OBESITY PANACEA

Back in June, I discussed the results of a large epidemiological study in women that showed that women with larger breasts have an increased risk of developing type-2 diabetes.

As soon as Travis and I read this study, we knew we had to do a follow-up study of our own to see if this finding was simply spurious or if there was actually something to large breasts that indicated health risk – beyond that explained by obesity per se.

The project that Travis and I began over a year ago has culminated in both a hot-off-the-press publication in the journal Obesity, as well as my presentation at this year’s Obesity Society meeting in Washington D.C.

In the study, we used body composition data acquired through MRI on about 100 premenopausal women to directly quantify breast size. By using MRI data we significantly improved the methodology used by the authors of the original study on breast size and diabetes risk, who relied on over 20 year recall of cup size as their key measure.

First, we sought to examine if breast tissue volume was associated with any cardiometabolic risk factors, such as glucose tolerance (a known antecedent to type 2 diabetes) and various blood lipids. Since the original authors found an association between cup size and diabetes risk, we expected to find an association between breast volume and cardiometabolic risk factors.

What did we actually find?

Breast volume was not associated with any of the cardiometabolic risk factors measured in any of the statistical models used. However, in these analyses, visceral or intra-abdominal fat was a strong predictor of numerous risk factors – a finding reported in numerous studies.

Next we decided to examine the associations between breast volume and other body fat depots. Here is where the story got interesting. First off, as one would predict, women with larger breasts had more subcutaneous (under the skin) fat in their thighs, abdomen, as well as more visceral and inter-muscular (or ectopic) fat. That is, bigger breasted women tended to carry more fat everywhere.

However, once we controlled for their level of obesity (body mass index and waist circumference) bigger breasted women were no more likely to have more subcutaneous fat in either lower body or abdomen, but were much more likely to have excess fat deposition in the dangerous visceral and inter-muscular depots.

Specifically, our study found that given the same age, body mass index (total obesity), waist circumference (abdominal obesity), women with the highest breast volume had approximately 1.1 and 1.3 kg more visceral fat and intermuscular fat in comparison to women with the smallest breast volume.

In other words, large breasts appear to indicate a phenotype characterized by the augmented deposition of fat in ectopic depots, such as visceral and inter-muscular fat – each of which is independently associated with increased cardiometabolic risk. The extrapolation of our findings suggests that excess visceral or intermuscular fat may be the conduit which explains the previously documented association between breast size and type-2 diabetes.

While our findings are intriguing (someone at the Obesity Society conference suggested I should get an award from the most “unique” study), there exist a couple clinical examples which corroborate our findings.

For example, approximately 40-50% of women undergoing liposuction of subcutaneous adipose tissue from the hips, thighs, or abdomen present with a paradoxical enlargement of breast size of at least one cup as well as a relative increase in visceral fat post-surgery. Additionally, highly active antiretroviral therapy among HIV-positive women is associated with a peripheral loss of functional subcutaneous fat but a compensatory increase in visceral and intermuscular fat (well documented lipodystrophy), in association with a significant enlargement in breast size.

Now before women with large breasts head out to get breast reductions, it is key to consider that our findings are quite preliminary, and furthermore that breast size only appears to be a proxy for other factors which are more likely to be causally related to health risk. Thus, further research in this area is clearly warranted before we begin screening disease risk by breast size. Nevertheless, when explaining our study findings at the conference, I heard many sighs of relief from women who perceived themselves to have smaller breasts.

Have a great Halloween weekend!

Peter

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Janiszewski, P., Saunders, T., & Ross, R. (2009). Breast Volume is an Independent Predictor of Visceral and Ectopic Fat in Premenopausal Women Obesity DOI: 10.1038/oby.2009.336
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Not that long ago I discussed how making certain behaviours such as being physically active and eating a healthy diet easier or more fun increases the chances that these behaviours are adopted by most people. For example, the use of cell phone texts to prompt you to park further from the grocery store door or to choose veggies over chips was shown to lead to some weight loss. Also, the video I posted a while back on the Piano Stairs, which has since gone viral, clearly shows that if the healthy choice becomes the easy or more attractive choice, people are more likely to take it.

I just got back from the 2009 annual meeting of the Obesity Society in Washnigton D.C., where I had the great pleasure to meet with many friends and colleagues such as Dr. Yoni Freedhoff of Weighty Matters blog as well as Dr. Arya Sharma of Dr. Sharma’s Obesity Notes blog.

While at the conference hotel, I was once again struck by how difficult it can be to make the healthy choice. For example, I had to ask the concierge where the stairs were so I could walk the 4 flights to my room instead of taking one of the 8 prominently displayed elevators. It turned out the stairwell wasn’t even marked – it was behind an unmarked door in the seating area of one of the cafes. Thus, it was virtually impossible for anyone to be able to take the stairs even if they wanted to (unless they were as oddly persistent as me). Additionally, the hotel restaurant basically had 1 option for breakfast – a buffet including plenty of high fat favourites such as sausages and bacon and lots of sugary cakes, muffins, cupcakes, not to mention “Vitamin D” milk which in fact had the same amount of vitamin D as the fat free variety but contained 70 kcals of fat in one serving (I guess “Fat Milk” doesn’t sound as enticing).

It turns out that the folks who created the Piano Stairs video have also tested their “Fun Theory” in other ways, so I thought I would share 2 more examples of how “fun and easy” leads to behaviour change. Below you will see two neat approaches to get people to throw garbage into a trash bin and to recycle bottles (email subscribers need to log onto Obesity Panacea to view). As I discussed with Dr. Freedhoff (while we waited at the airport for our delayed flights out of DC) – I believe this is the way that we may be able to get people to become more active and eating healthy – by making small but effective changes to their environment. Simply telling people to follow current guidelines for diet or physical activity when our environment is set up to make these behaviours impossible is not only short-sighted but frankly useless.

Enjoy the videos.

Peter




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I thought I'd take a quick break from talking about research today to advocate for a new campaign which I think will interest many of our Ontario readers, especially those who are interested in childhood obesity.  The program is called Spark Together for Healthy Kids, and is being coordinated by the Heart and Stroke Foundation of Ontario in the hopes of reducing childhood overweight and obesity, which currently affects 28% of Ontario children.

A background document on the program is available here, which makes a strong case that childhood obesity is a society problem, and requires a societal solution.  Thus, the goal of the campaign is to encourage a public movement in support of a healthier future for Ontario's children, and individuals are encouraged to join the campaign by signing The Spark Promise to our Children, which advocates for healthy, active places for kids to play.  People are also invited to join the Spark Facebook Group where they can connect with other individuals who feel strongly about childhood obesity, physical activity, and nutrition.  To me, the Facebook group is the coolest thing about this initiative, and I would encourage readers from anywhere in the world to check it out by clicking here.  Ending the childhood obesity epidemic is going to require that we come together as a community to advocate for positive changes, and this Facebook page is a great way to connect with like-minded individuals.  I've also got to say that it's nice to see a campaign like this using new media to engage their audience, and I hope that this becomes the norm for other public health initiatives.



Have you been involved with a project that has received a Spark Community Advocacy Grant?  We'd love to hear about your experience in the comments section below.

Travis
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It's not often that Peter and I come across a an exercise product that actually makes sense.  The GoWear Fit Armband was one, and pedometers are another.  In contrast to the many gimmicks that we have reviewed in the past, these useful products tend to be simple, evidence-based, and easy to implement.  Earlier this week I came across another product which I feel holds quite a bit of promise, and it is enthusiastically titled TimesUpKidz!.

TimesUpKidz! is a program which allows you to limit how much time individual users can spend on any computer.  It is aimed at limiting time for children, but I see no reason why it couldn't be used for adults as well.  You decide how much time a person is allowed to use the computer on any given day of the week, and during what hours.  Further, you can set mandatory breaks, such as a 15 minute break following every continuous hour of computer time.  Once the time limit is exceeded, users are locked out of the computer for a specifically designated period of time.


 


Mark, A., & Janssen, I. (2008). Relationship between screen time and metabolic syndrome in adolescents Journal of Public Health, 30 (2), 153-160 DOI: 10.1093/pubmed/fdn022
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It is amazing how many fitness products are based on simple stepping machines.  What's even more amazing, is that each and every one claims to be an "amazing breakthrough" which will change your body - and your life - forever.  Earlier this year I reviewed the Air Climber ("one of the biggest breakthroughs in exercise technology"), which is essentially a regular stepping machine that uses "Air Power Technology" (aka "air") to provide resistance, rather than the hydrolic pistons which provide resistance on most commercial stepping machines.  The machine is promoted by self-proclaimed "International Fitness Expert" and former American Aerobics Champion Brenda Dygraf.  Despite being hailed as "one of the most effective weight loss and body shaping programs ever" by the Air Climber promotional video, Brenda hasn't rested on her Air Climber laurels.  Thankfully, she is now promoting the even more advanced Cardio Twister stepping machine.

Like the Air Climber, the Cardio Twister is also essentially a stepping machine.  But, instead of stepping straight up and down, you step up and down and from side to side.  The stepper also has handlebars that move from side-to-side as you step, which they claim works your core and upper body as well as your legs, providing you with the ever-elusive whole body workout (if only walking, running, rollerblading, swimming, or any other free activity engaged both the upper and lower body!).  The Cardio Twister is a bit hard to describe, so for a better idea of how this "exercise breakthrough" works, I've embedded the promotional video below (email subscribers will have to visit the Obesity Panacea site to view the video).


Like the Air Climber, the Cardio Twister makes lofty claims (in fact, the websites for the two products are nearly identical, although the testimonials are unique for each product).  The Cardio Twister website suggests that you can use the Cardio Twister to "Lose 10 pounds or 10 inches in 10 days!", although they provide no information on how this is possible (or healthy) and the fine print is less enthusiastic - "Your results may vary.  You may be less successful".  They also claim that the moving handlebars keep your body in the "ideal workout position" for toning your abs, arms, chest and back.  Which is surprising, since the handlebars are actually moved by the motion of the steps, and not by your upper body.  Somehow your arms, chest, and back muscles are being sculpted by merely twisting your upper body back and forth!  That's a bit like dancing to The Twist as a way to define your arm and chest muscles!  Somehow that seems less than ideal.

Exercise and weight loss gimmicks products tend to fall into two general categories - those that are at least plausible, and those that are completely insane. Like the Air Climber, The Cardio Twister could produce fitness benefits, placing it in the former category. However, like any other stepper, rowing machine, or thigh master, I think that very few people are going to enjoy this product enough over the long-term for it to have a lasting impact on their health and longevity.  And at a retail price of $159.80, I think we should expect more from something touting itself as an exercise breakthrough.  Especially when the health benefits of free activities like walking and cycling are so well-established.

For more information on the Cardio Twister, you can visit their website here.

Travis

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Active transportation is one of the single easiest ways to get more physical activity into your day.  We all commute several times a day, and each of these trips represents an opportunity for physical activity through walking, cycling, or taking transit (which usually involves at least some walking) rather than driving. Active transportation may not sound like a tremendous way to reduce your health risk - I can understand if people doubt that a short walk or bike ride can have a long-term impact on health and longevity.  To illustrate the benefits of even minor increases in physical activity I have created the following graph using data from a paper by Michael F. Leitzmann in the Archives of Internal Medicine, which followed 250 000 Americans aged 50-71 from 1995 until 2001.  At baseline, all subjects completed a questionnaire detailing their level of physical activity, which the researchers used to then calculate the number of hours per week spent in moderate and vigorous physical activity, and to compare the risk of death associated with increasing amounts of activity.

This graph shows the relative risk of mortality across different levels of moderate physical activity (measured in hours/week).  As you can see, individuals who are completely inactive have by far the highest risk of mortality, while those with the most physical activity have the lowest risk.  But what is most interesting to me is that the greatest reduction in risk does not come from increasing physical activity among those who are already active. To be sure, moving from 1-3 hours of moderate activity per week to 4-7 hours of activity will reduce the relative risk of mortality. But, the greatest reduction in relative risk is seen when moving from complete inactivity to even minor levels of physical activity - less than one hour/week!  That is less than 10 minutes/day!  These results are only slightly attenuated by control for confounding factors including BMI, smoking status and family cancer history.  These results are cross-sectional, so we can't use them to infer causality (although I realize I am doing so to a degree).  Similar results have been presented in numerous studies, and for just about every major cause of mortality, to the point that I believe even slight increases in physical activity among those who are currently inactive could have a profound public health impact.

All of this brings me to a strange article that I came across in The Telegraph yesterday.  It reports on a new promotion by a brothel in Berlin (where prostitution is legal), which is now giving a €5 (~$7.50 USD) discount to patrons who commute by bike or public transit.  To receive the discount, patrons merely provide proof of their transit fare, or show their bike helmet or lock.  Thomas Goetz, the owner of the brothel, claims that the promotion has been a success for both the business and the community:

"We have around 3-5 new customers coming in daily to take advantage of the discount," he said, adding the green rebate has helped alleviate traffic and parking congestion in the neighbourhood.

The ethics of prostitution are well outside the scope of this blog, so don't take this to suggest that Obesity Panacea supports prostitution (legal or otherwise) in any way.  But this anecdote does seem to suggest that people will use active transportation when incentives (even minor ones) are in place.  This agrees with work by Ugo Lachapelle, which has shown that individuals who have access to a subsidized transit pass are more likely to meet daily physical activity recommendations than those who do note have access to such a pass (Mr Lachapelle discussed his work in an interview with Obesity Panacea earlier this year).

Let's imagine that this promotion were being offered not by a brothel, but by a popular coffee chain like Tim Horton's or Starbucks.  I would wager that some individuals who are currently inactive would choose to walk or take the bus in order to get the discount.  And over time, that could contribute to a reduction in health risk for those individuals.  It's not going to cure obesity, but keep in mind that the available cross-sectional evidence suggests that a relatively small increase in activity could dramatically reduce the risk of mortality in sedentary individuals.

What is also worth pointing out is that organizations that cater to individuals who commute by active transportation may also increase their business (just as Mr Goetz claims has happened for his operation).  Many people like myself already commute by bike or by bus the majority of the time, and I would gladly patronize an establishment which provided me a discount as a result (I am obviously speaking here of businesses in general, as opposed to brothels).

Promotions aimed at increasing active transportation really are a win-win for all parties:

• People who use active transportation are likely to experience health benefits as a result
• Businesses which provide active transportation discounts are likely to attract customers who already commute actively
• Roads and parking lots around these establishments are likely to become less congested for those who choose to commute by car
• The environment (and everyone else) benefits from less greenhouse gas emissions 
  

Active transportation is a great way to get more physical activity whether you are completely sedentary, or regularly active (don't forget that there is almost always a benefit to increased activity, the benefit is just greatest for those who are inactive).  It is pretty easy to work in 10 minutes of moderate activity each day, when you consider that those 10 minutes can include behaviors such as walking to the bus, or even just taking the stairs rather than the elevator at work.  And if you are currently inactive, those 10 minutes could have a noticeable impact on your health and longevity (although it is worth emphasizing that 10 minutes/day is not the ideal amount of physical activity, it is still a step in the right direction).  Let's hope that more businesses and communities here in North America realize the value of incentives for active transportation.

Have a great weekend,

Travis

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Leitzmann MF, Park Y, Blair A, Ballard-Barbash R, Mouw T, Hollenbeck AR, & Schatzkin A (2007). Physical activity recommendations and decreased risk of mortality. Archives of internal medicine, 167 (22), 2453-60 PMID: 18071167
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Patrick, K., Raab, F., Adams, M., Dillon, L., Zabinski, M., Rock, C., Griswold, W., & Norman, G. (2009). A Text Message–Based Intervention for Weight Loss: Randomized Controlled Trial Journal of Medical Internet Research, 11 (1) DOI: 10.2196/jmir.1100



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As many of our readers know, I performed my MSc under the direction of Dr Bob Ross at Queen's University (Peter is nearing the completion of his PhD in the same lab).  Dr Ross is a world leader in the measurement of body fat and body fat distribution, which is why many of our publications focus on the associations of various body fat depots with markers of metabolic risk.  During my time at Queen's I was also fortunate to work with Drs Jen Kuk and Lance Davidson (now at York and Columbia respectively), who were also studying with Dr Ross.  In the current issue of Ageing Research Reviews, Drs Kuk, Davidson, Ross, and myself review age related changes in body fat distribution in a paper creatively titled "Age-related changes in total and regional fat distribution".

Research from Dr Ross' lab, as well as research done by other groups, has consistently shown that visceral fat is strongly associated with increased metabolic risk.  As part of her PhD thesis, Dr Kuk has even shown that visceral fat is an independent predictor of mortality.  In contrast, after controlling for abdominal fat, the accumulation of lower body subcutaneous fat (the fat just beneath the skin) is often reported to be associated with reduced metabolic risk.  Take for example my MSc thesis which found that after control for abdominal fat, lower body subcutaneous fat is negatively associated with triglyceride levels, and positively associated with HDL cholesterol in elderly men and women.   In other words, if two people have the same amount of abdominal fat, the one with more leg and butt fat is likely to be the healthier of the two.

All of this brings me to our current review, which summarizes the changes in these and other fat depots with normal ageing.  As you might expect, the changes are not good - there is a progressive increase in total abdominal fat (and especially visceral fat), as well as a progressive loss of lower body subcutaneous fat.  So there is more of the bad fat, and less of the good fat.  What's more, these changes can occur even without changes in body weight or waist circumference.  So even without gaining weight, body fat percentage tends to increase with age, and the increase is mostly due to increases in the worst fat depots.  These changes can be seen especially clearly in this image that I created for my thesis introduction (I knew this would come in handy someday!).  Note that although both individuals have a waist circumference of 106cm, the older individual has dramatically more visceral fat, and less thigh subcutaneous fat.


Unfortunately there are other negative changes in body fat distribution with age, including increased fat storage in the heart, liver, bone marrow, and skeletal muscle, all of which are associated with increased metabolic risk, as well as increased risk of fractures in the case of bone marrow.  And as mentioned before, none of these changes are readily apparent when obesity is being measured by BMI or waist circumference alone, which are the most common measures used in the field (and which are pretty accurate in their own right).

But wait - it's not all bad news.  As part of his PhD thesis, Dr Davidson has previously shown that exercise is able to reduce total fat and visceral fat, as well as dramatically improving metabolic risk and functional health in elderly men and women.  So while normal ageing is associated with detrimental changes in body fat distribution, exercise can dramatically reduce these effects.  For what it's worth, Dr Davidson's work has also shown that a combination of aerobic and resistance exercise is the ideal strategy for improving both metabolic and functional health in the elderly.  It doesn't have to be intense (Peter and I helped oversee the resistance exercise in that study, and it was very low intensity for some individuals), but it can have a large impact on your quality of life.  Remember - no matter what your age, it's never too late to improve your health with a little exercise.

Travis

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Kuk, J., Saunders, T., Davidson, L., & Ross, R. (2009). Age-related changes in total and regional fat distribution Ageing Research Reviews, 8 (4), 339-348 DOI: 10.1016/j.arr.2009.06.001
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Two weeks ago I wrote a post on the psychosocial problems that are often encountered by overweight and obese youth.  Today, I would like to discuss a new paper in the same issue of the International Journal of Pediatric Obesity which examines psychosocial changes in overweight youth following attendance at a weight loss camp.

The study was performed by Dr Nicole Quinlan and colleagues at Duke University, and followed 130 overweight and obese youth who spent their summer at a weight loss camp in the United States.  The treatment program included a balanced diet, nutrition classes, extensive physical activity (5 hours/day, which seems excessive, but that's a topic for another post) and weekly group counseling sessions.  Before and after their stay, campers completed questionnaires on their attitudes towards body weight and dieting, self-esteem and quality of life, as well as having their height and weight measured by camp staff.


Travis

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Quinlan, N., Kolotkin, R., Fuemmeler, B., & Costanzo, P. (2009). Psychosocial outcomes in a weight loss camp for overweight youth International Journal of Pediatric Obesity, 4 (3), 134-142 DOI: 10.1080/17477160802613372
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While Travis and I often focus on the cardiometabolic and sometimes psychological complications of obesity, the consequences of carrying excess weight reach far beyond these two areas.

Take for example automobile collisions.

By and large, most cars on the road today are not built specifically to be driven by obese drivers. More importantly, the US Federal Motor Vehicle Safety regulations and New Car Assessment Program testing uses a crash test dummy with a BMI of ~25.5 kg/m2 to gauge how safe a given car, and what type of damage may be sustained by a passenger or driver of that car upon collision. Unfortunately, it is very likely that given the same type of vehicle and mode of collision, the mechanics of the trauma incurred by the driver and passenger will vary greatly when the BMI of these parties is 45 kg/m2 rather than 25.

Indeed, previous studies have found that increasing weight is associated with a greater mortality risk from a car crash, even when other factors such as seatbelt use, age, gender, seating position, and car weight are accounted for. Such a finding, however, does not allow us to deduce whether obese individuals are more injury prone given the same crash or simply if given the same injury sustained, obese people are more likely to die from complications.

For instance, some have previously hypothesized that excess fat among overweight and obese people may actually function as an “intrinsic airbag” or “protective cushion”, thereby potentially reducing the risk of injury during a car crash. These notions were purely hypothetical and not based on any scientific evidence.

In a recently published study in the journal Obesity, Kent and colleagues investigated the crash mechanics of obese versus normal weight subjects. Given that obese crash test dummies are not available, the researchers used 3 obese and 5 normal weight cadavers for their studies, in which the effects of a frontal collision travelling at 48km/h were investigated.

First, the authors found that during the crash the obese subjects generally experienced greater maximum forward movement from their seat towards the dash before their motion was arrested by the seatbelt – obviously, not so good.

Second, the obese cadavers tended to have a more reclined torso during the crash, with the hips sliding out of the seat more than among normal weight cadavers – a difference which may increase the risk of rib fractures and pulmonary trauma, as documented previously.

However, the authors observed that the increased hip excursion and decreased torso flexion forward in the obese cadavers may reduce the risk of the head striking some component of the vehicle interior in frontal or near-frontal impacts, thus explaining the previously documented reduced risk of head injury during a car crash among heavier drivers or passengers.

Thus, while the mechanics of the trauma seem to vary between normal weight and obese individuals, there seems to be not much evidence supporting the concept of obesity being protective against injury during a car crash. With the exception of a possibly lesser chance of head injury, obese subjects may actually be more injury prone during an automobile collision.

Peter

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Kent, R., Forman, J., & Bostrom, O. (2009). Is There Really a “Cushion Effect”?: A Biomechanical Investigation of Crash Injury Mechanisms in the Obese Obesity DOI: 10.1038/oby.2009.315
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