BALANCING THE SCALES
June 17, 1998
Who is fat? A new reccomendation from the National Institutes of Health says 55 percent of American adults are overweight. After a background report, Phil Ponce weighs in on the changes.
PHIL PONCE: For more we're joined by Dr. Xavier Pi-Sunyer, chairman of the NIH Obesity Guidelines Panel. He's director of the Obesity Research Center at St. Luke's Roosevelt Hospital Center in New York City. And Barbara Moore, president of Shape up America, a national campaign founded by Former Surgeon General C. Everett Koop to promote healthy weight and more physical activity. She's a nutritionist. Welcome both. Dr. Pi-Sunyer, why lower the weight that people are considered overweight?
DR. XAVIER PI-SUNYER, Chairman, NIH Obesity Panel: Well, the National Heart & Lung Institute was interested in issuing guidelines for physicians to-and they had to deal with assessment and with treatment. And for assessment we looked at the evidence as to where body weight begins to have an effect on illness and on death. And looking at the evidence-we took two and a half years to go over the evidence of many, many trials-it became clear to us that the risk begins to rise at a BMI of 25.
And it steadily rises from 25 to 30 with some of the major illnesses in America: cardiovascular disease, diabetes, hypertension, dislupidemia, osteoarthritis, gall bladder disease, and certain kinds of cancers. Now mortality also goes up, that is, death rates goes up. It goes up a little slower at first and then continues to go up and certainly at 30, where we define obesity, mortality risk is much higher. But between 25 and 30, the mortality risk increases-essentially doubles. So there is risk as we go up, and, therefore, we felt we should alert the American people that they were at health risk and that the health risk began at the BMI of 25.
PHIL PONCE: And you mentioned this BMI figure. Once upon a time there was the old height and weight charts for men and women. Why the use of this Body Mass Index? How does that help you?
DR. XAVIER PI-SUNYER: Well, the old Metropolitan Life Tables were based on insurance policy, and insurance-people who buy insurance are not representative of the whole population. Since that time there have been a lot of other studies, bigger studies, with different kinds of people that carry the spectrum of the population that are more representative, and they use BMI or calculated BMI.
BMI is good because it correlates with fat, which is what we're really interested about. It's simple to calculate, even though it sounds confusing. It's actually very simple to calculate. It is good for men and women. It's good for all special populations, so it's a very easy one-number method of trying to gauge the overall fatness of an individual, and it correlates very well.
PHIL PONCE: Barbara Moore, your reaction to this new lower standard.
BARBARA MOORE, Shape Up America: Well, I'm very pleased to see that the NHLBI has helped us shift over to the use of BMI for assessing overweight and obesity. I think that's a step in the right direction. My problem is-and I'm looking at it from the standpoint of the patient-is that the label is not helpful and it's not necessary. When Shape Up America developed a set of guidelines two years ago, we discussed this issue, and we made a concerted effort to avoid using terms like "overweight" in our document, which was intended, like this document, for physicians.
PHIL PONCE: And why avoid the term "overweight?"
BARBARA MOORE: Because it carries a pejorative to it, and basically what we're really interested in, of course, is, as Dr. Pi-Sunyer has said, we're interested in body fat. And overweight is a confusing term if you're really after body fat. So I think that it's helpful to just stay away from it. It interferes clinically with the bond that I think needs to take place between the physician and the patient.
Physicians do not have a good reputation in this country for being very sensitive toward obese people. And I think that giving them terms that will alienate their patients is counterproductive. You want them to work together as a constructive team. You don't want them to feel alienated right from the get-go during the assessment process.
PHIL PONCE: Doctor, is use of the term overweight alienate a patient from his or her physician?
DR. XAVIER PI-SUNYER: No. We call it risk factors. Cholesterol is a risk factor. Blood pressure is a risk factor. There are many other risk factors. Smoking is a risk facto. Overweight is a risk factor. We don't do it in a pejorative way. What we're saying is here's healthy weight. Healthy weight really ends at about a BMI of 25. We haven't changed the definitions. The definition of healthy weight at 25 was set by the Dietary Guidelines Committee in 1995.
The U.S. Department of Agriculture promulgated the dietary guidelines for America in 1995, with a BMI healthy weight limit. The limit was at 25. The WHO, World Health Organization, uses that definition. All the countries around the world, all the European countries, Asian countries, India, Latin America, they use that definition, so we're not doing something radical or new or different. We're really coming into line with what was already federal guidelines and what the rest of the world uses to define overweight.
PHIL PONCE: So in other parts of the world the 25 BMI is the indicator for overweight?
DR. XAVIER PI-SUNYER: That's correct. That's correct.
BARBARA MOORE: My argument is that the WHO does not have access to any science that we in America do not have access to. So the issue is what's the science here? In order to underpin this essentially policy document in a solid scientific footing, you have to make sure that the data are really solid beneath your feet. And my argument is that the mortality increase, which Dr. Pi-Sunyer alluded to, is not really statistically significant until you reach a BMI of 27. So I think we need to set the mortality issue aside when we're discussing a BMI of 25.
I agree with Dr. Pi-Sunyer that morbidity, especially diabetes and hypertension, risk goes up at a BMI of 25. But you see the problem is that there are 29 million Americans who have a BMI of 25 and 26. The question is: What proportion of those people face this increased risk? Probably less than 5 percent of those people face it. And here we are-we've got literally something like 27 million people who are being labeled overweight, like myself-I'm a BMI of 25-and face no increased health risk.
PHIL PONCE: Do you think this is going to put pressure on people to get diet drugs, or from physicians or add to the obsession that some people have about weight gain?
BARBARA MOORE: Well, I am concerned about that. The FDA, as you stated, recommends the use of drugs at BMI's of 30 and above unless co-morbidities are present, in which case you could consider it as low as 27. The NIH document, in my view, would have benefited from a cut point at 27. And if they wanted to define overweight beginning at a BMI of 27 because all cause mortality increases at that point, and it would correspond to the FDA cut point, I think that would have been a good idea.
PHIL PONCE: Dr. Pi-Sunyer, what do you think the impact is going to be? Is it going to make people a little more hyper about their weight in unhealthy kind of ways?
DR. XAVIER PI-SUNYER: I don't think so. I think we-you know-we talked about this when cholesterol was first described, when high blood pressure was first described as a risk factor. I think what we're trying to do is alert the public, not stigmatize them or scare them, or make them anxious. We tell them the truth, which is that their health risk goes up beginning at a BMI of 25. And I don't think Barbara will argue with that. Their health risk goes up. And so, as a result, is it not right to tell these people, hey, at that point, don't gain any more weight. The average American is gaining ½ pound a year, five pounds per decade. We want individuals who have a BMI of 26 or 26 ½ or 25 ½ to think about not gaining more weight. We're not-
PHIL PONCE: You're not saying these people should go on a diet.
DR. XAVIER PI-SUNYER: We're not telling them to lose weight.
PHIL PONCE: Or to get diet drugs.
DR. XAVIER PI-SUNYER: We are not telling them to lose weight. We're saying, hey, you have a risk factor. If you also have a belt size that's greater than 40 inches for men and 35 inches for women, you have an additional risk factor. And, therefore, you have to be careful about gaining more weight. If you're above a BMI of 30, then lose some weight, because at that point you really are not only at morbidity risk, that is, illness, but also a much higher death risk.
PHIL PONCE: Barbara Moore, is that the message you think people will take from this?
BARBARA MOORE: I would argue that the term "overweight," the word "weight" is in that term. It's, by implication, you're suggesting that you should be losing weight. And I would argue that we know that one out of ten 18-year-old girls is already indulging in very unhealthy practices like fasting, purging, taking laxatives, because they think that they're too fat. Now, I think that this is a nation that's obsessed with thinness, and to have the NIH, the prestige of the NIH added to this obsession by calling the BMI of 25 and 26 overweight is, I think, adding to that pressure and adding to that obsession.
PHIL PONCE: A very quick response, Doctor?
DR. XAVIER PI-SUNYER: Well, we're just saying that it's over healthy weight. Healthy weight is 25 and below. So I don't know how you want to say the semantics of it, but, in fact, is they are over a healthy weight.
PHIL PONCE: Dr. Pi-Sunyer, Barbara Moore, thank you both.
BARBARA MOORE: My pleasure.