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New NHLBI Clinical Guidelines for Obesity and Overweight: Will They Promote Health?

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New NHLBI Clinical Guidelines for Obesity and Overweight: Will They Promote Health? Commentary New NHLBI Clinical Guidelines for Obesity and Overweight: Will They Promote Health? ABSTRACT William J. Strawbridge, PhD, Margaret I. Wallhagen, PhD, RN, CS, and Sarah J. Shema, MS Objectives. The purpose of this study was to assess the justification, The 1998 clinical guidelines for the for overweight persons below the obesity on the basis of mortality, of the new treatment of overweight and obesity from the threshold appeared to be prevention of further National Heart, Lung, and Blood Insti- National Heart, Lung, and Blood Institute weight gains, rather than weight reduction. tute (NHLBI) guidelines on obesity (NHLBI) divide adults into 6 categories on However, in October 1999, results from and overweight and to discuss the the basis of body mass index (BMI): lower an American Cancer Society study were health implications of declaring all than 18.5, underweight; 18.5 through 24.9, published that, along with several commen- adults with a body mass index of 25 normal; 25.0 through 29.9, overweight; 30.0 taries,3–5 justified the inclusion of BMIs of through 29 “overweight.” through 34.9, mildly obese; 35.0 through 25.0 through 29.9 in the overweight cate- Methods. The relationships between 39.9, moderately obese; 40.0 or higher, gory on the basis of mortality, ignored or 1 NHLBI body mass index categories extremely obese. This classification identi- attempted to refute the caveats issued with and mortality for individuals older than fies 55% of American adults as overweight or the guidelines, and generally confused the 31 years were analyzed for 6253 Ala- obese, nearly double the percentage who careful distinction made in the report meda County Study respondents aged would be so identified on the basis of the sec- between persons designated overweight and 21 through 75 years. Time-dependent ond National Health and Nutrition Examina- those designated obese. The American Can- tion Survey (NHANES II), which used cer Society study results were based on the proportional hazards models were used 2 3 to adjust for changes in risk factors and higher BMI cutpoints. The new guidelines Cancer Prevention Study II, which enrolled initially came with a number of important more than 1 million subjects in 1982. Weight weight during follow-up. caveats. They noted that mortality risks for and height were measured by self-report. Results. Adjusted relative risks of persons with BMIs of 25.0 through 29.9 (the Subjects were divided into 4 groups on the mortality for 4 NHLBI categories com- overweight category) were only modestly ele- basis of smoking status and history of dis- pared with the category “normal” indi- vated and might be even less elevated for ease. For the majority of the subjects, the cated that only being underweight or older adults.They cited research that indi- association between BMI and mortality was a moderately/extremely obese were asso- cates considerable variation among ethnic U-shaped curve—low and high BMI were ciated with higher mortality. Specific minorities, including African Americans, in equally serious risk factors. In addition, only risks varied significantly by sex. boundaries for the lowest-risk BMI levels. a modestly elevated relative mortality risk of Conclusions. Our results are con- Further, the new guidelines noted exceptions about 1.2 was found for persons with BMIs sistent with other studies and fail to for very muscular persons and for persons of 25.0 through 29.9 compared with those in justify lowering the overweight thresh- less than 5 feet in height, for whom the stan- the reference category of 23.5 to 24.9. old on the basis of mortality. Current dard BMI calculation may not be valid. The study then focused only on the 29% interpretations of the revised guidelines The argument for health risks in the of subjects with no history of disease or smok- stigmatize too many people as over- newly labeled overweight category was based ing. These results indicated a less serious mor- weight; fail to account for sex, race/eth- more on morbidity than on mortality, which tality risk for persons with low BMIs and, nicity, age, and other differences; and is one reason individuals with BMIs in this compared with the 71% of subjects not stud- ignore the serious health risks associ- range were labeled overweight, not obese. ied, a slightly increased risk for persons with ated with low weight and efforts to Further, health providers were instructed to BMIs of 25.0 or higher. On the basis of the maintain an unrealistically lean body recommend weight loss for patients in the mass. (Am J Public Health. 2000;90: overweight category only if the patients 340–343) expressed a desire to lose weight or if they William J. Strawbridge and Sarah J. Shema are with also exhibited 2 or more cardiovascular risk the Human Population Laboratory, Public Health factors, such as type 2 diabetes, cigarette Institute, Berkeley, Calif. Margaret I. Wallhagen is smoking, hypertension, physical inactivity, with the School of Nursing, University of Califor- low-density lipoprotein cholesterol serum nia at San Francisco. Requests for reprints should be sent to William concentration of 160 mg/dL or higher, or the J. Strawbridge, PhD, Human Population Labora- presence or family history of coronary heart tory, Public Health Institute, 2151 Berkeley Way, disease. The thrust of the recommendations Annex 2, Berkeley, CA 94704-1011. 340 American Journal of Public Health March 2000, Vol. 90, No. 3 Commentary results from this small subsample of subjects, questions about the validity of the findings. wanted to avoid determining that low BMI the researchers (and others, in commentaries4,5) Racial comparisons could not be made because was associated with mortality simply because concluded that a definitive argument for the 98% of the nurses in the study are White. it reflected prevalent disease. Thus, we lowered NHLBI standards had now been To examine the validity of the new guide- adjusted for the prevalence of cancer, cigarette made, on the basis of elevated mortality rates.4 lines, with particular emphasis on the over- smoking, and respiratory disease (as indicated One physician called the results “irrefutable,” weight category, we used them to analyze the by chronic bronchitis, the only condition asked and the distinction in the NHLBI report impact of BMI on mortality for respondents in about in all surveys). We also adjusted for between overweight and obese was lost as the Alameda County Study. We tracked the physical activity, which we measured with a news accounts of the study used the 2 terms relationship between BMI and mortality in this scale based on frequency of performing phys- interchangeably.5 A similar blurring of the sample for 31 years, using an analysis method ical exercise, participating in active sports, overweight and obese categories had already that takes into account changes in BMI and and either taking long walks or swimming. occurred in an August 1999 review article that adjustment variables. Responses were “never,” “sometimes,” or recommended a weight loss program not only “often.” The scale has a range of 0 to 12 and for all adults with a BMI of 25.0 or higher but has been shown to predict all-cause as well as also for those with BMIs below 25.0 who Methods cardiovascular mortality in other analyses.18 experienced weight gains of 10 pounds or more.6 Study Population Statistical Analyses Before such sweeping recommendations that take the NHLBI guidelines out of con- The subjects were taken from the Ala- Cox proportional hazards models with text are accepted, a brief review of the mor- meda County Study, a longitudinal study of time-dependent covariates were used to ana- tality evidence and a consideration of the health and mortality that enrolled 6928 adults lyze the relationship between BMI and mor- likely consequences of such an emphasis on from a random household sample of Alameda tality. The time-dependent covariate option weight reduction are in order. County residences in 1965.15 Alameda County takes into account changes in BMI and Previous longitudinal studies of the effect borders San Francisco Bay and includes the adjustment variables reported by survivors of BMI on mortality found inconsistent cities of Berkeley and Oakland. In 1965, the during any subsequent survey.19,20 results. A 1987 summary of 25 longitudinal county’s age, sex, and racial/ethnic mix were Subjects were censored at loss to follow- studies reported that 9 found no relationship similar to those of the United States as a up or at the end of 1996. Deaths were included between BMI and mortality, while the others whole. Survivors were resurveyed in 1974, through 1996 and numbered 1295 (21% of revealed different associational patterns and 1983, and 1994, with response rates of 85%, study subjects) (Table 1). Results are presented different ideal-weight categories.7 The authors 87%, and 93%, respectively. for all subjects as well as separately by sex. attributed many of these differences to analyti- The analyses reported here are based on Two sequential models were used to assess the cal flaws. Such flaws are absent from recent data from 6253 subjects aged 21 to 75 years relative impacts of BMI on mortality. The first studies, but results are still not consistent. A at baseline in 1965 who did not die in the first model adjusted only for age and sex; the sec- large Dutch study reported an association year of follow-up and who had no missing ond model added race/ethnicity, education, between BMI and mortality for men but not values on any of the baseline measures chronic bronchitis, cancer, cigarette smoking, women, while data from the Cardiovascular (including adjustment variables). Women and physical activity.
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