There’s probably no greater public health issue than the long-term consequences of the childhood obesity epidemic. So the Wall Street Journal should be commended for digging into some of the important science behind this problem in a feature article in today’s paper. The author, Ron Winslow, is widely regarded as the best working journalist who regularly covers cardiovascular medicine. But I’m afraid the article fails to raise several key questions about the topic and therefore misses an opportunity to educate people about its complexities.
The article deals with the “growing concerns about the cardiovascular health of millions of children in the U.S. who are considered obese or overweight” and then focuses on one recent study published in Pediatrics that “suggests there is a simple way to assess a child’s arterial health with a calculation based on an often-overlooked component of cholesterol: triglycerides.” Winslow faithfully reports the main finding of the study, which is that the triglyceride to HDL ratio corresponds closely with arterial stiffness. A stiff vessel is a sign of “accelerated aging” and “likely raises the risk of dangerous outcomes relatively early in adult life,” writes Winslow.
Winslow notes that an NHLBI panel now recommends universal cholesterol screening for children between 9 and 11, but there is no mention that some experts disagree with this recommendation. Further, these screening tests focus on the measurement of LDL cholesterol. Winslow doesn’t discuss whether LDL would be equally effective as triglycerides and HDL at identifying children with stiff arteries. Winslow writes, reasonably, that high triglycerides and low HDL “are a hallmark reflection of the poor diets and sedentary lifestyles that researchers say are behind the wide prevalence of obesity among both children and adults,” but there’s a big gap between that association and concrete recommendations to measure HDL and triglycerides in children and, more importantly, to take actions based on these measurements.
Click here to read the full story on Forbes.
A large new study from Cuba shows the impressive benefits that can be achieved with weight loss and increased exercise. Much more ominously, the same study shows the dangers associated with weight gain and less exercise.
In the study, published in BMJ, researchers took advantage of a “natural” experiment that occurred in Cuba as a result of a major economic crisis in the early 1990s. Relying on 30 years of superb health statistics available in the country, the researchers analyzed the dramatic health effects associated with the economic crisis, which last from 1991 through 1995, and the subsequent recovery.
During the economic crisis caloric intake decreased and physical activity increased, resulting in a 5.5 kg reduction in weight and a very high (80%) proportion of the population classified as physically active…
Click here to read the full story on Forbes.
Earlier today I summarized the important new PREDIMED study published in the New England Journal of Medicine showing the cardiovascular benefits of the Mediterranean diet. This study– a rare and much welcome instance of a large randomized controlled study of a diet powered to reach conclusions about important cardiovascular endpoints– has been widely praised and will undoubtedly have a major effect in the field of nutrition and will influence lots of people to adopt some form of a Mediterranean diet.
The study’s major potential weakness appears to be that the control group didn’t get a fair chance.
Dean Ornish, probably the best-known and most passionate advocate of low-fat diets, goes much further in attacking the credibility of the trial…
The really great thing about the Mediterranean diet, by contrast, is that we know with 100% certainty that it is possible for people to live and eat this way, since they’ve been doing so for millennia. It’s true, though, that the new study didn’t really demonstrate that the Mediterranean diet is better than a true low-fat diet. But it did demonstrate that a Mediterranean diet is healthier than what most people are currently eating. So it’s a good example of a real world trial.
…Now that the Spanish PREDIMED study has been published, I think it must be considered the gold standard. Now it is up to the AHA, and Ornish, to prove that their diets are better than, or even as good as, the Mediterranean diet.
Click here to read the complete story on Forbes.
The hypertension field has been troubled by repeated observations that normal weight patients have more cardiovascular (CV) events than obese patients. Now a new analysis of a large hypertension trial confirms this finding but also suggests that it may be explained by either an adverse effect of diuretics or a protective effect of calcium-channel blockers in non-obese hypertensives.
Michael Weber and colleagues analyzed data from more than 11,000 patients randomized in the ACCOMPLISH trial to shed light on this problem. In 2008 the main results of the trial showed that the combination of benazepril and amlodipine (calcium channel blocker group, CCB) was superior to the combination of benazepril and hydrochlorothiazide (diuretic group) in reducing CV events in high risk hypertensive patients.
The new analysis, published online in the Lancet, confirmed earlier observations and found significant differences in outcome based on weight. However, the differences in outcome occurred mostly in the diuretic group. In the diuretic group, the rate for the primary endpoint was significantly different between the groups (30.7 events per 1,000 patient-years in normal weight patients, 21.9 in overweight patients, and 18.2 in obese patients, p=0.0034). In the CCB group the rates were not significantly different (18.2, 16.9, and 16.5).
To explain their finding the investigators proposed that “hypertension in obese and lean patients is probably mediated by different forms of underlying pathophysiology.” Obese patients, who are more likely to have increased plasma volume and cardiac output, will be responsive to diuretics, while lean patients are more likely to have involvement of the sympathetic and renin-angiotensin systems. They concluded that “diuretic-based regimens seem to be a reasonable choice in obese patients in whom excess volume provides a rationale for this type of treatment, but thiazides are clearly less protective against cardiovascular events in patients who are lean. An alternative therapeutic regimen that includes a calcium channel blocker such as amlodipine, which works equally well across all BMI categories, provides an advantage with respect to clinical outcomes in patients who are not obese.”
In an accompanying comment, Franz Messerli and Sripal Bangalore write that the effectiveness of hydrochlorothiazide in obese people in ACCOMPLISH “has little if anything to do with obesity per se, but simply reflects the fact that among obese patients there was a preponderance of individuals at risk for heart failure who were prone to respond well to diuretic treatment.” They argue that “amlodipine-based treatment should be used irrespective of body size” for the indication of hypertension. Diuretics, on the other hand, should be used for the prevention of left-ventricular dysfunction.
Click here to read the press release from the Lancet…
Social media may become an important weapon in the battle against childhood obesity, according to a new American Heart Association scientific statement published in Circulation. However, the statement acknowledges that the evidence so far from published social-media intervention studies has been “mixed” and that social media is also associated with troublesome drawbacks.
The statement delivers an overview of recent research in the role of social networks in health and obesity, and it reviews intervention strategies that employ various forms of social media. Because children are increasingly drawn to it, social media represents “natural points for intervention,” but the statement cautions that “identifying and measuring outcomes would be difficult.”
“Teenagers are texting and using Facebook and other social media as their primary communication with their peers, and we need to find out what factors can be incorporated into social media that will increase the effectiveness of these interventions to initiate and maintain weight loss in kids and adolescents,” said Jennifer S. Li, the chair of the writing group, in an AHA press release.
As an example of the delicate balance required in this area, the statement notes that children prefer texting over traditional paper diaries, but it also warns that social media plays a role in cyber bullying, privacy issues, sexting, and internet addiction. “Doctors need to understand digital technology better so that they can offer guidance to patients and their families on avoiding such issues, and will be aware of any such problems that occur,” said Li.
“The studies we looked at suggest that more parental involvement and more interaction with counselors and peers was associated with greater success rates for overweight children and teens who participated in an online intervention,” said Li. But the statement also acknowledges that the results of the few randomized trials of internet-based obesity interventions have been “mixed.”
Click here to read the AHA press release…
A few weeks ago Chester Cheetah, the official mascot for Frito Lay’s Cheetos, played an official part in the American Heart Association’s Dallas Heart Walk. Yoni Freedhoff, on his Weighty Matters blog, pretty much says what needs to be said about this disgraceful association between Frito Lay and the AHA.
This weekend I received a press kit from Jenny Craig. The diet company was publicizing the participation of tabloid celebrity Valerie Bertinelli, a Jenny Craig “brand ambassador,” in the AHA’s Los Angeles Heart Walk on Saturday. At first glance, Jenny Craig’s relationship with the AHA does not appear to be as awful as Frito Lay’s. After all, whatever else you may think about the company and its methods, obesity is a major problem, and if some people can defy the odds and lose weight with Jenny Craig then all the better for them.
But the Jenny Craig relationship brings up another, more subtle harm caused by these sort of increasingly popular arrangements in which nonprofit organizations accept money from for-profit corporations. I was astonished to read the second paragraph of the Jenny Craig press release:
Bertinelli, who has lost weight on the Jenny Craig program, recognizes the importance of being in good heart health, and owes her mother’s life to Jenny Craig. Bertinelli’s mother, Nancy, lost 54 pounds* on Jenny Craig after witnessing her daughter’s success on the program. In October of 2008, Bertinelli’s mother required emergency heart valve replacement surgery. After the successful surgery, the cardiologist pulled Bertinelli and her brother aside and told them that if their mother hadn’t previously lost weight, she would not have survived the surgery.
Scientifically and medically, this is an entirely irresponsible statement, if in fact a cardiologist did make this statement. My source for this assertion? The AHA itself. Here’s what an AHA science advisory had to say about this exact topic:
Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation.
One of the most important roles of the AHA is to encourage, develop, and support the use of evidence-based medicine. Why then does the AHA agree to partner with companies that flagrantly (Frito Lay) or more subtly (Jenny Craig) undermine that effort?
Fun facts: Jenny Craig is a wholly owned subsidiary of Nestlé. Frito Lay is owned by Pepsi.
Click here to read the Jenny Craig press release…
A newly launched nonprofit organization, the Nutrition Science Initiative, will try to find an answer to the question, “What should we eat to be healthy?” NuSI is nothing if not ambitious: its goal is to seek “the end of fad diets and high obesity rates.”
The founders of the organization, called NuSI (pronounced “new see”) for short, are Gary Taubes and Peter Attia. Taubes is the science journalist who helped launch the low-carb diet resurgence with his controversial New York Times magazine articles and subsequent books, Good Calories, Bad Calories and Why We Get Fat. Attia, who is the President of NuSI, trained in surgery at Johns Hopkins and the NIH before working as a consultant at McKinsey & Company.
Taubes explains the premise of NuSI:
NuSI was founded on the premise that the reason we are beset today by epidemics of obesity and type 2 diabetes, and the reason physicians and researchers think these diseases are so recalcitrant to dietary therapies, is because of our flawed understanding of their causes. We believe that with a concerted effort and the best possible science, this problem can be fixed.
NuSI originally started as a more modest endeavor, but has now received a significant commitment of financial support from a foundation started by billionaire hedge fund manager John Arnold. The aim of the organization is, as the following NuSI publicity slide states, to “create a Manhattan Project-like effort to solve” the problem of obesity in the US:
The NuSI scientific advisory board is composed of Alan Sniderman, a lipid researcher at McGill University, David Harlan, the former head of the Diabetes, Endocrinology, & Metabolic Diseases branch of the NIDDK and now at U Mass, Mitchel Lazar, of the University of Pennsylvania, and Kevin Schulman, of Duke University.
On his Weighty Matters blog, obesity clinician and writer Yoni Freehoff offers a perspective both critical and supportive of the NuSI agenda.
Click here to read the NuSI press release…
Two new randomized trials offer new evidence that bariatric surgery is highly effective in obese patients with diabetes. The results, according to Paul Zimmet and K. George M.M. Alberti, writing in an editorial in the New England Journal of Medicine, “are likely to have a major effect on future diabetes treatment.”
In the STAMPEDE trial, which was presented at the American College of Cardiology and published simultaneously in the New England Journal of Medicine, 150 obese patients with uncontrolled type 2 diabetes were randomized to medical therapy alone or medical therapy plus either Roux-en-Y gastric bypass or sleeve gastrectomy. Philip Schauer presented the main results.
Percent of patients with glycated hemoglobin level of 6% or less at 1 year:
Click to continue reading…