Dangerous NIH Weirdness
by Sally E. Smith

Well, the National Institutes of Health is at it again. In June, two divisions of the NIH released what they touted as "The first Federal guidelines on the identification, evaluation, and treatment of overweight and obesity in adults." Okay, let's get this straight. Our tax dollars are being used to issue guidelines on how to identify fat people. Heck, I've found that most people don't need to go to medical school in order to figure out who's fat; if the NIH would have just gone to a Bethesda schoolyard, they would have quickly realized that even preschoolers can identify fat people.

As for the evaluation portion of these mesmerizing guidelines, it seems to me that doctors already evaluate fat people in the two ways the NIH recommends: "You're overweight and you need to go on a diet," and "You're obese and you're going to drop dead if you don't buy my diet."

Ah, yes, then there's the omnipresent treatment facet of the guidelines. They provide a veritable--excuse the expression--smorgasbord of options: food diaries, exercise, etc. (behavioral treatment), starvation (dietary treatment), pill popping (pharmaceutical treatment), and slice and dice (surgical treatment). According to an NIH press release about the guidelines, "The most successful strategies for weight loss include calorie reduction, increased physical activity, and behavior therapy..." If these are the most successful weight loss methods, and in 1992 an NIH consensus conference that concluded that 95% of these attempts at weight loss fail, I'd hate to see what the NIH considers the least successful weight loss strategies!

And is this deja vu, or didn't the American Obesity Association and Shape Up America (the major players in which are also insiders in the incestuous NIH Committee world), come out with "guidances" a year or so ago that were--like the NIH's--going to be sent to every doctor in the country? Do I smell some kind of internal bickering and one-upmanship going on here? It reeks of political infighting to me.

The expert panel convened by the NIH was chaired by Dr. Xavier Pi-Sunyer, director of the Obesity Research Center, St. Luke's/Roosevelt Hospital Center in New York City. From information in an investigative report published in the New Jersey Star Ledger, we know that Pi-Sunyer sits on the advisory board of American Home Products, Wyeth-Ayerst labs, and Knoll Pharmaceuticals, all of which make diet pills. He was a consultant to Hoffman La-Roche, Knoll, Genetech, Eli Lilly and Weight Watchers International. He sits on a board created by Knoll Pharmaceuticals to provide research grants, and is an advisor to the American Obesity Association, which is also funded by the commercial weight loss and pharmaceutical industries. It's certain that Pi-Sunyer, his colleagues, and their weight loss industry/pharmaceutical company backers have a tremendous economic stake in these new federal guidelines, which--to repeat--will be sent to every primary care physician in the United States.

The cornerstone of these new, improved NIH guidelines is the redefinition of "overweight" and "obese." We all know that the definitions of "overweight" and "obese" are arbitrary; after all, the definitions change every few years. In defining "overweight" as a body mass index (BMI) of 25-29.9 and "obesity" as a BMI of 30 and above, the NIH responded to pressure from the World Health Organization, which adopted these definitions some time ago--despite there being little evidence of increased health risk with a BMI of 25-26.9. For liberal arts majors like me, who can't calculate BMI without straining my brain, a BMI of 30 is equivalent to a 6' 221 pound person or a 5' 6" 186 pound person. This redefinition, which means that 25 million more people are now considered "overweight," will do nothing to improve health, other than the health of the bank balances of the $33 billion diet industry.

In these guidelines, the NIH is once again focusing on weight rather than health. It is ludicrous and dangerous to create public health policy encouraging people to lose weight. For example, the guidelines recommend weight loss to lower high blood pressure, to lower high total cholesterol, and to lower elevated blood glucose in "overweight" people with two or more risk factors and in "obese" persons who are at increased risk. Yet research shows that dieting may cause high blood pressure, in that blood pressure increases with weight regain following weight loss. With the failure rate of weight loss attempts, weight regain is inevitable, so it is dangerous to prescribe weight loss for people with high blood pressure. Likewise, one of the dangerous side effects of the new diet drug Meridia is that it increases blood pressure, and that it should not be used by people with high blood pressure.

Responsible public health policy would recognize that co-morbid conditions such as hypertension, high cholesterol, and elevated blood glucose can be improved independent of weight loss, through changes in dietary habits and increased exercise; they can also be improved through safe, effective medications. Changes in dietary and exercise habits and medications are routinely prescribed for average size people with these conditions; I can only assume that these same treatments are not recommended because the NIH panel was blinded by their and their sponsors' economic interest.

Not that anything the NIH does should surprise me anymore, but the guidelines (which are public health policy) also recommend diet drugs for that 5'6" 186 pound (30 BMI) person, or someone with a BMI of 27 (27!?) with two or more risk factors, such as hypertension or high cholesterol.

But, of course, the NIH didn't stop there. If they're going to create abysmal public health policy, they might as well go all the way. Thus, the guidelines recommend that after doctors evaluate whether or not a patient is fat (again, that requires a lot of special training!), they evaluate risk factors and—are you sitting down?—determine the patient's waist circumference. Yeah, right. I'm going to let a doctor—a doctor who's not even an FA—measure my waist. Not! You see, according to the NIH, "excess abdominal fat is an independent predictor of disease risk." Of course, they failed to mention that research indicates that when weight is regained after weight loss, more fat accumulates in the abdominal area. So a lot of abdominal fat may be a predictor for disease, but if the underlying cause of the fat is yo-yo dieting, how in the world could they make public health policy encourage people to diet?

But the major problem with promoting assessment and evaluation and measuring waist circumference isn't that it's ludicrous, it's that it's dangerous. The NIH is putting fat patients at risk. Because of physicians' focus on weight, fat patients already delay seeking health care. By recommending that physicians advocate weight loss to their patients and determine their waist circumference, the NIH is ensuring that even more people will refuse to seek preventative health care and delay receiving care for a given condition. If and when this policy is implemented, you can be sure that more fat patients will avoid doctors like the plague.

So, once again the NIH has missed the point. As long as they continue to focus on weight rather than health, and as long as they keep trying to find ways to make fat people thin, our community will suffer. And as ridiculous and economically motivated as these guidelines are to us, there are millions and millions—25 million more than there were several weeks ago—of people who may become seriously ill or die because of bad public health policy and biased medical care. And that's unconscionable. ß