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Editor's Choice |
Obesity, fat, and public health
This issue is devoted largely to obesity. We are indebted to associate editors Debbie Lawlor and Nish Chaturvedi who have been responsible for its conception, commissioning material, reviewing the very large number of submitted manuscripts, and finally putting the issue together. The relationship between obesity and health has been subject of scientific debate for decades. Lester Breslow's paper, written in 1952 and reprinted here, demonstrates a strong relationship between obesity and all-cause mortality, with particularly strong associations with diabetes and vascular causes of death.1 Insurance companies provided the data for investigations in this era, and it is interesting that such sources have been forgotten, but were the forerunners of the modern cohort studies. The strongest evidence that reducing weight brings health benefit is provided by insured people who were charged excess premiums because of being overweight but obtained lower ratings following weight loss—their mortality risk fell dramatically. Breslow also comments, presciently, on the increased vascular and diabetes death rates of those of ‘normal’ weight—a topic examined in Chen's paper from China where the distribution of body weight is markedly lower than in Western countries.2
At a fence-straddling BMI of 25 kg/m2, and unable to increase my height, should I be worried? Campos et al.'s3 position on the ‘public health crisis or moral panic’ question is firmly on the side of ‘panic’. They estimate that the average American's weight gain over a generation is trivial and is the equivalent, quotably, of eating a Big Mac once every 2 months! This clearly does not square with other evidence demonstrating 25% increases in average calorie intake over 30 years and the equally quotable statistic that American airlines now consider an average passenger weighs in at 90 kg.4 Kim and Popkin,5 in their commentary, provide a robust rebuttal of each of the planks of Campos' argument, concluding that the selective use of evidence and lack of epidemiological insight underlie their mistaken position. Kim and Popkin are clear that there is a public health concern that merits attention.
Despite the wealth of evidence linking body mass index to premature mortality, diabetes, and vascular disease it is increasingly suggested that body mass index is a poor measure of adiposity and that we should move to better measures of fat mass and indicators of a central distribution of adiposity. Flint and Rimm6 suggest that body mass index may be a particularly poor indicator of health damaging adiposity amongst the young and old.
But what should be done about obesity? Several of our commentators highlight the lack of action over the last 50 years and the failure of public health to engage with obesity.7–11 But epidemiologists need to be better at public health policy if their work is to be translated into action. Lobstein12 draws attention to the unheard stakeholders who are often the objects of this public health policy debate—the poor, the black, the working mother—all of whom are considered blameworthy by some authority, but who have little ability to contribute to what he considers is a debate about human rights. Orbach, asks us to take a view of the other side of the obesity coin—does the focus on fat adversely affect the eating behaviours of girls and women? She suggests that public health may find itself part of the problem rather than the solution if it fails to acknowledge and repress the subtle pressures of the style industries that encourage ‘body hatred’.13
If you find that the surfeit of words too indigestible take a look at Felicia Webb's remarkable photographs ‘Obesity amidst poverty’.14 Felicia Webb is a freelance photographer who has documented the growing tides of obesity and anorexia, recently winning a prestigious award for a photoessay ‘Fat Times in the USA’.
Finally, this issue contains cohort profiles of two of Britain's major birth cohort studies—the 1946 and 1958 birth cohorts—and a contemporary pregnancy cohort—the Southampton Women's Survey.15–17 As the earlier birth cohorts move into later adult life, they are providing a massive resource for examining the life-course determinants of adult chronic diseases. The newer cohort, recruiting women in pregnancy, adds an extra dimension of intra-uterine development to our understanding of aetiology. As the investigators acknowledge, access to publicly funded research databases by other collaborators is desirable to ensure productivity commensurate with the investments, but achieving this is more difficult and is reliant on resources that are not yet forthcoming from research funders.
References
1 Breslow L. Public health aspects of weight control. Am J Public Health 1952;42:1116–20. Reprinted Int J Epidemiol 2006;35:10–12.
2 Chen Z, Yang G, Zhou M et al. Body mass index and mortality from ischaemic heart disease in a lean population: 10 year prospective study of 220 000 adult men. Int J Epidemiol 2006;35:141–50.
3 Campos P, Saguy A, Ernsberger P, Oliver E, Gaesser G. The epidemiology of overweight and obesity: public health crisis or moral panic? Int J Epidemiol 2006;35:55–60.
4 Rigby N. Commentary: Counterpoint to Campos et al. Int J Epidemiol 2006;35:79–82.
5 Kim S, Popkin BM. Commentary: Understanding the epidemiology of overweight and obesity—a real public health concern. Int J Epidemiol 2006;35:60–67.
6 Flint AJ, Rimm EB. Commentary: Obesity and cardiovascular disease risk among the young and old: is BMI the wrong benchmark? Int J Epidemiol 2006;35:187–89.
7 Simmons RK, Wareham NJ. Commentary: Obesity is not a newly recognized public health problem—a commentary of Breslow's 1952 paper on ‘public health aspects of weight control’. Int J Epidemiol 2006;35:14–16.
8 Stevens J, McClain JE, Truesdale KP. Commentary: Obesity claims and controversies. Int J Epidemiol 2006;35:77–78.
9 Bain C. Commentary: What's past is prologue. Int J Epidemiol 2006;35:16–17.
10 Uauy R, Lock K. Commentary: The importance of addressing the rise of overweight and obesity—progress or lack of action during the last 50 years? Int J Epidemiol 2006;35:18–20.
11 Olshansky SJ, Commentary: Prescient visions of public health from Cornaro to Breslow. Int J Epidemiol 2006;35:22–23.
12 Lobstein T. Commentary: Obesity—public health crisis, moral panic or a human rights issue? Int J Epidemiol 2006;35:74–76.
13 Orbach S. Commentary: There is a public health crisis—it's not fat on the body but fat in the mind and the fat of profits. Int J Epidemiol 2006;35:67–69.
14 Prentice A, Webb F. Photoessay. Obesity amidst poverty. Int J Epidemiol 2006;35:24–30.
15 Wadsworth M, Kuh D, Richards M, Hardy R. Cohort Profile: The 1946 National Birth cohort (MRC National Survey of Health and Development) Int J Epidemiol 2006;35:49–54.
16 Power C, Elliott J. Cohort Profile: 1958 British birth cohort (National Child Development Study). Int J Epidemiol 2006;35:34–41.
17 Inskip HM, Godfrey KM, Robinson SM et al. Cohort profile: The Southampton women's survey. Int J Epidemiol 2006;35:42–48.
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