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HEAD TO HEAD: R W Jeffery and N E Sherwood Is the obesity epidemic exaggerated? No BMJ 2008; 336: 245 [Full text]

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Children's cardiovascular risks

Gustavo E Villarreal   (5 February 2008)

Debate about fatness increases health risks

Kathy J. Kater   (24 February 2008)

Children's cardiovascular risks 5 February 2008
Gustavo E Villarreal, Physician private practice 208 Shilo, Laredo, Texas, 78045 Send response to journal: Re: Children's cardiovascular risks	From 1970 to 2004 obesity in children has seen a linear increase--in 2-5 year olds, a 3 fold increase from 5% to close to 15%, and in 6-19 year olds, a 4 fold increase from 5% to close to 20% (1). If we add this to the Bogalusa Heart Study findings at autopsy of atherosclerosis in children as young as 5- 8 years old and young adults in the aorta, coronary vessels and kidneys that strongly correlated to smoking, high cholesterol, high blood pressure and high BMI (2). High diastolic BP/Low HDL were weak correlators with these lesions, but cigarette smoking accelerated the disease process and the greater the number of CV risk factors, the greater the extent of atherosclerosis at autopsy (3). In 1999, a study of 9,167 children aged 5 to 17 in which those with >95% wt percentiles N=813 were compared with those <85% weight percentiles N=5,477 found that those who were overweight >95% percentiles had fold increases: 2.4 High Total Cholesterol, 2.4 High Diastolic BP, 3.0 High LDL, 3.0 High HDL, 4.5 High Systolic BP, 7.1 High Triglycerides, 12.6 High Fasting Insulin, >95% weight percentiles had 58% incidence of at least one risk factor for CHD (4). In the PDAY study the distribution of cardiovascular risks according to triglycerides were: CV risks correlated with TG, N=1342 ages 20-37, TG>150 associated high risk; 1.8 fold HBP, 3.1 fold DM2, TG 100-150 strongly associated with Insulin resistance syndrome, low HDL, high Insulin, high Systolic B/P (5).In young people in the US, fatty streaks found in all 3000 young people, the frequency of intermediate lesions increased steadily between 15 and 34 years of age, 10% had advanced plaques with necrotic lipid cores and fibrous caps, risk factors that increased lesions: Obesity, smoking (6-fold), Hypertension (4-fold) Raised fatty streaks in autopsies of 2,876 persons aged 15-34 that died of external causes were found in abdominal Aortas: 20% ages 15-19, 40% ages 30-34, right coronary Arteries, 10% ages 15-19, 30% Ages 30-34, correlation of fatty streaks; increased with age, low HDL, HBP, obesity. Bogalusa Heart Study and PDAY: CHD begins in childhood; traditional risk factors determine severity of disease. Predictors for risk of DM2 by Consensus Development Conference on Insulin Resistance (1998) High Plasma insulin levels either fasting or post-prandial, Independently of obesity or waist circumference, Family History. of DM2 (6) Since these risk factors are modifiable, this studies suggests that risk factor screening identifies patients at risk, to start lifestyle interventions and possible drug intervention since Higher BMI during childhood is associated with an increased risk of CHD in adulthood. The associations are stronger in boys than in girls and increase with the age of the child in both sexes. (7) In our family practice clinic in Laredo, Texas, after screening 240 Mexican American children in the border with obesity and acantosis nigricans aged 3-20, mean age 12, males 113, females 127, we found in the clinical setting these crude data: 19% Prevalence of impaired FBS or 2 hr gtt (47%males, 53% females), High c-peptide 1 hour post-glucola (1mg/kg) 85% prevalence(46% males, 54% females), High fasting insulin 53% prevalence (49% males, 51% females, metabolic syndrome (adult NCEP guidelines) 27% prevalence (males 44%, females 56%), Low HDL 64% prevalence (32% males, 68% females), High LDL 44% prevalence (54% males, 46% females), High triglycerides 23% prevalence (56% males, 44% females), High total cholesterol 12% ( 59% males, 41% females, DM2 prevalence 3% (71% males, 29% females), High blood pressure 15% prevalence (70% males, 30 % females), high uric acid 34% prevalence (67% males, 33% females), elevated liver enzimes 14% prevalence (73% males, 27% females), high fibrinogen 22% (37% males, 63% females), high PAI-1 24% prevalence (43% males, 57% females, microalbuminuria 25% prevalence (34% males, 66 % females) in microalbuminuria subjects prevalence of 24hr creatinine clearance < 60 ml/1.73 m2, 33% prevalence (14% males, 86% females). We found that 13% of this subjects had failing grades in school (<70) half the group was placed on metformin 1 gr bid and grades improved 20 points (90) at 3 months, half the group was placed on diet and exercise, the ones that lost weight increase their grades 20 points (90) at 3 months, the ones that didn’t lose weight remain with the same grades. It seems that we have a huge problem at our doorsteps, that calls for prompt screening, risk stratification and proper interventions. 1. NHANES I, II, II and 1999-2004 NCHS, CDC 2. Newman WP III, et al.Relation of serum lipoprotein levels and systolic blood pressure to early atherosclerosis: The Bogalusa Heart Study.N Engl J Med. 1986;314:138-144 persons aged 6-30 years and studied at necropsy: the Bogalusa Heart Study.Am J Cardiol.1992;70:851-858 3.Berenson Gs, et al Association between multiple cardiovascular risk factors and atherosclerosis in children and adults.N Engl J Med.1998;338:1650-1656. 4. Freedman DS, et al: The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study.Pediatrics.1999;103:1175-1182 5. PDAY: A Survey of Atherosclerosis Rontini MG, et al.Distribution and cardiovascular risk correlates of serum triglycerides in young adults from a birracial community: the Bogalusa Heart Study.Atherosclerosis.2001;155:201-209 McGill HC, et al.Association of coronary heart disease risk factors with the intermediate lesion of atherosclerosis in youth:the Pathological Determinants of Atherosclerosis in Youth (PDAY) Research Group.Arterioscler Thromb Vasc Biol.2000;20:1998-204. 6. Diabetes care 1998:21:310-314 7.Baker, J. L. et al., N Engl J Med 2007;357:2329-37. Competing interests: None declared
Debate about fatness increases health risks 24 February 2008
Kathy J. Kater, Psychotherapist, Specialist in Promotion of 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 the real question: what should we prescribe for our health in any case? Weight loss or management 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 power to chose—how we eat, how active or sedentary we are—but many of which are internally regulated, and thus are not. A host of studies have now eliminated the age old mystery about 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, the best anyone can hope for is to influence weight, not control it. Genetic predisposition aside, it turns out that the most common advice for reducing fatness has made things worse. Research published over fifty years ago 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 85% and 95% of this weight is predictably regained, with over half of all dieters gaining more weight than they lost. If you doubt this, check the National Institute of Health for the data, then check your own observations to 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 other unpleasant recommendation with a 90% failure rate would still be prescribed? Even so too many health authorities 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 that document what many of us working in the trenches to reverse disordered eating have known for years: body dissatisfaction does not serve as a motivator for healthy behaviors. To the contrary, unhappiness about weight is a catalyst for disordered eating, weight gain, and poorer overall health. Worry about weight is a self-fulfilling prophesy. In light of this, how can we persevere like Sisyphus in unrelenting talk about 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. But if fat phobia and efforts to lose weight contribute to the problem, what is the solution? The way out of this spiraling and dangerous problem requires the courage to ask the right question: fat or thin, what should we be doing for our health in any case? Few will dispute the evidence showing that fatter people who are well fed and fit are at lower risk for health problems than thin people who eat poorly and are sedentary. In light of this, what if instead of fear and loathing of fatness, health initiatives pushed the value, ways and means for wholesome eating and fitness for everyone—irrelevant of size? If instead of size or a BMI a sustainable, healthy lifestyle were the goal, then some people would remain fat, some would be thin, but virtually everyone would be healthier. Isn’t this the point? It is troubling that so few leaders in health care cannot see the forest for the trees: 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. Who 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