Ms. Huang, who works for an insurance company, is 50 years old. 168 centimeters tall and 90 kilograms in weight, she has been plagued by problems with her spine and calves. At a friend's suggestion, she went to the Fiberlife Clinic on Taipei's Chunghua Road. As well as prescribing medicines, the doctor there advised her to avoid high-heeled shoes, and wear shoes with air-cushion soles instead.

Talking about the origins of her weight problem, Ms. Huang says that she used to weigh 68 kilos, but after she gave birth to her son her weight just went up and up. Over the past 20 years she has tried various methods such as slimming teas, meal replacement formulas, slimming drugs, and acupuncture, spending several thousand NT dollars a month on average. At times she has been able to rapidly lose five kilos, but afterwards she has always regained them. Getting fat, losing weight, getting fat again, and again trying to lose weight, has pretty much been the cycle of her life for the last few years. Having no time for exercise, for breakfast she now just drinks low-fat milk; at lunchtime she eats out, so it is more difficult to control what she eats; and in the evening she generally has boiled green vegetables along with just a few bites of meat and barely a smidgeon of staple foods such as noodles or rice.

"Slimming is easier said than done. Twenty years of experience has taught me one thing: being overweight is something you can battle with your whole life," she says with a sigh.

1.8 million tubbies

Ms. Huang's story is more or less a microcosm of the experience shared by slimmers everywhere. As societies have grown more prosperous and food more abundant, and a sedentary lifestyle has reduced our ability to expend energy, the weight of the general population in industrialized countries has gradually risen. Once people become fat, they hope to find quick ways to get slim again, but these are rarely effective.

In the world's fattest nation-the USA-34% of people over age 20 are estimated to be overweight, and another 27% medically obese. The proportion of overweight and obese people in the population is now 14 percentage points higher than in 1980.

Today, Taiwan is also joining the fight against flab. According to the definition of obesity published this April by the ROC Department of Health, 32.5% of males and 32.7% of females are overweight or obese.

In January, the family medicine department at National Cheng Kung University Hospital (NCKUH) and the Taiwan branch of the US company Abbott Laboratories Services Corporation completed a survey of knowledge about slimming among the Taiwanese public. The survey found that a third of Taiwan residents have a Body Mass Index above the level defined as obese by the DOH. (Body Mass Index or BMI is a person's weight in kilograms divided by the square of their height in meters. The DOH defines a BMI over 24 as overweight, and one over 27 as obese. In the USA, a BMI of 30 or above is considered obese.) Seventeen percent of interviewees had experience of slimming, and another 9.3% were currently trying to lose weight. On average, the slimmers were aiming to lose eight kilos within seven-and-a-half weeks. The parts of the body they most hoped to slim down were the lower abdomen, the waist, the thighs and the buttocks, in that order.

Among the many and varied methods of slimming, women most often choose dieting and fasting, and less often consider exercise; for men, the opposite is true. Thirty percent of previous slimmers had sought to accelerate weight loss by "taking Western-type medicines." Among this group too, it is women who are particularly adventurous in trying all kinds of slimming drugs. But of consumers who had used slimming drugs and slimming foods, 80% had given up early because of excessive side effects.

Slimming overview

People are getting heavier and heavier, and ever more dissatisfied with their figures. Some people watch every pound for the sake of their looks, while others want to stay trim for the good of their health-slimming is a mass movement in the true sense of the term. Many individual slimming experiences and methods are privately passed from slimmer to slimmer.

Huang Pin-hung, director of the medical technology department at Taipei Municipal Yang Ming Hospital, has found a successful path to weight loss that he enthusiastically shares with others. His son, who is in senior high school, once reached 90 kilos in weight, and was depressed and constantly lethargic. A friend introduced Huang junior to replacement-meal "shakes," and in a month he lost 12 kilos. After this, Huang Pin-hung himself began drinking the liquid meals, accompanied by a regime of light, mildly spiced foods and jogging, and he too reduced his weight from 76 to 66 kilos.

"Slimming is challenging both in terms of understanding and of doing, because you not only have to learn about the changes in your body's metabolism, but you also have to change your personal behavior and dietary habits. In fact, to lose weight it's more important how you eat than how much," says Huang. He quotes the example of fast foods: at the slimming courses he teaches at Yang Ming Hospital, he suggests to participants that when ordering a hamburger at a fast-food restaurant they should ask the assistant to leave out the mayonnaise, they should not order fries, and they should choose orange juice instead of cola; in this way they can reduce calories by half.

Ms. Chen, a translator, has also been trying to lose weight for ten years. She once spent nearly NT$10,000 on diet shakes, but after drinking them for two weeks she found herself constantly plagued with diarrhea, so she gave them up. Later, at a friend's suggestion, she began to try slimming by acupuncture, accompanied by exercise and slimming teas. After three months and 20 acupuncture sessions, her weight had gone down from 65 to 56 kilos, giving her a great sense of achievement.

Mass movement

Slimming is nothing new, so what is special about the current wave of slimming that is sweeping Taiwan?

As ever, slimming and beauty centers are pumping out adverts featuring entertainment stars whose figures are sculpted into sensuous shapes. But ordinary citizens who don't want to spend big bucks can also take a leaf out of the stars' book by starting a DIY war on weight. If we look at the dazzling array of slimming books on the market, titles such as Got to Be Thin-Say Goodbye to Fat, Remold Your Figure; Slim Beauty; or Get Slim and Stay Slim invariably stress the real-life experiences of famous people or successful slimmers. Although the economy is in the doldrums, books of this kind often make it onto the nonfiction bestseller lists.

Many major hospitals in both the Chinese and Western traditions have taken note of the slimming trend and opened weight reduction clinics. Family doctors in every neighborhood appeal to slimmers with claims such as "specialist in obesity treatment," and "cocktail slimming therapy."

The Taipei Municipal Hospital of Traditional Chinese Medicine, which set up a weight loss clinic two years ago, primarily uses acupuncture treatment. Liu Kui-lan, director of the hospital's gynecology department, says that in theoretical terms, by stimulating acupuncture points on the body's surface (corresponding to meridians within the body), the treatment promotes metabolism and destroys local fat tissue. The advantage of acupuncture is that one can eat normally. Liu advises her patients to follow the old maxim of eating a hearty breakfast and a filling lunch but eating sparingly in the evening, because at night one's metabolism is slower, so if one eats too much the calories accumulate in the body; also, eating too much affects one's appetite the next morning, causing one to delay meals.

Dr. Liu says that acupuncture is most effective for people who are large around the waist, because abdominal fat tissue is less compact. One old gentleman who came for treatment had a beer belly the size of a woman eight months pregnant, but after three months of acupuncture he had lost seven kilos. "But not every patient can achieve such results. Generally speaking, the higher a person's Body Mass Index is, the more effective the treatment," she says.

Generally speaking, acupuncture slimming involves two sessions a week of 30 minutes each, making eight to ten visits a month. In that time, most people can achieve a weight loss of three to four kilos. But Liu stresses that acupuncture is less effective during the menopause, and for patients whose obesity is due to underlying illness.

A kilo a week is safest

Traditional Chinese medicine enters the fight against flab armed with acupuncture, slimming teas and ancient remedies; meanwhile, practitioners of Western medicine are eager to develop quick-acting medications.

According to NCKUH's survey of slimming knowledge in Taiwan, people here generally wish to rely on "external force"-medication-to lose weight, but are unwilling to change their nutritional habits or to exercise. This is why the "cocktail" slimming treatments that have emerged in the last two years are doing a roaring trade. But just what is cocktail therapy?

The term was coined by Chinese-American scientist David Ho to describe his method of treating AIDS patients by combining three drugs-a protease inhibitor and two reverse transcriptase inhibitors-to attack the AIDS virus by two different mechanisms. It highlights the enhanced effect of drugs used in combination.

As the name suggests, cocktail therapy for slimmers combines various methods of weight control (such as diet, exercise and drugs). The mix put together by different physicians may also differ.

Dr. Yang Ming-chuan, owner of the A-Sir slimming clinic, once weighed 110 kilos, but succeeded in losing 30 kilos using a combination of diet and medications. For a while he was taking both of the slimming drugs that were then approved in Taiwan. Although this was effective, the side effects were too great and he often experienced heart palpitations, nausea and insomnia. Later he realized he had not been accustomed to eating a large breakfast anyway, so he switched to taking the drugs only before his midday and evening meals. After much experimentation, he arrived at a safe drug regime with a minimum of side effects.

He sums up his own experience in his "3-2-1 slimming method for lazy people": drink at least three liters of water a day, remain active for at least 20 minutes after each meal, and eat 1000 Calories a day. As a successful slimmer himself, he is a living advertisement for his weight loss clinic.

However, since clinics have begun offering cocktail therapy to slimmers, there have been news reports of accusations from patients that they have been prescribed inappropriate medications. The Department of Health has discovered that apart from normal slimming drugs, the packs of medicines given to patients taking cocktail treatment sometimes also include drugs such as diuretics, laxatives, thyroid hormone, ephedrine, caffeine and Prozac.

An article by Dr. Huang Kuo-chin, general secretary of the Taiwan Medical Association for the Study of Obesity and a physician in the family medicine department at National Taiwan University Hospital (NTUH), points out that using drugs to cause water and feces to be expelled from the body will of course reduce weight, but long-term use of diuretics leads to imbalance between electrolytes and fluids in the body, while ephedrine can cause side effects such as abnormalities in blood pressure and heartbeat. When so many different drugs are used together, safety is also a concern.

Watch for the yo-yo

Dr. Feng Chun-han, formerly of the family medicine department at NTUH, who now runs the Fiberlife Clinic, says that the average rate of weight loss recommended by the DOH is 0.5 to 1 kilogram per week. But slimmers in Taiwan generally look for a quick fix, and many hope to reach their target weight within two weeks. This is certainly achievable if doctors use extreme methods such as prescribing high doses of slimming drugs, but this approach is harmful to the patient. The effects can range from acute gout and gallstones, to death.

"We should also realize that rapid slimming produces a yo-yo effect. In other words, once people stop taking the tablets, as many as 90% immediately start regaining weight, and it then becomes even harder to slim down again," says Feng Chun-han.

Huang Kuo-chin notes that currently only three slimming drugs are approved for sale in Taiwan by the DOH: phenylpropanolamine (PPA), Reductil and Xenical. These drugs mainly work by altering the transmission of nerve signals by the central nervous system so as to reduce the sense of hunger and increase the sense of fullness, or by blocking the absorption of nutrients in the gut. Each reduces the intake of calories into the body. According to overseas research, taking Reductil for a year can reduce body weight by 7-8%, and can also lower blood lipid and urea levels. But its side effects include headaches, dryness of the mouth, constipation, insomnia and increased heart rates. Xenical can also produce the same slimming results, but its side effects include more frequent bowel movements, soft or watery stools, abdominal pain, an urgent desire to defecate, and abdominal bloating.

In March, overseas news agencies reported an announcement by Britain's Department of Health that a person in the UK had died due to taking Reductil, and that 200 people had suffered side effects. However, the drug's makers, Abbott Laboratories of the US, point out that at present nine million people worldwide take Reductil, but only 34 have died from taking the drug. The death rate among users is only two per 100,000, far lower than the natural death rate of 400 per 100,000 among obese people.

The DOH's Bureau of Pharmaceutical Affairs states that DOH has received no reports of adverse reactions to the slimming drugs thus far authorized for sale in Taiwan, but it will continue to monitor them.

Last year, the Taipei City Bureau of Health found that 166 television advertisements for food products had broken the relevant regulations, and 90% of the offending ads were for slimming products. Entrepreneurs exploit consumers' vanity and eagerness to lose weight with adverts that vastly exaggerate the powers of the products concerned. In the ads, the products are promoted by film and TV artistes or explained by so-called experts, and stress that "you can lose inches from wherever you want to." But the bureau concludes that these slimming products, which in fact are simply foodstuffs, are "all ineffective" for weight loss.

"There are very few 'single weapons' that are really effective for weight loss. Medications can only play a supporting role," says Dr. Feng Chu-han of the Fiberlife Clinic. Feng states that one should approach slimming drugs with the attitude that "the advantages of taking the drug should be greater than those of not taking it, and it must not be harmful to your health."

Fighting fat

The most important reason for obesity is that the energy taken into the body from food exceeds the energy expended by the body, and the excess is stored as fat. The factors that affect this energy balance include lifestyle, diet, endocrine disorders, exercise, drugs and heredity. Most overweight people have high levels of blood pressure, blood lipids and blood sugar, and excessive fat in the liver. High blood sugar damages blood vessels, with effects that can include deteriorating vision, hardening of the arteries, poor blood circulation in the extremities, and disease of kidney and nerve tissues.

Many physicians and successful slimmers have come to the conclusion that there is no shortcut to weight loss. Finding the basic reasons why someone is overweight is the only way to genuinely solve the problem. If a person is overweight because they lack a clear understanding of the nutritional and calorific values of different foods, then it is enough for them to get advice from a nutritionist as to which foods to select in order to control their caloric intake. If the reason is overeating or binge eating due to emotional or psychological problems or social pressures, then this may require medical intervention in the form of long-term behavioral therapy or psychotherapy.

Apart from controlling calories in one's diet, "exercise has benefits that are generally recognized worldwide," says Feng Chun-han. He explains that exercise can relieve stress, improve one's ability to handle stress, and prevent the tendency to overeat caused by stress. It can also stimulate the liver to release glucose, thereby reducing the appetite.

To give the public a proper understanding of weight loss issues, in March Kaohsiung Medical University set up a Fun Slimming Club that is intended to combine education with entertainment and bring together physicians, psychologists, and sports coaches. Every other Saturday afternoon from two till five, the club will provide free courses to the public, such as health lectures, aerobic dancing, and group sessions to exchange experiences.

The Taipei City Government too plans to marshal the staff of its municipal hospitals and public health stations to provide slimming courses, in pursuit of the goal of having the city's residents lose 100 tons of fat.

Are you fed up with being overweight? Do you want to get slim? Start by taking a long, hard look at your current lifestyle and eating habits, and choose an easy form of exercise that you can stick with long-term. Good health and a slim, trim figure are not beyond reach!

Tips for a Slimmer, Fitter You

The failure rate among slimmers is very high, and many have had the experience of failing and starting again from scratch. The ideal way to lose weight is to combine controlling your diet with taking more exercise, and making these permanent practices. This is the only way to achieve the goal of being slim and healthy. The following principles for successful slimming are recommended both by the ROC Department of Health and by nutritionists:

Reduce your fat intake

One gram of fat produces nine kilocalories of energy. Some foods that don't seem oily actually contain a lot of hidden fat. These include nuts and seeds, such as almonds, walnuts, pistachios, peanuts, cashews or melon seeds. Therefore would-be slimmers should steer clear of these foods. When it comes to cooked foods, you should avoid fried foods, and cut down on foods containing large amounts of animal fat, such as fatty meat, pork rind, chicken skin, and goose skin.

Eat three regular meals a day

Digesting food consumes energy, and starving actually improves your intestines' ability to absorb nutrients, so when you do eat you will absorb more calories. It's best to eat three similar-sized meals a day, rather than starving yourself all day and then eating three meals' worth of food at one sitting. Avoid eating anything in the three hours before you go to bed.

Eat low-calorie foods

Choose foods that are bulky and filling but low in calories. These include vegetables such as gherkins, aubergine (eggplant), white cabbage, wax gourd, cucumber, bamboo shoots, white radish and carrots, and soya-bean products such as soft tofu. Low-calorie foods can be cooked by fat-free or low-fat cooking methods (such as simmering in bone broth made up from concentrate, or in fat-free stock). Overweight people are usually big eaters, and it is an unrealistically tough challenge to cut down on the amount you eat right away. A more practical approach is to reduce the amount of rice, meat and fish you eat, and replace it with vegetable soup, which is not only filling but also contains plenty of fiber, minerals and vitamins.

Cut down on processed foods

Eat more natural foods, such as brown rice instead of white rice, and wholemeal bread instead of white bread. Don't eat pickled or heavily spiced foods, which are high in salt. Fresh foods taste excellent of themselves, so when cooking them it is enough to add a little salt or soy sauce. Don't use monosodium glutamate.

Try the "333" exercise principle

When choosing what type of exercise to do, it is important to choose kinds that suit you and that you enjoy. You should exercise at least three times a week for at least 30 minutes each time, and during each workout you should maintain a heartbeat of least 130 beats per minute. Also, find ways to exercise in your daily routine: office workers can climb the stairs to their office, and if you travel to work by bus you can get off two or three stops early and walk the rest of the way.

9105077a.gif,9105077b.gif,9105077c.gif

Shoot some hoops, or dance to the music-30 minutes of exercise three times a week can keep you trim and healthy.

9105077d.gif

The reasons for obesity are complex. Sedentary modern lifestyles with too little exercise and too much to eat, an unbalanced diet, and hereditary factors, are all "perpetrators" behind bulging waistlines.

9105077e.gif,9105077f.gif,9105077g.gif,9105077h.gif

The range of slimming methods on the market is bewildering. But acupuncture, liposuction, slimming drugs and massage are all only auxiliary methods. For effective weight loss, there is no getting away from diet control and exercise.

9105077i.gif

Mr. Wang, a speech therapist, once weighed 156 kilos. With his doctor's help, and through his own determined efforts, he shed 60 kilograms of fat in ten months, and thus stands as a shining example of slimming success.