Alas, a Blog

Majikthise is worried that this recent JAMA study (.pdf link), which found that deaths-per-year attributed to “overweight” and obesity were much lower than previously reported – and which even found that the “overweight” tend to live a bit longer than people of “normal” weight – is being misunderstood. She points to this New York Times column by John Tierney, and also to this press release from The Center for Consumer Freedom (which I think is supported by the fast-food industry in some way).

Much of Tierney’s article is tongue in cheek (like the suggestion of picketing gyms, as if the JAMA study had found working out to be unhealthy). He also repeats some anti-fat stereotypes, like the assumption that fat people never exercise. But Tierney’s right on target when he says “the crusade against fat was never just about science.”

Majikthise dismisses the Center for Consumer Freedom’s critique of the CDC:

In the press release, the Center for Consumer Freedom basically accuses the CDC and the authors of the earlier study of propagandizing the public, if not of outright scientific malpractice. The data were there in the Center’s computers all along, they press release claims. Well, yes. Of course data sets used by Flegal and her colleagues [authors of the JAMA study] have been around for awhile. They’re the three National Health and Nutrition Examination Surveys (NHANES) compiled by the Department of Health and Human Services and used for countless studies over the years. But that doesn’t mean that it should have occurred to the scientists who made the earlier estimates of obesity-related mortality to use the same statistical methods as the Flegal team.

I don’t think Majikthise has fairly dealt with most of the CCF’s critique. The CCF is critiquing, I think, not just the flawed “400,000 fat deaths per year” study, but also the anti-fat ideology that made it seem appropriate to the CDC to take an obviously questionable study and trumpet it all over the media. From the CCF’s press release’s “timeline”:

March 2004 The CDC releases its report during a highly publicized news conference saying obesity kills 400,000 Americans a year and is poised to become America’s number one preventable death, resulting in alarming front page headlines across the nation.

May 2004 Science magazine reports on the 400,000 deaths figure: “Some researchers, including a few at the CDC, dismiss this prediction, saying the underlying data are weak. They argue that the paper’s compatibility with a new anti-obesity theme in government public health pronouncements — rather than sound analysis — propelled it into print.”

November 2004 The Wall Street Journal publishes a front-page story on errors in the 400,000-deaths study. The paper notes the study “inflated the impact of obesity on the annual death toll by tens of thousands due to statistical errors … Dr. Pechacek wrote to colleagues that he had warned two of the paper’s authors, as well as another senior scientist, ‘I would never clear this paper if I had been given the opportunity to provide a formal review.

The point is, the “400,000” study did not get an enormous P.R. push because of scientific merit. There was an idealogical need to trumpet a study proving that fat is “the new tobacco”; and by serving the needs of ideology rather than science, the CDC put itself in a position where it deserved criticism. (Nor can the criticism be dismissed as solely coming from fast-food industry flacks; independent fat activists have been making the same criticisms since the study came out.)

The huge publicity given the “400,000” did have a scaremongering effect; it encouraged a level of anti-fat hysteria unjustified by sound science. (“Hysteria” is the correct word; the director of the CDC called fat worse than the black plague.) The CDC made itself a leader of the “fat=bad” mentality that emphases bathroom scales and self-loathing for the fat, rather than emphasizing healthy eating and exercise for everybody. Isn’t that something that merits criticism?

Majikthise then goes on to discuss the JAMA article itself. The article made two findings: First, that being overweight is actually associated with a longer lifespan than being “normal” weight. And second, that being obese (rather than just overweight) contributes to about 112,000 deaths a year.

It’s telling how different Majikthise’s approach is, when considering each finding. When it comes to the idea that “overweight” people might be healthier than “normal” weight people, Majikthise is skeptical, suggesting several alternative explanations.

Being overweight is good for you, the flacks insist. Well, not exactly… (Being overweight is probably healthier than yo-yo dieting, eating disorders, or extreme bariatric surgery, but this study doesn’t bear on those important issues.) […] The effects of being overweight are uncertain […] But does being slightly overweight actually improve people’s health? Or is this finding some kind of artifact? […] It certainly doesn’t follow that it’s better to be overweight throughout one’s life, rather than just during the critical years. […] Brooks, Tierney, and the restaurateurs also overlook the fact that being overweight is itself a risk factor for future obesity. […]

(Gee, being overweight is “probably” healthier than having an eating disorder? Thanks.)

There’s nothing wrong with skepticism, of course. But I can’t help but notice that, when it comes to the harms of obesity, suddenly Majikthise’s skepticism vanishes, and alternative ideas aren’t even mentioned:

…There is no doubt that obesity increases the risk of death and ill-health. […] this study suggests that if obesity rates increase, excess deaths will increase as well.

In fact, Majikthise sounds more certain about the obesity/death association than the JAMA authors themselves do. From the JAMA article:

Other factors associated with body weight, such as physical activity, body composition, visceral adiposity, physical fitness, or dietary intake, might be responsible for some or all of the apparent associations of weight with mortality…. 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.

Many of the factors that Majikthise suggests might confuse the findings regarding “normal” weight people – yo-yo dieting, weight-loss surgery, etc – seem if anything more likely to be an issue with obese people. So why aren’t those factors also reason to question the findings about obesity? Majikthise, like all of us, lives in a culture with an anti-fat ideology. It’s anti-fat ideology, not sound logic, which says that findings that “overweight is healthier” should be treated skeptically but “obesity = death” findings from the exact same study, arrived at with the exact same methodology uncritically accepted.

That same ideology also dictates that, even if being overweight might not kill you early, it’s important to bring up the possibility that it’ll ruin your life in other ways. As Majikthise writes:

The study didn’t even attempt to measure the detrimental effects of excess weight on general health or quality of life.

Well, no, it didn’t; that’s outside the scope of a mortality study. To be fair to Majikthise, the study authors themselves brought up this concern. Curious, isn’t it, that the study authors didn’t feel obligated to suggest that there might be detrimental effects of underweight on general health or quality of life?

Imagine for a moment that a new study found the “male early death” factor isn’t as large as once believed. Would people feel the same need to temper this good news by reminding us that maybe men will be living longer, but their quality of life might still suck? Would people still be objecting if newspaper columnists treated such a finding as the good news it is? I doubt it.

Even if obesity “only” kills 100,000-odd people per year, that’s still a lot of preventable death.

There’s probably no word I’m less fond of, in the fat-mortality debates, than the word “preventable.”

What does that mean? “Preventable” how?

Majikthise seems to be thinking of weight-loss diets (i.e., “Maybe relatively modest weight loss will also turn out to be a huge benefit for people who are already obese.”) I’d point out that there are virtually no studies that show that obese people can either 1) reliably become non-obese over the long term through weight-loss dieting, or 2) improve longevity by losing weight. As the JAMA article writers say, “Even if body weights were reduced to the reference level, risks might not return to the level of the reference category.”

Given the incredibly high failure rate of weight-loss diets over the long run – and the damage done by failed weight-loss diets not only to physical well-being, but also to self-esteem and mental health – I don’t believe that pushing weight-loss as a remedy is justified. Weight-loss fanatics have dominated the conversation about fat for over half a century; what can they show for their efforts? Are Americans now less fat? Are we happier about our weights and our bodies?

Pressuring Americans to be thinner has a record of utter failure for longer than most of us have been alive. If people were capable of thinking reasonably about weight, that would be enough to convince most of us that it’s time to try a different approach. But anti-fat ideology is too powerful, much more powerful than logic. It doesn’t matter how much the new data differs from the old: the remedy is always the same. Diet, diet, diet, weight, weight, weight.

Tierney and others imply that if mere overweight is good for people, then our public health programs must be misguided. But if being overweight really extends people’s lives, then we should redouble our public health efforts to stop millions of overweight Americans from drifting into obesity. For these people, even a small weight gain could have dire consequences.

The study actually found no consistent connection between weight and mortality until BMIs of 35 and over. (“The majority of deaths associated with obesity were associated with BMI 35 and above”). Since “overweight” was defined as BMI 25-30, it would actually take a very substantial weight gain to put an “overweight” person into the high-risk category; this study does not support the idea that “a small weight gain could have dire consequences.”

Maybe relatively modest weight loss will also turn out to be a huge benefit for people who are already obese. Even preventing further weight gain in obese people might save many lives. If so, perhaps obesity interventions are even more cost-effective than we thought.

There’s a lot of “maybes” and “perhapses” going on there, and no actual evidence. But in our society, no one is expected to question the ideology that says fat people must be pressured to worry about weight (since we’re so unpressured already!). In our society – in anti-fat ideology – all unfounded speculation seems reasonable so long as it endorses losing weight as the solution.

Again – and I know I repeat this a lot, but it needs repeating – there has never been a diet that’s been shown in a peer-reviewed study to lead to healthy, sustainable weight loss in most fat people over the long run. Much more often than not, weight loss dieting leads to depression, damaged self-esteem, moodiness, long-term weight gain, and in some cases the ill effects of weight cycling – but not to long-term weight loss.

So Majikthise is arguing for an “intervention” that fails to work around 95% of time; that has nasty side effects; that makes the condition it addresses worse at least as often as it makes it “better”; and all of this is to address “modestly” higher risks that may be attributable, in significant degree, to other factors. If the “condition” being treated was anything but fat, we’d think that was crazy. But in our society, it’s difficult to even see irrationality, because anti-fat ideology has clouded everybody’s vision.

* * *

There are probably a lot of preventable deaths in that 111,909 figure. Fat people, due to the enormous pressure to not be fat, are more likely to have tried diet after diet, leading to yo-yo dieting – and, quite possibly, to a higher weight in the end. A lot of obese people would be healthier and live longer if they remained steadily obese, rather than weight cycling. Similarly, extreme weight-loss surgeries – liposuction, stapling, etc – could easily be shortening fat lives. (For one thing, those interventions are sometimes fatal.)

Second of all, the belief that fat is the most important barometer of health discourages fat people from steady, lifelong exercise and healthful eating. A lot of fat people try exercise and better eating for a while, but then quit because it “failed” to make them non-fat.

More appropriate definitions of “success” – such as being able to walk a treadmill longer without losing breath – would prevent many deaths. Unlike weight loss, the empirical data on the benefits for fat people of regular exercise is very strong, and the negative side effects almost non-existent. (I think Majikthise agrees with me that it’s better to emphasize health than weight.)

Majikthise begins her post by criticizing John Tierney’s Times article. This may be the only time I’ll ever agree with John Tierney rather than Majikthise, but I think Tierney has a better grasp on the real problem. The main message Tierney suggests isn’t “eat all the big macs you want!” but “anti-fat hysteria needs to be mocked.” The main message Majikthise conveys, despite her good intentions, is “possibly overweight people are healthy, although maybe that’s just a statistical artifact, but we must not lay off the obesity-equals-death message.”

Fat lives would be both better and longer if we could spread the former message widely, while burying the latter message as deeply as possible.