Editor`s Opinion: Bigger Than Behavior

    Contributions to this issue of Ostomy Wound Management include reviews about the effects of obesity on skin and healing as well as results of the first study published to date on incision care and discharge concerns of patients following Roux-en-Y gastric bypass bariatric surgery.

These and other obesity-related topics require increasing attention from clinicians and researchers because the news about obesity rates is not good. In its 2003 report on obesity and overweight, the World Health Organization (WHO) observes that “Obesity rates have risen three-fold or more since 1980 in some areas of North America, the United Kingdom, Eastern Europe, the Middle East, the Pacific Islands, Australia, and China.”¹ The numbers are particularly troubling in the US where, in the year 2000, approximately one third of adults and 10% of children ages 2 to 5 were reported to be obese.^2,3 Sadly, the US simply appears to be ahead of the curve. Obesity rates are actually increasing more rapidly in non-industrialized than in industrialized nations as a result of “increased consumption of more energy-dense, nutrient-poor foods with high levels of sugar and saturated fats, combined with reduced physical activity.”¹

    This “lifestyle” explanation of the cause of obesity is familiar to everyone. Yet we cannot help but wonder why rates are higher in some industrialized countries than in others. In one extensive population health study of 55- to 64-year-old Caucasian men and women, 31% of persons living in the US and 23% of those living in England were obese — a statistically significant difference.⁴ Obesity used to be a major concern in the southern parts of the US only. Now, concern has spread, so to speak, across the country.⁵ This begs the question: what is the problem with people in the US? Why have our collective waistlines increased at approximately the same rate as the number of diets, diet pills, diet books, and exercise clubs?

    One of my favorite class activities as a nursing instructor involves applying several personal and public health models to a common problem. Inevitably, this leads students to conclude that “personal responsibility” models fail to address a variety of risk factors. For example, using traditional health models to address the problem of obesity will lead to the usual “culprits” — too much food, not enough physical activity. A more comprehensive model would include environmental risk factors such as the positive correlation between increased urban sprawl and obesity rates.^5,6 A more comprehensive approach also would acknowledge that, regardless of nationality or race, obesity rates increase as income and educational levels decrease.⁴ The relationship between economic factors and the ability to purchase healthy, usually more expensive, foods is straightforward.⁷ This not only affects calorie and fat intake; less expensive, highly processed “fast” foods also tend to contain higher amounts of additives and flavoring. Of those, the effects of amino acid glutamate on the propensity for obesity (especially on a fetus) have been considered⁸ but very little is known about the potential effects of other chemicals on obesity.

    In his book Fast Food Nation, Eric Schlosser⁹ describes his visit to one of a handful of companies responsible for the taste of the majority of products people in the US consume. “Artificial” or “natural” flavor is the secret behind the taste of highly processed foods and the uniformity of fast food across the country but, as Schlosser observed, the ingredients of the additives do not have to be disclosed as long as the chemicals are “generally regarded as safe.” Although that may be true, I find it difficult to believe that the regular consumption of products containing a potpourri of chemicals does not affect our health and well-being. For example, a commonly used flavor (artificial strawberry) contains 47 (yes, 47!) different chemicals. We worry about the sugar in soft drinks and the calories and fat in snack foods but perhaps because so little is known about them, we rarely think about the plethora of chemicals in these products.

    Last but not least, evidence that socio-economic status is not “just” about income or education is increasing. The way we live and work and our real or perceived status in life affects our health.⁴ Evidence from a recent animal study provides fascinating data about a potential socio-economic status, stress, and health connection.¹⁰ Exposed to the same amount of psychosocial stress, subordinate mice gained more weight than dominant mice and both groups gained more weight than their control counterparts. Also, after the stress subsided, the dominant mice increased their energy expenditure; whereas, the subordinate animals did not. In a second experiment conducted by the same researchers it was observed that, given a choice, subordinate animals ingested more calories from fat while dominant animals ate more carbohydrates. Are humans also simply “wired” to eat more when under stress and eat differently depending on our sense of self, ability to control our lives, and perceived place in society? Does the answer to curbing the obesity epidemic lie in developing healthy communities and reducing socio-economic disparities and stress? Or should we pay more attention to regional and national food differences, including the consumption of additives?

    Clearly, if we want to get serious about curbing the obesity epidemic, we need to broaden our approach. Of course personal choices such as diet and exercise are important. But the observed regional, socio-economic, and national variations cannot be ignored. This epidemic is bigger than personal behavior.

1. World Health Organization. World Health Organization Global Strategy on diet, physical activity and health. 2003. http://www.who.org. Accessed May 12, 2006.

2. Flegal K, Carroll M, Kuczmarski R, Johnson C. Prevalence and trends in obesity among US adults. JAMA. 2002;288:1723–1727.

3. Ogden C, Flegal K, Carroll M, Johnson C. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:1728–1732.

4. Banks J, Marmot M, Oldfield Z, Smith JP. Disease and disadvantage in the United States and in England. JAMA. 2006;2037–2045.

5. Lopez R. Urban sprawl and risk for being overweight or obese. Am J Public Health. 2004;94:1574–1579.

6. Jackson R, Kochitzky C. Creating a Healthy Environment: The impact of the built environment on public health. Washington DC. Sprawl Watch Clearinghouse; 2002.

7. Moore LV, Diez Roux AV. Associations of neighborhood characteristics with the location and type of food stores. Am J Publ Health. 2005;96:325–331.

8. Hermanussen M, Tresguerres JA. Does high glutamate intake cause obesity? J Pediatr Endocrinol Metab. 2003;16(7):965–968.

9. Schlosser E. Fast Food Nation: The Dark Side of the All American Meal. New York, NY: Harper Collins Publishers;2002.

10. Moles A, Bartolomucci A, Garbugino L, et al. Psychosocial stress affects energy balance in mice: Modulation by social status. Psychoneuroendocrinology. 2006;31(5):623–633.