Obama Health Care and Fat

From Obama’s big health care speech:

Under my plan, we’ll make sure insurance companies cover evidence-based, preventive care services – weight loss programs, smoking-cessation programs, and other efforts to help people avoid costly, debilitating health problems in the first place.

“Weight loss programs” and “evidence-based… services” are mutually exclusive sets. There is no weight loss program which has been shown to bring about substantial, long-term weight loss in a peer-reviewed study.

A real evidence-based approach would lead to the conclusion that “weight loss programs” are useless, and in some cases can even do great harm.

That said, I think Obama’s health plan might be beneficial to fat people on the whole, because it includes “outlawing insurance company discrimination against people with pre-existing conditions.” If being fat is considered a “pre-existing condition,” then this would do an enormous service to fat people who are typically turned down by insurance companies.

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47 Responses to Obama Health Care and Fat

  1. Isn’t it amazing that weight loss programs are thought of as evidence based?

    I work in a field that still believes this, while also generally believing that “diets don’t work” — but they justify their programs by saying they aren’t diets. Argh.
    What this does present is an opportunity. It’s possible to say, if we really, truly, want to engage in “other efforts to help people avoid costly, debilitating health problems in the first place” — what do WE think those would be? Addressing the underlying (intersectional) issues of poverty, power imbalance, housing, education, employment, criminalization of segments of the population, stigma, discrimination in health care, reproductive rights, immigration policy — for a start. And doing all we can to eliminate food insecurity, increase access to healthier foods in “urban deserts” and safe opportunities to be physically active — not to prevent fatness but so that everyone can afford the opportunities that only some, by wealth or geography, have access to. I have no doubt that there are many people who want better health, but are blocked from access to care and the things that tend to keep people healthier.

    I think we need to advocate that it’s bankrupt to use obesity and overweight as a proxy for health. We have many other ways of measuring health — what do obesity and “overweight” rates tell us about a population anyhow? If weight and health status can be predicted by income level — why not address income level directly?

    Compared to the disasterous McCain plan, Obama’s is much better, but it still won’t address the inequity overall. I’m still in favor of a single-payer plan for all that is as good as the coverage I currently have (about the same as what Obama’s government plan would look like), with the option of private insurance for those who insist they need something fancier.

    I’m in favor of health care, not health insurance. If we all had access to good, equitable care, in combination with addressing some of the real drivers of poor health, we would be able to afford it by taking the ability of insurance companies to make a profit out of the system.

  2. 2
    Kutsuwamushi says:

    The idea that weight-loss programs are evidence based reminds me of the South Korean phenomenon of “fan death.” The idea that sleeping in a closed room with a fan turned on can kill you has no evidence behind it, but it’s still accepted common knowledge–even by many medical professionals.

    That said, I feel forgiving towards Obama’s weight-loss comment, because you would never know that weight-loss programs are even controversial, unless you read deeply into the issue. Everywhere you turn, there are otherwise “respectable” professionals and publications who treat the possibility of weight loss–if you follow the right program–as a given. It doesn’t suggest the same credulity as thinking that vaccines cause autism, since that debate at least has both sides represented in the mainstream press.

    I may feel more forgiving, though, because I’m a young, uninsurable woman who has pre-existing conditions since childhood, and am only able to get health care because I’m lucky enough to have relatively wealthy parents who love me and will pay the extortionate COBRA premiums. Even though Obama’s plan is far from what I want, pre-existing conditions are a big deal for me.

  3. 3
    Dianne says:

    Addressing the underlying (intersectional) issues of poverty, power imbalance, housing, education, employment, criminalization of segments of the population, stigma, discrimination in health care, reproductive rights, immigration policy — for a start.

    I agree. It’s amazing how often people are blamed for, essentially, poverty. If you’ll excuse an anecdote, when I was in residency a young women who was morbidly obese came to me for help in losing weight. I asked her about her routine, what she ate, how much she exercised, etc in the hopes that there’d be somewhere that a change could be made that was practical, harmless, and sustainable. It soon became clear that she was working more hours than I was–2 full time jobs* and one part time job for a total of a good 110 hours per week, not including transit time. Needless to say, she mostly ate fast food and never felt like exercising much. My honest advice would have been “quit 2 of your jobs and unionize the third–your health is never going to improve** until you have a living wage working 40 hours a week”. But she would have just though I was being sarcastic or obnoxious or flat out crazy if I’d said that so I fell back on the usual BS about checking her thyroid and finding time to exercise. Needless to say, her thyroid was fine and she didn’t lose weight with the standard advice. And needless to say, I failed her as badly as if she’d presented with a raging bacterial bronchitis and I’d told her to go home, chew on some moldy bread, and hope it was growing Penecillium. But I still haven’t figured out what I could possibly have said that would be useful.

    *Technically, they were “part-time jobs”–39.5 hours per week–so that the employers didn’t have to pay benefits. In reality, she was pressured to work unpaid overtime so they were really 42 hour/week jobs.

    **Yes, overweight or obese and unhealthy are two different things, but obesity so bad that it is stopping you from moving easily is unhealthy. Too bad we can’t do crap about it. Well, gastric bypass surgery can be effective in some cases but it’s pretty extreme and dangerous in its own right.

  4. 4
    Dianne says:

    One further rant: You can’t have an optimized medical system without universal health insurance. It just doesn’t work. Many different models of universal health care, from the Canadian all government all the time model to the German multiple competing companies model seem to work reasonably well, each with its own advantages and disadvantages, but if a significant percentage of the population is uninsured the health care system just isn’t going to work at maximum efficiency.

  5. 5
    PG says:

    It is silly to stress about weight as a number of pounds on a scale, but the fat levels in the body do have an effect on the likelihood of developing Type 2 diabetes (fat affects insulin receptors). Fat reduction programs — ones that help people figure out how to minimize the unhealthy fats in their diet — could be useful in improving people’s health. For example, if Dianne’s patient had a life coach who spent a typical day with her and could help her find how to fit a diet lower in ‘bad’ fats into that exhausting day, that would have been useful. Also, for people with a psychologically driven reason to eat unhealthily or not to exercise (e.g. eating to cope with depression the same way other people will medicate depression with alcohol or drugs; not exercising because of low self esteem about one’s appearance in gym shorts), a program that helps them work through that could be useful.

  6. 6
    Brandon Berg says:

    That said, I think Obama’s health plan might be beneficial to fat people on the whole, because it includes “outlawing insurance company discrimination against people with pre-existing conditions.”

    How exactly does that work? Doesn’t that mean that healthy people have no incentive to buy health insurance, since they’ll be able to sign up with no penalty after they get sick?

  7. Dianne, I have no idea how this advice might have been received, but if you were to listen and then say, given how much you are working and how little spare time you have, losing weight is going to be really hard, if not impossible. You are such a hardworking person, is there any way for you to get some more education so you can get a higher paying job that will allow you to work fewer hours for better pay. In the short term, don’t worry about weight as much as just try to fit in physical activity where you can (walking on breaks and to/from the bus), and make the healthiest choices your time and money will afford (bringing baggies of mini carrots to eat with a grilled chicken sandwich and milk at a fast food place, for example) and do all you can to get sleep and relax.
    I wonder if a health professional telling someone they know they are doing the best they can might not reduce some stress and stigma. And hearing from a highly educated person that you have potential to earn more money by gaining more education might be encouraging — but I know most health care practices aren’t set up to address the “social determinants.”

  8. 8
    Ampersand says:

    Doesn’t that mean that healthy people have no incentive to buy health insurance, since they’ll be able to sign up with no penalty after they get sick?

    Brandon, my guess is that Obama intends to outlaw the practice of refusing coverage to people with pre-existing conditions, but to allow for some sort of other penalty, such as a “penalty fee” for people who sign up late. I assume it would be in some way scaled to income.

  9. 9
    PG says:

    For that lovely little extra bit of screwed-up-ness, apparently the military has been discharging soldiers for what the DOD claims are “pre existing mental health conditions,” so the military won’t have to take responsibility for caring for their brain trauma and PTSD.

    The Obama plan doesn’t allow insurance companies to point-blank refuse to cover someone, but it doesn’t cap how much they can charge, so many people with pre-existing may be priced out of the private market and go into the national plan.

  10. 10
    mac9 says:

    “There is no weight loss program which has been shown to bring about substantial, long-term weight loss in a peer-reviewed study.”

    I don’t believe this is true. A book by Gary Taubes goes into this is more detail. It’s called Good Calories, Bad Calories.

    Also, a super interesting article by the same: What if it’s all a big fat lie?

  11. 11
    mck says:

    I guess I missed something. Could someone explain how weight-loss programs are dangerous and don’t work? I’m a fat person who’d like to stop being fat. You’re not saying that there’s no way to lose weight, are you?

    I’m confused. And fat.

  12. 12
    Dianne says:

    well rounded: A much better answer than the one I gave, but I think it would still be met with a response of something like, “If I had the money to get more education I wouldn’t be working 3 jobs in the shitwork sector in the first place.” Better financial aid for education would probably be needed (including money for people to live on, something that many financial aid programs ignore entirely). That’s a different topic altogether, though…

    Maybe there should be some sort of loan/grant program to encourage people to change life habits that led to poor health. They might be used for things like going to school to get a degree that would allow for a better paying job and more time available to spend on health, intensive drug/alcohol/tobacco rehab, full time PT to recover properly from injuries or illnesses rather than having people limp through “partially disabled” but having to work, and so on. One could make some sort of incentive to encourage people to use the time and money wisely, i.e. link whether the loan had to be paid back in full to some sort of health measure–not pounds per se (let’s not invite people to become anorexic), but maybe improvements in diet, time spent exercising, reduction in dangerous habits such as smoking, etc. Not sure how that’d work: it might be too difficult to make fair and reasonable rules.

  13. 13
    Sailorman says:

    It is arguably difficult to change your static weight. But is it simpler, relatively speaking, to keep from gaining fat in the first place. And if you never gain it, you never need to lose it.

    The FA movement does not seem to distinguish between the concepts
    “acquiring additional fat is not ideal, therefore we should strive to avoid getting fatter than we are”
    and
    “possessing fat is not ideal, therefore we should strive to eliminate it.”

    Politically I suppose it makes sense to lump everything into “anti fat” and thus attack it with comments on weight gain, but from a physiological perspective those two things are quite different.

  14. 14
    Dianne says:

    mac9: Sorry, but Taubes is full of it. The Atkins diet, if accompanied by caloric restriction and increased activity, results in about as much weight loss as any other diet–that is, about 10 pounds on average and essentially no change in health measures (blood pressure, glucose, cholesterol.) A large drop out rate was seen in all groups as well. Reference.

  15. 15
    Sailorman says:

    mck Writes:
    October 6th, 2008 at 5:38 am

    I guess I missed something. Could someone explain how weight-loss programs are dangerous and don’t work? I’m a fat person who’d like to stop being fat. You’re not saying that there’s no way to lose weight, are you?

    I’m confused. And fat.

    Forget about weight and get in shape. You will lose fat (probably but not necessarily; I don’t know how much fat you have) but you may not lose much weight, as muscle is heavy. You also may not change your overall shape all that much; you may not end up looking skinny. But the part of “being fat” which you don’t like is probably not related to the fact that you have fat cells. if you get healthy it may change a lot.

    [shrug] Healthy living is simple to describe, but very hard to do in practice. Sort of like meditating well: “just sit still and don’t think for an hour” sounds simple until you try it.

    Still, we know that some things work to get healthier for most Americans. You probably know them, too; there’s no magic pill.
    -Eat more dark green and orange vegetables, and fewer processed foods.
    -Eat more fiber.
    -Drink more water.
    -Slow down your eating; learn to stop eating when you are hungry. Leftover food is OK.
    -Eat lots of healthy snacks during the day (“graze” rather than “gorge.”) this keeps you from getting really hungry, which leads to eating fast, which is less than ideal (see above.)
    -Exercise daily
    -moderate, if you can, the stuff you like but know is really bad for you. Pretty much nobody is capable of eliminating fun stuff. you aren’t either, so don’t try. Skip this step if you need to. Don’t make denial the focus, so that you end up giving up on the whole “getting healthy” thing if you don’t like denial. better to have exercise all the time and eat lots of ice cream, than no exercise and no ice cream. you can eat lots of ice cream and still be very healthy, but it’s hard to be very healthy if you never exercise or eat vegetables.

    you will note that “watch your weight” is not on that list. You will also find that the “simple” list is very difficult to actually DO, lol

    if you figure out a way, let me know.

  16. 16
    Mari says:

    Sailorman, it never ceases to amaze me how people who are oh-so-concerned about us fatties health, love to come on our blogs and tell us what’s wrong with us.

    FA is not about promoting gaining weight for the sake of gluttony. Our virtue is that dieting doesn’t work because it involves elements of food elimination that are equivalent to starvation. Further, study after study has shown that most dieters gain the weight back and then end up weighing more than they did before.

    It becomes this vicious cycle where the dieter is then punished for not having controlled. Sadly, dieting is now being replaced with weight-loss surgery which is even more problematic than the most hard-core diet. I, as a fat woman, do not want to gain weight and most fat people don’t. However, if it does happen, we don’t want to be stigmatized. We want to be treated as human beings.

  17. 17
    Ampersand says:

    Mck, there are a lot of ways to lose weight; but for most people, no method of weight loss will lead to a significant amount of weight lost over the long term. The chances of a fat person becoming a non-fat person and maintaining it over the long run are just barely above zilch. Furthermore, attempting to lose weight can be bad for your physical health and your self-esteem.

    So yes, that is what I’m saying.

    I explained why I think this in detail in this post; please read it if you’d like.

    I wouldn’t advise you to give up hope of being healthy, or happy, or liking yourself and your body. (I don’t know if any of these things are problem areas for you; they have been for me.)

    Based on what I’ve read of the evidence, however, I think fat people like you and me are better off concentrating on building our health and self-esteem without attempting to lose weight.

  18. 18
    PG says:

    In a bit of fairness toward Sailorman, there is a range of viewpoints in the FA movement, as in any other movement. I agree wholeheartedly with Mari’s statement that we who are overweight or obese do not want to be stigmatized. However, I also have encountered Fat Advocates who declare that obesity is equivalent to a high BMI and therefore a stupid measurement of health risks. Only ignoramuses use a metric as oversimplified as BMI to make medical determinations. Obesity actually is measured by percentage of body fat, which is why someone who appears of average size can be more obese than someone who is larger by volume. For example, I don’t look overweight when I’m dressed because I wear a size 6/8, but I have high body fat, low muscle mass and a freakishly high cholesterol level — I’m medically overweight. I’ve also encountered the view that there’s no relationship between fat levels in the body and propensity to develop Type 2 diabetes.

  19. 19
    Ampersand says:

    PG, there are many, many medical and government authorities who define obesity as a high (i.e., 30 or over) BMI. It is the most common definition, and one used in nearly all the academic studies of obesity and morbidity, as far as I can tell.

  20. 20
    Dianne says:

    Everyone knows BMI is an imperfect measure at best. But no one’s come up with a simple, reproducible, non-invasive method that’s better so we’re stuck with BMI as the standard for the moment.

  21. 21
    PG says:

    The NIH/NLM’s definition of obesity specifically distinguishes weight from fat levels:

    “Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat and/or body water.”

    I’m not sure how much more the federal government can do to say that high BMI =/= obese.

    I don’t know if they qualify as “simple,” but there are many ways to determine someone’s fat level, from the good ol’ high school gym class fat pincher, to the “Omron Handheld Fat Loss Monitor” ($40 at Bed Bath & Beyond!). Measuring height and weight and then dividing is lazy, and worse than useless when it tells people like me that we don’t have a health problem, and people like my sister (who is the same height, but significantly heavier because she has bigger bones and more muscle) that they do.

  22. 22
    Sailorman says:

    Mari, did I tell you something was wrong with you? I don’t think I did.

    I do think that the FA movement runs into a cognitive problem insofar as the “accept people for who they are” piece (with which i agree) and the “random weight loss diets do not work” (with which I agree) disagree with the concept that it is OK not to want to be fat, and that it is OK–maybe even a good idea, in certain respects–to not to become fat, if avoiding it is reasonably doable.

    In fact, your response is sort of indicative of the problem that I see. I am discussing whether it is possible to modify habits to AVOID GAINING weight.” You are responding “diets don’t work to LOSE weight.”

    Using myself as an example; i am overweight. Not obese, but overweight. Still, I would like to lose weight. I probably can’t for long, though in my case I might be able to as I have access to some help. Chances are fairly slim though.

    However, not only would I like to lose weight, I would like to avoid gaining any MORE weight. As compared to losing, this is a much more doable goal. this is also a worthwhile physiological goal, from the perspective of my knees.

    Does this make you uncomfortable? Does it make you uncomfortable that i have an opinion different from yours, or that i answer the question of someone who asked how to lose weight? If so, I don’t really see how that is my problem.

  23. 23
    Ampersand says:

    Sailorman, what kind of peer-reviewed research exists — preferably a long-term clinical comparison study — that indicates that people can consciously choose not to gain weight as they age?

    Also, I don’t think there’s evidence that the gaining of pounds over the years is, in most cases, unhealthy. If that were the case, I’d expect heavier older folks to have a higher mortality than the same-age but thin, and that’s not the case. But if you have legitimate evidence you can link to, or cite, I’d be interested.

  24. 24
    Ampersand says:

    PG wrote:

    The NIH/NLM’s definition of obesity specifically distinguishes weight from fat levels:

    “Obesity means having too much body fat. It is different from being overweight, which means weighing too much. The weight may come from muscle, bone, fat and/or body water.”

    I’m not sure how much more the federal government can do to say that high BMI =/= obese.

    PG, I’m not saying that the government never defines obesity in the way that you describe. I’m saying that it frequently and routinely defines obesity according to BMI. As do all other major sources of finger-wagging fat-hatred.

    For example, take a look at the first three links on the webpage you yourself linked to — all three the links under the big heading “Start Here.” These are the most prominent links on the page.

    The first link leads to this NIH page. I’ll quote the heading and first paragraph:

    What Are Overweight and Obesity?

    The terms “overweight” and “obesity” refer to a person’s overall body weight and where the extra weight comes from. Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat. The most useful measure of overweight and obesity is the body mass index (BMI). BMI is based on height and weight and is used for adults, children, and teens. For more information about BMI, see “How Are Overweight and Obesity Diagnosed?

    If you follow that last link — to another NIH page — you’ll see that it says that overweight and obesity are diagnosed by using BMI (although it notes a couple of limitations of BMI). If your BMI is over 30, then you’re obese.

    The second link on the page you cited also leads to an NIH page. This page mentions some limitations, but says:

    The BMI table below provides a useful guideline to check your BMI. First, find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. A BMI of 25 to 29.9 indicates a person is overweight. A person with a BMI of 30 or higher is considered obese.

    The third link, to a non-government website, says:

    Your BMI is based on your height and weight. Doctors consider BMI to be a better measure of health risk than your actual weight in pounds. In fact, the medical terms “overweight” and “obesity” are based on BMI values. A BMI of between 25 and 30 is defined as overweight, and a BMI of 30 or more is considered obese. The higher your BMI, the greater your risk of developing a weight-related illness, such as type 2 diabetes or heart disease.

    You could also look at the CDC’s definition of obesity (“An adult who has a BMI of 30 or higher is considered obese”), or the tens of thousands of federal and state government pages found using a simple google search.

    The government uses high BMIs to define obesity. That’s what they do most of the time, over and over, in study after study and fear-mongering claim after fear-mongering claim. With all due respect, PG, to claim that the government is doing all it can to oppose this is ludicrous.

  25. 25
    Doug says:

    Diane–

    All you’ve shown is that one poorly administered study produced bad results!

    While individual metabolism varies significantly, low carbohydrate diets consistently produce healthier participants than other diets do–which makes sense given the massive impact of insulin driven by carbohydrates, and the mere 10,000 years the human race has had to evolve to accommodate an agricultural diet.

    Cherry-picking belongs on trees, not in scientific data.

  26. 26
    Sailorman says:

    Ampersand Writes:
    October 6th, 2008 at 1:04 pm
    Sailorman, what kind of peer-reviewed research exists — preferably a long-term clinical comparison study — that indicates that people can consciously choose not to gain weight as they age?

    I am not sure that you and I are talking about the same thing.

    I weigh more than I did 15 years ago. Most folks do. Is that the age-weight issue you are talking about?

    If you have lived out west at all, you may notice that (anecdotally, of course,) the increase in weight with age is related to decreased activity. There are plenty of insanely active 65 year olds in colorado, and the ones who are as active as they were when they were 35 look, in some respects, pretty much as they did when they were 35. Of course for most of us a combination of timesucking work, bad knees, and other things make that difficult if not impossible.

    [shrug] On a personal level, when i used to be skinnier, I ate everything in sight but probably engaged in strenuous aerobic activity for 10-20 hours a week. If i manage that level of clinical activity for two hours now i am having a good week. Do i need a clinical trial to suggest that those two things are linked?

    I don’t see that as a “fat” issue so much as a “time” issue. If I started reliably playing soccer, volleyball, biking, etc–which I have, at various points in the past–then i have little doubt that i would be less fat–which has happened at various points in the past. This makes sense, of course. but it reflects my choices in life, not a ‘failure of a diet’ or something.

    Also, I don’t think there’s evidence that the gaining of pounds over the years is, in most cases, unhealthy. If that were the case, I’d expect heavier older folks to have a higher mortality than the same-age but thin, and that’s not the case. But if you have legitimate evidence you can link to, or cite, I’d be interested.

    Well, “health” /= “mortality.” let’s get that out of the way right off, shall we?

    I am alive and fat, and, all other things being equal, less healthy than I would be if I were alive and thin. (I have been in similar physical condition and thin) I am less comfortable, more prone to joint pain, more prone to injury, etc. I am also more limited in what I can do with my body (albeit better suited to survive a short term famine) which I view as a cost of health. Heck, losing weight would probably even make me snore less.

    If your measure is “am I dead or not?” then you eliminate all those other issues. I don’t know why you would do that, but it doesn’t make any sense to me. Why do you use such a restricted level of “health” or, if you don’t, why do you use the term “healthy” when you mean “long lived?”

  27. 27
    Ampersand says:

    Doug, can you cite some well-conducted, peer-reviewed studies that have shown low-carb diets safely produce long-term, significant weight loss in a majority of users? (By “significant,” I mean enough to turn a fat person into a “normal” weight person, or failing that at least 40lbs for people weighing 300lbs or over; and by “long-term,” I mean at least 3 years, and preferably 5 or more.)

    Dianne, unlike you, has cited evidence to support her statement. Until you can do the same, you’d be better off not accusing her of cherry-picking.

  28. 28
    Ampersand says:

    Sailorman –

    I do live out west. I’m not sure I agree with your anecdotal observations — there are thin folks who stay inside, and fat folks who lead active lives. Furthermore, even if your observations were true, that doesn’t say anything about causality.

    In any case, it seems that your answer to my question is, you have no valid evidence that people in general can successfully, healthily choose to avoid gaining weight as they get older.

    Finally, most people think that there’s a strong relationship between health and mortality, and mortality — unlike issues like “comfortable” — is measured with a great deal of accuracy across a large population, making it especially suitable for statistical analysis.

    It’s interesting to me that anti-fat ideology — after literally decades of harping on mortality as the single most important justification for anti-fat hysteria — is now suddenly talking about other health issues. I do think those other health issues are important to address — not just for fat people but for all people — but in the particular case of discussing fat, it seems like the anti-fat side has a predetermined conclusions (FAT IS UNHEALTHY!!!!!!!), and then lines up the evidence to support that prefab conclusion.

    Ten years ago you would never, ever have found a prominent anti-fat person saying that mortality isn’t important, but health is. Today it’s a cliche. To what do you attribute this change?

  29. 29
    PG says:

    Ampersand,

    You’re right that the gov’t has used BMI as a cheap substitute for actually measuring fat, but they do seem to be saying “obese” is a description of one’s fat level.

    Also, one reason to talk less about fat’s effect on mortality is that cardiology is an amazing field. The ability of medicine to prolong the lives of people who 40 years ago would be dead of their conditions is stunning: pacemakers became reliable in the late 1970s; statins are now a standard tool in treating people with high cholesterol and weren’t available until the 1980s; ditto balloon angioplasty as a standard alternative to bypass surgery; stents didn’t come into widespread use until the 1990s. I can’t think of another field where there has been so little in the way of public health advances and so much in pharmaceutical/surgical advances to reduce mortality. (Medicine’s big answer to lung cancer still seems to be “well, don’t smoke or work in a coal mine.”)

    I’m not sure there’s reason anymore for an obese person to die from obesity-related causes, so long as she has competent medical care (obviously, a big “if” in this country); her diabetes gets insulin, her blocked arteries are cleaned out surgically and with drugs. (I’ve been told that I have another few years to try to get my cholesterol down with better diet and exercise, and if I don’t do it by then, I’m going to be a Lipitor candidate.) Even if she has a heart attack, her survival chances are much greater than they were a generation ago. I don’t know that it affords a fantastic quality of life, but it does keep life going and keeps the people who are stressing about fat as a public health problem from talking about mortality.

    It’s sort of like that pro-war comparison of how Iraq and Afghanistan must not be that bad for our soldiers in because they’re not dying at the rate they did in Vietnam. It cheerfully ignores the advances in technology that allows Walter Reed to patch up a person who would have been DOA from the same wound 40 years ago. It’s not that the field of battle is safe; it’s that field medicine is excellent.

  30. 30
    Staunch Woman says:

    Obama is good at making different campaign promises to different people, depending on where he is, and to whom he is speaking at the moment. None of them will actually come to fruition if he wins.

    Gee….if he does win the presidency, what’s he going to do next? He’s spent virtually his whole adult life campaigning for the next higher office. What’ll he do during his four years of avoiding the duties of the presidency? Start campaigning to be elected God?

  31. 31
    B.Adu says:

    Sailorman,

    “acquiring additional fat is not ideal, therefore we should strive to avoid getting fatter than we are”

    No-one is fatter than they are.

    And PG,

    I love the tag line on your blog,’ just because you’ve won the argument, doesn’t mean you are right’

    When it comes to the ‘obesity’ argument, these are the words I live by.

  32. 32
    PG says:

    SW,

    Obama is good at making different campaign promises to different people, depending on where he is, and to whom he is speaking at the moment.

    Well, yes; if you’re speaking at a nursing home, you talk about what you’ll do for the elderly; if you’re speaking at a college, you talk about what you’ll do for young adults. Would you like to present any evidence for your implication that these promises are contradictory of one another? At least Obama states openly and frequently that he will raise taxes on the $250k+ households back to Clinton era levels and will end the war in Iraq in order to fund his promises, whereas McCain hasn’t mentioned in public that his tax cuts will require massive reductions in Medicare and Medicaid funding in order to maintain the budget neutrality he’s promised.

    Gee….if he does win the presidency, what’s he going to do next? He’s spent virtually his whole adult life campaigning for the next higher office.

    Really? For what office was he campaigning while in college? (People actually have pointed out that it was a shortcoming that he wasn’t in much of leadership positions while at Oxy and Columbia.) For what office was he campaigning when he worked as a community organizer? when he worked for Project Vote?

    At Harvard Law, he managed to be president of the Law Review while achieving a magna cum laude GPA, which indicates that he’s well capable of holding a leadership position while fulfilling his other responsibilities. How did he fail in his obligations as an attorney at Davis, Miner, Barnhill & Galland, or as a con law lecturer at UChicago? Please explain how he “avoided his duties” in any of these positions.

    I am happy to discuss Obama’s shortcomings. I had a running series of posts on my blog last year all titled, “PG hearts Obama, but…” and could write another dozen about everything from his stupid insult against Justice Thomas to the potential for moral hazard in his health care plan.

    But I am getting sick of these vague insults with no evidence behind them, that really can be summarized as “I don’t like this guy.” Fine, you don’t like him. What an utterly useless comment.

  33. 33
    Sailorman says:

    Ampersand Writes:
    October 6th, 2008 at 2:00 pm
    …It’s interesting to me that anti-fat ideology — after literally decades of harping on mortality as the single most important justification for anti-fat hysteria — is now suddenly talking about other health issues. I do think those other health issues are important to address — not just for fat people but for all people — but in the particular case of discussing fat, it seems like the anti-fat side has a predetermined conclusions (FAT IS UNHEALTHY!!!!!!!), and then lines up the evidence to support that prefab conclusion.

    Ten years ago you would never, ever have found a prominent anti-fat person saying that mortality isn’t important, but health is. Today it’s a cliche. To what do you attribute this change?

    I would say that most people experience fat as affecting health. most people do not like being fat,and find it somewhat limiting. The normal assumption–reasonable, if you ask me–was that because of the perceived effects and limits it would also, therefore, affect mortality. Mortality is easier to measure and discuss, though it is an overly broad marker; since it was easier to measure, that is what people talked about.

    So the mortality assumption appears to be wrong, absent new data. But the underlying health issue and awareness remains. mortality is still important. but it’s not the only issue of importance. It never was.

  34. 34
    Thene says:

    If there were really no environmental or behavioural factors that cause people to be fat, then you’d find fatness evenly distributed across the world. You don’t. This doesn’t mean that fat is a bad thing, or even that it’s a personally controllable thing – unless you can choose to up and move to an environment planned on completely different principles, which most people can’t. It just means that blaming and shaming people for fatness is completely moranic.

  35. 35
    Ampersand says:

    Maybe I missed it — who claimed that there are no environmental or behavioral factors that cause people to be fat?

  36. 36
    PG says:

    If there are behavioral factors that cause people to be fat, then presumably there is at least potential for behavior modification. As I noted above, many people (including myself at times) use food the way that other people, less socially acceptably, use alcohol or drugs: to feel better emotionally. It’s the bit of truth in the chocolate-during-PMS cliche.

    Thankfully I don’t seem to suffer from depression in any long term or clinical sense, so that’s a relatively small factor in my fat concerns, but for people who are less lucky in mental/emotional health, it may be far more significant. If people can receive therapy or medication that leads them to stop abusing alcohol or drugs in order to self-medicate their mental health, then presumably they can receive therapy or medication to stop “abusing” food. So the idea that there’s nothing any individual, given the right set of tools, can do about their weight or their fat level seems unnecessarily pessimistic.

  37. 37
    Sailorman says:

    Amp, you never addressed the issue of differentiating between “not getting fatter” and “losing fat you already have.”

    What is your position on that? Do you agree with me that it is easier, generally speaking, to avoid getting fat than it is to lose weight?

  38. 38
    Joe says:

    Here’s a fun one. I went to the doctor today. Nurse measured my body around the belly button. I asked the dr. about it. He said the insurance companies are asking for it because “an expending waistline directly correlates with type II diabetes and other health issues.” As best I recall.

  39. 39
    Ampersand says:

    PG:

    If there are behavioral factors that cause people to be fat, then presumably there is at least potential for behavior modification.

    Actually, this doesn’t follow, if by this you mean that behavioral modification can make a fat person non-fat. Just because behavior causes a situation to come into existence, doesn’t logically establish that the situation is subject to reversal via behavior.

    (If I carve a statue out of stone, that’s a behavior. But that doesn’t mean that I can make behavioral changes that will cause the statue to turn back into the original stone shape.)

    As I noted above, many people (including myself at times) use food the way that other people, less socially acceptably, use alcohol or drugs: to feel better emotionally.

    It’s fairly well known that binge eating — which is what I guess you mean here — is made more likely by dieting, not less likely. However, it’s not true that all fat people are bingers, nor is it true that all binge eaters become fat.

    So the idea that there’s nothing any individual, given the right set of tools, can do about their weight or their fat level seems unnecessarily pessimistic.

    It’s interesting how my statement — which was fairly careful and hedged in — has been warped into a rather more extreme version in what you’re saying here.

    I’m not saying that no individual can ever do anything about their weight or fat level. I’m saying that for the large majority of fat people, there is no healthy way of losing a significant amount of weight that will be sustainable over the long term.

    Without a doubt, there are behavioral ways of dropping weight. But for the large majority of fat people, the weight lost won’t be significant and long-lasting. And many methods of losing weight are bad for health, in the long run.

  40. 40
    Ampersand says:

    Amp, you never addressed the issue of differentiating between “not getting fatter” and “losing fat you already have.”

    What is your position on that? Do you agree with me that it is easier, generally speaking, to avoid getting fat than it is to lose weight?

    I have no idea. I haven’t seen any valid evidence on the question, one way or the other. Nor have I seen any evidence that normal weight gain due to aging is unhealthy.

  41. 41
    Sailorman says:

    Ampersand Writes:
    I have no idea. I haven’t seen any valid evidence on the question, one way or the other. Nor have I seen any evidence that normal weight gain due to aging is unhealthy.

    ? I am not talking about “normal weight gain due to aging.” Not that I know exactly what you mean by that, in any case–what do you consider “normal?”

    I am talking about the process where, to put it simply, people get fat BEFORE they are old, and/or the process whereby they get fat over a short period of time. neither of those are weight related.

    As far as I can tell, you already think it is essentially hopeless to try to lose weight if you are fat. I want to know if you also think it is hopeless to try not to become fat in the first place.

  42. 42
    Shira says:

    I want to know if you also think it is hopeless to try not to become fat in the first place.

    Yes, it is. You don’t have direct control over your weight – irrespective of size – beyond a very narrow, 10-30 pound, genetically-determined range that may go up or down with age or illness. The one thing it isn’t a function of is how much you eat and how much you exercise. For more information about this phenomenon, including references to experiments involving attempts to induce obesity in naturally lean male prisoners, and vice versa, see this article at JunkFoodScience.

    A taste:

    Groups of “equally dedicated volunteers at the Vermont State Prison” signed up, committed to eating as much as they could for 200 days to try to get fat. Far from being easy, it wasn’t. In fact, most of the men found it so extremely difficult that many considered dropping out. Forcing themselves to eat so much became so unpleasant a few even barfed after breakfast. “Most of them developed an aversion to breakfast,” wrote Dr. Sims. Virtually all of them at least doubled the amount of food they usually ate and simultaneously reduced their activity, and many were eating as much as 9,000 to 10,000 kcal/day he said. Still, only twenty men managed to gain 20 to 25% of their weight with great difficulty and the others couldn’t, even though they were consuming more calories than the others, wrote Dr. Sims.

  43. 43
    PG says:

    Just because behavior causes a situation to come into existence, doesn’t logically establish that the situation is subject to reversal via behavior.

    Not if there are other factors like basic physics — the passage of time, the alteration of matter — in play. Having sex gets you pregnant; there’s no un-sex by which you become un-pregnant. However, weight isn’t generally the kind of on-off switch that pregnancy is. It’s gradual, and it is reversible. Certainly it is subject to alteration only within a certain range, but to the extent that one is at the high end of the range, and a disproportionate amount of the weight is from fat, being at the lower end and with a lower proportion of fat is preferable for health. We inevitably lose bone mass as we age because our older bodies can’t make new bone as quickly as the old breaks down, but it’s still worthwhile for women to modify their eating to include lots of calcium.

    It’s fairly well known that binge eating — which is what I guess you mean here — is made more likely by dieting, not less likely.

    I am not sure that emotional eating = binge eating. You can drink to self-medicate without getting drunk, and you can eat to self-medicate without “binging,” i.e. eating uncontrollably or so much that you make yourself sick. I wrote an example from my life but I think this is getting too personal for me, so I deleted it and will end here.

  44. 44
    B. Adu says:

    ‘As far as I can tell, you already think it is essentially hopeless to try to lose weight if you are fat. I want to know if you also think it is hopeless to try not to become fat in the first place.’

    Sailorman,

    Why can’t you stop shooting the messenger?

    Diets and healthy eating have not permantly reduced the weight of those who are fat or plump or thin. What exactly is there to disagree with?

    It’s not about wanting to lose weight, it’s about the way human biology responds to what we have tried thus far that is the issue, until we can find other ways to overcome that, we will continue to fail, it is tooo simple.

  45. 45
    bradana says:

    I think that there needs to be a distinction made regarding the degree to which an individual’s fat is gained or supported by behavior versus what comes from a natural tendency to fat. There are some people whose inactivity, stress, and diet contribute to the bulk of their fat. So when Sailorman says that people should try not to get bigger, he’s right, for some segment of the population.

    There are other people, like me, who have been fat for the majority of their lives. Diet and excercise regimens may make me smaller, but I will never be a “normal” weight. My body works just fine at a larger weight.

    By labelling all fat as bad, there is no way to accept the fat that is natural for some people. There is no way to redirect people to eat what is natural and healthy for them. There is no way to allow individuals to determine the level of activity that is optimal for them. When there is only one way to win the battle of fat, by shrinking to some arbitrary “normal” weight, some of us are going to fail. What’s normal for one body isn’t necessarily normal for another.

    The easiest way to tell how much of your fat is made by behavior is to eat when you are hungry, stop when you are full, eat what makes you happy and do the things you love to do. Live your life, your body knows what it needs.

    Oh and no diet is going to work. The diet industry is built on the idea that diet’s will only succeed enough to convince people it might work for them. They make their money on the majority of people who fail to lose and then go out and buy another diet. The diet industry doesn’t have your best interests at heart, they have their own need to make money.

  46. 46
    Sailorman says:

    Huh. My understanding–which may be wrong–is that we have found differences in populations of similar genetic makeup (determined, usually, by ethnicity as a proxy), but which differ in terms of, say, income or geographical location.

    So when you make the suggestion that weight is beyond our control because it is genetically mandated, that simply does not seem to match the existing data. Admittedly, it is quite possible that once you have reached an adult age, your body and brain have developed mechanisms that make it difficult to significantly change your weight. But that is entirely different from the question of whether or not it is possible to control where that endpoint is headed, PRIOR to reaching a state of equilibrium.

    So when you look at changes in obesity across national populations, for example, you can ask “are those changes occurring at a speed which appears to be genetically linked?” If you look at Japan, for example, the number of obese men in their 40s changed from 23 percent to 34 percent over about 25 years. Do you think that is genetics? Or do you think that is behaviorally linked?

  47. 47
    Ampersand says:

    Do you think that is genetics? Or do you think that is behaviorally linked?

    Don’t forget about environment — and interactions between biological and environmental factors.

    (Sorry I’m not in this thread more. Too much work to do.)