Obesity as a Disease

In the Washington Post, Esther J. Cepeda asks what to me seems to be an odd question about obesity:

Is obesity truly a disease that requires medical treatment and prevention, as the American Medical Association recently proclaimed? Or is it still more accurately a “condition” with too many variables and factors to shoehorn into a neat category?

Perhaps by "condition" Cepeda means "symptom"? Which would potentially put obesity in the same category as pneumonia - the cause may be a bacterial or viral infection, but you can start treating the pneumonia before you know the exact cause? Or is it because obesity has a behavioral health element, and the comment represents resistance to treating conditions with a significant psychological element as diseases? The author opines that it does not matter, "if a label with more gravitas is what it’ll take for obesity to be taken seriously, then let’s go with it", but at heart it does matter because if the public perception remains "Obesity results from a lack of willpower - if you have the strength to push away from the table it's nobody's fault but your own", the label the medical community uses has little relevance save perhaps as to determining whether and when treatment should be covered by insurance.

The author makes some good points about nutrition - most doctors know little about it, and too few doctors given any appreciable amount of counseling or information to their patients about weight.

In 1998, the National Institutes of Health recommended that health care professionals advise obese patients to lose weight. In 2011, research published in the Archives of Internal Medicine found that of participants in government health surveys, one-third of obese patients and 55 percent of overweight patients said a doctor had never told them they were overweight.

I know of doctors who believe that they fulfill the first duty by telling patients, "You should lose weight," which usually has all of the impact and relevance as, "You should stop smoking," or "You should exercise more." Making the statement isn't enough. As for the rest, yes, there are significant numbers of people in our society who are in deep denial about how they appear to other people, but I don't believe for a moment that the typical obese person is not aware that he or she carries more than a few extra pounds. For a typical obese person, being told "You're overweight" would be roughly as insightful as telling them, "Hey - you still have a pulse."

Something else to recall is that a big part of how we, as a society, perceive "overweight" has to do with societal standards of beauty, not whether or not a person has achieved a healthy weight. A copy of the Enquirer I saw yesterday at the supermarket checkout stand had a typical tabloid cover about which celebrities - as is usually the case, all women - had gained weight, and which had lost weight to the point of being skeletal, never mind that the celebrities that are "too skinny" may be starving themselves down to the size that allows them to obtain employment. Margaret Cho's account of how she was pressured to lose (too much) weight for her TV show is a couple of decades old, but remains illustrative.

Meanwhile, if you're inclined to pretend that "You should lose weight" is an easy answer, take a look at people you know - overweight, normal, skinny - and contemplate how many of them, in the absence of an illness or surgical procedure, experience or sustain a significant change in their weight. You may know somebody who lost weight and slowly (or quickly) gained it back, you may know somebody who put on weight during (for example) a pregnancy and didn't lose the weight afterward, you may see weight change associated with a physiological change (e.g., menopause), but most people remain relatively constant. From that short list, of those who lost weight and sustained that loss, take a look at how many of them gained the weight during adulthood (e.g., after a pregnancy) and were returning to baseline as opposed to having been overweight throughout their entire lives. Now contemplate the billions of dollars spent each year on diet plans, diet pills, diet supplements, and the like and ask yourself, "If that many people know that they are overweight and want to lose weight, why isn't it happening?"

It's easy enough to ridicule the diet industry as pitching easy answers. What the typical diet book or plan is really pitching, I think, is the notion that you can lose weight without being uncomfortable. The tried and true formula for losing weight is "eat less and exercise more", but people don't really want to hear that. It's not easy to do, and its not easy to sustain. Nebulous comments about "changing your lifestyle"... to include eating less and exercising more... are similarly unhelpful. I am of the opinion that the advice should be tailored to the patient, and should be concrete and case specific. Also, "eat less and exercise more" is not particularly useful advice to somebody whose level of activity will make it difficult for them to lose weight even if they're on an extremely low-calorie diet, or if their weight or other health conditions prevent them from engaging in significant physical activity.

The author suggests that part of the problem lies in "self-esteem",

Perhaps even worse: neither the medical community nor the patient population has figured out sensible, neutral ways to even approach the topic of obesity in the context of the doctor-patient relationship. Part of this can be blamed on Americans’ need to put self-esteem ahead of health, and some also rests on physicians’ bias and poor people skills.

A national survey published in a fall 2011 edition of the journal Pediatrics found that parents feel blamed and respond badly to words such as “fat,” “obese” and “extremely obese.” Parents said they’d feel more motivated if a doctor said their child had an “unhealthy weight,” a “weight problem,” or a “high BMI” (Body Mass Index).

And... we're back to the notion that most overweight people don't know that they're overweight, and that parents of overweight children don't understand that their children are overweight. Again, there are some people who live in a state of denial, but most people - adults and children - are acutely aware of their weight problems. If they're not, society is full of people who will happily draw it to their attention. If patients are more likely to respond when doctors approach the issue with a degree of sensitivity, odds are that's because of their history of acute awareness of their weight and involves the predictable human response to negative judgment on something they're ashamed of or that already caused them to experience a history of judgmental, perhaps abusive comments.

I hope that labeling obesity as a disease helps encourage a response to obesity that is focused less on surgical intervention and more on behavioral health, exercise and nutrition. I do know somebody who, after struggling with eating disorders, has stabilized for a couple of years at a healthy weight - but only after intensive psychological and nutritional counseling. To get that type of treatment you pretty much need to be starving yourself to the point that you need to be hospitalized - even if, prior to that particular manifestation of your psychological condition, you were previously "clinically obese".

Part of me thinks the entire focus is incorrect. The concept of BMI is predicated upon a somewhat average individual, and it becomes a useless measure when applied to bodybuilders. Why do we draw from that the notion that bodybuilders are the exception. We know that we can make poeple of any weight healthier by helping them engage in additional physical activity. I would not argue that we should refrain from offering nutritional advice, but during the broad range in which weight is primarily a cosmetic issue as opposed to an imminent health issue I think we should focus on trying to find people develop types and levels of physical activity that fit with their lifestyles, and which can help them avoid additional weight gain while improving their physical health and muscle tone - providing appropriate education about how the initial effect of exercise can be to increase appetite, and also to modestly increase weight as the person starts to add muscle mass. Put the focus on health, not weight.

"Hey, Kid - Get Off Your Lawn!"

Talk about your crotchety old people.....

Chill Out to Lose Weight?

Oh, come on.

Now, in a provocative new paper, British researchers argue that rising indoor temperatures are contributing to obesity. The research team included scientists from several disciplines, including health psychologists, biologists and those who specialize in the effects of indoor environments....

The average temperature of living rooms in Britain, around 64.9 degrees Fahrenheit in 1978, had risen to 70.3 degrees by 2008. Bedrooms, kept at 59 degrees in 1978, were up to 65.3 by 1996, the last year figures were available.

Okay... I lived in England in the early 1970's and during the cooler parts of the year our house was a veritable refrigerator. So at night we curled up with hot water bottles at our feet under lots of warm blankets. The average room temperature was low because the house was heated with fireplaces, and sometimes it's better (and easier) to wear a sweater than to build a fire.

A more realistic perspective on this issue, and a perspective that reveals it as unrealistic, comes toward the end of the piece:

Dr. C. Ronald Kahn, a Harvard Medical School professor who does research on brown fat, says it might actually help with weight control over time, provided people stick with it.

“When we put people in a 60-degree room, they increase their energy expenditure by 100 or 200 calories a day if they’re in light clothing,” like hospital scrubs, he said. “They’re not shivering. They activate their brown fat.”

So there you have it. Cool your house down to sixty degrees and wear nothing but scrubs and the pounds will melt off - well, let's call it a slow melt. Act like a normal human being by dressing appropriately, putting on a sweater, wrapping up in a blanket or turning the thermostat back up and you won't. As the good doctor says, "most people won’t stay at that temperature for very long."

You can accomplish the same thing by walking 1 - 2 miles per day (at whatever speed you like), but you'll be comfortable. And in better shape.

How to Get People to Eat Better

The modern poster boy for healthier eating, Jamie Oliver, seems to be under attack from all sides. First, he's saying you can cook healthy, good tasting meals in thirty minutes? "Real cooks know better." Second, he's lecturing Americans on their diet when there are still fat people in England? The nerve!

The response to the first argument seems obvious. Sure, if you have the time, money, knowledge and resources you can create a better meal experience with a few hours of work than you're likely to get from one of Jamie's recipes. But let's be honest here: Oliver's not trying to compete with you or with a quality restaurant experience. He's trying to compete with packaged foods like Hamburger Helper and Rice-a-Roni, and take-out from places like McDonalds and KFC. By all means, take the whole day to prepare a healthy feast for your family, but let's not pretend that the majority of people have that luxury or that, even if they had the time, kitchen gadgets, ingredients and knowledge, that it would be their priority.

The second criticism represents a failure of logic, and I'll admit that I picked the low-hanging fruit from the linked article. Oliver is trying to guide British people toward healthier food choices, but even if he weren't his comments as directed toward the U.S. market wouldn't be any less valid. Besides, he's getting very rich in the process - so let's embrace his criticism as part of the American way. ;-)

The more serious argument raised in the "who's a Brit to tell us how to eat" article is that the primary cause for the change in our waistlines comes not from diet but from inactivity. I think it's fair to say that's part of the cause - even as we eliminate recess from elementary school days and open charter schools that have no athletic or exercise facilities, we complain that kids don't spend enough time playing outside. Heck - it wasn't so long ago that you had to walk your type document over to the copier, and distribute copies into co-workers' mail boxes - not a lot of exercise, but at least you had to get up and move a little bit. In most workplaces you can achieve those same tasks more quickly and efficiently without leaving your desk chair. Yes, society is a lot more sedentary than was historically possible.

But it oversimplifies things to argue that "If you're working twelve-hour shifts at the car plant, you can eat whatever you want." It's not just blue collar workers who are heavier than their historic peers. Nor were all blue collar workers historically recognized for their slim waistlines. The reality is, we've moved as a society toward packaged and prepared foods. Thanks to corn subsidies we have food that's full of corn, corn syrup, and fatty beef - and it's cheap. Restaurant portions, including fast food portions, have grown substantially in size over the years. Yes, when McDonalds introduced its fries in 1955 they weighed 68 grams, the same as a modern "small fries" - but the "small" size is what we now feed to our kids. An 1955 soda was 207 mL. A child's soda is now 354 mL. Last time I went to a movie, the large popcorn bucket was approximately the size of a battleship. (I exaggerate only slightly.) It's pretty easy to get a large soda that's a liter or more in volume - five or more times the amount offered in 1955.

There's also profit in upselling. How much money do you suppose McDonalds has taken in over the decades with its simple question, "Would you like fries with that?" How many times have you been asked a similar question - "Would you like a large? It's only 25 cents more." Meanwhile, behind the scenes, "test kitchens" that are really sophisticated laboratories attempt to determine what flavors, odors and colors are most likely to make you crave more, buy more, eat more, and your packaged, prepared and fast food purchases are engineered accordingly. We eat more than we used to eat, and it's in no small part by design. (Another example of capitalism at work.)

You want to lose weight? Eat less, exercise more. Or 'simply' eat less. But our food culture isn't going to make it easy for you.