Nocebo: The Power of Negative Thinking?

Doctors Need to Appreciate the Effects of Prescribing and Describing Therapy

Maybe it's the power of marketing. Maybe it's faith in our doctors. Or maybe the physical effects of what we believe are more powerful than we like to think. In any event, new data indicate that how doctors describe what they give us may effect us in powerfully positive or negative ways.

It's a Sham
Placebos, and their lesser known counterparts nocebos, are sham treatments. The difference is in the response to the therapy. Placebo, from Latin meaning “I will please” is often delivered in a manner that leads the patient to expect a positive effect. Nocebo, meaning “I will harm,” is associated with negative responses to inactive therapy.

In a study reported today (http://bit.ly/gec3tz), people's pain levels fluctuated greatly based on what they were told about a pain medicine they had been given, including an increase in pain when told they were no longer being given the drug – when in fact they were still receiving it. (The nocebo effect.) So, patient belief was a strong indicator of whether the drug worked or not, even though the dose of the drug did not change throughout the experiment.

Nocebo effects can be enhanced, too, with warnings the therapy will likely produce negative effects. In other words, a placebo “sugar pill” is given to patients who are led to believe that the pill will provide pain relief; the nocebo effect is enhanced with a warning that the pill will likely cause adverse effects, such as nausea.

However, the doctor does not have to say anything for the nocebo effect to kick in. Patient beliefs may be established long before he or she shows up at a doctor's office. In Science Translational Medicine, researchers suggest that doctors may need to consider dealing with patients' beliefs about the effectiveness of any treatment, as well as determining which drug might be the best for that patient. For example, people with chronic pain will often have seen many doctors and tried many drugs that haven't worked for them. Professor Irene Tracey at Oxford University, said, “They come to see the clinician with all this negative experience, not expecting to receive anything that will work for them. Doctors have almost got to work on that first before any drug will have an effect on their pain.”

All science needs a mechanism of some kind, so what is behind these powerful placebo and nocebo effects? It’s not clear, but the evidence does suggest that it’s not all psychological. Physiologically, there appears to be an endorphin release in the brain that accompanies a placebo response. Placebos given to people who are told they are pain killers will actually elicit analgesic effects via both drug-related (neuropharmacological) and neurologic (neuroanatomical) avenues. In other words, the body’s response is similar to what one would expect from actual medicine despite the fact that the sugar pill given contains no medication.

Additionally, placebos commonly elicit beneficial therapeutic responses in anxiety and depressive disorders. The psychological behaviorism theory considers the placebo a stimulus conditioned to elicit a positive emotional response. Some research suggests that pain sensitivity and pain anxiety increase susceptibility to placebo effects.

Stunning Effects
While not as commonly known as placebos, nocebo effects can be stunning. For example, in one study, patients were told they were receiving either a relaxant, a stimulant, or an inactive agent; in point of fact, all patients received the inactive agent. Patients told they were getting a relaxant showed reduced stress levels, while those who thought they were getting a stimulant showed increased arousal levels.

With the heart pain known as angina, for example, sham surgeries work in up to 70% to 80% of patients who show clinical improvement great enough to increase the key measures of heart function (known as functional class). Similar data are also are seen in heart failure patients who show improvement in functional class or, at the very least, significant improvement in quality of life.

Placebo drug therapy isn’t quite as “effective” as that sham surgery was, but it still is quite common. In a study by Italian investigators, 600 patients with histories of drug side effects were given inactive placebos and more than 1 in 4 showed “drug” side effects. The nocebo response was significantly higher in women than in men. So, the nocebo effect occurs frequently in clinical practice. In clinical trials, too; it’s rare that a placebo will elicit significantly more side effects than the comparison drug therapy, but it is not uncommon that in sheer numbers more stomach upset is reported with the placebo, despite the fact there should be NOTHING in the inert agent to cause stomach upset.

By the way, even mechanical devices can show placebo/nocebo effects. In a study called VPS II, pacemakers were implanted in patients but only half were activated; the rest were in monitoring mode and collecting information but not actually pacing the heart. Despite the fact half were turned off, both groups showed similar improvements.

Finally, it’s not just the words and manner of the doctor that can influence the effects of placebos. Evidence suggests you can literally build a better placebo by taking into account size, color, shape, and “brand” of the sugar pill!

With doctors using more and more technology while spending less and less time with patients, it’s important that doctors appreciate the power of prescribing and describing a therapy – whether it’s a real therapy or a perceived therapy.

Teens Think They’ll Live Forever, Which May Explain Their Food Choices

Teens just can’t catch a break in the health department.

Last week we learned, if nothing changes, today's obese kids will have heart attacks much earlier than their parents. http://bit.ly/9R3647 It’s because of the epidemic of obesity seen in children and adolescents today. As a result, if we are not successful and the obesity problem remains or – heaven help us – gets worse, our kids today will start having heart attacks by the time they hit their 30s and 40s.

Also, last week, we learned that excess stress during adolescence may be setting young people up for more mood disorders as adults. http://bit.ly/azJOrI If there is one thing more universal among young people today than obesity, it’s stress. So, that’s just great news! And we learned that kids with hypertension have more learning disabilities. http://bit.ly/cKX6PP Since obesity is tightly tied to the development of high blood pressure – well, you can see the problem.

Is There Any Good News?

Here at the American Heart Association meeting, investigators reported that maintaining a healthy lifestyle from young adulthood to middle age plays a huge role in achieving a low cardiovascular disease risk profile in middle age.

In other words, the solution to the more-heart-attacks-sooner problem of tomorrow is helping young people make more heart healthy choices today.

Here’s the data: Researchers studied the long-term follow-up of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Researchers wanted to know whether adopting a healthy lifestyle from young adulthood to middle age can lead to a low cardiovascular disease risk profile in middle age – we already know that your risk factors in middle age play a big role in how healthy or unhealthy your cardiovascular system is years later.

CARDIA included 2,498 black and white participants 18 to 30 years old in 1985 at baseline. Compared to their peers, a healthy lifestyle was one that included:
• Not being overweight or obese
• Having no or only moderate alcohol intake
• Eating a diet with more potassium, calcium and fiber
• A lower intake of saturated fat
• Being more physically active
• And never smoking cigarettes.

After 20 years, more than 60% percent of people with all five healthy lifestyle factors from young adulthood to middle age showed a much lower risk profile compared to the less than 6% of people with none of the healthy lifestyle factors.

In this study, risk profile was based on common factors that influence your heart health: blood cholesterol, blood pressure, smoking, diabetes and history of heart attack. That means, for young people who had healthier lifestyles, they were less likely to later have major risk factors like high blood pressure, high cholesterol, etc.

We know that middle-aged adults with fewer cardiovascular disease risk factors have a longer life expectancy, dramatically lower rates of heart disease, better quality of life, and lower health care costs as they age. The same would appear to true of young people, too.

More good news: overall, even in this age of obesity, the majority of young adults have a low cardiovascular risk profile; they don’t have hypertension, they don’t have high cholesterol levels, etc. The majority! Only about 7% of American middle-aged men and women satisfy the low cardiovascular disease risk profile.

So, young people are starting out way ahead of their parents – but they’ll lose that advantage quickly if they don’t change some of their lifestyle habits.

Bottom line: More emphasis should be devoted to encouraging healthy lifestyles among young adults.

Not sure how to talk to kids about food? Last week I noted the fine line between obesity and eating disorders. At the time, I recommended this post, from Psychology Today, on talking to kids about eating, food, and weight. http://bit.ly/9mPKby

Forget You Even Know the Word Exercise: Choose to Move

Had another great conversation with a world-class medical investigator today, whose specialty is diabetes. Once more, the topic turned to the impossibility of getting middle-aged and older adults to exercise.

Maybe the real problem is the word itself. Exercise brings forth images of weightlifting, jogging, calisthenics. (Cripes, a shudder just went down my spine: I hated PE when I was a kid!)

The American Heart Association has the right idea and they call it: Choose to Move.

Here at the AHA meeting, investigators reported on this national Web-based intervention program. The 3,796 women in the organization’s national 12-week Choose To Move program were provided weekly activity guides and requested to complete surveys on activity, quality of life and readiness for activity.

Researchers evaluated 892 women who completed the program. Participants improved their activity from a median 240 to 343 kcal/week. What does that mean? Glad you asked. In daily conversation, the word calorie is used instead of the more precise scientific term kilocalorie. When a fitness chart says you burn about 100 calories for every mile you jog, it means 100 kilocalories.

So, we burn calories when we are active (notice I did not say the E word) and all these women did was increase the number of calories burned in a week by a little over 100 calories – and their body mass index improved from 29.3 to 28.9 kg/m2 after 12 weeks. Also, they were scored on how much energy they had and their overall well-being; both improved with such a small increase in activity.

Forget jogging; depending on your weight, 100 calories would be about what you would burn in a 20-minute walk. That is do-able for just about anyone!

For more than 2 years now, I walk 2.2 miles with my youngest son (he’s 16) every night. Eric and I are both in much better shape.

There is an old saying, “Use it or lose it.” Don’t think about the E word. Exercise is something we did in school and we either loved it or hated it. Sadly, that became our mental image of exercise and now we think we have no time or energy for that. Or we just think we would look ridiculous in our old gym suits. The trick is to realize that all you need is a different point of view: move it or lose it.

NOTE: The American Heart Association has a FREE 12-week online nutrition and fitness program. Go to http://bit.ly/9dNfAu

The Eyelids Have It: Your Eyelids May Predict Risk of Heart Attack, Death

Think of me as a medical version of Lewis Black: When a medical story falls through the cracks, I’m there to catch it. Here’s a story from the American Heart Association meeting in Chicago that should have gotten some attention:

Cholesterol deposits on eyelids, which has the jaw-breaking name of “xanthelasmata,” (say that 3 times fast) predict your risk for heart attack, artery disease and early death.

The Danish team reporting the data say that because half of the people with the deposits have normal blood cholesterol levels, the eyelid lesions may be an important independent marker of underlying artery disease.

Here’s what the study showed:

Copenhagen researchers established the presence or absence of xanthelasmata at baseline in 12,939 people. Of these, 1,903 developed heart attacks, 3,761 developed ischemic heart disease and 8,663 died during up to 33 years of follow-up. Cumulative incidence of ischemic heart disease and heart attack as a function of age increased in those with xanthelasmata, and the proportion surviving decreased.

Xanthelasmata predicted 51% increased risk of heart attack and 40% increased risk of ischemic heart disease. Those with xanthelasmata also had a 17% increased risk of death after adjustments for well-known cardiovascular risk factors including blood cholesterol levels.

OK, here’s the hard science for those who enjoy it: The results suggest that other factors besides cholesterol levels — including capillary leakage, characteristics of macrophages or intercellular matrix components — “may predispose certain individuals to both xanthelasmata and to atherosclerotic disease and early death,” researchers said.

“In societies where other cardiovascular disease risk factors can’t be readily measured, presence of xanthelasmata may be a useful predictor of underlying atherosclerotic disease,” researchers said.

One editorial note: This flies against some earlier data. In 2008, investigators reported no link between xanthelasmata and cardiovascular disease risk. (Read the story here: http://bit.ly/9I1LVU) Granted, it was a much smaller study, so the work from the Danish investigators may be more reliable because of its sheer size.

Doctor, You’re Getting on My Nerves

Make sure it’s a nurse who takes your blood pressure!

A recent study in the British Medical Journal reported that blood pressure recorded by doctors was higher than that recorded by other health professionals. It was a big difference: 9 mm Hg systolic (the first number commonly given when reporting blood pressure) and 7 mm Hg diastolic. It’s not that doctors don’t know how to take blood pressure readings! Due to an affect called white coat hypertension, blood pressure measured in the clinic by doctors tends to be higher than that measured by nurses.

Is the lower blood pressure actually the correct blood pressure? A large study by La Batide-Alanore and colleagues (Journal of Hypertension) showed a similar difference between blood pressure readings made by doctors and nurses, with the added finding that the nurse recorded blood pressure was closer to the patient’s daytime average blood pressure (so-called ambulatory blood pressure) than the pressure recorded by the doctor.

That’s what the new BMJ study found, too: daily blood pressure readings outside of the clinic were very similar to what the nursing staff recorded in clinic. The new study also adds to our knowledge by finding two exceptions: Ambulatory blood pressure readings tended to be slightly lower for women than for men and lower in older people (>65 years) than in younger people. Also, the difference was similar whether the people studied were already on blood pressure medicines or not.

For a number of reasons, we seem to choke up a little in the presence of doctors. We're nervous about what they may tell us. Maybe we feel they're rushed and we feel rushed, too. Whatever the reasons, there is one thing for sure: Have confidence when a nurse takes your blood pressure. And, doc: Don’t take it personally.

(By the way, the British Medical Journal allows free access to research studies. If you want to read the full study, here's a shortened link: http://bit.ly/dswIbW .)

Nobel Prize Winner Sir James W. Black (1924-2010)

Whether you know it or not, you have benefited greatly by the work of this man who passed away this week.

It is extraordinary to create a new drug that is the first of its kind; Sir James W. Black, MD did it not once but twice. If you have ever taken a beta-blocker (like atenolol, propranolol, or carvedilol) or an over-the-counter heartburn remedy (such as Zantac or Pepcid) you are indebted to Dr. Black. If you have never required either class of drugs, you still owe a great deal of gratitude to this scientist.

I have interviewed several Nobel Prize winners through the years, with the first being Dr. Black. What a place to start! His work helped take medicine to a new place that continues to produce life-saving drugs.


A Whole New World
Early drug development was based on chemical modification of natural substances. For example, early Greeks used willow bark as a fever fighter. Today we know it as aspirin. Another mainstay of medicine came from a beautiful country garden flower called foxglove; in 1775, an old woman’s home cure was first recognized as containing a powerful heart medication called digitalis.

Sir James W. Black, MD was one of the pioneers who introduced a more rational approach to drug development based on understanding basic biochemical and physiological processes. Instead of synthesizing drugs from naturally-occurring compounds, Dr. Black and others looked to purposefully build drug molecules that would directly interact with cells and cellular processes throughout the body.

Here’s just one example of how this works. Epinephrine and norepinephrine have opposing effects in the body. In 1948, American scientist Dr. Raymond Ahlqvist suggested these opposing effects were mediated by different receptors in the target organs. He called these different receptors alpha- and beta-receptors, suggesting that substances could selectively stimulate these receptors (agonists) or inhibit these receptors (antagonists). It was this theory that inspired Dr. Black and his colleagues.


A Nobel Life
Like many Nobel Laureates, Dr. Black’s personal story was colorful. In describing his education, this Scottish doctor admitted he “coasted, daydreaming, through most of my school years.” At 15, a math teacher “more or less man-handled me into sitting the competitive entrance examination for St Andrews University.” The fourth of five children from a staunch Baptist family, there was no money to send another kid to university, but that did not matter when his test scores led him to a full scholarship.

After earning his doctorate, he decided against a career as a medical practitioner due to what he perceived as the insensitive treatment of patients at the time. (To understand just how uninspiring medicine was back then, read my posting on the $14 Billion Heart Attack here: http://bit.ly/5PEh2j.) Instead, he joined the University of Glasgow in their veterinary school, eventually establishing the school’s physiology department.

He developed an interest in the way adrenaline affects the human heart, particularly those suffering from the often crippling chest pain known as angina. He had a theory to annul the effects of adrenaline, so he joined ICI Pharmaceuticals in 1958, where he created the first beta-blocker, propranolol. The discovery of this drug was hailed as the greatest breakthrough in the treatment of heart disease since the discovery of digitalis two centuries earlier.

He saw that the general idea might be applied to treat stomach ulcers, but his employers weren’t interested. So, Dr. Black left ICI in 1964 and joined Smith, Kline and French. (After numerous acquisitions and mergers, the company is known today as GlaxoSmithKline.) There, in 1975, he developed cimetidine (sold as Tagamet) which became the best-selling drug in the world. The drug that Tagamet knocked out of the #1 slot for worldwide sales: propranolol.

Based on this pivotal research, Dr. Black shared the 1988 Nobel Prize in Physiology or Medicine with Gertrude B. Elion and George H. Hitchings for their discoveries of “important principles in drug treatment.”

Of all the things Dr. Black and I discussed 10 years ago, this stands out:

He met his wife, Hilary, when they were both students at St. Andrews University. Upon graduation, Dr. Black stayed there as a teacher while his wife completed her degree in biochemistry. Dr. Black called his wife “the best student I ever had.” Her eclectic pursuit of knowledge led her to study law and later poetry.

Calling her "the mainspring of my life" until she died in 1986, he said, “Intellectually, she was the most exciting person I have ever known.”

Dr. Black, many could say the same about you.

2001: A Medical Odyssey

How Did Experts Do in Predicting What Medicine Would Look Like Today?

In 1987, 227 world-class scientists were asked to predict the state of medicine in the 21st Century. This was no simple survey: the full report was 203 pages of statistics and analysis, commissioned by Bristol-Myers and conducted by Louis Harris and Associates,

When I originally wrote about the predictions, my work was front-page news in medical and lay news outlets. Now, the future is here: how did the experts do?

• They predicted a 67% cancer cure rate: Pretty much right on target. Today, the 5-year survival rate for cancer overall is 66%. (The comparable cure rate when the experts made their prediction: 54%.)

• No more heart bypass: Missed it by a mile. Specifically, cardiovascular scientists predicted most of the 230,000 heart bypass surgeries being done in 1987 would be replaced by less invasive procedures. Well, there are now 1.3 million such minimally invasive heart interventions done each year; but far from being replaced, nearly twice as many heart bypass procedures are being done each year in the US today (448,000) compared to 1987. It’s partly a factor of an aging population, but mostly it’s a realization that specific types of patients still do better with open surgery.

• 61% predicted an AIDS vaccine by the year 2000: Way too optimistic. Later this year, experts will gather for the 10th annual AIDS Vaccine Conference. In their preliminary program, the chairs of the conference state that despite “encouraging progress…we remain a long way from an affordable, effective vaccine against HIV.”

• A majority predicted an AIDS cure by 2010. Nope. (To be fair, 73% of the infectious disease experts surveyed in 1987 were at complete odds with most of the other experts and saw little or no improvement in treating AIDS by 2000.)

• The death of traditional psychoanalysis. Saw this one coming and, not surprisingly, the central nervous system experts who predicted this were way over-confident. (The word cocky also comes to mind.) Granted, the percentage of patients who receive psychotherapy is about 28.9% today compared to 44.4% in 1996-97. Still, that’s far from “little or no role” for psychotherapy. Importantly, there’s one big reason for the downturn in psychotherapy: financial incentives (insurance reimbursement) favor short medication visits compared with longer psychotherapy sessions. However, given growing concern regarding the widespread use of psychotropic drugs coupled with recent research showing the benefits of cognitive therapy, reports of the death of psychotherapy are greatly exaggerated.

• The “Golden Age of Biology.” Dr. Leroy Hood, whose work revolutionized genetic engineering and biology, said, “I think we will develop every bit as revolutionary technologies in the next 10 years as we have in the past 10 years.” Frankly, if the survey were repeated today, I suspect many of our current world-class scientists would agree and say the same thing about the next 10 years in medicine.

Finally, the experts in 1987 were nearly unanimous on one point: that disease-prevention would do more than advances in either treatment or diagnosis. For example, while steady improvement was predicted for “curing cancer,” there was almost complete agreement that a smokeless society would be the most effective strategy in the prevention and treatment of lung cancer.

25 Years Ago, Kids Were Fitness Failures; It 's Only Gotten Worse

Overwhelming Evidence Heart Disease Starts in Childhood

In September 1985, I wrote: “In the middle of a wellness boom, our children’s fitness is a bust.” Twenty-five years ago, in an age of 10K runs, aerobic fitness centers, and Jane Fonda workout videos, our kids were physical wrecks. Since then, things have deteriorated to a point where some might think of the 1980s as “the good ol’ days.”

Today’s kids may be the first generation to have a shorter lifespan than their parents, but parents can stop the obesity epidemic. http://bit.ly/17KfEK Here are some ideas and links to more information.

• Getting young kids to eat better is not as hard as you think. That’s because the biggest influence on their eating habits is mom and dad. As I explained some time ago, if you want your kids to eat better – especially younger kids – then buy better foods. http://bit.ly/7rDkdd Just today, I reminded a friend who wants to lose weight that the easiest way to avoid junk food is to not buy it!

• Consider the French Paradox. Research scientists have been puzzling for years over why the French eat more fat than Americans yet have a lower incidence of heart disease and a much thinner population. This explains a lot: there is a huge difference between what French and American children eat for lunch at their schools. Similarly, there is a big difference in what French and US parents teach kids about food. http://bit.ly/d4emHj

• Are kids fat because we’ve taken the fun out of fitness? Experts think there is too much focus on sports and not enough on just moving. http://bit.ly/8N59ne It doesn’t take a lot. For almost 2 years now my youngest son and I have walked about half an hour every day. It’s great fun for us and both of us have lost weight.

• Studies conducted over the last several decades provide overwhelming evidence that heart disease often starts in childhood. Fortunately, even without weight loss, kids who exercise show a big reduction in markers associated with a greater risk of heart disease. http://bit.ly/570QzE

• Do you eat when stressed? Guess what: Kids often have the same response. Sadly, many parents are blissfully unaware just how stressed out their kids are today. http://bit.ly/4EhLDH And, frankly, all work and no play makes kids more than dull; it’s why they're so anxious and depressed. http://bit.ly/6Tx829

• If kids have a weight problem, it’s a family problem. You won’t have a lot of authority if you tell your child he needs to lose weight when you’ve just opened a sack of potato chips. Think extended family, too: Youngsters are more apt to be fat with regular grandparent care. http://bit.ly/bDdCZT Clearly, grandma and grandpa need to up their babysitting game.

This isn’t rocket science, although you might think so given our complete failure at addressing these issues. It requires paying attention, avoiding mixed messages, and making better nutrition and more activity priorities.

Killer Salt has been Given More than a Fair Shake

Food Giant Knew It was Using Weak Research to Confuse the Public

People who should know better are warning of the coming war on salt. They are deriding efforts to curb our consumption of this vital but wildly overused mineral.

The source of their “war” propaganda was a recent paper in the New England Journal of Medicine. The authors estimated that cutting daily salt intake by 3 grams (less than a teaspoon), would dramatically improve health in the United States, including a huge impact on stroke and heart disease deaths. http://bit.ly/4sh1xu Indeed, if we could curb our salt habit, experts say we would prevent about half a million strokes, another 500,000 heart attacks, and save some $32.1 billion in medical costs over the lifetime of adults ages 40 to 85. http://bit.ly/ausqjY

So, what’s the confusion? In a word: marketing.

Earlier in my career, a bright Oregon scientist claimed to have discovered that a lack of calcium and not an excess of sodium was linked to hypertension. I know this because I covered the story for many of the consumer and physician publications I worked for at the time.

Shortly thereafter, another scientist who had an insider’s point of view let me know I had been duped. (Me and a thousand other reporters.) Turned out I was talking with a researcher whose office had funded the study, much to his dismay. The doctor who did the calcium research had turned to one of the largest manufacturers of salty snack foods for investigational support (money). In an interoffice memo, the corporate director of research and development questioned the investigator’s “weak” results, but recommended funding his work.

Why? He stated that the data would confuse the public and “release the pressure on sodium for the time being.” Moreover, he noted that the controversy over salt would return, but the study would provide a break from the nonstop negative press being given to high-sodium-content foods. The memo even went so far as to suggest that since the researcher’s scientific credentials were weak the company should provide him “with scientific assistance to enhance his credibility and promote visibility.” (Note: his emphasis, not mine.)

The memo also suggested releasing the data during a time when most leading heart doctors in the U.S. would be out of the country attending an international cardiology meeting. The memo noted that this would give the calcium story several days of media attention before any medical authority could get caught up with the news and caution against the findings of the calcium study.

I am not naming the researcher since I doubt he was privy to the in-house intrigue that was the determining factor behind his funding. But I offer this as a cautionary tale. We saw this once before with the tobacco industry doing everything in its power to support really bad science that very effectively confused the public. Clearly, some within the food industry were taking notes.

The “Obesity Paradox” Suggests Many of Us Need to be a Little Less Weight Obsessed

Could we be getting to the point where your doctor says you’re definitely obese and that’s just fine?

Maybe and, if we do, it will be because of the “obesity paradox.” In brief, growing evidence suggests all of us should take a deep breath and chill a little over older adults who are overweight or a little obese. Not morbidly obese – which is a medical term, by the way, and not an editorial comment – but rather a specific weight classification technically known as obese (or category 1 obesity). That’s because once obese people develop heart disease, they live longer than those who are thin (what has previously been considered normal or even optimal weight - See "me"). Plus, they live longer than those who are morbidly or super obese (again, that’s medical terminology, not editorializing).

I was reminded of this recently while listening to results of the largest clinical trial of people with heart failure and preserved ejection fraction. Ejection fraction is that small portion of blood pumped out of the heart with each heart beat. About half of all people with heart failure have a fairly normal or “preserved” ejection fraction. Like many studies in the last few years, when the I-PRESERVE trial data were analyzed to determine the effect of obesity on outcomes like death or hospitalization, the best results were seen among those people who were obese. The worst outcomes were seen in the thinnest and the fattest groups of individuals.

The stylishly thin Dr. Markus Haass of Theresien Hospital Mannheim, Germany, finished his presentation in November at the 2009 American Heart Association meeting by saying, “If I ever develop heart failure, I had better gain some weight.” In taking questions from the audience, a San Francisco doctor stood up, acknowledged his own obesity, and admitted “I really like these results.” The audience laughed and he added, “This is more evidence that the definition of normal body weight may be set too low.”

Just What is Normal?
Doctors use body mass index or BMI as an important measure of body fat. What is your BMI? All you need to know is your height and weight, then use a calculator like the one here to determine your BMI: http://www.nhlbisupport.com/bmi/

These are the categories used to define weight:
• Underweight = <18.5
• Normal weight = 18.5-24.9
• Overweight = 25-29.9
• Obesity = BMI of 30 or greater

In recent years, doctors have refined the category of obesity even further to include:
• Any BMI ≥ 35 or 40 is severe obesity
• A BMI of ≥ 35 or 40–44.9 or 49.9 is morbid obesity
• A BMI of ≥ 45 or 50 is super obese

A Little History
In 2002, a study of nearly 10,000 patients surprised a lot of people. Investigators looked at patients undergoing a common heart procedure called angioplasty and evaluated the results based on BMI. While the procedure was equally successful in all the weight groupings studied, normal BMI patients had a higher incidence of major in-hospital complications, including cardiac death and this difference was statistically highly significant (p = 0.001). After 1 year, more people with normal BMI had died compared with overweight or obese patients (p < 0.0001).

The study raised a few eyebrows, but because the results were so different than what was expected, it was largely dismissed as a likely anomaly. Then in 2005 (after more reports of such “anomalies”) Katherine Flegal, PhD, who is a senior researcher at the Centers for Disease Control (CDC), published a paper in JAMA that concluded that overweight and obesity accounted for far fewer deaths than thought. Specifically, instead of the 365,000 deaths in 2000 (the CDC’s own numbers) her study estimated that only 112,000 deaths in the US that year were associated with obesity (BMI of 30 or higher).

Dr. Flegal also found that people who were overweight but not obese (BMI of 25 to less than 30) were less likely to die during follow-up than normal weight individuals (BMI of 18.5 to less than 25). The greatest risk of death was among the leanest (BMI <18.5) and among the most obese (BMI of 35 or higher.) In other words, as you get older, it’s looking like being a little bit chubby is actually protective against death.

He Said What?
Back to the presentation I talked about earlier. After the audience member said he and his waistline were relieved and encouraged by the results, Dr. Haass who presented the I-PRESERVE data said: “It is better if you are young and have no major chronic disease to be a little on the lean side but once you develop heart failure or have a (heart attack) you better have a little so-called overweight because this is prognostically an advantage.”

Think about that statement: Once you have a heart attack or develop heart failure, you need some excess weight. Can you imagine your doctor saying, “Well, you’ve had a heart attack, so I’m giving you a special diet because you need to put on a few pounds.” As you might imagine, there are a number of doctors who are nearly going ballistic over data that even hints at such a recommendation.

Yet, if you have a BMI that makes you overweight or a little obese, maybe your doctor should not have you worry too much about weight loss. Certainly, once you have had a heart attack or have developed heart failure, you have plenty of other things to worry about, but maybe your weight shouldn’t be one of them – unless, of course, you have a BMI of 35 or higher, where all the data suggests you need to lose some weight.

There have been a total of 84 papers published since that first article in 2002 referred to this “obesity paradox,” which isn’t nearly enough data to bring an end to the debate. (I suspect it’s just getting going. Medicine moves slowly, sometimes even glacially.) But perhaps we need to stop obsessing so much about gaining a few pounds as we age, because if there is one thing pretty obvious from decades-worth of data it’s how massively unhealthy yo-yo dieting is. This never-ending loop of weight loss and weight gain is absolutely not healthy for anyone. So, you’re older and a little overweight? Frankly, that’s probably just fine.