* More than 300 million adults worldwide are obese.

* Almost half of these individuals live in developed countries and as many as 23% of American adults are obese.

* Obesity results in $100 billion in healthcare costs each year in the United States.

* Obesity results in 300,000 preventable deaths each year in the United States.

* Obesity nearly doubles your chances of developing high blood pressure.

* Nearly 70 % of cardiovascular disease cases are related to obesity!

* The U.S. Surgeon General has developed a national action plan to reduce obesity.

STATISTICS PROVIDED BY:

The National Institute of Diabetes and Digestive and Kidney Diseases

The National Institute of Health

The Center for Disease Control and Prevention

The Na tional Women's Health Resource Center

A recent study from the journal Public Health reported obesity as being a greater health risk than smoking, drinking or poverty. Obesity was more closely associated with major illnesses and a poorer quality-of-life in comparison to people that smoked, drank, or lived in poverty. Researchers found that half of the people who are obese have an additional chronic condition such as heart disease, cancer or diabetes. This study was based on a telephone survey of 10,000 Americans and used only body mass index to assess obesity and overweight. Regardless, the results are cause for great concern.

You must also keep in mind that some individuals may fit into more than one category, and sometimes even all of the categories. However, the researchers stated that more people are overweight or obese than are, collectively, daily smokers, problem drinkers or living below the poverty line. Of course, being in more than one category puts your health status at an even greater disadvantage.

Obesity is a huge burden on the health care system now and will be even more so in the near future. It is a largely a preventable disease however it is a medical condition in many cases. This is very unfortunate but it is not something that should be dismissed as static. You can make a change or you can help someone make a change toward healthier living. One of the authors said the survey "demonstrates that public health officials should intensify their fight against obesity to levels that at least match the public health campaign against smoking".

Sturm, R., and K. Wells. Does obesity contribute as much to morbidity as poverty or smoking? Public Health. 115(3): 229-235, 2001.

Unfortunately, this is not a joke, and it's definitely no laughing matter. There are a large number of Internet resources for more information on either subject, such as www.diabetes.org and www.diabetesonestop.com. The newsletters from the American Diabetes Association have provided a wealth of knowledge (and many statistics and research facts in this article).

Type 2 Diabetes (T2-D) is associated with a marked impairment in the ability of the hormone insulin to stimulate glucose uptake in skeletal muscle. Most diabetic patients are obese and have high blood levels of lipids (fats) and glucose (sugar). Both of these blood levels can contribute to insulin resistance. Correct insulin is necessary for the cells of the body to pull sugar (glucose) from the blood to use as energy. Thus, it is a negative cycle (high blood glucose leads to insulin resistance and insulin resistance leads to high blood glucose!). Over the long-term, high blood glucose levels can lead to damage of the eyes, kidneys, nerves and heart.

Fortunately, while diabetes is serious, it is largely preventable and is also possible to control with lifestyle modifications, although it can't be "cured". Patients can learn to take care of their diabetes by decreasing their blood glucose levels through nutritional and exercise interventions and subsequent reductions in body fat. In fact, with weight loss, exercise, and better nutrition, many diabetics can greatly reduce (or eliminate) the need for medications. Any treatments should be discussed with a medical professional before changes are initiated.

However, enough optimism, it's time to look at the hard facts and the sad state of diabetes in North American (and the rest of the world).

* T2-D affects 140 million people worldwide.

* 16 million Americans have diabetes.

* Diabetes is the 6th leading cause of death by disease in America.

* In America, the total annual cost of diabetes to the nation is more than $100 billion.

* ~25% of all Medicare costs are spent on people with diabetes.

* Obesity is the most important determinant of insulin resistance.

* No one is able to escape the effects of diabetes (i.e. death of family and friends; financial; health care costs; etc.).

The chance of death due to diabetes is increasing primarily due to cardiovascular disease. More depressing is the fact that the risk of death increases with lower socio-economic status, likely because these people are less educated, and due to the fact that you can buy loads of saturated fat and sugar for a couple of bucks just about anywhere. Cardiovascular disease sucks. Having been a spectator of an open-heart surgery at the foot of the operating table, it is clear that no one who has the choice would want to go through that ordeal. Imagine your chest ripped open, your heart fixed up, and your chest sewn up with wire. Bring on the morphine.

THE CHILDREN

The most disturbing issue surrounding diabetes is the impact that it is having in adolescents and in specific ethnic groups. Nowhere is it more sad or obvious as to what harm a sedentary lifestyle and a fast food nutritional intake can have on a person's health than in children. Overweight children are becoming more common, health problems are greater, and T2-D is being seen more and more at younger ages. Risk factors for overweight kids include overweight parents, high-fat diets, watching too much television, and being from poor families.

Unfortunately, overweight children often simply become overweight adults. Because it is difficult for people to lose body fat as one grows older, public health experts hope that preventing excess weight gain in children will avert health problems later in life. Researchers at the Centers for Disease Control and Prevention confirmed that American adolescents are developing T2-D. However it is difficult to detect T2-D in children because rarely do they show symptoms (these take years to manifest). Thus, it is extremely important to initiate educational, nutritional, and physical activity programs as soon as possible at all socio-economic levels.

ETHNIC GROUPS

Overall, the number of American diabetics increased at least 33% over the 1990's and as obesity continues to increase, so will diabetes. Unfortunately, this impacts certain ethnic groups to a greater extent than others. For example, Native American Indians have a very, very high number of T2-diabetics in their communities (3 three times the national average). African Americans may have an even higher rate of diabetes (10.8% of all African Americans - 2.3 million). It is hoped that educating these peoples on nutrition and physical activity will help combat the disease.

NUTRITION

American's fat consumption has decreased over several decades from 40 % to 34 %, however the rate of obesity has risen from 12 % in 1991 to at least 23% today. This may be due in part to the vague "official" nutritional recommendations and the massive fast food industry. The general public believes in a low fat and high carbohydrate diet, however they don't know that there are both good and bad fats and good and bad carbohydrates.

In fact, some research shows that neither the total amount of fat or carbohydrate a person consumes can predict diabetes. Researchers suggest it may not be the quantity of fat or carbohydrate that you eat, but rather the quality. Improving the quality of your food intake and monitoring the quantity will help prevent against overweight and obesity.

Hu et al. (2001a) have written a tremendous paper on the role of nutrition in diabetes. They found that for carbohydrates, one should consume more low-glycemic carbohydrates and a high fiber content. In contrast, everyone should consume minimal refined flour products to prevent large increases in blood sugar and insulin after meals.

Recommended carbohydrate foods are oatmeal, whole unrefined grains, fibrous vegetables, apples, and other fibrous fruits, while breads and sugar based foods (soda, candy, etc.) should be eliminated. In diabetic individuals, a diet of low-glycemic carbohydrates can improve blood sugar control and if you are obese, you should absolutely eliminate all high-glycemic carbohydrates from your diet. In fact, a meal of high-glycemic foods does not cause people to feel full, and may lead to more eating! In summary, this relationship has been established: High-glycemic carbohydrates develop obesity, and obesity develops diabetes.

In their thorough review, Hu et al. (2001a) also found that a high intake of saturated fat and trans-fatty acids likely promote diabetes. In contrast, an increase in a person's intake of poly-unsaturated fat and Omega-3 fatty acids could help prevent diabetes. It is wise to decrease consumption of saturated fats (animal fats), margarine, butter and hydrogenated vegetable oils (i.e. the oil that french fries are cooked in). Salmeron et al. (2001) recommend decreasing your intake of trans-fatty acids (hydrogenated vegetable oils) by replacing them with non-hydrogenated polyunsaturated fatty acids will help decrease your risk of T2-D. One place to start is reducing your intake of fast food.

In replacement, everyone should try to consume more fish oils and non-hydrogenated vegetable oils (i.e. olive oil). Most of the research presented is based on association. For example, in the Netherlands, diets containing a lot of fish are associated with lower risks of diabetes. Researchers suggest that one must follow the correct diet for a long time (i.e. make it part of your lifestyle) in order to see benefits. For example, fish oils (Omega-3 fatty acids) have benefits for "cell membranes" and help insulin function properly, however this will not happen overnight just because you had a salmon steak!

Basically, a typical "Westernized" diet should be avoided. All the negatives (i.e. saturated animal fats and sugars) seem to be associated with one another (i.e. they are all found in your typical fast food meal). In reality, everyone should try to:

* Decrease animal fat (saturated fats) and hydrogenated cooking oils.

* Increase fish and flax oils (poly-unsaturated Omega-3 fatty acids) and vegetable oils.

* Decrease high-glycemic carbohydrate intake. Don't drink regular soda!

* Increase fiber from whole grains

* Increase fruit and vegetable consumption

At the 2001 ENDOCRINE SOCIETY meeting, alternative treatments of T2-D were recommended by Arsenis and Goettelman. In this study, diabetic patients reduced animal protein intake from 2-3 times a day to once every other day (vegetable protein was substituted) and stopped all consumption of plain sugars. Patients liked the new diet and the fact that they did not have to fast, take low calorie diets or receive appetite suppressants. The metabolic profile of many patients improved and it even helped some to stop using certain medications. The authors concluded that the reduction of animal protein and sugars help to improve the quality of life and metabolic profile of diabetic patients.

LIFESTYLE

In addition to diet, another contributing factor to obesity is that 60 % of Americans don't get enough activity and 25 % get NO activity. A recent study examined almost 40000 males over the age of 40 and how the amount of TV they watch relates to their T2-D risk (Hu et al., 2001a). Researchers showed that more TV was significantly associated with higher risk for diabetes and that increased physical activity is associated with less risk for diabetes.

The key point is that if people get up and moving that they may be able to decrease their risk of diabetes. This information should be applied towards youths as well. In addition, for obese people, simply losing 5-10 pounds can have a dramatic positive effect on their health!

Even inadequate sleep can have an effect on diabetes according to research from the lab of Dr. Eve Van Cauter. In a study, subjects that got restricted sleep (< 7h) for 5 nights had impaired insulin sensitivity (Mander et al., 2001). It may be due to disruption of bodily functions due to shortened sleep. Thus, one of the functions of sleep may be to assure normal blood sugar levels. That's another "Western world" lifestyle factor that may contribute to diabetes.

On a related note, "Excessive Daytime Sleepiness" (EDS) is becoming more prevalent. This condition is associated with diabetes and is considered as an important public health problem because it is a strong risk for public safety. Its prevalence is estimated to occur in 5% to 15% of the general population.

INTERVENTIONS

According to the National Institute Health, 35-40 % of adult American women and 20-24 % of adult American men are trying to lose weight at any given time. An interesting story came out of Philadelphia last month. Philly was rated the fattest city in the USA for January of 2000 and the mayor urged the city to lose weight. The city has taken the challenge and this year sits at 3rd, while Houston is now the fattest in the USA. On a whole, obesity and diabetes are more prevalent in the Southern United States!

In a study presented at the American Diabetes Association conference, diabetic patients have the greatest improvements in symptoms after following a program that combined a proper exercise and diet approach (Alpizar et al., 2001). Obesity remains the major obstacle to the achievement of satisfactory glycemic control in T2-D and often limits management of cardiovascular risk factors. After nutritional education and guidance, as well as an increase in daily physical activity, modest weight losses and improved diabetic factors were noted (Reynolds et al., 2001). Again, these stress the need for education and guidance.

If you are active, if you eat a variety of healthy foods (natural produce, lean meats, un-refined grains), and if you are of a healthy weight, than the fear of diabetes and obesity should be minimal. When asked how to avoid diabetes, Dr. Ronald Kahn said, "Stay thin! If you are not, get thin!" After all, obesity is the most important determinant of insulin resistance.

For active people of a healthy weight, it is not unrealistic to include the odd "Western" meal in your weekly schedule without causing panic. However, the consistent intake of a high-sugar, low-fiber, high-saturated fat diet, along with a daily sedentary living pattern precludes people to the awful diseases that are diabetes and obesity.

REFERENCES

Alpizar, M., et al. Effectiveness of an Exercise Program and Diet Plan in the Control of DM2 Patients. American Diabetes Association, 61st Annual Conference, 2001.

Hu, F., et al. Diet & risk of Type II diabetes: the role of fat & carbohydrate. Diabetologia 44: 805-817, 2001a.

Hu, F., et al. Physical Activity and Television Watching in Relation to Risk for Type 2 Diabetes Mellitus in Men. Arch Intern Med. 161: 1542-1548, 2001b.

Mander, B., et al., Short Sleep: A Risk Factor for Insulin Resistance and Obesity. American Diabetes Association, 61st Annual Conference, 2001.

Reynolds, L., et al. Lifestyle intervention reduces multiple risk factors in obese patients with poorly controlled insulin-requiring type 2 diabetes mellitus. American Diabetes Association, 61st Annual Conference, 2001.

Salmeron, J., et al. Dietary fat intake and risk of type 2 diabetes in women. Am. J. Clin. Nutr. 73(6): 1019-1026, 2001.