The Fat's in the Fire, Again

by Gina Kolata
Copyright 1998 The New York Times
Reprinted with permsision of
The New York Times (January 11, 1998)

The editors of the august New England Journal of Medicine gave their guilt-plagued overweight readers a New Year's gift. Losing weight, they wrote in their Jan. 1 issue, is "an ill-fated New Year's resolution."

Their evidence is taken from one of the largest studies ever conducted on the risks of obesity. In the study, which was published in the same issue, researchers analyzed the fates of 324,135 white adults who were followed for 12 years. They found that the excess risk of dying associated with obesity was modest and declined as people age. By age 65, the effect was virtually absent. It disappeared altogether by the time people reached 74.

But the reaction to the editorial, written by Dr. Marcia Angell and Dr. Jerome P. Kassirer, was decidedly mixed. Many Americans merely shrugged. Here we go again, they said. Another example of scientists saying one thing one day and another thing the next. Why should anyone believe them?

Outrage was the reaction among medical experts who have made the fight against obesity their life's mission and career. They charged that the eminent editors trivialized a major medical problem.

So is it risky to be fat? Perhaps, some experts say, the problem is that the question is too vague. A more specific question: Does being fat make it more likely that a person will develop chronic disorders like diabetes, high blood pressure and high levels of blood cholesterol? The answer is a resounding yes.

"Obesity is associated with a tremendous increase in diabetes," said Dr. Claude Bouchard, an obesity researcher at Laval University in Quebec. Fat people are up to five times more likely to develop the disease and three times more likely to develop high blood pressure, Bouchard said.

Another question: Is there an ideal weight (one at which the risk of dying is lowest)? The answer is, once again, yes. Dr. June Stevens, the lead author of the obesity study and an epidemiologist and nutritionist at the University of North Carolina, points out that her data and those of similar studies indicate the ideal weights are pretty much the same as those on the height and weight charts.

Being overweight may be politically incorrect, but a new study says it has little to do with a higher risk of death.

The data are associated with a measure called body mass index, in which the ideal is a number between 19 and 25. (To find your body mass index, divide your weight in pounds by your height in feet squared. Then multiply by 4.89. A woman who is 5 feet 5 inches tall and weighs 126 pounds has a body mass index of 21. A man who is 5 feet 10 inches tall and weighs 146 pounds has a body mass index of 21.)

But the question raised by The New England Journal of Medicine editors is different: Does obesity lead to an early death? When they argued that it did not, the fur flew.

Drs. Angell and Kassirer say the evidence that losing weight reduces the risk of premature death is "limited, fragmentary and often ambiguous." Why, they ask, is obesity such a rallying cry for public health and obesity experts, who trumpet it as the second-leading cause of preventable death, after smoking, in the United States?

Could it be, they wrote, that the "medical campaign against obesity" comes from the tendency to "medicalize behavior we do not approve of"? If science can say that obesity is a major cause of premature death, it follows that it must be treated, with drugs if necessary. Doctors repulsed by obesity can justify giving out pills, even those of uncertain value, because it is seen as a major health risk.

Never mind that every drug to date has been only minimally and temporarily effective, and some are even dangerous. The popular fen-phen combination has been banished, after two of the drugs, phenfluramine and dexfenfluramine, were found to be associated with rare and serious heart valve defects.

Fen-phen, though, was no means the only dangerous diet fix. A few years ago, a clinic in Brussels gave out combinations of Chinese herbs to dieters. A hundred women ended up in dialysis, their kidneys destroyed, say Belgian investigators, who add that some of these women are developing kidney cancer.

"In this age of political correctness, it seems that obese people can be criticized with impunity, because the critics are merely trying to help them," Drs. Angell and Kassirer wrote.

Yet many public health experts are adamant that obesity must be fought relentlessly.

Last week, Dr. C. Everett Koop, the former surgeon general who now heads a public health campaign called "Shape Up America," fired off a press release quoting a letter to The New England Journal that he wrote with Dr. JoAnn Manson of Harvard Medical School and Dr. Theodore VanIttallie of Columbia University. In their letter, the doctors argued that obesity causes 318,000 excess deaths a year and said, "It is difficult to justify complacency in the face of this growing epidemic now afflicting more than 58 million Americans."

"The only disagreement is among people who don't know the facts and don't have the scientific evidence," Dr. Manson said in a telephone interview.

Not surprisingly, others disagree about the disagreement. "No one is saying that being obese is good for you or is healthy," said Steven J. Milloy, the executive director of the Advancement of Sound Science Coalition in Washington. But its risks, he said, have been "way overemphasized."

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