How Long Can Healthy Obese People Stay Healthy?
Monday, December 9, 2013
Dr. Sean Wharton, Burlington, Ontario
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.
Monday, December 9, 2013
Perhaps a new definition of “healthy” is in order based on what is happens in the body in terms of inflammation. Quote from page 191 of The Modern Nutritional Diseases: and How to Prevent Them by Fred and Alice Ottoboni:
“BIOCHEMICAL LESSON: The significant point is that good health depends on regulating the D5D enzyme. High insulin levels due to dietary sugar and starch and high dietary omega-6 to omega-3 ratios, stimulate the D5D enzyme, and move the biochemical set point from normal toward inflammation. On the other hand, control of dietary sugar and starch, reduction of LA in the diet, and a daily supplement of fish oil to provide EPA will inhibit the D5D enzyme so that the appropriate amounts of both proinflammatory and anti-inflammatory eicosanoids are produced. Keep in mind that all of the eicosanoids, both the so-called good and bad, are important. The body is designed to use eicosanoids with opposing effects to control vital functions. In a state of optimum health, the good and the bad eicosanoids balance one another.”
There you have it. Inflammation is stimulated by high levels of insulin and/ or omega-6 lenoleic acid (LA). Reduce sugar and LA intake in either slim or healthy people and inflammation ceases to be a problem.
Smokers, especially, would benefit from sugar and LA reduction. On the island of Kitava where about 80 percent of the adult population are daily smokers, there is no heart disease. The major difference between Kitava and much of the rest of the world is that the modern foods of commerce have not arrived. Kitavans produce most of their own food. Excerpts from The Kitava Study:
During an inventory in 1989, we found what appears to be one of the last populations on Earth with dietary habits matching what would have been the case for the population of Homo sapiens in their original habitats on the island of Kitava, one of the Trobriand Islands in Papua New Guinea’s archipelago…We noted a lack of sudden cardiac death and exertion-related retrosternal chest pain among Kitava’s 2,300 inhabitants (6% of which were 60-95 years old), as well as among the remaining 23,000 people on the Trobriand Islands…Despite a fair number of older residents, none of whom showed signs of dementia or poor memory, the only cases of sudden death the residents could recall were accidents such as drowning or falling from a coconut tree. Homicide also occurred, often during conflicts over land or mates. Infections (primarily malaria), accidents, pregnancy complications, and old age were the dominant causes of death, which is in agreement with findings among other similar populations…The main results of the Kitava study, that there is no ischaemic heart disease (and no stroke, see Chapter 4.2), are unanimously confirmed by medical experts with knowledge of the Trobriand Islands or other parts of Melanesia. Likewise, Jüptner noted no cases of angina pectoris, myocardial infarction or sudden death during his 5 years as a provincial doctor on the islands at the beginning of the 1960s, when the population was roughly 12,000. http://www.staffanlindeberg.com/TheKitavaStudy.html
Monday, December 9, 2013
In medicine we often deal with probabilities, and this commentary argues rather succinctly that we simply don’t have enough information and will most likely never get enough information to know the extent or the rate of disease faced by Stage 0 patients in their future. There are simply too few of them to be able to study as a group and publish anything meaningful based on the small numbers. Dr. Sean Wharton then concludes that since there is not enough information about the “healthy obese” that he would continue to treat individual risk factors and advise the “healthy obese” to refrain from gaining more weight. Since being a regular reader of your blog, I would strongly suspect that you would be in agreement with the author. I find this position to be difficult to support. After all, the basic facts seem to argue rather forcefully for a completely opposite conclusion. Here are the facts as I understand them: 1) Obesity is highly correlated with a large number of life threatening diseases, 2) Obesity is progressive in nature for most people, 3) There are very few people with no comorbidities to obesity, as a matter of fact, the number is so small that it is hard to study the population. As the BMI increases, it becomes harder and harder to find people at Stage 0. As we do not really know what will happen to this small cohort of people as they age with obesity and as we are only seeing them at a particular moment in time rather than over a lifetime, it seems prudent to help them fight obesity. rather than just recommending that they stop future weight gain. Since we have ample evidence that even a 5-10% decrease in weight can have significant health implications, shouldn’t we assume that the individual in front of us at this moment is more likely to fall into the larger pool of people that will eventually develop health issues than to hope that this individual will fit into the tiny 3.5% of those that “might” never develop the diseases that are so common to the obese? It seems that a better argument would be to help the individual stabilize their weight while working towards a modest weight loss over time. Telling the healthy obese that they are safe and do not need to worry about the future seems a bit too hopeful in my opinion. Respectfully,
Elina Josephson
Monday, December 9, 2013
The main concern with the Kramer article should be that it does not even adjust its results for obvious confounding factors like age, sex and smoking. They are not taking relative risks from published papers. They are just taking raw numbers of events from the published papers and then calculating their own new, completely unadjusted, relative risks from the raw numbers. The relative risks that they get are quite different from the relative risks in the published articles. These unadjusted results are pretty meaningless. It’s surprising that this even got published.
Their search strategy also seems quite difficult to replicate.
Monday, December 9, 2013
While 3% is small, in Canada that 3% amounts to 1 million people. In the US, 10 million. Surely it is possible to construct a study that would include enough people. It might not be as easy as studying unhealthy obese, but not impossible.
Tuesday, December 10, 2013
I agree with Elina Josepheson.
Tuesday, December 10, 2013
Elina,
I consider myself a healthy obese patient, I weight 400lbs with no metabolic issues. My BP is normal (when taken with properly fitted buff), my cholesterol is below 150, my fasting blood sugar is low normal (the doctor who most recently ran that test was a bit surprised herself, not my reg PCP), no sleep apnea…hmm not sure what else to even mention…my main medical issue is Lipedema and Lymphedema, and those are the very conditions that contribute to my excess weight, thus a BMI that puts me in the Morbidly Obese category. I very much respect and appreciate doctors who treat me the patient FIRST, verses my obesity. When a “health obese” patient does appear in a doctor’s office I believe the first thing that should be done it to find the cause of the excess weight, and address that issue. My experience had been despite being healthy, I was still told to eat less, move more…and when my weight still did not change I was written off as non-compliant. When in fact diet and exercise does little for either condition, whereas a proper diagnosis would then lead to treatment that does help such as manual lymph massage and compression wrapping. So not, not to say do “nothing” about our weight, but at least get us the real medical treatment we need. Both Lipedema and Lymphedema are progressive conditions and it’s very upsetting for patients to just be harped on about weight and not given treatment options that will actually slow the progression and perhaps reverse the swelling causes by the conditions. Read more about my thoughts here: http://born2lbfat.com/treat-the-patient-not-the-obesity/
Tuesday, December 10, 2013
Sarah,
I could not agree with you more that each individual should always be treated as an individual first, and never seen as simply the manifestation of a particular disease. In the best possible world, each doctor will remember to have common sense and logic. This alone can often go a long way toward trouble shooting, (in your case, dealing with the obvious causes of your high BMI), rather than just having a knee jerk response to obesity. Telling any of us to just eat less and move more does not work, in your case (and in all cases) it is simply bad medicine. I have no issue with treating each individual as an individual–in my personal care I simply insist on it. What I take issue with is the idea that just telling the “healthy obese” to maintain their weight as a wait and see strategy. In most cases, the waiting will eventually lead to seeing more weight gain, higher BMI’s, new and more severe health issues. Is this true for everyone? It is clear that we do not yet know. However, since most doctors are seeing patients at a particular moment in time and are not able to predict the future, this is going to be true for the vast majority. This does not and never will or can take the place of a thorough physical with individual attention to the causes of obesity. After all, treating obesity is nuanced and personal at its core. The multiple causes of obesity necessitate a truly individual approach to the disease for all of us.
Wednesday, January 1, 2014
Elina,
For many fat people, just avoiding weight gain is a significant victory. It can be extremely difficult to lose weight and keep it off. So stopping weight gain and maintaining a stable weight for many years can be a major accomplishment. For some people achieving this requires the help of a doctor and a significant change in lifestyle. If they are also able to lose weight (and they wish to do so), then weight loss can be the next step.