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A Weighty Issue!

Lawrence I. Bonchek, M.D., F.A.C.C., F.A.C.S.
Editor in Chief

Dr. Lawrence Bonchek
Pardon the title's pun; obesity is no joke. It is estimated that about one third of Americans are overweight, and another third are obese. *  Not many abnormalities in a medical practice afflict 2/3 of the population, and it should come as no surprise that we are devoting an entire issue of the Journal to this pervasive problem. The impact of obesity on the body is so far-reaching that one issue of the Journal cannot contain all the insightful material we have gathered about this topic. We offer several key articles herein, and, as I detail below, we will publish more in future issues. Despite widespread recognition of the adverse health consequences of obesity, and the continuing efforts of a host of professional, commercial, and voluntary organizations to educate the public about weight loss through modification of diet and lifestyle, there is a continued increase in the rate of obesity in men and children. And though the rate of increase of female obesity in the United States has leveled off somewhat, this is "thin" consolation indeed, as the incidence here remains the highest in the industrialized world.
What are we to make of all this? One is tempted to suggest that this self-inflicted epidemic is simply the visible, corporeal manifestation of a self-indulgent society. America still considers itself—despite the recent Great Recession and other evidence to the contrary—the "richest country in the world," and the manner in which we eat "feeds" that presumption. Portion sizes once considered "supersize" are now standard. Eating is, after all, the one indulgence that not only satisfies a universal human need, but carries with it a variety of socially approved pleasurable psychological associations, such as family togetherness and socialization. It’s also a gratification that gives good value for money and is affordable for most everyone. Too, physical activity has inevitably become less common in a service economy, rather than a manufacturing one.

One also cannot avoid wondering how many people eat more because they have lost the oral gratification of smoking. In 1991, Williamson and coworkers at the CDC related changes in body weight to changes in smoking status in 748 men and 1137 women who were weighed in the First National Health and Nutrition Examination Survey (NHANES I, 1971 to 1975) and then weighed a second time in the NHANES I Epidemiologic Follow-up Study (1982 to 1984). The mean weight gain attributable to the cessation of smoking was 2.8 kg in men and 3.8 kg in women, but it is more important that major weight gain (greater than 13 kg) occurred in 9.8 percent of the men and 13.4 percent of the women. [1]  Sepkowitz, in the ezine (online magazine) Slate, provides a highly entertaining, well referenced, and informative overview of this topic. [2]  In the 1930s and 40s, cigarette brand Lucky Strike employed an ad slogan—"Reach for a Lucky Instead of a Sweet"—that was well known and popular, though not to the candy industry.

An interesting corollary of the relationship between body weight and smoking is the fact that despite the increased incidence of certain cancers in the obese, including lung cancer in non-smokers, this relationship is reversed in smokers, in whom higher weight is associated with a lower incidence of cancer, even after correcting for the obvious fact that patients with terminal cancer lose weight. It is tempting to speculate that this inverse relationship in smokers merely reflects the unfortunate reality that thinner smokers consume more cigarettes than do fatter smokers because they satisfy more of their oral urges with smoking.

In this issue we bring you comprehensive and informative reviews of obesity and cancer, cardiovascular disease, sleep apnea, reproductive issues, as well as psychological factors. There is, of course, an authoritative review of bariatric surgery by Dr. Alan Brader, who heads the LGH program. It is so uncommon for weight loss to be accomplished by self-discipline alone—i.e. by reduced caloric intake and increased caloric expenditure—that the only consistently effective treatment is now bariatric surgery. Indeed, the Holy Grail for pharmaceutical manufacturers is the development of a safe and effective appetite suppressant pill, which I'm tempted to call pharmaceutical will power. Several such drugs are in clinical trials, hoping to overcome the tarnished reputation of that category since fen-phen was found to cause tricuspid regurgitation and right heart failure.
Also in this issue, our regular section on Imaging Insights by Dr. Leigh Shuman is devoted to obesity. Finally, the section on medico-legal affairs asks whether obesity is legally a disability. In our last issue we had an article by Prof. Alan Caniglia[3]  of Franklin and Marshall College that elicited considerable comment, and I'm delighted now to introduce another member of the faculty at F&M. The author of the current article on obesity and the law, Professor Laurie T. Baulig, Esq., from the Department of Business, Organizations, and Society, has spent much of her career as an attorney grappling with the legal aspects of disability in industry.
In upcoming issues look for comprehensive articles on the metabolic consequences of obesity, urologic complications, specific concerns in the pediatric age group, and LGH's community response.
My personal thanks to all the authors who have responded with such enthusiasm and insight to my request that they participate in this special issue. I'm sure you will agree that it is indeed special.
Finally, I want to remind you that Drs. Bentz and Purzycki discussed the scientific aspects of Concussion in the Fall 2008 issue of the Journal, [4]  well in advance of the recent attention the subject has received in the mass media. It seems that when Sunday afternoon TV is affected, everyone finally notices, and there has been a veritable explosion of reports about the consequences of allowing injured players to return to the field soon after a head injury. Even the House Judiciary Committee has criticized the National Football League and Commissioner Roger Goodell for their handling of brain injuries, and the NFL has recently made some major changes in its policies and practices. You can also find the prescient JLGH report online. [5] 
Also, if you read the excellent article about bariatric surgery, be sure not to overlook the thorough discussion of its psychological aspects in the article by Collins and Bentz on Behavioral and Psychological Factors in Obesity.

*  Overweight in adults is defined as a Body Mass Index (BMI) of 25.0 to 29.9 kg/m2; obesity is a BMI ≥ 30.0 kg/m2. Dr. Ibarra, author of the excellent article on Obesity and Cardiovascular Disease in this issue, notes that other measurements such as waist circumference, waist to hip ratio, and waist to height ratio are useful in assessing cardiovascular risk and may be more predictive of risk than BMI alone. In children, BMI values at or above the 95th percentile of the sex-specific BMI growth charts are categorized as overweight.

[1]  Williamson DF, Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med. 1991;324:739-45.

Sepkowitz, K. Smoke-Free and Fat: The health hazards of kicking the habit. Slate. Posted Thursday, Oct. 13, 2005 (< a>

[3]  Caniglia, AS. Can a Non-Science Major Become a Scientist? J Lanc Gen Hosp. 2009; 4: 84-86

[4]  Bentz, JE, Purzycki, EJ. Concussion: Not So Minor and Injury. J Lanc Gen Hosp. 2008; 3: 84-90.