Rethinking Obesity

The CDC estimates close to 80% of adults and one third of children meet clinical definitions of being overweight or obese, an unfortunate change that started growing around 40 years ago. Now it is estimated that more Americans live with extreme obesity than those with HIV, Parkinson’s and Alzheimer’s combined. Most of the medical community’s response to the shift has been to blame the individual for being overweight, as obesity as we have been told is a person failing that strains healthcare systems, shrinks GDP and saps military strength. Obesity is a global epidemic that is used as an excuse to bully overweight people in one sentence and then inform them in the next that it’s being done for their own good. The fear of becoming fat, or remaining that way drives many people to spend more on dieting every year than is spent on movies or video games. 45% of adults say they are preoccupied with their weight some or all of the time which is an 11 point rise since 1990; and alarmingly nearly half of 3-6 year old girls say they worry about being fat.

The emotional costs regarding the subject are incalculable. All the blame, shame, pointing, guilt, name calling, bullying, assumptions, and accusations,  it’s a vicious circle that does not help even in the slightest, and can lead to depression which can make the situation even worse. Weight is the reason some parents don’t get out of the car when they drop their children off at school, the reason some people disappear when it comes time to take photos, why some people will spend hours preparing elaborate meals for their families to sit eating a salad and not touch it, or not do things because they feel they can’t do it and don’t want to be stared at.

It has been said that for about 60 years researchers and doctors have known that diets do not work; since 1959 research has shown 95-98% of attempts to lose weight fail and two thirds of dieters will gain back any weight lost plus a few extra pounds to go along with it, the reasons are biological and irreversible. Starting in 1969 research showed losing 3% of your body weight could result in 17% slowdown in metabolism; a body wide starvation response occurs that bombards the body with hunger hormones and drops internal temperature until the body rises back to the highest weight. Meaning that to keep the weight off you have to fight the body’s energy regulation system and battle hunger cravings all day, every day, and most likely for the rest of your life.

Weight and health are not perfect synonyms, this is a debate that some of the medical establishments have been going over and over again. While it is true that nearly every population level study finds that overweight people have worse cardiovascular health than those who are not, people are not averages they are individuals. Studies have shown anywhere from one third to three quarters of those classified as obese are metabolically healthy showing no signs of insulin resistance, high cholesterol, or elevated blood pressure; and close to one quarter of non-overweight people are lean unhealthy. A study in 2016 that followed subjects for 19 years found that unfit lean people were twice as likely to develop diabetes as fit chubby people. Point being that no matter the size, habits are what really matter. Indicators ranging from regular exercise, fruit and vegetable consumption, to grip strength can provide better snapshots of health than glaring at a person from across a room.

The tragedy and terrible irony is that for around 60 years obesity, which is now a global epidemic, has for the most part been treated like a fad dieter: if everyone just tries the exact same thing one more time, there will be different results. It’s time for a paradigm shift, we may not become a skinnier country, BUT there is a chance to become a healthier one.

What is scary is that some overweight people don’t eat properly and practically starve themselves trying to drop weight, and have panic attacks when they finally break down and eat; those people end up getting sick. Many share the same stories of ending up seeing a doctor and being told to keep doing what they are doing and not to add more than a few hundred calories to their diet, being assured once they get small enough their body’s will start to process food differently. That is basically the equivalent of having an eating disorder and being congratulated for it.

Simply ask any overweight person about their interactions with the healthcare system and you will find that most will have similar stories of seeing the eyes roll, the skeptical questions, and having treatment denied, delayed, or even revoked. Healthcare systems are to be trusted authorities and primary gateway to healing. For obese people that is not always the case, rather they are more sources of unique and persistent trauma; sometimes no matter what they go in for or how much pain is being experienced the first thing they are told is that it would all get better if only they would just put down the candy, or to just start exercising and diet without giving any additional advice on how to go about it.

This is not just an anecdotal phenomenon, most doctors have shorter appointments with overweight patients and show less emotional rapport. Negative words such as noncompliant, weak willed, or overindulgent highlight overweight people's medical histories with much higher frequency. Doctors were presented with case histories of patients suffering with migraines in one study; with everything else being equal doctors reported overweight patients had a worse attitude and were less likely to follow their advice, and that’s when they were seen at all.

A 2011 poll of South Florida OB-GYNs showed that 14% had barred all new patients weighing more than 200 pounds, some of these doctors may be applying the same presumptions as society does. Sadly some even still feel that shaming overweight people is the best way to motivate a person to lose weight, but this is the last area where tough love should be prescribed. Some argue for more stigma against overweight people saying that some don’t realize they are obese and if they do it’s not enough to stir them to do anything about it. Shaming may have a slim chance to help some to quit smoking but that won’t work for obesity, this belief is out of step with over a generation of research into obesity and human behavior. Research suggests that shaming people may have increased the problem by making it less likely for a person to bring up habits and issues with doctors and family members.

Jody Dushay, endocrinologist and obesity specialist says most of her patients have tried countless diets and have lost hundreds of pounds only to regain it all and more before going to see her; and telling these patients to try harder in harsher terms only set the up to fail and blame themselves. Naturally not all of the healthcare system sets out to denigrate overweight patients, some do damage because of subtler and more unconscious biases. Studies have shown that thin doctors are more confident with their recommendations expecting patients to lose more weight and are more likely to think dieting is easy.

Many administrative and financial structures doctors work within help to reinforce this with the problem starting in medical school. According to a survey medical students receive an average of 19 hours of nutritional education over 4 years of instruction, that’s 5 less than it was 9 years ago. This compounds when doctors get into daily practice, primary care physician get about 15 minutes for each appointment which is barely enough time to ask what patients ate that day let alone the years adding up to it, making a more empathic approach to treatment not very cost effective. CT scans and blood tests generate reimbursement rates from hundreds to thousands of dollars, while a session of diet and nutrition counseling can reimburse as little as $24.00.

Some doctors get alerts from electronic health record software before they see a patient that is over the overweight threshold, as they are often required to prove to hospital administrators and insurance providers that they brought up the patient’s weight and formulated a plan to bring it down regardless of what the patient had the appointment for. Failing to do so could result in poor performance reviews, low insurance company ratings, or being denied reimbursement if they refer patients to specialized care.

Some doctors regardless of specialty think weight falls under their authority says Kimberly Gudzune, obesity specialist at Johns Hopkins, going on to add she often spends months working with patients to set realistic goals and plans only to have other doctors threaten it all, making patients feel like failures and they have to start all over again and sometimes they just don’t return at all.

Working within a system that neither trains or encourages the healthcare providers to meaningfully engage with higher weight patients some doctors fall back on recommending fad diets and delivering bland motivational platitudes.  461 doctor had their interactions recorded in one study, 13% of patients got a specific plan for diet or exercise, and only 5% got help arranging a follow up visit. In survey in 2016 found that twice as many overweight Americans have tried meal replacement diets than had received counseling from a dietician.

Unfortunately all of this makes overweight people more likely to avoid the healthcare system. Several studies have shown that women who are overweight are more likely to die from breast and cervical cancers which is partially attributed to reluctance to get screenings. Erin Harrop of the University of Washington states studies show that overweight women with anorexia contrary to the stereotypes of the condition are twice as likely to report vomiting and abuse laxative and/or diet pills; and thin women take around 3 years to get into treatment while larger women take on average 13 years waiting for their disorders to be addressed.

It’s not just the negativity in play, it’s also the do-gooders, perhaps stopping a larger woman to tell her how brave she is for wearing that short skirt or sleeveless dress on a 95 degree day.  Fat shaming works visibly and invisibly, in public and in private, it’s hidden and everywhere all at the same time. Research shows that larger people, especially women, make less money and are less likely to be hired or promoted. 500 hiring managers were given a photo of an overweight female applicant in a 2017 study, 21% of those described her as being unprofessional despite having no information about her at all. Only Michigan and a few cities outside of it have officially prohibited workplace discrimination on the basis of weight.

It seems as the number of overweight Americans rises so do the biases against them, and they have become more severe; more than 40% of Americans classed as being obese say they experience stigma on a daily basis. In a 2015 study larger people who felt discriminated against were shown to have had shorter life expectancies than those who didn’t. The irony of the stigma and shaming is that it makes overweight people eat more not less, it hurts not helps. Cortisol the stress hormone kicks in and increases appetite and can reduce the will to exercise, it can even improve the taste of food.

Being overweight is the number one reason why children are bullied at school. In a case of good intentions gone wrong some states even send BMI report cards home with children as intervention which is unlikely to change their weight but almost certain to increase bullying from those closest to them. Numerous surveys show that higher weight people experience the worst discrimination from their own families. 89% of participants in a 2017 survey were found to have been bullied by romantic partners. Effects of being overweight intensify when layered with other types of discrimination according to a study in 2012. Most unique aspect of being overweight is that it isolates those who are from each other.

The rate of obesity has doubled in 73 countries just since 1980, and increased significantly in 113 others. Yet in all that time not a single nation has been able to reduce its obesity rate. Much like American institutions of health they have become obsessed with body weight and are overlooking what is really killing us: the food supply. Diet is a leading cause of death within the USA being responsible for over 5 times the fatalities of gun violence and car accidents combined. The problem really isn’t how much that is being eaten, rather what is being eaten.

For over a decade research has shown quality of food affects risks for disease independently of effects on weight. Such as fructose being more damaging to insulin sensitivity and liver function than other sweeteners with the same calories; and nuts consumed 4 times per week can lead to 12% lower diabetes incidence and 13% lower mortality rates regardless of weight. Biological systems for regulating energy, hunger, and satiety are thrown off by consuming foods high in sugar, low in fiber and injected with additives; which surprisingly can make up to 60% of the calories typically consumed. Eliminating these multi-trillion dollar poisons from the food system will not be easy or happen quickly. The food chain from factory farms, to school lunches are contaminated with Mars or Monsanto, especially at places such as McD’s working tirelessly to lower costs and raise profits by designing processed products to make you addicted. Much responsibility is placed on the patient without consideration of how the societal infrastructure affects how they eat.

All though it seems frightening, there is much a person can do right now to help improve their lives, such as shifting the focus from weight to health and from shame to actual support. There is an infinite complexity to every individual’s relationship to food, exercise and body image is right at the center of treatment. Weight is an emotional subject, telling a person to lay off the cheeseburgers is never going to work unless they know what that cheeseburger is actually doing to them.

In 2017 the US Preventive Services Task Force found the decisive factor to obesity was not the diet patients were eating but how much attention and support received while on it. Subjects receiving more than 12 sessions with a dietician had significant reductions in rates of prediabetes and cardiovascular risks, those with less has almost no improvements, yet despite these recommendations for intensive multicomponent behavioral counseling the vast majority of insurance companies and state healthcare programs define this term to mean 1-2 sessions.

USA spends $1.5 billion on nutritional research compared to $60 billion on drug research. It’s no wonder the healthiest organic foods can cost up to 8 times more, and they seem to get more expensive which each passing year.

Cardiovascular risks of sedentary lifestyles are well documented, but rather than help to mitigate these risks and disproportionate impact on poorer communities it seems institutions are exacerbating them. A mere 13% of children in the USA walk or ride bikes to school, and less than one third take part in daily gym classes. More and more workers commute over 90 minutes each way, which is a predictable outgrowth and underdevelopment of public transportation and over investment in freeway, parking, and strip malls. The public has been told to eat more veggies and use the stairs in a country where having the time for daily exercise is now a luxury and eating well is not affordable.

Most effective health interventions aren’t health interventions, they are policies to help ease the hardship of poverty and free up time for movement, play, and parenting. In today’s society that seems like it will never change attitudes towards overweight people, when it comes down to it, it is still up to the overweight person to decide how to endure. Will they continue the same path and not change or try to move on, there is no magical cure, and as of yet there is no time machine. What there is, is the revolutionary act of being happy in your own skin in a world that says you shouldn’t be. Everyone has to do the best with the body that we have, and should leave everyone else’s alone and mind your own business. Awareness is not about making overweight people feel better about themselves, rather those people being denied basic civil rights to just be.