I am catching up on blogging and reading this weekend, and I have a confession: sometimes I read blogs that are not entirely pro-fat acceptance. I especially enjoy reading blogs by medical and nutrition professionals that are basically compassionate about fatness, yet define their work as "obesity reduction."
One of those places that I read from time to time is a blog called Weighty Matters by a Canadian physician subtitled: "An obesity medicine physician's take on all things weighty!" My favorite quote from Dr. Yoni Freedhoff is this one:
The only goal worth setting is living the best you can. If you can't
eat less and you can't exercise more within the context of a lifestyle
that you're actually enjoying, then whatever your weight is, it's great.
It's followed by this sentence, "Remember that even a 5% weight loss has a significant medical benefit" within the context of a post on dieting, and one of many harsh critiques of Canada's Food Guide, but it makes me love him a little bit. And it's Dr. Freedhoff's blog led me to this one: Dr. Sharma's Obesity Notes. (I'm getting to the point now, I swear.) The bio on the web site reads: "Dr. Arya M. Sharma, MD/PhD, FRCPC is Professor of Medicine & Chair for Cardiovascular Obesity Research and Management at the University of Alberta." (I think that I am, as a KITH fan, fond of Canadians). Here's the evidence of compassion (you can see him speak it yourself on a tiny video here) that I require before delving into a blog like this one, in FAQ in response to the question "Does dieting make you fat?":
As most people who have been on a diet, you have probably found
yourself heavier after every diet than you were before. This is because
each time you try to lose weight, you program your body to gain the
weight back and to put on extra reserves just in case you decide to
lose weight again. There is good evidence that dieting may be the best
recipe to just keep getting fatter. So unless you are seeking
professional obesity treatment, the best solution may be to just eat a
healthy diet and to be as physically fit as possible at your current
weight. You may not lose any weight, but the health benefits are
guaranteed, and you will certainly feel a lot better.
Sounds a little "HAES-y" to me. There's plenty of the standard medicalization of obesity stuff too, to be sure. To be expected, he is also the medical director of the Edmonton Capital Health District's weight management (including bariatric surgery) programs.
Dr. Sharma posted in the end of March 2008 a post called "Obesity Classification: Time to move beyond BMI?" which starts off strong with this:
As most clinicians will readily agree, when dealing with indiviual
patients, both measures [BMI and waist circumference] lack sensitivity and specificity with regard to
identifying the presence or risk of obesity-related risk factors,
comorbidities, psychopathology, global functioning or quality of life.
He goes on to say:
...basing the decision on who to treat and who to leave well alone solely
on measures of weight or size is neither sensible nor does justice to
the complexity of the relationship between excess body fat and its
impact on health and well-being.
And even goes so far as this:
Telling healthy large people who have no apparent comorbidities,
functional limitations or reduced well-being to lose weight may be
counterproductive in that it can introduce and reinforce
dissatisfaction with body image, foster frustrations and despair (given
the poor long-term success of weight loss attempts) and lead to
unhealthy behaviours focusing on weight loss (e.g. excessive exercise
or dieting) rather than on healthy lifestyles (which are possible at
almost any weight).
Amen, Dr. S.
So, here's his proposed, first draft solution, with 5 stages of obesity:
Stage 0: no apparent
obesity-related risk factors (blood pressure, lipids, glucose, etc.),
physical symptoms, psychopathology, functional limitations, or
impairment of well-being
Stage 1:
presence of obesity-related sub-clinical risk factors (elevated blood
pressure, impaired fasting glucose, fatty liver, etc.), mild physical
symptoms (dyspnea on moderate exertion, occasional aches and pains,
etc.), mild psychopathology, mild functional limitations or mild
impairment of well-being
Stage 2:
presence of established obesity-related chronic disease like
hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux
disease, polycystic ovary syndrome, depression, anxiety disorder,
moderate limitations in activities of daily living and/or well being.
Stage 3:
established end-organ damage like myocardial infarction, diabetic
complications, severe osteoarthritis, significant psychopathology,
significant functional limitations and impairment of well-being
Stage 4:
severe (end-stage?) disabilities from obesity-related chronic disease,
severe disabling psychopathology, severe functional limitations and
severe impairment of well-being
On one hand, I appreciate the enhanced complexity of a system like this one, and the ability of such a system to underscore that states such as defined as stages 0 and 1 truly exist. On the other hand, I'm not sure I like where this might be going for stages 2-4 -- does this mean that I will be seen as non-compliant if I don't consider the risks of surgery to outweigh the benefits, just because I have an "obesity-related" chronic disease? I would definitely fall into that classification for a number of those criteria. What is the proposed treatment for stage 2? Is there any evidence that it's any more effective than it would be for any other stage? Or is it a matter of enhanced monitoring for potential problems, more insurance coverage for treatments that I might want, like sports massage, so I can maintain a higher level of physical activity?
Another issue I have with this classification system is that it appears to assume that obesity is the cause of the co-morbidities rather than co-existing with them -- that is, how can a physician know (or assume) that the osteoarthritis is caused by obesity rather than something that a patient would have developed regardless of weight? To say that blindness as a complication of diabetes is actually a complication of obesity is far too simplistic for me.
And in the comments for this post, Dr. Yoni of Weighty Matters has this to say: "I imagine even groups like NAAFA might feel this to be worthwhile."
I need to stop for now, as little one is waking from a long nap (which allowed me the opportunity to do this work!) but your perspective and comments are welcomed, desired, needed, as long as they are civil. I know this is a controversial subject.
Comments (20)
I'm not sure where he gets the idea that weight loss is going to cure PCOS, much less depression and anxiety. I had all three at 125 pounds. I'm pretty sure I'm not a freak exception in that regard, either.
@Meowser - Yeah. Did you read his post? I don't totally think he is assuming that "addressing obesity" is going to alieviate those things. Hmm.
How are you, anyhow, aside from awesome?
The weather has been gorgeous lately, non?
I'm goofing off as the tiny terrific terror is still sleeping -- I call my little one that as earlier, there was an attempt to stick a sharpened pencil in my ear while I was blogging (standing behind me on the computer chair, pretending that the pencil was a syringe for giving me a shot for my non-existant cough -- I may have a bariatric physician in the making). I should probably get up from the computer and eat some supper.
Wow, that's one amazing kid you have there! (Maybe you should break the pencil tips, though.)
Yeah, I love love LOVE this weather. I feel like I've been waiting all my life for it, after 9 months of clouds and rain.
Admittedly I did not go to his site and read the entire article, but when he calls depression and anxiety "obesity-related chronic disease" (well, okay, if you mean that medications used to treat those things can make you gain hella weight, but I'm not getting the impression that that's what he meant) it makes me a little concerned I don't have the SW points stored up to handle it.
I'd love to take a day trip up to Oly some time soon, if you think you might be up for a visit.
I loved "occasional aches and pains," 'cause it's not like that's the result of being human, or anything!
@Meowser - Yes! Come for a visit. Next weekend isn't good, but August looks good overall. There are many fun things to do here.
I can see it now.....a fat person undergoes a "lifestyle change," loses their benign adipose tissue, and starts telling everyone "my obesity is in remission."
On a more positive note, those with "end stage" obesity will finally stop being told to lose weight....
You know, I almost don't understand doctors like that. On the one hand, they're saying practically everything we as a group have been saying for a long time. And yet, on the other hand, they have to spout the same old rhetoric, which they just said themselves was false. I KIND of get it - I mean, they're being bombarded with the same messages that make people go on diets in the first place - but if they, as a DOCTOR, can honestly say "we know diets don't work, but diet anyway" what's the point of the last part of that sentence?
As for classifying obesity in general - instead of classifying it, I'd rather get rid of it altogether. I'd be willing to bet that, if doctors completely ignored the "obesity" part of a patient's medical history, the majority of those patients with problems would be able to have those problems attributed to something else altogether. I don't know if I'm expressing that clearly enough (kind of in a brain fog today).
Sigh. Another example of a doctor blaming "aches and pains" and other issues on being fat. If I was 130 pounds and had aches and pains I'm sure the doctor would try to find out why, but if I have aches and pains at 200 pounds it must be because I'm fat -- end of story. Nevermind that my main pain, my knee, started when I was 10 because I was very active and ended up with a problem that a lot of high school football players get.
I have two words for those doctors:
Cognitive Dissonance.
(Maybe we should classify them in stages based on how badly afflicted they are by CD).
I don't know, it seems like a step in the right direction for me. Moving from "Everyone who isn't very thin needs to lose weight" to "people with medical conditions that are correlated to fat need to lose weight" is I think a pretty significant step, even if there's still a long way to go.
But I am disturbed that he puts depression, anxiety and psychopathology on the list as fat related diseases.
I don't think it matters how many different ways you try to classify the degrees of being fat. There will always be people who don't fit any of the classifications for a variety of reasons. I don't fit any of them, simply because I have good numbers as far as blood sugar, blood pressure, and cholesterol, but I have physical problems that cause mobility issues (fibromyalgia, arthritis, and severe lower back pain). None of those are caused by my weight, 2 of them may be aggravated by my weight, and all of them complicate exercising to improve my mobility.
Even though doctors know dieting doesn't work and sets you up to become even fatter, they are so stuck on the notion of only thin/"normal" people are healthy, that they are too ready to blame on fat any ailment a fat person has. Until that mindset can be changed, classifications don't help us, they only marginalize us (and further divide us as to bad/good/better/best fatties). That's not a place I want to be.
Shit, I had no idea my anxiety and depression were related to my obesity. Wish I could go back and tell my skinny teenage self before she did anything stupid.
Also, dyspnea after moderate exertion? What's moderate? I get a little out of breath from running up the stairs. Does that count? FWIW, I think I always have.
Still, that's a sight more encouraging than what my doctor usually tells me. Half-a-bravo for that man.
I think that this is where much of the medical establishment is with regards to fat people.
Many doctors agree (sounds like a commercial) that dieting doesn't work as a long-term strategy, but still see all of these problems that they would say are caused by fatness, and want to be able to do something about them. This doctor/researcher is the one I've heard state it the most clearly, and he also says that for most people, it's probably better to maintain health than to try to lose weight.
What Vesta says highlights the difference between where these (good) doctors are, and where fat accepting patients are: We want to say, help us to be as healthy as we can be without going after weight loss. In my experience, what doctors hear is "this patient doesn't want to lose weight." What I think that I'm saying when I talk to my doctor is: "trying to lose weight directly isn't going to work for me, what else can we do?" And I think that many doctors are able to hear that better than before.
What I found intersting about Dr. Sharma was his openness -- which highlights the cognitive dissonance.
Reading his site is intriguing.
It would be fascinating to see a doctor who said upfront that losing weight isn't part of her or his agenda. If it happens as a side effect of some other treatment -- such as a treatment that results in an overall increase in mobility -- that is okay. But taking weight loss off of the table, so to speak, or at least de-emphasizing it, that would be interesting for some doctors to try. I'm sure there are some that are currently trying this approach.
I am not going to go to medical school now, and I realize that I'm so not a type-A that I probably never would have made it through medical school, but sometimes I really wish I had chosen that path.
@ Miriam: But I am disturbed that he puts depression, anxiety and psychopathology on the list as fat related diseases.
Exactly.
Without considering depression and anxiety disorder (which I have, by they way, had since my skinny early childhood), I would be classified as Stage 0. With depression and anxiety disorder factored in, I would be Stage 2. Surely no-one would contend that fatness causes clinical depression?
Another thing I find problematic is that although these Stages reframe 'obesity' according to its effect on one's health (rather than the BMI), the mode of classification assumes an inevitable progression of the 'disease'. Which, as has previously been pointed out, assumes 'obesity' has a causal relationship with the various conditions listed for the various stages (and even that those conditions cannot exist without 'obesity' coexisting). Gah.
And this is just going to become another tool to beat fat people over the head with: "Ok, you might have been at Stage 0 for 30 years now, but that's sheer luck. Sooner or later the axe is gonna drop and you'll be at STAGE 4! Booga, booga. Lose weight or die!"
@Fatadelic - It would be interesting to have a conversation with Dr. Sharma about these points (not that this is going to happen).
Bariatric physicans see mostly people who interpret their own symptoms as being caused by fatness, I would think. The "well fat" or people whose do not believe that fat is causing the problems they are having are not seeing these specialists, so I'm sure that is playing a role in his perceptions.
I do recommend reading his entire post, as some of the detail is lost in the cutting and pasting.
omg...Yoni Freedhoff. My head explodes just thinking about him. I've read his editorials and blog in the past. I almost wanted to like him, but...I just couldn't do it.
@peggynature - I know, he's close to getting it, but then, not so much.
I think it's hard when doctors see only patients who themselves believe their obesity is the problem. It would be fascinating to know what would happen if a patient went to him and said, yeah, I'm interested in exercising more and eating better, but weight loss doesn't have to be part of the equation (that's sort of what I say to my doctor when I'm in my best FA mindset).
I hope your summer is going well. I will get to blogging again at some point, I hope. There's so much to write about, and so little time, and so many others doing it so well.
Hi Peggy,
If someone came to me and told me they didn't want to lose weight, just exercise more and eat healthier, I'd be happy to have them see our dietitian and trainer and work with them on whatever it is they might want to improve.
As I've posted many times in the past, weight's personal, just as whether or not a person feels losing weight is a good idea for them is personal.
Regardless of a person's weight, I would never presume to tell anyone that they "had" to lose weight or "should" lose weight.
I think, as I believe Dr. Sharma does (disclosure - he's a friend of mine), that weight is a risk factor for many conditions. Of course risk does not mean guarantee and as evidenced by many different publications, there are absolutely folks who meet medical definitions of overweight or obese who are healthier than their healthy weight counterparts. I think too that weight contributes to many conditions and that in many but certainly not all cases losing weight can improve those conditions and that in many cases but again certainly not all, that improvements in those conditions can improve my patients' qualities of life.
You should know too, that in my practice we don't use any number goals - not pounds, body mass indices or body fat percentages. Our goal is to help people figure out the healthiest lives they can enjoy, not the healthiest lives they can tolerate because if life is only tolerable, that's not good enough.
Sincerely,
Yoni Freedhoff
Dear Dr. Yoni Freedhoff,
Thanks for your comment -- it certainly answers our speculations. Having a blog is a weird thing in that people are able to wonder about you as they would a "celebrity" even if you don't think of yourself as one.
As one of the few doctors who openly discusses these issues, it's great to hear what you have to say on your blog and here.
I do appreciate reading Dr. Sharma's blog and yours.
I did post a comment or two on your blog, myself. And I wish more physicians shared your perspective on assisting people in figuring out the healthiest lives they can enjoy (not only tolerate).