Patients wonder: Is it OK to enjoy food again?

Some physicians worry that recent findings confuse anti-obesity messages and say excess weight remains a health risk.

By Susan J. Landers — Posted May 16, 2005

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Washington -- Extra pounds are not necessarily associated with excess mortality -- at least that's one of the findings in a new study published in the April 20 Journal of the American Medical Association.

It's a conclusion that some physicians say could disrupt efforts to curb the nation's obesity epidemic. Already, the study has had the unintended consequence of spawning full-page ads in a national news magazine and in newspapers across the country, mocking the idea that obesity is a major health threat.

"Americans have been force-fed a steady diet of obesity myths by the 'food police,' trial lawyers, and even our own government," said the ad, paid for by the Center for Consumer Freedom, a nonprofit group funded by restaurants and the food industry.

The study also fueled CCF criticism of the Centers for Disease Control and Prevention's 2004 estimate that 400,000 deaths annually are related to obesity, which the agency later determined was incorrect. The new findings peg the figure at 112,000 deaths per year related to obesity and none associated with overweight, defined as a body mass index of 25 to less than 30.

"Following the CDC's declaration that our love handles cause 400,000 deaths a year, everyone from the governor of Arkansas to top USDA officials began saying Americans are eating themselves to death. They are now eating their own words," according to the CCF.

The resulting concern is that patients will see such messages not as spin but as permission to indulge.

"I guess it shouldn't surprise me that [the ad] would use an unexpected finding from this study to say it's OK to be a little heavier," said Joseph A. Skelton, MD, director of the NEW Kids (nutrition, exercise and weight management) program at Children's Hospital of Wisconsin. "Hopefully we won't see a backlash, because we are still in the thick of an epidemic. But it could take away focus."

If this scenario played out, it would be the result of a narrow view of the many issues involved when it comes to weight and health. "While our study suggests that the mortality associated with obesity is less than previously thought, that doesn't mean it is not associated with anything," said Katherine M. Flegal, PhD, lead author and a CDC researcher. "There are other conditions you might develop because you are overweight."

These are what keep doctors counseling patients to slim down, even when it appears to be a losing battle. Rates of obesity, defined as BMI greater than 30, have nearly doubled since 1980, according to the CDC.

But the study does not address associated co-morbidities except for smoking. "It didn't take into account diabetes, hypertension or high cholesterol," said Amy Stone, MD, an internist and assistant professor of medicine at George Washington University Medical Center in Washington, D.C. "These are the things that obesity predisposes you to, and these are the things that lead to cardiovascular death, which is the No. 1 cause of mortality in the United States."

The numbers game

Despite the uproar, the study's lowering of obesity's toll is good news as it reflects broad adoption of preventive health practices that include better control of cholesterol and blood pressure, both of which have brought down mortality levels for people of all weights, suggests a second study and an editorial in the same JAMA issue.

"Except for diabetes, CVD risk factors have declined considerably over the past 40 years in all BMI groups," says the study, "Secular Trends in Cardiovascular Disease Risk Factors According to Body Mass Index in U.S. Adults." The researchers say that although obese people still have higher risk factors than lean counterparts, the levels of these risk factors are much lower than in previous decades.

"Obese persons, just like others, smoke less and have lower cholesterol levels and lower blood pressure," said Caroline M. Apovian, MD, director of the Nutrition and Weight Management Center at Boston Medical Center and not affiliated with either study.

Dr. Apovian said the recent wide-ranging estimates of obesity-related mortality speak to how hard it is to figure out how much death is caused by obesity. "That's the only lesson that can be learned from this study. Not that it's OK to be overweight."

Physicians should stay on message about weight loss, she said. "All this study shows is that the mortality rate has decreased and is no different in overweight than in normal weight people. But what kind of quality of life are we talking about? These are people who are developing diabetes and heart disease but we are keeping them alive longer because of medication."

The study also suggests there may be a new level of complexity to weight management that had not previously been apparent. Dr. Flegal and colleagues unearthed the puzzling finding that being underweight also was associated with excess mortality, especially among the elderly.

Weight issues are "something our society and other countries around the world need to know as much as we can about," she said. "We need to keep looking at the information and trying to monitor the situation and get some sense of what the implications are."

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Obesity's toll: The newest numbers

A study in the April 20 Journal of the American Medical Association has come up with a much lower tally of deaths associated with obesity than two earlier efforts, which estimated the totals at about 200,000 and about 400,000. According to this recent study, relative to the normal weight category of a body mass index of 18.5 to less than 25:

  • Being obese, or having a BMI of 30 or greater, was associated with 111,909 excess deaths.
  • Being underweight, or having a BMI less than 18.5, was associated with 33,746 excess deaths.
  • Being overweight, or having a BMI of more than 25 but less than 30, was not associated with any excess mortality.

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External links

AMA primer on management of adult obesity (link)

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