Microsoft word - editorial for volume 30 ijo.doc

Editorial submitted for Volume 30 IJO but never published

Has the International Journal of Obesity been a success?

Alan N.Howard,
Downing College, University of Cambridge, Cambridge CB2 1DQ,UK

On the occasion of the publication of the 30th volume , it is appropriate to consider
how and why the International Journal of Obesity(IJO ) was started and if it has lived
up to the aspirations of one of it’s founding editors.
The idea of the IJO began in the early 1970’s when I attended a meeting on obesity at a resort on the Rhine, Germany .One of those presenting a paper was a distinguished scientist George Bray at that time working in Los Angeles .During one of the social breaks to partake of the wine at Rudesheim, I chatted with him about the future of obesity research. At that time I was very much involved with the UK Association for the Study of Obesity(ASO) which met regularly at the Royal Society of Medicine in London. In the 1960’s this group had been started under the chairmanship of Ian Mclean Baird to promote Obesity Research in the UK. I had also been a founder member , the scientific secretary for their first national meeting and for a short period the general secretary(1). George Bray and I discussed the idea of having an International Congress on Obesity and founding a new international journal and agreed to consult our colleagues back home. Our committee was enthusiastic about having a congress but lukewarm about the journal . Trevor Silverstone the chairman of the ASO felt it was his job to organise the Congress but in view of my prowess as an editor of the first national meeting (2), I was given the task of being editor of the Congress publication (3) .I had previously had dealings with a London Publishing house, Newman & Co who had an office just off Oxford St. They had successfully published another conference on “ Nutritional Deficiencies in Modern Society (4) which I had organised and edited as chairman of the British Food Education Society .It proved an excellent choice for publishing the Proceedings of the first International Congress on Obesity(3) , held at the Royal College of Physicians ,Regent’s Park , London in 1974. The message I received from the ASO committee was that it was up to me as an individual to organise a journal on obesity, if that was what I wanted. So I approached Newman & Co and asked if they would like to take it on. After several months of deliberation they agreed. So I informed George Bray of the good news and he became the editor for North America and I was editor for the rest of the world for the new International Journal of Obesity( IJO) to be published as a quarterly. We quickly appointed an Editorial Board from well known investigators drawn from people we knew and those we had met at the First International Congress on Obesity. This had the appropriate effect of publicising the IJO as a serious journal, and at the same time encouraging leading authorities to send us their papers. The managing director of Newman & Co was John Libbey. Later on he took over the journal as John Libbey & Co , with Eldred Smith Gordon directly responsible for the publication. John Libbey was keen to get the support of the ASO and later arranged for members to obtain the IJO at a preferential rate and it became it’s source of information about the Association. Later on John Libbey in 1987, sold the IJO to MacMillan. Although he has been criticised by some ( see George Bray’s contribution p--) he was perfectly entitled to sell it since he owned the intellectual property rights and had been astute enough to see it’s potential and to make investment in it. Eldred Smith Gordon subsequently started his own publishing company specialising in nutrition. It is interesting to examine my own motives at this time. I believed that obesity needed a journal devoted to itself. It was already a serious problem, and the Framingham study and others had already shown that obesity was a risk factor for diabetes, hypertension, coronary heart disease and stroke(5-7) .It was clear that there should be much more research if progress was to be made in combating the condition .At that time government agencies throughout the world were giving more funds for medical research .If there was a new journal it would stimulate more research on this important topic. Scientists would need to publish their results, and the journals available were already oversubscribed with papers . Also at that time scientists were starting to look at research topics as a unity. In other words if you worked in the field of obesity you needed to know as much as possible about the subject, not just as nutritionist, biochemist, or pharmacologist etc. Thus a journal devoted solely to obesity would serve a real need. With more meetings taking place, researchers needed to know what was going on in their field quickly so the publication of abstracts of papers and posters of meetings would become important . Also at the larger congresses, satellite meetings were becoming very popular and these needed a separate publication to the main proceedings. The IJO has certainly fulfilled the role expected of it, and has made a highly respected contribution to obesity research. The IJO was a peer review journal, which necessitated two reviewers. During the first year or two the editors had to accept almost all the papers submitted which received reasonable reviews. By so doing it was just possible to obtain enough material to fill the journal. Later on one could be more selective. Among the first papers were 14 from USA, 7 from UK, 2 from Germany, 1 each from France Italy and Sweden. George Bray and I never received nor asked for an honorarium for our work but received expenses to pay our secretaries. It involved me for at least one whole day a week and the work load was doubled when George Bray took 1978 off as sabbatical leave. We did it as “a labour of love” and hopefully for the advancement of science. I especially thought it an honour to be an editor of a budding new international journal on a subject of great interest to me. My own research interest was in the field of Very Low Calorie Diets( VLCDs) for the treatment of Obesity. In the 1970’s and 80’s I published several of my own papers in the IJO and elsewhere on this subject in collaboration with Ian Mclean Baird at the West Middlesex Hospital, London and colleagues at Addenbrooke’s Hospital, University of Cambridge where I had established an obesity clinic.(9-13) Most of the investigators in this field at that time were using the term “protein sparing modified fast” .Since our formulation was a complete diet, I used my editorial license and introduced VLCDs instead as a better terminology .I organised a very successful satellite meeting on VLCD’s on the Italian Island of Ischia following the 3rd Int Congress on Obesity in Rome in 1980 , published as a supplement to the IJO(14). I have always been an entrepreneur, so it seemed logical to me that the obese public should have the benefits of the diet I had devised by introducing it into the marketplace. Armed with US and UK patents I sought financial backing and after many disappointments a Californian family , Jack ,Eileen and Vaughn Feather, took it on and formed a company “Cambridge Diet International” to sell our “ Cambridge Diet”. Jack Feather was an early subscriber to the IJO and read with interest my paper with Ian McLean Baird(10) published therein. They owned a home in Surrey and in the summer of 1979 during a visit to the UK,a meeting was arranged and subsequently plans made to manufacture the diet in California the following Spring It was an enormous financial success in the US in the years 1982-3.But like all successful diets it was very controversial. No doubt the publishers of the IJO were besieged with angry letters from numerous academics because in 1982 after 5 years as editor I was asked to resign. It seems my commercial success was incompatible with editorship of the IJO (see George Bray’s contribution , p---). Call it luck if you will , but it has to be acknowledged that if it were not for Jack Feather’s subscription to the IJO and his interest in obesity, my editorship of the IJO might have lasted another 20 years. Not to be discouraged , I wrote a book entitled “The Cambridge Diet “ published by Jonathan Cape one of our prestigious UK publishers and which became a bestseller(15) . I sponsored two more satellite meetings on VLCDs .One in 1989 was held in Cambridge in the Howard Building , Downing College , a gift from the Howard Foundation , a charity established to disseminate the profits from the Cambridge Diet . The proceedings were published in the IJO as a supplement to the 2nd European Obesity Conference held in Oxford (16). The second was in Kyoto, Japan as a satellite meeting to the the 6th International Congress on Obesity in Kobe , Japan and published as a supplement to the American Journal of Clinical Nutrition(17).In the end my endeavours proved worthwhile since the UK Dept of Health in a COMA report(18) pronounced VLCDs safe when used properly and appropriately labelled. Together with Stephen Kreitzman from Emory University,USA, I continued our work at our laboratory ,Howard Foundation Research, established at the Cambridge Science Park. We were able to show that nitrogen loss on a VLCD(one of the major concerns of the critics of the diet) was no more than theoretically expected(19).The results were published as a monograph by Smith Gordon. Thus I and my colleagues felt vindicated. In 1984, I had set up a company in the UK which now owns a factory manufacturing the diet and which exports to more than 25 countries worldwide(20,21 ). Whilst at the time, I was extremely disappointed in having to give up my editorship of IJO, I remember it as an important and fruitful period in my life but I was able to move on to other good works. I certainly was very proud when my contribution to obesity research was recognised at the International Congress in Kobe (22 )( fig.1). Perhaps today the views of my colleagues might be different. Academics are encouraged to collaborate with industry especially when intellectual property is generated. In my University it is now rare to find an eminent scientist who is not a director of a newly founded high tech company on one of the Cambridge Science Parks. In my own case the Cambridge Diet was financially very successful and by establishing a charity, the Howard Foundation(23), I was able to fund not only my own research but those of others at the Department of Medicine in Cambridge and elsewhere. I was especially pleased to be able to create a personal chair of Human Nutrition at the University of Ulster in N. Ireland for David Thurnham an expert in Vitamin E and carotenoids. Has the IJO lived up to our initial high hopes which were to help conquer obesity? When it began in 1977,obesity was a serious problem; now it is a catastrophic epidemic, and of supreme concern to Government authorities. One could suggest that the IJO has been a dismal failure . However, I believe this view would be mistaken. There is very little that the contributors to IJO could have done to stem the rising incidence. The answer to the obesity epidemic is prevention not treatment. Once a person is obese, it is easy to reduce their weight in the short term but the incidence of weight regain is high and a huge percentage of people regain their pre-treatment weight. The successful ones are those who are on some kind of permanent food restriction (24 ).The prevention of obesity is a political problem, not a scientific one. The causes of obesity are the over-consumption of calories due to very large portions of food being served and quickly eaten in restaurants or at home (25). At the age of 75, I now spend most of the year in retirement in the South of France in the city of Cannes. Thus I have plenty of time to observe the French who are extremely passionate about eating good tasting food. There is no major obesity problem in France (26) .It is extremely rare to see the super obese although many older people are overweight. In most French restaurants, the portions are extremely modest. Often the main dish of meat or fish is served without carbohydrates such as potatoes or rice. Modest portions of French bread are available at all times, usually without butter. Moreover the French take time over their meals. It is rare to get away from a restaurant before 90 minutes has passed and the whole place is a buzz of conversation. The main meal is taken at lunchtime which lasts at least 2 hours. In consequence, winter or summer, all commercial activity closes down in the middle of the day. The French eat fewer calories more slowly . This applies even to fast food. About I million people eat at McDonald restaurants in France everyday. However, the media reports that the French take twice as long ( 22min.) as the Americans ( 11min.) to eat their fast food meal. It is encouraging to note that recently the UK government has been looking into the composition of school meals, which it is proposed should be lower in sugar ,salt and fat. Future prevention lies in education especially among school children and possibly some kind of financial inducement to eat fewer calories. It is not easy for governments who, whatever advice or action they take, are likely to be accused of developing a “nanny state.” Also they have to deal with industrial lobbies who have a vested interest in promoting a higher consumption of fat and sugar My interest in obesity research began over 40 years ago. Thus before I became Editor of the IJO.I had already been working in the field over 15 years. As a young nutritionist in the 1960s, I became interested in the dietary treatment of obesity . One of the reasons being that I was overweight and needed help myself. I was appalled at the constant stream of dietetic rubbish produced by journalists in newspapers and magazines. So with considerable enthusiasm I became the first consultant editor for a new UK magazine “ Slimming Magazine “ launched by Audrey Eyton of F-plan fame(27). I resigned after 6 months because every monthly issue had a new diet which had never been tested before and was bound to work , and which I was expected to extol on numerous TV tours. At that time I was secretary of the ASO and the members of the committee clearly did not like my involvement with a magazine whose purpose was to help the public and I was asked to resign from being secretary. Later in the year I learned that my chief critic on the committee Derek Miller of Queen Elizabeth College, London had taken the job himself as the consultant editor, but in fairness to him he did resign from the committee Fortunately I was able to stay on and be involved in the editorship of the First International Congress on Obesity and founding the IJO. As now there were many best selling diet books on slimming which never explained how you were able to lose the weight and never ever gave audited weight loss results. I hoped that the IJO would attract serious academic nutritionists who could examine different methods and survey their effectiveness, or that the writers of the diet bestsellers would carry out some clinical trials to support their claims and sales. I was disappointed. Among my US contemporaries the investigators of Optifast(28), a VLCD similar to the the Cambridge Diet, were one of the few who published their results. Another phenomenon I have observed is the continual re-invention of the low carbohydrate diet among the best selling authors. It is a topic on which I have a continuing interest .In the mid 19th century, a Victorian undertaker , William Banting, discovered that the avoidance of carbohydrate promoted satiety and he wrote a pamphlet promoting the virtue and effectiveness of eating a diet of protein and fat in modest quantities(29) (Fig2).He became internationally famous and incidentally predated Robert Atkins’ Diet Revolutions (30,31) by 100 years About every 25 years the low carbohydrate diet method gets rediscovered or relaunched. Among those who have also promoted it are John Yudkin (32) , Herman Tarnower with his Scarsdale diet(33),Montignac (34), the Hellers (35) and myself with the Cambridge Diet(15) .As was the case originally for Banting, a re-launch is greeted with much medical controversy. It is very timely that a group of academic researchers from Denmark have recently validated the positive effect of low carbohydrate diets in promoting weight loss and published their results in the IJO (36) .There is now a need to establish the mechanism of the low carbohydrate effect despite some resistance among academia to investigate a topic which is popular among the public or is very commercial. My own early research in this field illustrates the difficulties. In the 1960s I read Yudkin’s book(32), and was sufficiently impressed that I started working with a local miller in Cambridge on a novel loaf of “ bread” made from wheat germ and soya which had almost the same composition as beefsteak. I conducted a double blind trial with general practitioners in Cambridge in which a placebo brown loaf was compared with this so called “Cambridge Formula loaf” in their obese patients. The results were modestly good in that both groups lost weight but those consuming the Cambridge loaf lost statistically 50% more weight. In those days posters had not been introduced and I was able to present my data as an oral communication to the UK Nutrition Society. After my presentation I was expecting some congratulatory comments , but instead pandemonium broke out as one of the very senior members claimed that the results were a fabrication and that I had been paid by the milling company to present them. There then followed a stormy debate which held up the next paper for 30 minutes while it was decided if my abstract would be included in the proceedings. The chairman Sir David Cuthbertson , Director of the Rowett Insitute , Aberdeen, acted as moderator and it was decided that my abstract could be published(37) but with a note that the views expressed were those of the authors and not necessarily of the Society .The incident again illustrates the problems of any would be serious research worker who discovers something useful and which is also commercial (the Cambridge Formula Loaf was very successful : in one week 1
million loaves were consumed).As then, it could be today a useful adjunct to a low
carbohydrate diet. What I was trying to achieve in my early days was a rigorous
scientific testing of dietary methods for the treatment of obesity by carrying out
clinical trials. At that time there was no specialist journal on this subject and the
results were published in the Practitioner(38) , thanks to the editor William
Thompson’s interest in obesity research in community medicine. My view then as
now is that there needs to be greater collaboration between manufacturers of diet
products , diet best seller writers and academia. One of the reasons for starting the IJO
was the hope that this would happen and that such results could be published. It rarely
happened: but since obesity is now such a severe problem research workers in our
field should give serious thought to the idea.
There is natural reluctance among authors of popular slimming books to have their
claims investigated and to have the possible demonstration that their method either
doesn’t work or is unsafe to be broadcast to the world. Such could also be said for
commercial products. There should be some mechanism whereby claims and safety of
weight reduction methods could be investigated, possibly by a government agency as
was done in the UK for Very Low Calorie Diets(18). Obesity is now such a serious
problem in developed countries that the investment by governments would be very
worthwhile. Moreover publication of the results , review and discussion of reports
would make excellent reading in the IJO . I would thus achieve one of my original
aims for the Journal, namely to advance the dietary treatment of obesity.
Both academics and the public alike are looking for the wonder medication which will
prevent or cure obesity . Then people could eat until their heart’s content and not have
to worry about slimming. Yesterday leptin was the big hope. Today it is
rimonabant(39) a drug which inhibits the cannaboid receptors in the brain and which
has received much attention in the media recently. When such an end point is
reached, the event will surely signal the demise of the IJO . The publishers can rest
assured that this is likely to be a long way off. My own legacy will then not be a diet
but some beautiful Palladian style buildings at Downing College, Cambridge.
Like my co-founding editor George Bray , I wish the IJO a successful future in
helping to combat a difficult problem: obesity .

1. Howard AN. The History of the Association for the study of obesity. Int J Obes 1992; 16 (suppl. 2): 51-58.
2. McLean Baird I, Howard AN (edits). Obesity, medical and scientific aspects of the first symposium of the Obesity Association of Great Britain held in London, October 1968. Livingstone: Edinburgh; 1969. 3. Howard AN (edit). Recent advances in obesity research vol. 1. Newman: 4. Howard AN, McLean Baird I. Nutritional deficiencies in Modern Society. 5. Kannel WE, Brand N, Skinner J et al. The relation of obesity to blood pressure and the development of hypertension: the Framingham Study. Ann Intern Med
1969; 71: 89-99.
6. Feldman R, Sender AJ, Siegelaub AJ. Differences in diabetic and nondiabetic fat distribution patterns by skinfold measurements. Diabetes 1969; 18: 478-
7. Ashley FW Jr, Kannel WB. Relation of weight change to changes in atherogenic traits: the Framingham Study. J Chronic Dis 1974; 27: 103-115.
8. Howard AN, McLean Baird I. A long term evaluation of very low calorie semi-synthetic diets. Int J Obes 1977; 1: 63-78.
9. McLean Baird I, Howard AN. A double blind trial of mazindol using very low calorie diets. Int J Obes 1977; 1: 271-278.
10. Howard AN, Grant A, Edwards O, Littlewood ER, McLean Baird I. The treatment of obesity with a very low calorie liquid formula diet: an
impatient/outpatient chief comparison using skimmed-milk protein as the chief
protein source. Int J Obes 1978; 2: 321-332.
11. Howard AN, Grant AM, Challand GS, Wraight EP, Edwards O. Thyroid metabolism in obese subjects after a very low calorie diet. Int J Obes 1978; 2:
12. Grant AM, Edwards OW, Howard AN, Challand GS, Wraight EP, Millo IH. Thyroidal hormone metabolism in obesity during semi-starvation. Clin
Endocrinology 1978; 9: 227-231.
13. McLean Baird I, Littlewood ER, Howard AN. Safety of very low calorie diets. Int J Obes 1979; 3: 399.
14. Mancini M, Howard AN (edits). Evaluation of very low calorie diets. Proceedings of satellite symposium to the 3rd International Congress on
Obesity held in Ischia Italy. Int J Obes 1981; 5: 193-352.
15. Howard AN. The Cambridge Diet. Jonathan Cape: London, 1985. 16. Stock M, Munro J (edits). Satellite conference on Very Low Calorie Diets to the Cambridge 2nd European Congress on Obesity. Int J Obes 1989; 13 (suppl.
2): 1-200.
17. Atkinson RL, Pi-Sunyer FX (edits). Very low calorie diets. Proceedings of a satellite conference to the 6th International Congress on Obesity held in Kyoto
Japan. Am J Clin Nutr 1992; 2: 1755-3055.
18. Department of Health and Social Security. Report on health & social subjects No 31: the use of VLCD in obesity. HMSO: London; 1987. 19. Kreitzman S, Howard AN. The Swansea trial: body composition and metabolic studies with a VLCD. Smith Gordon: London; 1993. 20. Howard AN. The Cambridge Diet – 20th Anniversary edition. Cambridge 21. Howard AN. 22. Oomura Y, Tarui S, Inove S, Shimazu T. Progress in obesity research proceedings of the 6th International Congress on Obesity, Kobe Japan. John Libbey: London; 1990. 23. Howard AN. www. 24. Ryttig KP, Rossner S. Weight maintenance after a VLCD weight period and the effects of VLCD supplementation. J Intern Medicine 1995; 236: 233-239.
25. Critser G. Fat-Land: how Americans became the fattest people in the world. 26. Detournay B, Fagnani F, Charles MA et al. Obesity in France. Rev Epidemiol Sante Publique 1999; 47: 385-388.
27. Eyton A. F-Plan diet. Penguin: London; 1982. 28. Genuth SM, Castro JH, Vertes V. Weight reduction in obesity by outpatients by semi-starvation. J Am Med Assn 1974; 230: 987-991.
29. Banting W. Letter on corpulence. Harrison: London; 1869 (fourth edition). (full text available on 30. Atkins RC. Dr Atkins’ diet revolution. Bantam: New York; 1973. 31. Atkins RC. Dr Atkins’ new diet revolution. Avon Books inc.: New York; 32. Yudkin J. The complete slimmer. Mac Gibbon and Kee: London; 1964. 33. Tarnower H, Baker SS. The complete Scarsdale medical diet. Bantam: 34. Montignac M. Dine out and lose weight. Artulen: London; 1991. 35. Heller RF, Heller RF. The carbohydrate addicts program for success. 36. Due A, Toubro S, Skov AR, Astrup A. Effect of normal-fat diets, either medium or high in protein, on body weight in overweight subjects: a
randomised 1-year trial. Int J Obes Relat Metab Disord 2004; 28: 1283-1290.
37. Howard AN, Anderson TB. The treatment of obesity with a bread of high protein and low carbohydrate content. Proc Nutr Soc 1965; 24: 28.
38. Howard AN, Anderson TB. The treatment of obesity with a high protein loaf. The Practitioner 1968; 201: 491-496.
39. Bays HE. Current and investigational anti-obesity agents and obesity therapeutic treatment targets. Obes Res 2004; 12: 1197-1211.

Figure 1
The author receiving a commemorative plaque at the 6th International Congress on
Obesity in Kobe Japan inscribed “Presented to Alan N Howard in Recognition of his
Outstanding Service as Founder and Editor of the International Journal of Obesity”
Figure 2
William Banting (1796 - 1878) the “great grandfather of low carbohydrate diets”.

Address for correspondence

Dr A. N. Howard
The Howard Foundation
Whitehill House
Granhams Rd
Great Shelford
Cambridge CB2 5JY, UK



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