The Western world, including Ireland, is suffering from an epidemic of obesity, according to the World Health Organisation, and while the language is dramatic, the definition is precise.
"An epidemic refers to a situation affecting over 10 to 15 per cent of the population," says Dr Donal O'Shea, the director of the Republic's first hospital-based weight-management and obesity service, at St Columcille's Hospital in Loughlinstown, Co Dublin. "Obesity is undoubtedly emerging as one of the major health problems in Ireland."
First, let's define our terms. Your weight depends on many factors including gender, height, age build and level of physical activity While the dictionary definition of obese is "fat or fleshy" the medical definition is based on Body Mass Index, (BMI) which is itself a calculation based on weight and height. To calculate your BMI, divide your weight in kilograms by the square of your height in metres.
A BMI of less than 20 is considered underweight. If your BMI is 20 to 25 your weight is considered normal. A BMI of between 25 and 30 can be regarded as overweight, however, if you're aged 50 or more, research suggests that you are better off being slightly plump rather than slightly thin.
Someone with a BMI of 30 or over is considered obese. There are three classifications of obesity. Class 1 is when you have a BMI of 30 to 35; class 2 obesity is more serious, with a BMI of 30 to 40, and people with a class 3 obesity have a BMI of 40 plus.
Within these definitions, the North/South Ireland Food Consumption Survey last year found that one in five Irishmen and more than one in six Irishwomen are obese. That's 18 per cent of the population and represents a 67 per cent increase in obesity over the past decade.
The change accounts for the rapid increase in type 2 diabetes, as increased fat intake puts pressure on the pancreas to make more insulin, and eventually the pancreas cannot keep up. Also, the range of illnesses associated with obesity will lead to an increased drain on healthcare resources.
It is against this background that St Columcille's Hospital, which already had a diabetes clinic, opened its new service, under the aegis of the East Coast Area Health Board. Two-thirds of its patients are coming from other hospitals, having presented with diabetes, breathing or orthopaedic problems associated with weight; the other third have been referred by their GPs.
The clinic, which is not yet open officially nor up to its full complement of staff, draws on best international practice, which suggests that successful weight-reduction programmes are based on a physician-led multidisciplinary team of surgeon, dietician, psychologist, physiotherapist and podiatrist.
"The idea has been received enthusiastically, and the East Coast Area Health Board is very encouraging about supporting and expanding the service," says O'Shea.
The sequence of treatment includes clinical assessment, support from dieticians and psychologists, a three-month diet and exercise regime and a follow-up review. If no progress has been made, drug therapy may be offered, with surgery held as a final option.
The protocol begins with a full medical.
"It is amazing how many people with obesity never receive a thorough medical assessment of heart, lungs, abdomen. Some basic tests need to be done - screening for diabetes; is thyroid a contributory factor; checking blood pressure and cholesterol levels. While many people with obesity may have some of the above, there are very large people who don't have high blood pressure and may be very healthy, even fit."
Next comes a review of the patient's eating habits and lifestyle. "We would be advising patients that there have been fad diets in recent years, suggesting, for example, that if you go on a low-calorie diet, you can lose two stone in two months, but in fact the only way to lose weight and to keep it off is lose it slowly and consistently.
"We suggest a hypocaloric diet, which means you take the average amount of calories you would need for your weight and lessen it by about 500 calories. So someone very overweight may need about 3,500 calories a day. The hypocaloric diet would be prescribing 3,000 calories a day, working with the patient.
"The dietician goes into chapter and verse - breakfast, dinner and tea - devising an eating plan based on the food pyramid and also paying attention to portion size.
"This approach is do-able, it's sustainable and it can work. You aim for a 10 per cent weight loss in the first year. So if you are 20 stone, if successful, you would go down to 18 stone, feel a lot better, and are, hopefully, on your way . . . If you drop to 16 stone in a year on a yo-yo diet, you could well be back up to 23 stone the following year."
The clinic does not yet have a gym, and the exercise and fitness aspect of the programme needs to be developed. For obesity which is likely to cause associated health problems, all you may be able to do is lie on a bed and raise your legs and arms, says O'Shea. "Others may be already taking exercise, and our aim may be to build them over time up to 40 minutes' brisk exercise three times a week.
"Swimming is good, particularly for hip and bone problems. There are now many more swimming pools available for public use. Our patients may want to use them during the day, when there are less people there. Visibility is a huge block to taking exercise when you're big. Some might prefer the option of buying an exercise bike and use it at home.
"There is still a huge taboo about being fat in this country. We would give hope, 'this is what we're going to do, you're not being sent away'. While the fact of the matter is weight gain is an imbalance of energy intake and output, you don't blame. Blame is hopeless. People are blaming themselves anyway. Self-esteem is probably low, job promotion and marriage prospects have been clearly shown to be affected. There is a terrible social stigma around being grossly overweight, and we are not here to add to that."
The protocol normally includes a psychological assessment, though the clinic does not yet have a full-time psychologist. Part of the psychologist's role is to analyse eating behaviour: what, when and how a patient eats and, crucially, the link between feelings and food.
In Dublin last month, Susie Orbach used the term "emotional literacy" to describe the way we can dive for a doughnut to help us feel better when we're down, instead of attempting to look at the underlying reason for the problem. We used to call it comfort eating.
"The psychologist helps our patients link their thinking with their problem actions, raising awareness, and work together to find effective strategies and problem-solving ways," says O'Shea.
A patient who tends to feel a bit low, for example, and therefore wants to snack midmorning, could set her alarm clock for that time, in order to prevent herself from slipping into seeking food as a comfort instead of looking for an alternative.