The New York Times, Duff Wilson, July 27, 2010

When the Robert Wood Johnson Foundation decided in 1991 to take on Joe Camel, it became the nation’s largest private funding source for fighting smoking. The foundation spent $700 million to help knock the cartoon character out of advertisements, finance research and advocacy for higher cigarette taxes and smoke-free air laws and, ultimately, to aid in reducing the nation’s smoking rate almost by half.

But a few years ago, the Johnson foundation, based in Princeton, N.J., added another target to its mission, pledging to spend $500 million in five years to battle childhood obesity. As the antiobesity financing rose to $58 million last year, a new compilation from the foundation shows, the organization’s antismoking grants fell to $4 million.

The steep drop-off in private funds illustrates the competition under way for money as public health priorities shift. In the race for preventive health care dollars, from charities and from federal and state government sources, the tobacco warriors have become a big loser. And the nation’s battle to shed pounds has in its corner the White House, with Michelle Obama leading a new campaign against childhood obesity. Shortly after the first lady kicked off the “Let’s Move” program, the administration awarded more funds to fight obesity than tobacco through two big new money sources for preventive health. The funds, totaling $1.15 billion, came from economic stimulus and health care reform legislation. They still provided more than $200 million for tobacco-use prevention, but much more to grapple with obesity.

The changes in financing are also evident across the country. State governments have used tobacco’s billions to balance their budgets while cutting $150 million from antitobacco programs over the last two years. On the airways, obesity public service announcements are lining up while a “Truth” campaign about tobacco languishes for lack of money.

“Don’t forget tobacco,” pleaded a commentary this month in The New England Journal of Medicine.

One in five Americans still smokes.

But one in three is obese.

And competition for attention is growing between the two biggest issues in public health.

“I don’t see anybody else rushing into the vacuum,” says Dr. Steven A. Schroeder, former president of the Johnson foundation. “The sad thing is, smoking, despite all the harm it does, is left pretty much an orphan.”

Dr. James S. Marks, senior vice president of the foundation, said it had to pick its targets. “When we made the commitment to spend $500 million in obesity, we made the commitment to see if we couldn’t do for childhood obesity what we did in tobacco,” he said.

The decline in state funding to prevent smoking has distressed advocates. The 1998 Tobacco Master Settlement Agreement between 46 states and cigarette companies provided more than $200 billion through 2025. For a while it financed preventive programs like the “Truth” media campaign from the antismoking group American Legacy Foundation. But as states used money elsewhere, “Truth” spending declined, to a low of $35 million last year from $104 million in 2000.

“The industry outspends us in a day what we spend in a year,” said David Dobbins, chief operating officer of Legacy.

And even as states were raising taxes on cigarettes to record levels — a proven way to deter smoking — they were shifting that revenue to general funds. Both tobacco industry analysts and antismoking groups say that states have become addicted to tobacco money but are using less of it for prevention efforts.

“Overall funding on tobacco control is down because of dramatic cuts in state spending in recent years,” Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, said in an interview. “In the last several years we’ve seen the rapid progress in both adult and youth smoking rates slow to a crawl largely because of a decline in overall spending at the state level on tobacco prevention and cessation.”

State funding for antitobacco programs dropped to $567 million last year, from $717 million two years earlier, a 21 percent cut, according to an advocacy groups’ report titled “A Broken Promise to Our Children.”

While the federal government has made up for some of the state decline in antitobacco funding, it is spending even more on antiobesity efforts. And despite politic statements, there is undeniable competition for public health money.

“In our reaction to the obesity epidemic, sometimes we have taken our eye off other issues,” Terry F. Pechacek, of the Centers for Disease Control and Prevention office on smoking and health, said in a recent interview.

But Dr. Howard K. Koh, assistant secretary for health, focused on what he said was unprecedented funding from the federal government for both issues.

“Rather than pitting one disease against another, we want to uphold comprehensive prevention policies,” he said in a phone interview. Dr. Koh said the administration was directing $722 million to tobacco control and research this year and $821 million to obesity control and research.

The tobacco funding includes industry fees to set up a new regulatory office in the Food and Drug Administration. About half of the tobacco funding and most of the obesity funding is in research financed by the National Institutes of Health, illustrating the relative newness of obesity research.

In addition, the 2009 economic stimulus package included $650 million for “prevention and wellness strategies.” In February, state smoking quit lines received more than $44 million. In March, obesity programs received 62 percent of a $372 million award while tobacco programs received 38 percent.

Kathleen Sebelius, secretary of health and human services, made the awards in March a month after joining with Mrs. Obama to help kick off the first lady’s campaign against childhood obesity.

Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco, asked, “Given that tobacco kills four times as many people as obesity does, why is the government putting more money into obesity?”

Kenneth E. Thorpe, a professor of health policy and obesity researcher at Emory University in Atlanta, defended the shifting resources, noting that obesity rates had doubled since 1985. And health problems related to being overweight now account for about 30 percent of the increase in health care spending, he said.

“The smoking rate, fortunately, has been coming down. Not far enough, but that’s moving in the right direction. Obesity is moving in the wrong direction,” he said.

Congress also created a $15 billion, 10-year Prevention and Public Health Investment Fund as a part of health care reform.

The first $250 million went in June to increase the number of primary care doctors, nurses and other health care workers — more to battle sickness than promote wellness, critics said. Jeff Levi, executive director of the Trust for America’s Health, a nonprofit advocacy group, said he was disappointed that the money was “diverted.”

Dr. Koh, the assistant secretary, an oncologist and formerly a Harvard professor and Massachusetts state health chief, said, “It was a one-time investment and we need those providers to deliver preventive services.”

Out of the second $250 million, $16 million went in June to obesity prevention and $16 million to tobacco cessation. Parts of other funds could be used for those purposes. But the nation’s leading antismoking groups had written Ms. Sebelius in April asking for about 30 percent of the total, which would have been $150 million.

Next year the prevention fund from health care reform rises to $750 million and to $1 billion after that, so the dueling organizations fighting smoking or obesity will be competing for a much larger pot of money.

Antismoking Efforts Lose Ground to Obesity Fight – NYTimes.com.

NPR, Patti Neighmond, July 28, 2010

The health effects of being overweight or obese are well documented. Extra pounds add extra risk for diabetes, heart disease and certain cancers, even among children. But new research also documents significant social and economic consequences of being overweight since high school.

A group of teenagers take a morning jog at the Wellspring Academy in Reedley, Calif., in 2009. The school specializes in helping teens and college students lose weight. A new study shows teens who remain obese risk a lifetime of chronic health problems and poverty.

Philippa Clarke, an epidemiologist at the University of Michigan, wanted to know what happens to people who’ve been overweight since adolescence. So, she used national data that tracked 5,000 high school graduates for two decades. She compared one group of 40-year-olds who were normal weight at high school graduation but gained weight gradually over time with another group of 40-year-olds who were chronically overweight since age 19.

Weight And Poverty

“We found that those people who were persistently overweight were more likely to not have gone on to have any further education beyond their high school [diploma]; to be receiving welfare or unemployment compensation at age 40 and to have no current partner,” said Clarke.

Clarke says the chronically overweight were 50 percent more likely to be unemployed, on welfare and single. Her study didn’t address why, but Clarke suggests these adults probably experienced discrimination as children that diminished their self-esteem and, in turn, their aspirations.

Yale psychologist Kelly Brownell directs the Rudd Center for Food Policy and Obesity at Yale University, where research, by Rebecca Puhl, has found overweight people are 26 times more likely to report discrimination than their normal-weight counterparts. And, Brownell says, overweight kids are far are more likely to report being teased.

“Teasing that comes directly from teachers in some cases, certainly from peers and even sometimes from their families. This gets internalized so overweight children feel inferior, feel like there’s something defective with themselves and therefore they tend not to aspire. This isn’t true in all cases, but a lot of them tend not to aspire to such heights because they don’t believe they deserve it,” he said.

Brownell says discrimination against overweight individuals has increased 66 percent over the past decade despite the fact that more adults are becoming overweight.

One of the reasons, Brownell says, may be that people think overweight adults have only themselves to blame. They should eat less and exercise more. But, he says blame is simply unreasonable, when it comes to children and weight, especially in low-income neighborhoods where markets are often inadequate and places to exercise are nearly nonexistent.

“The social climate and our toxic food environment is so disastrous that more and more people are having trouble resisting it,” Brownell says. “That’s really what’s explaining the high prevalence of obesity. So it’s unfair to put people in an environment where weight gain is a very strong possibility and then to blame them for having the problem.”

Changing the environment is key to solving the problem.

Pediatrician Joe Thompson is a specialist in childhood obesity at the University of Arkansas College Of Medicine. Thompson is also director of the Robert Wood Johnson Foundation Center To Prevent Childhood Obesity. He says Arkansas has made inroads into the obesity problem by offering more healthful choices in school cafeterias and vending machines and that those efforts have paid off in the battle against obesity.

The rate of the epidemic has slowed nationwide and Arkansas has actually managed to stop the rate of increase among children, Thompson says.

via Impact Of Childhood Obesity Goes Beyond Health : NPR.

Mothers often say they get confusing advice about exercise during and after pregnancy

Obesity levels among pregnant women have reached epidemic levels, putting the health of their babies at risk, experts say.

The health watchdog NICE has issued new guidelines encouraging women in England to attain a healthy weight before they get pregnant.

It also advises them against eating for two once they conceive.

It says almost half of women of childbearing age are overweight or obese, which could harm their child.

Many women feel they are offered confusing and conflicting advice about their health during pregnancy.

The guidelines from the National Institute for Health and Clinical Excellence are aimed at cutting through that. They discuss weight and exercise before, during and after pregnancy.

Celebrity culture

If a woman is obese during pregnancy, she has an increased risk of developing serious complications like pre-eclampsia, gestational diabetes, miscarriage and stillbirth. She is also more likely to have a Caesarean section.

“It can set a worrying example, by encouraging new mums to embark on drastic weight lost programmes, which are not only unrealistic, but can also be very unhealthy”

NICE says women with a body mass index of more than 30 should be encouraged to lose weight before they become pregnant. During pregnancy, losing weight can be harmful to the unborn child, so women are advised to eat healthily and to do gentle exercise.

After they have given birth, women are told they should lose their baby weight gradually. Experts from NICE say celebrities who regain their pre-baby figures very fast can put unrealistic pressure on ordinary mothers.

“Women should understand that weight loss after birth takes time, and physical activity and gradual weight loss will not affect their ability to breastfeed,” said Professor Mike Kelly, NICE public health director.

“Losing weight gradually can actually help women maintain a healthy weight in the long term.”

NICE also wants local authorities to offer women more opportunities to exercise, at an affordable price, and with creches for their children.

“There’s been an exponential increase in obesity among pregnant women,” said Professor Lucilla Poston, from King’s College, London, who helped develop the guidance. “It’s very worrying, as there are so many potential risks for the mother and her baby.”

The National Childbirth Trust welcomed the move to bring clarity to the issue. Chief executive Belinda Phipps said women were presented with a lot of conflicting advice about exercise.

“It can set a worrying example, by encouraging new mums to embark on drastic weight lost programmes, which are not only unrealistic, but can also be very unhealthy,” she said.

Professor Sir Sabaratnam Arulkumaran, president of the Royal College of Obstetricians and Gynaecologists, said he hoped the new guidelines would be actively promoted by the government.

“We need to support women who are overweight by encouraging them to lead healthier lifestyles. This includes providing them with advice on diet, nutrition and exercise.

“These healthy behaviours should occur throughout a woman’s lifetime and not just when she is considering starting a family or during pregnancy.”

via BBC News – Overweight pregnant women are target of new guidelines.

Overweight people may respond more to a piping hot pizza, but they don’t necessarily eat more of it in a single sitting, according to a new study.

Reuters, Rachael Myers Lower, July 21, 2010

University of Bristol graduate student Danielle Ferriday and her faculty advisor, Dr. Jeffrey Brunstrom, wanted to know if overweight and lean people responded differently to “food cues,” and, if they did, how the mind translates these different levels of “desire-to-eat.”

“We all need to eat and we all encounter many food-related cues in our everyday lives,” Ferriday told Reuters Health.

Ferriday enrolled 52 normal weight and 52 overweight women in the study, exposed them to the sight and smell of pizza and measured how much they salivated, as well as their psychological responses.

While lean participants didn’t salivate much more once they saw and smelled the pizza, the overweight participants salivated about a third more than usual once the pizza showed up. They also had more desire to eat, measured by a standard scale, than the lean study subjects.

However, the overweight participants didn’t eat more, even after being told to eat as much as they’d like.

What that means, say the researchers, is that the overweight don’t necessarily eat more when at the table, but, because of their heightened sensitivity to the cues, they may be called to the table more often.

“This is potentially important, because this sensitivity may encourage snacking” and other bad eating habits that are “associated with increased energy intake, overweight and weight gain,” the investigators write in the July issue of the International Journal of Obesity.

The study couldn’t answer why overweight people are more turned on by food. It is not clear, for example, whether they are born that way or do eating habits learned and developed over time cause a change?

While all the subjects in this study were women, “we suspect that the findings would apply to men too,” Ferriday noted.

SOURCE: link.reuters.com/deh78m International Journal of Obesity, online June 15, 2010

Overweight want more at a meal, but don’t eat more | Reuters.

The Huffington Post, John Whyte, July 19, 2010

It’s always somebody else’s problem. Even when it comes to our own health, we always think the latest risks never apply to us. Most patients know that being overweight predisposes them to diabetes. But nine times out of 10, when I tell my patients with diabetes that if they lost weight, they might be able to improve their diabetes control, the response back to me is “Dr. Whyte, I’ve been overweight for 20 years… and I’ve only been diabetic for a year.” They either simply do not make the connection or they just do not want to see it.

Unfortunately, that ignorance is no longer restricted to their own health; research also shows that many patients have wrong perceptions of their children’s weights. What do I mean?

The majority of parents recognize childhood obesity as a serious health problem. Yet, nearly 85 percent of parents of overweight children think their child as being at a healthy weight. If you consider that a third of children are overweight or obese, it’s obvious that the numbers don’t add up. In some ways, this is no surprise: no parent wants to admit that their child is overweight. Doing so can damage a child’s self-esteem at a tender age when image and self-concept are being developed. Parents also shrug it off as “baby fat” that children will lose in their older years.

But the sad truth is that school-age children and teenagers aren’t babies; carrying extra weight can’t always be blamed on the growth process. Some parents may also feel that extra weight on their kids is proof that they are providing for them sufficiently, which is a rewarding feeling for parents. On the other hand, it’s possible that a lot of parents just don’t know what a “healthy weight” is. Ask yourself: Do I know how fat is too fat?

Parents aren’t the only ones at fault. Doctors also are to blame. Many pediatricians hesitate to bring up a child’s weight to the parents. Interestingly, data show that parents are more likely to misclassify their child’s weight if their pediatrician fails to comment on it. In fact, less than 8 percent of parents recalled being told by their pediatrician that their child was overweight.

Even though pediatricians have a responsibility to intervene for the good health of the patient, it isn’t always this clear. Some pediatricians are not aware of the latest guidelines, other others are worried about offending parents by suggesting that their child is overweight or obese.
So what’s my advice to parents of overweight children?

Well, it’s important that you don’t feel discouraged if your child is overweight – most kids are nowadays. But at the same time, don’t neglect it. You can actually help curb the rise in childhood obesity. Your children’s generation is the first to have a shorter life expectancy than their parents! No parents want this for their kids.

So, get educated. Learn about what obesity is, what dangers accompany it, and how to detect it in your children. Then take action. Ask your pediatrician about your child’s weight, and keep track of your child’s BMI-for-age in between visits. Learn how to prepare healthier foods at home. Promote more physical activity. Maybe even lead by example and join your kids in getting active.

It’s important to be honest with yourself early: one study shows that 73 percent of the heaviest nine-year olds will still be obese at age 50. Much of the focus on the fight against obesity has been on school lunches, vending machines, fast food marketing, and video games. And kudos to Mrs. Obama for raising awareness of childhood obesity.

But if we all acknowledge childhood obesity as a problem, but think it doesn’t apply to our kids (and chances are it does!), then we will never solve the problem.

Parents are central to that solution. Loving your kids isn’t about spoiling them with their favorite junk foods and turning them into couch potatoes. It’s about caring for their health. Show your kids how much you love them by being honest with yourself about their weight and looking out for their healthy future.

REFERENCES

“F as in Fat: How Obesity Threatens America’s Future 2010″. Trust for America’s Health, 2010: http://healthyamericans.org/reports/obesity2010/Obesity2010Report.pdf

“Parents’ Healthy Weight Perceptions and Preferences Regarding Obesity Counseling in Preschoolers: Pediatricians Matter;” Raquel G. Hernandez, MD, MPH; Tina L. Cheng MD, MPH; and Janet R. Serwint, MD; Clinical Pediatrics; June 3, 2010.

John Whyte, M.D., MPH: Childhood Obesity: What We Don’t Know Can Hurt Us.

Overweight women should slim down and have counselling before they get pregnant because being fat poses such a serious risk of them having a premature baby, doctors warn today.

Women carrying excess weight have up to a 30% greater chance of having a baby before it reaches 37 weeks gestation, medical researchers in Canada write in todays British Medical Journal. Premature babies are at much higher risk of dying or suffering a range of illnesses and impairments.

Those who are overweight or obese have an extra 30% risk of having their child induced before 37 weeks, and have a 26% chance of delivering their baby prematurely before it reaches 32 weeks, according to a team of researchers led by Sarah McDonald, an associate professor in the maternal-fetal medicine department at McMaster University in Hamilton, Ontario.

“Ideally, overweight or obese women should have pregnancy counselling so that they are informed of their perinatal risks and can try to optimise their weight before pregnancy,” the authors say.”

Unlike many causes of pre-term birth, maternal overweight and obesity represent a potentially preventable cause of the leading source of neonatal mortality and morbidity and morbidity through childhood,” they add.British doctors who look after pregnant women, mothers and children said they backed the proposals.Professor Sir Sabaratnam Arulkumaran, president of the Royal College of Obstetricians and Gynaecologists, said:

“Maternal obesity is a public health concern as there are consequences for both mother and baby. For the mother, it could lead to cardiac disease, diabetes and pre-eclampsia as pregnancy can aggravate these conditions. These women should therefore receive obstetric care

.”Health professionals, including family doctors, need to work with overweight women to help them slim down before conceiving, added Arulkumaran, the leader of Britains 5,500 maternity care doctors.”We have said in our Maternity Standards document that pre-pregnancy counselling and support, both opportunistic and planned, should be provided to women of childbearing age with serious existing medical conditions including obesity BMI > 30″, he said.”This requires a multi-disciplinary approach with GPs and midwives to encourage women to achieve an appropriate weight level during the pre-conception stage.

It is something which needs to be handled sensitively but we need to point out to women the long-term benefits of a healthy lifestyle for them and their children.”However, the Royal College of Midwives suggested that mere exhortation of would-be mothers to keep their weight in check may not work.Janet Fyle, the unions professional policy advisor, said:

“There is a public health message that needs to be conveyed to women considering becoming pregnant, of the potential impact of being overweight when pregnant.”Of course midwives know that they need to provide women with the information and support about eating healthily and exercise in pregnancy. We can tell women about the right diet and exercise, but this has to be done within the context of their lives.”Can they afford the right food? Can they get access to gyms or swimming pools? There are social contexts to consider and one size does not fit all.”Tam Fry, of the National Obesity Forum, said: “It is absolutely crucial that a woman who is serious about childbirth gets herself into shape before conception. If she doesnt, she is running the risk not only of endangering her own health but also that of her intended child.

“Not only is it a tragedy to have to have a Caesarean section delivery if you are a very overweight woman, because its the safest way of getting the baby out, but it could adversely affect the childs health and be crippling to NHS maternity services.”

via Obese women should slim before conceiving | Life and style | The Guardian.

Being overweight is certainly risky for your physical health, but new evidence suggests that it may carry an added mental-health burden as well.

Studies have linked overweight to a host of health problems, including heart disease, diabetes, hypertension and stroke, but research led by Dr. Diana Kerwin at Northwestern University now shows that extra weight may also contribute to lower cognitive performance. Culling data from the Women’s Health Initiative, a long-term, multicenter study of postmenopausal women between the ages of 65 and 79, Kerwin’s team found that for every one-point increase in body mass index (a ratio of height and weight used to measure overweight and obesity), study volunteers experienced an accompanying one-point drop in cognitive performance scores.

Although the women’s memory scores were within the normal range, heavier women still did worse than their thinner peers.

Kerwin says she was surprised to discover that the association persisted, even after controlling for factors such as hypertension, stroke and diabetes. Initially, she had expected to find that obesity’s effect on cognition was mediated by heart and circulatory pathways such as blood flow and blood pressure. “Our results tell women who are obese that they shouldn’t feel falsely confident that it’s okay if you are obese even if you don’t have high blood pressure or diabetes,” says Kerwin, who published her results in the Journal of the American Geriatric Society. “Just being obese could still affect your cognition as you get older.”

The authors speculate that obesity itself may affect the brain, and that the mechanisms may include genetic factors that predispose people to obesity, or hormones such as cytokines and estrogen that are released by fat tissue.

In fact, Kerwin’s team is already seeing some hints that estrogen may play a role in cognition in obese women. In a closer analysis of the study’s 8,745 volunteers, researchers found that women who carried more weight in their abdomen (the “apple” shape) experienced slightly less cognitive decline than those who were heavier in their lower body (the “pear” shape). In postmenopausal women, says Kerwin, abdominal fat still produces small amounts of estrogen, which may have a protective effect on the brain, preserving cognitive function.

Still, she says that theory needs to be tested with additional research. Overall, the study supports the idea that overweight tends to reduce people’s cognitive reserve, thus leading to poorer intellectual performance. While the new findings do not link this cognitive decline to long-term consequences, such as a higher risk of dementia, previous studies have shown that diminished cognitive reserve can indeed predict future dementia. “This study opens up new ways of thinking about how obesity can affect cognition,” says Kerwin.

Study: Why Older, Overweight Women Have Worse Memory – TIME.

A federal advisory committee voted narrowly against endorsing a drug vying to become the first new prescription medicine for obesity in more than a decade, signaling heightened concerns for possible health risks associated with a new generation of diet pills.

The advisory committee to the Food and Drug Administration voted 10 to 6 that the safety concerns, like increased heart rate, possible birth defects and psychiatric problems, overrode the potential benefits of the drug, called Qnexa and developed by Vivus.

The meeting was closely watched by both the medical community and Wall Street as a sign of how the F.D.A. might handle new obesity drugs. Typically, the agency has paid extraordinary attention to safety because weight-loss drugs have a history of safety problems and because the medicines are likely to be used by millions of people for long periods of time.

The committee vote suggests that drug safety will continue to be paramount.

“No one wants to conduct a large public health experiment on the population,” one panel member, Elaine H. Morrato of the University of Colorado, Denver, said.

The F.D.A. is scheduled to decide by late October whether to approve Qnexa. It usually abides by the advice of its advisory committees. But a split vote like this one is often viewed by the agency as less definitive. Indeed, several panel members said they could just as easily have voted the other way.

The outcome of the meeting could portend a more difficult time for two other new obesity drugs that will face advisory committee hearings this year — lorcaserin from Arena Pharmaceuticals and Contrave from Orexigen Therapeutics.

The F.D.A. and most panel members did not question the effectiveness of Qnexa. Results from clinical trials suggested that in reducing weight, Qnexa was superior to the currently approved drugs and to the other two possible new ones.

Those getting the highest dose of Qnexa lost an average of 10.6 percent of their weight after one year, compared to 1.7 percent for those on a placebo.

The F.D.A. had five safety concerns that the panel spent most of the day addressing: possible psychiatric problems like depression and suicidal thinking, impaired memory and concentration, acid buildup in bodily fluids that could increase the risk of kidney stones, an increase in heart rate that could portend cardiac problems and possible birth defects.

Qnexa is a combination of two already approved drugs: phentermine, the part of the fen-phen combination that remained on the market after fen-phen was withdrawn in 1997 for causing heart valve problems, and topiramate, an epilepsy and migraine drug sold as Topamax by Johnson & Johnson. Phentermine, a stimulant, is responsible for the faster heartbeat, and topiramate causes the other side effects.

Leland F. Wilson, the chief executive of Vivus, said the company was disappointed with the vote but not deterred from trying to win approval. “The advisory committee vote is a recommendation, not a final step,” he said in a brief conference call.

Trading in Vivus, based in Mountain View, Calif., was halted on Thursday during the panel’s meeting, but shares plummeted 56 percent, to $5.27, in early after-hours trading. Shares of both Orexigen and Arena fell late in the day after the committee vote.

In after-hours trading, however, Arena was up somewhat. That could be because investors see its drug as having a better safety profile than Qnexa, although it is less effective in reducing weight.

About one-third of American adults are obese and another third overweight, so a successful diet drug could garner sales of billions of dollars a year.

Yet there have been few, if any, successful obesity drugs. The two existing drugs approved for long-term use — Meridia from Abbott Laboratories and Xenical from Roche — have modest sales, in part because of side effects and limited efficacy. Three years ago, the F.D.A. declined to approve rimonabant from Sanofi-Aventis because of concerns about suicide risk and depression.

Vivus argued on Thursday that obesity itself was a health risk, associated with a higher risk of diabetes, heart disease and other problems. “Obesity treatment can improve health and save health care dollars,” Dr. Louis J. Aronne, an obesity expert at Weill Cornell Medical College and a consultant to Vivus, told the committee. “Weight loss now appears to be like a gift that keeps on giving.”

In the trial, Qnexa improved blood pressure, blood sugar and cholesterol levels. But Dr. Mary Roberts, the F.D.A. reviewer of the drug, said it was unclear if the improvements would translate into what really matters, a reduction in heart attacks, strokes and death.

Bariatric surgery, which can produce weight loss of 15 percent or more, has been shown to reduce risk of heart attacks and prolong lives. But the only study that tested this for a diet drug — Meridia — actually found an increase in heart attack risk.

Most of the committee members spent two days this week on another panel weighing whether the diabetes drug Avandia should be removed from the market because of suggestions it raises the risk of heart attack.

That seemed to color the debate on Qnexa a little. Some committee members said that the yearlong trials of Qnexa did not provide enough information to judge long-term risks and that it was better to keep the drug off the market than to have problems arise later.

via F.D.A. Panel Votes Against Obesity Drug Qnexa From Vivus – NYTimes.com.

If you had to choose one public health problem to attack, which would it be: teenage smoking or childhood obesity?

To answer that question, you might want to pose another. Who will have the harder road in life, or indeed the longer one: the teenage puffer or the chubby child?
Pitting smoking against obesity is tricky because it can mean comparing apples and bonbons, but there is some suggestion that a kind of weird zero-sum game is actually going on. And some smoking opponents fear that a choice has been made — with obesity the winner, quite possibly for the wrong reasons.

“Obesity is the new kid on the block, relatively speaking,” said Kenneth E. Warner, dean of the University of Michigan’s school of public health. “Tobacco is old news.”

When it comes to smoking, said Stanton A. Glantz, director of the University of California at San Francisco’s Center for Tobacco Control Research and Education, “we really haven’t had anyone pushing it to the top of the agenda.” That is a problem. “It’s not that I am for obesity,” he said, but he finds it less than encouraging, for example, that the hugely influential Robert Wood Johnson Foundation is pulling back from its anti-smoking efforts while directing its money and resources to preventing childhood obesity.

Then there is Michelle Obama’s campaign, Let’s Move, to prevent childhood obesity. And in May, the White House Task Force on Childhood Obesity announced its goal — reduce the rate of childhood obesity, now 17 percent, to 5 percent by 2030.

With all this effort directed at childhood obesity, along comes a report saying that progress against teenage smoking has stalled. The report, from the Centers for Disease Control and Prevention, showed smoking among high school students at 19.5 percent in 2009. The goal had been to reduce it to 16 percent by 2010.

There are a variety of estimates for the death toll from obesity, Dr. Warner said, but, whatever it is, “the death toll from smoking is higher.”

Even if it were possible to calculate the lifetime health risks a fat child faces, combating obesity is not so easy. Jeffrey Friedman, an obesity researcher at Rockefeller University, notes that there are many assumptions about what will work — more healthful foods in schools, a soda tax, getting children to be more active. Yet no interventions, when tested in large studies, have caused a big difference in children’s or teenagers’ weights.

Suppose, though, there were a method, and suppose the nation had to make a choice between proven anti-obesity programs and proven anti-smoking programs. What would be best for a child with a predisposition to be obese and to smoke? Should you have programs that would prevent the child from gaining weight? Or should you wait until the child is a teenager and institute programs to prevent smoking?

“That’s a hard call,” said Kelly D. Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University. When it comes to health, “it’s hard to think that anything could be worse than smoking,” he said. But obesity has a social stigma attached, which “carries a cost no matter what the medical consequences are.”

It’s an even harder call than that, Dr. Friedman says, because it is so difficult to assemble a group of children in whom obesity was actually prevented. Without such a group, investigators cannot rigorously assess long-term health benefits. Maybe someone with a genetic predisposition to be fat and get high blood pressure, for example, would get high blood pressure even if obesity were prevented. It might be like taking an aspirin when you have the flu — your fever might go down, but the infection is unchanged.

On the other hand, Dr. Friedman noted, the question of health benefits is answered for smoking. A person who stops will almost immediately substantially reduce the risk for heart disease. The person’s risk for lung cancer will be nearly frozen at whatever it was at the time smoking stopped. Half of teenage smokers quit.

But if smoking continues, heart disease risk remains high, and the risk of lung and other cancers continues to increase.

“I certainly don’t want to go on record as saying too much money is going into obesity prevention,” Dr. Friedman said. Yet “smoking very clearly represents a substantial health risk.”

Of course, no one wants to set up a contest for which is worse, smoking or obesity. They are the two main culprits when it comes to preventable deaths, Dr. Warner said. He also said that he did not think a shortage of money was an excuse to favor one prevention program over the other. “Yes, in some objective conceptual world there is tradeoff,” he said. But “let’s face it, there’s an awful lot of useless stuff we spend money on.”

James S. Marks, a vice president at Robert Wood Johnson, said the foundation was spending less on anti-smoking efforts but had not abandoned them. The foundation’s role, he said, is to get efforts started — as it did with smoking prevention. “Now we are doing it with obesity.”

Whether a Child Lights Up, or Chows Down – NYTimes.com.

How do you prevent a deadly disease that is projected to afflict one third of all Americans born today and is caused largely by hard-to-change habits such as too much soda and snacks and too little physical activity?

You could combine the broccoli and cauliflower in the school cafeteria for more colorful eye appeal. Put out 30 basketballs in gym class instead of two. Teach the wonders of water for 15 weeks straight (and remove everything else from vending machines).

Those changes – along with hundreds of others, large and small – signficantly reduced several major risk factors for type 2 diabetes, researchers concluded last week after studying the most comprehensive attempt yet to attack the epidemic through the schools.

Lifestyle prescriptions – you should eat a balanced diet – are notoriously difficult to stick with. But these limits were impossible to avoid.

“Instead of selling candy for a fund-raiser, they were selling carnations. And those are the sort of things that made it holistic across the environment,” said Wayne Grasela, senior vice president for food services in the Philadelphia School District, where six middle schools took part in the three-year national program.

The plan was to intervene early, before diabetes develops – and at a young enough age to learn new habits that could prevent or reduce obesity, a major risk factor for the disease. Numerous physicians helped craft the program, but all the action took place in the schools.

“They are already there. They already take physical education and they already eat lunch in the school,” explained Barbara Linder, who oversaw the study for the National Institutes of Health.

So researchers set about changing the school.

In gym, for example, “instead of doing layups, with most kids standing in line, we had things set up so balls were being passed back and forth while they waited,” said Gary D. Foster, director of Temple University’s Center for Obesity Research and Education, who chaired the national study.

Dumbbells, jump ropes, and medicine balls were distributed to groups, with rotations every 45 to 90 seconds to keep everyone moving. Pop music was played so that gyms were seen as “fun places to be with cool things to do,” Foster said.

In the cafeteria, the standard pizza was replaced with the same manufacturer’s whole-grain, lower-fat version. That shaved nearly 100 calories per slice and the kids didn’t notice, said Amy Virus, a registered dietician at Temple who coordinated the study’s nutrition component.

Nothing but water – not even 100 percent fruit juice – was stocked in vending machines. “Did they miss the juice? Sure, in the beginning,” Virus said, “but they got used to it. And they were buying the water.”

Supporting the effort were posters in classrooms (kids dancing, kids eating fruit), decals sent home over Christmas (TAKE THE FAMILY TV TURNOFF CHALLENGE!) and postcards in summer (“Be active for 60 minutes every day.”), even a healthy version of Jeopardy!, with 25 cards in English and Spanish.

An estimated 24 million Americans have diabetes, a chief cause of kidney failure, limb amputations, blindness, heart disease, and stroke. Although type 1 diabetes is caused by an auto-immune disorder, type 2 – more than 90 percent of the cases – is often linked to lifestyle factors that lead to weight gain and a gradual loss of the ability to control blood sugar.

Once rare before adulthood, type 2 diabetes has been rising steadily in children. Blacks and Hispanics are at particularly high risk; the government now projects that half of all babies born in those minority groups will develop diabetes later in life.

The new program was designed by researchers at seven major universities and targeted schools that enrolled high percentages of poor and minority students.

They began the interventions in 21 schools – three in each city – in the fall of 2006, when the students were in sixth grade; another 21 schools were designated as controls. A total of 4,603 students completed the study in June 2009, at the end of eighth grade.

Analysis showed that there were significantly greater reductions in several diabetes risk factors – body-mass index scores, average insulin levels, and the percentage of students with the largest waists – at the intervention schools vs. the controls.

All those differences were more pronounced among the 50 percent of students who were overweight or obese to begin with. Within that group, the interventions were associated with 21 percent lower odds of being obese at the end of eighth grade, the researchers reported.

The results were published last week online in the New England Journal of Medicine.

via Battling the bulge | Philadelphia Inquirer | 07/05/2010.