FEATURE — Winter 2005

Samuel Klein is the William H. Danforth Professor of Medicine and Nutritional Science, and director of the Center for Human Nutrition.

Weighing Answers to Obesity

At the Center for Human Nutrition, Danforth Professor Samuel Klein and fellow researchers manage obesity and nutrition on multiple fronts.

By Judy H. Watts

Trust me, I’ve been through the mill,” says Beth Henk of the emotional anguish she has endured because of obesity. The program manager of Washington University’s Weight Management Program, Henk has lost 445 pounds: first 200 pounds at the Diet Center and then 245 pounds at the Weight Management Program, an arm of the Center for Human Nutrition, which gastroenterologist and nutritional biochemist Samuel Klein directs. “Before I met Dr. Klein, I had gone to doctors who could only berate me. I’m Caucasian, and it was as if they were telling me: ‘Tomorrow, I want you to be an African-American male. I don’t know how you’re going to do it, but that’s what you should become.’ By the next day they would have forgotten about me, but I always remembered the cruel things they said.

Beth Henk, now program manager of the Weight Management Program, personally benefited in her battle with obesity from the School of Medicine’s and, in particular, Professor Klein’s care and expertise.

“And if you do forget about your weight for a few minutes,” Henk continues, “a guy on the street will yell, ‘Why don’t you go on a diet?’ or someone sitting in a car in the next lane will make a pig sound at you.”

In a culture that glorifies underweight-but-often-strategically-augmented bodies while it entices everyone to ingest oversized portions of calorie-rich food, millions suffer pain and prejudice because of what they weigh. According to the U.S. Department of Health and Human Services (DHHS), nearly two-thirds of American adults are overweight; 30.5 percent are obese. Childhood obesity is also epidemic: As many as 1 in 5 children are overweight, DHHS reported in 2002; numbers have doubled in the past two to three decades. The increase includes adolescents and all age, race, and gender groups. Obese children are now developing diseases once found only in adults, such as Type 2 diabetes; many suffer from low self-esteem and depression; and they tend to become heavy adults.

How Do You Score?
The body-mass index is a measure of body fat based on height and weight that applies to both men and women. To calculate your score, multiply your weight in pounds by 704, divide by height in inches, and divide again by height in inches.
<18.5, underweight with increased health risks;
18.5–24.9, normal with normal health risks;
25.0–29.9, overweight with increased health risks;
30.0–34.9, category Obese I with high health risks;
35.0–39.9, Obese II with very high health risks;
40, Obese III with extremely high health risks.

Excessive weight takes a severe toll on the body as well as the psyche—putting adults at risk for diabetes; heart disease; stroke; hypertension; gallbladder disease; osteo-arthritis; sleep apnea and other breathing problems; and uterine, breast, colorectal, kidney, and gallbladder cancer.

“With premature death on the rise and the illness, suffering, and economic costs that accompany obesity, we’re experiencing the dark side of our technological growth,” says Samuel Klein, the William H. Danforth Professor of Medicine and Nutritional Science, and director of the Center for Human Nutrition (CHN). His responsibilities at CHN include medical director and program founder of the Weight Management Program, director of the Clinical Nutrition Research Unit, and director of the Veronica and Robert C. Atkins Center for Excellence in Obesity Medicine. Klein also is chief of the Division of Geriatrics and Nutritional Science and associate program director of the General Clinical Research Center, both at the School of Medicine, and past president of the North American Association for the Study of Obesity and the American Society of Clinical Nutrition. (His list of scientific publications is similarly indicative of his expertise and energy.)

“Obesity represents a bad interaction between our environment and our genes,” Klein continues. “We are genetically programmed to consume food and store excess food energy as fat. At the same time, we have labor-saving devices, motorized transportation, sedentary work and entertainment—our surroundings actually make it difficult to be physically active! Plus, we have calorie-dense food at our fingertips. It’s a deadly combination.”

“Obesity represents a bad interaction between our environment and our genes,” Klein says. “We are genetically programmed to consume food and store excess food energy as fat. At the same time, we have labor-saving devices, motorized transportation, sedentary work and entertainment—our surroundings actually make it difficult to be physically active! Plus, we have calorie-dense food at our fingertips. It’s a deadly combination.”

To help restore Americans’ health and ultimately prevent obesity from developing, Klein and his colleagues at CHN have mounted a multiple-tined attack on obesity: pioneering research; one-of-a-kind community programs for children, families, and the elderly; all-too-rare nutrition education for medical students; and a caring clinical program for the public (see Caring Clinical Component sidebar below).

First front: pioneering research

Danforth Professor Samuel Klein (left) confers with Bernard Miller III, a Weight Management Program physician, regarding patient Mary Hornbostal. Hornbostal is a research subject enrolled in a study evaluating the effects of dietary macronutrient composition on weight loss and obesity-related medical complications.

The research portion of the Center for Human Nutrition is supported primarily with a Clinical Nutrition Research Unit (CNRU) grant from the National Institutes of Health (NIH)—one of only eight nationwide. Today, $35 million in NIH grants help support the 78 Washington University investigators in the CNRU—a dramatic increase since its inception six years ago with grants of $13 million. “The Clinical Nutrition Research Unit helps advance investigators who then obtain additional grants that help support the unit,” says Klein. “It’s a whirlwind of strength that keeps getting stronger!”

Research is directed at understanding the mechanisms responsible for the subcellular changes obesity produces, which in broadest terms affect the normal breakdown of food, its transformation into energy, and its storage, and lead to metabolic disease. One NIH grant funds a major effort to pinpoint the relationship between obesity and the growing problem of nonalcoholic fatty-liver disease. Increased fat in liver cells can become associated with inflammation, fibrosis, and even cirrhosis, Klein explains, noting that while an estimated 25 percent of American adults—excluding alcoholics and hepatitis C carriers—have fatty-liver disease, 80 percent of very obese people suffer from it, and about 2 percent of those have cirrhosis.

Nada A. Abumrad is a renowned cellular lipid physiologist. As the Dr. Robert C. Atkins Professor of Medicine and Obesity Research, she holds the nation's first endowed chair specifically dedicated to obesity research.

In a multi-center NIH study, researchers are, in part, examining low- and high-carbohydrate diets’ effects on bones, kidneys, blood vessels, and exercise tolerance. Still other CRNU investigators explore treatment approaches ranging from liposuction (which does not mitigate disease) to diet, devices, and medication.

To complement the powerhouse of talent conducting research on the whole-body level with human participants, Klein in 2004 recruited renowned cellular lipid physiologist Nada A. Abumrad. As the Dr. Robert C. Atkins Professor of Medicine and Obesity Research (a chair established with a gift from the Atkins Foundation), Abumrad holds the nation’s first endowed professorship specifically dedicated to obesity research. A specialist in the biology and physiology of adipocytes, or fat-storage cells, her CNRU collaborations will “provide tremendous opportunities to evaluate interesting hypotheses and translate her discoveries to applications that will help patients,” Klein says.

Abumrad has identified a cell protein called CD36 that helps long-chain fatty acids enter muscle and fat tissue. She is now working with the heart and intestine. “We are looking at how this protein—regulated by diet and hormones—affects susceptibility to becoming obese, diabetic, or atherosclerotic,” she says. Abumrad suspects that CD36 level is a major factor in some fat-storage differences between men and women, and that the gene that expresses it may play a role in individual reactions to diet.

Reaching the community

Richard Stein (left), research assistant professor of medicine, is director of the Center for Human Nutrition’s Family Lifestyle Intervention Pilot Program. Above, Stein meets with Susan Garcia and Keith Bohacik, who are participants, along with Bohacik’s son and Garcia’s son and daughter (working with trainer in background), in a one-year School of Medicine pilot study looking at the effects of families exercising together at the West County Family YMCA in Chesterfield, Missouri.

“No medical center alone can treat the major epidemic of obesity,” says Klein, “and that’s why, thanks to the generosity of philanthropists, BJC HealthCare, and Washington University, we’re treating people in a community setting and testing theoretical knowledge of best approaches. Our models may help other communities.” CHN’s Family Lifestyle Intervention Program, or FLIP, directed by Richard Stein, research assistant professor of medicine, is a one-year pilot study in partnership with the West County Family YMCA in Chesterfield, Missouri. Because children lose weight and exercise more effectively when their families are involved, entire households stream to the Y for meetings with a behavior therapist, a dietician, and an exercise physiologist over nine months. “Everyone likes the program, and they’re all losing weight,” Klein reports. “The data so far look very encouraging.”

Underserved elderly adults in the community are served by the Nutrition Education Assessment and Treatment program, or NEAT. Initiated by community health activist David Yawitz and directed by Monique Williams, instructor in medicine, NEAT provides two health fairs a month and interactions with health-care providers that are new to most elderly people. In the course of an hour, they receive nutritional-health, cognitive-function, and physical-status evaluations, and pharmacists review their medications. Many report that they’ve learned what to do for themselves and what to discuss with their doctor. NEAT also partners with the OASIS Institute, which provides follow-up intervention to improve frail individuals’ functioning in the community. Founder Marylen Mann, A.B. ’57, M.A. ’59, established the national organization to enrich the lives of older adults.

Caring Clinical Component
When Jim Peuster, a 6-foot computer analyst and manager who lives in Bethalto, Illinois, and works in downtown St. Louis for Amdocs, Inc., entered the Weight Management Program in November 2004, he weighed exactly what he did when he began an Optifast™ diet at then-Deaconess Hospital in 1987. Although Peuster had initially lost a lot of weight, it crept back on; he did a second stint in 1991, married his wife, Barb, the following year, and then “basically just kind of let go” until his weight reached 331 pounds.

Once Peuster spotted the Weight Management Program listing in the Yellow Pages, he placed a call and soon got with the program. At press time, after 38 weeks, Peuster has lost 109 pounds—and learned a lot about wise weight management.

Two years at a glance
The patient-supported program starts with a comprehensive physical evaluation, a psychological profile, and a nutrition assessment. During its three stages, patients see doctors and medical assistants, behavior counselors, registered dietitians, and physical therapists in a supportive, nonjudgmental atmosphere. Stage 1 (20 weeks): Weekly meetings of a small, fixed group of people who support one another as they learn about all aspects of weight management and follow individualized meal plans. (Peuster had found the Optifast regimen easy to follow and requested that meal replacements be part of his nutrition plan.) Stage 2 (36 weeks): Transitions to conventional meal plans; weekly reinforcement meetings; continued progress in weight loss and exercise. Stage 3 (1 year): Monthly sessions to support healthy living.

Dieting insights
Based on research, Samuel Klein offers some observations: • No single diet suits everyone. • How portions are best controlled—with meal replacements, low-fat diets, low-carbohydrate menus, or high-protein plans—depends entirely on the individual. • Portion control is key, because calories-in, calories-burned is still how everything works. • The key to success is making lifestyle changes in small steps and stages that can be incorporated and maintained forever. •  Even a small upset in the energy balance can cause weight gain or loss. Eating as little as 10 calories a day more than you burn—the equivalent of a LifeSaver™—will cause more than a pound of fat gain in one year. • The USDA food pyramid is still evolving. “Not all fat is bad: Increasing marine fat and monounsaturated fatty acids will have positive health effects,” he says. “Too much refined sugar is bad; too much carbohydrate could be bad. What should be considered is a weight-loss diet that also causes healthy outcomes. One might change one’s diet and not lose weight but still be healthier than before.”

“We could never have launched programs like these without the generous support we received from the Atkins Foundation, which established the Veronica and Robert C. Atkins Center for Excellence in Obesity Medicine; BJC HealthCare; the Kilo Diabetes Foundation; and the David A. and Linda S. Yawitz Fund in Geriatrics and Community Science,” Klein says emphatically. “We are grateful to them—and to the BJ Hospital Foundation; Larry Shapiro, the dean of the medical school; and Kenneth Polonsky, the Busch Professor of Medicine and chairman of medicine, who have supported our efforts in obesity.”

For his part, Polonsky expresses appreciation for Klein’s contributions ranging from “patient-oriented research of the highest quality” to “outstanding” leadership, under which “the School of Medicine’s programs in nutrition and obesity have flourished and are now regarded as among the best in the country.”

“Dr. Klein is terrific; there’s no question about it,” says longtime research collaborator John Miles, professor of medicine in the Mayo Clinic’s Division of Endocrinology and Metabolism. “He’s a highly creative thinker who can forge strong alliances. He also has humility, and it’s absolutely sincere.”

Teaching doctors

As Beth Henk learned before she discovered CHN and as Klein acknowledges, most doctors don’t know much about obesity. “Physicians are not equipped to manage it,” Klein says. “Even now, there’s very little training of that sort in medical schools.”

Except at the School of Medicine. In addition to lectures, seminars, and hands-on clinical rotations in obesity and nutrition, the Center for Human Nutrition is using funds from the Atkins Foundation endowment to support a first-of-its-kind nutrition and obesity educational program of Web-based interactive modules in which students can follow patients’ progress. Medical students observe treatments and results, study slides and questions and answers, and take a test beforehand and afterward to measure acquired knowledge. Again, says Klein, openhearted philanthropy made it all possible.

A man who Polonsky adds is “energetic and entrepreneurial” and who Henk says is “great at multi-tasking,” Klein is moving briskly forward on all CHN fronts. And as he and his colleagues continue to examine the connection between obesity and disease, Klein says: “We might be able to block the link. The expertise and collegiality of the faculty here make Washington University an outstanding institution for addressing the key clinical and research issues in obesity.”

Judy H. Watts is a free-lance writer based in Santa Barbara, California, and a former editor of the magazine.

For more information on the Center for Human Nutrition, please visit: http://chn.im.wustl.edu/.