The link between lower socioeconomic status and obesity has been well documented (at least for Western women). While this is often attributed to the increased expense of healthy foods, it may well be that increased psychosocial stressors including food insecurity, low-walkability neighbourhoods, higher density of fast-food outlets, anxiety, depression and other mental health problems also contribute.

A new study by Eva Münster and colleagues from the University of Mainz, Germany, just published in BMC Public Health suggests that over-indebtedness may be a further factor in promoting weight gain. Over-indebtedness can be defined as lack of possible debt redemption in due time due to the relation of income and cost of living even after a remarkable cutback in standard of living.

Münster and colleagues examined data from a cross-sectional study on over-indebtedness and health including 949 over-indebted subjects from 2006 and 2007 and an independent representative telephone health survey of 8318 subjects.

After adjusting for socio-economic (age, sex, education, income) and health factors (depression, smoking), the over-indebted individuals were almost twice as llikely to be overweight and almost 2.5-times as likely to be obese than non-over-indebted individuals.

It is estimated that, as a result of the recent financial turmoil, about 3 million German households (7.6 %) corresponding to more than 6 million residents are currently over-indebted.

In their discussion, the authors focus heavily on the possible contribution of the expense of healthy foods, although they do acknoweldge the fact that at times of financial distress, individuals may be more preoccupied with issues other than living healthy lifestyles.

I would further suggest that the very same psychosocial behaviours that promote over-indebtness (risk-taking, impulsiveness, poor-planning, etc.) may also promote weight gain, especially in our current obesogenic environment.

At least the study suggests that there is little reason to assume that financial distress will result in people eating less - if at all, the opposite appears true.

AMS
Edmonton, Alberta

Just, when we thought things could not possibly get any worse, the Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation (RWJF) on July 1 released a report, with the rather unfortunate name F as in Fat: How Obesity Policies Are Failing in America 2009.

According to this report, adult obesity rates increased in 23 states and did not decrease in a single state in the past year, while the percentage of obese and overweight children is now at or above 30 percent in 30 states.

Mississippi with its 32.5% rate of adult obesity, has the dubious honor of topping the list for the fifth year in a row. This brings the total number of states with obesity rates greater than 30% to four, including Mississippi, West Virginia (31.2 percent), Alabama (31.1 percent) and Tennessee (30.2 percent) - not that surprising, considering that 8 of the 10 states with the highest percentage of obese adults are in the South. Overall adult obesity rates now exceed 25 % in 31 states and exceed 20% in 49 states and Washington, D.C.

Colorado continues to have the lowest percentage of obese adults at 18.9 percent (this is not far from the Canadian average).

For the full News Release click here

For the Executive Summary of the Report (8 pages) click here

For the Full Report (108 pages) click here

Remember, the obesity epidemic is a health tsunami in slow motion!

AMS
Edmonton, Alberta

I’ve previously blogged on how research on social networks suggests that obesity may well be socially contagious!

So what about obesity in people who actually live together?

This question was now addressed by Natalie The and Penny Gordon-Larsen from the University of North Carolina, Chapel Hill, NC, USA, in a paper published this month in OBESITY.

The objective of this study was to examine whether romantic partnership and duration of living together are related to incident obesity and obesity-promoting behaviors, by which the development of obesity in one individual increases the risk of obesity in his/her spouse.

The researchers examined two large data sets from the National Longitudinal Study of Adolescent Health: (i) 6,949 US adolescents (wave II, 1996) followed into adulthood (wave III, 2001-2002) and (ii) 1,293 dating, cohabiting, and married romantic couples from wave III, including measured anthropometry and self-report behavior data.

Perhaps not surprisingly, the analysis clearly showed that individuals who transitioned from single/dating to cohabiting or married were markedly more likely to become obese than those who were just dating. 

For both men and women, living with a romantic partner for 1 year or more increased the likelihood of incident obesity by up to 3-fold compared to single/dating individuals. This risk became even stronger for couples who lived together more than 2 years.

Cohabiting/married couples reported less physical activity, more screen time and other sedentary behaviours that may promote weight gain. The authors also speculate about possible impact on portion size (the lean person gradually adapting to the obese partner’s eating habits and requirements).

From my own clinical practice, I can only confirm that a partner’s lifestyle is often reported as a significant barrier for weight control. In fact it is not at all unusual to find that the efforts of one partner struggling to control their own weight is blatantly sabotaged by the other (intimate saboteurs). This can take the form of continuing insistence on bringing home or preparing excessive amounts of high-caloric foods, preference of social activities that involve sedentary behaviours and excessive eating (and/or drinking), reluctance to use active transportation for social outings or to engage in regular shared physical activity,  etc.. 

In more than a few cases, I have seen longstanding romantic relationships breakup, when one partner ultimately insists on changing their own lifestyle, despite the complacency or sabotage from their spouse.

On the other hand, it is generally not easy to bring up the subject of weight in a relationship without this being seen as a personal attack (not unlike the difficulty of addressing excessive alcohol consumption, smoking, or mental health problems in a partner). It is often up to the obese partner to make the first move. 

Marriage-induced weight gain - certainly an interesting topic for family medicine!

AMS
Edmonton, Alberta

Unfortunately, for people challenged by overweight and obesity, weight regain after intentional weight loss is the rule rather than the exception. Thus, the majority of people trying to control their weight tend to go through cycles of weight loss and weight regain.

However, whether or not people who intentionally weight cycle have a higher risk of overall weight gain and mortality has been hotly debated.

In a paper just published in the Archives of Internal Medicine, Alison Field and colleagues from Harvard Medical School, USA, analysed the relationship between weight cycling and mortality in the over 40,000 women participating in the Nurses’ Health Study who provided information on intentional weight losses between 1972 and 1992.

Women who reported they intentionally lost at least 9.1 kg at least 3 times were classified as severe weight cyclers, whereas women who intentionally lost at least 4.5 kg at least 3 times were classified as mild weight cyclers.

Between 1972 and 1992 around 10% of women were heavy cyclers, whereas 20% of women were mild cyclers. As expected, weight cycling was positively associated with BMI at baseline - thus, only 40% of noncyclers were overweight or obese compared with 74% of the mild cyclers and 87% of the severe cyclers. 

During the follow-up period, weight cyclers gained significantly more weight than noncyclers (5.2 kg for severe cyclers and 4.1 kg for mild cyclers) compared with only 2.6 kg for noncyclers. In age-adjusted models, severe cyclers in early and middle adulthood had a 30% higher mortality rate than noncyclers, but this relationship was no longer significant after adjusting for BMI at age 18 years, weight change from age 18 years until 1976, physical activity, change in activity, smoking, postmenopausal HT, and alcohol intake.

This is what I take from this study: 1) severe weight cycling is associated with twice the weight gain than with noncycling; 2) the increased mortality risk of severe weight cycling is probably more related to the increased weight gain, rather than the cycling per se.

My message to patients remains the same: there is little point in losing weight if you are not going to keep it off - in the end, you are likely to simply end up being heavier than before.

In other words, as I have said before, preventing further weight gain should be the first step in obesity management - weight loss should only be encouraged by methods and programs that have a high likelihood of long-term success.

AMS
Edmonton, Alberta

Readers of these pages may recall an earlier post in which I proclaimed that the problem with fast food was more the “fast” than the “food” (no time to be thin? Jan 17, 2008). I have also regularly blogged on the emerging science on sleep (or rather lack thereof) and weight gain (Is Sleep Apnea a Significant Problem in Sleepy Kids? Jan 15, 2009).

Now, a new OECD report on social trends, including things like time spent on meals and time spent sleeping, shows that France, a country known for being one of the slimmest in Europe (10% obesity), spends the most time eating and sleeping compared to countries like Mexico or Canada with markedly higher obesity rates (around 20%).

According to the report, the French spend on average nearly 9 hours a day in bed and more than 2 hours a day eating and drinking — nearly twice as much time at the table as Americans, Canadians or Mexicans.

This of course does not imply that the French eat more - in fact, it is easier to overeat when you are gorging and gulping down your food than if you sit down to a slow 3 course meal (remember, the enteric-hypothalamic satiety axis operates on a 20-40 min time frame).

While there is only so much that can be derived from these type of comparisons, the findings are remarkably consistent with the emerging science of the importance of stress and sleep in relationship to obesity.

But there are certainly inconsistencies: Americans, with one of the highest rates of obesity, get almost as much sleep as the French; Koreans and Japanese, with less obesity, are at the lower end of the sleep scale.

So although obesity may well be a “symptom” of a society that does not take enough time to eat and sleep - the relationship is unlikely to be that straightforward.

Nevertheless, I’d certainly like to see an intervention trial that examines the effect of slow eating and more sleep on obesity prevention or management - may have to move to France to do it?

AMS
Edmonton, Alberta