Tuesday, Jan. 05, 2010

By Maia Szalavitz
Time Magazine

Dr. Vincent Felitti, founder of Kaiser Permanente’s Department of Preventive Medicine and director of its obesity-treatment program, was seeing some good results. His patients were losing 50, 80, even hundreds of pounds. He might have considered the program a success, if not for the fact that the participants who were doing the best — those who were both the most obese and losing the most weight — kept dropping out.

Felitti was baffled. Why, invariably, did so many patients quit just as they approached their healthy goal weight? Ella, for instance, a middle-aged woman who entered the program in the mid-1980s morbidly obese at 295 lb., had managed to whittle her frame by 150 lb. over six months. “Instead of being happy, she was having anxiety attacks and was terrified,” Felitti says.

He asked Ella what she thought was going on. “Finally, the story comes out,” he says. “She had been molested as a child, both within her family and outside it. She tried to escape by marrying at 15, at her mother’s urging. It was a disastrous marriage — her husband was crazy jealous. They divorced in two years. She remarried. Her new husband was also jealous. He was convinced that when she was out hanging the laundry, she was sexually posturing to attract the neighbors.”

When Ella was overweight, Felitti learned, her husband was less suspicious. And her fear of his rage — perhaps he saw her new slimmer weight as a provocation? — was probably spurring her anxiety.

Felitti wondered if there was something similar barring weight loss in other patients — or causing obesity itself. In the late ’80s, he began a systematic study of 286 obese people, and discovered that 50% had been sexually abused as children. That rate is more than 50% higher than the rate normally reported by women, and more than triple the average rate in men. Indeed, the average rates of sexual abuse are themselves unsettling: according to a large 2003 study conducted by John Briere and Diana Elliott of the University of Southern California, 14% of men and 32% of women said they were molested at least once as children.

In recent years, studies by both Felitti and others have largely confirmed the association between sexual abuse — as well as other types of traumatic childhood experience — and eating disorders or obesity. A 2007 study of more than 11,000 California women found that those who had been abused as children were 27% more likely to be obese as adults, compared with those who had not, after adjusting for other factors. A 2009 study of more than 15,000 adolescents found that sexual abuse in childhood raised the risk of obesity 66% in males in adulthood. That study found no such effect in women, but did find a higher risk of eating disorders in sexually abused girls.

Discoveries by Felitti and colleagues have also helped give rise to broader work linking stressful experiences early in life — as early as in the womb — to effects on health and behavior later on, such as an increased risk of heart disease or becoming addicted to drugs. Scientists are finding that such effects are not only long-lasting, but can even be inherited by future generations.

In decades of experiments with rats, for instance, neuroscientist Michael Meaney at McGill University in Canada and his colleagues have shown how such environmentally induced traits can be passed down — then undone, also by environment. Meaney studied rats with differing maternal styles — some were naturally nurturing (they licked and groomed their pups constantly), others were less attentive and even neglectful (mother rats placed in stressful environments like isolation had greatly decreased capacity for nurture). What researchers found was that these behavioral traits were passed down to future generations: pups born to neglectful mothers endured stressful childhoods and grew up to become neglectful mothers themselves. But when babies born to stressed or less attentive mothers were instead placed with nurturing, affectionate mothers, that early experience changed the pups. They adapted quickly to the new mothering style and grew up to tend carefully to their own offspring. These pups’ adaptation was then passed to successive generations as well.

When Felitti first presented his Kaiser Permanente data connecting obesity with child molestation at a national meeting on obesity in 1990, most colleagues dismissed him immediately (one even claimed that obese people made up such stories to justify their “failed lives”). David Williamson, an epidemiologist at the Centers for Disease Control and Prevention (CDC), was the lone exception. He said that a large epidemiological study was needed to determine whether there were any implications of Felitti’s findings for public health.

Felitti knew that he had just the right data set: Kaiser Permanente has the largest medical-evaluation facility in the developed world, diagnosing some 58,000 patients annually. Even if only a minority agreed to discuss their childhoods and allow anonymous use of their medical records, that would be a huge sample. And so the Adverse Childhood Experiences (ACE) study was born, as a collaboration of Felitti and another CDC researcher, Dr. Robert Anda.

For the past several decades, the ACE study has recorded reports of negative childhood experiences in more than 17,000 patients. Adverse experiences include ongoing child neglect, living with one or no biological parent, having a mentally ill, incarcerated or drug-addicted parent, witnessing domestic violence, and sexual, physical or emotional abuse. The researchers then searched for correlations between these experiences and adult health and the risk of disease.

The connections became clear: compared with a person with no adverse childhood experiences, or ACEs, a person with four or more has almost double the risk of obesity. Having four or more ACEs more than doubles the risk of heart attack and stroke, and nearly quadruples the risk of emphysema. The risk for depression is more than quadrupled. Although many of these outcomes could reflect the influences of genes and other environmental influences — beyond those occurring in childhood — the tight relationship between increasing ACE numbers and increasing health risks makes the role of child trauma clear. Dr. Jack Shonkoff, director of Harvard’s Center on the Developing Child, calls the research “a tremendous contribution.”

But how does the psychological experience of childhood neglect cause physical effects like obesity, heart attack or stroke? There are at least two interconnected pathways — one physiological, the other psychological.

The psychology is relatively straightforward: being abused or otherwise traumatized is painful, and food can be a numbing or comforting escape. Hence, abused children may turn to overeating, which causes obesity. Indeed, ACEs are also strongly linked with other types of unhealthy “self-medication”: for instance, cigarette smoking (which accounts for the increased rate of emphysema among high ACE scorers) and drug abuse (having four or more ACEs increases the risk of injectable-drug use by a factor of 10). As Felitti puts it, “Being fat [or having other unhealthy behaviors] is not the problem. It’s the solution.”

The psychological effects often exacerbate health problems that the physiological stress response has already caused. High ACE scorers who do not overeat, smoke or take drugs still have high rates of obesity, heart disease, depression and diabetes. The mechanism for these risks appears to lie in the biology of the stress-response system and in the way environment affects a person’s genetic activity.

For most of human evolution, a stressful world would have been marked by famines or periods of starvation, and that environment might have resulted in a particular pattern of gene expression that would have prompted the body to store more fat in preparation for the next bout of scarcity. Today, of course, the same response to stress would result in obesity. This theory of a thrifty fat-storing system that kicks in under high levels of early stress was originally proposed by British physician David Barker.

If, for instance, a modern child’s early life experience — in the womb and during the first five years, particularly — is constantly stressful, it would be incredibly energy-consuming, says Dr. Bruce Perry, senior fellow at the ChildTrauma Academy. “If your genes get the message that you are entering a stressful world, it makes complete adaptive sense to take the existing metabolism and tune it up to deposit fat and store energy to prepare for what the body is expecting will be a challenging and stressful life,” he says.

“Early adverse experience can disrupt the body’s metabolic systems,” says Shonkoff. “One of the cornerstones of biology is that our body’s systems when they are young are reading the environment and establishing patterns to be maximally adaptive.”

Researchers also posit that high levels of stress hormones caused by ACEs can wear down the body over time. A temporary spike in blood pressure in response to a stressful event may be useful to power an adaptive fight-or-flight response, but over the long term constant high blood pressure could raise a person’s risk for heart attack and stroke. Studies have also found that consistently elevated levels of stress hormones, like cortisol, can lead to permanent damage in certain brain regions linked to depression.

Recently, scientists have discovered that these changes can themselves be passed down from one generation to the next — a burgeoning new area of study called epigenetics. Such research may have significant and long-term implications for the prevention of obesity, addiction and other illnesses related to early life stress. After all, reducing childhood exposure to trauma in one generation may further benefit that generation’s children and grandchildren.

Some initiatives, such as the nurse home-visiting program and President Obama’s proposed Promise Neighborhoods program, already put this theory into practice, by offering support and services to low-income parents in order to reduce child abuse, increase access to prenatal care and provide parenting education and high-quality day care.

The goal is not only to improve conditions for the current participants of such programs, but also hopefully to reduce the risk of problems in successive generations, including major causes of death and disability like obesity, heart disease and stroke. “It’s not a secret that there is a growing epidemic of obesity and there’s no question that the way we eat and the way we exercise, or do not exercise, is contributing to it. But it’s a huge mistake to attribute it just to the need to close down fast-food restaurants and turn off the TV. There’s important biology here early in life that needs attention,” says Shonkoff.

January 6, 2010, 11:07 am

Many parents overestimate how much physical activity their children get, a new study found.

Compared to adults, children seem to be moving constantly. So it’s no surprise that most parents who are quizzed about their child’s physical activity level describe their children as fairly active.

But a new study of nearly 2,000 British school children suggests that many parents overestimate the amount of physical activity their children are really getting.

The researchers equipped 1,892 British school children, ages 9 and 10, with accelerometers, gadgets that measure all physical activity during a given time period. The research, known as the Speedy study (an acronym for Sport, Physical Activity and Eating Behavior: Environmental Determinants in Young People), collected the exercise data from children at 92 schools in Norfolk, England, between April and July 2007.

A child was deemed inactive if he or she recorded less than an hour a day of moderate and vigorous physical activity. Although the majority of children studied were getting a sufficient level of physical activity, a sizable minority of children were not. Overall, 39 percent of girls and 18 percent of boys studied were getting less than an hour of physical activity each day.

But if you asked the parents of the inactive children to describe their child’s activity level, the vast majority — 80 percent — described their children as fairly or very physically active, according to the findings published in the American Journal of Preventive Medicine. Interestingly, the children themselves had more awareness about their lack of physical activity. Overall, 40 percent of children overestimated their physical activity compared to their peers.

But it wasn’t the parents of overweight children who were most likely to guess wrong about physical activity levels. The parents who were most out of touch about their child’s physical fitness were more likely to have children who were slim. Parents of girls were also more likely to overestimate physical activity. The researchers noted that parents should be educated about the importance of physical activity for children even if the child is not overweight.

“Parents of children with a lower fat mass index appear to assume that their children are adequately active,” the study authors reported. “Increasing awareness regarding health benefits of physical activity beyond weight control might help reverse misperceptions of physical activity levels and encourage behavior change.”

Your chair is your enemy.

It doesn’t matter if you go running every morning, or you’re a regular at the gym. If you spend most of the rest of the day sitting — in your car, your office chair, on your sofa at home — you are putting yourself at increased risk of obesity, diabetes, heart disease, a variety of cancers and an early death. In other words, irrespective of whether you exercise vigorously, sitting for long periods is bad for you.

That, at least, is the conclusion of several recent studies. Indeed, if you consider only healthy people who exercise regularly, those who sit the most during the rest of the day have larger waists and worse profiles of blood pressure and blood sugar than those who sit less. Among people who sit in front of the television for more than three hours each day, those who exercise are as fat as those who don’t: sitting a lot appears to offset some of the benefits of jogging a lot.

So what’s wrong with sitting?

The answer seems to have two parts. The first is that sitting is one of the most passive things you can do. You burn more energy by chewing gum or fidgeting than you do sitting still in a chair. Compared to sitting, standing in one place is hard work. To stand, you have to tense your leg muscles, and engage the muscles of your back and shoulders; while standing, you often shift from leg to leg. All of this burns energy.

For many people, weight gain is a matter of slow creep — two pounds this year, three pounds next year. You can gain this much if, each day, you eat just 30 calories more than you burn. Thirty calories is hardly anything — it’s a couple of mouthfuls of banana, or a few potato chips. Thus, a little more time on your feet today and tomorrow can easily make the difference between remaining lean and getting fat.

You may think you have no choice about how much you sit. But this isn’t true. Suppose you sleep for eight hours each day, and exercise for one. That still leaves 15 hours of activities. Even if you exercise, most of the energy you burn will be burnt during these 15 hours, so weight gain is often the cumulative effect of a series of small decisions: Do you take the stairs or the elevator? Do you e-mail your colleague down the hall, or get up and go and see her? When you get home, do you potter about in the garden or sit in front of the television? Do you walk to the corner store, or drive?

Just to underscore the point that you do have a choice: a study of junior doctors doing the same job, the same week, on identical wards found that some individuals walked four times farther than others at work each day. (No one in the study was overweight; but the “long-distance” doctors were thinner than the “short-distance” doctors.)

So part of the problem with sitting a lot is that you don’t use as much energy as those who spend more time on their feet. This makes it easier to gain weight, and makes you more prone to the health problems that fatness often brings.

But it looks as though there’s a more sinister aspect to sitting, too. Several strands of evidence suggest that there’s a “physiology of inactivity”: that when you spend long periods sitting, your body actually does things that are bad for you.

As an example, consider lipoprotein lipase. This is a molecule that plays a central role in how the body processes fats; it’s produced by many tissues, including muscles. Low levels of lipoprotein lipase are associated with a variety of health problems, including heart disease. Studies in rats show that leg muscles only produce this molecule when they are actively being flexed (for example, when the animal is standing up and ambling about). The implication is that when you sit, a crucial part of your metabolism slows down.

Nor is lipoprotein lipase the only molecule affected by muscular inactivity. Actively contracting muscles produce a whole suite of substances that have a beneficial effect on how the body uses and stores sugars and fats.

Which might explain the following result. Men who normally walk a lot (about 10,000 steps per day, as measured by a pedometer) were asked to cut back (to about 1,350 steps per day) for two weeks, by using elevators instead of stairs, driving to work instead of walking and so on. By the end of the two weeks, all of them had became worse at metabolizing sugars and fats. Their distribution of body fat had also altered — they had become fatter around the middle. Such changes are among the first steps on the road to diabetes.

Conversely, a study of people who sit for many hours found that those who took frequent small breaks — standing up to stretch or walk down the corridor — had smaller waists and better profiles for sugar and fat metabolism than those who did their sitting in long, uninterrupted chunks.

Some people have advanced radical solutions to the sitting syndrome: replace your sit-down desk with a stand-up desk, and equip this with a slow treadmill so that you walk while you work. (Talk about pacing the office.) Make sure that your television can only operate if you are pedaling furiously on an exercise bike. Or, watch television in a rocking chair: rocking also takes energy and involves a continuous gentle flexing of the calf muscles. Get rid of your office chair and replace it with a therapy ball: this too uses more muscles, and hence more energy, than a normal chair, because you have to support your back and work to keep balanced. You also have the option of bouncing, if you like.

Or you could take all this as a license to fidget.

But whatever you choose, know this. The data are clear: beware your chair.

Notes:

The term “calorie” sometimes causes confusion. Most people, when referring to the energy content of food, use “calorie” instead of “kilocalorie” — which is the actual unit that food energy is measured in. When I refer to 30 calories, I am following this convention and therefore technically mean 30 kilocalories. For metric system users, that’s about 125 kilojoules.

For sitting a lot causing heart disease, obesity, diabetes, certain cancers and early death, independently of whether you exercise regularly, see, for example, Katzmarzyk, P. T. et al. 2009. “Sitting time and mortality from all causes, cardiovascular disease, and cancer.” Medicine and Science in Sports and Exercise 41: 998-1005. (This study looked at the fates of 17,013 Canadians over a span of 12 years.) See also Dunstan, D. W. et al. 2010. “Television viewing time and mortality: the Australian diabetes, obesity and lifestyle study (AusDiab).” Circulation 121: 384-391. (This study considered 8800 Australians followed for a median time of 6.6 years.)

For the negative effects of sitting a lot on healthy people who exercise regularly, see Healy, G. N. et al. 2008. “Television time and continuous metabolic risk in physically active adults.” Medicine and Science in Sports and Exercise 40: 639-645. For fatness and three hours of television, see Dunton, G. F. et al. 2009. “Joint associations of physical activity and sedentary behaviors with body mass index: results from a time use survey of US adults.” International Journal of Obesity 33: 1427-1436.

For energy expended during sitting as opposed to gum chewing, fidgeting, and standing, see Levine, J. A. et al. 2006. “Non-exercise activity thermogenesis: the crouching tiger hidden dragon of societal weight gain.” Arteriosclerosis, Thrombosis, and Vascular Biology 26: 729-736. For weight gain by slow creep, see Hill, J. O., Peters, J. C. and Wyatt, H. R. 2009. “Using the energy gap to address obesity: a commentary.” Journal of the American Dietetic Association 109: 1848-1853. Note that the process of gaining weight is different from the process of losing weight.

For fatness versus leanness being a consequence of small differences in daily movements, see Levine, J. A. et al. 2005. “Interindividual variation in posture allocation: possible role in human obesity.” Science 307: 584-586. For some doctors walking four times further than others while doing the same job, see Conzett-Baumann, K. et al. 2009. “The daily walking distance of young doctors and their body mass index.” European Journal of Internal Medicine 20: 622-624. I have borrowed their “long-distance” and “short-distance” terminology.

Two outstanding papers provide fascinating overviews of the more sinister aspects of sitting. See Hamilton, M. T., Hamilton, D. G. and Zderic, T. W. 2007. “Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease.” Diabetes 56: 2655-2667; and Pedersen, B. K. 2009. “The diseasome of physical inactivity — and the role of myokines in muscle-fat cross talk.” Journal of Physiology 587: 5559-5568. The Hamilton et al. paper discusses the results for lipoprotein lipase, and describes how sitting differs from standing in terms of muscles flexed. The Pedersen paper discusses a variety of other compounds that are released by active muscles, as well as the impact they have on metabolism. For muscular activity in rats and the production of lipoprotein lipase, see Bey, L. and Hamilton, M. T. 2003. “Suppression of skeletal muscle lipoprotein lipase activity during physical inactivity: a molecular reason to maintain daily low-intensity activity.” Journal of Physiology 551: 673-682.

For the physiological impact of men reducing how far they walk for two weeks, see Olsen, R. H. et al. 2008. “Metabolic responses to reduced daily steps in healthy nonexercising men.” Journal of the American Medical Association 299: 1261-1263. For the advantages of taking breaks from sitting, see Healy, G. N. et al. 2008. “Breaks in sedentary time: beneficial associations with metabolic risk.” Diabetes Care 31: 661-666.

For the advantages of having a stand-up desk attached to a treadmill, see Levine, J. A. and Miller, J. M. 2007. “The energy expenditure of using a ‘walk-and-work’ desk for office workers with obesity.” British Journal of Sports Medicine 41: 558-561. For a set of radical suggestions regarding how to reduce sitting, including the idea of attaching the television to some kind of exercise device, see the crouching tiger hidden dragon paper mentioned above.

The advantages of rocking chairs have mostly been explored in the elderly. See, for example, Pierce, C., Pecen, J. and McLeod, K. J. 2009. “Influence of seated rocking on blood pressure in the elderly: a pilot clinical study.” Biological Research for Nursing 11: 144-151. However, I see no reason why rocking wouldn’t be preferable to passive sitting in younger people too. For the advantages of using a therapy ball instead of a desk chair, see Beers, E. A. et al. 2008. “Increasing passive energy expenditure during clerical work.” European Journal of Applied Physiology 103: 353-360.

ScienceDaily (Jan. 6, 2010) — With obesity rising markedly, reliance on the accuracy of food labeling is an important weight management strategy. Since people who are trying to reduce their weight are encouraged to choose meals labeled as “lower in calories” or “reduced-energy” in restaurants and supermarkets, it is essential that the listed data are accurate. In a study published in the January 2010 issue of the Journal of the American Dietetic Association, researchers from Tufts University found that some commercially prepared foods contained more calories than indicated in nutritional labeling.
Measured energy values of 29 quick-serve and sit-down restaurant foods averaged 18% more calories than the stated values. Likewise, measured energy values of 10 frozen meals purchased from supermarkets averaged 8% more calories than stated on the label.
The commercially prepared restaurant foods and supermarket frozen convenience meals were obtained in the Boston, MA, area. The energy content was measured and compared with nutrition data stated by the vendor or manufacturer. The restaurant chains included both quick-serve and sit-down establishments with broad distribution throughout the United States.
Because the goal of the study was to examine the accuracy of stated energy content of foods typically selected for weight control, specific restaurant menu items were chosen based on three criteria. Selected foods were (1) less than 500 kcal/serving as stated on the label, (2) typical American foods and (3) among those with the lowest stated energy contents on the menu. Supermarket purchases were focused on frozen complete meals that would be alternative choices to eating out.
The authors found a further complication with some restaurant meals. Five restaurants provided side dishes at no extra cost. The average energy provided by these items was 471 kcal, which was greater than the 443 kcal for the entrées they accompanied. Furthermore, some individual foods had discrepancies that were extreme, including three supermarket-purchased complete meals and seven restaurant foods that containing up to twice their stated energy contents.
The authors also note that the US Food and Drug Administration allows up to 20% excess energy content but weight must be no less than 99% of the stated value. This might lead manufacturers to add more food to the package to insure compliance with the weight standards and thereby exceed the stated energy content.
Lead investigator Susan B. Roberts, PhD, director, Energy Metabolism Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, and colleagues write, “These findings suggest that stated energy contents of reduced-energy meals obtained from restaurants and supermarkets are not consistently accurate, and in this study averaged more than measured values, especially when free side dishes were taken into account, which on average contained more energy than the entrees alone. For example, positive energy balance of only 5% per day for an individual requiring 2,000 kcal/day could lead to a 10-lb weight gain in a single year. If widespread, this phenomenon could hamper efforts to self-monitor energy intake to control weight, and could also reduce the potential benefit of recent policy initiatives to disseminate information on food energy content at the point of purchase.”

Have we simply reached a maximum level of tubbiness?
msnbc.com
updated 9:22 a.m. PT, Wed., Jan. 13, 2010
America’s rapid rise in obesity appears to have leveled off, with new government figures showing no significant increase in a decade.
But there’s little reason to cheer. More than two-thirds of adults and almost a third of children are overweight, and there are no signs of improvement.
Experts say they’re not sure whether the lull in the battle of the bulge can be attributed to more awareness and better diets — or whether society has simply reached a maximum level of tubbiness.
“Maybe in this environment, this is as overweight as we’ll get,” said Gary Foster, director of the Temple University Center for Obesity Research and Education.
Being thin is the exception
Not only are the vast majority of adults — 68 percent — overweight, 34 percent are obese; and 17 percent of children are obese. Even the youngest Americans are affected — 10 percent of babies and toddlers are precariously heavy.

The most recent Centers for Disease Control and Prevention data, from the years 2007 to 2008, were contained in two reports published online Wednesday in the Journal of the American Medical Association.
“The absolute numbers here are staggering,” said Foster. “This isn’t something that should be celebrated.”
The new data are based on health surveys involving height and weight measurements of 5,700 adults and 4,000 children, surveys the CDC does every two years.
“In the most recent decade, we saw a slowing in the increase,” said Carolyn Ogden, the report’s author and a CDC researcher who has tracked obesity for years. “It was better news, but it’s still a serious problem.”
In most age groups, black adults had the highest rates of obesity, followed by Mexican-Americans and whites.
Heaviest boys getting heavier
Among children ages 2 to 19, 32 percent were too heavy — a rate that was mostly unchanged. But disturbingly, most obese kids were extremely obese. And the percentage of extremely obese boys ages 6 to 19 has steadily increased, to 15 percent from about 9 percent in 1999-2000.

Ogden said it was disappointing to see no decline, and troubling that the heaviest boys seem to be getting even heavier. The study didn’t examine the causes, but Ogden cited the usual reasons — soft drinks, video games and inactivity — as possible explanations.

“We shouldn’t be complacent. We still have a problem,” Ogden said.

Dr. William Dietz, an obesity expert with the CDC, cautiously called the results promising. “We’re at the corner; we haven’t turned the corner,” he said.
Turning point?
One factor in the plateau may be the barrage of information about the obesity epidemic — and what to do about it, said Foster.
“There’s an increased availability of healthier options than there was five years ago,” he said.
School- and community-based efforts to emphasize fitness and healthy eating may also have had some effect, although Foster acknowledges that there’s no good data to prove the point.
“I think there’s lot of things you could point to, but the truth is, it’s a confluence of factors,” he said.
One of those factors might be the intersection of genetic predisposition to obesity and an environment that encourages weight gain, Foster said.
“This is about what we can expect,” he said. “For it to go down, we’re going to have to greatly change the environment for the better.”
The obesity epidemic is considered a top White House priority. President Barack Obama has pushed to make obesity prevention part of health care reform. Overhaul measures pending in Congress include encouraging employer-based wellness programs and requiring large restaurant chains to list calories. And Michelle Obama has made childhood obesity and healthy eating habits a pet project.
People like Darrell Pender are paying attention.

Obesity “is constantly in the news,” said Pender, a 42-year-old New York City computer technician who decided to get serious about fighting fat after being diagnosed with diabetes three years ago.

Pender was tempted by a TV ad for obesity surgery, but chose a less drastic option — a nutrition support group that he credits with helping him make healthier food choices. So far, he’s lost 50 pounds over several months. At 350 pounds, he’s still very obese, but his diabetes is under control and he feels healthier.

The step-tracking gadgets are easy to use and relatively inexpensive. Plus, evidence indicates that they truly inspire people.

By Jeannine Stein

January 11, 2010

If the journey toward fitness begins with a single step, make sure it’s counted with a pedometer.

These little step-tracking gadgets now have a solid track record when it comes to motivating people to exercise. And their popularity is growing.

Inside this small-as-an-egg device are the keys to exercise success that have eluded far more complex and expensive fitness programs: accountability, goal-setting and being able to monitor progress. If the objective is to reach 10,000 steps in a day (the recommended amount), seeing a tally of 4,000 steps at 3 p.m. is a wake-up call to start walking.

“When we ask people to start an exercise program, it’s important to have measurable, achievable goals, and adding this self-monitoring component is very critical,” says Simon Marshall, associate professor of exercise and nutritional science at San Diego State University. “We don’t know why exactly, but keeping a number, a prompt, in our consciousness on a regular basis is important, and that’s why pedometers are superior to other methods. It’s on you all the time.”

Pedometers are easy to use day after day in various settings, none of which has to be a gym.

Perhaps better yet, the average cost is around $20.

“People describe them as being like little personal trainers,” says Catrine Tudor-Locke, associate professor and director of the Walking Behavior Laboratory at Pennington Biomedical Research Center in Baton Rouge, La. “They provide ready, real-time data so you can make decisions about how you’re going to spend the rest of your day and make adjustments as needed.”

Los Angeles-based personal trainer Harley Pasternak has been studying the health habits of various cultures for his latest book, “The 5-Factor World Diet.” He says, “What I found was that in the 10 healthiest countries in the world, they all have different [dietary habits]. But one thing they all share is that they all walk way more than we do in America. For those in these 10 countries, being fit and healthy is about having an active lifestyle, while here in America, being fit is about performing an exercise in a room designated for fitness.”

Pedometers can create that lifestyle balance that many Americans otherwise would lack.

Fits any lifestyle

At 12:30 on a recent afternoon, Dr. Kathy Magliato’s pedometer already reads 19,000 steps for the day. “I’m a cardiothoracic surgeon who’s also a busy mommy with two small kids, so I run around quite a bit,” she says. She typically gets her steps in while doing rounds at St. John’s Health Center in Santa Monica or Torrance Memorial Medical Center. On days when she’s in surgery for 10 hours, she takes her children for a walk when she gets home.

Magliato clipped on her first pedometer six years ago after the birth of her first child. With 10 pounds to lose and no time to go to a gym, she had to do something to stay in shape — both for herself and as a role model for her patients, many of whom have heart disease. Through walking and watching her diet, she dropped the 10 pounds and realized that walking provided the activity she needed, which some fitness experts and researchers say is the key to true health.

“When my patients tell me they can’t work out because they don’t have time, I say, ‘Look at my lifestyle.’ ”

Pedometers have even made their way into the White House. In October, Peter Orszag, director of the Office of Management and Budget, issued a pedometer challenge through the end of 2009 to all willing agency employees. In an office blog post, Orszag (a runner and marathoner) wrote: “This year, as part of their budget submissions, federal agencies have been asked to report on their efforts to improve the health and wellness of their employees. I want to make sure that the staff at OMB doesn’t just talk the talk on wellness, but that we also walk the walk — literally.”

With approximately 115 to 200 men and women taking part, weekly step averages went from 10,871 the first week (beginning Oct. 4) to 13,000 in early December. (Final tallies aren’t yet available.)

Research confirms that monitoring daily steps helps people get the recommended amount of exercise, bolsters their cardiovascular system and often contributes to weight loss.

A 2007 study in the Journal of the American Medical Assn. analyzed data from 26 studies assessing pedometer use among adults and found the device to be linked with considerable increases in physical activity and decreases in blood pressure and body mass index. In a 2004 study in Medicine & Science in Sports & Exercise, 27 people were assigned to a pedometer-based exercise group with an emphasis on daily steps and 33 people to an exercise program emphasizing time spent exercising.

At the end of the study, the pedometer-based program proved to be more effective in increasing daily activity than the time-based program.

Set a goal

Clipping on a pedometer and counting steps — even brisk ones — isn’t the end of the fitness story. “It’s one thing to wear a pedometer, but it’s another to have a goal in mind of how many steps you want to get,” says Karen Croteau, a professor in the department of exercise, health and sport sciences at the University of Southern Maine. “These gadgets are effective when serving as a cue, but that has to be in conjunction with setting goals.”

She suggests that new users monitor steps for a few days to find a daily average before upping the amount. Some fitness experts recommend adding 5% to 10% of the starting average per day, but Tudor-Locke believes that fitness levels and daily routines should be taken into consideration. “One person has to juggle child rearing while another has different lifestyle impediments,” she says. “People should find out where they are and realize that more is better.”

And while walking 10,000 steps a day is admirable, reaching that goal every day over a long period of time may cause a fitness plateau, in which cardio gains stop and weight sneaks back on. In that case, users must increase both steps and intensity.

(But keep in mind, walking shouldn’t be the only exercise in the repertoire. Strength training for both the upper and lower body prevents muscle loss and helps stave off bone deterioration, both important as people age.)

Choosing a pedometer can be challenging, considering how many models are on the market. Some are equipped with accelerometers that record movement and intensity. Others tally weekly steps, have calorie counters and come with software to track progress. Some cellphones now come with a pedometer, but since the devices track steps by monitoring hip movement, they won’t work if left on a table or in a purse on the floor.

Many exercise physiologists and trainers generally recommend starting with a basic model that just counts steps and costs about $20. To ensure accuracy, count out from 20 to 50 steps a few times, checking the pedometer. If the count is within a few steps, it should be adequate. You can always upgrade later to a model with more bells and whistles.

Says Marshall, “You’re only limited by how creative you can be.”

Studies have shown that a lack of sleep can lead to an increased risk of health detriments such as obesity, diabetes, hypertension, and heart disease. In the Journal of Clinical Nutrition, Dr. Sebastian M. Schmid, of the University of Luebeck in Germany, investigated the effect sleep deprivation on physical activity.

NEW YORK (Reuters Health) – A number of studies have linked chronic sleep deprivation to a heightened risk of obesity, diabetes and heart disease. Now, a small study suggests that low levels of physical activity during the day may partly account for the connection.

In a study of 15 healthy men, researchers found that a couple nights of grabbing only four hours of sleep caused the men to curtail their physical activity compared with days where they had gotten the standard eight hours the night before.

In contrast, there was no evidence that sleep loss altered blood levels of appetite-regulating hormones or caused the men to eat more the next day — effects that have been seen in a number of previous studies.

The implication is that there may be a broader range of reasons for the link between sleep loss and weight and health, the researchers report in the American Journal of Clinical Nutrition.

Practically speaking, the findings offer adults another reason to get enough sleep.

For healthy adults, that means regularly getting seven to eight hours per night, lead researcher Dr. Sebastian M. Schmid, of the University of Luebeck in Germany, told Reuters Health in an email.

A number of large epidemiological studies have found associations between poor sleep and higher risks of obesity and other health problems. Since then, a few small studies done in the sleep lab have attempted to find the possible reasons for the connection.

In some, researchers have found evidence that sleep loss alters the regulation of the hunger hormones leptin and ghrelin, and may boost daytime appetite. Leptin, which helps regulate body weight, is secreted by fat cells; low blood levels of the hormone promote hunger, while increases tell the brain that the body is full and encourage calorie burning. Ghrelin is secreted by the stomach to boost appetite.

But another possibility is that sleep-deprived people are just too tired to be physically active during the day.

While that seems logical, apparently no human studies had examined the question before.

For the new study, Schmid and his colleagues had 15 healthy, normal-weight men go through two consecutive nights with four hours of sleep and two nights with eight hours of sleep.

After the first night, the men spent the day doing their normal activities, while wearing a wrist device that recorded their movements. After the second night, they came to the sleep lab, where they again wore the wrist devices and also had their levels of leptin and ghrelin measured and their calorie intake monitored.

The researchers found that, unexpectedly, the men showed no differences in their hormone levels, hunger or food intake after the four-hour night compared with the eight-hour night.

They were, however, less active after sleep-deprived nights — devoting both fewer minutes to physical activity and a smaller proportion of that time to more-intense exercise.

Last Updated: 2010-01-01 13:00:52 -0400 (Reuters Health)

When the men got eight hours of sleep, they spent an average of 25 percent of their active time performing higher-intensity exercise; that declined to about 22 percent with four hours of sleep.

Over time, such differences could affect a person’s weight and general health, according to Schmid’s team.

The findings do not mean that sleep loss has no effects on hunger hormones and appetite, as earlier studies have suggested that it does. However, Schmid said, the results do suggest that even modest sleep restriction — so common in today’s society — reduces physical activity, while hormones and appetite are “less affected.”

SOURCE: American Journal of Clinical Nutrition, December 2009.

Let’s Move
Michelle Obama’s “Let’s Move” program calls for a myriad initiatives that target what Mrs. Obama calls four key pillars: getting parents better informed about nutrition and exercise, improving the quality of food in schools, making healthy foods more affordable and accessible for families, and focusing more on physical education. In each domain, considerable efforts will emerge to provide tools and toolkits to families, schools and healthcare providers. For example, “the American Academy of Pediatrics, in collaboration with a broader medical community, will educate doctors and nurses across the country about obesity, ensure they regularly monitor your child’s Body Mass Index (BMI) provide counseling for healthy eating early on, and even write a prescription for parents laying out the simple things they can do to increase healthy eating and active play.” Let’s Move uses excellent principles of self-regulation by setting specific goals within each of its four pillars and enumerating strategies to reach those goals (e.g., to double the number of children that earn the President’s Active Lifestyle Award; to use the new “Healthy Food Financing Initiative” to bring more high quality fresh food to underserved communities).

Making a Good Thing Better: Three Ideas
Let’s Move is a dynamic initiative, equipped with a large government task force, and an emphasis on adding ideas as it grows. Wellspring’s experience and research suggests three ideas that could help:

• Emphasize Referral for Treatment as an Early Intervention: Previous studies support Let’s Move’s emphasis on more consistent diagnosis of obesity. Those studies indicate that when obese children are diagnosed as such based on their BMIs they become ten times more likely to receive dietary counseling compared to obese children whose doctors do not provide parents with their children’s BMI-based diagnosis(1). However, dietary counseling alone usually does not help. Such educational approaches rarely help overweight children and their families make the major changes in their attitudes and lifestyles required for successful weight change (2,3). Two expert groups have provided very useful sets of recommendations for treatment that healthcare providers can use to promote substantial change, and they can begin making such referrals when children reach the 85th% in BMI – the overweight level, rather than wait for those children reach the 95th% – the obese level (4,5). We favor the 7 Steps Model for the treatment of overweight young people because it strongly encourages pursuit of reductions in excess weight by adding greater intensities of interventions until success is achieved (5).
• Take a Stand Against Dietary Fat- Set a National Goal for Zero Fat grams per day: Goals for changes in eating are needed that clearly correspond to the overarching goal of reduction in overweight. The ideal goal might help overweight young people and their families focus on a key simple (easily remembered and readily understood) and measurable aspect of eating. This goal should, to maximize impact on weight, correlate with increased consumption of low caloric density high fiber foods (like fruits and vegetables), increase satiety, and help reduce consumption of total calories. A very-low fat goal satisfies those criteria (6). The vast majority of experts on obesity support at least a low fat goal, but in CBM and Wellspring we believe targeting as little consumption of all types of fat (not just saturated fats) produces the best outcomes. To support this position, tax incentives could be provided to restaurants that offer 5 or more entire meals that provide less than 10g of fat, tax levies could be added to high fat foods and so on. Encouraging everyone to set a goal for zero consumption of fat will help make the key point: Minimize consumption of fat every time you eat and you’ll find losing weight much easier (for those who are overweight). This goal will also help parents create a home environment conducive to preventing obesity in their children. This goal does not apply to babies, nor are we suggesting that people will succeed at eating zero fat per day. The goal will just help Americans get closer to the ideal – a very low fat diet.
• Provide Pedometers to All School Children: Using pedometers to measure steps promotes more activity and setting goals in addition to wearing pedometers encourages even more activity (7). As a society, we provide books to children in schools. Why not provide pedometers? In addition to the ideas on the Let’s Move website to get increased activities in the schools (and to and from school), how about acknowledging schools that offer principal’s walks before and after school – with pedometers, and targeting a mile walk around the school? Let’s make steps a focus in every family and every school.

Conclusions
CBM applauds Mrs. Obama’s incredibly important efforts to ameliorate the devastating problem of childhood obesity and looks forward to witnessing it mobilize our culture toward healthier lifestyles.

References
1. Kim C, Haemer M, Krebs NF. Parental and provider perceptions of children’s weight status: where and why the gaps. Obes Manage.2008;4:236-241.
2. Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R. Behavioral weight control for overweight adolescents initiated in primary care. Obes Res. 2002;10:22-32.
3. Stice E, Shaw H, Marti CN. A meta-analytic review of obesity revention programs for children and adolescents. Psych Bull 2006; 132:667-691.
4. Spear BA, Barlow S, Ervin C, Ludwig D, Saelens B, Schetzina KE, Taveras Em. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(suppl 4):253-287.
5. Kirschenbaum DS, DeUgarte D, Frankel F, Germann JN, McKnight TL, Nieman P, Sandler RH Slusser MD. Seven steps to success: a handout for parents of overweight children and adolescents. Obes Manage. 2009;5:29-31.
6. Kirschenbaum DS. The Healthy Obsession Program: Smart Weight Loss Instead of Low-Carb Lunacy. Dallas, TX: BenBella Books; 2006.
7. Bravata DM et al. Using pedometers to increase physical activity and improve health. JAMA 2007;298:2296-2304.

Reuters
NEW YORK (Reuters Health) – When it comes to weight-loss surgery for very obese adolescents, having the surgery sooner rather than later may yield a better long-term outcome, new study findings hint.
Surgical treatment for extreme obesity may be appropriate for some adolescents, Dr. Thomas H. Inge, of Cincinnati Children’s Hospital Medical Center, Ohio, and colleagues note in the Journal of Pediatrics.
Based on their experience, Inge told Reuters Health, “the timing of surgery for adolescent obesity is an important consideration, as ‘late’ referral for (weight-loss) surgery at higher body mass index (BMI) values may preclude reversal of obesity or extreme obesity within the first post-operative year and may increase the risk of weight regain over the long term.”
But regardless of body weight going into the surgery, weight-loss surgery improves cardiovascular risk factors and brings body weight down significantly in all patients, the study team found.
BMI — calculated by dividing weight in kilograms by height in meters squared — is a standard way to determine how fat or thin a person is. Values between 20 and 25 are typically considered normal. Any value of 30 or greater is considered obese. Morbidly obese people have a body mass index (BMI) of 40 or greater — equal to being about 100 pounds or 50 kilograms overweight.
To determine the effect of pre-surgery BMI status on outcomes in their younger patients, Inge’s team followed 61 adolescents for a year after they underwent the most common and most effective form of weight-loss surgery for severe obesity called Roux-en-Y gastric bypass.
The procedure involves stapling off the upper portion of the stomach to create a small pouch that restricts the amount of food a person can eat at one time. The surgeon also makes a bypass from the pouch that skirts around the rest of the stomach and a portion of the small intestine, limiting the body’s absorption of nutrients.
Inge’s team stratified the adolescents in their study into three groups based on their pre-surgery BMI. Group 1 consisted of 23 patients with a BMI between 40.0 and 54.9. Group 2 consisted of 21 individuals with a BMI between 55.0 and 64.9, and Group 3 consisted of 17 individuals whose BMI fell between 65.0 and 95.0.
The average BMI in the overall cohort, which was 60.2 at the time of surgery, fell by roughly 37 percent at 1 year after surgery, with little variation in BMI reduction among the groups, the investigators report.
It is noteworthy, the investigators say, that subjects in Group 1 — who had the lowest BMI going into the surgery — had the lowest BMI a year after the surgery. Still, only 10 patients (17 percent) achieved a BMI of less than 30 at 1 year. Eight of these 10 were from Group 1.
“In this investigation, we found that most adolescents within the highest ranges of baseline BMI…remained extremely obese…despite BMI reductions averaging nearly 40 percent,” the investigators note.
Adolescents “who present at higher weights and BMI values lose more weight than those who present at lower weights but also plateau at a higher weight on average,” they add. “The biological and potentially behavioral reasons for this are unclear.”
Regardless of pre-surgery BMI, weight-loss surgery led to a healthy reduction in blood pressure, cholesterol levels and triglycerides (harmful blood fats).

Dr. Jeffrey Zigman is an assistant professor of internal medicine and psychiatry at UT Southwestern and co-senior author of a new study that appearing online and in a future edition of Biological Psychiatry. Dr. Zigman and colleagues investigated why we eat when we’re full. Humans and mice share the same type of brain-cell connections and hormones, as well as similar architectures in the so-called “pleasure centers” of the brain. First, Dr. Zigman and colleagues evaluated whether mice that were fully sated preferred a room where they had previously found high-fat food over one that had only offered regular bland chow. Next, the team observed how long mice would continue to poke their noses into a hole in order to receive a pellet of high-fat food. Listed below is what they found.

ScienceDaily (Dec. 28, 2009) — The premise that hunger makes food look more appealing is a widely held belief — just ask those who cruise grocery store aisles on an empty stomach, only to go home with a full basket and an empty wallet.
Prior research studies have suggested that the so-called hunger hormone ghrelin, which the body produces when it’s hungry, might act on the brain to trigger this behavior. New research in mice by UT Southwestern Medical Center scientists suggest that ghrelin might also work in the brain to make some people keep eating “pleasurable” foods when they’re already full.
“What we show is that there may be situations where we are driven to seek out and eat very rewarding foods, even if we’re full, for no other reason than our brain tells us to,” said Dr. Jeffrey Zigman, assistant professor of internal medicine and psychiatry at UT Southwestern and co-senior author of the study appearing online and in a future edition of Biological Psychiatry.
Scientists previously have linked increased levels of ghrelin to intensifying the rewarding or pleasurable feelings one gets from cocaine or alcohol. Dr. Zigman said his team speculated that ghrelin might also increase specific rewarding aspects of eating.
Rewards, he said, generally can be defined as things that make us feel better.
“They give us sensory pleasure, and they motivate us to work to obtain them,” he said. “They also help us reorganize our memory so that we remember how to get them.”
Dr. Mario Perello, postdoctoral researcher in internal medicine and lead author of the current study, said the idea was to determine “why someone who is stuffed from lunch still eats — and wants to eat — that high-calorie dessert.”
For this study, the researchers conducted two standard behavioral tests. In the first, they evaluated whether mice that were fully sated preferred a room where they had previously found high-fat food over one that had only offered regular bland chow. They found that when mice in this situation were administered ghrelin, they strongly preferred the room that had been paired with the high-fat diet. Mice without ghrelin showed no preference.
“We think the ghrelin prompted the mice to pursue the high-fat chow because they remembered how much they enjoyed it,” Dr. Perello said. “It didn’t matter that the room was now empty; they still associated it with something pleasurable.”
The researchers also found that blocking the action of ghrelin, which is normally secreted into the bloodstream upon fasting or caloric restriction, prevented the mice from spending as much time in the room they associated with the high-fat food.
For the second test, the team observed how long mice would continue to poke their noses into a hole in order to receive a pellet of high-fat food. “The animals that didn’t receive ghrelin gave up much sooner than the ones that did receive ghrelin,” Dr. Zigman said.
Humans and mice share the same type of brain-cell connections and hormones, as well as similar architectures in the so-called “pleasure centers” of the brain. In addition, the behavior of the mice in this study is consistent with pleasure- or reward-seeking behavior seen in other animal studies of addiction, Dr. Zigman said.
The next step, Dr. Perello said, is to determine which neural circuits in the brain regulate ghrelin’s actions.