We have a health crisis! A CDC report published in September, 2024 indicated that the prevalence of obesity among American adults from 2021-2023 was 40.3% as defined by BMI >30 and the prevalence of severe obesity (BMI >40) in the same time period was 9.4% (1) which us up from 30.5% and 4.7% respectively in 1999. (2)
Obesity has unfortunately been linked to disease states like hypertension, diabetes, hyperlipidemia, cerebral and cardiovascular disease, kidney disease, cancer and much more. In a 2013 systematic review published in JAMA, Dr. Katherine Flegal and colleagues report that obesity with a BMI > 35 is associated with an increased all cause mortality. (3)
These constellation of endpoints are linked through a common syndrome - that is metabolic syndrome. This entity is caused by increased insulin secretion from excessive glucose and cellular insulin insensitivity both resulting from chronic caloric excess and lack of caloric expenditure. Metabolic syndrome is largely driven by lifestyle choices that lead to increased sedentariness, decreased physical activity and increased caloric intake.
The CDC recommends that all adults target a goal of 150 - 300 minutes per week of moderate intensity physical activity or 75 - 150 minutes per week of vigorous intensity activity. Moderate intensity is defined as activity requiring 3.0 - 6.0 METs (metabolic equivalent of task) which is the equivalent of a brisk walk or raking leaves. Vigorous-intensity is defined as >6.0 METs which is equivalent to running, carrying a heavy load up stairs, shoveling snow, etc. (4) According to these same guidelines, CDC reports that only 26% of adult men and 19% of adult women actually meet the minimum recommended physical activity levels. (4)
As physicians we are not immune from this reality. In a 2014 commentary, Dr. Katherine Barnett notes that 40% of the doctors were overweight and 23% were obese. She notes that the ingrained habits we pick up in medical school and on the wards of poor sleep, low quality but convenient nutrition (think the ubiquitous late night pizza delivery) and lack of physical activity contribute to this tendency toward poor health quality and obesity. (5)
Unfortunately, our lifestyle decisions have negative effects for our patients. In a 2007 commentary from the journal American Family Physician, Dr. Jo Marie Reilly discusses how physician obesity impacts the counseling that physicians give when discussing healthy lifestyles to patients. She writes,
Patients come to physicians expecting professional advice and a role model to emulate. Studies show that it is more difficult for physicians to give credible medical advice when they do not follow this advice themselves.
Furthermore, physicians who are not overweight are more likely than physicians who are overweight to proactively address obesity with patients before related comorbidities develop, and to do so more aggressively. (6)
As we seek to target obesity in ourselves for the sake of our patients we need to turn our focus to several important lifestyle modifications of our own. While we rightly focus on nutrition and the metabolic fuel that we ingest, in order to process the fuel that we consume, we need to have healthy cellular machinery and this is accomplished through regular physical exercise in the form of aerobic conditioning and resistance training.
There are numerous benefits to exercise that range from the physical to the mental and spiritual. But one of the most fundamental benefits is that regular physical exercise improves our skeletal muscle health.
Skeletal muscle plays a number of important roles in our overall physical health. The most obvious is that skeletal muscle is the primary tissue that creates movement. And its ability to create movement, thereby doing work, is adaptable to the stimuli that it receives. But a function of skeletal muscle that is not as immediately apparent is that it also serves as a glucose sink.
Glucose is the primary fuel that our body utilizes at the cellular level. Between fed and fasting states, our body is able to keep blood glucose levels within a very narrow range via the counter-regulatory signalling of insulin and glucagon. Through the action of the GLUT and SGLT transporters skeletal muscle absorbs between 70-90% of glucose from the bloodstream. (7)
Exercise has been demonstrated to increase blood glucose uptake through the translocation of GLUT-4 glucose transporters to the muscle cell surface in response to both insulin as well as exercise or muscle contraction. (7) Thus exercise improves insulin independent glucose regulation. (8)
One of the untoward side effects of obesity is development of intramuscular fat deposits. Fat deposits between muscle cells and within muscle cells not only impairs muscle function, but also results in decreased insulin sensitivity and the subsequently contributes to type 2 diabetes and metabolic syndrome. (9) Regular, physical exercise (specifically resistance training) can reverse this process of intramuscular adipose tissue deposition and improve the muscle's ability to absorb glucose. (10)
So, for us as physicians, we stand as witness on a daily basis of the massive cost that obesity places not just on the health care system but on the quality and quantity of life for our patients. Exploring ways of curbing this epidemic will yield dramatic results in the health and wellbeing of our entire population. But if we want to make a significant and meaningful difference in the lives of our patients, we need to model the choices that we confess. That means it is time for us to lace up the running shoes, grab some weights and hit the gym. Let's get after it!
References:
Emmerich S, Fryar C, Stierman B, Ogden C. Obesity and Severe Obesity Prevalence in Adults: United States, August 2021–August 2023. National Center for Health Statistics (U.S.); 2024. doi:10.15620/cdc/159281
Hales CM. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. 2020;(360).
Flegal DKM, Kit DBK, Orpana DH, Graubard DBI. Association of All-Cause Mortality With Overweight and Obesity Using Standard Body Mass Index Categories: A Systematic Review and Meta-analysis. JAMA. 2013;309(1):71. doi:10.1001/jama.2012.113905
Current Guidelines | odphp.health.gov. Accessed November 8, 2024. https://odphp.health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines/current-guidelines
Barnett KG. Physician Obesity: The Tipping Point. Glob Adv Health Med. 2014;3(6):8. doi:10.7453/gahmj.2014.061
Reilly JM. Are Obese Physicians Effective at Providing Healthy Lifestyle Counseling? afp. 2007;75(5):738-741. Accessed November 8, 2024. https://www.aafp.org/pubs/afp/issues/2007/0301/p738.html
Evans PL, McMillin SL, Weyrauch LA, Witczak CA. Regulation of Skeletal Muscle Glucose Transport and Glucose Metabolism by Exercise Training. Nutrients. 2019;11(10):2432. doi:10.3390/nu11102432
Lyon G. Forever Strong: A New, Science-Based Strategy for Aging Well. 1st ed. Atria Books; 2023.
Corcoran MP, Lamon-Fava S, Fielding RA. Skeletal muscle lipid deposition and insulin resistance: effect of dietary fatty acids and exercise2. The American Journal of Clinical Nutrition. 2007;85(3):662-677. doi:10.1093/ajcn/85.3.662
Marcus RL, Addison O, Kidde JP, Dibble LE, Lastayo PC. Skeletal muscle fat infiltration: Impact of age, inactivity, and exercise. The Journal of nutrition, health and aging. 2010;14(5):362-366. doi:10.1007/s12603-010-0081-2
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