I had the chance last week to have a conversation with Dr Ronald Grossman, a New York-based Internist. I have known Dr Grossman for over 15 years – he is a frequent (and extremely helpful) participant in the research work I’ve done in the therapeutic areas of HIV/AIDS and Hepatitis. Dr. Grossman has been in practice in New York for over 30 years. Following is an edited transcript of my conversation with Dr Grossman.
Noah: What has been the impact of the obesity epidemic on your medical practice?
Dr. Grossman: As you know, I have a middle class practice in mid-town Manhattan so the amount of obesity that I see is going to be less than other areas of the US. You may not know this, but I was born and raised in Nebraska. When I go back and visit there, what catches my eye is that there is a lot more obesity apparent in middle America and in the South. When I go to the South for medical meetings and to give talks to other physicians, and I get out onto the streets, you start to see the real impact of the disease. You mentioned before that this is going to be a much bigger problem in the future – I would say that we are there already! There is a very substantial amount of obesity.
Worse is what this implies for medical care. I think about obesity as a kind of “turning upside-down” of where evolution was going to take our species: at first, we humans were very physically active, whether it was getting our next meal or fleeing from animals that preyed on us. The point is that we evolved to keep moving: our ancestors had to move to eat. You got moving or you got eaten! And we have turned all of that upside down. We know the factors: inactivity, sitting in front of the computer, and easy access to the worst kind of food. In the past, the richest person could not eat anywhere close to the kind of rich caloric foods that the poorest person can eat today.
Gout is a great example. Gout is genetic but is often triggered by eating rich foods. In the past, only the rich could afford rich foods, so gout was regarded as a disease or the upper classes. Now that we have made the same kinds of foods totally accessible to everyone, and cheap, gout has become more widespread. Let me give you an example. I had a relatively young man in my practice yesterday, in his mid-40’s, who has hypertension, type-2 diabetes, and gout. He is not even 50. And I know that no matter how hard I try, his future is likely to include cardiovascular disease and possibly renal disease (renal = pertaining to the kidneys). It is statically almost inevitable that no matter how well he is treated, he will encounter major problems in the future. Obviously he is obese. The best I can do for him medically is to stave off that day of reckoning.
Noah: From your standpoint, what factors are contributing most strongly to this epidemic?
Dr. Grossman: In my view, there are really three things. First is the obvious: go and spend a few hours shopping at Wal-Mart. The junk food is piled to the ceiling and is sold at bargain prices. They do have some fresh food, but you almost can’t find it for the mass display of the chips. I visited there a few weeks ago and saw people, perhaps 400 pounds or 500 pounds, on these motorized scooters because they can’t support their own weight.
The second is the lifestyle, which is basically inactivity. We talked about that. And the third is that physiology gets in the way of weight loss. I was walking up from the subway the other day behind a very large woman, and I was thinking about the question: how did she get fat in the first place? How did WE as a population get so fat? Let me say that there is certainly a phenotype. For me, no matter how hard I try, I cannot get fat. Others have the opposite problem. Once you become obese however, huge shifts take place in the body that make it extremely hard for people to lose weight. Hunger is more acute for overweight people.
Here is an example. An overweight patient of mine had a large birthday celebration and was taken by his family to one of New York’s best restaurants. He had a 3-course meal. After he left the restaurant, he went to a pizza shop across the street and ate 3 more pieces of pizza. His obesity has triggered a complex process of acute hunger, as if his body is saying, “I want more.” And he was simply answering his tummy. Once you get to be obese, for example, 25% over one’s normal BMI, mechanisms kick in: lowered metabolic rates, smaller production of insulin, insulin resistance… all of these things kick in. Why? Well, as we evolved as humans, this instinct is what protects us. So it’s a huge obstacle.
Where can we attack this problem? You can’t forbid McDonald’s or Wal-Mart from doing business. What we need to do is inculcate our children from an early age to live healthier lives, to make better nutritional choices, and to be active – to make activity an important part of their lives. It all starts with children. Right now, we only pay lip service to good nutrition and healthy lifestyle in schools. We are not teaching our children properly.
In my own practice, I have a very tough time getting my patients who are sedentary to start exercising. You and I have spoken before and I know that you do a lot of running. But I just have a challenge convincing my patients to simply walk a half a mile a way. If they just did that, there are so many benefits: cognitive, circulatory, almost every parameter that you could improve. For many people, though, walking a mile is a big deal. What I often say is, “where do you live, and where do you work?” I make the suggestion that they get off the subway one stop earlier, which is 9-10 blocks. In New York, as you may know, 10 blocks is a half a mile. What that might mean for people is getting up in the morning 10 minutes earlier. Even that recommendation is met with a lot of resistance. The point I am trying to make is: don’t be passive! Don’t be sedentary! There are so many little things that people could do if we could get the message across.
Noah: From a medical standpoint, what are the consequences of obesity? What have you seen in your own practice?
Dr. Grossman: This is actually information that is relatively new – and by that I mean in the last 10-12 years. Where is the first place that most people begin to deposit fat? It is the abdomen. This in turn has an evolutionary basis: that is the body’s storage place. The body stores fat in the abdomen and not in the legs because you need your legs to move, to escape from prey, etc. Visceral abdominal adiposity is different from the fat in the skin. This fat is deposited around the viscera – and you can see it on an MRI scan. This abdominal fat functions differently than the fat in the periphery, such as in the arms or legs And it functions as an independent endocrine organ. It increases insulin resistance, it raises blood pressure, and it increases all manner of pro-inflammatory cytokines. And these cytokines are thought to be the initiator of the pro-inflammmatory process which starts the most deadly process of all: atherosclerosis. We thought in the past that getting fat around the mid-section was a part of aging. What these people have, though, is an inflammatory condition that initiates the process that leads to coronary disease, carotid artery disease, renal disease and type 2 diabetes. All of that from abdominal fat!
Why did Mother Nature make us that way? Well, humans were designed to store fat as protection in times of privation. If you could go back 3,000 years, do you think you would see any obesity? If we invented a time machine and did that, you probably could not see obesity. We are describing an exceedingly difficult situation in the modern world.
Noah: You probably see both ends of the spectrum: those who are fat and those who are fit. What are the differences between these two types of individuals?
Dr. Grossman: That is a tough question! It is very easy to say “discipline,” “organization” and a good job. And yet obesity even tracks down and overcomes very successful people. So the underlying issue is not how disciplined and organized you are, but how well you break out of that mould, that sedentary life. I have confronted patients and said: “What if you had a financial proposition that looked like a sure thing in your business…and you do the exact opposite? What would you think of yourself? Now look in the mirror and tell me why you can’t apply that kind of discipline and thinking to your physical health?”
But that does not work. People get it, but they don’t know how to apply it. They understand … but they can’t apply it to themselves.
I have other patients who are in phenomenal health. Yesterday a gay couple was in my office and they have two children by surrogate. Both of these guys are very fit and their children are fit too. It’s incredible. The two parents go to the gym 5-6 times a week, they apply proper nutrition, and their kids are already following in those footsteps. Parents need to set a good example.
Noah: Do you regard obesity as a medical condition?
Dr. Grossman: Absolutely! Not only a medical condition but one that my profession does not rank equally with the consequences of obesity. We say, “Let’s treat the diabetes, the stroke.” But obesity is fixable in the vast majority of people – and not with magic pills! It is not addressed well by my profession due to time and reimbursement. This is a consequence of the fractured and fragmented medical system in this country. Obesity is a medical condition by any definition: it has an etiology, it has consequences, and it has its biomechanical features. Think of what this epidemic will do to the orthopedic side in the future!! Will we able to afford all of these artificial hips and knees, and the accelerated arthritis?
Noah: What makes people more willing to change their diets?
Dr. Grossman: Well, although it is a relative minority, when you pull someone through a cancer or through a heart attack, that life-changing event is often something that motivates people, especially younger folks. When you have an 80-year old who has had a heart attack, chances are you are not going to get a lot of weight reduction. The people who change are the younger people who have come through a crisis.
Last year, one of my patients was visiting his mother in the hospital. While he was there, he felt chest pain and a few hours later was getting stented. He understood what happened to him, and after the procedure he took steps to correct it. You would have to do a psychiatric profile to see why that worked. But isn’t that too bad that you have to suffer something bad to make a change?
Noah: At the level of policy, what do you think needs to be done to combat obesity in our society?
We need good leadership. What is intriguing is that if you look at the body build of our President, would it not be cool if he could do a fireside chat each week and talk about health and fitness?He himself is a healthy and fit person. He is very good on the basketball court. It would be incredible if we could get some leader to pick up that ball and communicate a motivating message about the importance of health. It is powerful when someone who people listen to starts giving that kind of advice. I don’t know where that guru is going to come from.
Noah: What do you think about diet pills?
Dr. Grossman: There are no really effective weight loss drugs available. The only things that remain on the market are Xenical, and its over the counter version, Alli. You recall how those drugs work and what some of the side effects are – so no one wants to take it. None of the centrally-acting drugs like fen-phen are available anymore, nor would you want to use them. They pushed the wrong button in the brain. The only drug that seemed to work but which did not make it through clinical development was rimonabant. They saw good success, but there was a lot of suicidal ideation seen in the trials, so they pulled the plug on it. So we do not have a single available effective “anorexo-genic” drug. All we are left with is “lifestyle change,” and as I have said, that is extremely difficult.
AN INTERVIEW WITH DR CYNTHIA OGDEN (Epidemiologist / Branch Chief, Analysis, CDC/NCHS National Health and Nutrition Examination Surveys)
I had the wonderful opportunity yesterday to interview Dr Cynthia Ogden, an epidemiologist who works within the analysis group at the US Centers for Disease Control and Prevention (CDC) that reports on the NHANES database. “NHANES” stands for the National Health and Nutrition Examination Survey and is a continuous tracking study started in the 1960’s to evaluate and track the overall health and nutritional status of people living in the US. It is the only nationally representative examination survey of its type. This means that the survey results are the most reliable data we have to look at such indices as height, weight, and thus calculated body mass index (BMI) within the US population, as well as studies of nutrition and physical activity (the survey also includes accelerometer data which is a measurement of physical activity).
Before proceeding to discuss our conversation, there are some important terms that are used in this piece that I will define up-front for purposes of clarity (courtesy of Merriam Webster & Wikipedia):
Epidemiology: A branch of medical science that deals with the incidence, distribution, and control of disease in a population.
Prevalence: The total number of cases of a disease in a given population at a specific time.
Survey: A comprehensive examination of an area or population for a particular purpose.
Self-Reported Study: A type of survey, questionnaire, or poll in which respondents read the question and select a response by themselves without researcher interference. A self-report is any method that involves asking a participant about their feelings, attitudes, beliefs and so on. Self-reporting in studies can have validity problems. For example, study participants may exaggerate symptoms in order to make their situation seem worse, or they may under-report the severity or frequency of symptoms in order to minimize their problems.
Body Mass Index: A proxy for human body fat based on an individual’s weight and height. Body mass index is defined as the individual’s body weight divided by the square of his or her height. BMI, which is expressed as weight in kilograms divided by height in meters squared (kg/m2), is commonly used to classify overweight (BMI 25.0–29.9), obesity (BMI greater than or equal to 30.0), and extreme obesity (BMI greater than or equal to 40.0). An on-line tool to measure BMI can be found on-line at http://www.cdc.gov/healthyweight/assessing/bmi/index.html
Following is an edited transcription of my conversation with Dr Ogden:
Noah: Thank you again for your time today. I appreciate this opportunity. To start with, please tell us a bit more about the mission or charter of your group within the CDC.
Dr Ogden: I work within a group that operates the NHANES database within the National Center for Health Statistics (NCHS), a branch of the CDC. NHANES is a wonderful resource that we have here in the US, a survey that was started in the 1960’s which continuously assesses the general health of the US population. We have a huge mobile exam center [pictured below] that goes around the country and the survey includes measurements of participants’ height and weight (through a physical examination). The survey also involves a 2-3 hour questionnaire administered in participants’ homes. What’s important about NHANES is that it includes measured data (as opposed to self-reported data). No other survey has nationally representative actual physical measurements. It is a big, big survey.
We look at peoples’ height and weight which allows the measurement of “body mass index” or “BMI.” BMI is not a perfect measurement since a person could conceivably be all muscle mass, but it serves as a good proxy for obesity in most cases. Participants’ height and weight are automatically entered into the database, which means there is less room for error. There is also a component of the survey that is nutritionally related.
Because the study is now conducted continuously, we can obtain an estimate of obesity in the US population every 2 years. The study is tasked with providing health and nutritional information for the entire US population.
Noah: Please tell me a bit about your own professional background.
I have a varied background. I have a Master’s degree and a PhD from Cornell University. I studied urban planning and have a minor in nutrition. I did my doctoral dissertation in Rwanda looking at the nutritional status of children there. Afterwards, I did some training in epidemiology and then did a post-doc at the New York State Health Department and then did a 2-year training programming in applied epidemiology (CDC’s Epidemic Intelligence Service program). My long-term interest has been in the nutrition area – I’ve looked both at under-nutrition when I was in Africa, and now my focus is more on over-nutrition.
Noah: We know that obesity is a growing challenge in this country. I have even read that 50% of the US population could be obese by 2030! Tell us about some of the drivers of this epidemic.
Dr Ogden: Before I answer that, there is one point I would like to clarify. While the prevalence of obesity in the US increased dramatically in the 1980’s and 1990’s, during the last decade we have seen a possible leveling-off. In fact, between 1999-2007, we saw no change among men and boys. So while there was dramatic growth in the 1990’s and 1980’s, that rate of growth is now slowing particularly in certain sub-groups.
Obesity is a multi-faceted problem: you cannot just point to one thing. Our diets have changed — we eat out of the house more often and our serving sizes have grown. Children has decreased milk intake and have increased their intake of soda. Genetics, that always plays a role, but the gene pool has not changed that dramatically over the past 20 years. It really relates more to diet and physical activity. Additionally, there is an increase in “screen time,” (i.e., time spent in front of the computer), while at the same time, less physical activity. Time dedicated to physical education (PE) in schools may play a role as well.
Noah: It seems as though the US faces a greater obesity problem than other countries: is that true?
Dr. Ogden: We do have among the highest obesity prevalence rates in the world, but at the same time the US is not unique in this challenge: obesity is a problem facing many other countries. Yet similar to the US, some other countries have also seen a slowing in the rate of obesity over the past decade.
It also depends on how you collect the data. In the US, we collect measured data. However, in some parts of the world, the data are self-reported which often means that people may under-report their weight and over-report their height. Men especially over-report their height. It is much easier to compare different countries when you are looking at measured data.
Noah: Are there certain groups within our population that are being impacted disproportionately by obesity, such as those in lower socioeconomic groups?
Dr. Ogden: There are certainly differences in the prevalence of obesity in different groups. For example, among adults, African-America women have a higher prevalence. Among children, Hispanic boys and African-American girls have higher rates of obesity. Lower income females have a higher rate of obesity than higher income females however there is no significant difference in prevalence by income among males. Those are some of the differences.
Noah: Are there any bright spots in the data? I think you were saying that obesity rates in certain sub-groups have not changed over the past decade…
Dr. Ogden: As I said, there was no change in obesity prevalence among women between 1999 and 2007. And among men, between 2005-2008 there was no change. So we may be seeing a leveling off in women and slowing rates of obesity in men.
Noah: At a national level, what is our government doing to address obesity?
Dr. Ogden: Well, I am sure that you’re familiar with the “Let’s Move” campaign being promoted by the White House. And there are a lot of different efforts, including a childhood obesity task force. Many additional efforts are being led by the CDC.
Noah: Does the NHANES database look at peoples’ attitudes, especially as it pertains to adopting a healthy lifestyle?
Dr. Ogden: . The survey includes diet behavior questions along with a 24 dietary recall questionnaire and questions on physical activity. At different times, the survey also has included measurement of physical activity by having people wear “accelerometers” for the day to get real information on their physical activity. Accurate measurement of diet still is difficult.
Noah: One of the folks who follows me on Tumblr asked me to discuss the topic of home cooked meals vs. meals eaten outside the home. What is your perspective on that?
Dr. Ogden: Again, that is a very complex issue. But in general people are eating away from the home more. The USDA has reported that the contribution of calories consumed outside of the home grew from 18% in the late 1970’s to 32% in the 1990’s. Food consumed outside the home is also a larger proportion of families’ monthly budgets. Those are the two ways in which we look at this.
Also, there are studies that demonstrate that food available outside the home often may be higher in fat and caloric content.
Noah: What are some of the factors contributing to childhood obesity?
Dr. Ogden: Well, they are many of the same factors as in adult obesity, related to diet and lack of physical activity. One trend we’ve witnessed since the 1970’s is that there has been a shift in what children drink. As I mentioned earlier, the consumption of milk has gone down and the consumption of carbonated soda has increased. If you looked at sugary drinks, the highest group of consumers are teenaged boys.
Noah: Do you have any other comments to share?
Dr. Ogden: The problem of obesity is massive, but the good news is that we are not seeing the rate of increases that we saw in the 1980’s and 1990’s. At the same time, we have NOT seen a decrease in the prevalence of obesity. However, this is something that affects us all. If you look at the distribution of body mass index, what you can see since the late 1970s is a shift to the right; if you look at the whole distribution of BMI, it shifted to the right. Even the lowest levels of BMI got higher. It is not every single person, but as a population this is a major challenge.
(I would like to acknowledge and thank Joachim Osther for his contributions to this piece.)
“ More than one-third of U.S. adults (over 72 million people) and 17% of U.S. children are obese. During 1980–2008, obesity rates doubled for adults and tripled for children. During the past several decades, obesity rates for all population groups—regardless of age, sex, race, ethnicity, socioeconomic status, education level, or geographic region—have increased markedly.
“ In 2008, medical costs associated with obesity were estimated at $147 billion; the medical costs paid by third-party payors for people who are obese were $1,429 higher than those of normal weight.
The inspiration for this e-journal came to me during an early-morning 5am run several months ago in New York’s Central Park. As I ran, relishing the quiet awakening of the city, the un-crowded streets, and the beauty of secluded places amidst a wall of surrounding edifices, an idea emerged and took root.
It was an enticing vision that has been my complete preoccupation since.
The vision is simply this: a society that is built and organized around a vigorous state of physical conditioning – where being healthy and fit are not just the realm of athletes, the military and high-achieving individuals, but all people. I envisioned a world where daily bodily exertion becomes as habitual as morning coffee – not taken to an extreme, but where our physical and mental wellbeing as a human value is elevated to national priority: a society dedicated to making wellness its guiding principle.
I rode the elation of this vision for a brief few moments, surrounding by other individuals – men and women – challenging themselves on foot, on bicycles, or on in-line skates. But discouragement set in quickly: these people sharing the early-morning euphoria of exercise are the exception not the rule. America is not going to get up at 5am every morning to exercise.
A few weeks later, I read a scary statistic (which was published in The Lancet, a prominent British medical journal): half of people living in the US will be obese by 2030. That amounts to 164 million people. At that time, the cost of treating all of the obesity related illnesses – type-2 diabetes, heart disease, cancer, etc. - could be as high as $66 billion dollars. Imaging those figures against the backdrop of today’s economic crisis is staggering. Who is going to pay for all of the sickness that will result?
The drivers the obesity epidemic are well-known: an increasingly sedentary lifestyle and mass consumption of cheap, carbohydrate-intensive food. We eat too much and exercise too little. Add to that the burden of burgeoning neuroses (depression especially) and the growing time-absorbing American pastime of social networking, and the situation appears more bleak. Take a look at the CDC website and one sees us becoming progressively heavier over the past 2 decades.
No one seems to be doing anything about it.
Before I continue with this, I feel it important to provide a brief personal biography of my own professional and personal journey, and to describe why I feel it necessary to write this e-journal.
I have spent my career focused on health care. Over the past 20 years, I have worked with all possible diligence and effort to assist biopharmaceutical companies to develop and commercialize medicines for life-threatening infectious diseases, especially HIV/AIDS and Hepatitis B and C. This experience brought me into contact with many of the best physicians and researchers in the field – and it has been a great honor to spend hours talking with and solving problems alongside these talented, altruistic individuals.
In less than a decade, I have witnessed a marvel of modern medicine: the drugs I have helped to launch have transformed HIV from a deadly illness into a chronic manageable disease like type-2 diabetes. As I wrote in a recent article, the major challenges that lie ahead in the treatment of these viral diseases have more with social science and less with biological science: the needs that exist span proper diagnosis, coordination of care, and (particularly in emerging markets), ensuring access to care.
From a personal vantage point, I have seen my own life and health transformed over the past 6 years due to a re-dedication to fitness – running in particular. After going through a divorce in 2006, I took up running both as a way to lose weight and to cope with the emotional challenges of the divorce itself. I quickly lost 20 pounds and felt myself to have a re-charged and ever-optimistic perspective on my life. Over the course of less than 2 years, I underwent a transformation from not being able to fit into any of the khakis sold in J Crew – they don’t sell a 42 waist pair of pants – to running a 5K race in approximately 18 minutes.
More recently, I have started to think about ways that I can personally become involved in addressing the enormous challenge of obesity in this country. Having fought and (on a daily basis), continuing to fight this formidable foe, I started cultivating a desire to something meaningful – helping others discover the life-changing advantage of being physically well. And the question I have been asking myself since those first euphoric moments of Central Park clarity is how to translate this vision into a national movement, and to build momentum for this idea. I encourage you to share you own stories, and I plan to share mine.