I Take Up Space

Not sure how to answer this one since it is filled with misquotes and misrepresentations. Did you even read my post?

However I will offer some counterpoints since you actually offered research instead of just repeating words like they are facts.

1. I said no one can claim they PROVED that cigarettes caused cancer, but the link between smoking and cancer and other diseases is a very strong case. AND I said that there are lots of studies that demonstrate quitting smoking improves health of the individual (and btw, on the population level as well). How is that encouraging people to smoke?

2. I said that one of the problems with a lot of the research that purports to demonstrate the need to lose weight is to take a population study and apply it on the individual level. The study you quote demonstrates that at a population level, people with different BMIs will have greater risks for certain health factors and early death (though if I recall the full study, I think the early death was a matter of months not years). I do not disagree with this result. Nothing I wrote would disagree with this finding. What I disagree with is the assumption that taking the individuals who are in the higher ranges of BMIs and making them smaller absolutely will reduce their risk of death and comorbidities. Nothing in this study demonstrates this. This is a population study. There are multiple explanations for these differences that have nothing to do with weight itself. For example, there are some studies that suggest that the stigma of fatness and not the fat might be the reason behind these differences. I am not saying this is a fact or that it is the right explanation, but it is an alternative explanation with some currency in research and therefore should be considered when looking at this study.

3. You said, "Correlation is not causation --yup that's true. It's also true that obese people die younger, have a shorter life expectancy and a greater risk of many diseases, some chronic and fatal." But you (and the people who wrote up the research) are making an assumption about causation. You are saying the shorter life expectancy and greater risk are from the weight and that, by implication, reduction of weight will increase health. You don't know that and nothing in this study supports that assumption. The correlation is real, but the reason behind the correlation is not clear and needs further research.

4. Even if I concede that weight loss might help alleviate these early deaths and comorbidities, exactly what do you propose fat people do about this? Lose weight for the long term? So far no one has figure out how to do that and what's worse, there is growing evidence that multiple attempts to diet or cut up your stomach or take pills to reduce your appetite will lead to death and disability. You seriously are proposing that 65% of the population is just so undisciplined and uninformed that they haven't tried to keep weight off? By the way, since studies like this do not distinguish between dieters and non-dieters and weight-cyclers, we don't know if the people with higher BMIs who had higher incidences of death might be dying from the dieting. One might as easily could have written "Dieting Kills" as "Obesity Kills."

5. I'm sick and tired of the bull about paying for other people's health. In the United States, most people have to fend for themselves and most really fat people cannot get insurance and make do out of pocket on salaries that are significantly less that the average. Exactly how are you paying for my health care? Exactly where are all these costs coming from? And, btw, don't you think the cost of health care would be reduced significantly if every time an insured fat person went to the doctor their symptoms were ignore, they were given pills they don't need to lose weight and they are encouraged to have expensive surgeries that don't work or require multiple additional surgeries? Costs can be construed in so many ways. But the bottom line is this -- fat people are part of the population and in the same way that population statistics include poor people and minorities and seniors and sick people who "bring down" numbers and "add costs" you can't arbitrarily pull out a group of people and announce they are the problem. This is panic rhetoric, not science.

6. Finally, advocating acceptance is not encouraging people to be any size. Health at Every Size means not paying attention to size, but to health. Acceptance is encouraging people to be people. It is a civil rights question. Fat people are not less than human. They are part of society. They have been and always will be a part of the human race unless we move to a Logan's Run society where the weak, sick and unacceptable are killed and everyone is terminated at a youthful 30 years of age. That's what all this boils down to. It isn't about health or cost, it's about hate. And please, don't tell me how much you care. If you cared, you'd listen. Paternalistic shaming of fat people is not caring. It is what it always has been. It's bigotry wrapped up in pretty clothing. It's about singling out a group of people and saying to them, you don't belong, or at the very least, you are too childlike to be considered part of the adult world.

If you really want to show that you care, then consider the following review of studies like the one you cited:

http://jama.ama-assn.org/content/293/15/1861.full

It basically has found that in the same period where Americans have increased their weight as a population, their life-expectancy and incidences of diseases related to metabolic health have gone down. In other words, there are complexities in this research and methodology as well as other factors such as improvements in health care and preventative care have had an impact, without significant changes in weight.

Different factors are creating obesity and in this country not far away it will be 25 % of populatin taht will be obese without counting the overweight people in that. So it is not onl about moving and dieting and don't make it so easy to lose weight because it is not. Biggest loser is not a good show t watch because it is not the reality. Fit or not you are and I am pretty fit and know also how it works because I ge educated about the fact.

Dr Thomas' answer to your comment is excellent but as you did with her article, you might not read it all or carefully. So I'll leave a short comment. Her analogy to smoking is not saying it's not risky - on the contrary. She is explaining the scientific method. Now go back and re-read her article slowly and totally, and maybe you will understand it better. It's actually one of the best articles (if not the best) I've read on the subject - not only about obesity but explaining just how science works which many people are confused about.

I would disagree -- I think that if we ask the questions we are supposed to ask when reviewing research, then we can learn more not less. This is the process of science. It is how it was designed. An informed opinion is not problematic. Gut-level emotional responses can even be useful, if they lead to real critique and questioning instead of knee jerk responses. Of course, web forums are the worst place for this in many ways because it is possible to respond before thinking but it is permanent (or semi-permanent) by the time it is done.

The "alarming rate" is questionable. The use of percentages instead of actual numbers of incidences can create the illusion of large numbers when they aren't there. Also, the redefinition of baselines and standards has had a lot to do with the belief that children are getting fatter and suffering more. I'm not the best source of information on this, but I do know others who have looked into this and have pointed out that the incidences of Type-II diabetes among kids and adolescents are still in the 1 per 10,000 or so range, making it way less than 1% of the population. http://www.cdc.gov/diabetes/projects/cda2.htm is a report that outlines some of these issues.

One of the reasons for the increase might simply be detection. Kids are being tested for type-2 diabetes more often now, which has led to an increase in reports. That does not necessarily mean an increase in cases. Second, ethnic groups have much higher birth rates than white Americans and ethnic groups have much higher incidences of type-2 diabetes than white Americans, so the increases might also reflect a genetic component in a changing population.

As far as there being more fat kids. This also is a bit sticky from a statistical point of view. First, the way in which obesity is defined in children changed drastically in the 1990s. BMIs are very problematic with a population that can grow 5 inches in 3 months. Kids do not grow evenly over time and therefore what looks like a big weight gain might look like a growth spurt if you wait just a little. I can't put my finger on the reference but I know I read somewhere that in the 1990s either the CDC or the NIH just decided that the top 15 percentile of kids in a given age group were "overweight," with a small top percentile being defined as obese. In other words, it is arbitrary and a matter of convenience. But after this decision was made, those working with childhood obesity conveniently forgot all these problems of measurement and started just talking about prevalence like they had hard data. (Here is a reference that kind of, sort of explains how it is calculated now: http://health.howstuffworks.com/pregnancy-and-parenting/childhood-condit...)

Here's the thing. By their own system of measurement, kids are no longer getting fatter. http://jama.ama-assn.org/content/303/3/242.short (Note that the plateau occurred before Michelle Obama's current efforts.)

One last thought. It is true that sifting through all of this is "tricky" as you say, Amy, but what upsets me most is that when people are not taking the time to wade through and figure it all out, they still repeat things like they are facts: "Obesity kills." "Losing weight is healthy." "Americans are getting fatter." "Childhood obesity is on the rise." etc.

These have become memes, repeated over and over again until no one really knows how they know it, they just do. At that point, the information becomes a sacred cow instead of a proposition to be debated and examined.

What I say to my students who ask me how can anyone find the time to examine all the information coming at them and fully understanding it is: If you don't have the time to examine it, then don't repeat it.

The world is filled with many people and some people are more interested and/or have more talents in examining certain kinds of data than others. None of us have the time to sort through all this. I love medical sociology and I love thinking critically about how people speak about the world. This overlaps with my own experience of stigma, weight loss, weight gain and disabilities that have resulted from the cruel and unusual ways I tried to deal with all of this, but it isn't my only interest. Fatness is a great case study in how scientific research meets popular rhetoric, but I'm really more interested in the bigger questions of how to end stigma and how to improve our health care delivery system. But this is my forum for now.

But what I do know is that if I don't know and don't want to take the time to know, then I don't repeat it. The world of information would be a lot better off if people thought before they spoke (especially on the web).

Anyway, thanks Amy for some stimulating thoughts and for seeing that it is a tricky thing to examine information.

the study didn't find comorbidities or correlations with death. I said they found complexities in these relationships.

"Obesity is associated with a modestly increased relative risk of mortality, often in the range of 1 to 2. In this range, estimates of attributable fractions, and thus numbers of deaths, are very sensitive to minor changes in relative risk estimates. Thus, results are affected by the precision and bias in relative risk estimates. Additional precision might be gained from larger cohort studies, but bias because of nonrepresentative samples and the use of self-reported weight and height could lead to less accurate estimates."

The study does not account for all confounding factors because it was limited by the data (this is not an original study but a revisitation of earlier collected data).

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Here's a good discussion of the problems with obesity research, including discussing the implications of the JAMA article:

http://www.healthyweightnetwork.com/cntrovsy.htm#controvsy.htm

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But again you confuse correlation with causation. "Obesity continues to result in increased deaths" is a causation statement. The obesity category is correlated with increased deaths. We do not know and this study does not address the reason for this. Some possible alternative explanations would be:

*People with higher BMIs put off going to their doctors longer and therefore are not treated early enough to prevent death.

*People with higher BMIs are sent home and told to lose weight instead of receiving treatment, thus again delaying life saving and preventative care.

*People with higher BMIs have more cytokines from the stress of dealing with a social stigma on a daily basis and are therefore at higher risk for conditions that lead to early death.

*People with higher BMIs are more likely to have weight cycled (the study accounted for length of time at particular BMI, but not long term diet/weight history)

*People with higher BMIs are more likely to suffer iatrogenic deaths related to drug side-effects, surgery side-effects and other medical errors.

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But again, I assert all of this is moot because even if we concede that weight causes these premature death rates, we do not know why all people get fat and we do not know how to help them lose weight for long term.

But again, even if we concede that dieting and exercise might result in lower body rates, there is nothing in this study to demonstrate that lowering the BMI will result in better health. Black people are more prone to sickle cell anemia, but lightening their skin won't cure it. Bald men have specific risk factors that their hairier counterparts and women do not have, but the Hair Club or a sex change operation will not necessarily improve their health or lower their risks.

But again, even if we concede that lowering BMI is helpful, then what is wrong with the HAES approach? It emphasizes a healthy diet and exercise, the very behaviors that are supposed to result in weight loss. If this is really about health and not bigotry, then what is the problem? Why use BMI as a measuring stick when we have $35 blood pressure cups (or free stations in most pharmacies), $50 blood sugar testing kits and other relatively cheap tests to monitor metabolic health? In what way is advocating a behavioral approach over a shaming approach allowing fat people to waddle wild in the streets eating more than their fair share and then waddle home to sleep the rest of the time? What exactly do you think fat people do in their daily lives? We just all sit around waiting for an excuse to do the worst things we can to our bodies?

I am advocating healthy behaviors and good health indicators. I am advocating that in a culture that limits the life chances of fat people and treats them as less than human, approaches to health that emphasize weight loss are doomed to failure. This is a practical matter. It has some (though not conclusive, but it a severely underfunded body of research) evidence behind it.

If the diet advocates are right, then HAES will lead to long-term weight loss and that will lead to good health. If I am right, then HAES will lead to good health no matter what someone's size is. Either way the behaviors are the same and for someone to say, "but fat people just have to understand how bad they are" is rooted in something other than science, logic or concern.

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Oh, and since you assert that "...people who pay no taxes and pay no insurance premiums do not pay more. The rest pay for their share," when will you be sending me a check to pay my doctor?

I pay out of pocket for all doctor's visits, medical tests and medications, though we do qualify for some programs where the drug companies graciously give me and my husband some overpriced drugs. Since these companies continue to make double digit profits, I think all of us are being taken by them. If you are so worried about medical costs, then take a look at for-profit medicine and at the extreme overhead administrative costs of this inefficient system. 25% of all medical service fees at doctors' offices and hospitals are administrative because paid staff have to sift through the complexities of each insurance company and fight them tooth and nail to get approval for procedures. Pharmaceuticals and HMOs/Insurance companies post double digit profits. Physicians invest their money in these companies with no conflict of interest requirements. Medical mistakes are growing each year and by some estimates are in the neighborhood of the 3rd or 4th leading cause of death, even higher among adults under 40. Emergency rooms are closing all over the country because they are over-run with poor, uninsured people who have no where else to go for acute but not emergency care. Rates of pnemonia, asthma and other ailments are increasing rapidly in cities where water and air are getting dirtier. This doesn't even begin to address problems outside the United States. It is so easy to find a scapegoat when a system is this broke. It is no accident that the "War on Obesity" started in full swing when the Clintons failed to create universal health care and the panic over "Childhood Obesity" started after the Obamas failed as well.

Do you really believe that all our problems will be solved by The Biggest Loser? I guess it shouldn't surprise me. People, women, especially, have bought into the control my body, control my world mentality for a long time now.

I never said all diet advocates hated me or fat people. I said that emphasizing weight over health is a form of hatred and the only reason I can figure out why HAES would be threatening is if the goal is about bigotry not health.

Please save your sympathy. I'm a happy person and quite comfortable in my own skin. I am not threatened by anyone who advocates weight loss. I resolved those issues personally years ago. One of the tell-tale signs of stigma is constructing a person who discusses their own stigma as being defensive or in pain. I am neither. So whatever pain you are feeling is not mine.

I am a medical sociologist who is concerned with the social contexts to medical care. The obesity "epidemic" and "war on obesity" is health policy and, in my informed opinion, one that is costing us a lot and not producing much good health. It just happens to be an aspect of health policy that I have considerable personal experience. I am well-researched and open to changes in the ways in which I think about this. I am not obsessed. I, like most scholars who have come this far in their education, am interested in furthering my own knowledge and presenting what I know to the world.

The national registry is not proof of much. Most of the people on there have moderate weight loss and do not follow up after the 2 year mark. I, myself, am a success story for a bariatric clinic in New Orleans. I don't know if it exists any more but I lost 130 pounds and kept it off for over 2 years.Then my health fell apart and I ended gaining all of it back plus about 90 pounds (turns out I have hypothyroidism that remained undiagnosed and untreated for over 10 years). I'm sure just like me, many of the people on the registry didn't come back write down the weight gain. Since there is no effort to account for that possibility, the registry remains flawed.

I don't really care if someone loses weight or gains weight. Because I advocate not emphasizing size, I am accused of encouraging weight gain or discouraging weight loss. This is not so, but apparently I can deny it multiple times and still be misunderstood. Weight is complex. I know people who advocate HAES who lost weight when they began to emphasize health not weight in their own habits. I know people who have gained. I personally have stayed stable for over 10 years now. I wish them all well as I do you.

What concerns me most though is that you have stated that it isn't a civil rights issue because it is about behavior. I am not advocating that people have the right to distort the truth. I am advocating that the truth should be pursued and it is not being pursued in this realm.

But people are people no matter how good or bad they are. We have this new concept in our country I've heard labeled "healthism." Since the 1970s we've been moving away from an understanding of health as contextual and not always under our control to a belief that if we are "good" then our health will be good. This is not supported by evidence. Plenty of "good" people who eat "right" and exercise who still get sick. Germs, dna and environmental conditions affect our bodies. Baby boomers may not realize this yet, but age can create problems as well.

So deciding that it's okay to take away the civil rights of people if they are deemed unhealthy is problematic. Exactly who decides this? Do you get the implications of your statement "society has a right to impose costs on the exercise of civil rights"? Really? So you want to speak, I get advocate a cost to that freedom? You want to vote, I get to tax you? Didn't we answer these questions already with the end of Jim Crow laws?

If you truly want to advocate for health and well-being, then how is HAES not doing that?

here are the Basic Principles of Health At Every Size:

1. Accepting and respecting the diversity of body shapes and sizes.

2. Recognizing that health and well-being are multi-dimensional and that they include physical, social, spiritual, occupational, emotional, and intellectual aspects.

3. Promoting all aspects of health and well-being for people of all sizes.

4. Promoting eating in a manner which balances individual nutritional needs, hunger, satiety, appetite, and pleasure.

5. Promoting individually appropriate, enjoyable, life-enhancing physical activity, rather than exercise that is focused on a goal of weight loss.

(source: http://www.sizediversityandhealth.org/content.asp?id=76)

If these principles make you uncomfortable, then I suggest you rethink the "we're just advocating" part. Are you seriously going to say to someone who is metabolically fit but fat, who eats well, who exercises regularly, that they still have to lose weight? If health is the goal, then what is the problem?

Anonymous - I am ashamed of myself for thinking previously that you were just an industry troll who is probably being paid to follow blogs and wipe out HAES wherever you find it. NOW I know that you are personally invested in being right about the obesity model. You have a psychological stake in this.

Sorry, but we can't take your personal experience, and the intensity of your belief in it, as proof that your beliefs are right for everyone. Just as population studies cannot guide the individual, individual case studies cannot guide larger groups. I suggest you go back and re-read Dr. Thomas's very excellent explanations of research methodology and analysis.

You adopted a HAES approach when you cleaned up your nutrition act. Like some, but not all, people who do this, you lost weight. But you also found that your body started to fight you. You "toughed it out" mentally, and kept going. Okay, but were there costs in other areas of your life? When we choose one psychological battle to fight, we are choosing others to ignore. There is not infinite mental energy to spend.

I bet if you came out of your anonymous cloak and shared your whole self with us, we would find things (if we were so inclined, which most of us aren't, spending our mental energy elsewhere...)to criticize as strongly as you criticize obesity and the obese. You give us a partial picture, and want to speak for all of mankind.

I'm not falling for that. I wonder how many other readers will.

Thanks!

Thanks for the thoughtful response, Stabby.

The cytokines research is very interesting to me as a medical sociologist because it also has implicated stigma and stress. There is evidence (mostly in Phelan and Link's work) that stigmatized populations have more health risks. This is one of the reasons cited for the strong link between health and socioeconomic status, which exists even if you account for access to health care. In the US, the lowest socioeconomic levels have health care access in the form of Medicaid and yet they continue to have more health risks than the general population.

Have you seen Peter Muennig's discussion of stigma and obesity-related illnesses? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2386473/ He looks at cytokines and other enzymes as a connection between stigma and physical health.

Also, nice summary of Muennig's work and other implications of the war on obesity in Engber's column on Slate: http://www.slate.com/id/2231508/pagenum/all/

I find the complexities of how the mind, the body and the social environment come together to create both health and illness fascinating and I hope future medical research will move in the direction of integration of these various systems to more holistically understand this wonderful thing called the human body.

So you and your family and your -- ahem, *people* -- are wholly without any sort of any even merely possible health risk factors?

It all evens out in the end, you know. It really does.

You're going to die just like all the rest of us. I promise. No, really.

for starting this discussion at Brave Girl Eating. I think the strong attachment to weight as a premier health indicator is born in part from the desire to have quick and dirty, simplistic answers. Unfortunately this does not work well in complex situations.

Understanding causation is only a part of that complexity, but I hope I added something significant to the issues you raised.

I know of no canonical nutritional guidelines for HAES and I know that there is diversity in what people do and recommend.

The principles put out by ASDAH state: "Promoting eating in a manner which balances individual nutritional needs, hunger, satiety, appetite, and pleasure."

I think (but might be wrong) that what you've experience on HAES boards is that many of the people there do not want to have any kind of diet talk because of past abuse and personal histories. I long for a day when "diet" means the composition of what we eat and not "way to lose weight." I'm encouraged by the number of younger people who are not dieting and I hope someday the trigger of the word "diet" and discussions of different regimens will not be so emotionally charged.

My personal stance is that what people eat should be a matter of personal choice. Beyond that I am open to great variations, but I understand some choices work better than others.

I'm glad you found something that worked for you and that you are concentrating on health not weight loss.

thanks Shaun. Well said and worth a lot more than 25 cents.

This is the key fact here. The original Framingham study showed a mortality benefit from "overweight" (BMI > 25) and only a slight risk from obesity (BMI > 30). Other people came along later and played with the data and started throwing out subjects they didn't like. The data on this edited list of subjects seems to show more hazard of obesity. If you stick to the original group of subjects and don't play games with the data, the data support a much lower estimate of risk from obesity.