Obesity: size really doesn’t matter
by Paul Campos

IN January 2003, as America prepared to go to war with Iraq, the US Surgeon -General, Richard Carmona, warned the nation that it faced a far more dangerous threat than Saddam Hussein’s supposed weapons of mass destruction. Rather than focusing on the danger posed by nuclear, biological and chemical weapons, Carmona told his audience, "Let’s look at a threat that is very real, and already here: obesity."

According to the latest BMI (the BMI is a simple mathematical formula that puts people of different heights and weights on a single integrated scale) figures, 64.5 per cent of American adults are either "overweight" (meaning they have a BMI of between 25 and 29.9) or "obese" (defined as a BMI of 30 or higher). Studies have found an association between even mild amounts of "overweight" and a significantly increased risk of premature death.

The proportion of the population that maintains a dangerously high weight continues to climb: obesity in America has increased by more than 50 per cent over the course of the past decade. If the authors of these studies are correct, America is facing a health crisis that, in the words of one anti-fat warrior, will make AIDS look "like a bad case of the flu".

This, then, is the case against fat: America, we are told, is on the verge of eating itself to death. The core belief of those prosecuting this case is that the BMI tables testify to a strong, predictable relationship between increasing weight and increasing mortality. That, after all, is what most people assume when they read that medical and public health authorities have determined a BMI of 25 or above is hazardous to a person’s health. This belief, however, is not supported by the available evidence.

A 1996 project undertaken by scientists at the National Centre for Health Statistics and Cornell University analysed the data from dozens of previous studies, involving a total of more than 600,000 subjects with up to a 30-year follow-up. Among non-smoking white men, the lowest mortality rate was found among those with a BMI between 23 and 29, which means that a large majority of the men who lived longest were "overweight" according to government guidelines. The mortality rate for white men in the supposedly ideal range of 19 to 21 was the same as that for those in the 29 to 31 range (most of whom would be defined now as "obese"). In regard to non-smoking white women, the study’s conclusions were even more striking: the BMI range correlating with the lowest mortality rate was extremely broad, from around 18 to 32, meaning a woman of average height could weigh anywhere within an 80-pound range without seeing any statistically significant change in her risk of premature death.

In almost all large-scale epidemiological studies, little or no correlation between weight and health can be found for a large majority of the population — and indeed what correlation does exist suggests that it is more dangerous to be just a few pounds "underweight" than dozens of pounds "overweight". So, let us look at the most cited studies for the proposition that "overweight" is a deadly epidemic in America today. Anyone who bothers to examine the evidence in the case against fat with a critical eye will be struck by the radical disconnect between the data in these studies and the conclusions their authors reach.

"Overweight, Obesity And Mortality From Cancer", published in the New England Journal of Medicine in April 2003, was the subject of front-page stories in many of the nation’s leading newspapers. For example, a Los Angeles Times article reported that the study provided "the first definitive account of the relationship between obesity and cancer". The article went on to quote the study’s authors to the effect that perhaps as many as 90,000 deaths a year from cancer could be avoided if all adults maintained a BMI below 25 throughout their lives. The disjunction between this study’s actual data and the alarmist headlines its authors helped generate is especially remarkable.

Among supposedly "ideal weight" individuals (BMI 18.5 to 24.9), the study observed a mortality rate from cancer of 4.5 deaths for every 1,000 subjects. Among "overweight" individuals (BMI 25 to 29.9 - a category that currently includes about twice as many adult Americans as the "ideal weight" cohort), the cancer mortality rate was 4.4 deaths for every 1,000 subjects. In other words, "overweight" people actually had a lower overall cancer mortality rate than "ideal weight" individuals.

Most Americans, and indeed most doctors, simply assume that the heavier you are, the more likely it is you will suffer from coronary artery disease — hence the various clich`E9s about "artery-clogging" fast food and the like. Yet several studies have specifically investigated the question of whether a high percentage of body fat correlates with the incidence of coronary artery disease. Answer: no, it does not. Even massively obese men and women do not appear to be more prone to vascular disease than average.

It is true that increasing weight is associated with high blood pressure and certain types of heart disease. But even here there is considerable evidence that this correlation is not necessarily a product of being fat, but rather of losing and then regaining weight. Obese patients who have been put on very low-calorie diets subsequently display much higher rates of congestive heart failure than equally fat people who did not attempt to lose weight in the first place. The biggest evidentiary problem for those who insist there is a strong causal link between increasing weight and heart disease is that deaths from heart disease have been plunging at precisely the same time that obesity rates have been skyrocketing.

Indictments in the case against fat invariably focus on diabetes, because Type 2 diabetes is much more common among heavier-than-average people. It has become routine to claim that America is about to be overwhelmed by a diabetes epidemic, that for the first time Type 2 diabetes is being seen among children, etc, and that the solution to this crisis is to make fat people thin.

Actually, the definition of diabetes has changed (from a fasting blood sugar of 140 to a blood sugar of 126) and many more people have been diagnosed as suffering from the disease. Several recent studies indicate that the key to avoiding Type 2 diabetes is not to try to lose weight (indeed, there is much evidence that dieters are far more prone to the disease than average), but rather to make lifestyle changes in regard to activity levels and dietary content that greatly reduce the risk of contracting the disease, whether or not such changes lead to any weight loss.

If we were to employ the logic of the anti-fat warriors, does this mean that we should be encouraged to gain weight so as to protect ourselves from, among other things, cancer, osteoporosis and most of the major pulmonary diseases?

There are some groups of heavier individuals — usually those with BMI figures in the mid-30s and above — who do suffer from worse health than those of "ideal-weight". Yet this does not of itself prove that such people’s problems are caused by their excess weight. There are many other factors that disproportionately affect the heaviest people in our society, and that also correlate with poor health: most notably a sedentary lifestyle, poor diet, dieting-induced weight fluctuation, diet drug use, poverty, access to and discrimination in health care, and social discrimination generally. None of these factors was taken into account in Annual Deaths Attributable To Obesity In The United States, the Jama study responsible for the "fact" that fat kills 300,000 Americans a year.

This is an edited extract from "The Obesity Myth: Why America’s Obsession With Weight Is Hazardous To Your Health", to be published next month in the US by Gotham Books. — The Guardian

Blood test at birth can help detect fatal disorders

WASHINGTON: A simple and inexpensive blood test performed at birth can dramatically increase chances of survival of babies born with potentially fatal disorders such as severe combined immunodeficiency disease (SCID).

Duke University Medical Center physicians have performed stem cell transplants in 136 infants with SCID in the past 22 years.

The survival rate for 38 infants receiving transplants in the first 3.5 months of life is 97 per cent, but the rate drops to 69 per cent for infants who were transplanted after that age, Rebecca Buckley, reports in the April 23 Annual Review of Immunology.

The main cause for the drop in survival rate is serious infections SCID babies develop in the first few months of life.

Infants with SCID have little or no immune system. Without treatment, they die of infection before their first or second birthdays.

But for infants without a known family history of SCID, the average age of referral for immune testing is approximately six months, Buckley said. "The tragedy is that most patients are critically ill by then", she noted.

Buckley believes that all newborns should be screened for immune deficiency disorders at birth. "SCID is a paediatric emergency. There is no screening for any primary immunodeficiency disease at birth or during childhood and adulthood in any country. —ANI

Patient care: Why dissatisfaction?
by Dr J.D. Wig

AS clinicians, our desire is to do what is best for our patients and to provide support during their illness. However, it has become difficult to provide a compassionate care to our patients and their relations. Sometimes the clinicians meet the family for the first time under difficult emotional circumstances.

Before the phenomenal progress in modern medicine, advances in diagnostics and high-tech intensive care unit, seriously ill patients died at home, surrounded by their loved ones, who clearly knew best how to comfort family members in their period of crisis. This situation allowed family members to feel as if they were doing everything or providing the best care possible at home which included touching a loved one or perhaps providing a small amount of food.

The scene has changed now. The simple gestures offered at home have been replaced by the provision of respiratory assistance in the hospital, nutrition by the intravenous route and several other life-saving interventions. The relatives no longer have an active role in the care, thereby exacerbating the sense of helplessness and frustration. The families and friends often request unrealistic therapies.

The worthy goal in the ongoing challenge is to provide optimal care to our patients. The importance of developing and maintaining high-level listening skills need to be emphasised and so is the improved communication with the patient and family members. Patients and their families are suddenly thrust into an atmosphere rife with the emotion of loss and responsibility. They are probably unwilling to accept treatment failure as an outcome. A meaningful presentation of the patient’s condition, potential treatment options, and the implications that each choice may have on the future clinical outcome is extremely important.

The discussion needs to include talks about the quality of life as well. Physicians in this way will provide the most compassionate care. It is also valuable in setting realistic expectations for patients and families, and overall increased satisfaction with the care provided. Compassionate understanding at such a time of crisis needs to be recognised in defining new standards of excellence and compassion in the care we provide.

Poor or inconsistent communication between doctors and patients and inadequate pain control have been identified as the major problem areas during the care in the hospital. Patient-specific prognostic reports needs to be delivered/communicated to the patient and the family members. Effective communication is essential to perceiving and facilitating patient and family readiness for healthcare decision-making. It is important that patients and families understood the clinical situation, and felt heard, and understood.

Most families rate, the clinician’s communication skills, along with continuity and accessibility, as more important. Improving communication will improve family satisfaction as well as the quality of care. It is important to communicate uncertainty regarding the patient’s diagnosis, prognosis, or treatment options. In difficult situations clinicians should understand that families may not react in the way the clinician expects. It is important to acknowledge strong emotions that come up in a way that allows the person with the emotion talk about why he or she feels that way. Allow a family member to talk about his/her anger.

Building alliances with family members is an effective strategy for delivering a bad news. It is usually best to present a balanced picture of both positive and negative scenarios or by saying that it is a bit too soon to tell, and that I will consult you all along the way hoping for the best, I will do everything in my power to see that the patient remains comfortable.

Good communication is not just language skills. It is a matter of psychological insight and self-awareness on the part of clinicians. Managing a sick person is entirely different from diagnosing an illness and prescribing therapy for it. Listen thoughtfully. Desire for information is high. A patient has the right to enquire about his or her own treatment decisions. A discussion about the risk involved is highly important. Satisfaction is the key to reducing misunderstandings. Satisfaction is based on meeting patient desires and needs. This is relevant to all aspects of the doctor-patient-family interaction in modern times. Perceptive use of eyes, ears, hands and the heart will go a long way in countering dissatisfaction.

The writer is Professor and Head ,Department of General Surgery, PGI, Chandigarh