Solutions involve three pillars of lifestyle modification
Obesity is a disease that nobody wants and everyone tries to avoid, yet it affects more people than almost any other disease. It is complicated, for there are a multitude of contributors. Lifestyle modifications are of the utmost importance when it comes to a solution. These include diet, fitness and stress reduction.
There is a foundation of components to almost every diet. At the base of every good food pyramid should be a vegetable‐rich, nutrient‐dense diet. In other words, people should aim to consume these elements because they have been shown to help with weight loss, treat chronic disease and improve overall health (1). Diets such as the DASH (Dietary Approaches to Stop Hypertension) diet and the Mediterranean‐type diet have shown beneficial effects for not only weight loss but also other diseases such as hypertension, chronic kidney disease, diabetes and heart disease.
A New York Times article published on Jan. 3, 2016, entitled “A Healthy Diet’s Main Ingredients? Best Guesses,” notes that we don’t know all the science behind what makes a good diet. I would agree with this, since research is an evolving process.
However, one element in the article that I strongly disagree with is that the principal investigator for a 2006 study on whether a low‐fat diet reverses disease concluded that diet composition has no effect in reversing chronic disease (2). Of course, she was making this statement in 2006, when there was less evidence of potential reversal of disease with diet. Low‐fat diets in isolation are hard to perform; most of the participants can’t stick to the regimen and/or they replace fat with refined grains.
Also, while this may have been the case for this one specific low‐fat diet study, we have seen time and again that a vegetable‐rich, nutrient‐dense diet does have effects that may reverse diseases such as cardiovascular disease, diabetes, chronic kidney disease and a host of others. Caldwell Esselstyn, M.D., showed the effect of a vegetable‐rich, nutrient‐dense diet on cardiovascular disease in 1995 (3). Dean Ornish, M.D., showed the effect of a similar diet on prostate cancer reversal in 2008 (4). I see reversal of chronic diseases, such as those mentioned above, regularly in my practice. Diet composition, therefore, does matter when it comes to reversing disease.
I would agree, as the New York Times article alludes, that we can’t reduce one macronutrient in isolation and expect great results. For example, the dietary guidelines have been obsessed for many years with low fat. Unfortunately, this has not resulted in better health and less obesity as mentioned above. The most recent statistics show an increase in the prevalence of obesity for adults in the United States. In fact, the obesity rate has increased by 17 percent over the last 10 years as recently documented by the CDC (5). Now 38 percent of Americans are obese [body mass index (BMI) >30 kg/m2), more are overweight (BMI 25‐29.9 kg/m2) or normal weight (BMI 18.5‐24.9 kg/m2). The greatest prevalence is among those who are middle aged, 40‐59 years, followed by those 60 years and older. The good news is that the obesity rate has not increased for children. However, for adults, this epidemic continues to grow. And the expense to the U.S. health care system is enormous, with $147 billion spent in 2008 (6).
Why is obesity good? The answer is not necessarily what you think! Obesity is beneficial because it is the body’s cry for help. The solution is multifactorial, including diet, exercise and stress management.
Can you be obese and fit?
Exercise always seems to be beneficial. While it may not garner tremendous weight loss, it is helpful in maintaining weight loss, and it may reduce the risk of premature death. A recent observational study in Sweden found that those in the highest quintile of aerobic exercise reduced their risk of premature death by 51 percent (7). Those who were normal weight, regardless of fitness, had a greater reduction in premature death — 30‐48 percent — than even those who were in the highest aerobic activity level, but obese.
However, within the obese cohort, those who were in the highest quintile of fitness did see a 29 percent reduction in premature death. The moral of the story is that those who are obese are not fit compared to those who are normal weight, regardless of activity level.
Yet, among obese patients, there is a gradation with premature death: Those who are most aerobically active benefit over their obese counterparts who are not. This Swedish study began with a population of 18‐year‐old men and followed them for almost 30 years.
What is a TOFI and why is it dangerous?
A TOFI is an acronym meaning thin on the outside, fat on the inside. For example, patients who have central obesity can have normal BMIs. How do you measure central obesity? It involves the waist‐to‐hip ratio (WHR). When the WHR is over a certain level, then there is central obesity. For men it is >0.90 WHR and for women it is a >0.85 WHR. A recent observational study showed that patients who had central obesity but normal BMIs had a greatly increased risk for mortality (8).
In men, there was an 87 percent increased risk of death. But even more interesting was the fact that normal weight, centrally obese men had two times the risk of mortality compared to those who were obese without central obesity. For women there was a 48 percent increased risk compared to those with normal weight without central obesity. Patients were followed for 14 years. Therefore, just because someone has normal BMI does not mean they are healthy or fit. The researchers recommended weight training to help with central obesity beyond just diet.
Stress and weight gain, really?
Yes, really! Psychosocial or emotional stress may be significant with weight. In a meta‐analysis (a group of 14 observational studies), results showed the effects of psychosocial stress were related to weight gain (9). The researchers hypothesized that it may have to do with the hypothalamus‐pituitary‐adrenal (HPA) axis, which raises the level of cortisol release in the blood. The weight gain occurs most commonly around the waist.
There is a blood test that measures morning cortisol levels, which is when cortisol is highest. If cortisol is above normal, then supplements such as l‐theanine, valerian root or fish oil, as well as dietary changes, exercise, meditation, yoga and some medications can help. We also tend to eat when given stressful tasks to perform, especially when presented with food (10).
To reiterate, a positive way to think about obesity is that the body is screaming for change. Also, central obesity can occur in normal weight individuals and go undetected. Its impacts are as great as, if not greater than, high BMI. But, fortunately, most contributors to obesity are modifiable.
(1) Altern Ther Health Med. 2008 May‐Jun;14(3):48‐53. (2) JAMA. 2006 Jan 4;295(1):39‐49. (3) J Fam Pract. 1995 Dec;41(6):560‐568. (4) Proc Natl Acad Sci U S A. 2008 Jun 17;105(24):8369‐8374. (5) cdc.gov/nchs/data/databriefs/db219.htm. (6) Health Aff (Millwood). 2009 Sep‐Oct;28(5):w822‐831. (7) Int J Epidemiol. online Dec 20, 2015. (8) Ann Intern Med. online Nov. 9, 2015. (9) Obesity (Silver Spring). 2011;19(4):771‐778. (10) Stress. 2015;18:507‐551.
Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, go to the website www.medicalcompassmd.com or consult your personal physician.