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WEIGHT GAINS PROMINENCE ON MORTALITY TABLESA new bout of epidemics are ravaging the U.S. population. These plagues are not the result of potent germs gone amok, but of other factors that are less tangible and more perplexing. Like lethal germs, these chronic diseases are taking a powerful toll, causing widespread illness and killing thousands. but strange to say their virulence goes unrecognized.
"The epidemic of obesity far outstrips the epidemic of AIDS in the inner city," states Kirschner, an endocrinologist and obesity specialist. "You might say, ‘People aren’t dying in the streets,’ but down the road a bit they will be dropping off from complications of this condition." While the trend is serious in adults, the physician calls it "alarming" in children. "Go into any middle school in the U.S. and see how many kids are fat. It will knock your socks off," he exclaims. "Fat as children, fat as adults." Why are Americans so overweight? Most of us know the answers already. The physician points out that the numbers started rising with the advent of fast food restaurants. "Fast foods are high fat foods," he says. "They’re cheap and taste good." A cheese Whopper is 1,000 calories, he points out, almost a whole day’s caloric intake; and half of the vegetables eaten in the U.S. are French fries. But Kirschner observes that you can feed three hungry kids for about 10 dollars at McDonald’s, and when there’s not much income, that’s tough to beat. Lack of exercise is the second big contributor. He observes that physical education programs in schools have suffered massive cutbacks; and that this generation of kids is a lot less active than prior ones. Last but not least is genetics. "We’re just starting to appreciate the role of genes," the endocrinologist observes. Thrifty gene syndrome – a recently recognized phenomenon – was a boon in the days when man was a hunter and loaded up on calories afer a kill, then had to wait until the next kill to eat. The human body was equipped for feast or famine. "Now it’s all feast," Kirschner states. "If you have a genetic predisposition and you’re inactive and eat mega calories, you come out with serious weight gain." So what’s so bad about being fat? He says that aesthetics are not the issue. Life-threatening disease is. Cardiovascular dysmetabolic syndrome – a constellation of problems linked to obesity – includes diabetes, hypertension and abnormal cholesterol and lipids. These, in turn, lead to accelerated cardiovascular disease and its complications, including heart attack and stroke, and eventually a shortened life span. The physician points to a chart – plotting body mass index (BMI) against death rates – which was created by insurance companies to set up mortality tables. To calculate BMI, weight and height are both taken into account. A BMI of 25 to 29.9 is considered overweight and one of 30 or more is deemed obese. When a person has a BMI of 30 (about 40 pounds over ideal weight), the odds of dying sooner increase significantly. At a BMI of 40, mortality doubles. So what can be done? "The easiest thing is for a doctor to tell someone to lose weight," he says. "The hardest thing is for the person to actually lose the pounds." For those carrying 25 to 40 extra pounds, there are a number of new, effective drugs, chief among them Meridia and Xenical, he explains. But for those with a more serious weight problem, there isn’t much that works. Kirschner often prescribes Optifast combined with a very low calorie diet. Many of his patients have lost as much as 40 to 60 pounds in six months, but he calls the method "expensive and difficult." For those who need to lose 100 or more pounds, GI bypass surgery may be the only option that works. A 10 percent loss of body weight may not make someone thin, but there are considerable health benefits. "When 20-year-olds were dying of HIV, everyone was concerned," he states. "Then the gay community got behind the AIDS-eradication effort and it became a major focus. There are no advocates trying to get on top of the obesity problem. "Our efforts to control obesity are like the little Dutch boy putting his finger in the dike. We’re losing this battle because we have neither the ability nor the technology to treat this wide scale epidemic." Diabetes Takes Hold
The current epidemic of Type 2 –also known as adult onset or non-insulin dependent – diabetes is among adults as well as children. "Children are becoming more obese," says Javier Torrens, MD, (above) a diabetes specialist and assistant professor of medicine at NJMS. He points to consumption of large amounts of soda and juice, as well as high fat foods and lack of exercise, as the most likely culprits. "The majority of people with Type 2 diabetes whom I see are obese," he explains. "If you want to improve your diabetes control, you have to change your lifestyle and lose some weight."Torrens agrees that there are no terrific methods for losing weight and keeping it off. He says nutritional counselors help patients diagnosed with diabetes to assess their food intake and figure out how to cut 500 calories a day from their diet."I counsel patients to try to lose a half to one pound per week, for a total of 10 percent of their body weight. The blood sugar and cholesterol will follow suit," he says. Exercise is crucial, the specialist advises. "Aerobic exercise is best," he says. "But you need to walk 20 to 30 minutes each day, for instance, in order to see any real benefit." A recent study by Stephen Schneider, MD, an endocrinologist and diabetes specialist at UMDNJ’s Robert Wood Johnson Medical School (RWJMS), has shown that exercise can significantly lower blood sugar even with no weight loss. "But diabetes is not temporary," states Torrens. "You can control it, sometimes without drugs, but it never goes away." Even if all readings are normal, he explains, the diabetes "will roar back if you fall off the wagon." Unfortunately, as with many illnesses, the majority of patients don’t seek medical help until things get serious. "Then it can be difficult to manage," Torrens explains. "Some people will do fine on diet and exercise for awhile, but most will progress to the point where they need medication," he states. He points out that medication does not cancel out the need for dietary changes and exercise. There are more than 10 different oral medications for diabetes and six different types of insulin for those who are not able to reach the target for sugar control. Obesity, hypertension and elevated cholesterol (triglycerides) may develop first, states Torrens. This may be followed by glucose intolerance and then diabetes. But the physician is very hopeful. "Now I can say to someone who is newly diagnosed: ‘Don’t be too upset. We can prevent complications through lifestyle changes and medication.’ "You can’t do anything about genetic predisposition. But we have solid evidence that good, aggressive treatment will prolong the lives of patients with this disease." The next question, of course, is can it be prevented? The Finnish Diabetes Prevention Study recently demonstrated that Type 2 diabetes can, in fact, be prevented. Changes in lifestyle, such as increased physical activity and decreased fat intake, reduced the risk of developing diabetes by 58 percent in people at high risk for the disease. In the U.S., the Diabetes Prevention Program is testing if lifestyle modification, or medicines, can prevent diabetes. The results are not yet available. Rising Threat of Asthma
Asthma is gripping all industrialized countries worldwide. Recurrent bouts of breathlessness, wheezing, coughing and chest tightness are the hallmarks of the disease, although not all sufferers have all symptoms. Episodes can range from mild to deadly, occasional to frequent. Despite potent drugs, asthma kills about 5,000 Americans yearly. Recurrent airway inflammation is now understood to be the root of the disease. If left untreated, the ongoing inflammation will eventually produce irreversible changes in lung structure. New therapies aim to prevent flare-ups, since each episode can add to the progressive damage to the airways. There are two major classes of drugs currently used to control asthma. Anti-inflammatories are often prescribed to be taken daily – for chronic control – to diminish symptoms caused by inflammation. Bronchodilator medications serve as "relievers"to stop an attack in its tracks. A third and very new class of medicines–leukotriene receptor antagonists–interferes with the allergic process that often produces asthma symptoms. The four oral antileukotriene drugs currently available help to open the airways, reduce inflammation and decrease mucus production, and need to be taken only once or twice a day. Insights into the disease process coupled with new, more effective medicines should be curbing this epidemic. No one quite understands why the numbers continue to be so alarming, says Stanley H. Weiss, MD, (left), an epidemiologist and associate professor of preventive medicine at NJMS and associate professor of quantitative methods at UMDNJ’s School of Public Health. The culprits seem to be both genetic and environmental. In addition, some family physicians and pediatricians are not trained in the correct use of the newest medications for the disease. "Many only treat acute episodes," explains Weiss. "They’re not looking at the long-term picture." A predisposition to allergies is often a precursor to asthma. Studies indicate that indoor allergens and irritants –particularly dust mites and tobacco smoke – may serve as triggers to the onset of disease in susceptible children. American kids tend to spend a lot more time indoors than previous generations and houses are better sealed. Also, high indoor humidity may lead to increases in dust mites and mold. Exposure to cockroaches and rat feces are also being investigated as possible triggers, particularly in inner cities, says Weiss. Data indicates that exposure to cats, cockroaches, dust mites and tobacco smoke will trigger episodes in those with allergies who already have the disease. Exposure to dogs and fungus can also set off attacks. According to the epidemiologist, about 10 percent of adult asthma is linked to the workplace, with chemicals such as latex particles from powdered gloves being the prime culprits. Lessening exposure to these irritants will prevent episodes. Specific outdoor pollutants, among them ozone, diesel fumes, sulfur dioxide and particulate matter, can also worsen the illness in those who are sensitive to them. Weiss, Leonard Bielory, MD, an asthma specialist and associate professor of medicine at NJMS, and investigators working at the Environmental and Occupational Health Sciences Institute, a collaboration between UMDNJ and Rutgers, have recently written a grant proposal to investigate the link between diesel fumes and asthma in children. The investigators hope to expand and follow up on a pilot study that looked at the asthma prevalence rates of third, fourth and fifth graders in several elementary schools in Passaic. Weiss says preliminary data from that study suggest that in this age group, asthma rates (defined as asthma diagnosed by a physician) are at least 10 percent and may be as high as 25 percent. The researcher thinks that idling school buses – parked near the school buildings – and commercial traffic may be contributors. He is also interested in the possible link between early infection with one or more respiratory viruses and childhood asthma. In addition, he is participating in a Newark study analyzing the relationship of ozone levels, pollen and mold counts to emergency room visits. Although African-American adults have only a slightly higher rate of asthma than whites, they are more than twice as likely to die of the disease. But it is in kids that the disparity is truly shocking – African American children die from asthma at a rate that is four times as high as white children. Alzheimers And The Elderly Those who are thin and breathe easily still are not immune to the ravages of aging. Looking down the pike, experts warn that we could be in for some big trouble. When the most senior baby boomers climb over the 75 mark in approximately two decades, it could herald the beginning of an epidemic of Alzheimer’s disease.
He explains that about 3 percent of people ages 65 to 74 and 19 percent of those 75 to 84 are diagnosed with the disease; and close to 50 percent of those 85 and over are affected. A projected nine million people will be afflicted with Alzheimer’s by 2040. Aupperle, who also serves as director of the division of geriatric psychiatry at RWJMS, points out the difficulty of estimating these numbers because the disease is so grossly underdiagnosed. It is frequently a nightmare for families and physicians alike. Fear and stigma weigh upon family members, who turn to harried and sometimes inadequately prepared physicians to see them through the years-long ordeal. Consequently, many patients who could benefit from cutting edge pharmacotherapy and early diagnosis don’t receive proper treatment until the disease is well advanced. "The sooner the medication is started, the more efficacious it will be," he explains. "Those who are diagnosed and treated early may see minimal decline for some time." Newer compounds currently in clinical trials, and "cocktails" of various drugs with some proven efficacy, may extend this period. In some cases, Alzheimer’s is not diagnosed until the affected person’s life is in disarray, evidenced by such things as car accidents, stoves left on and checks bouncing. When it’s diagnosed this late in the game, he explains, "It is much more challenging to stabilize the behavioral and functional complications of the disease." The psychiatrist advocates more user-friendly screening techniques and earlier identification of those with even mild symptoms. Strategies to head off the epidemic include furthering genetic studies. The gene known as ApoE4 has been identified as a risk factor for Alzheimer’s disease. For those with one or two alleles for ApoE4, the risk for the disease increases two-fold; with two alleles, the risk is four- fold. He explains that genetic screening cannot currently be used for diagnosis because many people who test positive for the allele will not develop the disease. "People who test positive for the alleles may think disease onset is imminent when they won’t be affected for decades if it all," says Aupperle, adding that pre-symptomatic genetic testing has the potential to do harm, in terms of higher insurance rates and emotional turmoil. Although the available therapies cannot fix or stabilize patients for the longterm, such as those for diabetes and hypertension, Aupperle states that "current treatments can effectively push back the clock for a period of nine months to a year, or more." He feels hopeful about the future: "Five years ago, we had nothing. Then in the spring of 1997, the first well-tolerated Alzheimer’s drug, donepezil (Aricept), was approved by the FDA. Now we also have rivastigmine ( Exelon), approved in 2000, and galantamine (Reminyl), approved in 2001, for symptomatic treatment." All of these medications can stabilize the decline in activities of daily living associated with the disease. More recent studies are demonstrating that these compounds can ameliorate the behavioral complications, such as agitation and depression, which manifest as the disease progresses. In addition, they are also associated with delayed nursing home placements. Aside from benefitting the patient, caregivers report less stress. There are a variety of new drugs under development that have novel mechanisms of action. In addition to medications, an Alzheimer’s vaccine, that has shown promise in mouse models, is currently being tested on a small population of human volunteers that already exhibit symptoms of the disease. The vaccine aims to prevent the formation of amyloid plaques, which lead to the death of brain cells. Presently Aupperle is making efforts to improve the early diagnosis and treatment of Alzheimer’s disease by tailoring diagnostic and treatment procedures for primary care doctors, and educating the public. He stresses that early recognition of the disease by physicians and enhanced awareness of changes in cognition, mood and daily activities by patients and family members will result in better care for the patient. Aupperle concludes: "Right now we’re only able to provide symptomatic treatment. However, over the next decade we could see an explosion in the field that may stem the tide of this epidemic." You can access the COPSA Institute for Alzheimer’s Disease on the Web at http://rwja.umdnj.edu/~coyne/copsa.html or by phone at 1-800-424-2494. |
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The magazine of the University of Medicine and Dentistry of New Jersey |
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"It
may be unusual for us to think of epidemics in terms of noninfectious
disease," says Marvin Kirschner, MD, (below), professor of medicine
at UMDNJ-New Jersey Medical School (NJMS), "but life-shortening obesity
is currently a major epidemic in the U.S., most notably in the inner cities
where it affects 20 to 30 percent of the population." Statistics
show that obesity has doubled in this country over the last 30 years.
More than 50 percent of women – who are more often affected than
men – are significantly overweight.
Obesity
and diabetes – like Siamese twins – are joined at the hip. As
the numbers of obese Americans climb, so do the tallies of those affected
by diabetes. As the age for serious weight problems goes down, so, too,
does the age of onset of diabetes.
More
than 17 million Americans have asthma, about 6 million adults and 11 million
children and teens. Like obesity, it is a raging epidemic that hits minorities
and the poor hardest. And like the "fat" epidemic, tools to
combat its astronomical increase have not been particularly effective.
Prevalence has doubled in the last 15 years; and in children under 5,
the incidence increased more than 160 percent between 1980 and 1994.
Why?
It may just be simple arithmetic. "Boomers" are a large group
and most have enjoyed good health, leading them to a ripe old age. "The
average age of onset of Alzheimer’s is
the mid-70s. In prior generations, many people died before they reached
this age," says Peter Aupperle, MD, (left), director of
the COPSA Institute for Alzheimer’s Disease at UMDNJ’s University
Behavioral HealthCare.