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'It's Making Us Fat'

"It's Making Us Fat": The new American health scourge, a Philadelphia Inquirer series, June 10,11, and 12, 2001

Overweight, with much to lose

Our push-button world has changed us. It's proving costly.

Sunday, June 10, 2001

First of three parts

By Marian Uhlman

INQUIRER STAFF WRITER

It was 6:15 on a recent morning when Jan Migeot's alarm clock woke her up. As usual, the Wayne tax manager reached over to her nightstand for the remote and clicked on the TV - the first energy-saving motion of her day.

Over the next hour, she'd throw clothes in the washing machine, stack breakfast plates in the dishwasher, and drive her 17-year-old daughter, Jaclyn, three miles to school - a chance to catch up on their busy lives.

It was a typical American start to the day, a flurry of tasks made easier by technology.

But those conveniences help explain why Migeot, at 5-foot-3 and 164 pounds, is overweight - along with more than 60 percent of adults in the United States.

The ballooning of the nation's girth is one of the country's top public-health concerns, and medical experts blame our push-button lives.

The TV remote, the garage-door opener, the computer - these and many more are robbing us of chances to move and burn calories.

But that's just half the story, the experts say.

Food today is everywhere. Gas stations sell doughnuts; office-supply stores sell candy; cookies are as common in offices as the file cabinets they sit on.

"We have switched to an environment where there is the potential to feast every day and where the opportunities and needs to be physically active have decreased significantly," said Andrew Tershakovec, director of the weight-management program at Children's Hospital of Philadelphia.

The result is fatter people of every age and race - from surgeons to salesmen, from teachers to truck drivers.

Particularly alarming to health officials is the number of Americans who are so overweight that they are considered obese. Twenty-seven percent of adults have reached that threshold - compared with 15 percent two decades ago - putting them at higher risk for such health problems as diabetes, heart disease and stroke.

No single change tipped the scales. Rather, experts point to the accumulated weight of small changes that sabotage discipline and willpower.

"There are probably hundreds of little things in the environment that cause us to eat a little more and to be less physically active," said James O. Hill, director of the Center for Human Nutrition at the University of Colorado Health Sciences Center. "Just a few calories either way per day can lead to substantial weight gain."

For instance, a potato-chip lover whose workplace vending machine switched from a one-ounce bag to the popular 1 1/2-ounce bag munches 80 more calories a day. Since 3,500 additional calories fuels a one-pound weight gain, eating the bigger bag daily at work can add a pound in just nine weeks.

Decades of struggle

Once on the drill team at Cardinal O'Hara High School, Migeot (pronounced Mee-Joe) has struggled with her weight for decades.

For the last five years, she has yo-yoed between 150 and 174 pounds, depending on the diet she was on, the stress in her life, how much time she had for exercise, and hours spent at work.

On that recent morning, the 48-year-old was in the midst of a new regimen. Her goal was to shed 20 pounds and feel more energized by working out in the gym for one hour every day and eating no more than 1,500 calories, despite the many temptations.

If she failed, she worried that her physical ailments - high blood pressure and knee problems - would worsen. She didn't want to be like her grandmother, who was so heavy she couldn't get to Migeot's first wedding.

Back home after driving Jaclyn to school, Migeot made herself a bowl of oatmeal, which she eats for its health benefits, not its taste. To make it more palatable, she sprinkled on almond slivers and a spoonful - about 30 calories - of a vanilla-flavored non-dairy coffee creamer.

The creamer "is the stuff I should cut out totally," she said. "I can't. I have to enjoy what I am eating."

Even so, Migeot was still on track to meet her 1,500-calorie goal, having dished out roughly 375 calories.

At 8:10, dressed in a navy-blue sweater set and snug wool shorts that she hoped would soon fit better, Migeot opened the back door and walked a few steps to her 1993 red Mercedes SL 500 with automatic transmission and electric seats and windows.

She was running late for work, but stopped for gas, swiping her credit card at the pump rather than walking to the cashier.

Needing cash, she drove across the street to the bank, parked by the automatic teller, and found it wasn't working. She circled the bank, pulled into a lane, and used a pneumatic tube.

Moving less, eating more

No one knows how many fewer steps Americans are taking, or how much less energy they are expending. In the old days, no one bothered measuring.

But walking, say, a fifth of a mile less a day, about 500 steps, means from 10 to 20 calories not burned. That may not seem like much, but in a year it could mean one or two pounds.

"We have systematically eliminated the opportunity for physical activity by the way we live," said Greg Heath, a physical-activity expert with the Centers for Disease Control and Prevention. People are "trading off caloric expenditure for time saved. . . . It is a vicious cycle."

And more calories need to be burned. In government surveys, men say they eat about 2,455 calories a day, though that is probably low because people underestimate what they eat. Still, that's 200 calories more a day than in the late 1970s. Women average 1,646 - about 100 more a day.

Though hard to measure, these subtle shifts are instigating the substantial weight gain of the last 20 years, experts say. That's not to say other factors, such as genetics and personal responsibility, aren't playing a role, but they can't by themselves explain why so many are gaining weight.

"There hasn't been a change in the genetic makeup of people over a short period of time," said R. Arlen Price, an expert in the genetics of obesity at the University of Pennsylvania.

An array of temptations

After 25 minutes in the car, Migeot pulled into a vast parking lot at West Pharmaceutical Services headquarters in Lionville, Chester County. Virtually all 310 of West's employees drive to work. Some would bicycle but say there's too much traffic.

Migeot prowled for a space near the door, but the choice spots, as usual, were claimed. As she walked inside, she berated herself for being late.

Her knee was aching, a reminder of ski-related surgery last fall, so she took the elevator to the second floor. She walked a half block to her office, put down her briefcase, and headed down to the cafeteria for coffee.

Besides coffee, the cafeteria's breakfast spread included an array of doughnuts, muffins, cereals, fruit, bagels and yogurt.

"I might succumb," said Migeot, who allows herself a "not-too-fattening" cafeteria snack about once a week. Having tried so many diets, she thinks she's a good judge of calories.

In fact, most people have no idea how many calories are in their food, said Eileen Ford, codirector of Drexel University's Nutrition Center. "You can easily swing your dietary intake by 500 calories without blinking an eye."

Migeot picked up a cherry muffin sitting near a "low fat" sign - 175 calories, she estimated. She took a 12-ounce cup and filled it half and half with black coffee and with coffee from a machine serving a cappuccino-like drink - 60 calories, she guessed.

Later, she would be surprised to learn that the muffin had about 200 calories and her coffee was over 100. "It is not like a cream puff," she moaned. "It is just a cup of coffee."

Ensconced in a cubicle

As always, the warren of cubicles and offices in the financial department was quiet when Migeot returned with the snack that would bring her to about half her 1,500-calorie daily goal.

Most of West's employees are tethered to computers - a big change from a decade ago, when the firm was introducing the technology and people would get up a lot to do work and discuss business.

Once planted at her desk, Migeot didn't need to go far: eight steps to the printer, 18 to file cabinets, 38 to a photocopier. But most of the time the tax manager sat - writing notes on a tablet, reading documents on the computer, placing phone calls, and sending e-mails to colleagues a holler a way.

That morning, Migeot was on her feet no more than eight minutes an hour - including bathroom breaks. A dozen years ago, she estimated she would have spent twice as long walking around, looking up information in a library, lugging around ledger books, and talking to colleagues.

Other West jobs have shifted more dramatically.

Joanne Neizer estimated that when she worked in the secretarial pool 20 years ago, she walked two hours a day, up and down stairs, delivering messages, mail, reports. Today, entry-level workers barely get up, she said.

Bob King, a research director who worked as a chemist 20 years ago, remembers standing to run tests. Today, chemists usually sit at desks, analyzing tests done by sophisticated equipment.

Even West's skilled factory workers, who once carried 75-pound bags of raw materials for medical equipment, now attach the bags to suction cups that lift and carry.

Only the smokers, it seems, move more. Banned by company policy from lighting up on the property, they walk half a block to a red butt can down the road.

Hoping for a breakthrough

Migeot slipped out of the office at 11:15 a.m., feeling a "little guilty," and drove 10 minutes for her twice-weekly session with her personal trainer, Tracy Peal, a former college basketball player who manages Better Bodies Cross Training Center in Exton.

"Trust me," Migeot said. "I don't look forward to it."

On other days, she goes to West's gym, but Migeot says she needs Peale - her coach, her cop.

If she strays, she answers to him.

"I need pounding a little," Migeot said. "It is so easy to lapse because of everything."

Migeot has put on at least a dozen pounds every decade since her early 20s when she weighed around 120. She gained, lost, and regained the first 12 pounds working full time and studying at night for bachelor's and master's degrees at St. Joseph's University.

She lost weight after Jaclyn's birth in 1983 and her divorce soon after, but it crept up to 146 by the late '80s as demands of work and home "became more and more complicated."

In 1989, after she remarried, she tried to follow a Weight Watchers diet, but her husband loved cooking and by 1992, she was up to 155. She exercised several days a week at the Upper Main Line YMCA. That ended when her husband fell ill, a time when she also turned to food for comfort.

When he died of heart disease in 1996, she was at an all-time high, 175 pounds.

She lost 20 of it that summer at the Jersey Shore, walking two hours a day and eating fish, chicken and plenty of vegetables. But she couldn't keep it up when she returned to regular life. The Atkins and Zone diets didn't help.

Now, she is convinced that Peal's pounding will be the breakthrough, well worth $50 an hour.

Migeot walked into the cool gym, wearing a sleeveless blue shirt over biker shorts and a sports top, and launched into the cross-training machine.

"If [Peal] sees me slowing down, he'll say 'faster, faster,' " she said, breathing hard as she pumped the pedals.

Peal and Migeot joked a lot, but he rarely cut her any slack. Once she begged him to bring a halt to leg repetitions with 30-pound weights. He refused, helping her with the last few lifts.

As she neared the end of her hour, she lay on her back raising and lowering a ball between her knees to her chest. She had tears in her eyes.

Her efforts that morning left her "very, very tired." But she likely burned 400 more calories than if she had spent the hour at her desk.

Fitness isn't in fashion

Some people are turning to fitness clubs and exercise routines to make up for the calories they no longer burn in the normal course of a day.

For instance, about 40 of West's 310 workers use its gym every day, enough for the program director to wash five loads of towels, offer four exercise classes, and sell a dozen pieces of fruit.

"But they are in the minority," said Hill of the University of Colorado - "pockets of people who are eating healthy and exercising regularly."

The percentage of Americans who exercise enough to get sustained health benefits (20 minutes vigorously three times a week, or 30 minutes moderately five times) has barely budged over the decade - from 24.3 percent to 25.4 percent.

About 29 percent of adults say they don't exercise at all.

Lunchtime surprises

When Migeot got back to her office at 1 p.m., she said she was "still shaking" from the workout and needed lunch.

At the cafeteria, she poured a diet soda. She smelled the beef tacos, but kept her distance. Fond of bread, Migeot also bypassed the biscuits and chicken, the deli bar and the grill with cheeseburgers. She filled a small plastic container with tomatoes, peppers, lettuce, tuna fish, and oil and vinegar.

She also picked up a pretzel, figuring it might stop the shaking. It was small, 100 calories she guessed.

Actually, it was 230 calories. Together with her salad, she had now reached about 1,200 of her 1,500-calorie goal.

Still, Migeot made healthier choices at lunch that day than did many West employees. Cafeteria manager Tracy Buckley says that if she stocks the freezer with Italian ices and ice cream, the high-calorie ice cream is the first to go.

When she caters an office meeting, she finds leftover fruit but not a single cookie.

Kelly Brownell, director of the Yale University Center for Eating and Weight Disorders, says that for centuries, people were driven to eat calorie-dense foods in times of plenty to survive times of famine.

"We are hard-wired to eat foods high in sugar and fat like ice cream," he said. "It's a problem of ancient genes in a modern environment."

A carrot-cake encounter

Migeot brought her salad to her desk, where she sat answering the phone between swallows.

An hour later, she made a trip to a file cabinet where a coworker told Migeot that a lawyer's birthday was being marked with carrot cake.

With this news, her willpower evaporated along with her 1,500-calorie goal. Carrot cake was her favorite.

"This is bad," she said.

Everyone's birthday is posted on departmental bulletin boards at West - and celebrated with food.

"People spend the whole day resisting invitations to eat," said psychologist Thomas A. Wadden, director of the Weight and Eating Disorders Program at the University of Pennsylvania. "Sooner or later they will give in."

After congratulating the lawyer, Migeot asked with a laugh: "You had to have a damn birthday?"

She sampled a few crumbs from the platter before cutting through the generous cream-cheese frosting for a 1 1/2-inch slice. Though she'd hoped it was less, the slice was probably 400 calories, about what she'd burned off in her workout.

In the 1970s, recalls West chemist Bob King, food came into the office as a treat: twice a month, his labmates pitched in for doughnuts and coffee. By the '80s, it was cheesesteaks or pizza every Thursday.

Now food litters the file cabinets near his office: a 37-ounce jar of cheeseballs, three chocolate boxes, pretzels, potato chips and soft drinks. The office goodies, he said, contributed to the expansion of his waistline to a 40 from a 34 a dozen years ago.

"I would rather have food than sex," said King, who was trying to lose weight. "I sit here thinking about what everyone else is eating."

Regrets at day's end

As Migeot pulled out of the West parking lot at 5:30 p.m., she remarked: "This the worst time of the day. I am starting to get hungry."

After sitting for a manicure at the Chesterbrook Shopping Center, she went into Genuardi's market to say hi to her daughter, who worked at the coffee bar, and pick up a salad.

Migeot served herself just under a pound of salad - beets, egg whites, chicken salad, Caesar salad, a prepared broccoli salad, and a splash of blue-cheese dressing.

"I am so tempted to say I was pretty good today, but I know I was bad," she said, regretting the carrot cake. "I am confronted with the fact I am eating 2,000 calories a day. No wonder I am not losing."

That evening, as Jaclyn emerged from the bathroom, Migeot got a whiff of her daughter's vanilla-scented hand lotion. Again, she was reminded of food.

She fell asleep watching television. She had programmed it to shut off automatically.

* Tomorrow: Overweight children struggle to change.

Are You Overweight? Calculate Your BMI

1. Multiply your weight in pounds by 704.5

2. Divide the result by your height in inches.

3. Divide that result by your height in inches a second time.

* The answer is your Body Mass Index (BMI). In adults, a BMI of 30 or above is considered obese; 25 to 29.9 is overweight; and 18.5 to 24.9 is healthy weight. (The formula is more complex for children.) A 5-foot-9 man would be obese over 202 pounds and overweight between 169 and 202.

* Health risks increase gradually as the BMI climbs above 25. A BMI over 30 means a much greater risk of heart disease and diabetes.

* Not everyone with a high BMI has higher health risks. A muscular athlete might not have excess body fat.

Confronting an epidemic of heavy children

In a sedentary society awash in food, the young struggle.

Monday, June 11, 2001

Second of three parts

By Marian Uhlman

INQUIRER STAFF WRITER

Paul VanWright walked into the crowded fourth-floor meeting room at MossRehab hospital in Philadelphia and looked from one child to the next, hoping he didn't know anyone.

The 16-year-old was sure his friends would tease him about going to "fat camp" if word got out that he was taking the twice-weekly weight-management class.

Even if he could keep it a secret, Paul imagined the class would make him "an exercise prisoner," forced into sets of 100 push-ups.

"I wasn't glad to be there, but I knew deep inside I needed to be," said Paul, who had gained 50 pounds in six months and now carried 330 pounds on his 5-foot-9 1/2 inch frame.

While Paul is large - his friends at Philadelphia's George Washington Carver High School of Engineering and Science affectionately call him "Big Paul" - he is by no means a rarity today.

The percentage of adolescents who are overweight has nearly tripled since the late 1970s to 14 percent. The prevalence of overweight elementary students has nearly doubled to 13 percent.

The surging numbers presage an explosion in America's health problems.

"We are sitting on a ticking chronic-disease time bomb," said William H. Dietz, director of nutrition and physical activity at the Centers for Disease Control and Prevention (CDC). "The diseases that are going to follow on the epidemic of childhood obesity are going to drive disease-care costs in a way we haven't seen before."

Sixty percent of overweight children between ages 5 and 10 already have at least one risk factor for heart disease, such as high blood pressure, according to the CDC. And doctors are worried by the small but increasing number of children with Type 2 diabetes. The disease, linked to being overweight, was practically unheard of in children 20 years ago.

Why is all this happening?

It "can't be explained by anything else except for environmental change," Dietz said.

In a world awash in food, cars, and high-tech entertainment, children are sitting more, eating more, and exercising less.

"The average American child grows up in a home with three TVs, three tape players, three radios, two VCRs, two CD players, one video-game player, and one computer," reports the Kaiser Family Foundation.

Time at computers is 1 1/2 hours a day, for those who have access. TV watching averages three hours.

Meanwhile, walking and biking trips by children ages 5 to 15 dropped 40 percent between 1977 and 1995, partly because parents worry about their safety.

Teenagers are eating more calorie-packed foods: six times more cheeseburgers than 20 years ago and double the amount of pizza and salty snacks, said Barry Popkin, a University of North Carolina nutrition professor.

One-fourth of all vegetables that teens eat are french fries.

In search of help

Paul did not come alone to MossRehab's first weight-management class.

With him last January were his sister, Aleaha, and his mother. Besides worrying about Paul, his mother was concerned about Aleaha, 12, who was gaining weight, as she had at her age.

"You don't want to see your children go down the same road you went down," said his mother, Kim Twyman.

To Paul's relief, he didn't spot anyone who would tell his friends where he'd be after school for the next eight weeks - learning about portion sizes, calories and food labels, doing aerobics and weightlifting, and getting personal coaching from a counselor.

Like Paul, the other 16 children met the government definition for being overweight based on their weight, height, gender and age.

Cortni Mays, a blue-eyed 11-year-old, remembered the moment two years before, in third grade, when she realized her body was changing.

"When I looked down at my hands they seemed real big," she said. Soon, "they became fatter and fatter."

The 122 pounds on her 4-foot-8 frame was also slowing her down. Once a good runner, she found herself easily winded, unable to keep up with her friends on the ball field across the street from her Lawncrest rowhouse.

"They would jump higher than me," Cortni said. "They could do splits. They could do cartwheels. They could bend over and touch their toes. I couldn't. It made me real sad."

She retreated into her home to eat, watch TV, and play computer games. When her parents tried to limit her food, she would sneak snacks.

"I was really hungry," Cortni said. "If I wanted three cookies, I knew Mom and Dad wouldn't let me have it. I waited until they went out of the kitchen."

Cortni's mother, Tracy Mays, admitted she would yell after finding snack wrappers in Cortni's room. Seeking help, Tracy Mays found that weight-loss camps were costly and diet programs were geared to adults.

Although some hospitals have programs for overweight children, the need was underscored to University of Pennsylvania researchers recently when they sought 80 teen volunteers for a federally funded weight-loss study. They got more than 1,000 phone calls from area families.

The MossRehab program, which is jointly run with Albert Einstein Medical Center, also received 1,000 calls.

Temptations and frustrations

Paul's surge in weight to 330 pounds began after a frightening incident in his Logan neighborhood caused him to retreat into his home last summer.

He was walking home with Chinese take-out food when a man approached asking for change for $20. Paul said he didn't have it and walked on, but the man followed and flashed a gun. He demanded Paul's money. Paul had only a dollar, and the man let him go.

For the next month, Paul holed up in his tidy bedroom, playing video games and eating.

The incident played into Paul's genetic risk of gaining weight if he doesn't exercise or if his eating habits go off kilter. Not only is his mother overweight, his 42-year-old father weighs about 390 pounds.

Paul's world is full of obstacles to keeping a healthful weight.

One of two nearby basketball courts doubles as a venue for drug deals, Paul said. The other is always packed.

The corner stores are an oasis for cookies, candy and soft drinks. Any time he ran an errand for his mother, he would buy a snack for himself.

At home, his mother kept a well-stocked kitchen and Paul indulged without thinking.

A typical Saturday, for instance, started with three eggs, three slices of cheese, fried sausage and glasses of Kool-Aid. An hour later, he said, he would down a bag of chips. At 2 p.m., he would eat a second breakfast with his mother, a late riser, followed by a 380-calorie burrito snack. Dinner was usually something fried.

When he saw a TV commercial announcing a new fast-food hamburger or taco, he said, he would make a mental note to buy one.

At school, a crammed schedule meant he had no gym this year. And, the cafeteria served delicious chocolate-chip cookies and pizza.

"It was everyday life for me," Paul said.

As Paul learned, starting with that first class, his eating and exercise habits weren't much different from those of the other overweight children. Most drank a whopping 800 calories or more in soft drinks and juice a day.

Debra DiLiberto-Mazda, the nutrition teacher, introduced herself by showing her picture as a 275-pound eighth grader. By her mid-20s, she was up to 325 pounds and had tried every diet imaginable, even having her jaw wired shut.

Eventually, she got her weight down to 175, which she's maintained for 20 years. Her solution was to cut down on fat and sugar, eat more fruits and vegetables, and exercise daily.

That is the message of the MossRehab program. Because losing weight is so difficult, the goal for the children is to slow or even stop gaining. They should slim down as they grow taller - a window of opportunity that grown-ups no longer have.

Still, Mazda told the children, after all these years she prays every day for restraint.

Paul was impressed with her story. He figured that if she could lose that much weight, maybe he could, too.

The family must cooperate

Research over the last 20 years has found that, for a child to get a good shot at losing weight, the family must change its ways.

"It is hard enough for anyone to lose weight when there is a lot of snack food available. You can't expect an 8- or 9-year-old to have the maturity to change their eating habits by themselves," said Richard Strauss, who directs the child weight program at Robert Wood Johnson Medical School in New Brunswick, N.J.

Without the whole family changing, a child might feel deprived and resentful, and relapse is more likely, according to treatment guidelines developed by a 1997 government-appointed panel of obesity experts.

Paul's mother was committed from the start. First, she quit smoking. Then, she stopped frying food, and bought turkey instead of ground beef.

Before the program, she loved to see her family "sit around the table stuffed. As a mother, I felt I did my job," she said. "But the food was actually killing them. That is what woke me up here."

Confronting the future

During the third MossRehab class, while doing toe-touching exercises, Paul hurt his back. He left the class feeling defeated, and as the evening wore on, even worse.

For the first time, he said, he could imagine his future as an overweight man. He was terrified.

"A 16-year-old shouldn't have back problems," he thought while lying on his bed staring at his blue ceiling. "I realized I had to do something. That's when I was determined to lose the weight. I did not want to end up in the situation my father's in."

His father has had back-to-back heart attacks. He also has diabetes and hip and knee problems.

"When I looked at my father, knowing it is in the genes and the way I am eating, I realized I could develop those problems," Paul said. "That's my main motivation to lose weight. He can't toss a football. I want to do that with my kids when I have kids."

Paul likely was born with a greater chance of being heavy than most people. But how much heavier he will be depends on how well he can combat his environment.

"Basically, the stronger the family history, the stronger the genetic loading, the more apt someone is to become obese," said R. Arlen Price, an obesity genetics expert at the University of Pennsylvania.

Research shows that a child with one significantly overweight parent has about a 50 percent chance of becoming an overweight adult. Two heavy parents, as Paul has, put a child at about an 80 percent risk.

"The genes you are talking about here promote obesity in certain environmental circumstances," said Rudolph Leibel, a genetics expert at Columbia University. "But they are not 100 percent predictive of obesity."

Success and confidence

Paul had lost nine pounds by February, midway through the program.

He said his friends noticed, so Paul told them what he was doing.

"They said, 'That's cool,' " Paul said. One friend wanted information so she could sign up. "I know that my friends accept it, and it gives more encouragement for me."

At the final class weigh-in, he was dismayed to learn he had gained back two pounds, but he was told he was adding muscle mass. A few weeks later, Paul had lost six pounds, bringing his weight down to 315.

What he had learned in class was changing his way of life, though the MossRehab program staff couldn't predict how Paul and his classmates would fare over time.

Paul enjoyed the fast-paced aerobics, exercise bikes, and pickup basketball. At home, he started lifting weights most nights, and his family began walking together twice a week. Aleaha lost weight, too.

At the first nutrition class, Paul was shocked to learn that about 15 small pretzels (about one ounce) made up a serving size - far less than the family-size package he sometimes consumed in an afternoon.

He cut his Kool-Aid down to two or three small glasses a day from six or seven jumbo glasses.

He stopped snacking on burritos, choosing apples or carrots that his mother made sure were in the house.

He started packing lunch - a sandwich with no mayonnaise, two apples and a juice - and stayed away from the cafeteria's chocolate-chip cookies.

Paul doesn't miss the quantities he used to eat.

"I realized I don't need it. . . . Hunger is when your stomach is growling."

He also feels more confident about his future. "I can change the outcome of being like my father."

* Tomorrow: Why Type 2 diabetes also is on the rise.

Helping Your Child

  1. Plan menus as a family.

  2. Talk to your child about cutting back on juice and soda and drinking more water.

  3. Keep few high-calorie snacks in the house. Stock up on healthier choices such as fruits, vegetables, and low-fat yogurt.

  4. Ask for low-fat menu options when dining out.

  5. Turn off the TV and plan an exercise program for the whole family, including walks.

Source: MossRehab/Albert Einstein

What Are the Culprits?

  1. In 1970, 6 percent of sixth graders had a TV in their bedroom. By 1999, 77 percent of sixth graders had a set in their bedroom. Kaiser Family Foundation

  2. Almost half of young people ages 12 to 21 do not participate in vigorous physical activity on a regular basis. U.S. Department of Health and Human Services

  3. The average child in the U.S. sees 10,000 food ads per year; 95 percent are for fast foods, sugared cereals, soft drinks or candy. Kelly D. Brownell, Yale University

As America fattens, diabetes surges

Lives in change: Dealing with diabetes, weight.

Tuesday, June 12, 2001

Last of three parts

By Marian Uhlman

INQUIRER STAFF WRITER

Helen Clay remembers all too well the moment in the emergency room when she was walloped with a new reality.

Too exhausted to go to church that morning, the Chester supermarket cashier had a friend drive her to the hospital. As she was lying in a cubicle, feeling weak and disoriented, someone announced the results of her blood test.

Suddenly, the bustling staff turned quiet, and everyone's eyes were on her.

The sugar level in Clay's bloodstream was more than nine times normal - so high she could have slipped into a coma.

"You should be knocking at the pearly gates," a nurse said.

Until that moment, Clay, 49, had no inkling that she had Type 2 diabetes. Nor did she realize how much her weight was a factor. At 5-foot-6, she weighed over 200 pounds.

Over the last decade, the prevalence of diabetes in this country has jumped 40 percent - a leap that government health officials pin largely on America's piling on of pounds.

Today, more than 15 million Americans have Type 2 diabetes, and about 80 percent of them are overweight to some degree.

"Obesity is the main reason behind the dramatic and worrisome surge in Type 2 diabetes," said Allen Spiegel, director of the Diabetes Institute at the National Institutes of Health.

The rate of obesity - the most severely overweight - has jumped more than 50 percent in the last 10 years.

While many heavy people are healthy, particularly if they exercise, a person's medical risks escalate with weight.

"Obesity is not a cosmetic issue any more," said Ali H. Mokdad, a senior epidemiologist at the Centers for Disease Control and Prevention, which in 1999 declared the problem an epidemic. "It is a risk factor for several chronic diseases such as diabetes."

People with diabetes are two to four times more likely to develop heart disease and more than twice as likely to have a stroke.

And diabetes leads to about 86,000 lower-extremity amputations a year, 35,000 new cases of kidney failure, and more than 12,000 cases of blindness.

Propelling both obesity and diabetes - and making the twin epidemics hard to fight - is the way Americans now live.

People are barraged by food at every turn, enticing them to eat more. They also enjoy more energy-saving devices, guaranteeing that they move less.

As Helen Clay was to learn, making the changes that would keep her healthy meant doing battle with her surroundings every single day.

Living with diabetes means changing a lifestyle

Clay had been in the hospital only a day in 1993 when her diabetes training began, and it would continue for 10 weeks more in "diabetes school."

"They didn't play around," she said about the doctors, nurses and dieticians who came to counsel her in the hospital, often leaving reading material behind. "Laying there, it all doesn't sink in. They can't tell you all you need to know."

Type 2 diabetes, by far the most common form of the disease, arises when the body loses its ability to adequately remove sugar from the bloodstream. When this process, regulated by insulin, is disrupted, the uncontrolled sugar can injure blood vessels, cascading into serious health problems.

Much harder than giving herself insulin shots - which she learned in three days - was trying to change the way she lived. If she could keep her blood sugar from swinging up and down, she could delay the ravages of diabetes.

She would have to be tough on herself and eat regular, healthy, measured meals. She would also have to learn to avoid a lot of her favorite foods that were fattening or raised her sugar levels.

Until then, she had thought nothing of grabbing leftover fried chicken for breakfast. Or refilling her plate at a buffet line. Or indulging her love of candy and chocolate.

She would also have to exercise, something she never thought, about even though she was a faithful follower of her son's basketball career at Chester High School.

"It is a lot to do," said Clay, who was particularly frightened by the pictures of foot ulcers and amputations that she saw in diabetes school. "I had to have a life change. . . . You don't drop everything right away."

For starters, she made sure she had half a bagel when she woke up, instead of reaching for the fat-laden chicken legs from the refrigerator or eating potato chips when she got to work. She switched from regular soft drinks to diet soda and banned salt from the house.

And she began to walk, if only a block at first.

Other changes came more slowly, such as cutting the sugar in her orange juice by diluting it with water and ordering baked - not fried - food at restaurants. She learned to help herself to smaller portions on buffet lines.

She also became a regular at diabetes support-group meetings at Crozer-Chester Medical Center to keep up her resolve.

"She made a decision not to let diabetes control her," said Karen Rockwell, a diabetes nurse educator who taught Clay's first diabetes class and became her cheerleader.

But modern life throws up daily opportunities for failure. Studies show more than half of people with diabetes say they don't exercise regularly, and many don't keep to their meal plans.

"They drive around the corner, and there is a Dunkin' Donuts," said Paula Konstantinides, director for community education at Virtua Health system, which saw 10,000 outpatients last year - double the number of five years ago. "They say to themselves, 'I worked 10 hours today, I don't want to be on the treadmill.' "

"It is a very uphill battle," said Gail Thatcher, diabetes nurse specialist for the Philadelphia Department of Public Health. "You have to have willpower and determination not to go along with everyone else."

Soon after her diabetes diagnosis, Clay said, a longtime customer at the Acme Market where she works baked her an Easter bunny sheet cake, thick with white icing. She thanked her and brought it home for her neighbors to eat.

Still, when work got busy, Clay would miss lunch, which she was supposed to eat at a set time to keep her sugar under control. Instead, she would sometimes succumb to the red licorice fish at her checkout aisle.

A "fair weather girl," as she calls herself, who doesn't like walking in the cold, Clay found she couldn't do her morning mall walk when she worked the early shift.

"Some days you can be so good," she said. "And some days the cravings come and get me."

Some have no symptoms; some think they're just tired

Like about five million Americans who unknowingly have Type 2 diabetes, Clay had been clueless about the symptoms.

Two months before her emergency-room crisis in 1993, Clay said, she was exhausted and saw her doctor. Her throat was dry, and food had no taste. She urinated so often that, fearing she wouldn't make it upstairs to her bathroom, she brought a bucket to the dining room of her Chester rowhouse.

Finally on that Sunday when Clay felt too sick to go to church, her cousin begged her to go to the emergency room.

Patients "who have clear-cut symptoms are often missed for years" by health-care workers, said Marian Parrott, medical director of the American Diabetes Association.

Many with diabetes show no symptoms or dismiss them as vague problems such as being tired.

Other patients may be missed because the disease is spreading beyond the traditional 40-plus age group. Of people in their 30s, 3.4 percent now have diabetes - a 62 percent leap in the rate from a decade ago. Doctors are surprised to find children with Type 2 diabetes, which used to be called adult-onset.

While in retrospect, Clay realizes that she was an obvious candidate for the disease, she said "it never crossed my mind," and Clay claims her doctor didn't discuss it.

The diabetes association first published screening recommendations alerting doctors to the risk factors of weight, age and family history the same year she fell ill, Parrott said.

Clay, now 56, has almost every major risk factor for diabetes.

The disease runs in her family - a grandmother, her father, and a sister.

She is African American, a group that is 1.7 times more likely to have diabetes than the general population. And when diagnosed, she was over 45.

She didn't exercise and was overweight - 225 pounds at the time.

While a hefty body alone doesn't guarantee getting diabetes, carrying too much fat, especially around the belly, can upset the delicate insulin-sugar balance.

Fat is not like a passive pillow. Scientists have recently learned that the acids released by fat thwart insulin from doing its job of ordering sugar to move out of the bloodstream and into muscle and fat cells.

They also think that fat secretes other compounds that may further disrupt insulin, which also regulates the amount of sugar that the liver makes.

On the other hand, exercise can boost insulin's effectiveness. A Finnish study published last month showed that even moderate exercise, along with some weight loss, can prevent the disease in the first place.

People with diabetes need all the support they can get

In July 1999, while attending an Order of the Eastern Star Convention at Philadelphia's Adam's Mark Hotel, Clay was feeling drained and had a convention nurse check her blood sugar.

It was at least three times normal - the highest level, she said, since her emergency-room crisis. It confirmed what she hadn't wanted to admit. She was eating too many sweets, especially chocolate.

Her new doctor "fussed at me a lot," Clay said, and sent her to a diabetes refresher class.

Diabetes patients need all the help they can get when it comes to support for their lifelong battle - refresher classes with updates on new medicines, nagging friends, vigilant coworkers, caring relatives.

At her class, Clay was again struck by the scary pictures, but it was only a year later, after a bout of pneumonia last fall, that Clay dropped about 20 pounds to 203 and came within range of coming off insulin - a potential payoff of weight loss for some people with diabetes.

"I have worked as long as I have and I am as independent as I am, I don't want my daughter and my son to look after me," Clay said. "I don't want my kids to feel burdened."

Meanwhile, her friends, coworkers and family are staying on her case.

Her daughter Pam learned during Clay's pneumonia that she was not taking her medicine properly. Her mother doesn't know it, but after she leaves for work, Pam secretly comes to her house to check the pill containers.

"I love my mother," Pam said.

Evelyn Jenifer, who works with Clay at the Acme in Ridley Township, threatens to call Pam if Clay reaches for her favorite red licorice fish.

If she heads for the macaroni or a dessert at church suppers, friends berate her.

And her walking partner, Gloria Howard, whose late husband had diabetes, makes sure they do at least 1 3/4 miles. Clay even jogs the last lap.

"Knowing people are watching you and care about you" makes all the difference, Clay said.

Are You at Risk for Type 2 Diabetes?

Those at greatest risk for Type 2 diabetes are overweight, inactive, and have diabetes in the family. While the disease most often strikes people over age 45, it is spreading to younger groups. In some people, there are no symptoms.

Symptoms

  1. Frequent urination

  2. Unusual thirst

  3. Extreme hunger

  4. Unusual weight loss

  5. Extreme fatigue

  6. Irritability

  7. Frequent infections

  8. Blurred vision

  9. Cuts and bruises slow to heal

  10. Tingling and numbness in hands or feet

  11. Recurring skin, gum or bladder infections

Treatment

  1. The disease can be managed with one or a combination of insulin injections, oral medications, diet and exercise.

Source: American Diabetes Association

For More Information

  1. American Diabetes Association: 1-800-DIABETES (1-800-342-2383), www.diabetes.org; for Philadelphia-area events, 1-888-DIABETES.

  2. National Diabetes Education Program: http://ndep.nih.gov.

  3. U.S. Centers for Disease Control and Prevention: www.cdc.gov/health/diabetes.htm

"It's Making Us Fat: The new American health scourge," appeared on June 10, 11, and 12, 2001.