Obesity Survey

[Fizzwizz]

Fizz - I see you are working in Swansea - i think they are only doing around 20 ops per year.

12 this year, which is far short of the 350 recommended in the NICE guidlines!

Go and talk to the dietitians - they see people regularly eating more than double their requirements - with very high fat intakes and alot of sucrose..

Indeed, people eat too much and often the wrong types of food. I've spoken to dieticians whose role is invaluable in the NHS for a variety of roles, but the evidence shows that their intervention has liitle impact on obesity

I also think in general that people are getting less and less active - that is an underlying cause. Exercise programs may not work because for the rest of the day most people are sitting down ! There is no doubt that unless people want to change you will not make any progress.
My worry is for the kids who are over wt and parents who are feeding them rubbish!

Again, this is the myth. There is no doubt that most of aren't doing enough exercize, exercize is definitely healthy and aids weight loss, but it doesn't have an impact on obesity. there are numerous very active people who are obese (i ran the Llanelli 10k last year). If someone is overweight by a stone or two, then eating better and getting more exercize will probably be enough. But if you're 5 stone overweight it won't, not in the long term.

Surgery is not the answer for the vast numbers and dealing with the issues why people eat is. Often it is due to lack of understanding, boredom etc.
Often tacking the issues around overeating will bring success but there isnt enough help out there .

There are some psychological conditions that cause weight gain, and these are screened before surgery is considered. The point is that people over eat. You make the point of boredom, but slim people get bored to and don't eat. Why is this? It's because eating gives pleasure .. I'm sure we all agree. So the assumption made is that we are over indulging .. we don't know when to say "enough pleasure now else I'll get fat". The truth is that we only gain pleasure from food if we are not sated. Slim people don't graze because they won't get pleasure from it. They are not denying their lack of satiety.
We blame the grazing on a variety of things like boredom, but the core truth is that we shouldn't be hungry, the thought of that packet of crisps should make us feel green at the guills, .. but alas for me it doesn't.

The only time I stop grazing is when I have something to take my mind of it, the same way as something can take my mind of my toothache for a while. My tooth doesn't hurt because I've nothing to do, it just becomes harder to ignore.

 

[saz1]

You may call it hunger, that may be what it has been named as. I completely disagree there, a book cannot name individual feelings or body functions when it has to do with food decisively. The need to eat in my case certainly was not hunger, and I refuse to accept the explanation. Overweight people often eat beyond feeling full, beyond feeling sick and beyond being put off the idea of food, how can that be called hunger? It can't. I have not been brainwashed into any ideology either. Of all the overweight people I know, not one has become the way they are by being hungry or following a suitable diet for their lifestyle or by being hungry.

 

[Fizzwizz]

Overweight people often eat beyond feeling full, beyond feeling sick and beyond being put off the idea of food,

These are the people who have other (pychological) issues, they are the ones that cannot be helped by bariatric surgery ... hence the screening. they are not the normal profile for obesity.

Of all the overweight people I know, not one has become the way they are by being hungry

Call it lack of satiety then, though we are now debating semantics. If they're sated they won't eat, they won't even derive pleasure from it. Lack of satiety causes over eating.

 

[fergus]

I think you make a number of very good points Fizz.

I agree that it's far too simplistic to say that obesity is on the rise simply because people eat too much and exercise too litle. I'm sure we all know of people who eat like Olympians, take little excercise yet stay slim. At the same time I can also think of people who eat much less than I do yet are overweight, despite their excercise programmes. If each of us know people in these categories then we probably have a large number of people who defy the easy explanation.

It looks to me as if the overeating and inactivity are symptoms of the metabolic disorder rather than the primary cause of obesity, just as we mentioned earlier, Fizz. This would more easily explain why many people seem to report greater physical energy and reduced appetite when they change the types of calories eaten rather than the number.

Lack of satiety despite sufficient calories also suggests that the body's cells are unable to access those calories. This might also point towards hyperinsulinemia and insulin resistance.

Ally, with respect, I doubt you can say that you have any obese patients who do not have hyperinsulinemia. Insulin levels are very rarely measured in the UK. Do you request serum insulin measurements in your patients, because the NHS doesn't? I have a friend who carries out these tests privately and assures me it is virtually unheard of for an overweight or obese patient not to have elevated insulin levels.

To my mind, the greatest advance we could make in the treatment of obesity and diabetes would be the introduction of serum insulin measurements for patients with weight issues. Then we might be able to identify pre-diabetes many years before the current diagnostic tests, and simultaneously recommend dietary changes to reverse the condition.

All the best,

fergus

 

[candy1567]

HI Fiz

while i agree with some of your points certainly about ppl who have psychological issues as well as they tend to comfort eat and use food as a crutch, am still not convinced surgery is the answer, but like everything else if i did have the answers they i would be a very rich person indeed!!!!!

My partner luvs food (hes a chef) he breathes food!!!! hes 6' 1 about 14 stone or thereabouts and always stuffing his mouth he doesn't believe in having a snack for dinner, there for inbetween meals, he has at least 4 main meals a day and numerous snacks and he doen'st put any weight on, he doens't do much excercise and recently had a MOT at the docs and everything came back normal, the only thing he suffers is with is his feet hurt from standin on them all day!!!!

Now me i only have to look at a bacon butty and i gain 5 pound it doesn't even have to pass my lips!!!! this has been like this all my life not just after ive been diagnosed as diabetic.

Also, if obesity is recognised as a metabolic disease and the NHS have all the stats and no that obesity is on the rise, then why does funding have to be applied for and why does it take so long to come through

 

[Fizzwizz]

Now me i only have to look at a bacon butty and i gain 5 pound it doesn't even have to pass my lips!!!! this has been like this all my life not just after ive been diagnosed as diabetic.

LOL, me too! I did read a paper that showed thin people overestimate the food they have eaten in the day, and obese people underestimate it. I think there's some truth in this, but I also agree that different people can consume vastly different amounts, but this doen't make any difference. Your husband, the same as you, eats his fill. His 'set point weight' is regulated well. In other words he consumes the right amount of food to maintain his weight. If he ate less he'd loose weight, more and he'd gain weight. So his body regulates his weight well with an appropriate hunger/satiety response.
I'm sure your metabolism needs less calories, but this is not the cause of your problem. I've heard many people tell me they have a slow metabolism - maybe they have but this isn't the cause. Whatever your baseline metabolic rate your hunger/satiety centre should still regulate your weight automatically.

Also, if obesity is recognised as a metabolic disease and the NHS have all the stats and no that obesity is on the rise, then why does funding have to be applied for and why does it take so long to come through

This is politics. Unfortunately decisions about where NHS money is spent is a political decision, not a technical one. Technically bariatric surgery would save the NHS thousands every year, this has been shown in several studies. Unfortunately, the NHS makes funding decisions based on politics. It spends money where the public perceive it should be spent. This is why technically very inefficient services like ITU exist. Technically the money is better spent elsewhere (it would save more lives) but the public wants to know there will be an ITU should they ever need it.

Unfortunately for obesity, the public still perceives bariatric surgery as cosmetic surgery, ignorance about obesity, and lack of understanding of the benefits means many people are anti-bariatric surgery. Also, only a third of us are obese, and non obese people don't perceive they will need the service. Compare this to cancer, where anyone can be afflicted! Almost everyone thinks money should be spent there, this is because we want the NHS as a safety net to our own health, not an efficient service that reduces poor health nationally.

Despite an unquestionable technical argument for bariatric surgery, whilever the public perceive it as they do the NHS will not spend any more on it. Beacause of this only 10% of NICE recommended surgeries happen.

 

[catherinecherub]

I think that the government does not fund enough for research into any eating disorder. Whilst obesity is probably the major problem there are also anorexics . Their problems are poorly researched as well as binge eating and bulimia. Most professionals state that eating disorders, including obesity, are the result of emotional, psychological and social cultural issues. Some of us do fall into those categories but some of us cannot explain why we overeat and become obese.
I think that the opinion I have formed is carry on with the research and spend more money on it, whilst allowing people to have the surgery for those who are so desperate that they cannot see another option. The only thing that worries me about the surgery is if this problem has no answer to it at present , because we dont know the issues that cause us to overeat, then how will the person cope with wanting to eat . Surely they will still want to overeat but now they cannot because of the restriction imposed by the surgery. That too would make the person unhappy .
Diabetics who overeat prior to diagnosis have two goals, to loose weight and in so doing manage their diabetes. Perhaps two goals motivate us more than if we only had the weight issue. We loose weight without surgery because we know the complications we face if we don't. It is the major weapon we have for controlling our condition.
Catherine.

 

[Fizzwizz]

Hi Cath

I think that the government does not fund enough for research into any eating disorder.

I think this government grossly underspends on research and education, but don't get me started on politics I'll be up all night!

allowing people to have the surgery for those who are so desperate that they cannot see another option.

Anyone with a BMI over 40 (or 35 with comorbidities) is desperate whether they realise it or not. A 40 year old person with BMI of 40 has already lost 8 - 12 years of life.

The only thing that worries me about the surgery is if this problem has no answer to it at present , because we dont know the issues that cause us to overeat, then how will the person cope with wanting to eat . Surely they will still want to overeat but now they cannot because of the restriction imposed by the surgery. That too would make the person unhappy .
.

Most bariatric surgery does not work by preventing a person from eating, it works by supressing appetite so the person does not feel hungry.

Diabetics who overeat prior to diagnosis have two goals, to loose weight and in so doing manage their diabetes. Perhaps two goals motivate us more than if we only had the weight issue. We loose weight without surgery because we know the complications we face if we don't. It is the major weapon we have for controlling our condition.

Unfortunately the research shows that to not be true You're 95% likely to have regained your weight after 10 years of onset of diet and 66% likely after 2 years.

- National Institute of Health. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: NHLBI produced publications, 2000.
- Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346(6):393-403.
- McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, et al. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003;139(11):933-49.

 

[catherinecherub]

Thanks for that Fizz, they were only my thoughts and opinions. I still like to think, that six years on from diagnosis, I am managing my weight successfully and will continue to do so. To date I am not tempted to overeat but do allow myself treats on occasions. According to the research, I have four years before I fall off the wagon. I hope that I will become the exception to the rule and so will many others on this forum. I am enjoying this debate.
Catherine.

 

[Fizzwizz]

I hope that I will become the exception to the rule and so will many others on this forum. I am enjoying this debate.Catherine.

5% do, so it's not impossible. I hope all goes well ... Fizz

 

[Trinkwasser]

My point is that the effect of insulin upon the first law in the human metabolism is sufficient to significantly change the outcome.

Now, it might be possible to make a fundamental change in the lipolysis and lipogenesis balance simply by measuring the effect of insulin levels upon the 'closed system'. For example, it might be possible to study the effect on weight in patients where serum insulin levels were identical, but the type of calories consumed were different. One might look at weight and hunger on 30 units per day from principally carbohydrate sources. Another might measure the outcome if those calories were taken in proteins and fats.

That would be one helluva interesting thesis, possibly groundbreaking!

fergus

This is being worked on, the hyperinsulinemia is an important factor, and how it links to leptin and other hormones. That would be an interesting study, using an insulin clamp in a metabolic ward to see how levels of other things change with different diets, then seeing how they change when the insulin is unclamped and the diet kept the same.

 

[Trinkwasser]

this is because the opinion and success of one person is meaningless. Medicine is evidence based.

I completely agree. In the words of David Hume, we are more likely to meet a thousand liars than one miracle. However, there is significant evidence of the particular efficacy of carbohydrate restriction as a treatment for diabetes and obesity surely?
The work by any scientists such as Magnus-Levy, Bauer, Pennington, Bruch, Le Magnen to name but a few suggests a perspective on these conditions that seems largely ignored or forgotten now. More recently, studies such as the one from Duke University last month suggest a line of research that ought to be pursued a lot more vigourously than it is.
My worry is that there is such a determination not to recognise the effectiveness of carb restriction that it is in effect discouraged. This, in diabetic terms, is certainly a common experience despite the clear wording in things such as the BNF which recommend carb restriction as the first line of attack, before oral medication, after diagnosis of type 2 diabetes.
This wording perhaps dates from a time when carb restriction was considered clearly and rationally, not as it is today.

All the best,

fergus

Agreed, it's NOT just the opinion of one person, there are thousands of success stories, and not just with diabetes. The problem is they are NOT being followed up, no-one will finance the studies to turn the anecdotes into data, there simply isn't the profit in recommending a decent diet over recommending dangerous levels of carbs (profitable) and high levels of medication (profitable) in fact many studies will specifically eliminate well controlled diabetics.

 

[Trinkwasser]

There are muliple factors why people gain wt - actually working in the field my take is that may be there is a metabolic process that is to blame but what about the mountains of food some people are eting - sadly a fact the theorists overlook.

That's exactly what is being researched elsewhere in the linkage between insulin levels, insulin resistance, leptin, leptin resistance etc. The question being addressed is WHY some people don't stop the eating behaviour.

In my case I never put on weight *until* I was put on the High Carb diet, and further reducing the fat caused me to balloon. It was the carbs that gave me the carb cravings, not uncommonly found although considered heresy by people indoctrinated into the Eeevils of Fat

The exercise thing works backwards in me too, and is worse in other members of the family. I was always comparatively fit and active until the diet knackered me. Getting and keeping my BG down returned the energy I'd lost, and removed the weight I'd gained.

Now our familial genes involving insulin resistance even in skinny fit people may be rare, or they may not. One thing is undeniable though, since Ancel Keys there has never been such an explosion in all the (often genetically based) diseases the Heart Healthy Diet was supposed to cure.

 

[diabetesmum]

I have just read the last couple of pages of this thread and feel ............. dunno ......... a bit weepy tbh, which isn't like me at all!

Fizz, your explanation of why fat people eat 'too much' has been like a light bulb going on in my head, it explains so much for me. And your comment about people of 40 with BMIs of 40+ having already lost 12 years of life has stopped me in my tracks. Now I really do feel desperate, but that's probably a good thing. Thank you very much, please keep posting when you have time .

Ally, your assumptions about fat people eating mountains of junk and sitting on the couch all day are so generalised that they they border on the insulting. How do you explain all the thin people who eat 'badly', aren't particularly active and yet stay thin? I can think of 2 such people within my own family. The whole obesity issue is a lot more complicated than you appear to think.
Sue

 

[hanadr]

Whereas everyone writing on this thread has made some good points,I as a cynic feel thwat the government doesn't want to sort it ou. If they did, wheree
could they put BLAME and who would be the next pariahs?
Ally people with BMIs of 40+, probably do eat a lot, but I can attest that at least 1 person with BMI 29.5 eats VERY little.

 

[Thirsty]

diabetesmum, I think ally talks a lot of sense. Eat nothing and you won't get fat, you'll die of starvation. Deciding exactly what and how much to eat is the tricky part, and I suspect that the arguments will continue long after we're all dead.

He said, cheerfully.

 

[diabetesmum]

Thirsty,
Yes, but the point I was making was that it's how and why we decide what to eat (or not) and how much of it that's complicated, and yet many people including Ally seem to think it's all very simple. I found Fizz's comments about the satiety thing very enlightening. There has got to be more to the obesity issue than commonly assumed.

The implication (to my mind) is that all the overweight people in the world are lazy slobs who eat mountains of junk, and all the slim/skinny people are paragons of virtue who control their eating, have got the art of self denial down to a 'T', and have the self discipline to exercise regularly no matter what. This is what I take exception to.
Sue

 

[Fizzwizz]

the government doesn't want to sort it out.

Indeed they don't. The bodies who make decisions on where money is spent in the NHS have a political agenda, they admit that they don't believe decisions about funding should be made on technical merit (i.e how good atreatment it is and how many people it will help). they believe funding should reflect society's opinions. this means funding contains the same prejudices society has.

If society thinks obesity is self inflicted it won't want money spent on it, so the fund holders say "whatever you say" despite knowing it's not the best way forward.

This was illustrated also in the High Court ruling regarding the prescription of Viagra in 2002. The court made the point that what should be paid for by the NHS is a political rather than technical matter, and that the effectiveness and quality of a treatment cannot assist in deciding which services get priority in NHS funding.

The secret is getting society on board. The very same thing applies to BM strips too!

 

[ally5555]

phew - that was alot to read.

Obesity is rising for many reasons and food and lack of exercise are the major part. I am not calling people slobs at all but no one likes to admit they are nt perfect. When I see pts I ask them to be honest - its not helping me or them and when we agree on this it is suprising how we make progress.
a survey in wales showed that only 17 % of people actaully took any exercise at all .

Whether any will admit it but the vast majority of people who have a weight problem do eat more than they think. As little as 100 extra calories a day more than you need will mean a gain of a pound over 30 days!

Behind the scenes there is lot of good work being done - the MEND programe for instance is working with over wt kids and getting very good results because it is addressing the family problems not just the food!

 

[Fizzwizz]

Hi Ally
I hear what you are saying but all the studies show a regime of exercize and diet does not combat obesity. i agree we should all adopt this as a healthier lifestyle, and to shed some weight if you are "overweight", but it doesn't help obesity in the long term.

This is one of the problems, the healthcare profession has gone diet and exercize mad. Again I re-iterate these are vital for a healthier lifesytyle, and might help you shift a stone or two in the short term, but they don't help obese people. Because of diet and lifestyle being health push everyone is starting to think it's the answer.

To put it in simple terms. If a 20 stone man went to his Doctor and asked how he could lose his excess weight, you can bet your life the Doctor will say "eat less, eat better, and get some exercize".
What the doctor should say is "It is unlikely you will loose your weight for good without surgery, but eating less, eating better, and getting more exercize will improve your health.