Tag Archive for: overweight

BRI: It Just Doesn’t Matter

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Continuing our look at the BRI, the mathematician demonstrated that BRI is associated with body fat distribution. It makes sense; the waist measurement would provide an indication of fat around the waist. The next question is: would the BRI be a better predictor for cardiometabolic disorders than BMI?

BRI and Mortality

A group of researchers decided to use open-source data from the National Health and Nutrition Examination Survey database to examine the relationship between BRI and all-cause mortality. They coincided with the years that physical assessments were done including height and waist circumference; body weight was collected but not used in this instance. The time period began in 1999 and continued every two years through 2018.

There were two observations that were significant. First, in every demographic group, regardless of age, gender, or race/ethnicity, the BRI has increased during every examination period. As a country, the U.S. has gotten fatter. That matches every other measure such as body weight or BMI as well.

The second observation was that the hazard ratio (HR) increased as the BRI dropped below normal, then normalized when the normal BRI was reached, and the HR rose again as the BRI increased. Simply stated, there was an increased risk of mortality when people were too lean or too fat.

You may be wondering why I don’t give you a formula to do calculations for yourself. It’s very complicated and there are BRI calculators available on the website below. The main reason is that it just doesn’t matter—the BRI is no better at predicting mortality than the BMI. The researchers had the body weight data they needed to compare the BRI with the BMI directly. They just didn’t do it. However, looking at the mathematicians’ validation study, the categories of adiposity associated with BMI matches up quite well with the BRI and thus with body fatness. There’s no need for any more precision than is achieved with BMI.

The Bottom Line

It’s really the clinical use that seems to bother everyone, but with rare exceptions, the BMI gives an indication of body fatness. If physicians or other health care professionals cannot see the patient before them and realize they are too lean or too muscular to fit the typical interpretation of BMI, the fault lies with them, not the tool they are using.   

What are you prepared to do today?

        Dr. Chet

References:
1. JAMA. 2024; 332(16):1317-1318. 10.1001/jama.2024.20115
2. JAMA Netw Open. 2024; 7(6):e2415051. 10.1001/jamanetworkopen.2024.15051.
3. https://doi.org/10.1002/oby.20408
4. https://bri-calculator.com/#calculator

Body Roundness Index

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The Body Mass Index (BMI) has been used to provide an indication of whether someone is under weight, normal weight, overweight, or obese and the degree to which they are obese. There’s no measure of percentage of body fatness implied, but physicians and other medical professionals have used it for that purpose for a couple of decades. Why? It can be used to assess the potential risk of developing cardiovascular disease, pre-diabetes, and other metabolic conditions.

I happened upon a commentary in JAMA on the Body Roundness Index or BRI for short. It was published in response to a recent study published in a JAMA Network Open by researchers who examined the relationship between BRI and mortality.

Let’s start with this: what is the BRI? The BRI was developed by a mathematician. The reason was interesting; the developer told the commentator that the BMI is based on a “cylindrical” model but when she looked in the mirror, she felt she was more egg shaped. What she did, as a mathematician, was develop a model based on an “ellipse.” Why? She gave a couple of reasons.

The first reason is that BMI can misclassify individuals because it fails to distinguish between individual amounts of fat-free mass (FFM) and fat mass (FM). BMI also does not provide information about the distribution of body fat—specifically, visceral fat versus subcutaneous fat. She developed a mathematical model, to assess body fatness which would indicate where the fat is distributed. With some very complicated math, she developed the BRI. It uses only two measurements: height and waist circumference. The benefit of using the BRI is that it may be a better predictor of body fat than the BMI. Is it? We’ll check out the research study that began this examination of BRI on Saturday, because as Shaq famously said about getting in shape, “Round is a shape.”

The Insider Conference Call is tomorrow night. If you become an Insider by 8 p.m., you can participate in the call to get your questions answered.

What are you prepared to do today?

        Dr. Chet

References:
1. JAMA. 2024; 332(16):1317-1318. 10.1001/jama.2024.20115
2. JAMA Netw Open. 2024; 7(6):e2415051. 10.1001/jamanetworkopen.2024.15051.
3. https://doi.org/10.1002/oby.20408

Today!

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I’ve said before that in my opinion, the single most important thing you can do to limit the problems of aging is to get to a normal body weight and maintain it. If you’ve been overweight most of your life, as I have been, that can be a real challenge. While the research on what’s called Blue Zones is somewhat controversial, all we have are the observations of different researchers over the years. What seemed obvious to me, as a professional observer, is that people who lived longer seemed to be a normal weight for their height. And to me, that is the absolute goal to work towards.

It’s not easy, and it’s not going to happen overnight. But whether you’re 20, 50, even 70, if it takes you five years to get there, you’re still relatively young. That means that when you do get to be 80, you’ll actually be 80 instead of having died when you were 77. When do you begin to eat less, eat better, and move more to get to that normal weight for height?

Today. No matter how long it’s going to take, you begin today.

Insider Conference Call

I’ve been asked about cyanocobalamin, a synthetic form of vitamin B12. That’s the topic of the evening along with answering personal and product questions. If you’re not an Insider, become an Insider by 8 p.m. Wednesday evening and you can join in the conversation.

What are you prepared to do today?

        Dr. Chet

Obesity and Prenatal Omega-3s: Premature Conclusions

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Women frequently ask about prenatal supplementation, and omega-3 fatty acids are always part of prenatal recommendations; that’s why this study attracted my attention. Did they come to the right conclusions? I think the best place to begin is by reading the conclusion statement of the abstract, and then examine the data from the paper to see if it supports those conclusions.

Here we go:

“In this randomized clinical trial, children of mothers receiving omega-3 fatty acid supplementation had increased BMI at age 10 years, increased risk of being overweight, and a tendency of increased fat percentage and higher metabolic syndrome score. These findings suggest potential adverse health effects from n-3 long-chain polyunsaturated fatty acid supplementation during pregnancy and need to be replicated in future independent studies.”

Problems with the Conclusions

The difference in body weight was two pounds, with the fish oil group weighing more than the placebo group; neither group was classified as being overweight by international standards. With height being equal, that automatically meant that the BMI would be higher in the fish oil group. However, both groups would be classified as underweight based on standards for children five to ten years old. The implication was the omega-3 group might be overweight. They were not; in fact they were closer to normal weight than the lighter kids. The increased risk of being overweight isn’t supported by the data presented.

Related to the higher metabolic syndrome score, the researchers calculated the score using an algorithm that considered waist circumference, systolic BP, negative HDL cholesterol, the log of triglycerides, and the Homeostatic Model Assessment for Insulin Resistance or HOMA-IR for short. There was a difference of 3/10 of an inch in waist circumference, with the omega-3 group being slightly larger. There was no difference in triglyceride levels, and the omega-3 group had a higher HDL cholesterol level than the control group. There was no difference in systolic blood pressure between the groups. That leaves us with the HOMA-IR calculation.

Typically, serum insulin would be used in the calculation to determine the HOMA-IR number. They didn’t collect insulin data, so they used another indicator of insulin levels in calculating the HOMA-IR. The problem is that that algorithm was based on 21 adult subjects; it was never validated with a larger group or for use in children. I question its use, but for argument’s sake, let’s say it doesn’t matter.

The Real Problem

The real problem that I have is with the remark about a tendency towards increased percent body fat. When they assessed body composition at 10 years of age, they used bioelectrical impedance analysis (BIA). I worked on comparing methods of body composition analysis when I was a graduate student, so I can tell you from experience that underwater weighing is the gold standard for any group (and, yes, I’ve underwater weighed 10-year-olds). Specifically, there are two factors that are always concerning with BIA:

  • The algorithm is 95% dependent on height and weight. A two-pound difference in body weight in children could impact the calculation, even if the actual body composition was the same.
  • BIA is sensitive to fluid levels of the body. It assesses total body water and calculates fat mass by making an assumption about the water content of the remaining tissues. It’s not the best way to assess body fat in a major study such as this.

The Bottom Line

How?!!!

We hear that a lot when our grandson plays a videogame. When something happens that he doesn’t anticipate or understand, he yells “How?!!!” and that’s what I’m thinking right now. The most frustrating part of this research paper is their conclusion that omega-3 supplementation in the last trimester of pregnancy may result in adverse effects to the children.

How? How would supplementing with omega-3 fatty acids cause the offspring to have an increased risk of being overweight or obese? They did not provide any comment on how that could occur.

As it stands now, we really don’t know much more about omega-3 supplementation in the third trimester of pregnancy other than the kids whose mothers took omega-3 fatty acid had fewer serious asthma and allergy symptoms; because the incidence of asthma and allergies are rising steadily, that may be the most important observation from this study so far.

As for body composition? Not so much. This study will continue until the subjects are adults, so maybe further testing will yield more conclusive results.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN. 2024. doi.org/10.1016/j.ajcnut.2023.12.015

Obesity and Prenatal Omega-3s

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Scientists continue to research the causes of obesity. For many, as we’ll see, it’s not as simple as eating less and moving more; in the study I’m going to review this week, the researchers are going prenatal.

The Copenhagen Prospective Studies on Asthma in Childhood 2010 (COPSAC) is an ongoing longitudinal study to examine the effects of omega-3 supplementation in the third trimester of pregnancy on a number of factors. The primary objective was to see if allergies and asthma were reduced in the offspring of women who took the omega-3s versus those who took a placebo. Asthma or persistent wheeze showed a 31% reduction in risk in the group receiving fish oil compared to 23% the placebo group.

The researchers also collected a variety of anthropometric data, plus blood samples for metabolic and blood lipid analysis, and assessed body composition. In a prior paper when the children were age six, the omega group were about one pound heavier but with a proportional increase in lean and fat mass.

In the current analysis at age ten, the omega group were determined to have an increased BMI, increased risk of being overweight, a tendency for increased fat percentage, and higher metabolic syndrome score when compared to the placebo group. That doesn’t sound good. Does this mean women should avoid omega-3 fish oil during pregnancy, especially the third trimester? I’ll let you know on Saturday.

Tomorrow is the monthly Insider Conference Call. I’m going to cover starvation but not the Minnesota Starvation Study—you’ll come away stunned. I’ll also answer your questions. If you’re not an Insider, become one by 8 p.m. tomorrow and you can join in.

What are you prepared to do today?

        Dr. Chet

References:
1. BMJ 2018. doi: https://doi.org/10.1136/bmj.k3312
2. AJCN. 2024. doi.org/10.1016/j.ajcnut.2023.12.015

The Price of Obesity

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Continuing with comments made by Bill Maher, he suggests that the prevailing thought is that we can be healthy at any weight. Companies have embraced that thought with workout gear and other products featuring oversized models. Maher then goes on to talk about the ill health associated with being obese. Type 2 diabetes, cardiovascular disease, and cancer are associated with excess body fat. He says being overweight can compromise the immune system and cites statistics on the impact of COVID-19 on people who are obese. I checked them out, and he’s correct as it relates to hospitalizations, ICU placement, and mortality.

Fat and Fit Updated

I have repeatedly made the case that a person could be fat and fit if they exercise at a high level. That’s what the data from the Cooper Clinic demonstrated, and so did my doctoral research. I then add that it doesn’t matter—because very few people could or would do the work necessary. And that was correct, too.

But at 71, I think I was too optimistic in my recommendation even though that’s what the data suggested. The reason is that it’s difficult to maintain a high fitness level the older that you get. What’s possible at 30 years old is not at 50, 60, or 70 years old. The aging body changes.

The Price of Obesity

The cost of obesity is high. You may not have high blood pressure at 250 pounds while you’re younger and fitter, but you’re taxing your heart and cardiovascular system to sustain it. You may delay pre-diabetes and have perfect blood work—for now. And there’s a cost to your joints that may not be realized for decades, but when it hits you, you’ll find your world has shrunk because there are things you simply can’t do any longer.

I’ve been a runner for decades, but those days are over. I wonder if I had decided a decade or so earlier to lose weight and sustain 175 pounds instead of 225 whether my knee would have sustained less damage. Carrying 50 extra pounds generates forces up to ten times greater; that certainly has an impact on hips, knees, ankles, and feet.

Life Is a Struggle

Maher talks about how difficult it is to lose weight. There’s no question that it’s a struggle, but that’s no different than any worthwhile goal. It’s hard to get the weight off and difficult to keep it off. Even as the expert, I know that one well. Life is a struggle.

There is a commercial that we see repeatedly with an overweight woman in her 20s who is walking out her front door to go jogging. I think it’s powerful because she asks herself “What if a sprain my ankle?” and closes with her finishing her run. She’s at the perfect age to add the other components of eating better, eating less, and getting to a weight that is less taxing to her body. That’s aging with a vengeance in action.

The Bottom Line

I’m completely in favor of fat acceptance when it means loving and accepting those around you no matter their size. But if you see people you love trying to exercise and eat healthier, you can quietly let them know you’re rooting for them and will help in any way you can. Let’s not kid ourselves: it’s not the healthiest way to live, and sooner or later, we’ll pay the price.

Maher is a keen observer of the human condition and can be caustic in his commentary. But I think he’s got the tone and tenor just about right in his close:

“And that’s the saddest part. We can do this—I think. But by lying about it and making excuses, psychologically it’s telling ourselves that letting ourselves go is the best we can do. And I gotta believe that as Americans, we can still do better than that.”

What are you prepared to do today?

        Dr. Chet

Reference: https://www.youtube.com/watch?v=yfiWjnStE3w

Feast Mode!

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Comedian and political satirist Bill Maher has been one of my favorites since his first show Politically Incorrect aired over 20 years ago. He is also an outspoken critic of our nation’s health: it’s poor and getting worse. On a recent show, he used the term Feast Mode and explained why it’s a problem.

Feast Mode used to be going on vacation and eating whatever you wanted. It also used to be reserved for holidays such as Thanksgiving where you intended to overeat and then went back to a healthier way to eat, if not in the types of food, at least in the quantities. He suggests that Feast Mode now extends all year long for most Americans. I agree and have the numbers to prove it: close to 70% of us are overweight with 41.9% now classified as obese.

He goes on to talk about the politics of obesity, comparing the psychology of fat shaming to celebrating our fatness. No one should be shamed for being overweight, but that doesn’t mean that it’s healthy to be fat. He suggests that science gets re-written to support what you want it to be instead of reality. I would correct one thing: social science might get re-written, but hard science is based on hard numbers—and however we may feel about it, the number on the scale is the number on the scale. We’re not quibbling about five pounds here; we’re talking about 50 or 100 pounds or more beyond a normal weight.

The question is what does Feast Mode cost? I’ll cover that on Saturday.

Tomorrow night is the monthly Insider Conference call. I’ve got a couple of topics related to dietary supplements to cover and then I’ll answer Insider questions. Become an Insider before 8 p.m. tomorrow and join the discussion.

What are you prepared to do today?

        Dr. Chet

Reference: https://www.cdc.gov/nchs/fastats/obesity-overweight.htm

Triathlon Observations: Prepare to Compete

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Let me be clear: I think that the single most important thing that you can do to be healthy is to exercise regularly. Whether walking, swimming, or one of the hundreds of other types of exercise, talking with your physician about it may be all that’s required for you to get started.

Moving from exercise that helps your health to competing in fitness events requires more—that’s independent of your body weight lest you think I’m talking only about the very heavy people that competed in the triathlon. Here’s what I recommend.

First, you should have a stress test that assesses how your heart and blood vessels perform under maximal conditions. That applies to men over 40 and women over 50, for sure. But I also think if you have been overweight for over five years, you should have the test regardless of age. The maximal exercise test is not foolproof, but it’s the best available predictor of heart problems. This isn’t just me being a worrier; I’m sad to report that one participant died of a heart attack last Sunday. Getting checked out before you start is the best way to protect yourself.

Second, you should have a complete lipid profile, HbA1c, and a blood insulin test as a minimum. As I suggested in Thursday’s memo, you need to know whether you’re a prediabetic or even an undiagnosed type 2 diabetic. The best option for you would be to exercise, but when you push yourself hard for long periods of time, it’s going to affect your blood sugar levels as it would affect a diabetic’s, not someone who has a normal carbohydrate metabolism; for instance, you could pass out if your blood sugar gets too low, and if you’re out alone on a run, that’s a problem. You can deal with it, but you have to know if it’s an issue.

Third, you should get an orthopedic analysis. By that I mean that your joints should be evaluated for range of motion, tendon and ligament stability, and gait. Swimming affects the shoulders, bicycling the lower back, and running the hips, knees, and feet. Any abnormality will be exacerbated; for example, the forces you create when you run is five times your body weight. Do the math—that’s a lot of stress on your knees and feet.

Once you get the all clear, get after it. Start conservatively but if you have the urge to compete to see what you’re capable of, do it. I think if you want a challenge, whether to walk or run a 5K, swim a mile, or bike 50 miles, or combine them into a single event such as the triathlon, you should do it. Just make sure you get your body checked out before you do.

Final Observation

While I believe exercise is important no matter the level at which you do it, exercise won’t help you lose a lot of weight. Surprised? Remember the size of the people I mentioned that competed in the triathlon—not just overweight but obese? If they had put in the training, and I know some of the competitors and know that they did, you’d have thought they would have lost a significant amount of weight. They didn’t.

Burning calories helps with weight loss, but as a well-known expert once said “Americans can’t out run their appetites.” If you could exercise six or eight hours a day, you could probably lose weight without changing your diet, but I doubt you have that kind of time. You can use exercise as a tool to help you lose weight, and exercise pays major benefits in fitness, strength, and stamina. But you will not lose weight unless you also eat less and eat better.

What are you prepared to do today?

Dr. Chet

 

Triathlon Observations: Heavy and Healthy?

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The major observation I had as I volunteered at the Grand Rapids Triathlon was that the body weight distribution of the people participating in the triathlon mimicked the population of the U.S. We’re a fat nation; 70% of the population is overweight and half of those are obese. Those percentages also seemed to apply to the participants in the race.

In addition to being a regular Grand Rapids event, the Grand Rapids Triathlon was also the National Championship for the Clydesdale and Athena athletes. In order to qualify for the Clydesdale division, men must weigh over 220 pounds; for women to qualify for the Athena division, they must weigh over 165 pounds. Based on my observations, a majority of the participants would have qualified for that category, whether that was their intention or not.

There were men well over 300 pounds and women over 250 pounds that participated in the triathlon. Talking with several other volunteers, I said that unless they had a signed release from their physician, I would hesitate to let them participate. They countered that as long as people put in their time training, they were fit enough to compete. Good point, but that logic doesn’t really hold up. The primary concern everyone thinks of is cardiovascular disease and that makes sense. But if someone is overweight, the real concern is undiagnosed type 2 diabetes and orthopedic stress.

While I applaud their effort and would never want to prevent anyone from exercising, I would hope that they would have had a thorough medical exam before they took their first step. We can’t assume because they had trained for the race they were actually healthy enough to compete in the race. I’ll cover what those tests should be and a surprise conclusion that you don’t want to miss on Saturday.

What are you prepared to do today?

Dr. Chet

 

The Truth Behind the Obesity Paradox

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In my opinion, the short answer to the obesity paradox is that it doesn’t really exist. But what fun would that be? That doesn’t teach you anything. Let’s take a look at the problems with the research that contributed to this paradox.
 

Study One: Dialysis, BMI, and Mortality

A study of dialysis patients led to the first observation that people with higher BMIs lived longer (1). After tracking over 1,300 subjects on dialysis for a year, researchers found that those who were overweight had a decreased risk of dying and had fewer hospital stays when compared to those who were underweight. This may have been the study that yielded the name The Obesity Paradox. The problem? The study lasted only one year. Trying to generalize what will happen to all overweight and obese people on dialysis from a study that lasted only one year and at only a single location isn’t realistic. It raises an intriguing question, but we’ll need a much more extensive study to really make a solid prediction.
 

Study Two: The Rotterdam Study

I described this study on Thursday (2). While the study appeared to show a protective benefit from being overweight or obese, the subjects were elderly with an average age of 77 at the study’s beginning. One risk factor that you cannot change is age: the older you are, the more likely you are to die. But that’s not the whole story. We can probably say that older people may live longer with a little extra weight, but to extend that prediction to all age groups isn’t valid.
 

Study Three: BMI and Mortality

While this study claimed to analyze the data on over two million people, it was still a meta-analysis (3), which doesn’t yield cause and effect, just a statistical association. Further, they used studies of varying lengths without necessarily knowing exact causes of deaths. They also did not have precise BMIs on everyone; some studies included metrics such as BMI under 27.5 and over 27.5. They tried to include the highest number of subjects, but the quality of data varied and that made it a mess. Researchers chose too many different types of studies in the meta-analysis, and it just doesn’t work. I wouldn’t bet my life on it.
 

Study Four: A Broader Look

The real problem with every approach is the lack of acknowledgement that people with advanced disease may have lost weight before they were included in the study; diseases such as heart failure, diabetes, or renal disease will often lead to weight loss. Those who were heavier when disease hit had the benefit of extra energy stored as fat to deal with the disease, and that could explain the outcomes of those studies. It had nothing to do with being obese; it was a matter of timing.

A study published last month appears to confirm that (4). Researchers in the Cardiovascular Disease Lifetime Risk Pooling Project obtained data from 10 different longitudinal studies, including individual-level data and accurate mortality data. They found that as BMI increased, the death rate from all forms of CVD increased. For those who carried extra weight while younger, CVD occurred earlier, making it more likely they would die before their time.
 

The Bottom Line

As I said, there really is no obesity paradox. Being overweight or obese carries with it risks of degenerative disease. Some people may have better genes and may gain protection for a few years. But in the end, being overweight or obese carries a higher risk of various diseases than the limited protection from an advanced disease you may gain by carrying extra weight. So my advice is the same as it always was: if you’re overweight, your best bet for a long, healthy life is to lose it.

What are you prepared to do today?

Dr. Chet

 

References:
1. Kidney International, Vol. 55 (1999), pp. 1560–1567.
2. European Heart Journal (2001) 22, 1318–1327.
3. JAMA. 2013; 309(1): 71–82.
4. JAMA Cardiol. doi:10.1001/jamacardio.2018.0022.