Fighting obesity
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7452.1327 (Published 03 June 2004) Cite this as: BMJ 2004;328:1327
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EDITOR--Jain’s recent Editorial focuses on the rising prevalence of
obesity in the United Kingdom [1]. In Australia there has been a 2.5-fold
increase in the prevalence of obesity in urban adults 1980-2000 [2]. As
part of the Geelong Osteoporosis Study, we determined the body mass index
(BMI, kg/m2) for a randomly-selected sample of 628 women aged 60+ years,
1994-7 [3]. These data indicate that 38.5% of the women were overweight
(BMI 25.0-29.9) and 24.6% obese (BMI >= 30.0).
One advantage of increased body fatness is the positive association
with bone mineral density (BMD). In our sample, the correlation between
BMD at the total hip and BMI is 0.53 (P<0.001). The positive
association is attributed to mechanical loading on the skeleton [4] and/or
actions of mediators between adipose tissue and bone [5].
Using Cox proportional hazards models developed from prospective
follow-up for 9.1 year (median 5.6 year), we estimate that the relative
risk (RR) for any fracture increases 1.9-fold for each standard deviation
decrease in total hip BMD (RR=1.9; 95% confidence interval 1.6-2.4).
Similarly, the RR for fracture increases 1.2-fold for each standard
deviation decrease in BMI (RR=1.2, 1.0-1.5). Comparing overweight and
obese women with women of the same age but normal BMI, overweight and
obese women tend to be increasingly protected against fracture (overweight
RR=0.9, 0.6-1.4; obese RR=0.8, 0.5-1.3). Obesity may protect against
fracture through increased BMD. However, among women with the same age and
BMD, the obese are at higher risk of fracture than women with normal BMI
(overweight RR=1.2, 0.8-1.8; obese RR=1.7, 1.0-3.0).
Within our data set, the risk of falling was not associated with BMI.
The cushioning effect of adipose tissue could affect the biomechanics of a
fall. However, it is also likely that heavier body weights produce greater
forces on the bones at point of impact, thus explaining the increased
fracture risk.
Competing interests: None declared.
References
1. Jain A. Fighting obesity. BMJ 2004;328:1327-8.
2. Proietto J, Baur LA. Management of obesity. Med J Aust 2004;180:474-80.
3. Henry MJ, Pasco JA, Nicholson GC, Seeman E, Kotowicz MA. Prevalence of
osteoporosis in Australian women: Geelong Osteoporosis Study. J Clin
Densitom 2000;3:261-8.
4. Edelstein SL, Barrett-Connor E. Relation between body size and bone
mineral density in elderly men and women. Am J Epidemiol 1993;138:160-9.
5. Reid IR, Ames R, Evans MC, Sharpe S, Gamble G, France JT, Lim TMT,
Cundy TF. Determinants of total body and regional bone mineral density in
normal postmenopausal women - a key role for fat mass. J Clin Endocrinol
Metab 1992;75:45-51.
Competing interests:
None declared
Competing interests: No competing interests
The idea that "Junk Food" is the cause of increasing obesity and the
villification of the food industry in consequence is dangerous nonsense.
Through time and space, in amazingly differant nutritional
environments, there have been fat people, thin people and (dare one say
it?) desirable people.
It has been shown, compared to their 1940's forebears, teenagers of
today are bigger, fatter, take less exercise, but most significantly eat
less (in Calorie per day terms). A propositional logicist might conclude
the answer to the problem is people should eat more - which is not too far
removed from conventional dietetic advice for the obese to eat breakfast
(which we seldom do).
Historical information is interesting. Many will have recently seen
re-runs of the liberation of Normandy in 1944. Were the girls unusually
slender or their mothers haggard and skeletal on the Newsreels? No. The
Warsaw Ghetto (about 200 Calories per day) saw many die, but many who did
not (the camps awaited).
Current UK diets are spoken of as though there were some Halycian
Days when the British thrived on broccoli and Perrier water and all were
thin. This is nonsense.
How does today's Fast Food compare with Pork Pie, Black Pudding, Fish
and Chips, Stew and Dumplings and many other staples of the early 20th
century British diet? And of course people were not thin. Looking at
newsreels from the early twentieth century most people were quite well-
fleshed, except the physically labouring men who often looked quite gaunt
(and probably died before their seventieth birthday).
The "Obesity Epidenic" reminds me of H.L. Mencken's observation: "For
every complex problem there is a simple straightforward solution - which
won't work."
We desperately need good R&D on obesity. For too long the NHS has
brushed the problem aside. We also need "firefighting" interventions for
those with life-threatening disease now.
Currently there is nothing worth having and I struggle with many
patients who are effectively marginalised from NHS care to await a nasty
premature loss of normal function followed by an early death.
Competing interests:
None declared
Competing interests: No competing interests
Would Dr. Kapil know the major causes and average age of death of
rickshaw drivers compared with the taxi drivers?
Competing interests:
None declared
Competing interests: No competing interests
The epidemiological data supports that physical activity and diet
has a major role to play in causation of obesity. In India ,it extremely
difficult to find a rickshaw puller ( low food intake high caloric
expenditure occupation) obese while large percentage of Taxi drivers
(average food intake low caloric expenditure occupation)are obese.
National Governments need not wait for scientific evidence but should
start interventions at very young adolscent age ( 10-14 yeras) to prevent
the epidemic of obesity which is mother of common non communicable
diseases.
Dr. Umesh Kapil MD, DNB, FAMS ,FIPHA,FIAPSM
Professor Public Health Nutrition
Department of Human Nutrition,
All India Institute of Medical Sciences,
New Delhi 110 029, INDIA
kapilumesh@hotmail.com
Competing interests:
None declared
Competing interests: No competing interests
Dear Sirs,
With reference to Fighting obesity, evidence of effectiveness will be
needed to sustain policies, BMJ Vol 328 5 June, 2004
We support your call for increased research into effective
interventions against obesity. However, we wish to draw attention to some
inaccuracies in your description of the World Health Organization’s role
in this important global health issue. The WHO Global Strategy on Diet,
Physical Activity did not ever “implicate” the marketing of junk foods,
nor did it ever call for an immediate ban on the advertising of unhealthy
foods to children. Nor was the plan ever stalled, as you state. A first
draft was presented to our Executive Board in January 2004 and revised in
April after taking into account Member State comments. The second draft
was endorsed without further change by all of our Member States at the May
2004 World Health Assembly, as was originally scheduled.
While the strategy never called for bans, the first and final drafts
did both note that food advertising should not exploit children’s
inexperience or credulity and stressed the overall importance of the
information environment. The strategy specifically calls for countries to
discourage messages that promote unhealthy dietary practices and
recommends that governments develop multi-stakeholder approaches to the
marketing of foods to children, and to deal with such issues as
sponsorship, promotion and advertising. Further, the Strategy also
recommends that the private sector practices responsible marketing, which
supports the Strategy's goals.
Both drafts also contained recommendations that the intake of free
sugars should be limited, that fat consumption should be shifted from
saturated to unsaturated fats and for the elimination of trans-fatty
acids, as well as calling for increased consumption of fruit, vegetables,
legumes, whole grains and nuts.
These recommendations take into account Member States' input to the
Strategy, developed over two years of consultations. WHO sees the strategy
as a key instrument for addressing the global burden of mortality,
morbidity and disability caused by chronic noncommunicable diseases. The
organization is currently developing an implementation plan for the
strategy at regional and country level, which will take into account our
Member States' differing needs and circumstances.
Sincerely,
Dr Catherine Le Gales-Camus, Assistant-Director General,
Noncommunicable Diseases & Mental Health
Ms Amalia Waxman, Project Manager, Global Strategy on Diet, Physical
Activity and Health
World Health Organization, Geneva
Competing interests:
None declared
Competing interests: No competing interests
[dietary] saturated fat and cholesterol have nothing to do with the causation
of cardiovascular disease [CVD], let me suggest that one ugly factoid can
destroy an entire pretty 50 year old theory. Let me suggest 3 factoids
and an enigma:
1. Tukelauans were polynesians consuming 50% of their energy [about
5x Western amounts] from the most saturated fat on the planet, ~95% saturated
coconut oil, without apparent heart disease problems [until immigrating
to New Zealand] I.A.
Prior et als Am J Clin Nutr. 1981 Aug;34(8):1552-61.
2. Traditional Finnish Lapps with high animal fat/cholesterol intakes
and no apparent CVD.
3. No grain, and little fruit and vegetable eating traditional Greenland
Inuit without apparent CVD.
and the enigma about (serum) cholesterol in the LiVicordia
study [M. Kristenson et als, BMJ. 1997 314(7081):629-33] where 10%
lower serum cholesterol levels correspond with 4x more CVD [and
much larger amounts of carotid artery plaque]. I simplified the enigma
in this graph here
It is physically impossible to strong arm these data into the traditional
"diet-heart" hypothesis regarding saturated fats and cholesterol.
If Mr. Aslam is still looking for solutions to CVD in changing dietary
lipids (other than regarding beneficial omega-3's and detrimental trans
fats) he will be looking for a long time. Let me propose The Great Confounder
in CVD studies lies in the rarely measured homocysteine and its long term
deleterious effects and/or in the independent effects of the nutrients,
mainly B2, B6, B9 (folic acid) and B12, that lower homocysteine.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – Exasperated! Of course I am exasperated after reading
statements like; “... saturated fats and cholesterol have absolutely
NOTHING to do with the causation of cardiovascular disease ...” which make
a mockery of over 50 years of knowledge gained from cardiovascular disease
epidemiology.
While Mauritius ‘suffers’, credible evidence is awaited linking this
‘suffering’ to the diet change. And if it turns out to be so, though
unlikely in view of existing evidence, appropriate action should be taken
to set things right.
As eloquently pointed out by Dr. Nehrlich, the multi-factorial
etiology of cardiovascular diseases must be kept in mind. Effective
prevention requires modification of multiple factors and not diet alone.
While multiple theories may exist, one must adopt a stance which is
compatible with sound evidence. I await convincing evidence denying any
harmful effects of saturated fats on cardiovascular diseases. If tomorrow
there is such proof, my patients will get advice based on current quality
evidence.
As for the personal tone of Dr. Nehrlich’s conclusion, I again
believe that a response is not merited.
In conclusion, the primary reason for citing the Mauritian example
must not stand forgotten; governments and communities need to collaborate
in order to generate effective public health interventions.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – In response to Mr. Vos’s enquiry into the association
between any increased cancer incidence in Mauritius to the diet change
action; at least to my knowledge, no such linking evidence exists.
As evident from the debate on the electronic pages of BMJ, this issue
is a controversial one. A meta-analysis of prospective studies
investigating risk of lung cancer and fat intake found no significant
association between the two (1). Similarly, another meta-analysis found
no strong evidence linking a diet high in polyunsaturated fat and linoleic
acid with breast, colorectal or prostate cancers (2). For that matter, soy
based food intake has been shown to reduce the risk of endometrial cancer
(3).
There may very well be an association between polyunsaturated fats
and cancers, but compelling evidence should be brought forth in order to
bring about a change in dietary guidelines. It has to be seen that which
sort of diet is good for what sort of population
Every nutrient or for that matter anything has beneficial and harmful
effects. Mr. Vos’s point on utilizing micronutrients is well taken. Adding
a Pakistani perspective to it, the national policy recommending the use of
‘iodized’ natural salt has been helpful in controlling goiter in the
country.
REFERENCES
(1) Smith-Warner SA, Ritz J, Hunter DJ, Albanes D, Beeson WL, van den
Brandt PA, et al. Dietary fat and risk of lung cancer in a pooled analysis
of prospective studies. Cancer Epidemiol Biomarkers Prev 2002;11:987-92.
(2) Zock PL, Katan MB. Linoleic acid intake and cancer risk: a review
and meta-analysis. Am J Clin Nutr 1998;68:142-53.
(3) Xu WH, Zheng W, Xiang YB, Ruan ZX, Cheng JR, Dai Q, et al. Soya
food intake and risk of endometrial cancer among Chinese women in
Shanghai: population based case-control study. BMJ 2004;328:1285. Epub
2004 May 10.
Competing interests:
None declared
Competing interests: No competing interests
Mr Aslam, I understand your desperation and exasperation.
The "Mauritian Action" nevertheless -no matter how much you would wish it
had- has NOT blunted the rise in CVD at all.
Not only that, but the (expected) increase in diabetes (36%), hypertension
(you may know about its association with CVD)(20 %) and cancer (figures
unavailable to me at this time) would convince even the Drover's dog that
Mauritius is, indeed, on the wrong track . In fact it is (and you would be
an accessory) not even near a track.The authorities on Mauritius are
incompetent fools, incapable of thinking for themselves. Does this
characterise you, too?
Even though it is obvious to me that you do have the brains that does not
mean that you are able to use them.
There is little point in continuing this and I will close by saying that
future doctors like yourself had best stay in 'your neck o' the woods' as
we do have plenty of "Modern Medicine" here already.
I thought the comments by Eddie Vos were quite interesting.
Competing interests:
None declared
Competing interests: No competing interests
Consider the assumptions
"Unlike policies in the United States, which promote individual
rather than state responsibility for the obesity problem, the strategy in
the United Kingdom specifically states that the solution does not lie with
the individual or doctor's office."
It does not matter what the policy states; it is what it assumes.
Major focus on dietary changes and physical activity in the UK all assume
individuals will make the change.
Ironically for the author's statement, more measures in the US than
in the UK are aimed at enabling an informed choice.
In my PhD research, I have examined the policy alternatives and
programmes proposed in the UK and the US since 1981 and evidence shows
that the state-individual divide of responsibility is unclear in both
countries.
Competing interests:
None declared
Competing interests: No competing interests