Monday, December 9, 2013
Following last week’s flurry of articles and posts on the issue of “healthy obesity”, here is a commentary by my friend and colleague Sean Wharton, who holds a doctorate in both Pharmacy and Medicine and is the medical director of the Wharton Medical Clinic, a community based internal medicine weight management clinic.
The Annal of Internal Medicine article by Kramer et al. appears to contradict the Edmonton Obesity Staging System (EOSS) and a number of other recent articles by stating that healthy obesity is a myth. It is certainly attracting a lot of media attention. However, there are a number of concerns with this article, particularly as it does not really study healthy obese individuals.
Despite these flaws it does adds to our knowledge in this mirky field, but the conclusions may be reaching a bit.
As stated, the paper does not actually study healthy obesity, as many of the participants had more than 1 comorbid illness or had preclinical metabolic conditions.
In this paper, 24% of participants were defined as having healthy obesity (taken from the raw numbers).
In contrast, in a previous article that we published (in OBESITY), we found only 3.6% of obese individuals presenting in our clinic to truly have “healthy obesity”, i.e. no preclinical markers.
This clearly suggests that the authors of the Annals paper were rather liberal with their definition of “healthy obesity”, probably in order to get the numbers to perform meaningful statistics.
In fact, even in our article we did not actually study the 3.6% of patients with healthy obesity. Similar to the Annals paper, our definition of healthy (normal) was not healthy – we also included patients with preclinical disease as healthy. We also did this to get the numbers for statistics.
Had we gone with a definition of ”no preclinical markers” as healthy we would not have had the numbers, as these patients are so rare. This is why, we found the same result as Kramer et al., namely that the metabolically normal (healthy) obese patients were at increased risk of disease. But again, our definition was also too liberal.
So, the bottom line is that no one has studied truly “healthy obese patients”.
I believe that this 3.6% of our patient with true EOSS Stage 0, likely can stay healthy over 10 years, but who knows?
Anyone up for doing the study will need lots of participants.
It is worth noting that even with the liberal definition of “healthy”, the statistics in the Kramer et al. paper barely reach statistical significance (the CI are large and almost cross 1.0), the clinical significance of which is questionable.
If it is that hard to get to statistical significance with a large meta-analysis, it will be near to impossible to get the data for the 3.6% of obese patients with no preclinical markers.
Thus, the answer to whether or not healthy obese patients can stay healthy remains to answered.
For now, I am going to continue treating patients based on their individual risk, and if someone is obese with no clinical markers, I am going to advise them not to gain any further weight, live healthy, but not necessarily decrease their weight.
Dr. Sean Wharton, MD, PharmD.