Rapid Responses to:

HEAD TO HEAD: Patrick Basham and John Luik Is the obesity epidemic exaggerated? Yes BMJ 2008; 336: 244 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Is the obesity epidemic exaggerated? Clues from a developing country

Pascal Bovet, Arnaud Chiolero, Fred Paccaud   (4 February 2008)

Debate about fatness increases health risks

Kathy J. Kater   (21 February 2008)

Is the obesity epidemic exaggerated? Clues from a developing country 4 February 2008
Pascal Bovet, Senior lecturer University Institute of Social and Preventive Medicine (IUMSP), 1005 Lausanne, Switzerland, Arnaud Chiolero, Fred Paccaud Send response to journal: Re: Is the obesity epidemic exaggerated? Clues from a developing country	Basham and Luik submit that the epidemic of obesity has been exaggerated (1). We think that the large average weight gain of 10.9 kg in the U.S. population between 1960 and 2002 (2), which the authors allude to, is compatible with an epidemic (i.e. with an increase “clearly above normal expectancy"). Data from developing countries provide additional arguments in favor of a global epidemic, and further insight with regards to its scale and consequences. For example, based on three population-based examination surveys between 1989 and 2004 in the Seychelles (Indian Ocean, African region) (3), the yearly average weight gain of the population was two times larger in a rapidly developing country (3) than in the U.S. between 1960 and 2002 (2), respectively 0.46 and 0.26 kg per year. However, we agree with Basham and Luik that the consequences of the epidemic need further research. For example, the Seychelles surveys showed that, during the last 15 years, the upward trend in weight (the prevalence of overweight increased from 37% to 59%) was associated with a 50% increase of the prevalence of diabetes, as expected (4). On the other hand, mean blood pressure did not increase over time; moreover the relationship between weight and blood pressure unexpectedly decreased over successive surveys, independent of treatment (3). These findings from the Seychelles are consistent with the upwards trends for diabetes but downward trends for blood pressure (and blood cholesterol) in the U.S. population between 1980 and 2000, and lower risk of hypertension (and hypercholesterolemia) associated with obesity in 1999/2000 than in 1960/62, not fully accounted by treatment (5). A better understanding of the trends of obesity and its consequences is needed to inform effective prevention programs. However, the upward trends of weight in most populations are definitely worrying for specific diseases (e.g. diabetes) and this warrants prevention interventions without delay. This is especially true for developing countries, which may face both a particularly steep epidemic of obesity and a lack of resources for relying on treatment strategies to manage diabetes and other obesity- related diseases. References 1) Basham P, Luik J. Head to Head: is the obesity epidemic exaggerated? Yes. BMJ 2008;336:244. 2) Ogden CL, Fryar CD, Carroll MD, Flegal KM. QuickStats: mean weight and height among adults aged 20-74 years, by sex and survey period - United States, 1960-2002. MMWR 2005;54:771. 3) Danon-Hersch N, Chiolero A, Shamlaye C, Paccaud F, Bovet P. Decreasing relationship between body mass index and blood pressure over time. Epidemiology 2007;18:493-500. 4) Faeh D, William J, Shamlaye C, Tappy L, Ravussin E, Bovet P. Prevalence, awareness and control of diabetes in the Seychelles and relationship with excess body weight. BMC Public Health 2007, 7:163(e). 5) Gregg EW, Cheng YJ, Cadwell BL, Imperatore G, Williams DE, Flegal KM, Narayan KM, Williamson DF. Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA 2005; 293(15): 1868-74. Competing interests: None declared
Debate about fatness increases health risks 21 February 2008
Kathy J. Kater, Psychotherapist, Specialist in Promotion of Healthy Body Image, Eating, Fitness and Weight Private Practice, St. Paul, MN, USA, 55109 Send response to journal: Re: Debate about fatness increases health risks	The debate over whether the health risks of obesity are exaggerated seriously detracts from a more crucial concern. Whether or not obesity increases health risks, the real question is what should we do for our health in any case? Weight loss or control is constantly recommended—disregarding the fact that weight is not a behavior, and as such it is not ours to “control.” Weight results from a multitude of factors, some of which are in our control—how we eat, how active or sedentary we are—but many of which are internally regulated, and thus are not. In recent years a host of studies have shed light on why some sedentary folks can eat like horses and remain lean while their neighbors consume moderately, train for triathlons, and stay fat. If we limit ourselves to healthy means, over the long run the best anyone can hope for is to influence weight, not control it. It turns out that prescription of weight loss as a solution to fatness has made things worse. Research published in 1950 by Ancel Keyes first demonstrated how and why even a moderately restrictive diet is counterproductive for long term weight loss. New studies bear this out: weight can be lost on virtually any contrived plan to restrict calories or food groups, but between 80 and 95% of this weight is predictably regained, usually with added pounds. If you doubt this well corroborated data, just consider how many people you know who have gone on a diet once. If dieting was effective why would it be a perennial activity, and why would most dieters be fatter today than before their first diet? Aside from weight loss, what recommendation with so many unpleasant side affects and a 90% failure rate would still be prescribed? None the less we persist in the belief that if we can make people feel bad or afraid enough about their weight they will “do something” about it. This flies in the face of new studies documenting that body dissatisfaction does not serve as a motivator for healthy behaviors. To the contrary, research has finally confirmed what those working to reverse body image problems have known for years: unhappiness about weight leads to disordered eating, weight gain, and poorer overall health. In light of this, why do we persevere like Sisyphus in unrelenting talk about weight, the risks of fatness, and the need for weight loss as if this will make people repent? In four decades the thinner we have tried to be, the fatter we have become. Worrying about weight is a self-fulfilling prophesy. But if fat phobia and efforts at weight control are contributing to the problem, what is the solution? Studies have consistently shown that fatter people who are fit are at lower risk for health problems than thin people who are not fit. Given this, someone should be asking whether it’s fatness or lack of fitness that is the problem. But even this debate detracts from the vital question: what should we do in any case? The solution is so obvious, perhaps it defies notice. What if instead of fear and loathing of fatness, health promotion initiatives were to pushed the value, ways and means for wholesome eating and fitness for everyone—irrelevant of size? If a sustainable healthy lifestyle were the goal instead of size, some people would remain fat and some would be thin, but virtually all would be healthier. Isn’t this the point? It is troubling that so few leaders in health care cannot see that shifting the focus to how we live rather than what we weigh is an effective solution that empowers all people of every size and shape to be the best they can be. Few could argue that a fit and well-fed populous of diverse sized people would not be preferable to the status quo. Campaigns to support the development of healthy, realistic body images, wholesome, stable eating, and lifetime fitness habits regardless of shape, size, or weight could eliminate much of our population’s “weight problem.” Competing interests: None declared