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EDITORIALS: M E J Lean Prognosis in obesity BMJ 2005; 330: 1339-1340 [Full text]

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Obesity prevention through increased physical activity – what is needed?

Erik Hemmingsson   (13 June 2005)

If only it were that simple

Dr Raymond C Seidler   (13 June 2005)

thrifty obesity

Benjamin Dean   (13 June 2005)

Obesity in Severe Mental Illness

Paul Mackin, Allan H. Young   (13 June 2005)

Health Campaigns Targeting Obesity Should Ensure That Older People Are Not Misinformed

Renuka Visvanathan, Associate Professor Ian Chapman   (16 June 2005)

Re: Health Campaigns Targeting Obesity Should Ensure That Older People Are Not Misinformed

Michael EJ Lean   (17 June 2005)

Killing Diseases ...

Stevie M Gamble   (19 June 2005)

patient friendly advice

Mark Ashworth   (29 June 2005)

Obesity prevention through increased physical activity – what is needed? 13 June 2005
Erik Hemmingsson, Health educator, PhD Obesity Unit, Karolinska University Hospital, SE141 86 Stockholm, Sweden Send response to journal: Re: Obesity prevention through increased physical activity – what is needed?	In this week’s editorial (1), M E J Lean proposes that we all eat a bit less (0.418 MJ/day) and walk a bit more (0.418 MJ/day, equivalent to 2000 steps) to prevent 90% of obesity. If such recommendations are sufficient for the proposed effect, they may seem a reasonable sacrifice for the individual, and could therefore work in practice. In terms of promotion of physical activity (PA), however, we are up against an ever stronger head-wind, mainly through increased stress, and an increasingly hostile environment (car-clogged streets, threat of crime, lack of parks and bicycle lanes). Moreover, we now have more calorie-saving machines than ever – cars, lifts, computers, electric toothbrushes, etc, with more labour-saving gadgets being developed and marketed on a seemingly daily basis. Today the average adult in Western Europe walk about 8-9 000 steps/day. Amish people in North America, who refrain from using electricity and cars, accumulate 18 425 steps/day (men; 0% obesity) and 14196 steps/day (women; 9% obesity) (2). The promotion of lifestyle PA, i.e. carried out as a routine part of daily living as practiced by the Amish, is critical for long-term adherence. A similar but more realistic strategy for promoting long-standing PA routines is physically active transport, such as walking to and from the bus stop or bicycling to and from work. The current trend, however, is that we drive shorter and shorter distances, with public transport services deemed too unreliable and slow. We need to provide people with a realistic chance of acheiveing the necessary lifestyle change, for example by creating car-free areas where people live, safe and well-lit parks and bike lanes especially between the home and school/work, reliable public transport, shower facilities at work, and means of reducing preceived time pressures. We also need careful analysis of lifestyle change recommendations – is the efficacy established, are they converted into practice? 1. Lean MEJ. Prognosis in obesity. We all need to move a little more, eat a little less. BMJ 2005;330:1339-1340. 2. Bassett DR, Schneider PL, Huntington GE. Physical activity in an Old Order Amish community. Med Sci Sports Exerc. 2004;36:79-85. Competing interests: None declared
If only it were that simple 13 June 2005
Dr Raymond C Seidler, GP 13 Springfield Avenue kings cross NSW 2011 Send response to journal: Re: If only it were that simple	Maclean has suggested that the epidemic of obesity can be dealt with by a small incremental change in diet an exercise. many doctors know this already as do patients. The old aphorism of eating less and exercising more has been a part of GP advice for decades. Never have we had such institutionalised indolence in man's history, where taking 2000 stapps in a 24 hour period is considered exertion. With the accent on cars and appliances to obviate the necessity to move at all, we are up against it. I often point out that the average Australian in 1950 walked 18,000 steps per day and the whole nation was lean an fit, despite three large fat filled meals per day. If only people began to move the benefits would be self evident Competing interests: None declared
thrifty obesity 13 June 2005
Benjamin Dean, sho oxford Send response to journal: Re: thrifty obesity	Dear Sir, It is certainly of interest that increases in birth weight are linked with increasing risks of obesity in childhood(1). However when the findings of this study (2) indicate that obesity limited to childhood has limited impact on many outcomes in later life, you cannot help but feel something is being missed? Given the adverse prognosis associated with obesity (3) in adulthood, surely it is important that the reasons for these findings become unravelled. Excuse me if what I say contains a little too much conjecture. Several studies have found a strong link between low birth weight and an increased risk of ischaemic heart disease in later life (4). The risk of death was nearly three times as great in light babies. Several subsequent studies have confirmed the health benefits of a heavier birth weight, including reduced risks of stroke, heart disease and diabetes. From these results in can be argued that the consequences of some influences, including a high body mass index in childhood, depend on events at early critical stages of development. Simplistically this can be understood as a poorly nourished baby's body, imprinted with its prenatal experience, is born expecting to live in a state of food deprivation throughout its life. Thus its whole metabolism is geared to being small. Once born, the baby then finds itself in a time of plenty, it compensates by growing fast and certain systems are put under greater stress than previosuly expected. The evidence for the Barker hypothesis is my no means conclusive and is still a source of much discussion. The complex interactions between mother and foetus at both the level of genes and environment are clearly key in this debate and new evidence is coming to light (5,6). The thrifty phenotype hypothesis ( which suggests foetal adaptation to an adverse intra-uterine environment ) as explained above, does appear to be a good explanation of events. However given the available evidence, it seems there may be two different groups of indiviuals who are go on to develop obesity in adulthood - one group with low birth weights and the other with high birth weights. The evidence also appears to suggest that there is a huge difference in the risk of various pathologies between the two groups. In the UK it seems that the latter group with higher birth weights may become more numerous over time, which may have some interesting consequences. Yours, Dr B Dean 1. John J Reilly et al.Early life risk factors for obesity in childhood: cohort study. BMJ, Jun 2005; 330: 1357. 2. Russell M Viner and Tim J Cole Adult socioeconomic, educational, social, and psychological outcomes of childhood obesity: a national birth cohort study. BMJ, Jun 2005; 330: 1354. 3. M E J Lean. Prognosis in obesity. BMJ 2005:1339-1340. 4. Barker DJ, Winter PD, Osmond C, Margetts B, Simmonds SJ. Weight in infancy and death from ischaemic heart disease. Lancet. 1989 Sep 9;2(8663):577-80. 5. Kimm, Sue Y.S. Fetal origins of adult disease: the Barker hypothesis revisited-2004. Current Opinion in Endocrinology & Diabetes. 11(4):192 -196, August 2004. 6. Ong KK, Dunger DB. Birth weight, infant growth and insulin resistance. Eur J Endocrinol. 2004 Nov;151 Suppl 3:U131-9. 7. Flanagan DE et al. Reduced foetal growth and growth hormone secretion in adult life. Clin Endocrinol (Oxf). 1999 Jun;50(6):735-40. 8. Soto I N, Mericq G V. Fetal growth restriction and insulin resistance. New findings and review of the literature. Rev Med Chil. 2005 Jan;133(1):97-104. Epub 2005 Mar 10. Competing interests: None declared
Obesity in Severe Mental Illness 13 June 2005
Paul Mackin, Academic Specialist Registrar in Psychiatry Department of Psychiatry, University of Newcastle upon Tyne, Royal Victoria Infirmary, NE1 4LP, Allan H. Young Send response to journal: Re: Obesity in Severe Mental Illness	Professor Lean’s Editorial on Prognosis in Obesity (1) is a timely contribution to the literature on the relationship between increasing weight and physical morbidity and mortality in the general population. We would like to draw attention further to the extent of the problem of obesity in those individuals with severe mental illness. Major depressive disorder, bipolar disorders and schizophrenia rank among the top ten causes of disability worldwide (2) and this patient group suffers from excess physical morbidity and reduced life expectancy (less than 50% of which is accounted for by suicide (3)). Metabolic diseases, including obesity, are likely to contribute significantly to increased mortality in this population. It remains unclear whether mental illness in itself is an independent risk factor for the development of obesity and other components of the metabolic syndrome, or whether metabolic dysfunction is simply secondary to lifestyle. Iatrogenic causes of obesity are also likely to be important as atypical antipsychotic drugs, a commonly prescribed class of psychotropic medication, are known to cause weight gain, disorders of glucose homeostasis and hyperlipidaemia (4). It has recently been reported that there is a high prevalence of undiagnosed and untreated metabolic disease, including obesity, in psychiatric patients taking antipsychotic drugs (5), which may reflect poor monitoring and intervention due to a lack of awareness in primary and secondary care of this significant public health issue. Recent consensus statements have been published making clear the need for monitoring of metabolic disease in those patients prescribed antipsychotic drugs (4). Although the First Law of Thermodynamics (“move a little more, eat a little less”(1)) may hold scientific truth and credibility for those individuals motivated to loose weight and potentially increase longevity, many of the core psychopathological features of patients with severe mental illness (“depressed mood, lack of motivation, hopelessness, disorganised thinking, etc.) conspire against such lifestyle changes. References 1.Lean MEJ. Prognosis in obesity. BMJ 2005;330:1339-40 2.Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 1997;349:1436-42 3.Hansen V, Jacobsen BK, Arnesen E. Cause-specific mortality in psychiatric patients after deinstitutionalisation. Br J Psychiatry 2001;179:438-43 4.Consensus Development Conference on Antipsychotic Drugs and Obesity and Diabetes. Obesity Res 2004;12:362-368 5.Mackin P, Watkinson H, Young AH. Prevalence of obesity, glucose homeostasis disorders and metabolic syndrome in psychiatric patients taking typical or atypical antipsychotic drugs: a cross-sectional study. Diabetologia 2005;48:215-21 Competing interests: None declared
Health Campaigns Targeting Obesity Should Ensure That Older People Are Not Misinformed 16 June 2005
Renuka Visvanathan, Director (Geriatrician) and Senior Lecturer Aged and Extended Care Service , The Queen Elizabeth Hospital, Adelaide, 5011, South Australia, Associate Professor Ian Chapman Send response to journal: Re: Health Campaigns Targeting Obesity Should Ensure That Older People Are Not Misinformed	Editor- Advising apparently overweight older people to lose weight may do more harm than good. There is evidence that the risks of being “overweight” decrease with increasing age. Based on mortality, the ideal body mass index (BMI) is higher in older than young adults, with an optimum BMI for people over 65 years in the young adult “overweight” range of 27-30 kg/m2 (1). In a systematic review, Heiat and colleagues concluded that the relationship between BMI and mortality in people over 65 years is a flat bottomed ‘U- shaped’ curve, with mortality rising only at BMI > 31 kg/m2, and perhaps not at any BMI in people over 75 yrs (1). Weight loss is more common than weight gain in older people, and associated with poor outcomes, even when the weight loss is intentional and the person was “overweight” at baseline (2-4). In the prospective Cardiovascular Health Study of approximately 4700 community-dwelling people >65 years, weight loss of >5% over 3 years was substantially more common than weight gain of > 5% (2). Weight loss, but not weight gain was associated with a significantly increased risk of mortality (RR = 1.67, 95% CI = 1.29 2.15)(2). The association of increased mortality with weight loss persisted even at the highest baseline weight tertile (2). In a study of older men with BMI > 30 kg/m2, intentional weight loss was associated (P<0.001) with a greater rate of hip bone loss [-1.7%/yr] than in subjects with no weight loss [-0.1%/yr] or weight gain [0.5%/yr](4). The indiscriminate application of evidence from studies in younger adults to the management of older people is hazardous. We believe many older people are trying to lose weight inappropriately. There is a need to ensure that the majority of our elders are given appropriate advice; ‘keep physically active, eat sensibly and maintain weight. 1. Heiat A, Vaccarino V, Krumholz HM. An evidence-based assessment of federal guidelines for overweight and obesity as they apply to elderly persons. Arch Intern Med 2001;161(9):1194-203. 2. Newman AB, Yanez D, Harris T, Duxbury A, Enright PL, Fried LP. Weight change in old age and its association with mortality. J Am Geriatr Soc 2001;49(10):1309-18. 3. Wannamethee SG, Shaper AG, Lennon L. Reasons for intentional weight loss, unintentional weight loss, and mortality in older men. Arch Intern Med 2005;165(9):1035-40. 4. Ensrud KE, Fullman RL, Barrett-Connor E, Cauley JA, Stefanick ML, Fink HA, et al. Voluntary weight reduction in older men increases hip bone loss: the osteoporotic fractures in men study. J Clin Endocrinol Metab 2005;90(4):1998-2004. Competing interests: None declared
Re: Health Campaigns Targeting Obesity Should Ensure That Older People Are Not Misinformed 17 June 2005
Michael EJ Lean, Professor of Human Nutrition University of Glasgow Send response to journal: Re: Re: Health Campaigns Targeting Obesity Should Ensure That Older People Are Not Misinformed	In principle, it is correct to consider whether advise to younger people is appropriate to older people. With regard to obesity, the evidence on intentional weight loss is very scanty and mainly based on self-reports. Our study of intentional (at least intended) and measured weight loss amongst older type 2 diabetic patients, mean age 64 followed as a cohort until death, revealed a strong positive association with life expectancy: weight loss of 10 kg was associated with 3-4 years increased survival. (Lean MEJ, Powrie JK, Anderson AS, Garthwaite PH. Obesity, weight loss and prognosis in type 2 diabetes. Diabet Med. 1990 Mar- Apr;7(3):228-33). However it should be remembered that obesity is not primarily a killing disease. Its main impact, increasingly with age, is on disability and quality of life, through aggravation of a vast range of symptoms, including tiredness, breathlessness, back pain, arthritis, stress incontinence, depression... and the list goes on. Competing interests: None declared
Killing Diseases ... 19 June 2005
Stevie M Gamble, retired HMIT EC2Y 8BL Send response to journal: Re: Killing Diseases ...	Professor Lean notes in his Rapid Response of 17th June that ‘obesity is not primarily a killing disease’. On the other hand, malnutrition often is a killing disease, as Professor Lean himself recognised in the paper he co-wrote with Kelly et al five years ago: ‘Still hungry in hospital: identifying malnutrition in acute hospital admissions’ 1 That paper opened with this statement: ‘Ironically, in our affluent society characterized by excessive food and drink consumption, it is common to find malnourished hospital patients for whom other clinical problems dominate the view of ‘doctors and nurses who fail to recognize it due to lack of training in this matter’ It is not clear to me how asserting that ‘we all need to move a little more and eat a little less’ is going to help doctors and nurses to recognise malnourishment when they see it. Indeed, quite the reverse; it strongly reinforces the belief that the only nutritional problem in British society today is that we all eat too much. This is not a trivial matter, as Lean himself noted in the earlier paper: ‘Malnutrition has clearly observable aspects. Weight and subcutaneous fat losses, muscle wasting, oedema, lethargy, and ultimately death are among the most obvious. Other consequences of malnutrition include impaired immune responses,decreased respiratory and cardiac function and delayed wound healing.’ Tackling malnutrition saves lives; Lean and his co-researchers noted, for example that: ‘Decreased mortality rate, potentially by 50%, was shown in a large well-conducted controlled study of routine nutritional supplementation in geriatric patients.’ I am sure that Professor Lean is aware that the benefits are not confined to the old; specialist nutritional interventions as part of team care are partially responsible for extending life expectancy in patients with cystic fibrosis (CF). 2 Indeed, the BMI is one of the key clinical measures of status in CF; the higher the better. I do appreciate the desire to provide a catchy sound bite for reproduction in the press, but when an eminent researcher makes a statement which he knows to be factually incorrect, and which he himself has previously stated endangers the lives of patients, then it brings the entire profession into disrepute. It also ensures that the general public will turn an increasingly deaf ear to medical advice. Credibility is a finite resource; every exaggerated and misleading claim erodes it. Stevie Gamble 1. Q J Med 2000; 93: 93-98 http://qjmed.oxfordjournals.org/cgi/content/full/93/2/93 2. Clinical outcome in relation to care in centres specialising in cystic fibrosis BMJ 1998;316:1771-1775 http://bmj.bmjjournals.com/cgi/content/full/316/7147/1771 Competing interests: None declared
patient friendly advice 29 June 2005
Mark Ashworth, honorary senior lecturer Department of General Practice, King's College London, 5 Lambeth Walk, London SE11 6SP Send response to journal: Re: patient friendly advice	In Lean's editorial on obesity (1) I thought that the final summary quantifying the balance between exercise and food consumption was a vital piece of information, little known to health professionals. We can now tell our patients how much more exercise to take (2000 steps/day) and how much less food energy to consume (0.418 MJ/day). The only problem was that this isn't the language that patients understand. After consulting my son and daughter taking GCSE physics and A'level maths respectively, I finally calculated that 0.418MJ equals 100 Calories. Put like this, the message becomes clear to health professionals and patients alike. The message of the editorial can now be simplified to a statement that walking 2000 steps per day (the equivalent of 100 Calories) and eating just 100 Calories less per day will prevent 90% of all obesity. That message deserves a wider audience. Mark Ashworth 1. Lean MEJ. Prognosis in obesity. We all need to move a little more, eat a little less. BMJ 2005;330:1339-1340. 2. Bassett DR, Schneider PL, Huntington GE. Physical activity in an Old Order Amish community. Med Sci Sports Exerc. 2004;36:79-85. Competing interests: None declared