Glenn Berall is an up-close expert on Canada’s battle with fat. A Toronto physician whose obesity clinic serves 500 new patients each year and is by many accounts the largest practice in the country, Berall – who is cross-appointed to U of T’s Faculty of Nursing and Department of Paediatrics – has grave concerns about the future health of Canadians. That’s because the patients in his waiting room, besides sharing a weight problem, are startlingly young – they’re all under 18 and some are as young as one or two. And they signal a growing trend of unhealthy living that starts early and threatens to become a way of life for generations to come. Obesity, no matter what the age, continues to rise in Canada and around the world. More than half of Canadians today are overweight or obese. Fat people worldwide now outnumber the malnourished and the World Health Organization has officially deemed obesity an “epidemic.” As fat-related diseases, including diabetes, heart disease and even some types of cancer, rise in frequency and the projected healthcare costs of obesity grow at heart-stopping proportions, scientists are working to understand and address the problem.
WHY ARE WE SO MUCH FATTER TODAY THAN A GENERATION AGO?
There is no question that Canadians are getting fatter. The latest study released from the Canadian Population Health Initiative reveals that, in the past 20 years, overweight and obesity rates have more than doubled for adults and tripled for children. What is behind this trend?
Harvey Anderson of the Department of Nutritional Sciences, an expert in the physiological aspects of appetite control, believes that our changing environment is largely to blame. Larger serving sizes, inexpensive and accessible food and frequent snacking make it easier to overload on calories, he says.
“It’s very easy to get a few extra calories. If you look at how much obesity has risen in the last 25 years, for an average person to gain 20 or 30 pounds of extra body fat over a 20-year period, they would have to consume about 11 extra calories per day. That’s one potato chip.”
Glenn Berall agrees. “Fast food is far more available that it ever used to be, and serving sizes at restaurants have increased far beyond what the average person needs.” Junk food is also readily available in schools and at strategically-placed corner stores, he says, making healthy food choices more difficult for kids.
Berall, who in addition to hisU of T appointments is head of Paediatrics at North York General Hospital and a staff member in the Division of Gastroenterology and Nutrition at The Hospital for Sick Children, adds that higher calorie consumption is exacerbated by lower-than-ever activity levels.
“Physical education classes have diminished in frequency, and after-school programs for kids of working parents typically don’t incorporate a lot of physical activity,” he says. “Plus, kids don’t walk or bike home as much as they used to, and then they sit in front of the television or video game system and are sedentary again.”
Perceived lack of neighbourhood safety, combined with a culture of efficiency brought on by cars, may explain part of the childhood obesity story. “We’ve got a society that’s far too efficient. Everyone with a motor vehicle is dropping their kids off at school because they’re concerned about safety or they’re in a rush.”
Steven Penfold of History agrees that our dependence on cars may play a role. An expert on suburbanization and car culture, Penfold is interested in what happens to commerce and social life when people start driving everywhere.
“Cars have really narrowed the scope that we imagine walking,” he says. “If you compare how far people will walk in urban neighbourhoods versus suburban neighbourhoods, it’s quite different.”
And he adds that once we get into our cars, we’re reluctant to get out. “You can actually go to outdoor malls and watch people go into one store and then get in their car and drive literally down the mall to the next store rather than walk across the parking lot. Cars have totally changed the way we imagine the world.”
ARE GENETICS PARTLY TO BLAME?
Environmental factors aside, are some of us simply programmed to be fat?
Anderson, who also heads up U of T’s Program in Food Safety, Nutrition and Regulatory Affairs and works with the food industry to keep nutrition-based research top of mind, doesn’t believe so.
He argues that if genetics were a significant factor, we wouldn’t have seen this tremendous surge in obesity rates in the last generation. “We basically have the same genes we had 30 years ago – you don’t get a genetic shift in that amount of time.”
Berall agrees. “The only thing that’s changed in the past generation is our environment. We’ve become an affluent society where food is available everywhere, and our food processing and distribution systems are far better.”
He also dismisses the argument that large people often inherit low metabolism from their parents. “We’ve measured metabolism in hundreds of overweight and obese patients and found that they typically have normal metabolism. In fact, compared to a person at the same height and a normal weight, overweight people often have a higher metabolism because they’ve built extra muscle to carry the extra weight. So the slow metabolism story is absolutely wrong.”
One instance in which genetics do play a role is in a rare disease called Prader-Willi Syndrome. A genetic disorder that affects about one in 12,000 people, Prader-Willi is characterized by many factors including obesity and excess appetite due to the brain’s inability to recognize fullness signals.
Berall has worked with Prader-Willi patients and discovered that he can treat them without drugs by altering their diet and physical activity. “Our research suggests that we can treat even those isolated, genetically-based cases of obesity – so that just goes to show once again that the environmental factors outweigh the genetics.”
DOES SOCIOECONOMIC STATUS PLAY A ROLE?
Eating well can be costly. Fruits, vegetables and lean cuts of meat are unquestionably more expensive than pre-packaged foods with less nutritional value. And the cheap price of a burger-and-fries combo at the local drive-thru is certainly an attractive offer for the budget-conscious.
But does this mean that people at the lower end of the income spectrum are more likely to be overweight? Not necessarily, says Valerie Tarasuk of Nutritional Sciences.
Tarasuk, who studies the economic barriers to good nutrition, says that analyses of Canada’s population health and food expenditure data do not reveal a clear link between poverty and obesity. “There’s no question that people with low incomes purchase fewer fruits, vegetables and milk products – but this behaviour doesn’t necessarily translate into a greater likelihood of being overweight.”
In fact, Tarasuk has found that national surveys show income has an opposite affect on men’s and women’s propensity to be large – overweight and obesity rates tend to be more prevalent for high income versus low income men, and for low income versus high income women.
And fast food, while it may seem like an inexpensive route to a full stomach, is not even on the radar screen of Canada’s poorer families. “We have found that the lower the income, the less likely people are to purchase food away from home and the less money they’ll spend on it. So it doesn’t look like this is a fast food story.”
While Anderson agrees that poor people typically can’t afford fast food restaurants, he does point to the grocery store and its bounty of tempting alternatives for the cash-strapped.
“For three dollars you can buy a bag of potato chips and a two-litre bottle of pop, and right there you’ve met your whole day’s caloric needs.” So people who are hungry and short of money often choose foods that are high in energy but low in nutrients, he says.
Tarasuk suggests another way to analyze the socioeconomic link. “The issue perhaps is not what makes lower income people heavier, maybe it’s what prevents higher income people – particularly women – from becoming heavier.” Maintaining a small body, she says, takes time and resources that aren’t always accessible to everyone.
IS CHILDHOOD OBESITY AS BIG AN ISSUE AS ADULT OBESITY – OR WILL MOST KIDS LOSE THEIR “BABY FAT?”
Berall says childhood obesity must be taken as seriously, if not more so, than adult obesity. That’s because fat children are much more likely to become fat adults. And increasing numbers of kids show up in his office with weight-related illnesses historically reserved for adults.
“We’re seeing kids with diabetes, high cholesterol levels and metabolic syndrome [a condition that carries with it raised blood pressure, glucose intolerance and a greater risk of heart disease].”
Berall believes childhood is the crucial time to address obesity. “We really can’t afford to sit back at the peril of our children’s future health – and the costs to the healthcare system will be scary if we don’t do something about it.”
Margaret MacNeill of the Faculty of Physical Health and Education admits that there are some real health implications to consider, but she is concerned that we may be going too far in “pathologizing” larger bodies, particularly when it comes to adolescents. “Overweight kids may be at risk for future health problems,” she says. “But the vast majority are not currently diseased.”
MacNeill is the director of the Centre for Girls’ and Women’s Health and Physical Activity – which recently hosted an international symposium, “The Politics of Obesity” – and her own research interest is in how our culture negotiates different meanings around fat.
“Fat used to mean something positive – everyone loved the fat baby; fat meant that you were wealthy, that you could afford to have good food, while skinniness meant poverty. And now we’ve got this medicalized notion of fat – we’re pathologizing ‘the body at risk.'”
Based on her ongoing research into how Canadian youth interpret fitness and health through the media, at school and through peer interaction, MacNeill believes that the stigmatization and social implications facing overweight kids, and how they view themselves as a result, are just as important as the physical health implications.
“I do want kids to be healthy and active, but I think we are narrowing our vision of ‘normal.’ Moreover, there is great debate about who has the authority to define the dividing line between healthy and unhealthy based on the Body Mass Index [see sidebar], and whether inactivity – rather than levels of fat – is actually the problem,” she says. “I think there’s a wider range of healthiness out there that can and does exist. And I think it’s important to continually question our lines of reference and our very definitions of obesity.”
A national strategy for addressing the obesity issue must factor in the social and cultural issues facing kids, she says. “We need to find other ways to understand this by, for example, having behaviourists look at the activities of kids, how they behave in different situations, what happens when they’re called names. And we need to look at the politics of power relationships and the levels of understanding that go on between kids. We’ve got a long way to go.”
HOW CAN OBESITY BE TREATED?
In his practice, Berall takes a multi-pronged approach that includes collaboration with dieticians, a sports medicine physician and counselling services. “We don’t put patients on diets – that doesn’t work. What we have to do is get at the underlying cause in each circumstance and work on making changes that will work for life.”
Berall and his team help kids identify and control the frequency of high-calorie foods in their diet, time their meals better, get a clearer sense of their hunger and fullness signals and find more opportunities to be active – even if it means simply standing up while playing a video game. “Sometimes we’ll have kids ‘buy’ their sedentary time with five minutes of activity per half hour of sitting on the couch or at the computer. And we’ll encourage families to be active together.”
Berall doesn’t see many benefits to pharmacological treatment, and almost never prescribes drugs for his patients. “I think you need to work with the underlying variables, and the underlying variables do not include the absence of medication.”
Lawrence Leiter of the departments of Medicine and Nutritional Sciences and St. Michael’s Hospital agrees that successful treatment is dependent on a multidisciplinary approach, but he says developing a good infrastructure and strong resources takes a lot of money – money that just isn’t being invested in Canada right now.
Another problem, he says, is that those who really need treatment aren’t seeking it. “Healthy, younger women often seek weight loss treatment but patients who really need it – primarily obese men – don’t typically look for help.”
MacNeill emphasizes the need to keep fitness fun for everyone, especially kids. “If we push daily physical education on kids primarily as a means of getting fit, it will backfire. If people aren’t having fun, they don’t stick with it.”
The key, she says, is taking the main focus away from weight loss. “Fitness shouldn’t always be instrumental – maybe it’s just for the sake of moving. And short bouts of activity throughout the day can be very beneficial for bone health, and probably better for weight management, because that keeps your metabolism more revved at a steady rate.”
Anderson feels that we need to better regulate our physiologic systems through diet. He is studying various proteins to understand how they affect appetite signals, and has found that some high-protein foods – such as milk and baked beans – are successful in suppressing appetite for longer periods of time than high-carbohydrate foods.
A member of McDonald’s Restaurants’ advisory committee, Anderson hopes to encourage healthier menus – something he says is beginning to happen in the fast food industry – and he is also working toward developing “functional” foods that will help people with busy lifestyles maintain a healthier diet. “We need to set up the environment so that, as people are rushing through the grocery store or into the quick service restaurant, they inadvertently end up with a better food basket.”
Reflecting on the consistently low success rate in treating adult obesity, Anderson also firmly believes that our efforts need to focus on prevention in childhood. “The lack of government prevention is appalling. The solution has to start with activity and education on food choices in the schools. And we need to start talking to kids about the dangers of excess body fat the same way we talk to them about smoking and drugs.”
While many people feel they could stand to lose a few pounds, few consider themselves obese. But our social definition of “chubby” is closer to clinical obesity than we’d like to think.
For example, a widely-used measure of “overweight” and “obesity” is the Body Mass Index (BMI), which marries height and weight to produce a number that reflects either a healthy or unhealthy weight. A BMI of 18.5-24.9 is within the healthy range, 25-29.9 is classified as overweight, and over 30 is obese.
Consider this: If you are a woman who is 5′ 5″ tall and weighs 185 lbs., you have just tipped the “obesity” scales with a BMI of 30.8.
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