Health News Review

In The Atlantic, Lindsay Abrams wrote, “The Problem With All of This ‘Overweight People Live Longer’ News.”  She began:

The counterintuitive findings that people who are overweight live longer, published today in the Journal of the American Medical Association, couldn’t have been more perfectly timed, coming as it has right when people are resolving to be healthier — which involves, for many, losing weight.

In many places where this story has been picked up, including The New York Times, The Wall Street Journal, and Time, the implication seems to be that the push to get people down to a “healthy” weight has been overblown.

But that being overweight is associated with increased lifespan isn’t new. It’s called the “obesity paradox,” and studies documenting it have lead to widespread speculation about the potential “protective benefits” of excess body fat.

For some health advocates, the implication is downright offensive. Walter Willett of the Harvard School of Public Health, for example, lost his cool this morning on NPR, declaring, “This study is really a pile of rubbish and no one should waste their time reading it.”

But the study’s author, Katherine Flegal of the Centers for Disease Control and Prevention, mounted a solid defense: “It’s statistically significant.” Those three words carry weight — if an association has been found to be significant, it tells us that if nothing else, we need to acknowledge that the results are in some way legitimate and warrant our attention.

The findings are without doubt interesting, which on its own makes the study worth reading. The problem is that despite the grandness of the meta-analysis — it takes into account over 3 million people! — it still has an extremely limited scope. It looks at BMI, and only BMI, in relation to death, regardless of cause. It’s impossible to report on its baseline conclusion without taking into account substantial caveats.

Read her entire piece to see her perspective on those caveats.

On the Knight Science Journalism Tracker, Faye Flam wrote, “New Study Deems Overweight the new Healthy. Stories Miss the Big Picture.”

I was surprised at the similarities between all the news stories I read. Nearly all took the standard dueling experts format  with Harvard School of Public Health researcher Walter Willet playing the skeptic’s role. Some of the stories did a better job than others in letting Willet explain why he thought this latest study was “rubbish” as he put it.

I was still left wondering what the scientific basis had been for our current dividing lines between normal, overweight and obese. How did the medical community decide who was “overweight” before? Surely it must have been based on some science. What was the evidence in favor of the old standard and why did this new meta analysis suggest something so different? Does this new analysis really show that “overweight” is good, or merely that we haven’t yet figured out how to define normal and overweight?

The only network TV news story on the study that I happened to see was by Dr. Jonathan LaPook of CBS.  I was almost deafened to anything else he said on the air when I heard him say, “Now here’s what I tell my patients….”  I wrote to LaPook immediately after the program and told him that I thought that what he tells his patients (he’s a gastroenterologist) is irrelevant for a national TV news audience.  I wrote that it was a classic “journalism versus doc-in-the-box” confrontation.   Physician-journalists have to make up their mind:  Are they journalists when they appear on the air?  Or are they physicians giving advice to patients?  He’s not my physician.  I don’t care what he tells his patients. The program is labeled CBS News – not CBS MD Advice Column. He doesn’t have any right to use the national television platform to promote his own medical advice to a news audience. It crosses a line of journalism ethics.  I can cite clauses in the codes of ethics of the Society of Professional Journalists and the Radio Television Digital News Association and in the Statement of Principles of the Association of Health Care Journalists that address the ethical pitfalls herein.*

Would a political reporter be allowed to give his/her advice to readers/viewers about whom to vote for? Never.

Then why would we accept a medical journalist giving his advice to patients as part of a story?

 * Addendum 15 minutes later:

The Society of Professional Journalists’ code of ethics states “Analysis and commentary should be labeled.” At the time of the post-Haiti-earthquake physician-led news coverage, SPJ president Kevin Smith wrote “injecting oneself into the story … is not objective reporting, and it ultimately calls into question the ability of a journalist to be independent, which can damage credibility.” While the Haiti coverage is on an entirely different plane than commenting on the overweight study, the SPJ president’s comments about a physician-journalist injecting oneself into a story is the salient point.

The Radio Television Digital News Association Code of Ethics states “Clearly label opinion and commentary.” Dr. LaPook stopped being a reporter when he said, “Here’s what I tell my patients.”  He then became a physician-advice columnist.  But the segue came suddenly, without caveats or clear labeling or separation of reporting from advice commentary.

The Association of Health Care Journalists Statement of Principles states:

  • Recognize that most stories involve a degree of nuance and complexity that no single source could provide. Journalists have a responsibility to present diverse viewpoints in context. (My comment: He became his own single source.  This is fraught with ethical pitfalls.  Why should his advice to his patients – and his advice alone – be given this platform?)
  • Distinguish between advocacy and reporting. There are many sides in a health care story. It is not the job of the journalist to take sides, but to present an accurate, balanced and complete report. (My comment: He was advocating his own advice.  That’s not what journalists do.)

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Comments

Paul Scott posted on January 4, 2013 at 2:21 pm

Obesity is a moral panic. It’s a symptom treated like an illness. It is necessary but not sufficient for higher mortality. Paul Campos has documented this well. But the medical establishment has made its bed and studies like this are going to be attacked. Which is what the author of the CJR cover story just did as well.

    Anne P. posted on January 11, 2013 at 4:10 am

    Moral panic, indeed? I wish in this case Schwitzer had been more critical of the panicked attempts to find flaws instead of merely enumerating them.

    Would that the skeptics were skeptical when it comes to studies and stories that toe the official line, cancer screening recommendations, new treatments, etc.

Marc Beishon posted on January 4, 2013 at 4:12 pm

I think you’re being a bit hard on Jonathan LaPook – surely he’s there primarily as a doctor (if he’s practising that is) and not as a journalist. More to the point is why a doctor is trying to moonlight (unsuccessfully it seems) as a reporter and why they let him.

ThomasJasen posted on January 5, 2013 at 6:32 pm

HEALTH, FITNESS AND ME 12-03-2012

My friends call me Thomas Jasen. My adult kids call me anything.
In July, I had a complete left knee replacement. Recovery exercise has been both physically painful and mentally exhausting. My overweight body had become allergic to exercise. A fat-man’s voice in my head reminded me that outstanding physical agility in the army and physical stamina as an electrician did little to prepare me to be physically fit at 60 years old. Like watching Packer football, exercise should be a lifelong habit that transcends generations.

As a baby boomer, I went to UW-Madison in 1973. I came back to finish a baccalaureate degree after a 36-year hiatus. After returning home from a misguided war, my first civilian transformation as a freshman was during Madison’s cultural war.

Continuing my studies in 2009, I discovered that Stanford University proved that young black students who exercise 60 minutes a day increased their academic outcomes by 52 percent and closed the inequality achievement gap to 10 percent or less. The National Institute of Health reports that when older blacks exercised, they increase a healthy lifespan by 47 percent. This may mean that the odds of being near perfect while finishing school as an old man are better odds then getting a Powerball winning ticket. Soon I will flex the muscles in my geriatric brain as easy as the imaginary muscles in my biceps. Even my blind old drill Sergeant Putnam would not recognize me after 16 weeks of daily exercise in a UW-Madison personnel fitness program.

While exercising at UW Natatorium, my bionic knee falters from doing a dumbbell lunge to strengthen my hamstrings; my body feels the meticulous chemicals in processed foods drain my enthusiasm to exercise. The saturated fat barge of fake food swimming in my gut tries to convince me that my stomach hurts too much for bench dips. As I focus on my wimpy pectorals, an inebriated greasy burger sits on my left shoulder. It bellows how a shot of tequila, and free bar snacks will convince me that lifting a beer stein is less stressful. As I meditate for thinness in front of a lit candle, mirages from T.V. snack mascots fervently invite me to quit my righteous endeavor. Should I join the happy skinny actors in eating nutrition less corn syrup in yogurt containing methane ripened fruit?

The politics of chemically processed foods affecting black America was not a problem until we adopted a city lifestyle in food wastelands. The grandmothers in the garden saved many an underpaid underemployed black family. Thankfully, the extent of these illnesses should reverse from the virtues of physical exercise and the garden diet of our slave ancestors. We don’t have to be stigmatized as holocaust victims of congestive heart failure, ischemic heart disease, Type 2 diabetes, stroke, chronic obstructive pulmonary disease, chronic kidney disease, Alzheimer’s disease, and colon and lung cancer.

A UW-Madison black psychologist tells me that plutocracy has a tendency to interpret the lifestyles of American nutritional values and taste perspectives as superior to the food cultures of black, Hispanic, and Asian families. Non-white cultures enhance the applied practice of success through group collaboration. We use social skills of motivation, confidence, focus and mental toughness necessary for improving the health of individuals to insure the health of the village. So when you see me running down the street and I suddenly stop to slow my racing heart …come out in your flip flops and Packers t-shirt to shout words of encouragement before your children carry me to the nearest emergency room.

Without your input, my whale of a 320-pound body will struggle to bench press 100 lbs. My lone voice shouts out encouragement that only my exercise coach can hear. Yes, that inner voice has helped me lose nearly 50 pounds of candy, beer, chips and ice cream. Yet, with the Internet, text messages, and Tweets you too can help me to decrease my weight even further. You steer me to recipes you enjoy and exercises you find easy to do yourself. Before my second hand bed frame breaks, I want to lose another 50 lbs. I invite you to encourage me to exercise harder, goad me to swim faster or even entice me with a Greek baklava.

While I will happily invite people who love sweet potato pie, make flat bread, use curry rice, and hang wet noodles to my table, I will depend on Aunt Jemima and Uncle Ben to transcend my love for Kentucky Colonels and hamburger clowns into a motivational love for Jolly Green Giant vegetables, Thai noodles, Indian curry and Mexican jumping beans. The vegetables in my community garden is planted, grown and harvested in order to help free me from the synthetic chemicals, fertilizers and pesticides that keep me fat from animal antibiotics and synthetic hormones. And even when my body-fat decreases from a lack of Twinkies, pizza and French fries, it is because I attend community meals where I also invite you to learn new ways to enjoy real food. When I visit local farmers markets, my purchases will include the nearly 200 local fruits, vegetables and grains that are culturally or historically linked to my great-great grandfather’s diet.

My heirloom garden gets me to exercise for a purpose. The garden shares a cornucopia of squash, tomatoes, and corn with friends, strangers and acquaintances. No, I will never give up Grandma’s fried chicken or Aunt Earlene’s chocolate coconut walnut cake or for that matter my fabulous eggplant lasagna. But I will put more spinach, broccoli, tomatoes, carrots, lettuce, cauliflower, celery cucumbers, green beans, squash, asparagus, cabbage and mushrooms on my plate. Their antioxidants help prevent or reduce the advent of cancer, infections, Alzheimer’s and diabetes.

Why don’t I make the calisthenics of jumping jacks in the park and running around the block a ritual to prevent these preventable ailments? Because I make the mistake in believing, that everyone is watching and laughing as my body bounces along the sidewalk. Besides, running while black invites unwarranted police stops. Your intervention will give me the confidence not to be ashamed and to share my jogging while bouncing and swimming without drowning experience. These positive interactions will help publicize the inequalities of diabetes, heart disease, and kidney failure that disproportionally affect people of color.

Let us dispel another inaccurate and unsubstantiated claims that abdominal girth is a by-product of our black heritage. The quality of urban physical education and sports programs that give us tennis activist, Arthur Ashe, baseball activist, Hank Aaron, and football activist Jim Brown; is diminished by economic apartheid. Traditionally, blacks use historical reminders of the mighty rivers, mountains and plutocrats we have overcome with much, much less public support.

I want to enhance my mental and physical strength with the vegetables of my slave and sharecropper ancestors. According to the Center for Disease Control, in the 1850’s, blacks lived 20-40 years longer then their former slave owners. I know my great-great grand Uncle Bud, the freed slave of a Tennessee pig farmer looked as old as Moses, but I did not know he was 117 years old when he died in 1971. Today blacks live 20-30 years less then their Euro-American counterparts.

If you believe in the power of diversity and the richness of minority cultures, then Tweet me about Hindu Yoga, Chinese Tai Chi or Jamaican Machet’e. If you believe that together we can cross the bottomless abyss of manmade Cheetos and Fritos into the homemade land of skillet cornbread and African Yohimbine, then watch my image lose weight while eating salad drenched with sister Jackie’s homemade dressing.

Conversely, if you believe that the psychology of exercise increases your income, that exercise can make you smarter, that exercise improves your love life, or even that exercise helps you to forgive Republicans; then measure my progress/demise on Twitter.

ID-EGO-SUPER-EGO

Constantine Kaniklidis posted on January 6, 2013 at 1:27 pm

Critical Appraisal of the Obesity Paradox and the Flegal Study (JAMA, Jan 2013)

Constantine Kaniklidis
Director of Medical Research, No Surrender Breast Cancer Foundation (NSBCF)
European Association for Cancer Research (EACR)

Recently we have been treated yet again to the usual cacophony of poorly informed and misleading headlines, this time concerning the “obesity paradox” – that overweight and low-grade (grade 1) obesity are not associated with compromised mortality and that being overweight in fact is associated with lower mortality compared to normal weight people. So from the news media we have, with the NY Times Health section leading the pack in unsurprisingly hyperbolic fashion: “Study Suggests Lower Mortality Risk for People Deemed to Be Overweight” (NY Times, 1 Jan 2013), and even more recklessly from the same source “Our Absurd Fear of Fat” (NY Times, 2 Jan 2013), joining these others: “Big deal: You can be fat and fit” (CNN, 3 Jan 2013), “Being overweight linked to lower risk of mortality” (CNN International, 2 Jan 2013), “Few Extra Pounds Won’t Kill You—Really” (WSJ, 1 Jan 2013), “Being moderately overweight might not pose health risk” (LA Times, 1 Jan 2013), “Being overweight may increase odds of living longer” (Fox News, 2 Jan 2013), and from so-called “health” e-zines we have “Why Do Fat Guys Live Longer?” (Men’s Health, 2 Jan 2013), and from even medical news sources we have “A Few Extra Pounds Linked to a Longer Life” (WebMD, 1 Jan 2013), “A Bit Of Extra Weight Helps You Live Longer” (Medical News Today, 2 Jan 2013), and with even the respected NIH’s MedlinePlus weighing in with “More evidence for “obesity paradox”" (1 Jan 2013). Listening to these misinformed voices, as a medical researcher I bemoan the lost art of critical appraisal and the negative effects of the false assurance these headlines, and the study underlying them, will inevitably have. Let’s critically review the claims and see what’s really going on.

There are several significant methodological issues with the widely cited and – we will show widely misinterpreted – systematic review and meta-analysis (SR/MA) conducted recently by Katherine Flegal and colleagues [1] at the Centers for Disease Control and Prevention on the association between overweight and obesity, and all-cause mortality using standard categories of BMI (Body Mass Index). First and foremost is the choice of BMI as weight metric. In the Iowa Women’s Health Study [2], compared to BMI waist circumference (WC) was demonstrated to be superior as a risk indicator for all-cause mortality. Whereas BMI was associated with mortality in a J-shaped fashion, with mortality rates being elevated in the leanest as well as in the most obese women, the waist/hip circumference ratio was strongly and positively associated with mortality in a strictly dose-response manner. Indeed, clinical guidelines from the Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults [3] have recommended that when assessing risk of adiposity-related disease, both BMI and waist circumference should be considered, and the unabated increases in waist circumference (WC) and its the superior association with obesity are now extensively evidenced (see [14] and references therein).

In this same connection, the Danish Cancer Society (DCS) study from Jane Bigaard and colleagues [4] found that a 10% larger waist circumference corresponded to a 1.48 times higher mortality over the entire range of waist circumference, with a dose-response relationship between waist circumference and mortality for individuals of the same BMI throughout the spectrum (even for those in the normal-weight range as judged by BMI). Similarly, a meta-analysis [5] of 29 elderly (65 – 74 yrs) cohorts found that a large WC, defined as ≥102 cm (40.2 inches) in men and ≥88 cm (34.6″) in women, was associated with increased all-cause mortality relative risks for those the overweight and obese BMI categories compared with the ‘healthy’ weight and a small WC (<94 cm (37") in men; 88 cm in women and >102 cm in men) in adults with BMI <35 kg/m2 was associated strongly with multiple cardiovascular risk factors (CRF), these including hypertension, diabetes, and hyperlipidemia [7, 8], suggesting the limitation of Flegal study in its restriction solely to all-cause rather than cause-specific mortality. This is further suggested in the study from Stephen Farrell and colleagues [9] who demonstrated that low cardiorespiratory risk fitness (CRF) is a stronger predictor than BMI of all-cause mortality in women, with low CRF in women being an important predictor of all-cause mortality, again suggesting that BMI as a predictor of all-cause mortality risk in women can be misleading unless CRF is also evaluated and weighted in.

An additional methodological limitation is failure to control for the aggregate effects of smoking and reverse causality, that latter being the state in which diseases lead to both weight loss and higher mortality. The Scottish study from Debbie Lawlor and colleagues [10] that examined the unbiased association of directly measured overweight and obesity (based on direct measurement of weight and height, not BMI) with all-cause and cause-specific mortality in two large prospective cohort studies. With the first 5 years of deaths removed as control, overweight was associated with an increase in all-cause mortality among never-smokers (relative risk range = 1.12 to 1.38), while obesity was associated with a doubling of risk in men in both cohorts and a 60% increase in women. Furthermore, in both never-smokers and current smokers, being overweight or obese was associated with significant increase in risk of cardiovascular disease.

These findings demonstrate that with appropriate control for smoking and reverse causality, both overweight and obesity are associated with important increases in all-cause and cause-specific mortality, and in particular with cardiovascular disease mortality. What the Scottish study reveals uniquely is that smoking is in fact itself associated with lower BMI and is moreover strongly associated with many of the same adverse health outcomes such as diabetes, cardiovascular disease, and respiratory disease that are likely to show increased incidence in the overweight and obese, and finally, given the strong association of smoking with reduced BMI, it may be insufficient of wholly control its effects through the typical simple adjustment for smoking in multivariable models, since for instance measurement error is effectively inevitable (current smokers may for example identify themselves as past smokers). In addition, this Scottish study shows that reverse causality – in which diseases lead to both weight loss and higher mortality – could attenuate the apparent relationship of obesity to mortality, especially but not exclusively in studies with shorter follow-up periods and/or inadequate control for critical confounders such as smoking.

The Scottish study [10] therefore demonstrates that reverse causality may induce an appreciable underestimation of the effect of obesity on all-cause mortality [13], while smoking strongly works to effectively mask the effects of both overweight and obesity on all-cause and cause-specific mortality, consequent to both the strong association between smoking and lower BMI, and to the strong effect of smoking on all-cause, and cause-specific cardiovascular, and cancer mortality, since mortality in those with lower BMI is increased because of their greater likelihood of being smokers, not because lower BMI is inconsequential to health. And being either overweight or obese was associated with significant increases in cardiovascular (particularly from coronary heart disease) and in oncological mortality among never-smokers, and even in current smokers, being overweight or obese was still associated with insignificant increase in risk of cardiovascular disease. It is simply that smoking and reverse causality alone and more powerfully, jointly, mask the true effects of overweight and obesity on all-cause and cause-specific mortality.

This also underlines the highly questionable constraint to all-cause mortality adopted by the Flegal study [1], rather than assessment of cause-specific mortality from cancer, heart disease or diabetes, given that any association between weight and mortality for different disease categories may vary with the specific disease, and moreover may show stronger linkage with weight at lower thresholds of BMI than does all-cause mortality, not of course neglecting the clear importance of morbidity and disability and compromised QoL associated with long-term diseases.

It also neglects to caution the reader that BMI is not itself decisively established as a reliable measure of unhealthy adiposity (‘fatness’) since it is only metric of height and hence fails to account for other known disease and mortality factors such as (1) differing fat levels, or (2) differing fat distribution such as the highly unfavorable "sarcopenic obesity" in which we have elevated fat mass concurrently with lowered lean / muscle mass), or (3) muscularity, or (4) nutritional balance, among others (remember highly muscular individual for example can have a high BMI and therefore be categorized as overweight, while not necessarily carrying significant excess fat). In addition, while BMI reflects the influence of body height over body weight, it does not reveal body fat percentage (BFP), and it has been established that body fat percentage (BFP) correlates with risk factors for cardiovascular disease and metabolic syndrome and hence may be a useful predictor of risk, particularly in metabolically obese, normal weight individuals []. It is clear that focusing of the narrow associative "play" between BMI and mortality (and more artificially still, only all-cause mortality) is unrepresentative of real world practice where a wide spectrum of risk factors would assuredly be weighed to assess mortality (and morbidity) risk, such as hypertension, dyslipidemia, and glucose and insulin dysfunction among many others, with BMI playing a highly limited role in whole- patient risk evaluations. And it is now clear that abdominal obesity is more harmful than general obesity: so, for example the risk of diabetes increases with increases in abdominal fat mass, waist circumference, or waist-to-hip circumference ratio, and this is in fact independent of BMI value [17. 18], while viscerally deposit fat as opposed to fat elsewhere in the body is associated with higher risk for hypertension [19], and abdominal fat mass is a strong risk factor for stroke independent, gain independently of BMI [20].

But still further and critical erosion of the Flegel study's conclusions come from the recent NCI prospective cohort study from Yikyung Park and NCI co-researchers [11] who performed a prospective analysis using data from 183,211 adults aged 45–75 who enrolled in the population-based Multiethnic Cohort Study. This NCI review exercised uncommonly effective control for confounding from conditions that lead to weight loss and mortality by excluding participants (1) with a history of cancer or heart disease, (2) who ever smoked, and (3) who died within the first 3 years of follow-up. Under those controls, an increased risk of mortality was observed in participants with a BMI ≥ 27.5 in both men and women compared with the reference category of BMI 23.0–24.9 (with a BMI ≥ 35.0 carrying a greater risk of mortality in men than in women), so that among healthy never smokers, adult overweight and obesity were both associated with increased risk of mortality in both genders, confirming the findings of the other tightly controlled study just discussed, the Scottish study.

Therefore, the balance of critically reviewed and appraised evidence fails to support the contention of the Flegal study that overweight is associated with significantly lower all-cause mortality relative to normal weight and that obesity at certain lower levels (grade 1) is not associated with higher mortality, but rather the cumulative weight of the data to date continue to support the negative impact on health, mortality, and morbidity of being overweight or obese. And in this connection, it must be also remembered that intentional weight loss does in fact result in a decreased incidence of cancer, particularly female obesity-related cancers [12] and so the seductive but misleading findings of the Flegal study should not lull us into a false security and diminish the very real motivations for maintenance of health-favorable weight along with other dietary and lifestyle interventions.

With the prevalence of obesity being greater than 20% in many developed countries and increasing in developing countries, and with obesity being unambiguously associated with metabolic disorders, especially diabetes, cardiovascular diseases, pulmonary diseases, digestive diseases, and cancers, it is clear that weight loss must remain the central defense against the pandemic, associated with an increased risk of death, morbidity, and accelerated aging [23], of obesity [15], diabesity (the designation for the continuum of abnormal metabolic biologies from mild insulin resistance to established diabetes that includes any insulin dysfunctions secondary to obesity), and metabolic syndrome, and no one should, through the compromised methodologies and against-the-weight-of-the-evidence conclusions we have demonstrated within the Flegal study, sustain the illusion that overweight or obesity is other than detrimental and contributory to morbidity and mortality, both all-cause and cause-specific, within the context of these rising and unabated pandemics. We need such clear recognition to help avoid or mitigate what is expected to be the future obesity for adults in the United States, namely that by 2030 (as projected from the National Health and Nutrition Examination Study (NHANES)), 86.3% American adults will be overweight or obese, and 51.1% of them will be obese, with total health-care costs attributable to obesity/overweight doubling each decade to 2030 and accounting for 16–18% of total US health-care costs [16]. And overweight and obesity could account for 14% of all deaths from cancer in men and 20% of deaths in women as shown a prospective study of 900,000 US adults [21]. Therefore, as these considerations show, both overweight and obesity cause huge burdens for patients, family, and for society, locally and globally and cannot legitimately be perceived as in any way healthful. It will take a wide spectrum of coordinated health professionals, public education, sophisticated research into diagnostic and therapeutic tools and interventions, and proactive national policies to launch integrative and targeted initiatives to materially influence and slow these pandemics in obesity, diabesity and metabolic syndrome.

References
1. Flegal KM, Kit BK, Orpana H, Graubard BI. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013 Jan 2; 309(1):71-82.
2. Folsom, A. R., Kaye, S. A., Sellers, T. A., et al (1993) Body fat distribution and 5-year risk of death in older women. JAMA. 269: 483–487.
3. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults—the evidence report. National Institutes of Health. ObesRes. 1998;6(suppl 2):51S-209S.
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5. de Hollander EL, Bemelmans WJ, Boshuizen HC, et al. The association between waist circumference and risk of mortality considering body mass index in 65- to 74-year-olds: a meta-analysis of 29 cohorts involving more than 58 000 elderly persons. Int J Epidemiol 2012; 41(3):805-17.
6. Kramer H, Shoham D, McClure LA, et al. Association of waist circumference and body mass index with all-cause mortality in CKD: The REGARDS (Reasons for Geographic and Racial Differences in Stroke) Study. Am J Kidney Dis 2011; 58(2):177-85.
7. Janssen I, Katzmarzyk PT, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines. Arch Intern Med. 2002;162(18):2074–2079. 8. Balkau B, Deanfield JE, Despres JP, et al. International Day for the Evaluation of Abdominal Obesity (IDEA): a study of waist circumference, cardiovascular disease, and diabetes mellitus in 168,000 primary care patients in 63 countries. Circulation. 2007;116(17):1942–1951.
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13. Lawlor (see below); Flanders WD, Augestad LB. Adjusting for reverse causality in the relationship between obesity and mortality. Int J Obes. 2008;32(Suppl 3):S42–6.
14. Chuang HH, Li WC, Sheu BF, et al. Correlation between body composition and risk factors for cardiovascular disease and metabolic syndrome. Biofactors 2012 Jul-Aug; 38(4):284-91.
15. Xiao J, Yang W. Weight loss is still an essential intervention in obesity and its complications: a review. J Obes 2012; 2012:369097.
16. Y. Wang, M. A. Beydoun, L. Liang, B. Caballero, and S. K. Kumanyika, “Will all Americans become overweight or obese? Estimating the progression and cost of the US obesity epidemic,” Obesity, vol. 16, no. 10, pp. 2323–2330, 2008.
17. H. Lundgren, C. Bengtsson, G. Blohme, L. Lapidus, and L. Sjostrom, “Adiposity and adipose tissue distribution in relation to incidence of diabetes in women: results from a prospective population study in Gothenburg, Sweden,” International Journal of Obesity, vol. 13, no. 4, pp. 413–423, 1989.
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21. E. E. Calle, C. Rodriguez, K. Walker-Thurmond, and M. J. Thun, “Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. Adults,” The New England Journal of Medicine, vol. 348, no. 17, pp. 1625–1638, 2003.
22. Adams KF, Schatzkin A, Harris TB, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 2006;355:763-778.
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    Greg Voelm posted on January 7, 2013 at 1:17 pm

    Excellent analysis Constantine! You make us public health people proud.

    CarolynS posted on January 15, 2013 at 9:56 am

    Sadly, this analysis is itself flawed in numerous ways. Read the JAMA study and you will see that many, perhaps most, of the articles actually do adjust in a variety of ways for smoking, so called reverse causality and early deaths, and by and large do not find that these factors really make any important difference. The Lawlor study is a single study, outweighed by the numerous studies in the JAMA paper, and relies on deleting huge amounts of data and making comparisons with relative risks that are not even adjusted for smoking.

kgapo posted on January 7, 2013 at 10:17 am

What about the international media who just repeated the news without any attempt to examine whether it is well based? I can list more than 20 respected media that only published a translation of ‘Overweight People Live Longer’ with anything further? Should they at least publish something on all that has been written in the meantime here and in other media? What remains in the minds of the average citizen is that some kilos more don’t matter…

Cheryl Payer posted on January 7, 2013 at 2:51 pm

By all means refine the data to take account of smoking, reverse causality, waist to hips ratio, morbidity, and age (not mentioned here, but obese kids are probably a very different case than heavyset middle agers), etc. But in defense of the study, it was appropriate to use BMI because nearly everybody else in our culture uses it. Some doctors have berated me as overweight on the sole basis of BMI, although I have very short legs and therefore have a lot of trunk weight in proportion to my height. Journalists use the BMI all the time, parroting what they have been told. But if skinny people are neither AVERAGE weight in our society, nor OPTIMUM in terms of longevity, it seems high time to redefine “normal” weight and stop recklessly overdiagnosing obesity by BMI.

Constantine Kaniklidis posted on January 7, 2013 at 6:47 pm

Greg:
Thank for the appreciation. You and other readers may be interested in a fuller publication-ready version of my posting, available on my evidence-based Cancer Research Edge site, at: http://obesityparadox.evidencewatch.com/

Kgapo:
Yes, point taken, the international media were no less frenzied or naive than the US media, and you are correct as to, regrettably, what the last impression left is on readers. Thanks.

Cheryl:
Very shrewd point! You are absolutely right that a newly refined definition of normal adiposity is long overdue, both because of the health consequences of misclassification via the questionable and widely discredited BMI metric, and because of precisely what you identified – that we consequently have not only misdiagnosis, but overdiagnosis founded on BMI, which is a disservice to the people on the medical and psychological receiving end of these misidentifications. But I would, and have often, argued, that the commonality of BMI is both overestimated and in any ethical evidence-based medicine cannot justify its continued use when we have had overwhelming evidence of its inadequacies and distortions in hundreds of methodologically robust studies undertaken since the 1990′s. The study should have been circumspect, and explicitly so, in acknowledging that their findings are founded solely on a disputed metric, although as I note, there are other fatal methodological flaws in the study that compromise the legitimacy of the conclusions drawn, independently of the issue of BMI. As lawyers like to say in a different context, there is no justification for repeating a slander. Thanks for your insights!

Constantine Kaniklidis
Director of Medical Research, No Surrender Breast Cancer Foundation (NSBCF)
European Association for Cancer Research (EACR)