Leonard Soloniuk, MD had this to say about my recent post on the obesity issue:

I have seen the assertion that obesity is not a health problem in several different contexts, but Paul Campos appears to be quite flamboyant in his arguments. There seem to be several issues here including the utility of BMI is categorizing people at risk. The whole question of the efficacy of interventions is also subject to question.

One of the reasons Campos’s arguments are worth considering is the recent history of the abuse of science and epidemiology in the pursuit of political goals. Examples would be the HIV epidemic and the medicalization of handgun restrictions. In these cases, interpretations of data have been distorted to fit predetermined policy goals. Thus,
when the usual suspects (e.g. the CDC, JAMA, etc.) declare a new health crisis, skepticism is in order.

There are a number of issues that need clarification in this debate: What is the role of BMI? Is body fat a better predictor and a better secondary outcome to follow? What are the true risks for mildly overweight patients? Which interventions lead to improved outcomes.

However, it is difficult to take seriously an attack on Americans, ascribing to them the need to discriminate. This seriously lessens his credibility for all of his arguments. And that’s unfortunate, because a reasoned analysis of this issue would be quite welcome

I’m inclined to agree with with Leonard that the generic attack on Americans as “wanting to discriminate” is simply not helpful to serious discsussion of this topic, even if there is 200+ years of history showing way more discrimination in the US than we’d like. However, you can make an argument that handgun wounds showing up in emergency rooms constitute, or at least cause, a health crisis (morbidity and mortality in young inner-city men) even if the initial study of the article was clearly politically motivated. So we should not be ready as Leonard to dismiss the CDC/JAMA “establishment” and their views on obesity just because (for instance) as NRA members we didn’t like their views on gun control. (I’m more confused by Leonard’s critique of the CDC’s actions around HIV, but maybe he’ll enlighten me).

However, Leonard does get to the right set of questions, when he asks whether BMI, body fat percentage or anything else really matters, and what the outcomes for overweight people truly are. These clearly require more study with real data rather than emotion amongst the medical community, and I suspect there is emotion on both sides–as there clearly is in Campos’ views.

As a non-medical healthcare blogger, I’m though asking a slightly different question which is, “will these opinions become mainstream” and if so “will that change the way healthcare services (including drugs) are used?” And if you don’t think that psycho-social changes in attitudes to health can change service provisions in health care you might want to take a look at this article about how the Atkins low-carb diet fad has revolutionized the restuarant and food business. (Arrgghh. Can”t find the NY Times article I read last night so here’s one about the chain Ruby Tuesday’s profit rise on the back of their low carb menu).

Fascinating article extracted in The Guardian from a new book from Paul Campos suggests that obesity is not a health problem. Well worth reading the article, but basically he suggests that while fitness and excercise have some impact on health outcomes, in general people with a Body-Mass Index (BMI) in the “recommended range” don’t do any better and in some cases do worse than those who are above that range. In fact it’s better to be overweight by several pounds than underweight by a few. Additionally the desire to reduce BMI suggests that people who become thinner have the same health outcomes as those who were thin all along, and although there have never been studies to support this (because you can’t get fat people to stay thin long enough) the evidence suggests that it’s not true. Further, the “propaganda” causes health problems by encouraging yo-yo dieting and poor body image, particularly amongst young white women. This leads of course to the serious medical and psychological consequences of eating disorders.

I’m not sure I know enough to be convinced of his arguments, but of course the treament of obesity is big business and getting bigger for the pharmaceutical industry. Campos lays at least some of the blame for the acceptance of the argument that “obesity is a disease that needs treatment” at their door. The rest he ascribes to the desires of Americans to discriminate, and now that civil rights and political correctness have taken away the ability to aim that discrimination at ethnic minorities, obese people are an easy target.

So basically I can have that bacon sandwich so long as I go to the gym. But on an industry level this conversation about what to do about obesity has serious implications for physicians and pharmaceutical manufacturers. And if the answer is not to worry about reducing obesity per se, that has some profound implications for how we may treat some of our biggest disease classes–diabetes and cardio-vascular disease–in the future. We are very quick to go to the pill when “diet and excercise” hasn’t worked. But what if, even if the pill works in reducing obesity, it doesn’t in improving outcomes?