Should all obese people lose weight?

You may be obese, but does that automatically mean you're unhealthy?

The conventional wisdom is that if you're overweight or obese, you're in mortal danger because that extra weight is like a ticking time bomb ready to unleash diabetes, heart disease and other health complications.

But doctors have known for years that obesity doesn't affect all people the same way. An obese person could lead a healthy life while another person with the same body mass index, or BMI, could have severe medical problems.

Two studies published Monday suggest reframing the way medical practitioners look at overweight and obese patients. The studies question the notion that BMI and weight determine health -- even when someone is severely obese.

"Our study challenges the idea that all obese individuals need to lose weight," said Dr. Jennifer Kuk, assistant professor in York University's School of Kinesiology & Health Science in Toronto. One in five obese people may not have medical problems, the authors estimated.

The challenge is determining who are the "healthy obese" and those who may not have complications now but may develop them in the future.

The studies appear in two publications, the Canadian Medical Association Journal and Applied Physiology, Nutrition and Metabolism.

The first study analyzed data from 8,000 people in the National Health and Human Nutrition Examination Surveys, a cross section of the U.S. population.

The main question was whether BMI alone could determine who dies early, said Dr. Arya Sharma, the lead author.

The BMI measures weight relative to height but does not calculate body fat. A person who has a BMI between 25 and 29 qualifies as overweight; a BMI greater than 30 is obese. This measurement has been used as an indicator for obesity since the 1980s.

In the Canadian research, each person who qualified as overweight was given a ranking based on the Edmonton Obesity Staging System, which Sharma designed.

A person can be ranked from zero, which indicates no apparent medical risk, although his or her weight is considered obese. As the stages progress, the symptoms become more serious.

Stage one is borderline hypertension and elevated blood pressure. The person may have elevated glucose levels and mild physical symptoms such as pain and aches. The person does not have a clinical disease at this point.

Stage two is classified with obesity-related diseases such as hypertension, diabetes and sleep apnea. The person may face limitations on daily activities.

Stage three means the person has organ damage such as heart failure, diabetic complications and debilitating arthritis. The person may also be suicidal and depressed.

Stage four is the most severe, with end-stage chronic diseases, severe disabilities and functional limitations.

This method of ranking risk more accurately predicted someone's death in 20 years than using BMI.

"What the study clearly shows is you can't make that call based on BMI," Sharma said. "You're going to have to look at additional risk factors."

But the study looked at mortality -- not quality of life.

"Their study was largely mortality in the outcome," said Dr. Steven Heymsfield, executive director of the Pennington Biomedical Research Center in Baton Rouge, Louisiana, who was not involved in the research. "It doesn't mean your knees and hips don't have to be replaced. I still think that's an issue. You suffer certain social and employment stigma."

Researchers predictably found a correlation between health complications and heavier weight. But they also found "people who are out there, who are pretty healthy despite being large," Sharma said.

"Of course, people at a high BMI are more likely to have these problems, but 20% may be doing OK," he said.

In the other article published in Applied Physiology, Nutrition and Metabolism, Canadian researchers found similar results. Although higher BMI was associated with increased death risk, there was "considerable variation in the health risk profile" in the obese population, according to the report.

The study used data from the Aerobics Center Longitudinal Study consisting of 29,533 individuals and assessed their mortality 16 years later.

They found no difference in death risks between normal-weight individuals and obese individuals who were in stages zero or one of the Edmonton Obesity Staging System.

They "are at no greater risk of dying than normal weight individuals," said Kuk, the Toronto professor. "It challenges the notion all obese individuals need to lose weight"

Who are the 'healthy obese'?

Why are some people considered the "healthy obese" versus others who might be less overweight but have more obesity-related complications?

Genetics could play a role. A person's chances of getting diabetes, high blood pressure or arthritis with weight gain are stronger if he or she has parents or grandparents who also had the conditions.

Another factor is the quality of diet and level of fitness. These factors lower a person's risks even though his or her weight may qualify as obese. But other factors remain unclear.

Rather than focus on weight, Sharma suggests checking for chronic disease risk such as blood pressure and other factors in obese patients.

"The key message is I can't tell you how healthy someone is if you tell me height or weight on a scale," said Sharma, chair for obesity research and management at the University of Alberta. "I have to do additional tests for other health problems."

He designed the ranking system because of long waiting lists for obesity treatment on Canadian public health care. Doctors had to decide who should be treated first.

The ranking system shows not everyone is the same and helps "to identify who should actually lose weight and who are we torturing for no reason," Kuk said.

"It's a bad thing to have a sweeping brush for everybody," she said.

While doctors who treat obesity agree that BMI is not a good solitary measure of health, they said the papers have limitations.

Dr. Allen Rader, a member of the American Society of Bariatric Physicians, noted that a patient could need weight loss intervention even in the early stages of disease risk to "prevent or delay progression."

Dr. Howard Eisenson, executive director of the Duke Diet & Fitness Center, echoed the same concern.

If he had a 25-year-old patient, Eisenson said, he wouldn't tell the person, "You're fine. Don't worry because you don't have any chronic diseases."

"If we don't intervene now, by the time the person is 35 ... maybe some damage has been done and the unhealthy habits are more established," Eisenson said.

Doctors agreed that there should be a more sophisticated method of assessing risk in obese patients, rather than just weight or BMI.

Health groups such as the World Health Organization and the U.S. Food and Drug Administration have been using BMI as measure of obesity, which also determines whether people qualify for drugs or bariatric surgery.

While calling the proposed ranking system intriguing, Eisenson said, "It's not quite clear what the average physician should do."

Distracted eating may add to weight gain

If you are worried about your weight, paying more attention to what you eat, not less, could help keep you from overeating. Multitasking—like eating while watching television or working—and distracted or hurried eating can prompt you to eat more. Slowing down and savoring your food can help you control your intake.
That’s the bottom line from a report published in the April issue of the American Journal of Clinical Nutrition. A team from the University of Birmingham in the United Kingdom scoured the medical literature for studies that have looked at how attention and memory affect food intake. All of these studies had at least two groups, such as one group that ate a particular meal while watching television and another that ate the same meal without television.
These studies point to two key conclusions:

• Being distracted or not paying attention to a meal tended to make people eat more at that meal
• Paying attention to a meal was linked to eating less later on.

These results make good sense. Hunger isn’t the only thing that influences how much we eat during the day. Attention and memory also play roles. For example, after you start eating, it takes 20 minutes or so before the brain begins to start sending out “I’m full” or “I’m not hungry anymore” signals that turn off appetite. If you are hurrying or not paying attention, it’s easy to take in many more calories than you need in 20 minutes.
If you aren’t mindful of what’s going into your mouth, you don’t process that information. That means it doesn’t get stored in your memory bank. And without a memory of having eaten, you are more likely to eat again sooner than you might have if you ate mindfully.

Mindful eating

Mindful eating is an application of a broader approach to living called mindfulness. It involves being fully aware of what is happening within and around you at the moment. You can practice mindfulness during any daily activity—including eating.
Applied to eating, mindfulness includes noticing the colors, smells, flavors, and textures of your food. It also means getting rid of distractions like television or reading or working on your computer.
If mindful eating is a new concept for you, start gradually. Eat one meal a day or week in a slower, more attentive manner. Here are some tips that may help you get started:

• Set your kitchen timer to 20 minutes, and take that time to eat a normal-sized meal.
• Try eating with your non-dominant hand; if you’re a righty, hold your fork in your left hand when lifting food to your mouth.
• Use chopsticks if you don’t normally use them.
• Eat silently for five minutes, thinking about what it took to produce that meal, from the sun’s rays to the farmer to the grocer to the cook.
• Take small bites and chew well.
• Before opening the fridge or cabinet, take a breath and ask yourself, “Am I really hungry?” Do something else, like reading or going on a short walk.

Mindful eating can reduce your daily calorie intake. By paying attention to what you are putting into your mouth, you are more likely to make healthier food choices. And you will enjoy meals and snacks more fully. That’s a pretty good three-fer!

A good day to check your medications

Patrick J. Skerrett, Executive Editor, Harvard Health

For many people, medications are a mainstay for preventing and treating disease. Managing multiple conditions and multiple medications can be confusing, especially if you store some of your pills in the medicine cabinet and others in a kitchen cabinet or pill drawer. Every once in a while, it’s a good idea to take inventory of all of your medications. As a reminder to do just that, the American College of Endocrinology has declared April 15th as National Check Your Meds Day. Here’s what the college recommends:

• Look everywhere you may store medications—medicine cabinet, bathroom counter, toiletry bag, refrigerator, purse, sock drawer, etc.
• Check the label for the name of the prescription and the dosage. Confirm that what you got from the pharmacy matches what your doctor prescribed. Contact your pharmacy if they don’t match exactly.

One reason the American College of Endocrinology recommends this kind of inventory is that insurance companies or pharmacies may substitute one brand-name or generic medication with another one without notifying you. Although this usually doesn’t make a difference, it’s good to know exactly what medication and what formulation of it you are taking. (If you aren’t 100% sure what a particular pill is, you can look it up at the Pill identifier on Drugs.com.)
Another reason is that it’s important to check expiration dates. For most medications, going a few months beyond the expiration date is okay. Beyond that, it’s time for a new prescription.
If you have expired medicines, don’t just toss them in the garbage. They could pose a safety hazard to children or animals if they somehow get out of the trash. Medicines in dumps and landfills are also making their way into our drinking water. Some pharmacies take back expired medications. The Boston Police Department and some other local law enforcement agencies offer collection boxes for out-of-date medications. If you can’t find a take-back program, here’s what the FDA recommends for most drugs:

• Take the medication out of its original container, mix it with used coffee grounds, kitty litter, or dirt, and put this unappetizing blend in a plastic container with a tight-fitting lid or in a sealable plastic bag. Put the container or bag into your regular garbage.
• Scratch off the prescription label and any identifying information from the original container to protect your identity and the privacy of your health record, and recycle or dispose of the container.

The FDA’s Web site provides a list of the 25 “flush-only” drugs as well as more information on disposing unwanted medications.

New study links L-carnitine in red meat to heart disease

Daniel Pendick, Executive Editor, Harvard Men's Health Watch

Is red meat bad for your heart? A new study suggests it is, but not for the reasons you might expect.

There’s long been a perception—not necessarily backed by strong evidence—that eating steak, hamburger, lamb, and other red meat ups the risk of heart disease. The saturated fat and cholesterol they deliver have been cited as key culprits. A team from a half dozen U.S. medical centers says the offending ingredient is L-carnitine, a compound that is abundant in red meat.

According to this work, published online in the journal Nature Medicine, eating red meat delivers L-carnitine to bacteria that live in the human gut. These bacteria digest L-carnitine and turn it into a compound called trimethylamine-N-oxide (TMAO). In studies in mice, TMAO has been shown to cause atherosclerosis, the disease process that leads to cholesterol-clogged arteries. We know that clogged coronary arteries can lead to heart attacks.

So, case closed—don’t eat red meat? Sorry, nutritional science isn’t that simple.

“The studies of red meat and heart disease in humans are conflicting,” says Dr. Dariush Mozaffarian, associate professor of medicine at Harvard-affiliated Brigham and Women’s Hospital. “This new research was well-done and compelling, but it’s too early to decide that this molecule, TMAO, causes atherosclerosis in humans or that this is responsible for some of the associations of meat intake and risk.”

Dr. Mozaffarian, a cardiologist and epidemiologist, studies the health effects of dietary habits and other lifestyle factors in large populations. His team has previously pooled the findings of the best studies available on red meat and health and found that people who eat unprocessed red meat regularly have, at worst, only a slightly higher risk of developing heart disease. Unprocessed red meat includes virtually all fresh cuts of beef, pork, lamb, and the like.

“If you look at people who eat unprocessed red meat, there is a relatively weak association with heart disease,” Dr. Mozaffarian says. “It’s not protective—and healthier dietary choices exist—but major harms are also not seen.”

In the bigger picture, we do have pretty damning evidence about the harms of eating a particular type of meat. “Processed red meats—bacon, sausage, salami, deli meats—are associated with much higher risk of heart disease,” Dr. Mozaffarian says.

Research at the Harvard School of Public Health has shown that people who eat the most processed meats have a higher overall risk of death. The ultimate reason for this is not yet clear, says Dr. Mozaffarian, but it may be the huge doses of sodium delivered by all those low-fat deli sandwiches and salami-festooned platters.

And here comes other spoilers against the L-carnitine study: Processed meats generally contain less L-carnitine than does fresh red meat. Heart-healthy fish and chicken also contain L-carnitine, Dr. Mozaffarian points out—although five to 10 times less of it than red meat. “TMAO needs to be studied more in humans to understand the implications for public health,” Dr. Mozaffarian says. “This new research is very interesting but is not yet the final word.”

To further complicate matters, a study published online today in the Mayo Clinic Proceedings suggests that supplements of L-carnitine may help heart attack survivors reduce the chances of dying prematurely or reduce symptoms of angina (chest pain with exertion or stress).

L-carnitine supplements: “Think three times before taking”

There’s still a long way to go before we know the full story about L-carnitine and heart disease. Even so, the Nature Medicine report is very important, Mozaffarian says. It suggests that regularly eating red meat boosts the number of L-carnitine-loving bacteria in your gut. “It’s the best demonstration so far of two-way communication between ourselves and the bacteria in out gut: what we eat affects the bacteria, and what they do with what we eat can influence health.”

“Based on the Nature Medicine study, I’d be concerned about taking L-carnitine supplements,” Dr. Mozaffarian says. “There was no strong reason to take such supplements before the study, and now this well-done study suggests there may be harm. I would definitely think three times before taking an L-carnitine supplement.” The studies in the Mayo report were mostly small with short follow-up, and included only heart attack survivors.

Of course, there are reasons to avoid eating red meat that aren’t directly related to individual health. Cattle farming has devastating environmental effects, including production of greenhouse gases, water pollution, and deforestation. “Health effects in humans aside, red meat consumption is clearly bad for the health of our planet,” says Mozaffarian.

Benefit to improving diet and exercise at the same time

Daniel DeNoon, Executive Editor, Harvard Heart Letter

When you decide it’s time to live a healthier lifestyle, you’re likely to get better long-term results if you start improving your diet and increasing physical activity at the same time.
It may seem better to improve just one thing at a time.  But while you don’t have to make drastic changes overnight, a new study suggests that it’s best to begin by bettering both your nutrition and your activity level.
“This gives me hope that making two changes at the same time can work,” says Kathy McManus, director of the nutrition department at Harvard-affiliated Brigham and Women’s Hospital.

Counseling Advice for Lifestyle Management: The CALM Study

The study, from Stanford University researcher Abby King and colleagues, enrolled 200 people over age 44 whose diets and physical-activity levels were well below healthy standards. They were hoping to improve their lifestyles, but were not specifically trying to lose weight.
Study participants were randomly assigned to one of four groups:

• The diet-first group began with four months of counseling about improving nutrition, then received both nutrition and exercise counseling for eight months.
• The exercise-first group began with four months of counseling about increasing their activity level, then received both nutrition and exercise counseling for eight months.
• The simultaneous group got 12 months of both nutrition and exercise counseling.
• The control group got 12 months of stress-reduction counseling.

For all groups, the exercise goal was to increase moderate-to-vigorous physical activity to 150 minutes (two and a half hours) each week. The diet goal was to get five to nine daily servings of fruits and vegetables and to reduce saturated fats to 10% of total calories consumed.
What happened? The control group met none of these goals. Those in the diet-first group met their dietary goals.  Those in the exercise-first group met their activity goal. But only those in the simultaneous group met both goals.
On the other hand, nobody lost significant weight.  “Many of us are trying to do that, also,” McManus says. “We don’t know how this would play out if the focus of lifestyle change were on weight loss.”

How To Change Your Lifestyle

Lifestyle change is very hard to do by oneself. Most people need counseling and encouragement. McManus praises the Stanford study for providing much-needed data on how healthcare providers can help people achieve lifestyle change.  However, she notes that every individual has his or her own lifestyle and needs an individualized approach to changing it.
“The patient is really the expert in his or her own self-change. We are experts in medicine, but patients are experts on their own behavior,” McManus says. “We elicit dialog around that, building on any successful changes they’ve made in the past. And we develop connections about what matters to them and why it matters, understanding and empathizing with what they will miss if they leave out, say, the high-sodium snacks they’ve been eating.”
It doesn’t work merely to tell people what they must do, what they need to do, or what they should do.
“We use phrases such as, ‘Other folks have found,’ ‘Some have benefitted from,’ and ‘You might consider,’” she says. “Once patients feel listened to they are more open to what you have to say.”
Over time, McManus says, people place more importance on healthy behaviors and become more confident in their ability to make changes.
“Without confidence, behavior change chances are slim,” she says. “We go from that, to where the individual is driving his or her own intervention and behavior change.”

Tai chi improves balance and motor control in Parkinson’s disease

It isn’t every day that an effective new treatment for some Parkinson’s disease symptoms comes along. Especially one that is safe, causes no adverse side effects, and may also benefit the rest of the body and the mind. That’s why I read with excitement and interest a report in the New England Journal of Medicine showing that tai chi may improve balance and prevent falls among people with Parkinson’s disease.

This degenerative condition can cause many vexing problems. These range from tremors and stiffness to a slowing or freezing of movement, sleep problems, anxiety, and more. Parkinson’s disease may also disrupt balance, which can lead to frightening and damaging falls.

A team from the Oregon Research Institute recruited 195 men and women with mild to moderate Parkinson’s disease. They were randomly assigned to twice-weekly sessions of either tai chi, strength-building exercises, or stretching. After six months, those who did tai chi were stronger and had much better balance than those in the other two groups. In fact, their balance was about two times better than those in the resistance-training group and four times better than those in the stretching group. The tai chi group also had significantly fewer falls, and slower rates of decline in overall motor control. In addition, tai chi was safe, with little risk of Parkinson’s disease patients coming to harm.

Other smaller studies have reported that tai chi can improve quality of life for both people with Parkinson’s disease and their support partners.

These studies are significant because they suggest that tai chi can be used as an add-on to current physical therapies and medications to ease some of the key problems faced by people with Parkinson’s disease.

Into the clinic

Parkinson’s disease affects more than one million Americans. This brain disorder interferes with muscle control, leading to trembling; stiffness and inflexibility of the arms, legs, neck, and trunk; loss of facial expression; trouble swallowing; and a variety of other symptoms, include changes in memory and thinking skills. These changes can greatly reduce the ability to carry out everyday activities and reduce quality of life. Medications can help, but they sometimes have unwanted side effects.

Since the appearance of the New England Journal of Medicine study, tai chi classes specifically for Parkinson’s disease patients have sprung up across the country, and the benefits of tai chi for Parkinson’s disease have been endorsed by the National Parkinson’s Foundation. (You can see a video of a tai chi class at Brigham and Women’s Hospital for people with Parkinson’s disease at the bottom of this post.)

Several colleagues and I have developed a tai chi program for people with Parkinson’s disease. It brings together Harvard Medical School doctors and other clinicians with tai chi experts. The 12-week program uses the traditional tai chi principles that I describe in my newly released book, The Harvard Medical School Guide to Tai Chi: 12 Weeks to a Healthy Body, Strong Heart & Sharp Mind. This program is jointly sponsored by the Parkinson’s Disease and Movement Disorders Center at Beth Israel Deaconess Medical Center and the Osher Center for Integrative Medicine at Brigham and Women’s Hospital and Harvard Medical School. So far, about 50 people have completed the program.

We have also begun a small, preliminary study across multiple Harvard Medical School hospitals focused on understanding the interactions between cognitive function, mobility, and motor function in early stage Parkinson’s disease. The idea is to examine how the mind-body connection of tai chi slows the loss of mobility and cognitive function in individuals recently diagnosed with Parkinson’s disease. The results of this pilot study will be used to guide randomized trials to further test the impact of tai chi.

I foresee a growing number of hospitals in the country developing similar tai chi programs for individuals with Parkinson’s disease. In addition to easing balance problems, and possibly other symptoms, tai chi can help ease stress and anxiety and strengthen all parts of the body, with few if any harmful side effects. I look forward to the day when evidence-based tai chi programs become widely available and used by individuals with Parkinson’s disease world-wide.

Few plan for long-term care though most will need it

Mary Pickett, M.D., Faculty Editor, Harvard Health Publications

Two of every three Americans who reach age 65 will at some point need long-term care for up to three years. Yet the majority of those age 40 and older have done “little or no planning” for how they might pay for long-term care when they get older.

That’s a key finding from a new survey of 1,019 Americans over age 40 on the topic of long-term care. The survey was done by the Associated Press and NORC at the University of Chicago. Other interesting results:

• Most people underestimate the cost of nursing home care (it averages $6,700 a month) and overestimate what Medicare will cover.
• Few people are setting aside money for long-term care even as most worry about key issues of aging such as memory loss or being a burden to family members.
• Many people support public policy options for financing long-term care, either through tax incentives to encourage saving for long-term care or a government-administered plan.

Mismatch between perception and reality

As a primary care doctor, I see my patients struggle with how the cost of age-related care affects their lives and their financial realities. Long-term care costs are huge. We can’t afford not to think about them.

The U.S. Census Bureau estimates that $217 billion will be spent in 2015 on nursing home and residential care. This includes assisted living facilities and board and care homes. Currently, about 25% of these costs are paid out-of-pocket by older adults and their families. Almost two-thirds of the cost is paid by Medicaid and Medicare combined.

Medicare only pays for short-term care—20 days in a nursing home—when illness causes disability. After that, patients or their families must meet these costs out-of-pocket. Most older adults with chronic needs then “spend down” their funds to pay for long-term care until the money runs out. At that point, at poverty level, Medicaid support may be available.

Start early

Without a crystal ball, it’s tricky to plan for the future. It’s easy to convince yourself that you or a partner won’t need long-term care. But the statistics suggest you should start planning now, even if your plan isn’t perfect.

1. Talk with your family. Nearly 60% of older people who need long-term nursing or personal care rely fully on unpaid caregivers, usually their children or spouses. Sometimes this is an obvious arrangement. But your family must be flexible and committed. If a caregiver must stay at home, some family income will be lost. This is rarely a comfortable situation if everyone did not agree ahead of time.

2. Consider long-term-care insurance. Fewer than 3% of American adults have purchased a long-term care insurance policy. The average cost is high. A typical plan might cost $3,300 a year for a healthy 60-year-old couple. And it might pay only a $150 a day for up to 3 years. For a person who buys this insurance at age 65, there is a 45% chance of making a claim. If you never need long-term care, the payments you made to the plan are lost.

3. An “age in place” retirement arrangement might be right for you. Some campus-like retirement communities are designed to permit an older adult to “age in place.” This means you can go from a relatively independent life to a more dependent life while staying in the same community. Services often include recreation for the active elderly and 24-hour skilled nursing or rehabilitation services for the frail elderly. These organizations are called continuing care retirement communities. They are always expensive. Usually, they charge an up-front fee of $25,000 to $500,000. Then you pay a membership fee or rent each month.

4. Build up your savings. Making ends meet is a challenge. But in your working years, don’t underestimate how much you need to save. Many of us think, “After we no longer have our mortgage, we should be able to live on our savings.” It’s a good idea to factor long-term care into your savings plan. If disability strikes, you will need it.

5. Write an advance directive (“living will”). Some people receive intensive medical care after they become profoundly disabled. By then, some people who are in this situation are no longer able to communicate their wishes to family members and doctors. If you know that you would not want life-sustaining treatments in this condition, it is wise to record your wishes in a legal “advance directive.”