Wednesday, August 17, 2011

Will Losing Weight Make You Sick?

One of the intriguing (some would say frustrating) aspects of analysing large datasets is that this often raises more questions than it answers.

This is certainly the case with one of the studies on the Edmonton Obesity Staging System, published in Applied Physiology, Nutrition and Metabolism this week.

The paper looked at data from the Aerobics Center Longitudinal Study, a cohort of over 29,000 participants who attended the Cooper Clinic (Dallas, TX) for periodic self- or physician referred medical examinations between 1987 and 2001.

Of these, 5,453 men and 771 women both the met the BMI criteria for obesity and had enough information available to allow EOSS grading.

As reported before, irrespective of BMI, EOSS stage 0 and 1 participants had no significant impact on their risk of mortality over 16 years, which, however, was higher in EOSS stage 2 and stage 3 participants.

So, if not body weight (or BMI), what exactly were some of the characteristics of individuals with higher EOSS stages?

It turns out that apart from (as one may expect) the fact that individuals with lower EOSS stages reported eating more fruit and vegetables and had higher cardiorespiratory fitness (as an indicator that they were clearly more physically active), they were also less likely to have a history of weight cycling.

Indeed, lower EOSS stages were associated both with less lifetime weight loss as well as fewer (or no) episodes of prior weight loss.

This certainly poses the question, whether dieting or losing weight in fact increases the long-term risk of health problems and one can only wonder if the folks with higher EOSS scores would be better off had they never lost weight before.

Now, obviously, this association (as all associations) does not prove causality. It could well be that people who already have health problems may be more likely to engage in (or remember) previous weight loss attempts.

It may also be that worth noting that people who tend to engage in weight loss are the ones who often have significant body image and body dissatisfaction issues, as well as a generally higher prevalence of psychiatric illnesses than people who do not diet or lose weight. As psychiatric and mental health are part of the EOSS criteria, it may well be that this alone accounts for the association of yo-yo dieting and elevated EOSS stages.

Or, as we discuss in the paper:

…for the vast majority of obese individuals, lifestyle-based weight loss is not maintained over the long term (Wing et al. 1995). This is particularly concerning, given that weight cycling is associated with greater weight gain over time (Van Wye et al. 2007) and potentially worse health outcomes, compared with individuals who may have maintained a stable body weight (Blair et al. 1993; Wannamethee et al. 2002). Although we observed that greater reported weight loss was associated with worse EOSS scores, it is unclear whether individuals with more severe EOSS staging had attempted to lose more weight because of their poor health, or whether they had poorer health because they had weight cycled. Furthermore, it is unclear whether obese individuals without existing comorbidities will develop metabolic abnormalities if they remain at a stable BMI…

These are all intriguing questions for which we currently simply have no definitive answers.

However, it is certainly clear from this study that there are a significant number of people, who meet the BMI criteria of obesity, but do not appear to have any of the health problems that most overweight and obese folks tend to have. It is certainly unclear whether or not these individuals will experience any health benefits from attempting to lower their body weights, given that most people, who lose weight, will simply put it back on.

This is by no means implies that it is now “OK to be fat“, as some media has chosen to report on this study. At best, it means that for some people, it may well be OK to be fat, but these people certainly become rarer at higher ranges of BMI.

Whether those, who do have health problems are better served by interventions primarily focussing on changing health behaviours whilst promoting positive outlooks and size acceptance than by interventions primarily focussed on reducing their weight, will certainly remain a topic of debate for some time to come.

Nevertheless, the results of our study certainly add several shades of grey to the usual black-or-white discussions about the impact of body weight on health and do raise questions about simply recommending weight loss to anyone, who happens to meet the current BMI criteria for obesity.

AMS
Edmonton, Alberta

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9 Responses to “Will Losing Weight Make You Sick?”

  1. AcceptanceWoman says:

    I think it is okay to be fat, first off.
    Really.
    Just like it’s okay to be shorter than average, taller than average, to have a variety of skin tones and hair colors and shoe sizes and neck widths. People just come in a variety of sizes, and just by looking at someone, you can’t tell if they are “naturally fat” have become fat by dieting and regaining additional weight, have disordered eating, have eaten to provide comfort after some truly terrifying life circumstances, or anything else. As your own study seems to point to — the healthiest among us may well be those who have never weight cycled. And those people who haven’t ever weight cycled were probably less susceptible, as you point out, to body dissatisfaction to begin with.

    Some people are more susceptible to ill health than others. Those people (I’m probably one of them, so I might as well say “we”) might need to engage in a different set of health habits than the general population in order to achieve better health. So, for me, because I have type 2 diabetes, I cannot eat an unlimited portion of pizza (as I may have done in my early 20s) without some consequences to my health, in the short term, and if I were to eat this way on a regular basis, long-term consequences to my health. But, another person may be able to eat an unlimited portion of pizza without any awareness of the consequences to their health, and, it may not show up on their body as extra stored fat. Does that make it okay for me, or for the unaware pizza-eater, to eat that much pizza? It’s really not anyone else’s business how much pizza I eat, and if someone thinks that my fatness is due to ongoing excess pizza consumption, they are incorrect.
    So, yes, it is okay to be fat.
    It is okay to not be fat.
    It’s better to be healthy than not — I think that we’re finding more and more evidence that the best way to attain and maintain health is to apply a holistic model, and not brand any aspects of ourselves as “not okay” as long as they aren’t harming anyone else (and even if they could harm someone else, branding ourselves, rather than a behavior, as “not okay” isn’t likely to do much good).

    What’s probably not so good is ignoring your health, no matter what size you are. So, if knees hurt, or there’s difficulty breathing, or exercise is harder than you think it ought to be, or any other symptoms that could potentially be addressed, it’s a good idea to check those out. No matter what a person’s size is.

  2. Dr. J says:

    I wonder how age plays a role in this. For example, a younger person may well be fat and healthy by the EOSS scale so no problem, but, because of their obesity and associated lifestyle habits, as they age they acquire diseases that if they had lost weight when younger, would not have acquired.

  3. DeeLeigh says:

    Dr. J – do you really think that’s true, though? Everyone acquires diseases as they age. I haven’t noticed a lack of disease or death in thin folks.

  4. HopefulandFree says:

    I tend to believe “It’s okay to be fat.” In other words, fatness does not reflect (in any way) one’s value or one’s humanity. Unfortunately, fatness may determine one’s employability (or risk for joblessness and/or lower income), which in turn may severely limit one’s ability to access many other things (factors) related to health status: health care (including preventive and dental care), nutritious foods, secure housing, reliable transportation, safe environment to exercise, psychological support, social security and acceptance, opportunities to recreate and rest, etc. Over time, as humans get older, these factors (socially constructed), although separate from one’s physiological condition of fatness, may have a cumulative negative impact on health status. It would be interesting to see the research reports on fatness when these social factors (and others) are controlled for.

  5. Affectionforfitness says:

    Hi Dr. Sharma! Very interesting posts you have lately!

    Well, I think people are confusing the word “obese” with the stuff called “fat.” “Obese” is BMI terminology which refers to height and weight. It doesn’t categorize the more muscle-y people from the extremely flabby people of the very same height and weight. A person can be categorized as “obese” and be extremely fit. When I started doing heavy weightlifting, I gained a few pounds but lost many inches and 2 dress sizes. Did I get more “obese,” according to the BMI? Yes. Did I get more fat? No, I got *much* less fat.

    :-) Marion

  6. Anonymous says:

    How does the EOSS measure “limitations”?

    If you just ask people if they are limited in activities, someone may say “no” because they can manage daily living even though they can’t walk 1 k; someone else may say “yes” because they can only run a half-marathon while their friends can run a full marathon.

    Especially in cases where weight has crept on slowly over several years, a person may be adapting to their lessening ability without even realizing it. They gradually do less and less and not realize how limited they are, especially if their friends are equally inactive.

    ‘Limitations”, therefore would have to be measured, for example by treadmill tests. A test would give an accurate picture of ability.

  7. DeeLeigh says:

    That’s an interesting point, Anonymous. I’m torn between agreeing with you and thinking that it’s perfectly fine to have “limitations” defined differently for different people, based on their preferences and the demands that their lives place on them.

    For example, when I got my hip replacement, I wasn’t using a cane or regularly taking any pain killers, and could still walk to two blocks to the street car, stand up in it, and take it to work. I lived in a house with stairs and didn’t have any problems with them. I felt limited because I couldn’t do a dance class or walk the mile to work, and those are were two things that I wanted to be able to do. Also, I like to spend all day walking when I’m traveling, experiencing new places by exploring them on foot. Right before the hip replacement, I couldn’t walk for more than 5 minutes without my hip giving out. For me, that was completely unacceptable. However, I was still more active than some even in that condition.

    On the other hand, I have flat feet and have never been good at or enjoyed long distance running. At my fittest, I could run a mile (very slowly). But that doesn’t bother me. I wouldn’t want to run a marathon even if I was able to. I’m happy being able to walk long distances, run short distances, and having good endurance to hike in hilly areas and keep up a mildly strenuous activity for an hour or two. Oh, and I like to be able to walk up the 50 steps to my apartment without getting winded. For me right now, that’s fit enough.

  8. em says:

    I find the following quote from the Will losing weight make you sick? post disturbing.

    “It may also be that worth noting that people who tend to engage in weight loss are the ones who often have significant body image and body dissatisfaction issues, as well as a generally higher prevalence of psychiatric illnesses than people who do not diet or lose weight. As psychiatric and mental health are part of the EOSS criteria, it may well be that this alone accounts for the association of yo-yo dieting and elevated EOSS stages.”

    I am a 63 year old female on the edge of the overweight/obese category, with no other health issues. I am active and eat the way that I have been counselled to do. As a slim 16 year old, I was handed some mimeographed sheets by my doctor that contained a very early version of the Atkin’s diet with the comment that he didn’t know why it worked, but it did. Since that appointment until I met my present doctor, 4 years ago, I haven’t seen any health care professional that has not commented on my weight. These comments have ranged from a casual “lose some weight before you come back” to the humiliating “that’s not muscle” from a doctor who poked me all over while repeating it.

    I really don’t think significant body image and body dissatisfaction issues need to be blamed on psychiatric and mental health!

  9. Steve Parker, M.D. says:

    Weight cycling (yo-yo dieting) had no effect on death rates of women in the Nurses’ Health Study, although they did gain more weight over the years compared to the non-cyclers.

    -Steve

    Reference: Field, Alison, et al. Weight cycling and mortality among middle-aged or older women. Archives of Internal Medicine, 169 (2009): 881-886.

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