IJE Advance Access originally published online on December 23, 2005
International Journal of Epidemiology 2006 35(1):81-82; doi:10.1093/ije/dyi299
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Response |
Response: lifestyle not weight should be the primary target
1 School of Law, University of Colorado, CO, USA
2 Department of Sociology, University of California, Los Angeles, CA, USA
3 Department of Nutrition, Case Western Reserve University School of Medicine, Cleveland, OH, USA
4 Department of Political Science, University of Chicago, Chicago, IL, USA
5 Curry School of Education, University of Virginia, VA, USA
* Corresponding author. E-mail: Paul.Campos{at}colorado.edu
We are glad to see such a wide range of esteemed scholars engage complex questions surrounding the relationship between body mass and health. We are also pleased to see so many points of agreement between our respondents and ourselves. First, everyone is in agreement with the parameters of global weight change, as defined in detail by Flegal1—the average person has gained about one pound per year. Opinions vary sharply over the likely consequences of this creeping ‘epidemic’.
Second, as many acknowledge, the debate surrounding weight and health is often contentious and confusing because of economic and cultural factors that affect it at every turn. For instance, Kim and Popkin2 applaud our efforts in drawing attention to ‘some of the complexities in overweight/obesity and health relationships and [the] covert financial interests involved in obesity research and related promotion activities’. Similarly, Lobstein3 recognizes the need to acknowledge the current diversity of opinion on this subject. The powerful cultural and ideological factors that drive the current world wide obsession with thinness and fatness are eloquently discussed by Orbach.4 Her response illustrates the painful consequences—especially for women and girls—of modern tendencies to demonize certain foods and larger bodies.
In regard to the relationship between weight and health, we note Flegal1 agrees that ‘to date it is not clear what the major health effects of the trends in obesity and overweight have been’, given continually improving life expectancy and declining rates of many conditions such as heart disease. Similarly, Blair and LaMonte5 caution against the ‘uncritical acceptance of many of any claim about the health hazards of obesity’, and point out that ‘much of the extant prospective data indicate that there is little difference in risk across a very wide range of BMI values, and these associations may be different for various subgroups’. Even Rigby6 acknowledges this general point when he argues that optimal BMI may be lower for Asians, although he fails to note that much evidence suggests optimal BMI for people of West African descent is higher than for other groups or that it is difficult to find any difference in risk estimates for all-cause mortality among many subgroups across an extremely wide range of BMI values, i.e. 18.5–35. Given the disproportionate attention being focused on obesity among racial minorities, this represents an interesting selective citation of data.
We also agree that, as Kim and Popkin2 note, there are important risks associated with weight loss methods and products, and it troubles us that obesity researchers often ignore or understate these risks. We strongly support programmes that promote health, but such programmes should actually improve health, not merely attempt to make or keep people thin. This is the core of the debate about weight and health, and our view is captured by Blair and LaMonte's5 statement that ‘there has been an overemphasis on weight loss as a clinical target’.
Consider, for example, the interpretation Kim and Popkin,2 and Rigby6 give to studies indicating that increased physical activity and improved diet greatly decrease the risk of developing Type 2 diabetes. These researchers credit the modest weight loss associated with these lifestyle changes (one or two unit reduction in BMI values) for the improved health of the subjects in these studies. A more plausible alternative discussed by Blair and LaMonte,5 is that these lifestyle changes directly and independently prevented Type 2 diabetes. The belief that weight loss alone (rather than lifestyle changes) has positive health effects persists, despite a complete lack of controlled clinical trials demonstrating the health benefits of losing weight and maintaining the loss for 5 years or more. This crucial gap in the evidence may surprise scholars unfamiliar with the facts of the obesity debate.
We thank Kim and Popkin2 for the model presented in their figure 1, which outlines the key parameters in the debate. This model allows our view to be expressed by a straightforward equation:
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Consequently, we maintain that focusing on weight loss as a public health goal will be ineffective and possibly counter-productive, given that there is no safe and effective method to produce significant long-term weight loss in the vast majority of individuals, and that various lifestyle changes produce beneficial effects independent of whether they produce any weight loss. We are particularly concerned with the common and dangerous rationalization offered by Stevens et al.7 that ‘even if positive energy imbalance rather than excess adiposity is the direct cause of some morbidity, the solution will be the same: increased physical activity and reduced energy in the diet’. Such statements ignore that becoming more active and adopting a healthy diet does not result in significant weight loss for most people; that there are many so-called overweight and obese people who already have healthy lifestyles and do not need ‘treatment’ while conversely many lean persons have unhealthy lifestyles in need of improvement; and, most important, that many people pursue weight loss through harmful methods such as smoking, purging, chronic weight cycling, fad diets, diet drug use, and weight loss surgery. Given the demonstrable adverse health toll that such weight loss practices inflict every year, we do not believe it is merely a matter of semantics whether the public health establishment chooses to focus on lifestyle or weight loss.
Too many obesity researchers seem to think that the point of a healthy lifestyle is that it will make people thin, or keep them from getting fat. We believe the epidemiological literature fails to support their view. We advocate healthier lifestyles for the sake of health. The road to good health is wide enough for everyone.
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1 Flegal K. Commentary: The epidemic of obesity—what's in a name? Int J Epidemiol 2006;35:72–74.
2 Kim S, Popkin BM. Commentary: Understanding the epidemiology of overweight and obesity—a real global public health concern. Int J Epidemiol 2006;35:60–67.
3 Lobstein T. Commentary: Obesity—public health crisis, moral panic or a human rights issue? Int J Epidemiol 2006;35:74–76.
4 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.
5 Blair SN, LaMonte MJ. Commentary: Current perspectives on obesity and health: black and white, or shades of grey? Int J Epidemiol 2006;35:69–72.
6 Rigby N. Commentary: Counterpoint to Campos et al. Int J Epidemiol 2006;35:79–80.
7 Stevens J, McCain JE, Truesdale KP. Commentary: Obesity claims and controversies. Int J Epidemiol 2006;35:77–78.
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