From the ASDAH Blog Committee: A study published on December 3, 2013 in the Annals of Internal Medicine (“Are Metabolically Healthy Overweight and Obesity Benign Conditions?: A Systematic Review and Meta-analysis” by Caroline K. Kramer, MD, PhD; Bernard Zinman, CM, MD; and Ravi Retnakaran, MD) concludes that “obese persons are at increased risk for adverse long-term outcomes even in the absence of metabolic abnormalities.” Despite lots of media attention, all is not as it seems; the study has some significant flaws. Some excellent critiques have already been raised, for example in this article in the Huffington Post by Anna Almendraia. Almendraia quotes Glenn Gaesser, PhD, professor and director of the Healthy Lifestyles Research Center in the Arizona State University School of Nutrition and Health Promotion at some length. He labeled the meta-analysis “junk science” because
“[i]t fails to factor in the very important, well-established contribution of cardiorespiratory fitness to overall health. The fact that they did not [include fitness] renders this study almost uninterpretable.”
Psychologist Deb Burgard, PhD, and a favorite HAES® expert here at the Health At Every Size® Blog, was also quoted by Almendraia regarding the way in which the media treated the study’s release, including the ubiquitous “exhortation[s] for overweight people to shed pounds.” She noted the destructive nature of these news stories:
“In fact, she continued, fat people who repeatedly try to lose weight are more likely to yo-yo diet, or weight-cycle, than they are to maintain weight loss permanently. And because weight-cycling has been linked to cardiac disease and other problems, overweight people who are metabolically healthy could increase their risks of the very diseases they tried to avoid in the first place if they lose weight and gain it back again.”
Two weeks later, as the dust settles, Dr. Burgard shares with us her further reflections:
In my opinion, the most important thing to know about the Kramer analysis is that the risk ratios that they report from the specific studies are not from the studies themselves, which had used the usual confounder corrections for sex and age. Apparently Kramer et al. only controlled for the size of the individual study, so the data are uninterpretable. As an example, consider how distorted the data will be if one study that happens to be larger has an older sample or one with more men in it. Or a younger one with fewer men, for that matter. It is kind of astonishing that this paper was published until you think about the agenda to make higher weight a reimbursable reason for all kinds of “treatment.”
The next things to know are:
1. The study is being used to justify “treatment of obesity” in all cases (read the media reports and the accompanying editorial), and the data are utterly silent on this point (even if they had been arrived at properly, which they were not), since this is not a study of fat people who try to lose weight vs fat people who did not try to lose weight; rather, it is a collection of studies that look at higher weight people vs people who have always been thinner.
There is no study that I know that tests the fundamental assumption that a fat person losing weight will have the risk profile going forward of an always-thin person, because there is no large enough group of formerly fat people who maintain their weight loss, even in the Weight Management Registry. There are studies that show intentional weight loss is linked to earlier death, and studies that show weight cycling is linked to poorer health outcomes. And so using the study’s reasoning is going to push more people down the road that actually raises the risk of developing the very metabolic factors that are associated with the events they are saying are caused by obesity itself.
2. They are saying that the metabolic risk factors are the things that differentiate between people who are healthy and who are not, and then saying that if the “healthy obese” go on to have more events and death, it must their higher weight causing it. However, there are other obvious and compelling explanations for why higher weight people might be at a higher risk, including the higher probability that they are also poorer, more likely to be subject to racism, and less likely to have access to good (and unbiased) medical care, as well as being subject to weight stigma, weight cycling, and fewer opportunities for physical activity. There were no controls for any of this.
3. I would like to see a time come when a finding that higher weight people have more illness or die earlier (if arrived at properly) was framed as evidence of a clear health disparity for higher-weight people, implicating not the higher weight person’s body, but rather the obvious and empirically demonstrated problems in accessing the resources for a good life: racism, economic discrimination, lack of access to health care, weight bias and weight stigma within every sphere of life including medical care, etc. Do we really think that these factors will not have an impact on people’s health? Higher weight people have been on the defensive, saying, hey, we can be healthy! much more than demanding a level playing field and unbiased health care.