Santa's OK! Over 70 and overweight possibly a good idea.

There have been a number of studies of late that have concluded that being overweight (not obese, overweight) and elderly is in fact a good combination.

Well, here's another.

This study, published today in the Journal of the American Geriatric Society has Leon Flicker and his colleagues discussing the impact of weight on mortality over a 10 year period in 9,240 Australian men and women.

Their findings?

The minimum mortality risk was found at a BMI of 26.6 and as BMI decreased from there, risk increased, with the risk of death with a BMI at the lower end of the "normal" range being nearly double the risk of those who were "overweight". These results were sustained even when stratified into groups of initially "healthy" versus initially "unhealthy" subjects and when years one, two and three were subtracted from the study to eliminate those who might have lost weight prior to enrolment due to a chronic illness.

The one variable aside from weight that had a tremendous impact was being sedentary. Men who were sedentary were found to have a 28% increased risk of mortality across all weight categories while for women the risk was double!

Class I Obese participants had very similar mortality risks to normal weight individuals though as weight went up from there, so too did risk.

The results aren't exactly surprising. Previous studies have shown the same results and certainly the theory that older folks carrying some excess weight will have greater metabolic reserves to draw on to weather both chronic and acute medical conditions sounds feasible.

The main limitation of this paper is that BMI was used as a surrogate measure of body fat. This becomes problematic in a geriatric population due to both the natural course of aging (loss of muscle and conversion to fat) as well as the fact that BMI does not identify those with greater stores of visceral fat. A minor limitation was that height and weight were self-reported and given that we know self-reported heights and weight tend to make people taller and skinnier than they actually are (a phenomenon that one might expect to be exacerbated by age-related shrinking (there's an easy paper for someone)).

Interestingly though the paper's main limitations actually supports the authors' conclusions that BMI thresholds as we currently understand them likely should not apply to the geriatric population in that either weight is in and of itself protective or that BMI cannot identify risk in the elderly though perhaps fat distribution does (another potential paper), and while the authors for some reason didn't mention it in their conclusion, this paper would certainly suggest that the most important thing a primary care physician might do when faced with an overweight or obese geriatric patient would be to constantly encourage them to be active.

Flicker, L., McCaul, K., Hankey, G., Jamrozik, K., Brown, W., Byles, J., & Almeida, O. (2010). Body Mass Index and Survival in Men and Women Aged 70 to 75 Journal of the American Geriatrics Society, 58 (2), 234-241 DOI: 10.1111/j.1532-5415.2009.02677.x

Obesity the new #1 preventable cause of death - now what?

A study published last week in the American Journal of Preventative Medicine estimated quality-adjusted life years lost to both smoking and obesity.

Rather than going into the nitty-gritty of the study, and rather than opining on whether or not their stats are true or just statistical sleight of hand, I think the evidence would suggest it quite fair to simply conclude that obesity, like smoking, is very bad for your health.

So how many Canadians die a year due to obesity and diet related diseases? Conservative estimates ring in at around 25,000.

What about H1N1? Well according to the Public Health Agency of Canada H1N1 has killed 415 Canadians.

So how much money do you think the government has spent on H1N1 flu preparedness, immunization and awareness? I've seen television commercials, radio commercials, and print ads and I can't even begin to imagine the cost of immunizing the public and organizing the flu clinics. I can't fathom the dollars involved.

Want to make the argument that we didn't know how bad H1N1 would be and that we had to spend the money and the resources just in case? Fine. Let's talk West Nile Virus.

West Nile virus is probably a better comparison because just like obesity there's no vaccine and just like obesity public health campaigns consequently have to focus on education and prevention. Every summer there are spraying campaigns, television and radio commercials and print ads paid for by the Government of Canada telling us about the importance of bug repellent, long sleeves and getting rid of standing water. I'd be surprised if the government weren't spending between $50-100 million annually on West Nile related activities.

So how many people does West Nile Virus kill? Well, since 2002 there have been 38 West Nile virus deaths in Canada with the last death occurring back in 2005.

So 25,000 obesity and diet related deaths a year and what type of interventions are we seeing? None - except of course the most recent Ontario effort that ultimately will make bariatric surgery more difficult to get.

When are we going to start seeing hundreds of millions of dollars being spent on revamping nutritional education in schools, reforming school/hospital and city food, launching public health educational campaigns on the importance of eating frequently and understanding the energy in part of energy balance, legislation to put calories on menus, tax breaks for fresh whole foods, the creation of an evidence based and energy aware Food Guide, etc.?

Can you imagine how much money and resources would be spent and how much public awareness would be stirred up if West Nile virus killed 25,000 people each and every year?

Isn't it time to start taking the number one preventable cause of death in Canada at least as seriously as a disease that in the past 8 years has only killed 38 Canadians and in the past 5 has killed none?

Lubetkin EI, & Jia H (2009). Health-related quality of life, quality-adjusted life years, and quality-adjusted life expectancy in new york city from 1995 to 2006. Journal of urban health : bulletin of the New York Academy of Medicine, 86 (4), 551-61 PMID: 19283489

Is obesity responsible for the recent rise in youth cancer?

Last week the Canadian Cancer Society released its report Canadian Cancer Statistics 2009. In it they report that between 1996 and 2005 the incidence of cancer among Canadian 15 to 29 year olds rose 0.8% per year in males and 1.4% per year in females.

So the question of course is why? Why are cancer rates rising?

While I don't want to jump on the bandwagon of blaming obesity for all of society's woes certainly given the established link between obesity and cancer in adults it doesn't seem a stretch to me to wonder if it's the rising weight of Canadian youth that's leading to this rapid rise in cancer.

The Canadian Cancer Society may think weight's possible culprit too given that along with the obvious recommendations of "not smoking", "eating a healthy diet", "exercising" and "wear sunscreen", is "maintaining a healthy body weight".

I imagine time will tell as data from surveys that include variables such as weight may help shed some light on this disturbing trend.

Eat Red Meat - Die?

That's what a new study from the Archives of Internal Medicine suggests is more likely to happen to you if you eat lots of red meat.

The researchers followed more than a half million adults aged 50 to 71 who completed food-frequency questionnaires for a decade during which some 48,000 men and 23,000 women died.

The study controlled for confounding variables including: Weight, smoking, physical activity, education, age, marital status, family history of cancer, race, total energy intake, alcohol intake, vitamin supplement use, fruit consumption, vegetable consumption and menopausal hormone replacement therapy.

So after controlling for everything what did they find?

"There was an overall increased risk of total, cancer, and CVD mortality, as well as all other deaths in both men and women in the highest compared with the lowest quintile of red meat intake in the fully adjusted model."

"There was an overall increased risk of total, cancer, and CVD mortality, as well as all other deaths in both men (Table 2) and women (Table 3) in the highest compared with the lowest quintile of processed meat intake"

"When comparing the highest with the lowest quintile of white meat intake, there was an inverse association for total mortality and cancer mortality, as well as all other deaths for both men and women"

Translation?

People who at the most red and processed meat had higher rates of total deaths, cancer deaths and cardiovascular deaths while white meat seemed to confer some protection.

The authors conclude that these results further bolster the call to reduce red and processed meat consumption.

According to an article written by Sharon Kirkey from Canwest the Canadian Cancer Society has already responded by reportedly lowering their recommendations for red meat consumption to 500grams weekly.

Constrast that rapid response with that of the Heart and Stroke Foundation whose spokesperson's quote suggests she didn't even bother reading the study saying,

"But the biggest meat eaters in the study were also more likely to be "out of shape and overweight."

despite the fact that the study adjusted for the obvious confounders of weight and fitness.

And yes of course the Heart and Stroke Foundation's Health Check misinformation program still happily sells their seal of approval to red meat and Canada's Food Guide still allows for women to consume 1,050grams weekly and men 1,575grams weekly - facts that I'm sure the Beef Industry press releases and letters to the editor are bound to mention in the coming days.

Newsflash - Weight's not good for your health!

Published this week in the Lancet.

A meta-analysis summarizing 57 studies on the effects of BMI on mortality.

900,000 subjects in total and they excluded deaths in the first 5 years to eliminate the bias of death from subjects already dying (and consequently in many cases often quite skinny due to the wasting associated with many chronic illnesses).

The results?

All-cause mortality was lowest among those with BMIs in from 22.5 to 25.

Above a BMI of 25, every 5-unit increase in BMI translated to a:

30% increased risk for all-cause mortality;

40% higher risk for death from heart disease or stroke;

60% to 120% increase in renal, hepatic, or diabetic mortality;

10% increased risk for cancer-related deaths.

I wonder how folks who make their livings as contrarians to the risks of weight are going to spin this one?

Another Dubious Honour for Obesity

Saw a press release from the Canadian Liver Foundation yesterday.

Obesity has overtaken alcohol as the number one cause of liver disease in Canada.

Over 1.4 million Canadians apparently have non-alcoholic fatty liver disease or NAFLD.

15% of obese children have NAFLD.

NAFLD can of course progress to non-alcoholic steato-hepatitis or NASH.

NASH can progress to cirrhosis.

Cirrhosis can progress to death.

Sorry, can't think of anything funny to say today.

Are Antioxidants Dangerous?

Since the late 1980s antioxidants have been heralded as molecules that are dramatically important to our health. Multivitamins shout their antioxidant concentrations on their labels and food and beverages are promoted based on their antioxidant properties.

Antioxidants work by neutralizing free radicals, the byproducts of oxidative stress in the body - put simply, they are supposed to be working to protect us by neutralizing dangerous and damaging molecules that have been touted as being theoretical culprits in a myriad of disease processes.

This week a study was pre-released by the Annals of Internal Medicine that looked at the long term effects of selenium supplementation on the risk of developing diabetes. The reason researchers chose selenium is because it's a potent antioxidant and oxidative stress has been proposed as an important mechanism in the development of insulin resistance and diabetes and therefore researchers postulated that if they provided folks with more protection against oxidative stress, it might translate into protection against diabetes.

What the researchers found was that the more selenium provided to the study patients, the greater their risk (yes, I did say greater) of developing diabetes.

So what's going on here? I thought it was supposed to lower risk.

What's going on here is further proof that common sense does not dictate treatment response and that our bodies are big black boxes that don't always behave as predicted.

Interestingly that can be said about a few other heavily promoted antioxidants.

Beta-carotene, once expected to be a contender at reducing the risk of cancer development was actually shown to increase the risk and rate of lung cancer growth in Finnish smokers.

Vitamin E, once expected to help reduce the risk of heart disease, Alzheimer's, cancer and more, was shown in fact to be associated with increased rates of all cause mortality and increased risk of congestive heart failure.

At the end of the day, I'm not suggesting you should immediately stop your antioxidant containing multivitamin. The risks we're talking about here are far from astronomical and there may indeed be benefits to other disease processes. I do however think that consumers need to bear in mind that we really don't have nearly the understanding that folks think we have in terms of how individual micronutrients impact on our health and simply because something theoretically sounds healthy, doesn't make it a smart choice.

My recommendation is to remember that while we might still lack data about the individual components of food, where we've got a great deal of data is about food itself. Diets higher in fruits, vegetables, whole grains, nuts and fish and lower in red meats, refined carbohydrates and salts indeed have been shown to reduce the burden of chronic disease.

Focus on your food, not on your vitamins.

NEWSFLASH: Being overweight isn't good for you!

In what I'm sure will be a disappointment to those individuals who still persist in denying that there is medical risk associated with obesity a landmark study was published in today's New England Journal of Medicine.

527,265 people were followed for over a decade in determining the risk of weight on life expectancy. The study was controlled for ethnicity, smoking status, education, physical activity and alcohol consumption.

During the 10 years of follow up 42,173 men and 19,144 women died. The death curves were U shaped with dramatic increases in risk as weight climbed.

These data also included 186,000 non-smokers. In that group the risk of death from obesity and overweight was substantially strengthened.

When restricting their observations to those who were free of preexisting diseases again there was a strengthening of the relationship between weight and death.

The bottom line's not really news - being overweight or obese is bad for your health.

Dying, literally, for a Big Mac

Much to my amazement, there exists a group of individuals who vehemently deny that obesity is medically risky. They're organized, write books and blogs, and often appear on national news shows claiming that it's all a big myth perpetuated through a combination of bias and capitalism. Should any of them read this blog, I would love their viewpoint on yet another in a never-ending line of well designed medical studies that clearly demonstrate the risks of obesity.

In this weeks Journal of the American Medical Association, Kathleen McTigue et al. looked at death rates and heart disease in 90,185 women following across 40 States for an average of 7 years.

Her results were not in the least bit surprising: The heavier the patient, the higher the death rate. For those with body mass indices between 30-35 death rates increased by 18%; for those with body mass indices between 35-40 death rates increased by 49%; and for those with body mass indices greater than 40 death rates rose by more than 100%.

An easier and far less scientific experiment is for you to think to yourself how many people dramatically overweight people you know who have made it past the age of 75. Speaking for myself and including the literally thousands of patients I used to have when I was working as a GP, along with the thousand or so I saw in stroke rehab, along with my friends and family, I can only think of around 30 over-75-year olds who had BMIs greater than 40, and none of them were living easy, carefree, healthy lives - they all had significant weight related co-morbidities that made their lives very difficult.

I'm all for beating down bias against obesity, and there's no doubt that some folks with significant amounts of weight to lose will lead long healthy lives unaffected by their weights. That being said, some smokers don't die from lung cancer, but of course that doesn't make smoking any healthier.