“State of the Nation’s Waistline” is the title of a report prepared by the National Obesity Forum which makes the usual dire predictions about how obesity is getting worse and the failure of individuals, health professionals and the government to tackle the issue (1). Here is selection of some of the points made in the report:
- Obesity and weight management are a direct cause of many health problems
- GPs are best placed to provide tailored advice on the full spectrum of options available to treat obesity and prevent the complications which can occur, such as cardiovascular disease, type-2 diabetes and strokes
- Obesity is a major contributor to type-2 diabetes, it is essential that GPs are provided with better incentives to tackle obesity before it leads to major health complications
- Specific training on obesity management is missing from most GP training programmes, and most GPs are better equipped to deal with the consequences of obesity, such as heart disease, type-2 diabetes, and osteoarthritis, than they are to help patients deal with the underlying weight gain which has caused the problem.
It is evident from this that the report is based on the conventional conceptual framework for obesity. Essential this means that obesity (and excess weight) is the fundamental cause of many common diseases including heart disease, type-2 diabetes and stroke. Hence it follows that if the body weight can be reduced to values which are considered to be “normal” as determined by Body Mass Index (BMI) the health risks will be reduced. Although not spelled out specifically, it is clearly implied that weight loss can be achieved by calorie reduction.
Those responsible for the production of this report should be challenged on the following grounds:
- Where is the evidence that excess weight per se is a primary cause of various diseases/conditions of ill-health? Although there may be associations between the rates of heart disease and body weight, this does not demonstrate “cause and effect”. There are other possible explanations including the existence of a common factor which has an effect on both.
- BMI which is commonly used as an indicator of obesity is clearly “not fit for purpose”. Those with a BMI in the range 20-25 or thereabouts are considered to have the ideal weight and therefore the best of health. However those with BMI of 25-30 (“overweight) and over 30 (“obese”) are considered to be at an increased risk of developing various diseases. Furthermore these risks can be reduced if weight is lost so that a normal BMI is reached. In fact detailed studies have demonstrated quite convincingly that the highest life expectancy is observed for those who are overweight (2). Furthermore there is no indication that there is any deterioration in life expectancy until the BMI is above 35. In fact it has been established with people who are reasonably fit ( eg walking about 1 mile per day) that there is no variation in life expectancy with BMI. By contrast, those who took little regular exercise and were therefore unfit had a much lower life expectancy especially at high BMIs but also when the BMI was relatively low (< 18.5)(3). The importance of this finding is that the recommendations for increased exercise are basically sound. However this is because of a direct impact on the body and not indirectly via a reduction in body weight.
- Losing weight by calorie reduction just does not work. In the early 1990s a technology assessment conference in the USA evaluated the widespread attempts to lose weight. The following conclusions were reached. At any given time,
- Up to 40% of women and 24% of men are trying to lose weight
- Those who successfully remain on the weight loss programmes usually lose about 10% of their weight
- Up to 2/3 of the weight lost is regained within 1 year
- Almost all weight lost is regained within 5 years
- Weight loss is associated with increased mortality
- Many who are not overweight, especially young women are attempting to lose weight, which may have adverse physical and physiological consequences (4).
- There are several investigations which show that rather than improving health weight loss by the conventional calorie reduction approach actually increases the death rate (5).
This latest report is just preaching more of the same medicine which has failed so spectacularly in the past. It is now obvious to those with an open mind that a new approach is needed. From a public health perspective the really critical issue is type 2 diabetes which has increased by about 150% in the past 17 years. Those with this condition have a much greater risk of developing strokes, hypertension, heart disease and obesity than those who do not. Despite the fact that it is usually treated with drugs there are numerous case studies in which this condition can be successfully tackled by lowering the intake of carbohydrates, particularly those such as sugar which are highly refined (6). This is entirely logical and to be expected because diabetes is caused by excess glucose in the blood, which inevitably originates in the diet. When high levels of blood glucose persist, the body has to try to produce a continual supply of insulin. It is the insulin which causes damage to the various organs in the body resulting in many of the common diseases.
This knowledge provides compelling evidence that the prime cause is far too much sugar in the diet so the public health focus should be removing as much sugar as possible from the existing diet. Current public health messages are still far too vague and include references to saturated fats (7) and salt (8) even though the justification for reducing these nutrients has largely been discredited.
So the way forward is very clear. We need to reduce the intake of carbohydrates especially the sugar. This certainly a very simple message to get across and if there is a positive response there
should definitely be a reversal in the current adverse trends. For those who wish to reduce their weight they will find that this strategy is effective. Numerous case studies have confirmed that it is superior to the discredited conventional approach which is based on calorie reduction.
- Consensus Development Conference(1992) Annals of Internal Medicine 116 pp942-949