LETTERS A CALL TO SHIFT THE PUBLIC HEALTH FOCUS AWAY FROM WEIGHT Fildes et al.1 present sobering data on the reality of sustained weight loss for individuals with obesity. These authors concluded that current approaches to weight loss have failed and suggest, “research to develop wider reaching public health policies is needed to prevent obesity at the population level.” We agree that advances in research and policy should be leveraged to promote population health. However, we assert that this can best be achieved by shifting the focus away from markers of weight such as body mass index (BMI). BMI is a notoriously crude predictor of cardiometabolic health as well as mortality.2 Indeed, individuals with grade 1 obesity (BMI = 30.00---34.99 kg/m2) actually have a comparable risk of all-cause mortality to individuals considered to have a “normal” weight (BMI =18.50---24.99 kg/m2).3 Beyond merely relying on a crude marker of morbidity and mortality, the weight-focused approach to public health can actually contribute to poorer mental and physical health by promoting mood disorders (e.g., depression), poor body image, and eating pathology.4
Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Alfredo Morabia, MD, PhD, at [email protected].
Emphasizing weight (and weight loss in particular) can also perpetuate the stigma associated with obesity---stigma which itself has significant consequences for the health of individuals with obesity. Experiencing or anticipating weight stigma can lead to increased eating, activation of physiological stress systems, decreased physical activity, and health care avoidance. Moreover, weight stigma actually predicts weight gain over time in large longitudinal studies, including the nationally representative Health and Retirement Study.5,6 Therefore, when viewed through the lens of public health ethics, continuing the dominant weight-centric approach may violate the core principles of beneficence and nonmaleficience.7 Where, then, should we focus, if not on weight? There are many candidates that more directly assess an individual’s health risk (e.g., blood pressure, fasting blood glucose, cholesterol, or triglycerides). We believe the evidence is particularly strong regarding the role of fitness as a more effective focus than weight. Cardiorespiratory fitness repeatedly outperforms measures of fatness (e.g., BMI) in predicting cardiovascular and metabolic health as well as cardiovascular and all-cause mortality.2,8 The evidence is clear: sustained weight loss is an untenable goal for the vast majority of individuals with obesity and a fervent emphasis on weight is likely to do more harm than good. Thus, to effectively promote the health and well-being of all individuals (regardless of their size), researchers, clinicians, and policymakers should eschew weight as the primary outcome of interest. j Jeffrey M. Hunger, MA A. Janet Tomiyama, PhD
About the Authors Jeffrey M. Hunger is with the Department of Psychological and Brain Sciences, University of California, Santa Barbara. A. Janet Tomiyama is with the Department of Psychology, University of California, Los Angeles. Correspondence should be sent to Jeffrey M. Hunger, Department of Psychological and Brain Sciences, University of California, Santa Barbara, CA 93106
November 2015, Vol 105, No. 11 | American Journal of Public Health
(e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted July 24, 2015. doi:10.2105/AJPH.2015.302845
Contributors J. M. Hunger conceptualized the letter. J. M. Hunger and A. J. Tomiyama wrote, edited, and approved the letter.
References 1. Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an obese person attaining normal body weight: cohort study using electronic health records. Am J Public Health. 2015;Epub ahead of print. 2. Lavie CJ, De Schutter A, Milani RV. Healthy obese versus unhealthy lean: the obesity paradox. Nat Rev Endocrinol. 2015;11(1):55---62. 3. 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;309 (1):71---82. 4. Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10:9. 5. Hunger JM, Major B, Blodorn A, Miller C. Weighed down by stigma: how weight-based social identity threat influences weight gain and health. Soc Psychol Personal Compass. 2015;9(6):255---268. 6. Tomiyama AJ. Weight stigma is stressful. A review of evidence for the cyclic obesity/weight-based stigma model. Appetite. 2014;82:8---15. 7. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014: 983495. 8. Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a metaanalysis. Prog Cardiovasc Dis. 2014;56(4):382---390.
FILDES ET AL. RESPOND We are grateful to Hunger and Tomiyama for their interest in our recent article. We agree with their assertion that excessive focus on body weight may sometimes lead to negative psychological and behavioral outcomes for some obese individuals. We also agree that physical fitness is an important measure that is associated with long-term health outcomes. We disagree with the view that obesity should not be regarded as a focus for public
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LETTERS
health concern. Obesity is increasing rapidly in most regions of the world.1 Obesity is associated with greater risk of disease, including diabetes,2 heart disease,2,3 stroke2 and cancer.4 Obese individuals generally experience the onset of morbidity at younger ages, and more frequently experience multiple morbidity,5 than do individuals with more optimal body weight. Evidence for the relationship between obesity and mortality may sometimes be difficult to interpret because many serious health conditions are associated with weight loss. Nevertheless, results from the Global Burden of Disease study suggest that obesity and overweight are the fifth leading risk factor for mortality worldwide.6 Obesity is causally associated with high blood pressure and high blood glucose, which are estimated to be the first and third leading factors for mortality.6 Failure to consider body weight will neglect the proximal cause for intermediate measures including high blood pressure and high blood glucose. Modifying the physical, social, and economic environment in which people live so as to increase healthy eating, reduce sedentary behavior, and increase physical activity and physical fitness may contribute to controlling the increase in obesity. Easily measured metrics of body weight and body mass index are important in monitoring the achievement of these public health objectives. j
Contributors All authors contributed equally to this letter.
References 1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980---2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766---781. 2. Lu Y, Hajifathalian K, Ezzati M, Woodward M, Rimm EB, Danaei G. Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1.8 million participants. Lancet. 2014;383(9921):970---983. 3. Yusuf S, Hawken S, Ounpuu S, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366 (9497):1640---1649. 4. Arnold M, Pandeya N, Byrnes G, et al. Global burden of cancer attributable to high body-mass index in 2012: a population-based study. Lancet Oncol. 2015; 16(1):36---46. 5. Booth HP, Prevost AT, Gulliford MC. Impact of body mass index on prevalence of multimorbidity in primary care: cohort study. Fam Pract. 2014;31(1):38---43. 6. Global Burden of Health Risks. Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva, Switzerland: World Health Organization; 2009. Available at: http://www.who.int/healthinfo/global_burden_ disease/GlobalHealthRisks_report_full.pdf. Accessed July 26, 2015.
Alison Fildes, PhD Judith Charlton, MSc Caroline Rudisill, PhD Peter Littlejohns, MD Toby Prevost, PhD Martin C. Gulliford, MA, FFPH
About the Authors Alison Fildes, Judith Charlton, Peter Littlejohns, Toby Prevost, and Martin C. Gulliford are with the Department of Primary Care and Public Health Sciences, King’s College London, London, UK. Caroline Rudisill is with the Department of Social Policy, London School of Economics and Political Science, London. Correspondence should be sent to Martin C Gulliford, Department of Primary Care and Public Health Sciences, Capital House, 42 Weston St, London SE1 3QD UK (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted July 29, 2015. doi:10.2105/AJPH.2015.302853
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American Journal of Public Health | November 2015, Vol 105, No. 11
Letters to the editor referring to a recent Journal article are encouraged up to 3 months after the article's appearance. By submitting a letter to the editor, the author gives permission for its publication in the Journal. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge letters and to publish responses. Text is limited to 400 words and 10 references. Submit online at www. editorialmanager.com/ajph for immediate Web posting, or at ajph.edmgr.com for later print publication. Online responses are automatically considered for print publication. Queries should be addressed to the Editor-in-Chief, Alfredo Morabia, MD, PhD, at [email protected].
Emphasizing weight (and weight loss in particular) can also perpetuate the stigma associated with obesity---stigma which itself has significant consequences for the health of individuals with obesity. Experiencing or anticipating weight stigma can lead to increased eating, activation of physiological stress systems, decreased physical activity, and health care avoidance. Moreover, weight stigma actually predicts weight gain over time in large longitudinal studies, including the nationally representative Health and Retirement Study.5,6 Therefore, when viewed through the lens of public health ethics, continuing the dominant weight-centric approach may violate the core principles of beneficence and nonmaleficience.7 Where, then, should we focus, if not on weight? There are many candidates that more directly assess an individual’s health risk (e.g., blood pressure, fasting blood glucose, cholesterol, or triglycerides). We believe the evidence is particularly strong regarding the role of fitness as a more effective focus than weight. Cardiorespiratory fitness repeatedly outperforms measures of fatness (e.g., BMI) in predicting cardiovascular and metabolic health as well as cardiovascular and all-cause mortality.2,8 The evidence is clear: sustained weight loss is an untenable goal for the vast majority of individuals with obesity and a fervent emphasis on weight is likely to do more harm than good. Thus, to effectively promote the health and well-being of all individuals (regardless of their size), researchers, clinicians, and policymakers should eschew weight as the primary outcome of interest. j Jeffrey M. Hunger, MA A. Janet Tomiyama, PhD
About the Authors Jeffrey M. Hunger is with the Department of Psychological and Brain Sciences, University of California, Santa Barbara. A. Janet Tomiyama is with the Department of Psychology, University of California, Los Angeles. Correspondence should be sent to Jeffrey M. Hunger, Department of Psychological and Brain Sciences, University of California, Santa Barbara, CA 93106
November 2015, Vol 105, No. 11 | American Journal of Public Health
(e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted July 24, 2015. doi:10.2105/AJPH.2015.302845
Contributors J. M. Hunger conceptualized the letter. J. M. Hunger and A. J. Tomiyama wrote, edited, and approved the letter.
References 1. Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an obese person attaining normal body weight: cohort study using electronic health records. Am J Public Health. 2015;Epub ahead of print. 2. Lavie CJ, De Schutter A, Milani RV. Healthy obese versus unhealthy lean: the obesity paradox. Nat Rev Endocrinol. 2015;11(1):55---62. 3. 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;309 (1):71---82. 4. Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm shift. Nutr J. 2011;10:9. 5. Hunger JM, Major B, Blodorn A, Miller C. Weighed down by stigma: how weight-based social identity threat influences weight gain and health. Soc Psychol Personal Compass. 2015;9(6):255---268. 6. Tomiyama AJ. Weight stigma is stressful. A review of evidence for the cyclic obesity/weight-based stigma model. Appetite. 2014;82:8---15. 7. Tylka TL, Annunziato RA, Burgard D, et al. The weight-inclusive versus weight-normative approach to health: evaluating the evidence for prioritizing well-being over weight loss. J Obes. 2014;2014: 983495. 8. Barry VW, Baruth M, Beets MW, Durstine JL, Liu J, Blair SN. Fitness vs. fatness on all-cause mortality: a metaanalysis. Prog Cardiovasc Dis. 2014;56(4):382---390.
FILDES ET AL. RESPOND We are grateful to Hunger and Tomiyama for their interest in our recent article. We agree with their assertion that excessive focus on body weight may sometimes lead to negative psychological and behavioral outcomes for some obese individuals. We also agree that physical fitness is an important measure that is associated with long-term health outcomes. We disagree with the view that obesity should not be regarded as a focus for public
Letters | e3
LETTERS
health concern. Obesity is increasing rapidly in most regions of the world.1 Obesity is associated with greater risk of disease, including diabetes,2 heart disease,2,3 stroke2 and cancer.4 Obese individuals generally experience the onset of morbidity at younger ages, and more frequently experience multiple morbidity,5 than do individuals with more optimal body weight. Evidence for the relationship between obesity and mortality may sometimes be difficult to interpret because many serious health conditions are associated with weight loss. Nevertheless, results from the Global Burden of Disease study suggest that obesity and overweight are the fifth leading risk factor for mortality worldwide.6 Obesity is causally associated with high blood pressure and high blood glucose, which are estimated to be the first and third leading factors for mortality.6 Failure to consider body weight will neglect the proximal cause for intermediate measures including high blood pressure and high blood glucose. Modifying the physical, social, and economic environment in which people live so as to increase healthy eating, reduce sedentary behavior, and increase physical activity and physical fitness may contribute to controlling the increase in obesity. Easily measured metrics of body weight and body mass index are important in monitoring the achievement of these public health objectives. j
Contributors All authors contributed equally to this letter.
References 1. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980---2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766---781. 2. Lu Y, Hajifathalian K, Ezzati M, Woodward M, Rimm EB, Danaei G. Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1.8 million participants. Lancet. 2014;383(9921):970---983. 3. Yusuf S, Hawken S, Ounpuu S, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet. 2005;366 (9497):1640---1649. 4. Arnold M, Pandeya N, Byrnes G, et al. Global burden of cancer attributable to high body-mass index in 2012: a population-based study. Lancet Oncol. 2015; 16(1):36---46. 5. Booth HP, Prevost AT, Gulliford MC. Impact of body mass index on prevalence of multimorbidity in primary care: cohort study. Fam Pract. 2014;31(1):38---43. 6. Global Burden of Health Risks. Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva, Switzerland: World Health Organization; 2009. Available at: http://www.who.int/healthinfo/global_burden_ disease/GlobalHealthRisks_report_full.pdf. Accessed July 26, 2015.
Alison Fildes, PhD Judith Charlton, MSc Caroline Rudisill, PhD Peter Littlejohns, MD Toby Prevost, PhD Martin C. Gulliford, MA, FFPH
About the Authors Alison Fildes, Judith Charlton, Peter Littlejohns, Toby Prevost, and Martin C. Gulliford are with the Department of Primary Care and Public Health Sciences, King’s College London, London, UK. Caroline Rudisill is with the Department of Social Policy, London School of Economics and Political Science, London. Correspondence should be sent to Martin C Gulliford, Department of Primary Care and Public Health Sciences, Capital House, 42 Weston St, London SE1 3QD UK (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This letter was accepted July 29, 2015. doi:10.2105/AJPH.2015.302853
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American Journal of Public Health | November 2015, Vol 105, No. 11
