Dr. Sharma's Obesity Notes

Continuing my discussion of the paper by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, on what causes some people to gain weight, we turn to what the authors describe as, “Gradual Processes”.

Thus, in their extensive interviews with individuals seeking bariatric surgery, although most interviewees focused on explanations with a considerable sense of self-blame, many did report social structural factors as playing an important role in their weight gain, without using these as “excuses”.

“Zoë pointed out that outdoor exercise was too difficult for her in winter conditions, and indoor exercise in a gym was out of her reach financially, and gave specific policy recommendations: “They’re always telling people to lose weight, that we’re an overweight province. Well, help out a bit. Make gym memberships a little more cheaper, make it a little more accessible to people.”

Other barriers included occupational and domestic work schedules:

“When you’re sitting at a desk 40, 45, or 50 hours a week, you’re trying to establish yourself so that people are looking to you, so you get promotions as opposed to someone else, so you’re putting in those extra hours and you’re coming home tired. You’re sitting down for supper, and then it’s 7:00 at night.Okay, when do I do anything now?”

“Wanda explained, “I got the two kids. I have a gym membership, a family gym membership; it’s just that we never get there. I work all day. When I get home I’m tired. … Just finding the time is hard.”

As the authors note, leisure time distribution is a social inequality that particularly affects those with less income as well as mothers of young children.

Furthermore, social inequality related to the risk for occupational injuries with subsequent weight gain are likewise often not seen as related to the social determinants of health.

Finally, built environments and the cost of weight-loss programs were seen as contributing factors that made weight management efforts difficult or unsustainable.

I am sure that readers will have their own social determinants to contribute to this list.

AMS
Berlin, Germany

Continuing yesterday’s discussion of the paper by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, on what causes some people to gain weight, we turn to what the authors describe as, “Gradual Processes”.

Thus, in their extensive interviews with individuals seeking bariatric surgery the researchers found a group of patients, who neither started out as overweigh or obese kids but also were unable to identify specific “life events” that would have prompted their weight gain.

Rather, they describe their weight gain as a gradual but incremental process, most commonly attributable to subsequent cycles of “yo-yo dieting” or to a wide range of other factors that affected their eating (emotions, food addictions, cultural habits, irregular eating, or food quality and quantity) or activity behaviours.

The importance of weight cycle was illustrated by,

“As Vanessa, an office worker in her 30s, put it, “As good as I am at losing weight, after 5 or 6 months, I’m even better at finding it.” Elsie, a homemaker in her 50s, said that she had been dealing with this cycle since she was a child: “I remember when I was 8, I was always on a diet. … I think that’s what did it: watching your weight, adding it back on again, back and forth. Each time, you climb higher and higher.”

As for eating behaviour, both quality and quantity were mentioned, albeit not by the same people:

“Zoë, a customer service worker in her 30s, pointed the blame at food quality, referencing her enjoyment of fast food, and said wryly, “I’m 287 pounds. I didn’t get this way from eating soup broth.” In contrast, Elsie said, “I don’t eat a lot of junk anyway, but I guess I just eat too much of the good foods.”

This is in line with what I am always careful to point out – the nutritive quality of a diet has little to do with its caloric quantity. On the other hand, nutritionally poor diets are often also calorically dense, thereby making it far easier to consume excess calories.

While some participants reported emotional eating, this was often in response to “life events” (like losing a spouse), discussed in yesterday’s post. A more insidious form of emotional eating was reported as addiction to certain foods:

“Gladys, a disabled factory worker in her 50s, said, “I’m addicted to candy. I will not bring candy into my house ever again… I’ve gone now almost 2 months. …It’s almost like someone coming off drugs or something. You wean yourself off.” Vanessa said that she felt overwhelmed by her addiction to cheese: “I had a huge, huge, huge cheese addiction. A 500-gram [18-ounce] block of cheese I literally could eat in 2 days. … I feel really controlled by my thoughts for food.”

Cultural overeating was also described:

“Vanessa noted that as a child, “I wasn’t allowed up from the table until I cleaned my plate. … Every celebration is centered around food: potluck, buffet, jiggs dinner, everything. Our culture is really a food culture, and I guess most cultures are.”

Irregular eating patterns including meal skipping was also noted to contribute to weight gain:

“Heidi said, “I can go days without eating and … it doesn’t bother me at all. I can also have days where I’m like, ‘Oh my God, I can’t believe I just ate that—all of that.’ I go from one extreme to the other. … It’s like I never feel full.” Penny, a homemaker in her 30s, described similar experiences: “My biggest problem was never overeating, it was never eating enough. I would get up in the morning and not eat anything until supper time. It never, ever bothered me … I could go days without eating and it wouldn’t bother me.”

Finally in this category of Gradual Processes, the authors describe the issue of lack of physical activity or sedentariness:

“Jennifer said, “It’s the activity level. I work all day, and I’m sat on my butt all day long. I have two kids at home. So the story goes.” In addition, participants explained that once they had gained weight, it was very difficult to move comfortably. This was partially a physical problem, as Brian explained: “You get into a circle because you can’t [exercise] because you have the weight on. You need to do things to get the weight off, but you can’t do it because you got the weight on.”

In addition, once some weight has been gained, emotional factors can further limit physical activity:

“I want to be active. It’s something I’ve always wanted, but I feel [my size] is in the way. It ain’t that I can’t do it, because I can do it; it’s how I’m looked at while I’m doing it. … I can leave here and I can walk [3 miles] and back. I can do it. It’s just that when I’m doing it, it’s the fear I have that everybody is looking at me.”

Once again, all of these stories are quite typical of the many that I have heard before – it is evident that even with gradual progressive weight gain, reasons and interpretations differ widely.

If you have experienced progressive weight gain without this being prompted by any evident “life event”, I’d certainly love to hear from you.

AMS
London, UK

How do people become severely obese? Anyone, who thinks the answer is simply, “by eating too much and not moving enough”, is not only wrong, but is essentially missing the whole point of what it will take to find solutions.

A study by Julia Temple Newhook, Deborah Gregory and Laurie Twells from the Memorial University of Newfoundland, St. John’s, published in the Journal of Social, Behavioral, and Health Sciences, seeks to better understand what causes some people to gain weight.

The researchers conducted extensive interviews with individuals seeking bariatric surgery regarding their perspectives on their histories of weight gain and their explanations for weight gain as well as the emotions surrounding their weight gain experiences.

In today’s post, I would like to touch on what the authors describe as, “important life events”, which in some cases, interestingly enough, begin with being born.

Thus, for many participants, weight gain struggles began in childhood:

“Sam, an unemployed laborer in his 20s, said that he had been big since the age of 9: “It’s hereditary. A lot of people in my family are big.” Deirdre, an educator in her 40s, said, “I have never been slim. I have never been below a size 18, 20. Never. … I don’t remember as a child being small.” She added, “I know that part of it is genetics, because I really do believe that. I have a set of grandparents who were huge … I guess it is my metabolism.”

This is very much in line with my own clinical experience, where patients often describe always having been large for as long as they can remember with bullying and name calling belonging to their earliest childhood memories.

Others, on the other hand, describe a previous slim childhood or adult life, prior to rapid weight gain. In women, the most common life event likely to precipitate irreversible weight gain was pregnancy:

“Annie, a retired caregiver in her 60s, reported that she now weighs over 300 pounds, but recalled, “I only gained weight after I had my daughter … I was 127 pounds when I got pregnant … I went up to 181 and I never went below that after.”

But it was not just the course of pregnancy itself that was held responsible:

“…increased childcare and domestic workloads—that followed. Heidi, a customer service worker in her 30s, explained, “You don’t have the ‘you time’ to do what you need to do to try to take care of yourself a bit better. Everything is your children.”

Another major life event is loss of a dear one:

“Theresa, a retired educator in her 60s, talked about gaining weight after her husband died: “I ate my way through … That was my comfort I didn’t go the gym and I didn’t exercise … grief is strange. I was angry for a long time.”

This observation is also very much in line with the findings in my own practice, where I often see unresolved grief and trauma (emotional, physical or sexual) as a driver of dramatic weight gain. In my experience such negative life experiences can occur at any age (and virtually in anyone) and it is often possible to narrow down the exact temporal relationship between the event and subsequent weight gain.

For some, the life event was “simply” a change in “circumstances”:

“Jennifer, a manager in her 40s, said that when she moved from her rural home to an urban center for university, “I gained 90 pounds in about 9 months. … I was going to school so I wasn’t active at all, and I was eating takeout twice a day for my meals because it was cheap. I ate for free where I worked and I ate deep-fried food for all that time.”

This scenario is likewise not unusual – especially amongst the migrant and immigrant population, where adapting to a new life can often have profound effects on body weight for no reason other than having switched from one environment to another.

And then there was injury and illness:

“Derek, a customer service worker in his 30s, suffered a sports injury in his late teens: “I had a hockey injury, actually, is what started it. … I put on a lot of weight.” He said that his weight gain was exacerbated by a changing lifestyle as he entered the workforce: “Sports stopped. … My weight just ballooned. The only way I know to describe it is it’s like I went to bed being fairly active and in half decent shape and waking up and being 150 to 200 pounds overweight.”

Again, this scenario is not uncommon – I have previously posted on the remarkably high number of former competitive athletes in our bariatric clinic.

While life events were deemed an important contributor to developing severe obesity, this was not all that the interviewees had to offer.

More on other aspects of these investigations in the coming posts.

If certain life events have led to your weight gain – I’d certainly appreciate hearing about them.

AMS
Vancouver, BC

Regular readers are well aware of the mounting evidence on the importance of sleep deprivation as a driver of obesity.

Now, a paper by Kenji Obayashi from the Nara Medical University (Japan), published in the Journal of Clinical  Endocrinology and Metabolism, takes this issue one step further.

The researchers looked at the relationship between intensity of light in the bedroom, BMI and other variables in 528 elderly individuals.

Compared with the individuals with no to very low night-time light exposure (<3 lux – note: a full moon night is about 1 lux, twilight is about 3 lux), those with higher exposure (average ≥3) were significantly heavier (by about 4 lbs), had about one unit higher BMI, and about two cms larger waistlines. Individuals with greater light exposure, were almost twice as likely to meet BMI criteria for obesity.

These associations were independent of numerous potential confounders, including demographic and socioeconomic parameters.

Obviously, the meaning of these data are far from conclusive and it would be premature to draw any inferences regarding causality.

It may however be plausible to hypothesize that even minimal amounts of night-time light exposure can affect quality of sleep, thereby in turn, affecting metabolism (in ways in which we now know sleep-deprivation to do).

It would certainly be of interest to see how such findings can be reproduced in a more experimental setting – I would not be surprised if these findings can be confirmed and further highlight the importance of ensuring not only adequate duration but also quality of sleep.

AMS
Edmonton, AB

Obayashi K, Saeki K, Iwamoto J, Okamoto N, Tomioka K, Nezu S, Ikada Y, & Kurumatani N (2013). Exposure to Light at Night, Nocturnal Urinary Melatonin Excretion, and Obesity/Dyslipidemia in the Elderly: A Cross-Sectional Analysis of the HEIJO-KYO Study. The Journal of clinical endocrinology and metabolism, 98 (1), 337-44 PMID: 23118419

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Regular readers are well aware that I am more interested in the ‘whys’ of why people eat than in the ‘whats’ of what they eat.

Now a paper by Colin Chapman and colleagues from Upsalla University, Sweden, published in the American Journal of Nutrition, looks at the key lifestyle drivers of overeating, with a particular focus on TV watching, sleep deprivation and alcohol consumption as studied in controlled laboratory settings with healthy volunteers.

Their search of the literature yielded 8 television studies, 5 sleep studies, and 10 alcohol studies.

All three of these factors had significant effects on food intake in the laboratory setting with alcohol having the strongest effect, followed by sleep deprivation and TV viewing.

With regards to the possible mechanisms on how these behaviours affect food intake, the authors have the following to offer:

Alcohol consumption:

“Alcohol is known to induce alterations in circulating ghrelin, a peptide implicated in food reward. In addition, alcohol affects g-aminobutyric acid and opioid systems. The alteration of g-aminobutyric acid signaling in reward centers of the brain stimulates appetite, and opioid signaling has been implicated in regulating the orosensory reward components of eating. These pharmacologic findings are consistent with human studies that showed a greater increase in hunger during the early phase of a test meal after an alcohol preload compared with an energymatched carbohydrate preload. This mimics the pattern of response shown when the palatability of food is enhanced through flavor manipulation.”

Sleep Deprivation:

“There is similar evidence that links sleep deprivation to an increase in the hedonic value of food. Sleep loss causes a constellation of metabolic and endocrine changes, including an increase in circulating ghrelin. Interestingly, recent studies on sleep deprivation have found that it increases overall brain response to palatable food image. In particular, short sleep increased activation in brain areas involved in reward processing, such as the putamen, nucleus accumbens, thalamus, insula, and anterior cingulate cortex. This strongly suggests that sleep deprivation, like alcohol, leads to deregulation of reward system activation in response to food.”

TV Watching:

“Several of the studies included in the meta-analysis found that the effect of television viewing on food intake was most pronounced with high-calorie foods, which suggests that television viewing alters the saliency of food reward. Epidemiologic studies have shown a similar trend, in that those who watch more television tend to snack more while watching and to consume more energy-dense snacks. Additional evidence suggests that watching images of palatable food increases plasma ghrelin concentrations.”

The implications of all of this, when seen in the context of habitual reinforcement and perpetuation of such behaviours are worth noting:

“With regard to the lifestyle factors analyzed, all three, when experienced habitually, should strengthen memory traces that trigger reward expectancy to food cues: that is, when presented with rewarding food or food cues, people who often suffer from sleep deprivation or who often watch television or drink alcohol while eating are more likely to experience a greater reward response as a result. In addition, both alcohol and television likely become their own conditioned cues for those who consume food in conjunction with these factors.”

The authors are optimistic that addressing these factors early on (especially in kids and young adults) may be important measures to reduce the risk of obesity. Thus, they cite evidence that curbing alcohol consumption, increasing sleep time and reducing TV viewing may all lead to decreased accumulation of body fat.

Based on these findings I guess it is time to lay off the night cap, turn off the TV and go to bed.

AMS
Edmonton, Alberta

p.s. Hat tip to Carlene for pointing me to this article.

p.p.s. Maintaining this blog costs both time and money – if you have enjoyed these posts, please consider making a small donation to the upkeep of this site by visiting my website by clicking here.

Chapman CD, Benedict C, Brooks SJ, & Schiöth HB (2012). Lifestyle determinants of the drive to eat: a meta-analysis. The American journal of clinical nutrition PMID: 22836029

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