Ms. Widemark’s obesity position paper makes several statements that are simply not accurate, showing that she has not really researched this issue very well. Consider, for example, her first statement. She claims that obesity has not been conclusively linked to health problems, but that lifestyle issues such as poor food choices and a lack of exercise have been. She provides no reference for this statement. She simply makes it and wants us to believe it. However, as my initial statement shows, the evidence linking obesity to chronic illness is long-standing and overwhelming. While I reference several studies to bolster this claim, she simply wants us to take her word on faith.
Perhaps we would be more inclined to take her word if she were more accurate with her “facts.” For example, she claims that the CDC reduced its estimate of obesity-related deaths from 300,000 to 26,000. Once again, she provides no reference for this statement. A quick review of CDC documents, however, shows that she is quite wrong. In its May, 2005 document, the CDC says, “The latest study based on a nationally representative sample of U.S. adults estimates that about 112,000 deaths are associated with obesity each year in the United States.”1 This is more than 4 times what Ms. Widemark wants us to believe.
However, let’s ignore the facts and suppose that Ms. Widemark’s statement is correct. What would it mean if 26,000 deaths each year were related to obesity? It would mean THAT OBESITY IS AN INDEPENDENT RISK FACTOR FOR ILLNESS! In order for Ms. Widemark to be correct, the number of obesity-related deaths would have to be ZERO. As long as there are ANY deaths connected to obesity, we know that obesity is an independent risk factor for chronic illness. Thus, even though Ms. Widemark gets the number wrong by more than a factor of four, her statement supports my position. I appreciate Ms. Widemark helping me out like that!
Ms. Widemark then references the HAES study2, claiming that it shows that people can reduce risk factors without losing weight. Of course, she does not explain the study, because that would show you her statement is not complete. In the HAES study, the researchers followed 78 obese women who were “chronic dieters.” They gave some a traditional diet, and others they gave a “non-diet wellness program.” They then measured a few risk factors associated with chronic illness, essentially blood pressure and blood lipids. They measured other things such as eating behavior and self-esteem, but the only actual RISK FACTORS they measured were blood pressure and blood lipids.
The study did, indeed, show that those risk factors decreased in the “non-diet wellness program” participants, but that is no surprise. A much more detailed study which I reference in my initial statement3 shows that those two risk factors DO decrease just with exercise. However, many OTHER risk factors, which the HAES study DID NOT MEASURE, were NOT affected by exercise and were ONLY affected by weight loss. Thus, while the HAES study shows that SOME risk factors can be reduced without weight loss, a much more detailed study shows that MANY risk factors CANNOT be reduced without weight loss. This is why the authors of the more detailed study say, “Body fatness is a better predictor of CVD risk factor profile than aerobic fitness in healthy men. Although habitual physical activity is an effective strategy for preventing CVD, elevated body fatness is associated with an adverse CVD risk factor profile independently of aerobic fitness.” 3
Ms. Widemark then references a Cooper Institute study which, once again, she does not explain. In the study, the researchers put participants into several different groups and measured their risk of all-cause mortality as well as CVD mortality. In this study, the researchers themselves say, “Unfit men had substantially higher risk of CVD in all fatness categories, but there also was a direct association between body fatness and CVD mortality in fit men.”4 This is why their conclusion reads, “The health benefits of leanness are limited to fit men, and being fit may reduce the hazards of obesity.”4 Note, then, that the AUTHORS of the study say that they saw a DIRECT correlation between fatness and CVD mortality, even in fit men. This is why their conclusion does not say being fit ELIMINATES the hazards of obesity. It says that being fit can REDUCE the hazards of obesity, because their study clearly shows that there are hazards associated with obesity which fitness CANNOT eliminate.
Why, then, does Ms. Widemark claim the study says something with which the AUTHORS themselves disagree? Because of two things. First, she reports the relative risk of ALL-CAUSE mortality in men and claims that the differences are insignificant. However, they are not. She says, for example, that when normal, fit men have a relative risk (RR) of 0.83 for all-cause mortality and obese, fit men have and RR of 0.90 for all-cause mortality, that is not significant. However, that is nearly a 10% difference. Many researchers would not consider that insignificant. In addition, the fact that for BOTH fitness categories, the abnormally lean men had the highest RR, the normal men had the lowest RR, and the obese men were in between clearly shows that obesity by itself has risk factors, just as abnormal leanness does.
The other reason Ms. Widemark makes a statement with which the authors disagree is that, as was the case in the HAES study, her quote of the study is incomplete. She discusses only ALL-CAUSE mortality, not CVD mortality. When the authors looked specifically at CVD mortality, they showed that even in fit men, there was a statistically significant increase in CVD mortality risk with increasing body fatness.
Ms. Widemark then refers to the famous McGinnis-Foege study of 1993, where they estimate the actual causes of death in the United States. She correctly states that when they estimated that 300,000 deaths a year were due to “diet and activity patterns,” they did not consider obesity to be the ONLY factor in those deaths. However, they clearly state that they DO consider it a FACTOR. Thus, once again, Ms. Widemark has unwittingly added evidence for my argument. Even the McGinnis-Foege study considers obesity a RISK FACTOR for death.5
Interestingly enough, McGinnis and Foege recently wrote an editorial for the Journal of the American Medical Association6 in response to a new study that cataloged deaths in the United States in the year 2000. They speak favorably of the new report, and they give their ideas on why the new report has slightly different results from theirs. In their editorial, they specifically say that one of the reasons things have changed over the past 10 years is, “Public awareness has increased about obesity as a clear public health threat…” 6 Thus, despite what Ms. Widemark attempts to imply, McGinnis and Foege clearly see obesity as a risk factor in chronic illness.
Since I brought up the new study that cataloged deaths in the United States in the year 2000, it is instructive to see what the authors of THAT study say about obesity. In their results, they list that 400,000 people died in the year 2000 due to “poor diet and physical inactivity.” In their actual study, however, they factor out how many of those deaths are due to actually being overweight, and how many are due to poor diet and physical inactivity ALONE.
They say, “Thus, we believe a more accurate and conservative estimate for overweight mortality in 2000 such as 385 000...Overweight would account for the major impact of poor diet and physical inactivity on mortality….We estimate that poor diet and physical inactivity will cause an additional 15 000 deaths a year.”7 (emphasis mine) Thus, the latest study of actual causes of deaths attributes 385,000 of the 400,000 “poor diet and physical inactivity” deaths to obesity, and only 15,000 to physical inactivity by itself. The authors themselves state that they think 15,000 is conservative, and in their comment on the report, McGinnis and Foege, say they think it is too low.6 Nevertheless, both the authors of the most recent study on causes of death in the U.S. as well as the authors of the previous study all agree that overweight, BY ITSELF, causes many deaths in the U.S. each year.
One might wonder why the CDC estimate of 112,000 deaths due to obesity each year is so much less than the estimate being discussed here. Most likely, the CDC takes better account of physical inactivity and poor diet in its analysis. Nevertheless, whether the number of annual deaths due to obesity is 112,000 (as the CDC states), 385,000 (as the latest study states), or 26,000 (as Ms. Widemark incorrectly states), the fact is that since deaths ARE attributable to obesity, we know obesity is a risk factor for chronic illness.
Ms. Widemark goes on to claim that the dangers of “yo-yo” dieting are well-documented, but she provides no such documentation. This is not unusual for her, and it is also not the issue. “Yo-yo” dieting probably is bad for a person. However, the issue here is whether or not obesity is an independent risk factor for chronic illness. As the CDC estimate and the studies brought up by Ms. Widemark indicate, it clearly is.
Ms. Widemark then goes on to claim that Dr. Rudolf Leibel tells us that losing weight is beneficial. Once again, I applaud Ms. Widemark for making my case for me. Indeed, Dr. Leibel does know that losing weight is beneficial, because Dr. Leibel is an EXPERT on obesity and knows that it is a risk factor for chronic illness. However, Ms. Widemark then goes on to claim that Dr. Leibel says there is no satisfactory means of keeping weight down for most people. She does not quote him directly, but she does reference a talk he gave.8 If you listen to the talk, you will see that this is NOT what he says. In fact, what he says is that there is no ONE way that EVERYONE can lose weight. Thus, he says, “Even a little bit of weight loss can do a lot of good — modest weight loss improves health. Use whatever works, but is healthy. Try different approaches.”8 In other words, Dr. Leibel says that since there is no ONE way that EVERYONE can lose weight, you need to try to find what works for YOU.
I applaud Ms. Widemark for bringing Dr. Leibel up, because he has some very insightful comments on obesity and health. In one of his research publications, for example, he and his coauthors state, “Obesity in humans is an independent risk factor for myocardial infarction, stroke, type 2 diabetes mellitus, and certain cancers.”9 Thus, as an obesity expert, Dr. Leibel understands the health risks associated with obesity.
In a 2004 interview for the Journal of Women’s Health, Dr. Leibel is even more direct. When asked whether or not type 2 diabetes can be attributed to environmental changes, he says, “There has been an enormous increase in the prevalence of diabetes, and that increase is apparently the result of a parallel increase in adiposity [fatness]...The relevance here is that physicians who see a patient who is obese and has a family history of diabetes or is glucose intolerant can reduce that person’s chances of becoming diabetic by having her lose a modest amount of weight. Obesity in this context is an environmental trigger.”10
In other words, Dr. Leibel tells us that type 2 diabetes is on the rise because of rising obesity, that obesity is an environmental trigger for type 2 diabetes, and that women should LOSE WEIGHT in order to avoid type 2 diabetes. Thus, Dr. Leibel clearly disagrees with Ms. Widemark and agrees with the medical data that show obesity to be a risk factor for type 2 diabetes.
To show you just how important Dr. Leibel thinks obesity is as a risk factor for type 2 diabetes, here is what he says when asked what physicians should do to reduce their patients’ risk of type 2 diabetes: “If this patient is overweight, she is at high risk of developing diabetes soon. In either case, preventive strategies, for example, aggressive lifestyle intervention to reduce weight, should be initiated immediately.”10 Once again, not only does Dr. Leibel consider obesity to be a risk factor for type 2 diabetes, he considers it a STRONG risk factor, requiring IMMEDIATE attention.
Ms. Widemark then goes on to say that chronic calorie restriction can be a problem. Once again, she claims this is well-documented, but she gives no references. She discusses a supposed study that comes from the “Food Institute of the UK,” but gives no reference. This is not unusual for her, and it is impossible to know whether or not she is accurately portraying the study’s results. Once again, however, this is NOT the question. The question is whether or not obesity is an independent risk factor for chronic illness. As many of the facts brought up by Ms. Widemark indicate, it clearly is.
Ms. Widemark then claims that dieting can raise CVD risk factors. However, she once again gives no reference, so it is hard to determine whether or not she is portraying the supposed studies accurately. In fact, we know of SEVERAL studies that show quite the opposite: that dieting DECREASES the risk of CVD. For example, Fleming followed 100 men and women on four different weight-loss diets over the course of a year: a moderate-fat program without calorie restriction, a low-fat diet, a moderate-fat, calorie-controlled diet; and a high-fat diet. He found that the subjects who lost weight reduced their CVD risk profile significantly, except for the people on the high fat diet.11 Thus, the right kind of diet reduces CVD risk factors.
Another very recent study showed the same result. In this study, Dansinger and others followed 160 fat people for a year, putting them on one of four diets: Atkins, Ornish, Weight Watchers, and Zone. As the authors note, “Each diet significantly reduced the low-density lipoprotein/high-density lipoprotein (HDL) cholesterol ratio by approximately 10% (all P<.05), with no significant effects on blood pressure or glucose at 1 year. Amount of weight loss was associated with self-reported dietary adherence level (r =0.60; P<.001) but not with diet type (r = 0.07; P = .40). For each diet, decreasing levels of total/HDL cholesterol, C- reactive protein, and insulin were significantly associated with weight loss (mean r = 0.36, 0.37, and 0.39, respectively) with no significant difference between diets (P = .48, P = .57, P = .31, respectively).” Thus, as the people lost weight by DIETING, their CVD risk factors DECREASED.12
In addition, another study looked directly at left ventricular mass, which I discuss in my opening statement as being a serious risk factor for CVD. Over the course of four years, the study showed that weight loss reduced CVD risk. As the authors state, “In a multiple linear regression, a 10% weight loss independently predicted a 4.3/3.8 mm Hg decrease in 24-h systolic/diastolic BP...Long-term weight loss determines a sustained BP reduction during the 24 h and a decrease in left ventricular mass in overweight hypertensive subjects.”13 Thus, the studies show the opposite of Ms. Widemark’s claim. Weight loss decreases CVD risk factors.
Finally, Ms. Widemark mentions a 2002 study in the Obesity Research Journal that once again, she does not reference. She does give a website that talks about the study, however, so it was not hard to find the actual study. Not surprisingly, the study does not show what Ms. Widemark wants you to believe it shows. If one reads the actual study, one finds that the authors adjust the relative risk (RR) of all-cause mortality for people based on baseline health status. This tends to take obesity into account already, which skews the final results significantly. As the authors themselves state:
One possible reason we did not see a greater RR for obese women is that we adjusted for baseline health status as well as age and smoking in our model. Because conditions such as hypertension and Type 2 diabetes are to some extent a consequence of obesity, adjusting for baseline health status lessens the effect of obesity on mortality because some of its consequences are removed. In a separate analysis where we adjusted for only age and smoking status, the RR of the obese group (RR = 1.70) was significantly different (p = 0.04) from the normal-weight group.14
Thus, the authors of the study say that if they DON’T bias their results initially, they find that even after fitness, obesity DOES produce a significant risk for all-cause mortality. This, once again, shows that obesity is an independent risk factor. Please note what they also say in the quote listed above: “Because conditions such as hypertension and Type 2 diabetes are to some extent a consequence of obesity…” Once again, then, the authors of this VERY study explicitly state that obesity is a risk factor for hypertension and type 2 diabetes!
Of course, this is not surprising. Remember from my initial statement that Dr. Farrell of the Cooper Institute has already stated that obesity is an INDEPENDENT risk factor for chronic illness. Who is the lead author on this study? Dr. Steven Farrell of the Cooper Institute! Indeed, one of the studies Dr. Farrell uses to determine that obesity is an independent risk factor for chronic illness is this very study! Clearly, then, the study does not show what Ms. Widemark claims it shows. Instead, it shows that she is incorrect in asserting that obesity is not an independent risk factor in chronic illness.
This brings up a very important point. In several cases now, I have shown that the studies and resources Ms. Widemark cites DO NOT show what she claims they show. In fact, she often goes DIRECTLY against the very authors of the studies and resources she cites. To me, this indicates that Ms. Widemark really has not carefully examined the studies and resources she quotes. After all, who best knows what a given study or resource says than the authors themselves? Time and time again, however, Ms. Widemark must contradict the authors of the studies and resources she cites in order to come up with the conclusions she proposes. This is not the hallmark of someone who researches things carefully.
In conclusion, then, Ms. Widemark has given no evidence to support her claim that obesity is not a risk factor for chronic illness. In fact, the studies she cites actually show that obesity is an independent risk factor. In addition, the one expert she mentioned, Dr. Leibel, not only states that obesity is an independent risk factor for myocardial infarction, stroke, type 2 diabetes, and certain cancers, he also says that even a moderate amount of weight loss can improve health. This is not surprising, of course, as Dr. Leibel is an obesity expert. Ms. Widemark should take some time to consult references written by Dr. Leibel so that she can learn the health effects of obesity for herself.
References
1. http://www.cdc.gov/PDF/Frequently_Asked_Questions_About_Calculating_Obesity-Related_Risk.pdf Return to Text
2. Bacon L, Stern JS, Van Loan MD, Keim NL., Size acceptance and intuitive eating improve health for obese, female chronic dieters., J Am Diet Assoc. 105:929-36 (2005). Return to Text
3. Demetra D. Christou, PhD; Christopher L. Gentile, MS; Christopher A. DeSouza, PhD; Douglas R. Seals, PhD; Phillip E. Gates, PhD, Fatness Is a Better Predictor of Cardiovascular Disease Risk Factor Profile Than Aerobic Fitness in Healthy Men , Circulation111:1904-1914 (2005). Return to Text
4. Lee CD, Blair SN, Jackson AS., Cardiorespiratory fitness, body composition, and all-cause and cardiovascular disease mortality in men. American Journal of Clinical Nutrition. 69:373-80 (1999). Return to Text
5. J. M. McGinnis; W. H. Foege, Actual causes of death in the United States, JAMA, 270: 2207 - 2212 (1993). Return to Text
6. J. Michael McGinnis; William H. Foege The Immediate vs the Important JAMA, 291:1263 - 1264 (2004). Return to Text
7. Ali H. Mokdad, PhD; James S. Marks, MD, MPH; Donna F. Stroup, PhD, MSc; Julie L. Gerberding, MD, MPH, Actual Causes of Death in the United States, 2000, JAMA 291: 1238 – 1245 (2004). Return to Text
8. http://videocast.nih.gov/ram/ccgr011404.ram Return to Text
9. Weisberg, S.P., McCann, D., Desai, M., Rosenbaum, M., Leibel, RL, and Ferrante, A. Obesity is associated with macrophage accumulation in adipose tissue. J. Clin. Invest. 112:1796-1803. (2003). Return to Text
10. Nathan DM, Leibel RL., Toward optimal health: the experts discuss advances in diabetes management in women. Interview by Jodi Godfrey., J Womens Health (Larchmt). 13:365-70 (2004). Return to Text
11. Fleming RM., The effect of high-, moderate-, and low-fat diets on weight loss and cardiovascular disease risk factors., Prev Cardiol., 5:110-8 (2002). Return to Text
12. Dansinger ML, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial., JAMA 293:43-53 (2005). Return to Text
13. Schillaci G, Pasqualini L, Vaudo G, Lupattelli G, Pirro M, Gemelli F, De Sio M, Porcellati C, Mannarino E., Effect of body weight changes on 24-hour blood pressure and left ventricular mass in hypertension: a 4-year follow-up., Am J Hypertens. 16:634-9 (2003). Return to Text
14. Farrell SW, Braun L, Barlow CE, Cheng YJ, Blair SN., The relation of body mass index, cardiorespiratory fitness, and all-cause mortality in women., Obes Res. 10:417-23 (2002). Return to Text