everything you know about obesity is wrong - well, maybe not everything - Doctors Without Boredom

This essay about obesity, stigma, and medical practitioners by Michael Hobbes is arresting and convicting:

And the medical community’s primary response to this shift has been to blame fat people for being fat. Obesity, we are told, is a personal failing that strains our health care system, shrinks our GDP and saps our military strength. It is also an excuse to bully fat people in one sentence and then inform them in the next that you are doing it for their own good. That’s why the fear of becoming fat, or staying that way, drives Americans to spend more on dieting every year than we spend on video games or movies. Forty-five percent of adults say they’re preoccupied with their weight some or all of the time—an 11-point rise since 1990. Nearly half of 3- to 6- year old girls say they worry about being fat.

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Enneking told the doctor that she used to be larger, that she’d lost some weight the same way she had lost it three or four times before—seeing how far she could get through the day without eating, trading solids for liquids, food for sleep. She was hungry all the time, but she was learning to like it. When she did eat, she got panic attacks. Her boss was starting to notice her erratic behavior. “Well, whatever you’re doing now,” the doctor said, “it’s working.” He urged her to keep it up and assured her that once she got small enough, her body would start to process food differently. She could add a few hundred calories to her diet. Her period would come back. She would stay small, but without as much effort. “If you looked at anything other than my weight,” Enneking says now, “I had an eating disorder. And my doctor was congratulating me.”

Ask almost any fat person about her interactions with the health care system and you will hear a story, sometimes three, the same as Enneking’s: rolled eyes, skeptical questions, treatments denied or delayed or revoked. Doctors are supposed to be trusted authorities, a patient’s primary gateway to healing. But for fat people, they are a source of unique and persistent trauma. No matter what you go in for or how much you’re hurting, the first thing you will be told is that it would all get better if you could just put down the Cheetos.

There’s a lot to say about this, but I wanted to a highlight a few points that I agreed with and a few things that I want to quibble with. But first of all, I want to pull up this chart from one of the studies they cited, showing that unhealthy lean people are more likely to get diabetes than healthy obese people. (In this study, “healthy” meant normal blood pressure, blood sugar, and cholesterol.)

As you can see, being unhealthy and lean is indeed more dangerous in terms of diabetes risk than being healthy and obese! The problem is that if you’re obese and healthy, you’ve still got roughly twice the risk of developing diabetes than a lean person. It is unclear what other health risks traditionally associated with obesity are as reliable as diabetes (the study, for example, seems to have tighter curves for coronary heart disease), but I would guess that excess fat cells in the body in and of themselves are (in addition to promoting insulin resistance) probably an independent risk factor for osteoarthritis, liver and gallbladder disease, sleep apnea, and infertility or other hormonal issues. Furthermore, the biomarkers of “metabolic risk” identified in this study also aren’t identical to “a lifestyle of healthy habits” that Hobbes infers in this article.

This doesn’t change all of the important and good stuff that Hobbes writes about, but it does make it more complicated. Hobbes is correct when he says, “But individuals are not averages: Studies have found that anywhere from one-third to three-quarters of people classified as obese are metabolically healthy. They show no signs of elevated blood pressure, insulin resistance or high cholesterol.” But the longer one is obese, the more likely one is to eventually develop those markers of metabolic unhealthiness — which will then progress to life-threatening chronic diseases. And then once you actually have one of those diseases — as many people, obese or lean, do! — then losing weight has generally been shown to improve the control of those diseases.

What I liked:

• Doctors are bad at giving diet advice because they’re not trained to be health coaches or nutritionists, and quite frankly, they shouldn’t be. We should be training community health workers or paying community nutritionists to encourage people to eat healthy and exercise.
• “The central failure of the medical system when it comes to obesity is that it treats every patient exactly the same: If you’re fat, lose some weight. If you’re skinny, keep up the good work.” I think this is about right, mostly because it doesn’t actually say anything about healthy habits.
• The problem is much bigger than that of individual decisions. With an overabundance of calories available to people and many of our structural and systemic forces focused on delivering lots of unhealthy food, it’s no surprise that we are as unhealthy as we are.
• The problem is also not particularly so much about how much we are eating as it is what we are eating. A lean person who is eating nothing but empty calories while not exercising (which, I will readily admit, has been me at certain points in my life) is in real trouble.
• Stigma against fat people, especially in the medical community, seems to have a lot of harms and no benefits.

What I didn’t like:

• It was not clear from this story that no matter a person’s size, they do need to eat healthy and exercise if they want to be healthy. Only half of Americans get the exercise they need, and the average American diet isn’t particularly healthy, either. So while we absolutely have to reduce stigma against fat people and rethink the way that we approach obesity, there are still a lot of people (of all sizes!) who need to be eating healthier and exercising more. People who are obese that eat healthy and exercise — even if they don’t lose weight — do have a lower risk of developing diabetes, and that’s the message we have to get out.
• The piece took for granted that weight loss is impossible (or simply lifelong torture) once someone has reached a certain set point in their metabolism. This may be true for some people, but it’s certainly not universally true and shouldn’t be cause for us shrugging our shoulders and saying that only a system fix will help anyone. Given my own experience in practice and the general science of obesity, a lot of people do lose some weight when they start eating healthy and exercising, although it rarely gets them to a “normal weight”.
• Bariatric surgery wasn’t mentioned at all, even though it’s a huge and important place way in which people who are unhealthy and the medical community interact. Bariatric surgery really works to reduce weight and can improve diabetes control (or cure it outright) in people who have diabetes. It also requires participants to engage in exactly the sort of healthy behaviors they need to be doing anyway, so even if they never get the surgery they are still getting helpful advice on diet and exercise (as well as counseling). Plus, the vast majority of patients lose weight during this process anyway.

Anyway, here’s a link to a great discussion about what constitutes a healthy diet.