Arguments Against Obesity As A Disease #1: BMI Is Not A Good Measure Of Health
Over the past months, I have been involved in countless discussions and debates about whether or not obesity should be considered a chronic disease (as it has by the American and Canadian Medical Associations and a number of other organisations). I therefore thought it perhaps helpful if I discussed each of the common pros and cons on this issue in a series of blog posts. To begin this short series, I’d like to discuss perhaps the most common argument against calling obesity a disease, namely, the well-known shortcomings of BMI. As regular readers will know, I have long railed against the use of BMI as a clinical definition of obesity as it is neither a direct measure of body fatness nor does it directly measure health. In fact, its specificity and sensitivity to pick up health problems commonly associated with obesity (such as type 2 diabetes or hypertension) is so limited, that it would not even remotely meet the criteria commonly applied to other diseases for diagnostic testing. Thus, especially around the BMI cut off of 30 (widely used to “define” obesity in Caucasians), anywhere from 5-25% of individuals would be considered pretty healthy by almost any clinical measure. Even at higher BMI cut offs, it is not all that difficult to find individuals with very mild to non-existent health problems related to their size (as in EOSS 0-1). While some of these individuals may well go on to develop health problems over time, “risk for” a disease is generally not considered a “diagnosis” of that disease. Thus, even if an elevated BMI may indicate increased risk of obesity, it cannot be used to “define” an individual as having the “disease of obesity”. This shortcoming of BMI has been widely (albeit perhaps not widely enough) recognised, which is exactly why, for e.g. the Canadian Medical Association, in their declaration of obesity specifically states that, “BMI is a useful operational definition for obesity but should not be used as the defining characteristic of the disease….in the case of individuals who are very obese, issues of definition and measurement are not relevant.” (emphasis mine) Similarly the WHO in its definition of obesity states that, “BMI provides the most useful population-level measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness… Read More »
Guest Post: ICD-10 Code Coming For Sarcopenic Obesity
Today’s guest post comes for Carla Prado, PhD, Assistant Professor and CAIP Chair in Nutrition, Food and Health, University of Alberta, Edmonton, Canada Although obesity is often conceived as excess fat mass, we now know that individuals with obesity may have normal, high or low muscle mass. Low muscle mass (sarcopenia) is a debilitating condition associated with poor physical function, morbidity and mortality. The simultaneous appearance of obesity and sarcopenia (sarcopenic obesity) is an emerging area of interest as its prevalence is at rise. Importantly, sarcopenic obesity is the worst‐case scenario as both excess fat and low muscle mass have its own (and perhaps synergistic) metabolic and health‐related consequences. As a “hidden condition”, sarcopenia in individuals with obesity is undetectable by use of body weight or body mass index. The need for sophisticated measurements of body composition has limited our ability to fully understand this condition, as well as to establish preventive and treatment strategies, limiting the translation between research and clinical practice. This is about to change. As of October 1st, 2016, sarcopenia will have its own diagnostic code (ICD‐10 code). The World Health Organization International Statistical Classification of Diseases and Related Health Problems (ICD) is a standard tool used to report diagnosis and in‐patient procedures. Hopefully, this will mean that the official record and identification of sarcopenia in medical records will improve our understanding of the epidemiology, health management and treatment of this condition. According to the Aging In Motion Coalition, the establishment of an ICD‐10 Code represents a major recognition of the importance of sarcopenia, removing barriers to treatment and research on several fronts. Such barriers include awareness and attention, clear indications for treatment, and reimbursement. We expect Canada will champion the study of sarcopenia and sarcopenic obesity with special calls for funding, advocacy and public awareness. Carla Prado Edmonton, AB
Senate Report: Bold Policies To Reduce the Number of Demented Canadians
According to a report just released by the Canadian Senate, “In the past three to four decades there has been a drastic increase in the proportion of demented Canadians. Statistics Canada data reveals that almost two thirds of Canadian adults are now demented. Sadly, the increase in dementia rates among children is also dangerously high. About 13% of children between the ages of five and 17 are demented while another 20% are somewhat dull. These numbers reflect at least a two-fold increase in the proportion of demented adults and three-fold increase in the proportion of demented children since 1980.” Just replace the word “demented”with the word “obese” in the above paragraph and you will instantly see what is wrong with this report, which happens to in fact be about obesity, and not about Canadians at risk of or living with dementia. Only when speaking about “obesity crisis”, would an official report composed by professional writers on an important medical condition still use the name of the condition as an adjective. Indeed, the use of “people-first language” to describe someone living with a condition rather than being defined by that condition has long been accepted in the case of virtually every other condition. Thus, we speak of people living with addictions rather than of addicts, of people living with diabetes rather than of diabetics, of people living with psychosis rather than of psychotics, of people with arthritis rather than of arthritics, of people living with cancer rather than of the cancerous, you get my drift. Enough has been written on this issue here, here, here, here, here and here. A report that wants to be taken seriously as addressing the concerns and struggles of Canadian adults and children living with overweight or obesity could perhaps begin by ensuring that it uses the proper language. This is not to say that the report does not indeed make bold and important policy recommendations – it does, from taxing sugar-sweetened beverages to limiting advertising to children, to rewriting Canada’a Food Guide to food labeling to tax benefits to promote physical activity (and more). It even addresses (although in passing) the need to provide better treatments to people living with overweight or obesity. Just which of these policy recommendations will actually find their way into legislation and how much difference they’ll actually make remains to be seen especially as the recommendations come with no actual funding… Read More »
Health Benefits Of Intentional Long-Term Weight Loss?
Despite the difficulties inherent in achieving AND maintaining long-term weight loss, the health benefits for those who manage to do so are widely believed to be substantial. While the health benefits associated with intentional weight loss for some complications of obesity (such as elevated lipids and diabetes) are well documented, high-quality studies to back many other potential health benefits are harder to find. Just how well (or poorly) the putative health benefits of long-term intentional weight loss are documented for each of the many conditions associated with obesity, is now detailed in a comprehensive review of the literature that we just published in the Annual Reviews of Nutrition. The 40 page long review, which includes almost 250 relevant publications, supports the following main findings: Defining and assessing clinically relevant obesity and weight change are challenging tasks. In a given individual, there is often little relationship between the magnitude of obesity and measures of health. Despite its modest effect on long-term weight loss, behavioral modifications thatimprove eating behaviors and increase physical activity constitute a cornerstone for integral and sustainable weight management. Intentional weight loss is associated with a clinically relevant reduction in blood pressure, improvement in cardiac function, and reduction in cardiovascular events. The duration and magnitude of weight change required to achieve a significant benefit are still unclear. In individuals with impaired glucose metabolism at any stage, intentional weight loss achieved by any means is associated with a proportional reduction in T2DM prevalence, severity, and progression. Intentional weight loss is consistently associated with a clinically relevant reduction in triglycerides and increase in HDL cholesterol. The effects of weight loss on LDL cholesterol are less consistent. Overall, nonalcoholic fatty liver disease is commonly associated with excess weight and can show marked improvement with behavioral, pharmacological, and/or surgical weight loss. Very rapid weight loss, however, may worsen liver histology in some patients. Simi- larly, gallbladder disease is not only common in patients presenting with obesity but also highly prevalent after intentional weight loss. Obesity is widely recognized as a key modifiable risk factor for osteoarthritis, with sig- nificant improvements in pain and function reported with weight loss. Obstructive sleep apnea and obesity hypoventilation syndrome tend to improve with moderate weight loss; however, complete resolution is not common and is related to very significant weight loss. Asthma and COPD are clearly associated with obesity. Sustained weight loss seems to be associated with a significant improvement in asthma… Read More »
Obesity Is Not Smoking – Period!
The recent appointment of the Hon. Sarah Hoffman (NDP) to the post of Health Minister in Alberta has (as expected) prompted a wide range of remarks regarding her suitability for the job – not because of her qualifications as an administrator (these are uncontested) – but her size! In a slurry of comments ranging from misguided misogynistic remarks (sadly, including by members of the former government) to outright personal insults, the social media frenzy around this topic is anything but unexpected. The general story line is that someone living with obesity, who is thus obviously “unhealthy”, is not qualified be a health minister. Indeed, one letter writer in the Edmonton Journal likens putting someone living with obesity in this position, to appointing a health minister who smokes – a fatal (but common) misconception of what obesity actually is. For one, smoking is a behaviour – living with obesity is not! When you inhale the smoke of a cigarette you are doing something (a behaviour) – when you gain (or lose) weight, it is something your body does (whether you want it to or not). This distinction is fundamental: when I stop smoking, I become a non-smoker – end of story! When I try to lose weight, my body will do everything it possibly can to resist losing weight. My appetite will increase, my metabolic rate will slow down, my body temperature will decrease, my thyroid function will decrease, my sense of taste and smell will increase, as will my risk-taking behaviour and my susceptibilty to stress. All of these changes (often referred to as the “starvation response”) will work day-and-night to “sabotage” my efforts and in 95% of people who set out to lose weight, these mechanism will eventually win out – even years after starting on their diet. Every person I know who has ever lost a considerable amount of weight and is keeping it off, describes this as a daily on-going struggle. They are well aware that even the slightest interruption to their routine, an illness, an injury, a new medication, even just relationship issues or financial stressors and – boom – their weight is back, whether they like it or not. This is why the WHO, the FDA, the AMA and a growing number of health organisations around the world are now calling obesity a chronic disease, because sadly, we have yet to find a cure for this… Read More »
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