Soda pop, Uncle Mike and the importance of breakfast
CHARLESTON, W.Va. -- As part of his job, Dr. John Linton has talked with more than 500 West Virginians who weigh 300-plus pounds. They talk with him because they want to change. They tell him about stairways they can't get up, economy cars they can't drive, escalators, bus doorways, movie seats and restaurant booths they can't fit into.
"Every day, they contend with problems and hazards that don't even occur to most people," he said. They pay a huge price for being heavy.
"I've talked with people who were kicked off airliners because they couldn't buy more than one seat," he said. "And people who got stuck in amusement park rides while people in line yelled things like 'beached whale' and 'wide load' at them in front of their children."
As acting director for Charleston Area Medical Center's behavioral medicine department, Linton interviews people whose weight puts them at extreme medical risk. The more overweight they are, the more likely they are to get diabetes, heart disease, strokes and the more likely they are to die early.
Yet many people Linton interviews tell him they did not clearly understand that they were at risk until their weight became extreme or they had a heart attack or stroke.
Some needed information, he said. "But there's also the fact that, if a lot of the people around you are overweight, it's easy to tell yourself you're still OK."
That is an important clue to the state's soaring chronic disease rate, he said.
"A cardiologist friend said, 'I'll tell you why so many West Virginians are heavy,'" Linton said. "'When they go out the front door to their vehicles to drive to work, they look to the right and look to the left, and all of their neighbors look just like them, so it seems OK.'
"People tell themselves, 'I'm not different from everyone else, so it's nothing to worry about.'"
One in 3 adult West Virginians is obese, according to Centers for Disease Control and Prevention surveys.
Lots of reasons why
People become extremely heavy, at medical risk, for many reasons, Linton said. Some overeat for situational reasons. Those who work a night shift may eat constantly, trying to stay awake. Some medicines make a person feel constantly hungry. Many people eat mainly processed food and don't cook.
"As a breed, we Americans often have no idea what we put in our mouths," he said. "We don't know a lot about nutrition.
"Everyone eats for emotional reasons too, to a certain extent," he said. "Pleasure chemicals like serotonin go up when people eat. People who don't eat hot dogs will eat them at a ball game because they are connected with the pleasure of the game. People who don't eat buttered popcorn will eat a vat as big as their head at the movies.
"We eat more cookies around Christmastime than we eat the rest of the year. It only becomes a problem when you eat that way all year round."
The causes of serious overweight can be roughly divided into three categories, he said: emotional, environmental (surroundings) and genetic. "Sometimes it's all three.
"I always ask people, 'If I saw a picture of your third-grade class, would you be heavier than the other kids?' Half say yes. We don't know yet how big a part genetics may play in that," Linton said.
The others didn't get heavy till they were adults, he said. "Maybe they got hurt at work and couldn't move about easily. Or they got pregnant and gained 50 pounds, then never stopped.
"It's more complicated to treat obesity than it is to treat smoking and alcohol addiction. People don't have to drink or smoke to live, but they do have to eat, and they're constantly tempted by ads for junk food and soda pop."
Many cultures do not encourage overeating, he noted. "One man, a heavy fellow, went to Japan to work with his son for three months. Soon after he arrived, they went to a buffet restaurant. After his first plate, my friend went back for more food. The entire place went quiet. In Japanese buffets, you only go through once. If you go back twice, something is wrong.
"That man lost 30 pounds during his stay in Japan," he said. "It's a lot easier to eat a healthy diet when the environment encourages it."
Conversely, you're more likely to eat an unhealthy diet if the people you love eat that way.
"If you're 10, and Uncle Mike is 20, and he is 5 foot 10 inches and weighs 300 pounds, and he taught you how to fish and hunt and you love him, and when he takes you to a fast-food place to eat, and he has three hamburgers and a Big Gulp and an order of fries, well, that's your role model. Uncle Mike is who you want to be like."
For that reason, he said, many counselors refuse to treat a child for weight loss unless the whole family is involved.
Meal pattern matters
Another insight: About 8 in 10 dangerously heavy people tell Linton they eat no breakfast.
"They say, 'I never eat breakfast,' and they're proud, because they think it helps hold down their weight to skip that meal. But they're doing the exact reverse of what they need to do to lose weight."
Skipping breakfast sets up a destructive pattern in a person's body rhythm, he said. "The rule of thumb is, don't skip breakfast if you want to lose weight. Eat a breakfast low on carbs and sugar, a modest-sized lunch and a small dinner. Limit eating after dinner." Snack on low-carb and low-calorie foods in between.
Instead, most of his patients go in the other direction. They escalate their eating as the day goes on. They don't eat till lunch, snack in the afternoon, then eat a large dinner. "Then, after dinner, they really start eating, while they watch TV or surf the Web or read.
"They take in 35 to 40 percent of their calories from 8 o'clock to bedtime. People are often surprised at the extent to which they're doing this. Unfortunately, they're often eating something like a Little Debbie cake or high-fat popcorn."
Parents' eating patterns ripple out to their children. If parents skip breakfast, it's likely the kids won't eat much breakfast either, he said. If parents eat after dinner, the kids eat then too. Parents say, 'Oh, our family's all big. That's how we are,' but that may have more to do with eating patterns than with genetics."
One in 4 West Virginia fifth-graders are obese, with high blood pressure and/or cholesterol, according to West Virginia University screening.
The good news is, whole families can improve their health and lose weight by shifting their eating pattern, he said. If mornings are rushed, he said, prepare ahead: hard-boiled eggs, nuts or a banana with peanut butter, things people can grab easily. Another tip: Don't eat in front of the TV or computer.
Trauma can affect a person's weight, but "nobody can predict how," Linton said. One person will eat constantly for comfort, while another resists eating and develops anorexia or bulimia.
"There's research evidence that some women who were sexually traumatized as youngsters may gain weight to avoid being noticed by potential suitors or predators. That definitely happens, but it's important not to generalize." Not all sexually traumatized women become heavy, he said. And all women who are heavy were not sexually abused. "Obese people are already subjected to 'you're stupid, sloppy, lazy, and a drag on society.' We don't need to add a presumption that 'you've probably also been sexually abused.'"
Depression and weight are highly correlated, he said. "When both are there, you can't treat the obesity without treating the depression."
Depression can feed late-night eating too, he said. "As night falls, many people feel lonely and depressed, so they reach for the Cheetos and Cokes that kick up their pleasure chemicals. It makes them feel momentarily better, then they nosedive, so they eat more. So the cycle goes."
Diabetics who are depressed can have an especially hard time losing weight, he said, because they are less likely to do what they need to do to control their diabetes.
Depression medications also can cause people to gain weight. It can be a vicious cycle. Group support and exercise can help people break out of it, he said. "We need more group opportunities," he said.
Doctors, be more thorough
"It's not safe to assume patients know how to help themselves," Linton said. "And research shows that about 50 percent of what a physician tells the patient can be lost by the time they start their car in the parking lot.
Linton's patients often tell him their doctors told them to eat a healthier diet, but they weren't sure what that meant. They don't know, for instance, what foods are carbohydrate and what's protein. Some have never cooked. Others aren't sure how much exercise they can do safely.
Doctor's visits often last about 15 minutes, and "busy clinicians may say, 'I can't sit down with someone for two hours and explain the ins and outs of diabetes,'" Linton said.
Internet sites from the Mayo Clinic and American Diabetes Association can help too, he said. "But we've got to remember to tell patients about them."
Better yet, West Virginia is starting to build a network of multiweek classes in self-management and prevention of chronic disease. "That should help a lot," Linton said. Weekly support groups or self-management classes give a patient step-by-step help, so they're ideal for helping a person change habits, he said.
"If many of the people I interview had had a good self-management class early in the process," he said, "they probably wouldn't be talking to me."
"The bottom line is, change happens only when a person decides to change." But when a person does decide it's time to change, it's more likely to happen if the environment makes it easy or if a self-management class is available, he said.
"City and county government can do many things to help citizens of all weights stay fit or get fit. Charleston needs those kinds of things, more walking and running trails and bike paths, for instance.
"But change takes time. It takes awhile to parallel-park an aircraft carrier. It is increasingly easier to get healthy food at restaurants. You can get oatmeal at McDonald's now. More people are exercising. We're moving in the right direction."
Reach Kate Long at 304-348-1798 or firstname.lastname@example.org.
"The Shape We're In" has been supported by a Dennis A. Hunt Fund for Health Journalism fellowship, administered by the California Endowment Health Journalism Fellowships at the University of Southern California's Annenberg School for Communication and Journalism.