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Tuesday, September 11, 2012

Obesity Paradox ~ Can Losing Weight be Bad?

From Heartwire (free reg):  Obesity paradox strengthened by new SCAAR data in ACS.  Lest the acronyms drive you nuts, they are not mine (for a change!).  
SCAAR =  Swedish Coronary Angiography and Angioplasty RegistryACS = Acute Coronary Syndromes
PCI = Percutaneous coronary intervention (coronary angioplasty, angioplasty)
From the article:
Those who were deemed overweight or obese by body-mass index (BMI) had a lower risk of death after PCI than normal-weight or underweight participants up to three years after hospitalization ...
"In patients who have a chronic disease, obesity seems to have some kind of protective effect—what this is we don't know, it's difficult to say," coauthor of the new research, Dr Kristjan Karason (University of Gothenburg, Sweden), told heartwire. ...
Drs Stephan von Haehlin, Oliver Hartmann, and Dr Stefan D Anker (Charité Medical School, Berlin, Germany) agree that this research strengthens the existing evidence for the obesity paradox. They conclude that weight loss in patients with chronic illness and a BMI of <40 a="a" always="always" and="and" bad="bad" blockquote="blockquote" chronic="chronic" exists="exists" fact="fact" illness="illness" in="in" is="is" kg="kg" live="live" longer.="longer." loss="loss" m2="m2" makes="makes" not="not" patients="patients" single="single" study="study" suggest="suggest" that="that" to="to" weight="weight">
Things that make you go hmmmmm.  One caveat, this study doesn't address one's risk of cardiac disease that may be due to obesity/overweight.  But once you're sick?  It seems plausible that the excess weight = energy = perhaps endogenous DHA source and/or losing weight at this point causes more stress-induced negative impacts than benefit.  I'll still be trying to avoid any need for PCI ;-)

28 comments:

eulerandothers said...

Um, yeah, that does make me go 'hmmmm' but I think it's because my Firefox browser kind of scrambled it! What was it, anyway?

David said...

Ned Kock wrote about a similar phenomenon. I think the key is to know what their body composition is.
http://healthcorrelator.blogspot.co.uk/2012/06/lowest-mortality-bmi-what-is-its.html

Gabriella Kadar said...

Possibly the fatties, due to other health issues, were under more intense medical observation and in receipt of care than the skinnies.

RRX said...

Am I understanding correctly that this is re. weight loss AFTER the incident?

Unknown said...

I think the "health" argument for weight loss is a red herring, for one thing in most cases it doesn't provide sufficient motivation for people to lose weight and keep it off. Otherwise there wouldn't be so many obese people.

When people lose weight and keep it off it is because being leaner makes them happier. They look better, can wear different types of clothes, don't feel embarrassed when they have to squeeze into the seat on an airplane or at a theater, enjoy it when people tell them how good they look, are able to participate in more physically demanding activities.

Gabriella Kadar said...

I was just thinking about this again: obese people with heart disease may actually not only be consuming excess calories but also have a better nutritional status than thin people with heart disease. The aetiology for the morbidities may be different for each group.

Also, maybe Grandmother was right after all: children should not be skinny.

Asides:

The tight control Type 2 Diabetes study which was stopped due to deaths indicated that the body achieves a homeostasis even in 'disease' conditions. A stressor applied in the sense of tight glucose control upset this and too many patients died.

Galina L. said...

Sorry, what I am about to comment is a 100% speculation from my part. I observed it in many families - plump (not obese) members of a family usually are more robust ones and live longer.My wiry mother-in-law died at 83, my plump grandma still alive at 93, but for last 4 years lives with Alzheimer. Naturally lean old people look for me like they are unable to generate big amount of fat and also can't store fat in their arms, legs and faces, they have less weight to carry around and preserve muscles while doing so, all little fat they generate go to the wrong places, they feel like they can eat any amount of sweets they want eating because they are thin. My mother-in-law was drinking a black tea with sweets several times a day and was sure it was good for her. She thought it was an appropriate practice for an old person - less hassle to cook food, less need in more costly foods. However, she ate an obligatory soup with rye bread everyday and something normal once a day.

I think plump people in general push themselves to exercise more and to eat more healthy diets, while thin ones feel like they don't need to worry about their health. In most minds thinness equals healthiness.

mortalscoil said...

There is population data (NHANES) and suggests overweight BMI is associated with less risk of death than normal weight even when eliminating smokers from the analysis.

Gabriella Kadar said...

Galina, statuarial data indicates that people with BMI in the 26, 27 area live longer than skinny people. So whatever makes thin people thin is not always necessarily good nutrition, good nutrient absorption and general good health.

A bit on the plump side appears to be protective.

Also, it appears as people age, they do get thinner. When they start thin they have no place to go except the grave.

paleotwopointoh said...

What does the data on centenarians show? None of them ever look 'a bit on the plump side'.

Evelyn aka CarbSane said...

@RRX: Yes, AFTER the incident, so I tend to think what Gabriella is saying -- that having some energy stores to draw on is better in situations of decline (I worded that a bit differently, but I think it is in the same vein) -- is at play here.

OTOH, @paleotwopointoh, the centenarians tend to be lean (and active). When my mom rehabbed for her knee replacement she was in a nursing home for a few weeks. Her unit was not really segregated from the rest of the residents and she had lunch with a variety of residents during her stay. I also got lost quite a lot b/c of the confusing floor plan so wandered through other wings and general gathering areas. I didn't see a single obese person, and only one or two overweight. Most were on the thin/frail side. So what does that mean? The obese/overweight have died out before making it into a nursing home, or they fare better in declining years? Dunno ....

Evelyn aka CarbSane said...

BMI is a horrible measure of health. My BMI is borderline obese and yet at approaching 50 I have no health issues, plenty of energy, excellent (too?) bone density and am strong like bull. I rarely get sick and when I do it doesn't last long. However my stats look pretty bad on a medical chart.

In particular, while obesity clearly accelerates diabetes in those genetically predisposed and/or some level of metabolic derangement in many, there are many healthy overweight and obese people. There's some sort of fuzzy threshold (unique to each), however, where excess adiposity is almost universally detrimental. When it effects mobility, immunity, breathing, sleep, etc. it effects overall health.

Galina L. said...

Somewhere in my house I have a book (from 1970-s) by a dietitian from the Caucasus Mineral waters resort. He describes diets for different conditions - inflamed gallbladder, gastritis, cardiovascular conditions, obesity, kidneys problems. There is a table for appropriate weight for different ages and genders. If I remember properly, it was considered to be normal to reach max weight between 55 and 60 for males and females, then the body weight supposed to decline . If I locate that book, I will post more details.
My grandma doesn't look emaciated at 92, but she is not plump any longer, I noticed no one obese resident in her nursing facility. My mother-in-law looked emaciated, but my shorts size 12 fitted her well in waist.

Galina L. said...

I want to add - the recommended amount of food in that book is huge, except for obesity patients.

Gabriella Kadar said...

paleotwopointoh: 'Also, it appears as people age, they do get thinner.'

It appears that the sense of smell and the sense of taste declines with age in most people. Appetite becomes somewhat modified. Therefore if the diet is nutritional sound, then eating less as the metabolic requirements decrease with age results in a lowering of body fat stores. Which accounts for why those who live long lives slim down bit by bit as they age.

The majority of people do not become centenarians. There is more to their long life than whether they ever carried a few 'extra pounds'. One study of 100 and plus year old Ashkenazi Jews indicated very high HDL levels for example. This appeared to be a hereditary tendency because the diet was not geared towards elevating HDL. Oftentimes these oldsters have children in their 80s, grandchildren in their late 50s and great grandchildren in their 30s, and long lives 'run' in the family.

Furthermore adverse life circumstances do not appear to have a huge impact on the life expectancies of these people. I have personal aquaintance with women who endured not only concentration camps, but endured pregnancy and childbirth in slave labour camps during WW2. They are over 90 years old now and going strong. They most certainly didn't eat a Paleo diet.

Then there are centenarians who are STILL smoking!

What scientists are trying to figure out is what keeps these people going and going. There is a great variety in life styles, diets,etc.

I don't obviously have the biggest sample size, but in my practice, all of the oldies are very attached to famiy and friends. They live because they love.


Gabriella Kadar said...

Galina, the mineral water spas in Europe are brilliant. People figured out that water rich in sulfur or magnesium or even lithium(!) is good for certain health problems. And they are correct.

There is a website, Waters of the World, which provides comprehensive information and can be cross-referenced based on mineral, country, etc.

Meantime in North America the emphasis is on 'purity' of water. I.e. the lowest ppm of dissolved minerals! It seems to be syptommatic of the Puritanical attitudes. There are people who go to extremes by drinking distilled water. Purely bonkers.

Gabriella Kadar said...

Evelyn, body type is genetic. There are obese young women who have enormous rumps and thighs with sweet faces and thin necks. Until their female hormone levels are high, their health is protected. As they get older, testosterone levels are unopposed by progesterone and fat migrates to the neck area.

Meantime there are young women who have not much fat in the hips and rumps but their distribution is belly fat and thick necks. These are the ones who are in most danger for developing Type 2 diabetes and severe sleep apnea, heart disease, stroke.

These days I'm noticing an epidemic of PCOS. When I'm out shopping, I see many young women with the telltale hump of fat in the C8 area. Fertility clinics will have lots of business.

Galina L. said...

My aunt (father's sister) all her life worked as a resort doctor in Pyatigorsk (Northern Caucasus region of Russian Federation), I visited her several times, and also went there as a child with a summer camp for children with GI issues.At the age 10 I was diagnosed with inflamed gallbladder, I also had an eczema. Going to mineral resort once a year made huge difference in my conditions. As a result, I became well familiar with the resort healing practices. They not only offered different waters at different temperatures for drinking for different conditions on different schedules (45 min before each meal, or 30 min before meals, or once a day drinking mineral water), but there were mineral baths, radon water baths, staying in a chamber with radon gas (made huge improvement in autoimmune conditions), other procedures with mineral waters and mineral mads. My aunt traveled with group of doctors to learn about similar resorts in Europe, and proudly declared afterwards that her resort was the absolutely the best with more healing options. I took her word for it. My mother was healed at 8 years old with mineral mads from joints inflammation she developed while being in a foster home in Siberia for evacuated children during World War II, in my father case big kidney stone disintegrated and passed outside after 30 days of drinking special mineral water in the West Ukraine (Truskavetsz).

Victor Venema said...

You are right, BMI does not distinguish were the fat is and between fat and muscle. It was developed to compare populations with each other, which it can only do partially. It is used because it is easy and was not developed to judge the health of an individual.

Victor Venema said...

Galina L. suggested above that thin people may have a less good diet. Thin people they are not forced to think about their diet as they are not discriminated.

Related to this, as the study is for Sweden and paleo and low carb diets are pretty popular there, it would be nice if the researchers would test whether the more obese people in the study had a more paleo type diet. It could be that people with higher weight are faster to pick up such a new idea. (I know am not supposed to say this here ;-) )

Evelyn aka CarbSane said...

True, but unfortunately it IS used on the individual. You have kids being sent home with BMI warnings on report cards! This is one of those things that scares me with all of this obesity = increased risk of everything under the sun, and overweight = pre-obesity.

I will always be at higher risk :(

Evelyn aka CarbSane said...

Why shouldn't you say that here? That's a great observation re: Sweden, though I suspect looking at the paleo community that is quite international, if anything they tend to be less obese ...

What Galina says is true in many cases. Equating thin with health and overweight with disease is overly simplistic, and naturally leaner people can "get away" with a lot more -- on the bathroom scale anyway.

This is what makes the whole diet/weight thing so dicey. For example, sugar consumption -- even soda and candy -- can be metabolically innocuous when not in hypercaloric context.

Here's where I feel very conflicted. You have all these paleo types looking in people's carts and thinking all these other people are feeding themselves and their kids "wrong" and that it's their business because health costs impact all of us. They are upset that sat fat intake is currently still stigmatized as bad. What they don't realize (though I suspect they do) is that stigmatizing other food groups, and entire macronutrients (how many times have you heard sugar is sugar is sugar and it's rat poison or like shards of glass flowing through your veins) is not the solution.



Galina L. said...

It looks like having higher than BMI=25 could potentially put an adult person in a disadvantage in USA, not only a child who brings a report card with his/her BMI nowadays. Insurance companies started differentiate their premiums for people based on their health markers. My husband recently went through such evaluation, all his markers were fine, except LDL cholesterol, and BMI is slightly off (25.1) because he is very athletic. We plan to request a different cholesterol test from our family doctor. But what to do for a person who could be forced to pay more because of a wrong BMI number? Request an MRI in order to determine an exact fat amount around internal organs?

People often look for a reassurance for being relaxed about their life-style choices. I remember Paula Dean used to say in interviews that she could eat any food because her cholesterol numbers were excellent.

Lerner said...

That was my first thought also.

Some evidence of that: https://www.ncbi.nlm.nih.gov/pubmed/16824844
"CONCLUSIONS:

Most patients with NSTE ACS are overweight or obese. These patients receive more aggressive treatment, and, except for the extremely obese, have less adverse outcomes compared with underweight and normal-weight patients. Although obesity appears to be a risk factor for developing ACS at a younger age, it also appears to be associated with more aggressive ACS management and, ultimately, improved outcomes."

I'd also wonder if the fatter ones get triaged quicker, getting troponin and EKG testing when "time is muscle" and so got to the cath lab faster than the thinner ones.

Also, did the analysis control for age or not? The article at theheart.org doesn't mention so.

Lerner said...

"The aetiology for the morbidities may be different for each group."

That was my second thought, Gabriella. That might be these people, from the study abstract:
http://www.ncbi.nlm.nih.gov/pubmed/22947610?dopt=Abstract
"In patients with significant CAD undergoing coronary artery by-pass grafting and in patients with no significant CAD, there was no difference in mortality risk in the overweight groups compared with the normal weight group."

Perhaps those patients have something unusually bad going on, maybe they are very prone to plaque rupture/erosion, and being fatter didn't provide any protection. After all, the thinner people don't get ACS as much as the fatter ones do, so why did the thinner ones have ACS? Maybe they're hyper-inflammatory or whatever and that is more deadly post-event.

Taking the above quote again with different emphasis, "In patients with significant CAD undergoing coronary artery by-pass grafting and in patients with no significant CAD, there was no difference in mortality risk in the overweight groups compared with the normal weight group".

Why would fat supposedly be protective for post-PCI but not for post-CABG? (Yep, it's pronounced as 'cabbage' :)

With all of the ambiguity involved, it's way out of line for the study authors to be claiming that guidelines should be claimed - they sound like advocates to me.

Lerner said...

Hi, Victor. The 'obesity paradox' has been around for over 10 years, in many places. Not much chance it's a Paleo phenomenon :)

Lerner said...

Last but not least to be heard from are the "central adiposity is worst" views.

http://www.myhealthywaist.org/documentation-centre/index.html?no_cache=1&tx_stdoccenter_pi1[mod_type]=3&tx_stdoccenter_pi1[uid]=55

6 minute video

"The study showed that for any given BMI category, patients with an increased waist circumference had a much higher risk of death at one year than patients with a low waist circumference. Finally, Dr. Philip Barter and Dr. Paul Poirier explain that the obesity paradox may at first appear confusing, but when the data is further examined on the basis of abdominal obesity and not only BMI, it is clear that BMI alone no longer predicts mortality."

Take note that the 'skinny fat' do worst of all. However, from the graph of the Rico Survey data shown, there is still something going on which needs to be explained wrt fat being possibly protective - which I doubt but you never know.

P.S. The myhealthywaist.org group has names like Libby, Ridker and Balantine so whether they're right or wrong, those are the the big time.

Victor Venema said...

Good argument.

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