The use of the National Institutes of Health (NIH) Clinical Guidelines
to guide assessment and treatment of overweight and obese patients is the
source of considerable debate. The guidelines rely, in part, on research
with methodological problems.
Full Text (1704 words)
Copyright Decker Periodicals, Inc. Mar/Apr 1999 [Headnote]
ABSTRACT The use of the National Institutes of Health (NIH)
Clinical Guidelines to guide assessment and treatment of overweight and
obese patients is the source of considerable debate. The guidelines rely, in
part, on research with methodological problems.The standard treatments for
obesity outlined in the Guidelines have not proven to be successful long
term. Evidence suggests obesity may be a result of biochemical defects, not
eating and exercise patterns. Dieting, one of the recommended treatments, is
a known risk factor for development of an eating disorder. Further, there is
no conclusive evidence that weight loss improves health outcomes. Nutrition
education professionals need to develop approaches that improve health
independently of weight loss for Americans seeking to lose weight. gATE
31:116-118, 1999)
As nutritionists involved in promoting the overall health of
Americans, we are concerned that the National Institutes of Health (NIH)
Clinical Guidelines may cause more harm than good. Although the prevalence
of overweight and obesity is clearly increasing in the U.S., we question
whether the Guidelines provide guidance to practitioners about how and when
to treat obesity.
The Clinical Guidelines are derived from the examination of 800
references, which include well-designed randomized clinical trials with
large numbers of subjects, but also studies with limited numbers of
subjects, post hoc studies, meta-- analyses, studies with somewhat
inconsistent outcomes and/or specialized populations, and even uncontrolled
or nonrandomized trials and observational studies. Interestingly, the
editors of the New England Journal of Medicine (NEJM), who reviewed the same
body of literature, came to vastly different conclusions, summarized in a
January 1, 1998 editorial entitled Losing Weight-An Ill fated New Year's
Resolution.1
The Clinical Guidelines recommend standard, widely used treatments
(i.e., diet therapy, physical activity, behavior modification, pharmacologic
therapy, and surgery). Although standard treatments may be successful
initially, it is well documented that most people who lose weight regain
that weight within 5 years.2-5 A growing body of evidence suggests that most
forms of obesity are more likely the result of biochemical defects rather
than due to consumption of excess calories.6 Furthermore, the very
references cited by the Guidelines to support the recommended initial weight
loss goal of 10% of body weight actually show that less than half of the
participants of those trials could meet this goal.-10 In other words, we
have no effective long-term treatments for obesity, and none are on the
horizon.
We are also concerned that the Clinical Guidelines ignore what NEJM
editors described as "the dark side to this national preoccupation" (i.e.,
body dissatisfaction among women and teenagers, the negative consequences of
dieting, and the prevalence of eating disorders among adolescents and young
women). Dieting is a recognized risk factor for the development of an eating
disorder.11-13 A number of researchers have concluded that dieting is
strongly associated with the development of bulimia.14-16 Furthermore,
caloric restriction leads to bingeing behavior.17,18 The Guidelines, in
recommending that weight maintenance therapy be continued indefinitely, will
escalate our national preoccupation with weight and will exacerbate its
"dark side."
The association between overweight and morbidity or mortality is far
from certain. Epidemiologic studies have indicated that higher body weights
were neutral or positively associated with longevity.19-23 Of particular
concern to us is that the Guidelines target Body Mass Indices (BMIs) of 25
and above as being associated with "high" relative risk. We agree that
increasing weight and mortality are related at very high weights, but for
BMIs below 28, the relative risk of mortality increases only slightly.1 We
lack evidence that losing the 6 or 7 pounds that would result in a change in
BMI from 26 to 25 actually reduces risk. Even at higher BMIs, there is no
conclusive evidence that weight loss reduces risk. In a comprehensive review
of epidemiologic studies, no support was found for the commonly held notion
that weight loss, even among the overweight, leads to improved health and
increased longevity.24 Furthermore, weight loss may increase mortality.25,26
Barnard et al.27 reported that obese men and women significantly reduced
blood pressure and serum lipid, insulin, and glucose levels by changing diet
and exercise habits with little, if any, change in body weight. Barlow et
al.28 have shown that, in fact, lower risk of mortality has been found to be
positively associated with fitness, but not with fatness. These researchers
found that moderate- and high-fit men in BMI categories greater than or
equal to 27 had lower death rates than their low-fit counterparts. Low-fit
men with BMIs less than 27 were three times more likely to die young than
the fatter men who exercised regularly.
Are the Clinical Guidelines an appropriate prescription for treating
overweight and obese patients? We think not. First, health benefits can be
achieved without weight loss. Second, encouraging weight loss, especially
through dieting, is not likely to be effective and may result in a host of
additional physical and psychological problems.29
We encourage our professional colleagues to join us in developing and
testing "approaches that can produce health benefits independently of weight
loss [which] may be the best way to improve the physical and psychological
health of Americans seeking to lose weight."30 We conclude that weight loss
is not necessarily the answer to "How can fat people be healthy?"
The Division of Nutrition and Weight Realities endorses the New Weight
Paradigm.31 This paradigm has evolved through recognition of the limited
success of weight loss interventions. It challenges the medicalization of
obesity as demonstrated in the NIH Guidelines.We advocate acceptance of
one's self, as well as one's body size and shape, and we urge direct pursuit
of health and happiness, rather than viewing slenderness as a prerequisite
for these goals.
[Reference]
REFERENCES
[Reference]
1. Kassirer JP, Angell M. Losing weight: an ill-fated new year's
resolution. N Engl J Med 1998;338:52-4.
2. Garner MG, Wooley SC. Confronting the failure of behavioral
and dietary treatments for obesity. Clin Psychol Rev 1991;11:729-80. 3.
Leibel RL, Rosenbaum M, Hirsch J. Changes in energy expenditure resulting
from altered body weight. N Engl J Med 1995;332:621-8. 4. Wickelgren I.
Obesity: how big a problem? Science 1998;280:1364-7. 5. Wooley SC, Garner
DG. Obesity treatment: the high cost of false hope.
JAm Diet Assoc 1991;91:1248-51.
6. Schwartz MW, Seeley RJ.The new biology of body weight
regulation. JAm Diet Assoc 1997;97:54-8.
7. The Trials of Hypertension Prevention Collaborative Research
Group. Effects of weight loss and sodium reduction intervention on blood
pressure and hypertension incidence in overweight people with high-normal
blood pressure. Arch Intern Med 1997;157:657-67.
[Reference]
8. Wadden TA, Sternberg KA, Letizia KA, Stunkard AJ, Foster
GD.Treatment of obesity by very low calorie diet, behavior therapy, and
their combination: a five year perspective. Int J Obes 1989;13:39-46. 9.
Wadden TA, Stunkard AJ. Controlled trial of very low calorie diet, behavior
therapy, and their combination in the treatment of obesity. J Consult Clin
Psychol 1986;54:482-8.
10. Stamler MA, Stamler J, Grimm R, et al. Nutritional therapy
for high blood pressure: final report of a four-year randomized controlled
trial-the Hypertension Control Group. JAMA 1987;257:1484-91. 11. Cooper Z.
The development and maintenance of eating disorders. In: Brownell KD,
Fairburn CG, eds. Eating disorders and obesity: a comprehensive handbook.
NewYork: Guilford,1995:199-211. 12. Grodner M."Forever dieting": chronic
dieting syndrome. J Nutr Educ 1992;24:207-10.
[Reference]
13. Wilfey DE, Rodin J. Cultural influences on eating disorders.
In: Brownell KD, Fairburn CG, eds. Eating disorders and obesity: a
comprehensive handbook. New York: Guilford,1995:199-211. 14. Marchi M, Cohen
P. Early childhood eating behaviors and adolescent eating disorders. J Am
Acad Child Adolesc Psychiatr 1990;29:112-7. 15. Patton GC,Johnson-Sabine
E,Wood K, Mann AH,Wakeling A. Abnormal eating attitudes in London
schoolgirls-a prospective epidemiological study: outcome at 12-month
follow-up. Psychol Med 1990;20:383-94.
16. Brunner RL, St. Jeor ST, Scott BJ, et al. Dieting and
disordered eating correlates of weight fluctuation in normal and obese
adults. Eating Disord 1994;2:341-55.
17. Keys A, Brozek J, Henschel A, Michelson O, Taylor HL. The
biology of human starvation. Vol 1. Minneapolis: University of Minnesota
Press, 1950.
[Reference]
18. Garfinkel P, Kaplan AS. Starvation based perpetuating
mechanisms in anorexia nervosa and bulimia. Int J Eating Disord
1985;4:65263. 19. Keil JE, Sutherland SE, Knapp RG, Lackland DT, Gazes PC,
Tyroler HA. Mortality rates and risk factors for coronary disease in black
as compared with white men and women. N Engl J Med 1993;329:73-8. 20.
Menotti A, Keys A, Kromhout D, et al. Intercohort differences in coronary
heart disease mortality in the 25-year follow-up of the seven countries
study. Eur J Epidemiol 1993;9:527-36. 21. Rissenen A, Knekt P, Heliovaara M,
et al. Weight and mortality in
Finnish women.J Clin Epidemiol 1991;44:787-95. 22. Troiano RP,
Frongillo Jr. EA, Sobal J, Levitsky DA. The relationship between body weight
and mortality: a quantitative analysis of combined information from existing
studies. Int J Obes 1996;20:63-75. 23. Kabat GC, Wynder EL. Body mass index
and lung cancer risk. Am J Epidemiol 1992;135:769-74.
24. Lee IM, Paffenbarger RS. Is weight loss hazardous? Nutr Rev
1996;54:S116-24.
Andres R, Muller DC, Sorkin JD. Long-term effects of change in
body weight on all-cause mortality: a review. Ann Intern Med
1993;119:737-43.
[Reference]
26. Pamuk ER,Williamson DF Madans J, Serdula MK, Byers T Weight
loss and mortality in a national cohort of adults, 1971-1987. Am J Epidemiol
1992;136:686-97.
27. Barnard RJ, Ugianskis EJ, Martin DA, Inkeles SB. Role of
diet and exercise in the management of hyperinsulinemia and associated
atherosclerotic risk factors. Am J Cardiol 1992;69:4404.
[Reference]
28. Barlow CE, Kohl III HW, Gibbons LW, Blair SN. Physical
fitness, mortality and obesity. Int J Obes 1995;19(Suppl 4):S41-4. 29.
Polivy J. Psychological consequences of food restriction. J Am Diet Assoc
1996;96:589-92.
30. National Institutes of Health Technology Assessment
Conference. Methods for voluntary weight loss and control. Ann Intern Med
1992;116:942-9.
[Reference]
3:1 Robson JI, Hoerr SL, Petersmarck KA, Anderson JV .Redefining
success in obesity intevention: the new paradigm. J Am Diet Assoc
1995;95:422-3.
[Author Affiliation]
MARCIA HERRIN,1 ELLEN PARHAM, 2 JOANNA IKEDA, 3 ADRIENNE WHITE,
4 AND LAUREL BRANEN5
"NR" <[email hidden]> wrote in message
news:[email hidden]...
Quoted message said:-----BEGIN PGP SIGNED MESSAGE-----
Licquored up said:
A woman at a bmi of 28 who has
no abdominal fat is not at any significant health risk. She can be quite
healthy if she exercises daily and eat healthy food. On the other hand, a
woman with a bmi of 20, who never exercises and eats junk food is at a
severe health risk.
Unfit thin women fare better than fit[sic] fat women.
Am J Epidemiol 2002 Nov 1;156(9):832-41
Fitness and fatness as predictors of mortality from all causes and from
cardiovascular disease in men and women in the lipid research clinics
study.
Stevens J, Cai J, Evenson KR, Thomas R.
Department of Nutrition, School of Public Health, University of North
Carolina, Chapel Hill 27599, USA. [email hidden]
