Washington, DC; January 6, 1998 -- As a physician known for speaking candidly about issues affecting the public health, Dr. C. Everett Koop, the former U.S. Surgeon General -- is speaking out about a recent editorial on weight loss that was published in the New England Journal of Medicine (NEJM). Together with some of the nationís leading public health specialists, Dr. Koop has answered this editorial with a hard-hitting response that calls the NEJM position "one that trivializes the second leading cause of preventable death in the United States" -- obesity.
In a letter submitted to NEJM for publication in an upcoming issue, Dr. Koop and two noted authorities on obesity -- JoAnn E. Manson, M.D., Dr.PH of Harvard Medical School and Theodore B. VanItallie, M.D., Professor Emeritus of Medicine at Columbia University -- state that "the editorial is at odds with the totality of scientific evidence concerning the health risks of obesity..." Published in the January 1, 1998 issue of the New England Journal of Medicine, the editorial -- "Losing Weight -- An Ill-Fated New Yearís Resolution" -- was written by editors, Drs. Jerome Kassirer and Marcia Angell, neither of whom has any background in obesity research.
Citing several large-scale prospective epidemiologic studies which document an increased risk of death from excess weight, Dr. Koop and his colleagues challenged the position of the NEJM editorial that "the data linking overweight and death are limited, fragmentary and often ambiguous." In fact, the letterís authors estimate that a minimum of 20 percent of mortality from "natural causes" in the U.S. (excluding those deaths from accidents, suicides, infectious diseases, and those related to cigarette smoking) is attributable to unhealthy weight.
Applying this 20 percent risk figure to all-cause mortality statistics for the U.S., Dr. Koop and the obesity specialists further demonstrated why the national estimate of 300,000 premature deaths each year from obesity is a valid figure -- another matter questioned by the NEJM editorial. Using 1995 data from the federal Centers for Disease Control and Prevention (CDC), the three public health experts showed that of 1.6 million deaths from "natural causes," an estimated 318,000 U.S. deaths were attributable to excess weight. Accordingly, the experts stated: "We submit that an estimated 300,000 premature deaths each year attributable to overweight is a reasonable and conservative figure." Multiple studies addressing the association of weight with mortality from specific diseases, including heart disease, stroke, diabetes and cancer, corroborate this estimate.
Focusing specifically on the comorbid conditions for obesity -- those diseases that worsen as the degree of obesity increases or improve as obesity is treated -- Dr. Koop and his colleagues said "the picture of the obese struggling with years of debilitating and costly chronic diseases emerges." Obesity researchers have identified at least eight diseases that are comorbid conditions for obesity: hypertension, dyslipidemia, adult onset diabetes, heart disease, stroke, sleep apnea, osteoarthritis and deep vein thrombosis. It is well documented that weight loss can and often does ameliorate or completely resolve many of these conditions, and "data are beginning to emerge showing a reduced mortality among weight-reduced individuals," Dr. Koopís rebuttal letter states.
Besides the hard-hitting rebuttal letter authored by Drs. Koop, Manson and VanItallie, the NEJM editorial drew fire from numerous other obesity specialists and public health and nutrition authorities. In another letter submitted to NEJM, James O. Hill, Ph.D., President of the North American Association for the Study of Obesity (NAASO) said that he is especially "disturbed" by the editorialís suggestion that physicians should only provide treatment for obese patients who ask for treatment or who have medical complications from their obesity. "Many obese people who donít now have medical problems will develop them in the future. By dealing with the obesity early, we may be able to prevent these problems from happening," Dr. Hill said, adding that while he agreed with the NEJM editors on the importance of obesity prevention, "we need to help the millions of currently obese Americans by providing effective and safe approaches for long-term weight management."
George Blackburn, M.D., Ph.D., President of the American Society of Clinical Nutrition (ASCN), also spoke out about the NEJM editorial, especially the editorsí contention that the estimates of mortality among obese people may be "misleadingly high." According to this long-time obesity researcher, "Adult weight gain carries the same attributable risk as smoking with regard to preventable death."
Dr. Blackburnís position was echoed by health policy specialist Michael Fumento, who is the author of "Fat of the Land: The Obesity Epidemic and How Overweight Americans Can Help Themselves" (Vikings, 1997). In a commentary refuting the NEJM editorial, Mr. Fumento states that some of the largest and most detailed studies demonstrating the association between fatter bodies and shorter lives were actually published in the New England Journal of Medicine. A 1995 study cited by Mr. Fumento found that middle-aged women of average height who were just 30 to 40 pounds overweight increased their risk of death by 60 percent and by more than 100 percent for higher weights during the 16-year measuring period. By comparison, the passive smoking report issued by the Environmental Protection Agency (EPA) three years ago found a lifetime increase in lung cancer deaths of only 17 percent, yet it became the basis for sweeping federal and state regulations on indoor smoking.
What is "most galling" about the NEJM editorial, according to Mr. Fumento, is that the opinion piece "virtually ignores" the findings of the lead study in the same issue. The study, which was conducted by Stevens et al., concludes that "Excess body weight increases the risk of death from any cause and from cardiovascular disease in adults between 30 and 74 years of age." The study also finds that longest life was attained by those who had a body mass index (BMI) -- a measurement that takes into account both height and weight -- of between 19 and 22. The average BMI in the U.S. is 25 to 26. Using U.S. government criteria, a BMI of approximately 25 is the dividing line between a healthy and an unhealthy weight unless the person has specific health problems, like hypertension or adult onset diabetes where a lower BMI is the cut point.
In his commentary, Mr. Fumento also points out that NEJM editors Kassirer and Angell "have never published a single paper on obesity andÖessentially ignored the magazineís own findings in favor of a politically correct position." The NEJM editors have previously drawn fire from Dr. Harold Varmus, Director of the National Institutes of Health, and Dr. David Satcher, Director of the Centers for Disease Control and Prevention for a recent editorial that compared the governmentís HIV trials in developing countries to the unethical Tuskegee syphilis trials.
"It is difficult to justify complacency in the face of this growing epidemic now afflicting more than 58 million Americans," said Dr. Koop. He added that although weight loss is difficult and many people fail, recent research finds that many people try again and are successful. Thatís why he cautions: "The irresponsible use of editorial privilege to withdraw peopleís hope is a disservice to clinical medicine and to the American public."
Note: For the use of reporters, the following letters/commentaries are attached as references: