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The prevalence of childhood overweight and risk for overweight has reached epidemic proportions. Approximately 10% of annual health costs are due to overweight. Overweight in childhood is associated with increased risk and earlier onset for chronic diseases such as diabetes mellitus and cardiovascular diseases. Obesity has a profound negative affect on both the physiological and psychological health of children, adolescents, and adults, at great cost to society. Overweight is more prevalent in African American and Native American families than in whites. More national data on overweight in Native American and African-American children are needed. Television viewing contributes to overweight by replacing physical activity and increasing consumption of high-energy foods. Increased levels of physical activity in children not only promote lower body fat and may help prevent early development of chronic diseases, but also improve mental health.

Oklahoma’s population is 7.8% African Americans and 7.8% Native Americans. More than 56% of Oklahoma adults had BMIs >25 in 2000. Native Americans had the highest rate of BMI >30, at 28%, followed by African Americans with a rate of 26%. High levels of cardiovascular disease and diabetes exist in Native American and African American ethnic groups, especially in Oklahoma. The objective of this study was to assess the prevalence of overweight in African American and Native American families and also to examine correlates of childhood obesity in families. Ethnic groups were compared because overweight and diabetes are more prevalent in Native Americans than in African Americans in Oklahoma.

A convenience sample of 84 three-generation families was recruited from 10 sites in rural Oklahoma. Families were recruited through community contacts at health, senior, community, and tribal centers. A questionnaire for data collection was administered to each subject. The questionnaire consisted of 32 questions on socioeconomic, health, diet, and physical activity information. The questionnaire included a 3-day, 24-hour food recall, a 1-month food frequency questionnaire, anthropometric measurements, and family contact information. Forty-four families were Native American and 40 were African American. A diverse sample was obtained with 11 of 44 Native American tribes in Oklahoma represented. Each family was given an $85-incentive after all data were collected. Triceps skinfold measurements were taken, and weight and body composition were measured. According to National Institutes of Health guidelines for adults, a BMI of > 25 or <30 was defined as overweight, while a BMI of 30 or above was defined as obese. According to National Institutes of Health guidelines for children, a BMI at or above the 85th and below the 95th percentile was defined as at risk for overweight, while a BMI at or above the 95th percentile was defined as overweight. Activity levels were self-reported and choices ranged from one (no regular exercise program) to six (more than 3 hr weekly or 30 min daily of vigorous physical activity). The subjects estimated daily television hours, and this value was multiplied by seven to obtain weekly hours to compare these data with current recommendations. Three days of 24-hour recalls were self-reported.

Mean percent body fat of Native American parents was significantly greater than that of African American parents. Mean percent body fat and waist circumference were significantly higher in Native American children than in African American children. Children reported higher activity levels than parents or grandparents but averaged only 10 min daily of activity, while watching 16 to 21 hours of television weekly. Diets were high in fat, but within acceptable ranges for carbohydrate and protein. African American subjects had significantly higher-fat diets than Native American subjects. In this sample, approximately 90% of all parents and grandparents were overweight or obese. Native American and African American adults in this sample appear to have much higher rates of overweight and obesity compared with white adults. In this sample, 42% of African American and 61% of Native American children were overweight or at risk for overweight. These findings demonstrate the extent of the overweight problem in Oklahoma.

The activity level for all subjects in this study is quite low. None met the US minimum recommendation of 30 min/ day for physical activity. Daily television watching hours were generally excessive for children: 90.9% of Native American and 95% of African American children reported watching 4 hr or more daily. Children, parents, and grandparents in both ethnic groups exhibited sedentary lifestyles. This study showed a significant correlation between children and parents for television hours, indicating the possibility of a causal relationship. A significant relationship also existed between child BMI z scores and grandparent television hours. Child television hours and activity level of parents and grandparents were significantly associated. These significant associations indicate that sedentary caretakers facilitate children watching more hours of television and being less active.

Abdominal obesity has been associated with increased risk of cardiovascular disease, diabetes, hypertension, and cancer. Specifically, studies examining the relation between weight and prostate cancer have resulted in inconsistent findings. One reason for this could be the failure to distinguish the contribution of central and peripheral obesity. Computed tomography (CT) quantifies subcutaneous and internal abdominal (visceral) fat (VF), allowing measurements of visceral fat and determination of its relation with disease risk. Therefore, a recent study in Obesity Research investigated the relationship between visceral fat accumulation as measured by CT and the occurrence of prostate cancer.

Sixty-three incident, histologically confirmed, prostate cancer cases in Portugal were confirmed. Sixty-three age-matched healthy community subjects were included in the study as well. Body weight and height were measured and BMI was calculated. Body fat distribution was assessed by CT. Subcutaneous fat area (SF) was defined as the adipose area between the two defined contours and total fat area (TF) was defined as the sum of VF and SF.

Prostate cancer patients had a significantly higher mean TF, reflecting a clearly higher mean VF. A significantly higher risk of prostate cancer was found for each increase corresponding to one standard deviation in VF, TF, and SF. A significantly higher risk of prostate cancer was found for subjects in the upper one-third of VF and upper one-third of V/S ratio, whereas it was not significant for SF.

These findings suggest a role for visceral obesity, quantified for CT, as a risk factor for prostate cancer. However, ethnicity and family history of prostate cancer could be a potential source of confounding in the results. CT is more accurate and more reproducible than anthropometry for assessing body fat distribution. The action of the adipocytokines secreted by visceral fat cells, steroid hormone disturbances and increased levels of insulin or other hormones noted in visceral obesity may explain this association.

Theoretically, the goal of obesity treatment is to reduce body weight to normal. However, unsatisfactory results have prompted a change in the final outcome from large weight loss to moderate weight loss and control of obesity related risk factors, that is, hypertension, dyslipidemia and diabetes. Studies have shown that the morbidity related to these risk factors is significantly decreased by a 5% to 10% weight reduction, even if patients remain in the obesity range.

When goals are not reached or the progress toward them is unsatisfactory, people have impaired performance and often tend to abandon their attempt to achieve the unreachable goals. To improve the understanding of the weight loss expectations of obese subjects and of the factors that influence them, some Italian researchers analyzed the data of a large observational study that was recently established in Italy for a comprehensive measurement of health-related quality of life, psychological distress, and eating behavior in obese patients.

A total of 1891 obese patients seeking treatment in 25 Italian medical centers were included in this study. Diet and weight history, weight loss expectations and primary motivation for seeking treatment (health or improved appearance) were recorded via a detailed case report and a set of questionnaires. Psychiatric distress, binge eating, and body image dissatisfaction were tested by self-administered questionnaires (Symptom CheckList-90, Binge Eating Scale and Body Uneasiness Test).

In 1011 cases, the one-year expected BMI loss was > 9kg/[m.sup.2], dream BMI was 26 and maximum acceptable BMI was 29.3. The expected one-year BMI loss was significantly related to the maximum BMI loss during previous attempts. Age was also a strong predictor of weight goals. Psychiatric distress, body dissatisfaction and binge eating did not predict weight loss expectations. The primary motivation for weight loss was concern for future (33.4%) or present health (>50%), and only 15.2% wanted to improve appearance. Women seeking treatment to improve appearance had a lower grade of obesity, were younger and had first attempted weight loss at a younger age.

This study confirms a large disparity between physicians’ recommendations and patients’ expectations of outcomes in the treatment of obesity, a disparity that might account for the high dropout rate in weight loss. Obese Italian patients had unrealistic weight loss expectations. Some limitations of this study were the findings were restricted to obese subjects seeking treatment in a medical setting and therefore, do not provide information on the large number of obese subjects who do not seek treatment or who seek help in non-medical settings. Future research should evaluate how weight loss expectations may vary across different settings and how unrealistic weight loss expectations may be changed to achievable ones.

Abdominal obesity, measured by waist-to-hip ratio (WHR) or waist circumference, has been associated with an increased risk of type 2 diabetes, metabolic syndrome, myocardial infarction, hypertension and stroke. Simultaneous measurements of waist circumference and fasting triglycerides (TGs) have been proposed as inexpensive screening tools to identify men at elevated risk of CAD who are characterized by the atherogenic metabolic triad: hyperinsulinemia, elevated apo B, and small low-density lipoprotein.

Familial combined hyperlipidemia (FCHL) is the most frequent genetic lipid abnormality in humans, characterized by hyperlipidemia. FCHL subjects have a 5- to 10-fold increased risk of early myocardial infarction, mediated by genetic factors measured as the genetic relation to the proband, but also by abdominal obesity measured as WHR. To evaluate further the association of abdominal obesity with hyperlipidemia in relatives from well-defined FCHL families, a recent study from the Netherlands assessed the odds ratios (ORs) for the expression of hyperlipidemia in different categories of BMI, waist circumference and WHR in both FCHL relatives and spouses.

Fifty-two unrelated white FCHL index patients (probands) were discovered at the Lipid Clinic of the Utrecht Academic Hospital or the Maastricht Academic Hospital. Relatives and spouses of the probands visited the clinics, where they answered a standardized questionnaire and underwent a physical examination, which included lab work. Weight, height, and waist circumference were measured and BMI and WHR were subsequently calculated.

In total, 618 FCHL relatives and 297 spouses, representing a total of 52 families, were included in the study. In FCHL relatives, a graded, continuous effect of WHR on the prevalence of hyperlipidemia was found, ranging from 16% in the lowest WHR category to 57.6% in the highest category. In FCHL relatives, categories of BMI or waist circumference showed the same trend as found with WHR in FCHL, that is, a significant positive contribution to the prevalence of hyperlipidemia among FCHL relatives. In the whole study population, frequency of hypertriglyceridemia showed a significant interaction only between WHR categories and FCHL but predominant expression of hypertriglyceridemia was observed with higher categories of WHR in FCHL relatives but not in spouses.

The results clearly suggest that the genetic susceptibility to hyperlipidemia in FCHL has an interaction with abdominal obesity. It appears that WHR was the most informative and specific obesity marker associated with hyperlipidemia in FCHL. This knowledge is of value in genetic studies, where incomplete penetrance is an issue in the selection strategy and in medical treatment of FCHL subjects, where abdominal overweight should be addressed by weight loss strategies.

About 59 million Americans are suffering from a disease. This illness sneaks into peoples’ lives, and it grows on them as they perform daily routines such as eating lunch. But once this disease takes hold of a body, it could put a person at risk for heart disease and other serious medical complications. It could also cause a person to develop social problems, including poor self-esteem. This disease–which has reached a record high number of people in the U.S.–is called obesity, or having an excessively high level of body fat.

What is the cause of the nation’s expanding waistline? “Obesity is a very complex disease that involves many factors,” explains Myles Faith, an obesity researcher at the University of Pennsylvania. So far, scientists have identified obesity-causing factors ranging from the way people eat to how they spend their pastimes to genetics (heredity). And with approximately 300,000 people dying from obesity-related complications each year, an all-time high, scientists are determined to help find solutions that will stop this disorder.

DEFINING OBESITY

It takes more than a glance to determine if a person is obese. That’s why scientists measure a person’s Body Mass Index (BMI), a mathematical formula that calculates a person’s weight adjusted for his or her height. (For more on the BMI, see Web Extra, p.20.) If the BMI falls within a specified range, (25 to 29.9 kg/[m.sup.2]), an adult is considered overweight. For adults, if the BMI is above the overweight range (over 30 kg/[m.sup.2]), the adult is likely considered obese.

For people under the age of 20, scientists categorize the BMI differently. They use a chart of BMI ranges that’s specific to the person’s age and sex. And these ranges do not include a category for obesity. That’s because growing boys accumulate fat differently from growing girls. Additionally, developing bodies have ever-changing fat levels. “So we talk in terms of ‘underweight,’ ‘normal weight,’ ‘at risk of overweight,’ and ‘overweight,’” explains Michele Maynard, an epidemiologist (scientist who studies rates of diseases within a population) at the Centers for Disease Control and Prevention (CDC).

Scientists have found strong evidence that people who are overweight as kids and teens are likely to remain overweight or become obese in adulthood. Of particular concern: Since the 1980s, the number of overweight U.S. children between ages 2 and 11 has more than doubled. Even more staggering: In adolescents between ages 12 and 19, the number has more than tripled (see graph, p. 19). “We’ve also been seeing children and adolescents with increased frequency of type 2 diabetes (blood-sugar disorder) and high blood pressure,” says Maynard. “These are conditions once primarily associated with adults.” Why are so many bodies now tipping the scales?

BIG QUESTIONS

Like a machine, the body needs fuel to operate. When you eat, your body converts that food into energy. And what your body does not use for fuel is stored as reserve–fat. “Obesity is caused by an imbalance between energy input and energy output,” says Maynard. That means, when anyone consumes more calories (energy units in food) than he or she is able to use, or expend, the body is likely to gain fat.

But every person’s metabolism (chemical reactions in the body that change food into energy) is different (see diagram, p. 20). And the mystery of why some people tend to pack on fat easier than others has led scientists to search for clues. “We believe that genes (units of hereditary information) play a major role in obesity,” says Shirly Pinto, a biologist at Rockefeller University.

In 1994, scientists at Rockefeller University made a breakthrough: They discovered that fat cells produce an appetite-controlling hormone (function-controlling chemical), which they named leptin. This hormone keeps people at a healthy weight. It signals a brain region responsible for maintaining weight levels–the hypothalamus–information on how much fuel the body needs. In other words, leptin sends out the “I’m full” message. When you have fewer fat cells, less leptin is produced, signaling you to eat more. And with more fat cells, leptin levels increase, signaling you to eat less.

How does leptin relate to obesity? “In most cases, obese individuals have leptin levels that are higher than normal,” says Pinto. “In a sense, they should stop eating. But they don’t.” Scientists believe that some obese people may have genetic differences that cause their bodies to be resistant to leptin’s messages.

Since leptin’s discovery, scientists have found other hormones that are involved in how the body perceives food. Could hormone-regulating, fat-fighting medicines result soon? It’s too early to tell. How these natural hormones work alone–much less, how they interact with each other–is still unclear. “Scientists are just starting to piece this puzzle together,” says Pinto.

In the effort to lower America’s collective weight, getting told to shape up seems to have extended to a federal government anti-obesity campaign. Last year, the Centers for Disease Control launched a multimedia advertising blitz aimed at getting children to become more active, carrying the theme “Verb, it’s what you do.”

Criticized for being too vague and ineffective, campaign creators Saatchi & Saatchi have added $68.4 million to the $125 million price tag and have developed more direct suggestions to exercise-shy U.S. children. One print ad, for example, shows children playing volleyball and includes the words “Get out, go play.”

Meanwhile, Florida Governor Jeb Bush has appointed a task force to study how to bring down obesity levels in his state. With 60% of Floridians overweight, and obesity rates in all age categories increasing, citizens of Florida are becoming as round as their famous oranges. Less than 26% of Florida adults eat the daily recommended five servings of fruits and vegetables, with around the same amount categorized as physically inactive. The task force will pay particular attention to high-school age children, one quarter of whom are, or at risk of becoming, overweight. Their report will be out in February.

The epidemic of childhood obesity is attributed to the toxic environment of readily available, calorically dense food and drink. How does this environment interact with the genetic vulnerability to determine who becomes obese? What can this interaction tell us about who becomes obese and at what age they become obese? Answers to these questions could be of great value in preventing childhood obesity. There unfortunately have only been a few longitudinal studies of obesity in children.

Recently, investigators performed a longitudinal investigation of the growth from 3 months to 6 years of age of 70 children, 33 of whom had overweight mothers and 37 of whom had lean mothers. Risk group was defined by prepregnancy maternal body mass index (BMI): greater than the 66th percentile or less than the 33rd percentile for their age group. During the first 2 yr, the size and growth of children in the high- and low-risk groups were almost identical, and there was no relation between maternal and offspring body weights. The current report describes the relation of the risk group to the development of body size and body fat for this cohort from years two through six of life.

At year two, no significant differences in any measure were observed between the high- and low-risk groups. By year four, weight, BMI, and lean body mass were greater in the high-risk than in the low-risk children. By year six, weight was even greater in the high-risk than in the low-risk children (23.4 [+ or -] 6.4 compared with 20.4 [+ or -] 2.1 kg; P < 0.02), and, for the first time, fat mass was greater in the high-risk group than in the low-risk children (6.7 [+ or -] or 5.7 compared with 3.8 [+ or -] 1.2 kg; P < 0.02). Ten of 33 high-risk children exceeded the 85th percentile of BMI at year six compared with 1 of 37 low-risk children (odds ratio = 15.7). Accelerated weight gain was predicted by high-risk group status, greater weight at year two, and lower family income.

While anthropometric measures were not significantly different between groups at year two, weight and lean body mass were greater at years four and six, and fat mass was greater at year six in high-risk children.

Binge eating episodes (BEEs) are episodes of overeating characterized as the consumption of a large amount of food in a discrete period of time, followed by a sense of lack of control over eating. When binge eating is persistent and recurrent (2 days with BEE per week in the last 6 months) and is not accompanied by compensatory behaviors to avoid weight gain, it constitutes a diagnostic category called binge eating disorder (BED). BEE and BED may occur in individuals in those who have been associated with the severity of obesity. While the prevalence of BED diagnosis in Brazilian communities is low, BEE is a far more frequent condition. In contrast with BED, few studies have evaluated the association between the occurrence of BEE and overweight/obesity.

To evaluate this relationship, researchers included individuals who spontaneously participated in the overweight prevention week. Those participating had their weight and height measured and answered a brief questionnaire. BEEs were assessed based on DSM-IV criteria. An initial question addressed was that whether individuals had eaten in the last 3 months, in a discrete period of time, an amount of food that was larger than most people would eat in a similar period under similar circumstances. If the answer was yes, they were questioned on if they had felt a lack of control, and on the frequency of episodes. They were also asked whether they had a leisure physical activity on a regular basis in the last year and if they had been an obese child or an obese adolescent. The analysis included 2858 subjects.

Prevalence of overweight (BMI = 25 to 29.9 kg/[m.sup.2]) was 46.6% for men and 36.6% for women. Obesity (BMI > 30 kg/[m.sup.2]) was about two-thirds of the prevalence of overweight. BEEs in normal-weight individuals was 1.4% for men and 3.9% for women, whereas in overweight/obese, these prevalences were 6.5% and 5.5%, respectively (p < 0.01). After adjustment for age, socioeconomic variables, and childhood obesity, it was found that those who reported BEEs had an odds ratio of being overweight/obese of 3.31 (95% confidence interval: 1.11 to 9.85) for men and 1.73 (95% confidence interval: 1.05 to 2.84) for women.

Over the past two years, the Endocrine Society has identified obesity as an item worthy of pursuit on its legislative agenda because of the overwhelming health concerns associated with the condition and its co-morbidities. The Society’s membership includes many of the caregivers who are battling to help stem the tide of obesity, such as researchers into the causes of obesity, those working to create pharmacological treatments for obesity, clinical researchers studying potential treatments, and practicing clinicians treating obese patients and their co-morbidities. Our members recognize that every possible solution, including public policy, must be pursued to reduce the incidence of obesity. As the representative of leaders in the field of obesity research and treatment, the Society must play an integral role in any public policy solutions regarding obesity.

The Society’s objective regarding obesity is simple, but broad in scope: to examine all causes and contributing factors to obesity, and to find solutions and treatments for those causes. Several important policy initiatives have been launched over the last few years, including the creation of the Obesity Research Task Force by the NIH (National Institutes of Health), the goal of which is to examine obesity as a public health concern and determine its relevance to NIH’s mission. The task force released its draft Strategic Plan for Obesity Research in February 2004. The plan calls for NIH to undertake research exploring obesity prevention and treatment through lifestyle modification, pharmacologic and surgical approaches, and further examination of the link between obesity and its associated health conditions. The task force’s vision will help shape the future of obesity research. Some of the Society’s advocacy efforts are directed at maintaining the federal funding necessary to ensure adequate implementation of the strategic plan’s goals.

Another policy being considered by Congress and supported by the Society is the Improved Nutrition and Physical Activity Act (IMPACT). The IMPACT Act, sponsored by Senator Bill Frist (R-TN) and passed by the Senate in the 108th Congress, was intended to be a broad-based reform of obesity policy that primarily promoted enhanced physical activity and caregiver education by:

* providing training for health professionals and health science students to help them identify risk factors and prevent obesity;

* funding nutrition education through the CDC (Centers for Disease Control and Prevention);

* assisting local communities by encouraging increased physical activity through the creation of walking and bike paths;

* assisting with curriculum development at the state level to help students make healthy choices regarding nutrition and physical activity; and

* aiding clinics that serve those minority populations who are disproportionately affected by weight disorders to implement obesity prevention and treatment programs.

Unfortunately, the IMPACT Act was never heard in the House and must be reintroduced in 2005. While the failure of this act to become law was disheartening, it could also become an opportunity to create new, more comprehensive legislation in the 109th Congress.

The Society would like to expand the reach and scope of obesity public policy. In the coming year, we hope to examine legislation specifically targeting the pediatric population. New public policy initiatives might also include working with businesses and federal government employers to assist them in helping their employees lose weight.

The underlying causes of obesity continue to be hot topics of investigation among clinical and basic endocrine researchers. Endocrinologists are working to determine the root causes of obesity, including the factors regulating food intake, energy expenditure, body weight, and complications associated with the condition. Research is also being conducted to examine the potential efficacy of agents derived from gastrointestinal or gastrointestinal-related hormones that affect hunger and satiety. Such research is important as the prevalence of obesity increases and the demand for additional treatment options and alternatives continues to rise. One of our primary advocacy objectives is to lobby Congress on the importance of fully funding research agencies like the NIH so that potential breakthroughs in obesity research can become reality.

Several state and local governments are attempting to combat childhood overweight through legislation, particularly within the school setting. Members of some state legislatures are drafting and adopting legislation that increases physical education requirements, while underscoring the importance of nutrition and health curricula. In some local communities, consumer groups and lawmakers are working to curb the sale of snack foods and carbonated beverages on school campuses. Educating youth about overweight will ultimately aid in the fight against obesity. While the Society’s limited resources prevent a state-by-state legislative campaign, we hope to learn from state pilot programs and push for similar reforms at the federal level.

Just because you have obesity in your genes doesn’t mean that there isn’t anything that you can do about it. Environment can also play a big part in whether or not you are obese. Eating habits and lack of physical activity have a large role in obesity too. Generally Americans go with taste and convenience more than they do with nutrition. High-fat foods are usually the most convenient such as fast food.

In society today people are more rushed than ever. We are always in a hurry to get some where or do to something. This often leaves us with the feeling that we do not have time to eat a healthy meal, or to take the time to eat before said healthy meal. For this reason, we feel that we are forced to settle for what is fast, easy and convenient. Not only is fast food packing on unwanted pounds, it’s causing tremendous health risks in the process.

Besides the fast food eating way of life, we are more sedentary than ever. The age of sedentary is getting lower and lower with each passing year. Our children are watching more television, playing more video games, and spending more time on the computer than we used to as children. Now adults, we as children, spent the majority of our time outside playing or being involved in other physical activities. While children today are involved in sports, or dance, most overweight children are not. They pick up this conditioning from their parents who are teaching them these things. Because parents today are so rushed and so busy, they take the valued spare time they have to “veg out” in front of the television or computer. Children see these things and learn these things, therefore taking on the unhealthy lifestyle of the parents. We as adults and parents need to learn to be more active in our lives, and learn healthy eating habits. Not only for our health and well being, but to be role models for today’s children, that as adults, they do not end up overweight, and unhealthy.

An environment that promotes healthy weight is one that encourages eating nutritious foods in reasonable portions and regular physical activity. A healthy environment is important for all individuals to prevent and treat obesity and maintain weight loss.

Healthy environments can be created at home, school, work and beyond. Identifying and consciously avoiding high-risk situations in the environment can help in weight control efforts.