Obviously.....

Modern medicine has given us many beliefs that we all take for granted.  In fact, I believe that we do such a good job of taking them for granted that we come to absorb them as unquestionable facts, when we should be requesting facts to make sure they are true.  Not only does medicine help us incorporate many assumptions as facts, but it shoves them at us.  What kind of assumptions?  Well, it's unhealthy to be fat.  It's good to exercise.  It's bad to smoke (this one they may have done a good job of proving).  It's unhealthy to overweight.  Salt is bad for you.  Dietary fat is bad for you.  Trans-fats are bad for you. Dietary calcium is important to prevent bone fractures.  Vitamin D levels need to be above a certain level or you should supplement your diet with exogenous/dietary Vitamin D.  It's good to take a multivitamin.  Organic food is healthier.  Pasta is fattening (from my childhood).  Pasta is part of a low-fat, healthy diet (from my teenage years).  Pasta is fattening because it's high in carbohydrates and has little nutritional value (from my carbs-are-bad adulthood). 

Do we believe most of these things?  I think most people do and I'm the skeptic.  I generally keep quiet about my skepticism because it's a game where you don't know the answer until you're dead, and if I die a young death, I don't want to give anyone the satisfactions of saying, but of course, she wouldn't take her Vitamin D, her calcium supplements, and she salted everything.  She got what she deserved.  

So with that thought, I figured I would steer you to an article in the New York Times, "In Obesity Paradox, Thinner May mean Sicker." The article starts by talking about how among people with diabetes, those who are overweight fare better than those who are not, and the same is true for people with some other illnesses.  This is not the fashionable thing to say, we all believe (myself included) that if you have risk factors, then losing weight helps you to be healthier. 

 Harriet Brown writes:

In 2005, an epidemiologist, Katherine Flegal, analyzed data from the National Health and Nutrition Examination Survey and found that the biggest risks of death were associated with being at either end of the spectrum — underweight or severely obese. The lowest mortality risks were among those in the overweight category (B.M.I.s of 25 to 30), while moderate obesity (30 to 35) offered no more risk than being in the normal-weight category.

Whatever the explanation for the obesity paradox turns out to be, most experts agree that the data cast an uncertain light on the role of body fat. “Maintaining fitness is good and maintaining low weight is good,” Dr. Lavie said. “But if you had to go off one, it looks like it’s more important to maintain your fitness than your leanness. Fitness looks a little bit more protective.”

That is a message that may take a long time to reach your family physician, however. “Paradigm shifts take time,” Ms. Bacon said. “They also take courage. Not many people are willing to challenge the weight conventions. They’re just too culturally embedded, and the risk of going against convention is too high.”

Now let me just point out that the fact that heavier people may fare better with diabetes does not necessarily mean that a thinner person with diabetes who gains weight will do better, or that any given overweight person with diabetes might not do better if he loses weight (we all know people who control their diabetes with lifestyle changes and no medications).   It may mean that gaining weight helps, or it may be that there is something intrinsically different about thin vs. heavy people with diabetes. 

Finally:

In 2007, a study of 11,000 Canadians over more than a decade found that those who were overweight had the lowest chance of dying from any cause.  

As time goes by, we get fatter, and we also live longer.  What health assumptions do you make that might be hard to forgo? 

You're Too Fat!

We hear a lot about obesity and weight control these days: eat less, exercise more.  Our first lady is very interested, and it's fashionable to believe that more vegetables and less TV will make one thinner.  I say "to believe" because we really don't understand the role that exercise has in weight loss and, at least for some people, exercise alone is not enough to drop those pounds.  

What role do, or should,  doctors have in solving this epidemic we have of overweight and obese Americans (now 2/3rds of adults)?

Over on KevinMD, Dr. Arya Sharma blogs about why weightloss advice may be unethical: he notes that patients regain weight,  that advice is unethical, and that while weightloss may alter measures of risk, we don't have hard evidence that losing weight increases longevity.  Oh, and then their is the issue of sensitivity.

Yesterday, on Talk of the Nation, Neil Conan and his physician guest, Dr. Ranit Mishori, talked about how doctors address the issue of weight problems with their patients.  I listened to 20 minutes of the 30 minute broadcast, the link will let you listen, too.  The first person to call in noted that she had uncontrolled hypertension, she's 20 pounds overweight (despite power-walking 5 miles/day), has trouble controlling her eating, and her doctor reads her the riot act about how she has to get her weight under control.  Her response, despite continued high blood pressure readings, is to avoid the doctor, cancel and delay appointments, and to feel badly about herself.  The second caller said his doctor yelled at him for a half hour to the point that he cried and his response was to lose 110 pounds, which he has kept off.

Finally, there was recently a study in the journal Obesity which shows that overweight physicians are more likely to address weight/diet issues with obese patients than are physician who are overweight themselves. What the article doesn't say is whether patients are more likely to lose weight if their doctor (slim or not so slim) discusses the issue with them and encourages lifestyle changes.

If we had effective treatments for obesity, I think I would be more enthusiastic about encouraging doctors to be more engaged in weight loss, or first ladies' to promote growing vegetables, or mayors from banning super-sized sodas.  As is, we have little to offer, healthys and their medicines are certainly part of the problem for some folks, and those people who do lose weight and sustain their weight losses (a small percentage) are often self-motivated.  While I only heard the call-in patients' side of the story on the NPR piece, I was appalled that it sounded as though this patient was being told she must lose weight for adequate blood pressure control -- it seems to me that patients with illnesses that can be abated or controlled with lifestyle changes should be counseled to do so; if they don't or can't comply, then they should be offered aggressive pharmacologic treatments.  I know many thin people who require 3 anti-hypertensive medications to control their blood pressure, and many slim diabetics who require multiple medications.  And perhaps this patient's doctor is offering medications, but her presentation led the listener to believe that her physician feels her hypertension is her fault and there is little to do if she won't diet.
 

Fatter and Fatter

I have some questions about America's obesity epidemic.

The New York Times has an article about a mathematician who has been looking for the causes of obesity-- In a A Mathematical Challenge to Obesity, an interview with Carson Chow, Claudia Dreifus  notes that the average person weighs 20 pounds more now than in the 1970's.  I was alive then and it was the hey-day of processed food back when skinny people fed their skinny kids white bread with butter and sugar.   Mayonnaise (or rather Miracle Whip, what ever substance that might have been) was on everything, and oh for  twinkies, ring dings, chef Boy-r-Dee, and scooter pies....those were the days.

The mathematician proclaimed that the answer is that there is more food.  More is grown, more is available, it's cheaper and cheap food allows for the existence of fast food, something you can't have if the food costs a lot.  What I've noticed is that food is everywhere.  All the push to make school food healthier, get rid of soda machines, and encourage children to be more active (ah, the kids I know, even the heavy ones, are doing 3 hours a day of sports after school, it's no guarantee you'll be slender), but it seems that every day is a "special" day....a fund raising bake sale, someone's birthday, end of year party, weekly advisory where the kids rotate bringing baked goods, language class meal, trip to restaurant, snack parent at every sports game, followed by dinner, and when you go out, the servings are huge, and I, for one, find it hard to stop eating really good tasting food if I'm hungry and it's on my plate.  So I'll believe that food availability is the reason why people are fatter.  

So here's my question.  Obesity researchers study obese people and how they differ from normal weight people.  Why isn't everyone obese?  Why are only 1/3 of Americans  obese and only 1/3 are overweight?  Why aren't they studying the people who remain thin despite the fact that they are surrounded by food? Okay, so some people have very fast metabolisms, but others are don't seem to have any desire to overeat.  There may be lots of available food, but they don't want it, or they want it when they're hungry, but they have some and that's enough, a 'stop eating' mechanism kicks in at a point that keeps their weight low.  Why don't they have the desire to eat more when food is available?  And finally, there are those people who want more food, but for the sake of their health or their appearance, they limit their eating.  I've heard it said, "Well, if she really wanted to be thin, she'd eat less."  I don't buy it, I think there are differences between people besides a simple desire, or a weakness of character that makes self-control harder for some then for others.  I want to know why some people have faster metabolisms, less desire to eat, or more will power.  Okay, Dr. Carson, how does your mathematical model work for that one?

I'm not an alcoholic.  It's not because alcohol isn't available-- at any given time my house is stocked with an assortment of beers (I keep dark on hand because Roy likes it) and wines.  It's available, but most days, it's just not on my radar.  It's not because I have great willpower.  I like a drink or two, but after that I get very tired, and it's not fun to be out with people just wishing I could lie down.  I'm not an alcoholic because I'm not wired to want  to drink very often or very much.  I tend to think it's the same with obesity: some people crave food, or the wrong food, or way too much food, and others don't.  Availability may make it easier, but there are still thin people, and isn't it interesting that in more affluent socioeconomic circles, where food has always been readily available, obesity rates are lower.


As a society, we've made the statement that if you're fat, it's your fault.  The obese are the last group of people that it's okay to pass judgement on.  "Exercise more, Eat less."  It's a simple recipe.  Dr. Chow tells us there's no magic bullet.  It's stigmatizing to take weight loss pills or have bariatric surgery.  I've heard morbidly obese people say it's their own fault, as though they don't deserve to be thin, and they loathe themselves for eating too much.  I sometimes wonder if our prejudices about obesity hinder pharmaceutical research because-- if anyone wants my vote-- there should be a magic bullet.