Correspondence

The Obesity Problem

N Engl J Med 1998; 338:1156-1158April 16, 1998

Article

To the Editor:

I commend you and Dr. Angell (Jan. 1 issue)1 for recognizing that “the best public health approach is to concentrate on measures to prevent obesity” and stressing the importance of avoiding weight gain. However, even a modest degree of excess weight is associated with an increased risk of hypertension 2,3 and diabetes.4 The combination of the severity of the consequences of excess weight and the fact that approximately 24.7 percent of all U.S. women are overweight (defined as a body-mass index — calculated as the weight in kilograms divided by the square of the height in meters — of 25 to 29.9) and an additional 24.9 percent are obese (defined as a body-mass index >30)5 makes excess weight a major public health problem. It is one of the most common preventable causes of morbidity and mortality, and clinicians would be remiss if they did not discuss weight loss and weight maintenance with their overweight patients.

Alison E. Field, Sc.D.
Brigham and Women's Hospital, Boston, MA 02115

5 References

1
Kassirer JP, Angell M. Losing weight -- an ill-fated New Year's resolution. N Engl J Med 1998;338:52-54
Full Text | Web of Science | Medline

2
Yong LC, Kuller LH, Rutan G, Bunker C. Longitudinal study of blood pressure: changes and determinants from adolescence to middle age: the Dormont High School follow-up study, 1957-1963 to 1989-1990. Am J Epidemiol 1993;138:973-983
Web of Science | Medline

3
Huang Z, Willett WC, Manson JE, et al. Body weight, weight change, and risk for hypertension in women. Ann Intern Med 1998;128:81-88
Web of Science | Medline

4
Colditz GA, Willett WC, Stampfer MJ, et al. Weight as a risk factor for clinical diabetes in women. Am J Epidemiol 1990;132:501-513
Web of Science | Medline

5
Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes 1998;22:39-47
CrossRef | Web of Science | Medline

To the Editor:

We believe that you and Dr. Angell misrepresent the findings of the study by Stevens et al. (Jan. 1 issue),1 as well as many other observations in the medical literature dealing with the relation of obesity to the risk of cardiovascular disease.

Obesity is an increasingly serious problem, and it is unequivocally associated with substantial morbidity and increased mortality,2 particularly from cardiovascular diseases.3 Yet, your editorial contradicts the results of the study by Stevens et al. by concluding that there is no major risk of early mortality below a body-mass index of 27, and perhaps not much risk at higher levels. In the study by Stevens et al., the greatest longevity was actually associated with a body-mass index between 19 and 22. Moreover, in a 14-year prospective study of middle-aged women,4 a body-mass index above 23 but below 25 increased the risk of both nonfatal and fatal coronary heart disease by 46 percent. In a separate study in men 40 to 65 years of age, a body-mass index above 25 but below 29 increased the risk by 72 percent.5 . . .

Ronald M. Krauss, M.D.
University of California at Berkeley, Berkeley, CA 94720

Robert H. Eckel, M.D.
University of Colorado Health Sciences Center, Denver, CO 80262

5 References

1
Stevens J, Cai J, Pamuk ER, Williamson DF, Thun MJ, Wood JL. The effect of age on the association between body-mass index and mortality. N Engl J Med 1998;338:1-7
Full Text | Web of Science | Medline

2
Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med 1993;119:655-660
Web of Science | Medline

3
Eckel RH. Obesity and heart disease: a statement for healthcare professionals from the Nutrition Committee, American Heart Association. Circulation 1997;96:3248-3250
Web of Science | Medline

4
Willett WC, Manson JE, Stampfer MJ, et al. Weight, weight change, and coronary heart disease in women: risk within the `normal' weight range. JAMA 1995;273:461-465
CrossRef | Web of Science | Medline

5
Rimm EB, Stampfer MJ, Giovannucci E, et al. Body size and fat distribution as predictors of coronary heart disease among middle-aged and older US men. Am J Epidemiol 1995;141:1117-1127
Web of Science | Medline

To the Editor:

. . . You endorse the prevention of obesity but suggest that physicians “should provide advice if an overweight patient asks for help in planning a weight-loss program and recommend weight loss if a patient is suffering from health problems that can be ameliorated by weight loss.” This passive approach will not prevent weight gain in those at risk, nor will it prevent further weight gain in those who are already overweight. Furthermore, the rapid increase in body-mass index in the U.S. population over the past 15 years will most likely continue unabated if this passive approach is used. Because health care providers represent a trusted source of information about nutrition,1 we believe that they should counsel all patients who are overweight (body-mass index, >25)2 to avoid further weight gain, regardless of whether their patients raise the issue of weight. Abundant data confirm that weight loss reduces obesity-associated morbidity. Delaying counseling until such a condition has developed reflects ineffective attempts at prevention and increases the likelihood that patients will rely on inappropriate or unhealthy methods of weight control.

William H. Dietz, M.D., Ph.D.
Adele L. Franks, M.D.
James S. Marks, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 30341

2 References

1
Federation of American Societies for Experimental Biology, Life Sciences Research Office. Third report on nutrition monitoring in the United States. Vol. 1. Washington, D.C.: Government Printing Office, 1995:223.

2
Dietary Guidelines Advisory Committee. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 1995. Washington, D.C.: Department of Agriculture, 1995.

To the Editor:

You assert that loss of as little as 10 to 15 percent of body weight can ameliorate hyperglycemia, hyperlipidemia, and hypertension. However, these disorders can be resolved with little, if any, weight loss.1,2 For example, when 72 obese (mean body-mass index, 30) men and women consumed a low-fat diet high in complex carbohydrates and fiber and exercised daily for three weeks, significant reductions were observed in serum cholesterol (22 percent), triglycerides (26 percent), insulin (32 percent), and glucose (13 percent) during fasting, and in systolic (6 percent) and diastolic (8 percent) blood pressure.1 The average weight loss in these subjects was less than 5 percent of initial body weight. The results of the Dietary Approaches to Stop Hypertension trial, published in the Journal last year,2 demonstrated that subjects could reduce their blood pressure within two weeks by consuming a healthier diet, without losing weight.

These studies suggest that health problems frequently blamed on excess body weight are more likely caused by an unhealthy lifestyle rather than obesity itself. If so, then a singular focus on weight loss for medicinal reasons is entirely off target.

A continued focus on weight loss is counterproductive and potentially hazardous to health. The epidemiologic evidence cited in your editorial, indicating that weight loss may be associated with increased death rates, primarily from cardiovascular disease, may be explained in part by the observation that caloric restriction preferentially reduces body reserves of heart-healthy n-3 fatty acids.3 In addition to remembering that “above all else, do no harm,” we would be wise to heed one of Hippocrates' more insightful, if less well known, aphorisms: “Do not allow the body to attain extreme thinness, for that, too, is treacherous, but bring it only to a condition that will naturally continue unchanged, whatever that may be.”

Glenn A. Gaesser, Ph.D.
University of Virginia, Charlottesville, VA 22903

3 References

1
Barnard RJ, Ugianskis EJ, Martin DA, Inkeles SB. Role of diet and exercise in the management of hyperinsulinemia and associated atherosclerotic risk factors. Am J Cardiol 1992;69:440-444
CrossRef | Web of Science | Medline

2
Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-1124
Full Text | Web of Science | Medline

3
Tang AB, Nishimura KY, Phinney SD. Preferential reduction in adipose α-linolenic acid (18:3ω3) during very low calorie dieting despite supplementation with 18:3ω3. Lipids 1993;28:987-993
CrossRef | Web of Science | Medline

To the Editor:

You and Dr. Angell cited our 1993 paper as claiming “that every year 300,000 deaths in the United States are caused by obesity.” 1 That is not what we claimed. Instead, the figure you cite applies broadly to the combined effects of various “dietary factors and activity patterns that are too sedentary,” not to the narrower effect of obesity alone. Indeed, given the contribution of multiple diet-related factors to problems such as high blood pressure, heart disease, and cancer, we noted explicitly the difficulty of sorting out the independent contribution of any one factor.

J. Michael McGinnis, M.D.
National Research Council, Washington, DC 20418

William H. Foege, M.D., M.P.H.
Emory University, Atlanta, GA 30322

1 References

1
McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-2212
CrossRef | Web of Science | Medline

To the Editor:

Your editorial on losing weight touches on the complex cultural and economic issues of obesity. People are pulled in two opposing directions, both of which produce immense economic rewards for the purveyors of certain products and services. In contemporary U.S. society we are encouraged to eat mountainous amounts of high-calorie food, plentifully available in restaurants and fast-food emporiums as well as in attractively prepared forms in supermarkets. The fashion, advertising, diet, and exercise industries profit from both the desire people have to eat to excess and the discontent people have about the way they look. Education may be a weak competing force against such market incentives operating in a culture increasingly given to satisfying urges of all sorts and having the financial means to do so.

You are correct in saying that we should speak out against the infatuation with thinness, but we should also speak out against our infatuation with large portions of high-calorie, unhealthful food from which we seem constitutionally so poorly protected.

Arnold Werner, M.D.
Michigan State University College of Human Medicine, East Lansing, MI 48824-1316

To the Editor:

Your editorial highlights the ethical implications of preventive medicine and reminds us that prescribing medicine is or should be completely different from prescribing lifestyles.

Hans Gruber, M.D.
Gemeinschaftspraxis und Dialysezentrum, D-84028 Landshut, Germany

To the Editor:

In their article on age, body-mass index, and mortality, Stevens et al. only considered an association with high body weights. In this well-conducted study, the population of healthy men and women with body-mass indexes of less than 17 and of 17 to 18.9 were not studied separately.

The negative sequelae of maintaining a low body weight are generally unknown to people. In your editorial, you and Dr. Angell graphically describe the struggle of young people who strive to model themselves on their media-created idols. Some behavior of very thin people is not recognized as a problem, either by themselves or by their physicians. Problems only become apparent when such people discover that they are unable to change their behavior and beliefs. Eating and exercise patterns can challenge the success of pregnancy. Although eating little fat and exercising excessively for health and fitness are now considered desirable, they are not appropriate for very thin women who are pregnant. Media recognition of the risks of excessive thinness would detract from the acceptance and desirability of emaciation and would decrease the number of women seeking consultations for weight-related problems such as menstrual disturbances, abortion, infertility, intrauterine growth retardation, premature menopause, and osteopenia.

Suzanne Abraham, Ph.D.
University of Sydney, Sydney, NSW 2006, Australia

To the Editor:

With regard to your editorial, I believe that in order to avoid any accusations of a hidden agenda, you and Dr. Angell should give your ages and body-mass indexes.

For the record, I am 42 and my body-mass index is 24.85 (68 in., 158 lb).

Joseph P. Imperato, M.D.
Lake Forest Hospital, Lake Forest, IL 60045

Author/Editor Response

Drs. Kassirer and Angell reply:

Drs. Field, Krauss and Eckel, and Dietz et al. take us to task for minimizing the consequences of being overweight. Field points to the prevalence of the problem, as well as the risks. We acknowledge that the higher the prevalence of a problem, the greater its public health implications, but that does not mean the risk is any higher for the individual patient, and it is not a justification for treating him or her with more urgency.

As for the individual risk, we do not agree with the conclusions that Krauss and Eckel draw from the studies they cite. Even statistically significant increases in relative risk do not necessarily mean that the absolute increase in risk is substantial. For example, a 46 percent increase in the risk of coronary heart disease in middle-aged women with a body-mass index between 23 and 25 means that a very rare occurrence is somewhat less rare. Dietz et al. are also concerned by the increase in the body-mass index in the U.S. population, although they recommend only that overweight patients be counseled “to avoid further weight gain” — an easier proposition than recommending weight loss. Still, the tone of alarm seems excessive. Patients may give less credence to their doctors' admonitions if they cry wolf when patients reach a body-mass index of 25.

We thank Drs. McGinnis and Foege for their correction. They and Dr. Gaesser point out the considerable difficulty of knowing the contribution of excess body weight to morbidity and premature mortality. Calculations of attributable risk are fraught with problems. They provide only an upper bound for the effect of a single variable, because many other factors, both recognized and unrecognized, may also be contributing to the outcome. When several known factors are taken into account, it is even possible to find that they account for more than 100 percent of deaths — a nonsensical result.

We appreciate Werner's balanced view, as well as Gruber's warning against doctors' accepting an overly broad mandate. In our editorial, we acknowledged the risks of being substantially overweight (a body-mass index of 30 or more), but we also spoke in favor of individualizing the approach to obesity. Doctors should ask themselves what the impact of each patient's body weight is on that person. We continue to believe that when doctors overemphasize body weight and fail to consider the efficacy and risks of available treatments, the cure can be worse than the disease.

In response to Dr. Imperato: we are both older than you, and our average body-mass index is less than 24.85.

Jerome P. Kassirer, M.D.
Marcia Angell, M.D.

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