The Weight Conundrum

I'll start with the thorny issue: is obesity always as bad as we make it out to be? Are there some people who are considered medically "obese," but who are still healthy and fit?

Let's start with simply looking at how to define overweight/obesity. The most common metric for determining weight status is the BMI (Body Mass Index). By using a person's weight and height the BMI attempts to be a proxy for determining body fat percentage (accurate body-fat tests are expensive and complicated). The BMI was originally developed to determine the "fatness" of a population, but because of its simplicity, has been repurposed to compare individuals*. Overweight is defined as having a BMI of 25-30 and obesity is having a BMI greater than 30. Those with a BMI greater than 40 are typically referred to as morbidly obese. Other metrics include determining a person's ideal body weight and assessing how much above/below that they are or measuring actual body fat.

The "fat & fit" side of the argument points out that the BMI fails to consider a person's unique build and the density of lean body tissue. Elite distance runners have BMIs around the 18-20 end of the spectrum while  football players commonly run greater than 25, putting them in the overweight category. Does this mean they are less healthy? [and I can't type BMI this many times without pausing to calculate my own: it's 18.5]

Some studies, such as one done by epidemiologist Edward Gregg say that fitness is what matters.

"What was unexpected was those who tried to lose weight -- but didn't -- those people had a mortality benefit," Gregg tells WebMD. "And our best speculation as to the reason is there are behaviors that go along with weight loss attempts that are good for you. These may have positive effects regardless of whether a person is able to maintain weight loss. They adopt more active lifestyles, they change diets. Over the long haul they are not successful at losing weight, but these lifestyle changes seem to help." [source]

Other studies contend that regardless of fitness status, death risks are increased in overweight people. [like this one]

Body fatness is a better predictor of CVD risk factor profile than aerobic fitness in healthy men. Although habitual physical activity is an effective strategy for preventing CVD, elevated body fatness is associated with an adverse CVD risk factor profile independently of aerobic fitness.

And there are studies that are on the fence about it all, such as this one:

 In recent years, the "fitness vs fatness" issue has led to controversy and heated debate. Although the debate may never be fully resolved, the relative contribution of fitness and obesity to overall health and risk actually may be a trivial matter because a common treatment is already available for both low fitness and excess body weight. Increasing regular physical activity results in predictable increases in fitness, and it is widely accepted that regular physical activity is a core component of successful weight loss programs and, more importantly, of long-term weight loss maintenance. In essence, physical activity is the common denominator for the clinical treatment of low fitness and excess weight, making the "fitness vs fatness" debate largely academic.

Weight is a convenient mode for communicating health risks to people. Everyone has a weight, it's a simple number, no variables. Physical activity and diet are messier; there are different intensities, different lengths, different caloric needs, and no easy way to count any of it. But by taking the focus off weight would people be more likely engage is exercise? Do some people fail at weight loss and thus permit themselves to also forgo a healthy diet and exercise? If diet (I use this term to define a lifetime of eating, not a short-term fix**) and exercise were the goal and not just the means would they have more staying power?

Thoughts, thoughts, and none of it will be solved with this post. In fact, hopefully, I just opened a can of worms in your mind about weight....


~L









*A soapbox issue of mine.
**Yet another issue I get rather involved in...

Weight Loss Programs and Insurance

Another set of two articles to ponder.

The first comes from the Consumer Reports Health Blog: Commercial Weight-Loss Programs: The Evidence

The second comes from Dr. Judith Wurtman on the Huffington Post: Weight Loss: Should Commercial Programs be Covered by Health Insurance?

It's one of those never-ending battles: do weight-loss programs actually work? Some say they do, some say they don't, others say they only work short-term or never allow the participants to have a "normal" food life without gaining all the weight back. And what is the scientific evidence for them? Strangely, there have been very few studies. The blog post from Consumer Reports looks at two recent studies in the Journal of the American Medical Association (JAMA) that looked at lifestyle interventions and prepared meals to help with weight-loss.

The first study lasted one year and split the participants into two groups. The first group had diet and physical activity interventions for the full year, the second group started with just a diet intervention and started physical activity six months later. The results? The group that did both diet and exercise initially had a greater weight-loss at the six-month mark, but after adding exercise, both groups had similar weight loss at the twelve-month mark.

I'm not sold on the study design. I think delaying the exercise in one group, but still having both groups do it, confounds the results. The initial intention wasn't to determine if delaying exercise had any effect on weight loss; it was looking at the efficacy of diet and exercise interventions. If I were planning this study I would have one group with only a diet intervention, one group with only a physical activity intervention, and one group with both interventions. This would (hopefully) allow the researchers to determine which type of intervention, or combination of interventions, was most effective.

So a structured diet and exercise plan works, and helps the participants keep the weight off for at least a year. What about the other study? This study was looking at the effect of pre-packaged meals as part of a structured weight-loss program (this study was funded by Jenny Craig). It compared two groups: one that received ongoing support in addition to prepackaged meals during the initial weight loss, the other group received standard obesity counseling and monthly "contact." The group that received meals and structured support had greater, sustained weight loss.

I like a couple things about this study. First, I like that the two groups were clearly defined; there wasn't any crossing-over with their interventions. Second, a two year follow-up gives a better picture of whether the intervention worked in the long-term. I'm not necessarily a fan of prepackaged meals. I question whether people would actually follow the program if they had to pay the inflated price for all of these meals (the study participants received them for free). And I don't like the idea that people aren't taught the principles of feeding themselves with real, fresh food. I'll be honest, I'm not familiar with the Jenny Craig plans and their prepackaged meals. Perhaps participants are taught the basics of good nutrition, maybe they do learn what to prepare for themselves after the packaged phase. But I'm hesitant. Will these people become reliant on a company to tell them what to eat to stay "healthy" (read: thin). Will they trust their own instincts on feeding themselves? What lessons are they passing on to their children with this? And there are a few bigger issues: the disparity created by those who can't afford these programs and concerns related  to packaged foods. I worry about added salt, sugar, preservatives, and the loss of the concept of real food. (I would love to go on about my views of nutrition, health, weight, and food, but that is best left for another post...or series of posts)

And what to do with this information? This is where the second article I linked to heads: should insurance companies cover weight-loss programs? Insurers are willing to shell out big bucks for obesity drugs and surgeries. Why? Because obesity costs them. And why won't these same companies pay for commercial programs? I'm at a loss there. It appears that it is a cheaper, effective alternative (probably not as effective as surgery, but one could argue that it is more cost-effective). I wonder if the companies see less weight loss as less healthy. I personally think fitness is preferable to thinness and I would presume that diet/exercise programs would achieve that better than surgery. It's an argument that could go around and around.

Thoughts?

~L