Criteria differ in requiring waist circumference as one of the three risk factors. IDF also offers ethnic-specific values for waist circumference as follows: Caucasian origin, ≥37 inches (≥94 cm) for men and >31.5 inches (>80 cm) for women; South Asian, Japanese, and Chinese origin, ≥35.5 inches (≥90 cm) for men and ≥31.5 inches (≥80 cm) for women (IDF 2006) (See www.idf.org/metabolic-syndrome for additional details).
Impaired Mental Well-Being
Societal and individual responses to obesity can impair psychological health, which in turn can perpetuate obesity. Prejudices from an unsupportive social environment and social stigmatization are likely to affect psychological health, employment, housing, and overall quality of life (Link 2001). Stigmatization of and discrimination against obese people have been documented in many areas of life, including employment, education, and health care (Puhl 2009). Furthermore, negative attitudes toward obesity by health care professionals can act as a barrier in clinical practice (Teixeira 2010).
Common negative stereotypes attributed to people who are obese include lack of willpower, laziness, ugliness, weak will, emotional and moral instability, as well as being responsible for or to blame for one’s weight (Crossow 2001, Friedman 2005, Puhl 2009). The risk for such prevalent negative social messages arises because of the ease with which such attitudes can be internalized; thus, an obese individual may perceive these messages as realistic descriptions of him- or herself (Bacon 2001, Rogge 2004). In response, obese individuals, and those of average weight who feel overweight or obese, may place unnecessary restrictions on important aspects of their lives, such as going to school, changing jobs, buying stylish clothes, dating, enjoying a sexual relationship, and seeking medical care (Robinson 1996).
Women (including those who seek standard treatment as well as more drastic weight-reduction methods, such as surgery) report impaired mental well-being more often than do men or those who do not seek treatment for obesity (Kolotkin 2002). There is an association between a history of weight fluctuation and impaired well-being regardless of body weight (Foreyt 1995).
Impaired mental well-being can precipitate excessive eating as a way of coping with feelings of anxiety, sorrow, and sadness, and thus contribute to obesity (Adolfsson 2002). Excessive eating could also be a coping strategy to deal with obesity-induced stigma (Puhl 2003).
Growing Economic Burden
As the prevalence of obesity increases, so does the cost of caring for its consequences (Stern 2005). Multiple authors present figures to illustrate the enormous cost of obesity to the health care system, employers, employees, the obese, and the general public.
In 2009, reported annual obesity costs to the health care system range from $147 billion (Finklestein 2010) to $228 billion (Englehard 2009). Because the consequences of obesity are most evident as people age, Medicare/Medicaid pays 50% of this cost (Barkin 2010). Obese employees are more expensive (higher insurance rates) and less productive (Finklestein 2010). Research shows obese employees earn less (Barkin 2010) and pay 42% more for health care than persons of normal weight (Weight-control Information Network 2010). Even nonobese workers pay higher premiums to help cover medical costs of their heavier colleagues (Englehard 2009).
As young people gain weight at an increasing rate, their futures, individually and corporately, will be increasingly limited by missed opportunities and by the resources spent to cope with the consequences of obesity. Obese people are often judged less capable and are less often chosen to join a group or perform a job. Physical mobility may limit activities, and health problems reduce available time and money.
WHO and the World Bank recognize that diet-related problems, such as obesity, type 2 diabetes, cardiovascular disease, hypertension, stroke, and various forms of cancer, significantly contribute to disability and premature death in both developing and newly developed countries. Such health problems are overwhelming budgets and absorbing funds from other more traditional public health concerns, such as malnutrition and infectious disease, and placing additional burdens on already overtaxed national health budgets. Obesity is one of the principal contributors to noncommunicable diseases. Given this impaired physical health and its associated economic burden on individuals and societies as a whole, obesity is clearly a risk factor that warrants global attention.
Chapter 3
A Complex Mix of Factors
Physiological Factors
There are many causes for excess weight. However, genetic makeup clearly contributes to the tendency to gain weight. The gene pool influences body shape, adiposity, and susceptibility to disease. In Maffeis’ (2000) review of the literature, he reports that inheritance is responsible for 25–40% of the interindividual differences in adiposity. In 2005, Lyon and Hirschhorn estimated that 30–70% of the variation in obesity within a given population is the result of heredity (Lyon 2005). In most cases, environment greatly influences the expression of genetic material, making parental obesity an important risk factor for obesity in children. Of those who become obese as adolescents, 70% grow up to become obese adults (Zhao 2011). Science is working to uncover the many physiological pathways that influence body weight and to identify ways to interrupt or influence those biological pathways (Zhao 2009).
Medications can also contribute to weight gain. For example, steroids and most antidepressants stimulate hunger. Though such medications are helpful to treat the condition for which they are prescribed, it seems only fair that these side effects be explained and discussed, especially with the patient who is already overweight, before prescribing them.
Changing lifestyle can modify inherited risks, but to what extent? Patients come from different genetic backgrounds and have to play the hand that they are dealt. Therefore, the care providers may find it difficult to assess or appreciate the strength of the biological forces pulling someone toward food. Notice how patients describe their experience with a food-related problem. It is in this context that they must solve problems.
Over time, science will create more effective treatments for obesity, but lifestyle modification will continue to provide the greatest influence on both health and body weight. Lifestyle refers to the myriad choices that individuals make; those decisions that reflect their personal preferences and shape their daily routines. Lifestyle includes what, where, when, and how much one eats, what clothes the individual chooses to wear, the environment in which one lives and works, social relationships (e.g., family, work, friends), and personal hobbies. Most groups consider our modern lifestyle, particularly sedentary lifestyle and the influence of westernization, to be the cause of worldwide increases in overweight and obesity over the last few decades (WHO 2000).
With high-caloric food, large portions, and snack foods readily available, daily energy intake easily exceeds expenditure. The same genotype expresses itself differently in a hunter-gatherer society than in our society of computers and fast food. In 2011, the mismatch of our biological makeup and our convenience-driven environment has created a problem to solve. Part of the solution will be to redesign our environment.
Environmental Factors
Society has created an environment that nurtures obesity. Weight gain is a natural byproduct of modern convenience. There are countless culprits in our modern world: large food portions, desk jobs, remote controls, computer games, machines that do physical work for us, urban sprawl, snack dispensers, elevators, hard-to-find staircases, car culture, clever commercials, fast food, frozen meals, and so on. Individually, any single one of these isn’t going to make a population overweight, but when combined, these conveniences have reduced the activity levels and increased the caloric intake of an unsuspecting public.
Several new collaborations of local communities, private industry, service organizations, and national government are working to create environments that support physical activity and healthy eating. Resources for individuals and groups of all ages include: the President’s Council on Fitness, Sports & Nutrition (www.fitness.gov); Let’s Move! (www.letsmove.gov); Shaping America’s Youth (www.shapingamericasyouth.org);