and link you to our related resources.

NCI convened the first meeting of funded centers working together on issues relating energy balance, obesity, and cancer. My role at this meeting with Sarah Gehlert, leading our TREC at Washington University in St. Louis was to provide an overview of our Center and the projects we have embarked upon to address obesity and cancer, with a particular focus on translating our findings to the burden of cancer in Missouri. See our web site. 

Our 5-year funding sets us in motion to bring faculty together across our university and with neighbors across our state to move forward counteracting the burden of cancer due to obesity. We have previously written on just how great this is for our nation.(see Obesity and Cancer. Wolin, et al. 2010.) Now we are linked to colleagues in other centers to learn from our collective efforts. 

The quick summary of our center is available through this link. "Transdisciplinary Center Approach to Examine Multilevel and Multigenerational Associations Between Obesity and Cancer". 


Over the coming months we will add updates on progress as we expand our research and translation to practice to address obesity and prevent cancer.

Obesity, hormones, and breast cancer

We continue the theme of progress in understanding the causes and potential for prevention of cancer. This understanding has advanced substantially over the 30 years since Doll and Peto published their landmark report. Today I return to obesity, hormones, and breast cancer.

Doll and Peto noted that obesity was related to increased risk of postmenopausal breast cancer and that excess death might in part be due to later diagnosis of breast cancer among obese women. At that time the data were limited and the assumption was that this relation of obesity to breast cancer was through higher circulating estrogen levels¹. A new report from a collaborative reanalysis of 13 studies attests to how much data has been collected since that time. A detailed analysis of blood levels of hormones in over 6000 postmenopausal women reports the relations between obesity and numerous circulating sex hormones (see report).  Among the obese women, compared to lean women, the largest difference was seen for free estradiol. The blood level of estradiol is strongly related to risk of breast cancer in postmenopausal women ². Of note, women who reported bilateral removal of ovaries had lower testosterone levels than those who had natural menopause. This lower hormone level along with lower estrogen levels is consistent with the protective effect of surgery to remove ovaries on risk of breast cancer.  

Overall these data show that circulating sex hormone concentrations in postmenopausal women are strongly associated with established risk factors for breast cancer and likely mediate the effects of obesity on breast cancer. Further evidence in support of the pathway from obesity to hormone levels and then risk of breast cancer comes from the reanalysis of cohort studies, which show that the major effect of obesity could be explained through the circulating estrogen levels ³.

The 2002 IARC prevention report on weight control and physical activity clearly documented the importance of obesity for cancer mortality in men and women. The evidence accumulated over the past 30 years now gives a pathway and improved understanding of how obesity causes breast cancer. Strategies to avoid weight gain and promote sustained weight loss are essential components of any cancer prevention program at both the local and national level.

Literature Cited

1.         Doll R, Peto R. Avoidable risks of cancer in the United States. J Natl Cancer Inst. 1981;66:1196-1265.

2.         Missmer SA, Eliassen AH, Barbieri RL, Hankinson SE. Endogenous estrogen, androgen, and progesterone concentrations and breast cancer risk among postmenopausal women. J Natl Cancer Inst. Dec 15 2004;96(24):1856-1865.

3.         Key T, Appleby P, Barnes I, Reeves G. Endogenous sex hormones and breast cancer in postmenopausal women: reanalysis of nine prospective studies. J Natl Cancer Inst. Apr 17 2002;94(8):606-616.

Obesity increases risk of multiple myeloma – overwhelming evidence.

In our Prevention Snapshot we refer to data from a thorough analysis reported by Renehan who combined prospective cohort data separately for men (7 studies) and women (6 studies) and observed a significant increase in relative risk of 1.11 for a 5 unit increase in BMI for men 1. This meta-analysis also reported no meaningful variation in the results among the studies evaluating BMI and multiple myeloma. 

A subsequent updated analysis reported in full this summer by Wallin and Larsson 2 also summarize the prospective studies evaluating the association of body mass index and the risk of being diagnosed with multiple myeloma. For this study the authors searched for and identified published studies through January 26, 2011. A total of 20 studies (15 on incidence of multiple myeloma and 5 on risk of mortality) were included. Compared to individuals in the normal weight category, the risk of multiple myeloma was statistically significant for the overweight (RR, 1.12; CI, 1.07-1.18) giving a 12 percent increase, and for obese men and women (RR, 1.21; CI, 1.08-1.35), a 21 percent increase in risk compared to average weight adults. The risk estimates for mortality from myeloma were somewhat higher.


Why does this matter?
As I recently noted, 30 years ago when Doll and Peto reviewed the evidence on causes of cancer 3, and considered overweight under the category of nutrition (over-nutrition), they did not separate out any clear link to specific cancers or a percentage of all cancers that could be avoided through healthy weight maintenance. In the past 30 years the study of weight, weight gain, overweight obesity and cancer has refined our understanding of how much cancer is caused by excess gain in weight over adult years.

The association between cancer and obesity is now well established in the literature. The 2002 IARC report on Prevention Report on Weight Control and Physical Activity listed obesity and lack of physical activity as causes of cancer incidence and mortality 4. Specifically, obesity was described as a cause of esophageal, colon, uterine, kidney and post-menopausal breast cancer. Data from the ACS Cancer Prevention Study II, which followed more than 1 million men and women for an average of 16 years, showed an additional link to cancers of the prostate and pancreas, as well as to non-Hodgkin lymphoma and myeloma 5. That study concluded that 16–20% of cancer deaths among women and 14% of cancer deaths among men were attributable to obesity. Furthermore, the IARC monograph also reported that there was sufficient evidence to conclude that lack of physical activity increased the risk of breast and colon cancer — two of the most cancers in the US.

Since that report, numerous additional studies have been published and the synthesis by Wallin brings the data into sharp focus for myeloma.

We can now be confident in understanding that obesity causes many cancers (see our report on obesity and cancer. We note that the evidence is consistent across many studies, conducted in the US, Europe, Australia, and Asia. As we note in our Knol on Obesity, many chronic conditions are caused by excess weight and the burden to society is substantial. Myeloma is now yet another malignancy that is caused by excess weight. Our quick tips for keeping weight in check can help us all moving forward.

Related CNiC Posts

Obesity, Diabetes, and Cancer

Obesity: Disturbing Rates Even if Trends Show a Glimmer of Hope

Obesity Causes Lymphoma and Myeloma

Literature Cited

1. Renehan AG, Tyson M, Egger M, Heller RF, Zwahlen M. Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies. Lancet. Feb 16 2008;371:569-578.

2. Wallin A, Larsson SC. Body mass index and risk of multiple myeloma: A meta-analysis of prospective studies. Eur J Cancer. 2011;47:1606-15.

3. Doll R, Peto R. The Causes of Cancer: Quantitative Estimates of Avoidable Risks of Cancer in the United States Today. New York: Oxford University Press; 1981.

4. International Agency for Research on Cancer. Weight Control and Physical Activity. Vol 6. Lyon: International Agency for Research on Cancer; 2002.

5. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. Apr 24 2003;348(17):1625-1638.

Study of 1.4 Million Shows Early Deaths Linked to Overweight & Obesity - What Now?

In what in many ways is a definitive study on the topic, a very large analysis of 1.46 million adults further confirms that overweight and obesity significantly increase the risk of mortality (study). The analysis by Berrington de Gonzalez and colleagues, which appears in the New England Journal of Medicine today, pooled together data from 19 prospective studies that followed participants over time - noting participant's body mass index (BMI) and keeping track of participant deaths.

Because health status and smoking status can have an impact both on weight and mortality - sick people often lose weight, and smokers are often lean and prone to dying earlier than non smokers - researchers focused their analyses on participants who were both non-smokers and healthy at the study's start. The goal was to get a truer reflection of the impact that weight could have on health.

What they found was that as BMI increased above the normal range (BMI = 18.5 - 24.9), the risk of premature death went up. Those in the overweight category (BMI = 25 - 29.9) had a 13 percent higher risk compared to those with a BMI of 22.5 - 24.9. Those in the obese category (BMI = 30 - 34.9) had a 44 percent higher risk. While those in the super obese categories with a BMI between 35 - 39.9 and 40 - 49.9 had an 88 percent increase and more than double the risk, respectively. (BMI Calculator).

As found in some other studies, there was also some increase in risk for those who fell in the underweight category (BMI = 15 - 18.4) and in the lower end of the normal range (BMI = 18.5 - 19.9). The data suggest though, that these numbers may be capturing some residual health issues, possibly undiagnosed illness which causes some of this increase in risk among the very lean. Those participants in the underweight category who were regularly active - a marker for good health - had less of an increase in risk than those who weren't active. That the risk linked to underweight largely went away after 15 years of follow-up is another indicator that pre-existing illness may be at work in the group.

Perhaps the most notable finding from the paper is a clear and sustained increase in mortality seen in folks who fall in the overweight category (BMI = 25 - 29.9). Some previous results from some big studies, such as Flegal et al, 2007, found no increase in mortality in this category, most likely because they did not exclude smokers and those with illness as the current paper did.

What this new analysis clearly shows is that maintaining a healthy weight has real health benefits. While there will always be news stories and select journal articles calling into question the true benefits of a healthy weight, this paper shows that in the face of our growing obesity epidemic, where 66 percent of the US population is overweight or obese and therefore at increase risk of pre-mature death, we need to put to rest the question of whether overweight impacts health and start to answer in ernest the question: what are we going to do about it?

Related CNiC Posts
Weight
Diet
Exercise

Related Web Resources
Obesity: Economic Burdens and Costs (Graham A. Colditz, MD, DrPH)
Harvard's Nutrition Source

Lost in a Food Desert? Where Do You Buy Your Veggies?

This morning, I had the extreme pleasure of hearing Dr. Bill Dietz of the CDC's Division of Nutrition and Physical Activity in the Center for Chronic Disease Prevention and Health Promotion speak about Policy and Environmental Changes to Prevent and Control Obesity at the Washington University School of Medicine Grand Rounds. Dr. Dietz touched on many topics, but one that stood out to me was the focus CDC has on its list of priority strategies to address important health behaviors: increasing access to fruits and vegetables through retail stores.

I'm sure many of my fellow news junkies saw the NY Times Magazine story about Walgreens' new program to eliminate food deserts. A food desert the NY Times describes as "urban neighborhoods where there are few grocers selling fresh produce, but a cornucopia of fast-food places and convenience stores selling salty snacks (though, strictly speaking, the term can be applied to rural or suburban areas, too). Often the problem afflicts low-income areas abandoned or shunned by food businesses that focus on better-off consumers"

Food deserts are a problem that numerous non-profit and community groups have worked to tackle. Most notable is probably the Food Trust based in Pennsylvania. The Food Trust work has expanded to other states and has had some notable successes in encouraging supermarket development and expanded farmers' market programs. Perhaps it shouldn't be surprising then that when the US government announced the $400+ million Healthy Food Financing Initiative to bring grocery stores to underserved communities, it did so in Philadelphia.

Do big intiatives like this work? The general consensus is cautious optimism. Certainly having the White House behind programs like this is a big deal. But, as Marion Nestle noted, voluntary programs such as these don't always move us very far in the path to healthier communities. That businesses are seeing an opportunity here, perhaps points to some real movement (even if the cynic in me points out that this is about the bottom line for any business). I'm looking forward to seeing Walgreens provide some data on the successes (or not) of their program, something the Times article notes it has been unwilling to do so far. I'm also curious to see more data on whether these programs change fruit and vegetable intake, and ultimately rates of associated comorbidities, like obesity. Economic disparities have a big effect on food choices and the economic challenges facing families will be a big driver of our success in food access and numerous other health challenges.

That beer belly may be worse than you thought

That obesity had deleterious health consequences isn’t news, especially around here. Yet, we still find the results of a study out of Australia, published in Cancer Epidemiology Biomarkers and Prevention this week on weight gain and colon cancer risk compelling. Most adults experience weight gain over the course of their lives and this weight gain, even if your BMI remains within the “normal” range, can increase your risk of colon cancer. Bassett and colleagues found that each 5 kg (11 lbs) of weight gain in men significantly increased risk of colon cancer. Reports on the effects of weight gain for women are less consistent, and this report found no association.

Why might gender matter? Men and women tend to gain weight differently in adulthood. Men, in particular, tend to see a shift in body fat from the periphery to the trunk - that is, they put more weight around the middle - something called abdominal adiposity, or abdominal obesity if it gets bad enough. This central weight gain may be a stronger predictor than overall weight of cancer risk (along with other health outcomes). Abdominal obesity is associated with hyperinsulinemia, which likely plays a role in colon cancer risk. Men tend to accumulate more visceral fat.

Does this mean women are off the hook? Sadly, no – as regular CNiC readers have surely realized by now – “cancer” isn’t one disease with uniform risks. And weight gain increases risk of breast cancer in women as we’ve discussed before. So the findings on colon cancer are evidence that EVERYONE benefits from avoiding weight gain.

And since avoiding weight gain is easier than losing weight once you’ve gained it, watching weight gain is a good strategy for all of us.

Health and economic burden of obesity

As the prevalence of overweight and obesity continues to climb, the challenges of quantifying the impact of this epidemic to inform public policies and health services becomes more pressing. The consequences of obesity on population health are far-reaching—as demonstrated in extensive analyses of health and economic consequences. For example, Calle and colleagues reported data from over 900,000 men and women in the American Cancer Society Cancer Prevention Study II showing excess mortality from cancer among obese men and women ¹. Stewart and colleagues project the effects of obesity on life expectancy in the US and note that the adverse effect of obesity will outweigh any gains from smoking cessation ². Fontaine and colleagues estimate that obesity substantially lessens life expectancy for US adult. For those age 20 expectancy can be reduced by up to 17% ³. In sum, excess mortality observed with increasing levels of obesity can be summarized in a number of ways to guide polices and practices that may prevent weight gain in adult years and reduce the burden of obesity.

Who Bears the Economic Costs of Obesity?

Most of the early cost estimates took a societal perspective; nonetheless, partitioning the total burden of obesity to different sectors that share the costs provides incentives to address the distribution issue and adopt preventive strategies. In particular recent work by Finkelstein and colleagues shows just how much of the burden is carried through to payers who support medicare where obese individuals have higher costs than normal weight individuals ⁴. 

Costs for employers have been reported by Finkelstein et al. ⁵ and by Thompson et al.⁶. Finkelstein et al. used data from two national samples of full-time employed adults ⁵. They estimated that overweight- and obesity-attributable costs ranged from $175 to $2485 dollars per year depending on the degree of overweight and gender, approximately 30% of these costs result from increased absenteeism. Although those with Class-III obesity represent only 3% of the employed population, they account for 21% of the costs. Another important work by Finkelstein et al. quantifies the costs to tax payers. They found that, in 1998, total medical bill due to overweight and obesity might have been as high as $78.5 billion in the United States. Medicare and Medicaid finance approximately half of these costs, private insurance pays 30%-40%, and roughly, 15% paid out of pocket⁷. The increase in the medical conditions (such as hypertension and hyperlipidemia) treated among obese individuals has been suggested to be a key determinant of increased spending from private health insurance ⁸.

Using the 2006 medical expenditure panel survey, Finkelstein and colleagues show that the annual cost of obesity among full time employed individuals is $73.1 billion. 61% of these costs are incurred by those over a BMI of 35 kg.m2, who represent just 37% of the obese population ⁹.

The evidence is overwhelming that excess weight is associated with increased morbidity and mortality. Current estimates of economic expenses related to excess weight clearly underestimate the true costs to society. To date, the majority of these estimates have evaluated only a narrow range of overweight- and obesity-related illness; they have not included factors, such as the impact of reduced physical functioning ^10-12; and many have not accounted for the effects on those who are overweight but not obese. With the rising prevalence of overweight and obesity, we will continue to see growing effects and mounting costs on the individual, our communities, and our society as a whole. Finkelstein argues that obesity results from market forces, technologic advances that lower the cots of behaviors that promote obesity (inactivity at work, TV viewing, etc), and that obesity prevention efforts therefore must make it easier and cheaper to follow a healthy diet and engage in regular physical activity ¹³. 

Related CNiC post

Untapped benefits of physical activity

Obesity epidemic: Let's move from media attention to action

Literature cited

 

1.         Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. N Engl J Med. Apr 24 2003;348(17):1625-1638.

2.         Stewart ST, Cutler DM, Rosen AB. Forecasting the effects of obesity and smoking on U.S. life expectancy. N Engl J Med. Dec 3 2009;361(23):2252-2260.

3.         Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB. Years of life lost due to obesity. JAMA. Jan 8 2003;289(2):187-193.

4.         Finkelstein EA, Trogdon JG, Brown DS, Allaire BT, Dellea PS, Kamal-Bahl SJ. The lifetime medical cost burden of overweight and obesity: implications for obesity prevention. Obesity (Silver Spring). Aug 2008;16(8):1843-1848.

5.         Finkelstein E, Fiebelkorn C, Wang G. The costs of obesity among full-time employees. Am J Health Promot. Sep-Oct 2005;20(1):45-51.

6.         Thompson D, Edelsberg J, Kinsey K, Oster G. Estimated economic costs of obesity to U.S. business. Am J Health Promot. 1998;13:120-127.

7.         Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity: how much, and who's paying? Health Aff (Millwood). Jan-Jun 2003;Suppl Web Exclusives:W3-219-226.

8.         Thorpe KE, Florence CS, Howard DH, Joski P. The impact of obesity on rising medical spending. Health Aff (Millwood). Jul-Dec 2004;Suppl Web Exclusives:W4-480-486.

9.         Finkelstein EA, DiBonaventura M, Burgess SM, Hale BC. The costs of obesity in the workplace. J Occup Environ Med. Oct 2010;52(10):971-976.

10.         Coakley E, Kawachi I, Manson J, Speizer F, Willett W, Colditz G. Lower levels of physical functioning are associated with higher body weight among middle-aged and older women. Int J Obesity. 1998;22:958-996.

11.         Fine J, Colditz G, Coakley E, et al. A prospective study of weight change and health-related quality of life in women. JAMA. 1999;282:2136-2142.

12.         Fontaine K, Cheskin L, Barofsky I. Health-related quality of life in obese persons seeking treatment. J Fam Pract. 1996;43:265-270.

13.         Finkelstein EA, Strombotne KL. The economics of obesity. Am J Clin Nutr. May 2010;91(5):1520S-1524S.