Chairman: Harry R. Kissileff, Ph.D.
Rapporteur: Kathleen Keller, Ph.D.
Date: Thursday, September 11th, 2003

Title: "Eating behavior in normal weight and obese subjects"
Speaker: Professor Stephan Rossner, M.D., Obesity Unit, Huddings University Hospital Karolinska Institute Stockholm Sweden

Attendees and their Affiliation:

Harry Kissileff, Columbia University
George Collier, Rutgers University
Karen Acroff, Brooklyn College
Anthony Scafani, Brooklyn College
Diane Klein, Columbia University
Tim Kowalski, Schering Plough Research Institute
Emma Ylin, Brooklyn College
Marie Pierre St. Onge, Columbia University
Amy Samuelson, Glaxo-Smith Kline
Paul Curie, Barnard/Columbia
Jennifer Nasser, Columbia University/Obesity Research Center
Laurence Nolan, Wagner College
Kathleen Keller, Columbia University
John Kral, SUNY
Allan Geliebter, Columbia University
Carla Wolper, Columbia University/Obesity Research Center
Igor Schoman, SUNY
Veronica Duboroskaya, Beth Israel

Summary of Presentation:

Professor Stephan Rossner led the group in a fascinating discussion entitled "Eating behavior in normal weight and obese subjects." The talk focused on the increasing prevalence of obesity and summarized data on the eating behavior of lean and obese subjects in Sweden. Like the U.S., Sweden is witnessing an increase in the prevalence of obesity in both adults and children. Unlike the U.S., tracking the eating habits of Swedes as a population is relatively easy, given that the acquisition of food is socialized and largely controlled by the Swedish government. This fact has given Dr. Rossner a unique opportunity to study the food intake patterns associated with obesity in Sweden. Data from Nielsen et al, 2002 is referenced to show that indeed food intake has increased simultaneously to a rise in the prevalence of obesity. Fat makes up about 34% of the Swedish diet and cheese is one of the most frequently consumed foods. Similar to U.S. statistics, Swedes with higher income and SES consume healthier diets. Soft drinks and alcohol are both showing increased consumption in Sweden, and both might contribute to the rise Sweden in observing in obesity prevalence.

Dr. Rossner continued to describe several other behaviors that might contribute to the rise of obesity in Sweden. Physical activity has been decreasing, and Dr. Rossner provided data that only 3% of men over the age of 50 exercise. As in the U.S., portion sizes of foods are also increasing. However, the idea of "getting the most for your money" is still very much an American point of view. Emotional overeating was briefly discussed, and Dr. Rossner presented a slide entitled "10 reasons for Emotional Overeating," some of which were anxiety, anger, guilt, depression, frustration, boredom, and failure. Similar to patterns seen in U.S. dieters, Dr. Rossner described the “average” dieting day in a Swedish individual as skipping breakfast, having a normal lunch, snacking after lunch, eating a larger than average dinner, and then continuing to snack as the day goes on.

The next part of the presentation discussed how taste might influence obesity and food intake. Dr. Rossner suggested that very little data has been collected on the relationship between taste and obesity, and future studies should focus on this area. The speaker offered the following examples of how taste might be important in food intake. Women indicate that taste and food quality are major reasons for termination of a meal, while men indicate that they stop eating “because there is no more food left.” In Swedish restaurants, if olive oil is served on the table instead of butter, people tend to eat less bread and overall calories. We see a decline in taste and smell in the elderly, but very little has been done to understand the influence this may have on body weight. Much more work is needed in this area.

Dr. Rossner presented an interesting discussion of how public service TV may be used as a medium to disseminate information on healthful eating and weight loss. Although there are lots of cooking channels, people who watch chefs on TV don’t necessarily cook more. In Sweden, public television stations aren't attracted to the idea of "teaching" individuals how to eat better, so this medium as of yet remains unused.

Many drugs, such as antidepressants, anti-epileptics, insulin, glucocorticoids, estrogen, and beta-blockers increase body weight and associated co-morbididties. This is a major problem among users of these drugs. The mechanism of this drug-induced weight gain is unknown. With corticosteroids, carbohydrate craving may be involved. Dr. Rossner presented a study in which patients with sarcoidosis were studied for 1 year. Eating behavior (using the universal eating monitor) and body weight were monitored in these patients. Results indicated that when patients took steroids, there was an increase in hunger and food take not associated with a rise in leptin levels. This increase in food intake took place after 7 days. The mechanism is unknown.

What is the relationship between sweets and obesity? Dr. Rossner presented several slides to address this question. He discussed an instance where a dietician he worked with exhibited intense sweet cravings 8-10 days before menstruation. These cravings went away 1-2 days after menstruation. He surveyed 500 women and asked if they found sweets a problem. Women with higher BMIs indicated were more likely to indicated sweets as a problem for their weight. In another study, women with high levels of depression had higher BMIs and levels of sweet intake. In comparing obese verses normal women, there was no difference in mean level of sweet intake. The conclusion of these studies was that obese women had higher levels of sweet intake, especially during menstruation.

Does vision affect eating behavior? Dr.Rossner discussed a study blind and normal seeing individuals were measured using the universal eating monitor. Blind people ate slower. When controls were blindfolded, they also ate slower. Finally, Dr. Rossner discussed stress and eating rate. Stress may prompt eating. In treatment with sibutramine, subjects with more unrestrained eating lost more weight than restrained eaters. In addition, sibutramine decreased subjects' levels of depression early during treatment.

Discussion:

Carla Wolper: What about non-exercise activity in Sweden (like preparing foods for cooking, laundry)? This is low in the U.S. Is it low in Sweden as well? 

Rossner: Suggested that this is also a problem in Sweden. 

Jennifer Nasser: (Referring to a treatment study where patients lose about 5 kg of weight and can maintain for up to 5 years.) Are patients losing, gaining, or maintaining weight during this time? 

Rossner: The majority of weight loss, in ours and most studies, takes place in the first 6 months. We don’t know why this is so. Patients are maintaining weight during this time. 

Gary Schwarz: Have there been any Swedish drug trials using topiramate? 

Rossner: Yes, memory loss is a problem. 

Nori Geary: What is the dropout rate in your studies? 

Rossner: 50-60%, one of our problems is control of the study. 

Nori Geary: How frequently are patients seen in your studies? 

Rossner: 1 day/week for 12 weeks, followed by “booster” sessions. Patients don’t pay for service due to Nationalized health care. 

Janet Guss: (Referring to the 10 reasons for emotional overeating). Do you ask normal weight individuals why they overeat? 

Rossner: Yes. Many of our overeaters are night eaters. 

Jennifer Nasser: What are the meal customs in Sweden? 

Rossner: Sweden is one of the few countries where the government distributes food. Approximately 15% of calories are eaten at breakfast and 20-25% are eaten at lunch. 

Harry Kissileff: Do you have any control data for the treatment studies you presented? 

Rossner: No, this is a problem with these kinds of studies. 

John Kral: What is the seasonal variation, summer vs. winter, in night eating? 

Speaker: We haven’t looked in our lab, but Dutch studies don’t show any. Yanovski’s data in the U.S. show an increase of night eating in the winter. 

John Kral: What about using benzocaine to numb the tongue as a way to get people to eat less? 

Speaker: Yes, I think that has been tried, but not effective. 

Janet Guss: What is the prevalence of food programming for kids in Sweden? 

Rossner: In Sweden, food companies are restricted from advertising to kids. 

John Kral: (Added a comment to discussion on glucocorticoids and weight gain) Patients who receive kidney transplants are more likely to lose their kidney if they gain weight. 

Allan Geliebter: What about when patients stop taking drugs, like antidepressants, can they lose the weight that they gained? 

Rossner: No, but many of these medications aren’t meant to be withdrawn. 

Harry Kissileff: Do you know the mechanism behind estrogen induced weight gain? 

Rossner: No. It is not as common any more because the amount of estrogen in oral contraceptives has been greatly reduced. 

Allan Geliebter: Why do estrogen and tamoxofin (an anti-estrogen) both cause weight gain? 

Rossner: I don’t know. Much of this data was taken from a text book.  

Nori Geary: Tamoxifin has antiestrogen effects in many tissues, but not in bone. 

Janet Guss: (In relation to the short term studies looking at corticosteroids and food intake) Did you look at the relation between rate of eating and food intake? 

Rossner: No, we didn’t look at rate of eating. 

Allan Geliebter: Do you interpret the increase in leptin as a result of the increase in body weight or a direct effect of the corticosteroids? 

Rossner: We can’t tell. 

Nori Geary: (In reference to studies asking women if sweets were a problem) Is this specific for sweets, or do you think they find other food groups a problem too? 

Rossner: We didn’t take a diet history, so we can’t tell. 

John Kral: (Added a comment to the discussion on sweets and obesity) Dentists in this country have no interest in cutting down on sweets or cavities, so they don’t look at microorganisms as a proxy for sweet intake. 

Harry Kissileff: What studies actually show a relationship between sweets and obesity? 

Rossner: It is very difficult to find data, due to underreporting and other factors that may bias these studies. 

Jennifer Nasser: (In reference to discussion on sweets and obesity) Is it sweet-carbohydrate or sweet-fat that most obese women have a problem with? 

Rossner: We think it is both, but not sure. 

Harry Kissileff: (In reference to the study on vision and eating behavior). What were the people eating in this study? 

Rossner: Our typical meal, hash. 

Allan Geliebter: Is it possible the people in that study ate less because they ate more slowly? Did the blind people weigh less? 

Rossner: They were weight matched. It is possible they ate more slowly. Obese subjects ate 24% less when blindfolded without feeling less full. 

Jennifer Nasser: If you use liquid food and everyone is blindfolded, would you expect the same results? 

Rossner: Can’t answer that question, we don’t know. 

Anthony Sclafani: You might be able to use dark glasses instead of blindfolding. 

Allan Geliebter: Do depressed patients lose more weight (in reference to study on patients given sibutramine)? 

Rossner: Can’t recall. 

Laurence Nolan: It is pretty well established that the Rohrshock method doesn’t measure anything. APA has put out data that it is useless. 

Rossner: Well, you can also find data that this method is fine. There is a dispute among experts in the field. 

Nori Geary: In glucocorticoid studies, did you track plasma measures? 

Rossner: We checked compliance of taking of drug, but did not take plasma measures. 

Supported in part by Merck Research, Glaxosmithkline and The New York Obesity Research Center, St. Luke’s-Roosevelt Hospital.