Fat and Health
Big Liberty has already covered this on her blog, but I wanted to add a note about it here, too.
HAES advocates keep saying over and over again that weight isn't the real issue. If you have an issue with cardiac risk factors, then it's best to address those risk factors by tweaking your habits and, if necessary, using drugs. The same is true if you have an issue with high blood sugar. Control the blood sugar, and let your weight do whatever it's going to do in response to any changes you make. The number on the scale isn't the main issue.
Now, there's a study that strongly supports that view. It's a high quality analysis of population level data.
Anthony Jerant, Peter Franks. “Body Mass Index, Diabetes, Hypertension, and Short-Term Mortality: A Population-Based Observational Study, 2000–2006″ J Am Board Fam Med July-August 2012 vol. 25 no. 4 422-431
If you follow the link above, you'll find that the entire text of the study is available for free.
In analyses not adjusted for diabetes or hypertension, only severe obesity was associated with mortality (adjusted hazard ratio, 1.26; 95% confidence interval, 1.00–1.59). After adjusting for diabetes and hypertension, severe obesity was no longer associated with mortality, and milder obesity (BMI 30-<35) was associated with decreased mortality (adjusted hazard ratio, 0.81; 95% confidence interval, 0.68–0.97). There was a significant interaction between diabetes (but not hypertension) and BMI (F [4, 235] = 2.71; P = .03), such that the mortality risk of diabetes was lower among mildly and severely obese persons than among those in lower BMI categories.
Yes, not only were even the highest BMIs only weakly associated with excess mortality, fat diabetics are less likely to die than thin diabetics. This study also found that people with BMIs under 35 do not have an elevated mortality risk at all, not even when diabetes and heart disease aren't controlled for.
Once again, I'm just putting this out there.
Diabetes, real diabetes, is a health condition that needs to be carefully monitored and controlled. The repercussions of not doing so can be pretty horrific.
However, what the hell is "prediabetes," and does it really mean anything? Is it just a way for the drug companies to make basically healthy people into patients and increase profits? It has to be asked.
Phamawatch Canada is asking, in "Manufacturing Diabetes":
The diagnosis of pre-diabetes is bad news for patients and their families, most of whom have no idea about all the drama in the background. But it’s also bad news for society as a whole because of the enormous costs associated with treating millions of people who do not have a medical condition. But for the pharmaceutical and diagnostic industries, it’s a great turn of events — and there’s little doubt that Big Pharma has influenced the lower thresholds that have been put in place.
Health News Review printed this follow-up which contains links to other articles that are exploring the question.
Diabetes is a chronic disease that should be taken seriously, but slightly elevated blood sugar doesn't have the same effects on health as full blown diabetes - and slightly elevated blood sugar levels do not necessarily continue to rise until they hit diabetic levels. Is pre-diabetes simply a conservative approach to diagnosis, or is it just a cynical strategy being used by drug companies to create more customers?
I haven't had time to watch this yet, but I'm just putting it out there for discussion. It should be interesting.
Dr. Jacqui Gingras is a HAES advocate and Dr. Arya Sharma is Alberta's leading expert on obesity. I think it's fair to say that Dr. Sharma is somewhat less enmeshed in the size=health paradigm and in social prejudice than many others in his field. I'm hoping that it's going to be a sane and reasonable discussion.
Joseph Abdulnour initially posted this on Obesity Panacea.
The YouTube intro:
Dr Arya Sharma and Dr Jacqui Gingras debate whether obesity should be viewed as a disease in Ottawa, Ontario on June 7, 2012. The event was moderated by Dr Mark Tremblay, and was supported by a Café Scientifique grant from the Canadian Institutes of Health Research as well as an event grant from the Canadian Obesity Network and in-kind support from the Healthy Active Living and Obesity Research Group at the Children's Hospital of Eastern Ontario Research Institute. To download the audio of the debate, visit http://blogs.plos.org/obesitypanacea/2012/06/13/is-obesity-a-disease-debate-r.... Video by Joseph Abdulnour.
An interesting thing has been happening lately. Some prominent doctors have started (at least occasionally) sounding like...
I go back and forth on my opinion of this. Is our message being co-opted and twisted by the medical establishment, or are attitudes changing for the better? Is the weight centered paradigm finally shifting?
Here's something very HAES-like from Dr. Rick Kausman.
Dr Rick Kausman is a medical doctor who is recognised as the Australian
pioneer of the person-centred approach to healthy weight management. Rick
has written two books including the award-winning 'If Not Dieting, Then
What?', he is the creator of a number of other resources, and has had
several articles on healthy weight management published in peer-reviewed
journals. Dr Rick is a Director of the Butterfly Foundation and a Fellow of
the Australian College of Psychological Medicine.
He talks about "everyday foods" and "sometimes foods." He talks about "weight management" rather than "weight loss" (or HAES, for that matter). Part of me is really suspicious of that terminology, but I have to admit that it would be easy to frame the same behaviors I would call HAES as weight management, since for me, a fairly stable weight - over decades - has been a side effect of HAES. And to be completely honest, yeah. There are foods that I enjoy but don't eat very often or only eat in small quantites because my body doesn't feel good when I eat them or because they're very heavy. I guess those could be framed as 'sometimes foods.'
Anyway, this HAES/weight management thing seems like it might be worth discussing. The relationship between fat acceptance and weight management is complicated. I'm pretty sure that a significant number of people in the fat acceptance movement have been below their maximum weights for quite a while, but are still fat. There are many of us that sorta kinda manage our weight the way we'd be expected to if we were thin - just listening to our bodies and striking a balance. I call it HAES and I try not focus on weight or size, but I have to admit that it's convenient to have a stable weight and I'm glad it's a side effect of HAES for me.
In the end, the difference between HAES and "weight management" can be in the intent and the focus. The two can look very similar from outside. HAES is meant to be 100% weight-neutral, but in this society, 100% weight-neutrality is difficult. Is HAES-like behavior that's conceptualized as weight management really so different? Maybe it's not complete weight neutrality that's the most important; maybe it's simply the removal of weight or BMI-based goals. If mental health, energy levels, and medical numbers other than BMI are priortized and if the goal is not to reach a certain prescribed weight, then damn. It is indeed very close to HAES, and it might help a lot of people make peace with their bodies and find ways to feel better, both physically and mentally.
Then I remind myself that "health" is a social construct that's being used as a bludgeon in our society, and that maybe the people on the fat acceptance side who have an ideological problem with HAES ("Health At Every Size") have it for exactly this reason - that it can intersect with the softer side of the medicalization of fat bodies.
What do you think?
In the series on food and food processing I started by outlining the Beloved Fantasy of a Blissful Past (1), and then laid out a Framework (2) to discuss food processing itself and how we got here from there. In this post I will talk about one of the biggest drivers in the processing of food - the cost of food to the consumer, and what it meant for the development of our food environment. I will also take this opportunity to introduce one of the writers whose work I will outline to illustrate the changes over time – Ida Bailey Allen.
Those who fantasize about our Blissful Past frequently imagine some kind of pastoral utopia, where all food is produced locally, it is fresh, and Mom and Sis spend all sorts of time at home cooking from scratch and Dad and Bud sit at the table with Mom and Sis and Baby and eat this fresh food daily. Everybody looks like Katharine Hepburn and Clark Gable or Cary Grant (conveniently forgetting Mae West and W.C. Fields – but that is how selective memory works). Ummm… Not so much. Although there has been a great deal of change, that world of agrarian subsistence farming (to the degree that it ever existed) was destroyed with the birth of the Industrial Revolution. I will state this – that foods that would fall into the following categories of food processing and manipulation (categories generally considered “bad” or “linked” with obesity by the food nannies and wags) within our Framework (4) have been with us for the last 100 years (or longer in many cases):
- Canned meats and vegetables (of all types)
- Margarine (1871)
- Non-animal shortening (like Crisco) – 1911
- Dried soup or bouillon – 1908
This is just a short list. The development of each of these items responded not only to the need for shelf stability, but it also allowed the consumer to address the issue of cost in two ways. They lowered the cost to purchase the needed food (margarine and shortening are two examples as they replace both butter and lard) and/or retard food spoilage thus allowing the consumer to “stock up” when prices are lower and stabilize the cost of purchasing the food. Implicit in their use is also convenience – a home-made broth may taste better and could be more wholesome, but takes longer to prepare than bouillon. It might be more profitable (and cheaper) for an industrial worker to use the bouillon and work more hours than to spend the time making broth from scratch. So cost is an important driver of innovation in food processing (5).
The cost of food to the end consumer is of concern to everyone, because we all eat. Some of us might eat swordfish and others might eat potted canned meat, but we all need to eat so we can live. Economists pay close attention to the Consumer Price Index of which food is one component (3). Many organizations and professions pay attention to the cost of food for operational reasons (schools to budget for school lunches, and relief organizations to budget for relief operations – for example). Historians and economists who focus on the movement of consumer prices over the years look at the cost of food as drivers of human activity of all kinds. Scientists involved with food production (whether it is agriculture or food chemistry or food preservation – for instance) focus on how they can lower food costs through the use of technology. In short, the cost of food – whether in money or effort to obtain it – is a driving force in what we as humans do every day.
For the rest of this discussion, keep the following numbers in mind:
- For the purposes of discussion here, I have held the dollar in 1935 as the constant (1935 dollars = 1 dollar)
- A family budget of $9 per week for food for a family of 4 in 1935 was the equivalent of about $148 in today’s dollars
- A family budget of $20 per week for food for a family of 4 in 1952 was the equivalent of $170 in 2011
- The proportion spent on food by a family in 1952 was about 50%.
- According to the Federal Reserve Bank of Minneapolis consumer spending on food in the lowest 20% of household income was 16.2% versus 11.5% in the highest 20% income quintile (2009)
A great many things happened to the price of food in the intervening years. In fact, the proportion spent on shelter now occupies the highest percentage of expenditure, whereas in years past it was not so. The effect of the cost of food on the American home budget, and in food and diet developments is something that can be seen very clearly in the works of one woman – Ida (Cogswell) Bailey Allen (6).
Ida Bailey Allen was born in 1885 and died in 1973. During her lifetime she produced a plethora of books on cooking and home-making (even taking into account that many were new editions of previous works). Her 50 books sold 20 million copies. She pioneered cooking shows on radio and TV. She advised women on wartime cooking during both world wars, and her opinion was sought by many on topics of nutrition and diet. She was the food editor for the Ladies’ Home Journal. She established cooking schools in her youth, and home making clubs across the nation. She was the Martha Stewart of her time, lending her name to many companies such as Coca Cola, Nucoa Margarine, and The Golden Rule foods as endorsements and by editing cookbooks distributed by these companies. Her last book (Best Loved Recipes of the American People) was published in 1973 just shortly after her death.
Now, a number of writers have mentioned her role in gender-role enforcement, while others have (dismissively, I feel) short-changed her legacy. The 60’s and 70’s were not kind to her. James Beard and Julia Child took her place in the newly-affluent national food theatre, and she was said to maintain that “good home cooking was an antidote to the rising divorce rate” (7) – unflattering words which were quoted in her obituary. People – watch what you say or someone will put the silliest thing you ever said in your obituary. All of that aside, a closer look at her oeuvre belies her image either as a corporate shill, or an anti-woman crusader for what many may have considered the way things “ought to be”. She was a woman of her time, and needs to be considered within her social context.
The primary thrust of much of her work was focused on the home economy, and the proper preparation and utilization of food. Her training as a dietitian gave her the knowledge of food, its components and its utilization in the body. Her skill as writer and speaker allowed her to convey this information in ways her public could understand.
In 1924 she recommended to her readers ( 8 ) with a family income of $1,000 to $2,000 per year [$13,000 to $26,000 in today’s dollars using the Bureau of Labor Statistics (BLS) Consumer Price Index (CPI) calculator], a budget of 9 to 10 dollars per week to be spent on food for a family of four to five people. That works out to up to $520 dollars per year ($131 dollars per week or $6,840 per year in today’s dollars). That represented 52 to 27 percent of the family’s income. Today’s proportion is 25% or less. In 1935 (9), she presents a week of menus for 4 people at $9 per week. That is about $149 in today’s dollars.
In 1952, the picture changes considerably. Consider now that World War II has come and gone, but the Korean War is in progress. The pent-up demand for goods and services (including food) is working its way through the system, and the baby boom is in full swing. Food prices rise swiftly. So what starts to happen? Foods begin to be fortified, and new foods are created. Home freezers become more generally available, and commercially-frozen foods are increasingly available. At the same time, there is a rise in the availability of “convenience foods” (pre-cut, pre-packaged, and sometimes pre-prepared). Now her family food budget for a family of four is $20 to $30 per week (up to $254.65 per week in 2011 dollars). Her target families at this time were earning anywhere between $2,000 and $6,000 per year before all deductions. ($17,000 to $51,000 in today’s dollars). Most fell in between those two extremes, but as you can see we’re talking about the same social stratum here.
Her fundamental message in this 1952 book is one that would be fresh today – cook more, eat fewer convenience (pre-cut and packaged) foods, and pay attention to your food balance for nutrition. You can eat well for less. In this book, she sets forth – as is her custom – her concepts of balancing meals for optimum utilization of nutrients and calories. Yet she introduces concepts that have become business as usual for us today. For people who have very reduced food budgets, she advises supplementation (10) with Multi-Purpose Food , a soy product which was developed in 1937 to feed those who were to be refed from starving (from either famines or war – for instance). She claimed to have served it to enthusiastic gourmets at the Waldorf. She was documented to have served meals of leftovers at the Waldorf as well. These were publicity for her as well as public service efforts. Multi-Purpose food was around until 1980.
She also advocates for use of fortified flour, Cornell Formula bread (good stuff – actually), raw peanuts, and other fortification of foodstuffs either at home or purchased. She recommends advocating for food fortification in one’s area. In her milk budget section (11) (which was ‘out of control’ – her words - in some households with large numbers of children) she advocates dried milk as well as homogenized milk and milk products such as yogurt. This is also a departure from the pattern in other books, since technology had made available different milk “formats” than were available previously. For example, she talks about irradiated milk. Food irradiation was fairly new at the time. It makes us squawk with alarm, but at the time it was seen as a way to kill bacteria and pests to protect the purity of the food. Some still see it that way and advocate for it. I’m not going to reach for a warm glass of irradiated milk, but back then it was state-of-the-art for food preservation, and whether or not it is safe is really material for someone else’s web-page (though it would make for an interesting discussion).
So, the rising cost of food through the middle of the 20th Century drove changes in the types of foods available (greater number) with new developments in food science geared to maximize nutrition per dollar spent on calories. Ida Bailey Allen was not only a participant in these changes, but she advocated for the new foods in her home-making and cooking books. Specifically, and despite her advocacy of home food preparation and reduced use of prepared (pre-cut and packaged) foods, her readers also had another driver that pushed them toward the use of prepared and/or shelf-stable foods: time. I’ll discuss that in the next post, but I just wanted to leave you a treat to share with those who refuse to believe that there EVER was processed food in the past. In 1940, Ida Bailey Allen published a book entitled Ida Bailey Allen’s Time-Saving Cookbook. In it, there is a cool little recipe for Mexican Rice Timbales. They are shown as the cover art for the book. For your enjoyment, here is the picture and the recipe. It features pasteurized process American cheese: the cheese that isnot supposed to have existed “back then”. Enjoy!
(Edited to correct odd sentence and some typos and errors)
(1) In the post entitled Beloved Fantasy of a Blissful Past I noted that fat people DID in fact exist in times past, and that the question of whether or not processed food is the prime cause of obesity today is more complex than it appears.
(2) In the post entitled A Framework for Talking about Food and Processing, I laid out the following framework for the discussion:
- The reasons why food is processed
- How food is and has been processed and a definition of foods according to their level of processing as reflected in the following categories:
- Whole, Raw Foods
- Traditionally-Preserved Foods
- Home-Canned Foods
- Home-Frozen Foods
- Home-Frozen Foods
- Frozen Whole Foods (commercial)
- Shelf-Stable Foods
- Prepared Foods (includes whole meals ready to eat)
- The Hierarchy of Foods – how today’s perception of foods as being associated with a higher or lower class within society imbues them by association with a tag of “processed” or not irrespective of reality
(4) The food nannies, scolds, and wags usually go after Prepared Foods of all types, and Shelf-Stable Foods as their chief diet malefactors.
(5) War, as discussed previously, is another driver of innovation in food processing. I will likely do another post on that, because there have been some fascinating developments in the production of meals prepared for deployed soldiers.
(6) I’m a big fan of Ida Bailey Allen – I have amassed quite a collection of her books, booklets, and pamphlets. I use them for recipes all the time!
(7) From Ida Bailey Allen’s obituary in the New York Times, July 17, 1973.
( 8 ) Ida Bailey Allen, Home Partners or Seeing the Family Through. Privately printed, 1924; pp 12-13
(9) Ida Bailey Allen, Cooking within Your Income, published for F. W. Woolworth Co by W. F. Hall Printing Co. Chicago; p. 134.
(10) Ida Bailey Allen, Solving the High Cost of Eating; pp 31-33
(11) Ibid.; pp 10-16
To people who know me, it's no secret that I have arthritis in my knees and it gives me screaming fits. I went to see my orthopedist on the 14th for my yearly SynVisc shot (it lubricates the cartilage and is supposed to slow down the wear and tear). He ordered new x-rays of my knees and I got to see them - the right one is much worse than the left one, which I knew, it's the one that hurts and swells when I have to walk or stand.
I was diagnosed with arthritis in that right knee when I was 34, after I fell on it and had to have it drained because it swelled so badly (they drained almost a cup of fluid/blood out of it). In the ensuing 24 years, I've been prescribed ibuprofen, Voltaren, Naproxen, and now Celebrex. At no time have any of the doctors I've seen ever suggested physical therapy or exercises to strengthen the muscles that support my knees. They have, however, every one of them suggested weight loss. And before I found FA, I thought they might be right, and I tried their diets (and we all know where that leads, right?). I even had a nurse practitioner who suggested WLS because (according to her) no surgeon would replace my knees at my then-weight of 350 lbs (and I believed her, did it, lost weight, gained it back plus some more, and got some lovely complications to boot).
Then I realized dieting/WLS wasn't the answer, was compounding the issues with my health, and started looking for different answers. I found fat acceptance, then I found HAES, and I started reading (what else do bookworms do when they find a subject that interests them and is going to have a huge impact on their life?).
The epiphany part of this whole story comes in when my orthopedist told me that every pound a person weighs puts 7 pounds of pressure on their knees, and that losing weight would help my knees. I told him I'd already dieted my way up to where I am now, and had WLS and "see how successful that was?" I'm thinking I have to be proactive here, he's not going to come up with any suggestions to help me, so I have to think of something, so I asked him "What about exercises to strengthen the muscles that support my knees? Would those help? Would that delay having to have my knees replaced?" Can you believe it? He actually said that it probably would, and he would write me an order for physical therapy so they could show me what exercises to do and how to do them.
Now, I've been seeing him for the last 4 years, why couldn't he have suggested this 4 years ago? That's 4 years I've not been working on making my muscles stronger, and it's 4 years that my knees have been getting worse - all because the only thing he could recommend was weight loss.
I went to physical therapy on Friday, talked to the therapist, she looked at my x-rays (I also have some bone spurs in there, no wonder my knee hurts). She gave me a list of 4 exercises to do, showed me how to do them correctly, and I have to go back in 2 weeks to check on my progress and see if we need to add more. I also found out that I over-extend my knees when I straighten them - a result of the degeneration from arthritis.
I didn't know how badly out of shape the muscles in my right leg were until I started doing these exercises - my left leg is fine, doesn't hurt when I'm done. But my right leg is another story, and I'm only doing 1 set of 5 reps right now (twice a day). As soon as the pain decreases, I'll increase to 2 sets twice a day, then I'll go to 2 sets of 10 reps twice a day.
Now, I hate exercise, I have to put that out there. I've started and stopped more exercise plans than I want to count, but every one of those plans was designed primarily for weight loss and if I didn't lose weight while doing it, well, that wasn't being successful. So these exercises aren't designed with weight loss in mind - strength is the goal, less pain is the goal - those are goals that are definitely more achievable than weight loss. That's something that should have been given to me 24 years ago, when I was first told I had arthritis in my knees - strengthen the muscles supporting the knees, and there will be less wear and tear, less pain, less need for medication. Why aren't doctors telling this to fat people? Why do thin people with arthritis get physical therapy and all kinds of other advice, but fat people with arthritis get told "Lose weight, it's all we can do."?
Another quick link.
There's a new study out in the Journal of the American Board of Family Medicine: Healthy Lifestyle Habits and Mortality in Overweight and Obese Individuals. It's from a research group at the Medical University of South Carolina. The link above leads to the full study.
Here, "Healthy Lifestyle Habits" are defined as
- eating 5 or more fruits and vegetables daily,
- exercising regularly,
- consuming alcohol in moderation, and
- not smoking.
From the abstract:
When stratified into normal weight, overweight, and obese groups, all groups benefited from the adoption of healthy habits, with the greatest benefit seen within the obese group.
This table is from page 13 of the study. At the bottom are the number of healthy habits (out of the four above) that the subjects followed. The hazard ratios along the side are the comparative risks of dying early, with a BMI 18-25 person with four healthy habits set as "1". Anything above one is a higher risk.
Two things really jump out at me. First, the more healthy habits we have, the more our life expectancy matches the life expectancy of thin people with the same habits. When we've got all four, the gap is pretty much closed. Second, it's only the fat people with no healthy habits who have a dramatically reduced life expectancy in comparison to thinner people.
This is a strong confirmation of what HAES advocates have been saying for years.
Just a quick link. Yesterday, CBC Radio's Ontario morning had a piece on HAES featuring Jacqui Gingras, a professor at the Ryerson School of Nutrition. It's upbeat and encouraging.
You can listen here.
Favourite quote: In answer to "How do you determine what is healthy for you?"
Healthy... is being able to eat according to hunger and fullness, the signals inside our bodies... our ability to move in an embodied way; to move freely, without pain... to feeling good about ourselves, trusting ourselves, trusting our bodies to know what we need.
The term “Processed Foods” is one that we frequently treat as one that is universally understood and defined, or one that is “we all know” - rather like Justice Potter Stewart’s famous phrase concerning pornography – “I know it when I see it”. Truth, however, is more complicated than that.
When one person talks about processed food, they may be talking about anything that is not in its whole state before it is cooked (for instance, white rice could be considered processed food in that context). When another person talks about processed food, they could be talking about frozen, microwave-ready meals made for the purpose of dieting. There is a lot of daylight between those two extremes. In order to discuss food and processing meaningfully, we need a new framework and an agreed terminology.
What I will do in this post is lay out the terms of the discussion – the framework for talking about food, processing, and fat. I will talk about why and how food becomes ‘processed’ and the reasons why humans ‘process’ food. I will also define the common terminology we can use to talk about fat within the context of food and ‘processing’. Finally, I will show how this coalesces into what I call the hierarchical ideas about food which become the stick with which to beat fat people.
The first beam in this framework is the definition of a processed food. What is almost always missing in conversations about “pure” or “processed” food is an understanding of what constitutes a processed food. For the purposes of the discussion over the entries in the series, I won’t take the very nerdy and picayune position that chewing food or cooking food is processing food – while technically correct it is needlessly confrontational. I intend to be as descriptive as possible when discussing a food which has been altered from its original form in any way. In that way, it will be easier to tease out which kinds of processing are meaningful in a discussion of fat and which are not meaningful. Thus a definition of ‘processed’ food is meaningless absent a discussion of why food is ‘processed’ and how this is accomplished.
The Means of Processing Food
For as long as humans have been on Earth, foods which have been altered from their raw state (whole grains or plants, milk and honey as taken from the animals that produce it, or raw animal flesh from butchered animals) have been part of the food ecosystem. They were necessary to feed and nourish people throughout the year (for example, pickling), or for other reasons (shelf stability – the food can be kept on the shelf at room temperature without getting rancid or spoiling). These methods of processing were developed in response to these needs in addition to those of averting vitamin deficiencies, feeding of military forces, and food transportation needs.
Our modern society is so far from its roots in agriculture that we frequently forget the original purpose of food preservation which was to get through bad harvests or the non-growing seasons, while also preserving vitamins in the food to prevent disease. We needed to make foods stable so that an oxcart, or a rail car, could get them from point A to point B without refrigeration to retard spoilage. In place of these very basic requirements a new need (real or perceived) has arisen (convenience and speed of preparation) which accounts for the rise of the prepared frozen meal or the convenience food.
The latter are the ones who have caused the most recent concern, yet the food scolds and wags often point to foods preserved using techniques which are old as time, and offer instead foods of which we should be suspicious. For instance, we are told we should prefer a “sugar free”, 100-calorie pack of cookies over a strip of bacon, because the bacon (in their minds) is the evil source of salt and fat.
Traditional food preservation and preparation methods are frequently unlovely, but they are most effective. Smoking and salting food go back as far as the earliest human settlements. Bacterial and yeast action give us fermentation of milk products as well as fruit and grain (think yogurt, wine, and beer). Our Asian ancestors developed tempeh (fermented soybeans), and tofu. Our European ancestors gave us bacon, and ham, and aged beef, and smoked or dried sausages. Salted and brined foods abound in Africa. Beer was brewed in Mesopotamia. White flour was developed to prevent milled wheat from going rancid in a short time, and was then fortified to address the vitamin deficiency this causes. In all cases the needs of humans to preserve their food drove the development of methods that were achievable and cost effective for the time and the culture.
Canning food allowed our more recent ancestors to have tomatoes in December, but the techniques used to put food in cans trace back their lineage to Napoleon’s need to feed his army during his empire-building campaigns. Napoleon’s campaigns and pretty much every war humanity has ever fought brought about advances (great or small) in preserving food – from (allegedly) wet soybeans turning into tempeh under a saddle, to pressure-canning for Napoleon’s boys. Frozen foods (developed in the mid-20th century) offered a superior way to preserve vitamin content and fresher taste, and enabled us to have such delicacies as summer green beans in February simply by investing in a freezer and the electricity to run it.
The foods resulting from these techniques (some of which are thousands of years old) are ‘processed’ foods. All of these were around during that blissful past that commenters in my hometown paper like to bring up as having “no” fat people (I love it when they say “look at the old movies there were no fat people”). Some were around even before that, so it is false to say foods were ‘unprocessed then’. Yet, we need to find words to distinguish these foods from those that some suspect are causing ill effects in the population.
A Common Terminology for Processed Food
As a general rule, I’ll use the following words for the remainder of this series:
Whole or Raw Food : A food which is as close to its original state as possible. A whole grain qualifies, as does a raw vegetable or raw meat.
Staples: Flour, salt, sugar, butter, oil… This category can get hairy, and play a large role in this discussion. For now, anything that you would not ordinarily eat as a food without further cooking is here. Rendered fats (such as lard) are here.
Traditionally-Preserved Food: This vast umbrella term will embody food that has been salted, smoked, brined, pickled, dried, fermented (except for fermentation intended to produce alcohol such as wine or beer). Anything “potted” (cooked then packed in fat or some other medium) would be included here, as well as food products or sauces made by including microorganisms such as molds (e.g.: some cheeses). This is not an exclusive list, however, because I cannot say that I know all the means humanity has ever used to preserve food. Humanity is endlessly creative when it comes to feeding itself.
Home-Canned Foods: Food prepared and canned in the home, using any standard method. Jams are in this category, as are any foods or produce put in cans by home-canning methods. This could mean apple-pie filling or meat sauce.
Home-frozen Foods: Whole foods (such as garden produce or raw meat) preserved at home by freezing in a home freezer.
Frozen Whole Foods: These include whole foods preserved commercially by freezing and marketing as such. Your frozen raw fish fillets (not breaded or otherwise altered), and your frozen mixed vegetables fit in this category.
Shelf-Stable Foods: A lot of what we call ‘processed food’ fits into this category. You can have blue boxes of macaroni with cheese powder stuff, biscuit mixes, muffin mixes, condiments, syrups, cereal. Peanut butter is here, as are canned soups and other ‘just add water’ or ready to eat foods. If you can take it off a shelf and mix it up and eat it (or eat it straight off the shelf) it lives here. These foods tend to have a bunch of additives to allow them to stay moist, fresh-looking or tasting, mold-free, and unspoiled for some long time.
Prepared Foods: Your frozen diet food is here, ice-cream, frozen hamburgers, frozen meals of any kind, prepared pies that you buy at a store, frozen cakes… Anything labeled “processed ____ food product”… These all belong here. This is the home of another large population of foods we call ‘processed’ today. Ditto on the additives here.
I have chosen these words because they are as close to morally-neutral as I can get where food is concerned. They are descriptive, they offer information, but they are not ‘dog whistles’ for those who consistently give specific foods any kind of moral label. Yet, for the purpose of discussing food and fat, we also need to face what I call the food hierarchy.
Hierarchical Ideas about Food
The second beam in the framework is an understanding of the Food Hierarchy which rules the public discussion about food. Understanding this hierarchy and how it works is important in separating fact from fiction and prejudice. This hierarchy of foods has taken hold of people’s imagination, and reflects perfectly the societal views of poor people and fat people and this is where we run into trouble. Foods, even if they belong to any of the ‘processed’ categories listed above, can be considered (magically) morally correct or morally suspect by their identification with either the “rich and thin” or the “poor and fat”.
When I read any article by specific food or health writers in my hometown paper, and also read the comments by fellow readers, I am struck by the implicit hierarchy that has developed, and that many have brought up in BFB and other blogs in a variety of contexts. I read these articles between the lines and I find the prejudice pretty easy to spot. For example:
• Why is tempeh superior to cheese? A food wag may tell you that tempeh is a vegan option which has protein and low fat and is kinder to the earth than cheese (which requires the existence of a cow). He or she will also tell you that it won’t make you fat and/or that it will help you lose weight (neither of which are true). The first objection actually makes sense, provided you are vegan or vegetarian (or want to be), and that you like tempeh (I don’t happen to, but many do). The second is just fat hate disguised as concern.
• Why is a Serrano ham superior to sliced ham? Both have been treated with salt, but one is an artisan ham. I think a Serrano has the superior taste, but I will also argue that someone else might possibly prefer a sliced deli ham and that preference is just as valid. A good whole Serrano will cost you well over $1,000 (and a good bit of that is importation cost). You need to be pretty well off to eat Serrano on a regular basis. This is less true of commercial ham products like sliced deli ham. Still, a Serrano ham sandwich on a good piece of baguette won’t send a food snob to bed with the vapors, but sliced ham on white will – and you will be told you will get fat for eating the second option. Even so, each is still a ham sandwich (much as I adore Serrano, I have to admit this).
Now, don’t get me wrong here. I’m not a great fan of tempeh, I like cheese, and I like both types of ham, and I appreciate the qualitative difference between the options. None of this is about the foodstuff in and of itself. It is what the foodstuff symbolizes in the minds of the writers and wags who are forming opinions about food, and particularly food that has been prepared or ‘processed’ in some way that is associated with a lower class of society. Somehow the cheese (particularly inexpensive cheese that is accessible to poorer people) or the deli ham becomes a symbol of that which makes people fat, it is “processed”. Then, in a feat of cognitive dissonance that would rival Superman leaping tall buildings, the more refined expensive foods seem to lose their ‘processed’ nature by association with the thin and the rich, even if a given cheaper alternative does not contain suspicious ingredients that adulterate the food and could conceivably cause a problem.
So now, I’ve set the framework that we will use to talk about the different types of food processed in different ways. I’ve pointed out the food hierarchy that serves to confuse the issue and reinforce stereotypes and societal prejudice. Next post I will talk about the changes we have seen in food preparation and preservation over 100 years, how some of that came about, and what that has meant for fatties.
In the meantime – are there any other categories we should consider? Would you have more categories or fewer? Would you describe them differently? I’m looking forward to hearing your ideas.
(Edited to correct a grammatical error -- I'm sure I will find more of them - and my husband did find another typo)
This post is a follow-up to The Edmonton Staging System: Post 1, Basics.
The stated purpose of the Edmonton Obesity Staging System (EOSS) is to predict early death and disease in fat people. It's an attempt to define clinically significant "obesity" without resorting to BMI. But, the conditions it's based on aren't necessarily causally related to weight, so it doesn't really disassociate obesity from BMI. Instead, it associates the diseases of ageing with weight when they occur in fat people. People with BMIs under 30 won't be classified according to the system, even if they have the diseases and conditions that define the stages.
Every disease that kills fat people kills thin people too. Thin people get type II diabetes. Thin people can have high blood pressure, high triglycerides and high cholesterol. Thin people get heart disease and die of heart attacks, all while having BMIs under 25. Many fat people never develop diabetes and/or begin to experience the diseases of ageing at the same time of life that their thin peers do. However, when fat people begin to experience health problems as they age, the Edmonton Obesity Staging System will associate those problems with their weight and consequently weight may be treated as the root cause.
The structure of the EOSS suggests that any health problem that's correlated to higher weight is part of a progressive syndrome called "obesity." In reality, causality is always more complicated than that. For example, family history may play a more important role than weight in diabetes and heart disease, and joint problems may be partly or entirely due to injuries. These factors shouldn't be ignored when another risk factor (high BMI) is present. The way the staging system is structured implies that fat people will inevitably advance within its framework. Conveniently, that's usually true. Why? Because the conditions and diseases associated with a high BMI are also associated with ageing. Almost everyone, fat and thin, moves through the EOSS stages as they age. However, fat people don't inevitably move through them more rapidly. There are fat people who stay at stage 0 or 1 for many decades: 30, 40, or 50 years. An unusually large body is not a progressive disease.
It's not all about weight. If weight were the main factor in health and life expectancy, then we would be seeing much bigger differences between fat and thin people in mortality and morbidity. Hell, thin people would live forever. In reality, fat people don't necessarily die earlier or use significantly more medical resources than thinner people. Maybe the EOSS is partly an attempt to resuscitate the weight based health paradigm in the face of evidence that body mass index (BMI) doesn't do a very good job of predicting mortality or morbidity for individuals - or even populations, except at extremes.
I don't want to get down on the doctors too much. They're not the only ones responsible for the weight based paradigm. In fact, I'm pretty sure that the medicalisation of body size arose in the early twentieth century largely as a response to women's demands for thin, fashionable bodies (and that's a series of posts - or a book - in itself).
To be fair, we're weird here at BFB and in the fatosphere. We're fat people who accept our sizes and want our doctors to do the same. But we are not the majority of fat people.
Many (perhaps most) fat people are desperate to get thin at any cost because of the social stigma, blaming and shaming they're experiencing. Doctors are usually happy to provide "health" as an excuse. The problem is, there is no safe, effective way for most people to lose a significant amount of weight permanently. Every weight loss treatment - from yo-yo dieting to pills to weight loss surgery - has a (sometimes devastating) impact on quality of life and carries significant health risks. The Edmonton Obesity Staging System provides doctors with a way to say "no" to dangerous weight loss treatments for healthy fat people. Why would you provide someone with a normal life expectancy with surgery that could kill her or pills that could damage her heart? This is actually very sane.
The problem is that the staging system creates categories for "good fattie and bad fatties" - it makes healthy fat people into exceptions. However, everyone is going to turn into a bad fattie as they age and nobody, whatever their age or state of health, deserves to have their health problems blamed on their weight and potentially be told to "lose 100 pounds and call me in the morning."
So, if the EOSS is meant to protect healthy fat people from dangerous (and expensive) weight loss treatments based on a rough cost/benefit analysis, then so be it. I just hope that nobody is intending to use it to limit access to treatments for health conditions that are correlated to high BMIs ("hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, and anxiety disorder"). Even when the statistics say that a person's BMI is increasing their risk of disease or early death, it doesn't say anything about causation and it doesn't mean that weight loss will have any effect. Sometimes the condition is responsible for the high BMI, not vice versa. And in any case, everyone deserves good medical treatment regardless or what they weigh and regardless of whether or not they lose any weight.
I think all fat people would agree: if we experience a health problem, we'd like our doctors to use the same treatment plan that they would if we were thin. Even people who think that their weight is a problem that can be fixed still don't want to be denied treatment based on it.
Instead of providing a blow-by blow of the research behind the EOSS and the media coverage of it, I'll leave the links with you. There's a lot more analysis that could be done, here. Hopefully these links will help anyone who's interested in following up.
Dr. Sharma's Blog
These are some of the main posts on the Edmonton Obesity Staging System. There are more.
- February 11, 2009: Edmonton Obesity Staging System
- July 28th, 2009: Obesity Classification: Time to Move Beyond BMI?
- August 15, 2011: Setting The Stage For Obesity Staging
- August 16, 2011: Health Is Not Measured In Pounds
- August 18, 2011Should Causality Matter In The Edmonton Obesity Staging System?
- August 19, 2011: Can The Edmonton Obesity Staging System Better Guide Indications for Bariatric Surgery?
- August 22, 2011: Can The Edmonton Obesity Staging System Provide A Path For New Anti-Obesity Drugs?
- August 25, 2011: Public Health Implications of the Edmonton Obesity Staging System
- August 26, 2011: Moving Forward With The Edmonton Obesity Staging System
- September 5, 2011: Bariatric Surgery For Osteoarthritis Of Hips And Knees?
- October 8, 2011: Clinical Assessment: Edmonton Obesity Staging System
- October 21, 2011: Should EOSS Guide Access to Obesity Surgery?
The Arya Sharma article: Using the Edmonton obesity staging system to predict mortality in a population-representative cohort of people with overweight and obesity, August 15, 2011.
The Steven Blair article: Edmonton Obesity Staging System: association with weight history and mortality risk, August 24, 2011.
And... here's the press coverage. The source for these articles will have been this press release from Canada's National Research Council, entitled "System lets health providers better predict which obese patients are at risk for death – and which ones don’t need to lose weight at all"
- Vancouver Sun: Heavy but healthy? New formula slims down definition of dangerously obese.
- City News, Toronto: BMI Not Enough: Edmonton Staging System Gets To The Heart Of Obesity
- Time Healthland: Study: A New Measure of Obesity Helps Predict Early Death
- National Post: Fat not necessarily fatal, new studies find
- CBC News: Obesity score helps predict death risk
Some time ago, speaking of matters of fat with someone very dear to me, she said something that gave me pause. We were discussing, in general, the Keys starvation experiment in Minnesota during World War II. You can find information on it here. I noted the absolutely princely number of calories allowed to the subjects compared to what dieters (particularly women) are permitted today. She was unaware of the studies (I sent her links later), but then she brought up that perhaps food was more pure and less processed then (with the implication that it was less fattening).
I get where she was going with that. High-Fructose Corn Syrup wasn’t around then (although corn syrup as well as sorghum syrup were widely used in cooking), and neither was Aspartame; and yet, it is never that simple. In that moment I felt like was like contemplating an onion, with its many layers, or the bulb of a tulip, planted for Spring. I wish we had been able to continue the conversation. That statement contains within it a very modern fantasy which contains some grains of truth. This fantasy, in the hands of the fat-hating intelligentsia and food cognoscenti (as usual) can become yet another stick with which to beat fat people just for existing.
I have kept thinking about the phrase since then and, as I keep reading fat-hating food and health articles and comments in My Hometown Paper (the New York Times) I have found the name for that tulip bulb of my contemplation: The Beloved Fantasy of a Blissful Past… a fantasy of a time when no one was fat… A time when all food was local and pure and unspoiled… A time when people ate their ethnic foods and the evils of the Western Diet were yet to claim their victims...
That time has never existed. It has no more existed than some alternate world in which elves and humans coexisted in perfectly magic harmony. It is a beloved fantasy which feeds the delusion that all ills can be cured if only we could go back to some never-specified time when these ills did not exist. In this fantasy, if only our food were more pure, more local, all cooked at home, and to paraphrase the words of Edina Monsoon (in Absolutely Fabulous) so fresh and organic it still has composted horse manure on it, we would stop being fat and all of our problems would go away (1). Our food would not be as fattening.
We cannot go back to a time that never was. Fatties would not cease to exist if one could only stop grocery stores from selling sugared cereal, or if a given fast food joint refrained from using soda with high-fructose corn syrup (HFCS). There is no silver bullet. The quest to eliminate fatness by returning to that imaginary blissful past is a quest that is born to fail, taking with it the health of fat people, because we could never be nutritionally correct enough to bring it to fruition (2) . It is another baseball bat with which to smite the fatties, another way to be “concerned” about fat people’s health. Our image, our very being, is used and will be used to illustrate what happens if we eat “processed” food and we ignore the call to return to the blissful past.
The problem is these messages are powerful. They are delivered by those who have been anointed by the press as the cognoscenti. They are delivered by those whose skill at food preparation is exceeded by their ego and fat hate. They are delivered by those who place themselves upon a pedestal of “common sense” (eschewing facts) and whose opinion about fatties is sought by the media regardless of their actual qualifications. We are demonized as symbols of all that is wrong with food – but we know it never is really about health anyway.
In a series of posts I’ll be talking about food in the U.S. and occasionally from others countries for context. I am doing this because I’m tired of getting beaten by the stick of food correctness. I believe we need to look at the facts about our food culture(s) to dispel myths and to stave off the messages that come from the fantasy of a blissful past. In the same way that we look at pictures of fat people to see that, yes, there WERE fat people back then, we need to look at facts about food in historical context to counteract the moral opprobrium that a can of mushroom soup will garner from the cognoscenti.
I will draw from what I’ve learned from the impressive record left behind by American and English homekeeping authors of the 19th and 20th centuries (who were often learned in home economics and nutrition) who documented in a way that no statistic could the challenges that people had getting food on the table and how the fortification of foods along with new processing technologies and growing techniques helped our civilization to do that. I will also draw from my own experience as a person existing essentially within two food cultures, and what that has meant for me. What I aim to do with this framework is to offer into our evolving conversation a historical and cultural point of view about the American food culture as it evolved that can help dispel the myths about processed foods, while leaving room for exploring what some of the more modern developments in food processing may have reasonably have meant for human digestion and nutrition. I’ll also talk about the grain of truth that gives the fantasy its power.
In the meantime – what is your food culture and what might the term “processed food” mean within its context?
How would YOU define processed food within the American food culture?
Have you encountered the Fantasy of a Blissful Past and, if so, how?
See you in the comments!
(1) See Kate Harding’s very seminal essay on the ”The Fantasy of Being Thin” . She describes precisely the fantasy that if we could only lose weight, all the problems in our life would magically go away.
(2) A number of posts and comments on BFB, as well as a number of blogs in the Fatosphere have brought up the fact that you can be a perfect vegan and still be fat.
Some of you may have heard of the Edmonton Obesity Staging System. It’s gotten nods from size acceptance activists on social media sites because with its Stage 0 classification, it acknowledges that it’s possible to be fat and healthy and at a point where losing weight my any means necessary may not be advisable.
This is actually not a new idea. American guidelines dating back to the 1990s say the same thing. The National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity In Adults, The Evidence Report, published in 1998, only advises weight loss counselling for people who have a Body Mass Index (BMI) greater than 30, two other risk factors, and a desire to lose weight (chart, page 20). I can remember how happy I was when it first came out. It gave me something I could cite when doctors tried to push weight loss programs on me, when I had no risk factors other than a high BMI and no interest in dieting.
What is the Edmonton Staging System?
The Edmonton Staging System is chiefly intended to be a tool for rationing health care services in Alberta’s Health Care Insurance Plan. That’s Alberta’s single payer public health care system established under the Canadian Health Act.
What kind of health care services will be rationed? That's the big question. The most obvious are expensive weight loss treatments that may have a high net cost to the health care system; weight loss surgery in particular. However, this is a question that I'll revisit.
Who Designed it?
The Edmonton Staging System was developed by Dr. Arya Sharma and his colleagues at The University of Alberta. Steven Blair has also been involved in the research for the Edmonton Staging System. Dr. Blair is well known in fat acceptance circles for having done groundbreaking research for the Cooper Institute for Aerobics Research in Dallas in the 1990s; research that strongly indicates that activity level is a more important variable in health and fitness than BMI.
Dr. Sharma is a bariatric specialist and the founder and Scientific Director of the Canadian Obesity Network. On his blog, he questions the common beliefs about eating, activity level and weight, referring to the ubiquitous advice to lose weight by "eating less, moving more" as "the Nightmare on ELMM Street." He acknowledges that weight loss dieting is usually ineffective and sometimes counterproductive, long-term. However, it's important to remember that his career and livelihood are based on the idea that fatness is a disease that needs a medical cure.
Dr. Sharma and Dr. Blair may be more rational and compassionate than most people in the anti-obesity establishment, but they are not fat acceptance advocates.
So Without Further Ado, Here It Is
Stage 0: Patient has no apparent obesity-related risk factors (e.g., blood pressure, serum lipids, fasting glucose, etc. within normal range), no physical symptoms, no psychopathology, no functional limitations or impairment of well-being.
Stage 1: Patient has one or more obesity-related sub-clinical risk factors (e.g., elevated blood pressure, impaired fasting glucose, elevated liver enzymes, etc.), mild physical symptoms (e.g., dyspnea on moderate exertion, occasional aches and pains, fatigue, etc.), mild psychopathology, mild functional limitations and/or mild impairment of well-being.
Stage 2: Patient has one or more established obesity-related chronic diseases requiring medical treatment (e.g., hypertension, type 2 diabetes, sleep apnea, osteoarthritis, reflux disease, polycystic ovary syndrome, anxiety disorder, etc.), moderate functional limitations and/or moderate impairment of well-being.
Stage 3: Patient has clinically significant end-organ damage such as myocardial infarction, heart failure, diabetic complications, incapacitating osteoarthritis, significant psychopathology, significant functional limitations and/or significant impairment of well-being.
Stage 4: Patient has severe (potentially end-stage) disabilities from obesity-related chronic diseases, severe disabling psychopathology, severe functional limitations and/or severe impairment of well-being
A Few Thoughts
I'm not going to be one of the people cheerleading for this system. I have some serious reservations about the Edmonton Staging System's weight-centric view of health. It could easily be (mis)used to ration care for any type of condition that can be linked to weight, for anyone with a high BMI.
I think its use should be limited to weight loss treatments, and I think that Dr. Sharma and Dr. Blair are capable of much more insightful work. It's just a new format for a way of thinking that's been around for decades, and it reinforces the weight centred paradigm that's (ready?) epidemic in the medical establishment right now.
Next week, I'l post links to some studies that explain the reasoning behind the Edmonton Staging System and links to some posts that discuss how it can or should be used. I'll also look around for media coverage.
A report developed for the provincial government by the University of Manitoba has found that fat people are using only 15%* more medical resources than normal weight people per capita, and are not dying earlier. That is, Manitobans with 26+ and even 30+ BMIs are generally as healthy and long-lived as people whose weight is in the "normal" range.
This story has been all over the Canadian press this weekend, and I'll provide some links to the coverage tomorrow. However, I've tracked down and read (okay, skimmed) the original 200 page report.
Here's a link to the pdf: ADULT OBESITY IN MANITOBA: Prevalence, Associations, & Outcomes.
Let's take a look at it, shall we?
On the reasons for and uses of the report:
The main goal of this study was to combine administrative and survey data to provide Manitoba–specific results on the prevalence, trends, and outcomes related to obesity. These results will be used to inform public policy and program initiatives of Manitoba Health and the 11 Regional Health Authorities (RHA) in Manitoba.
On the use of health care resources by BMI:
We also investigated the relationship between obesity and the use of health care services including physician visits, hospital use, prescription drugs, home care, and personal care homes. This section, which capitalizes on the uniquely powerful health data system (the Repository) housed at MCHP, provides the most important contributions from this study. Overall, the results revealed that while the Obese group almost always had the highest rates of health service use, the differences between it and the Normal and Overweight groups were relatively small. That is, the health care system is not being overwhelmed by the demand for health services related to obesity. This finding is particularly important because no previous studies have been able to provide this kind of analysis on a large representative sample with such comprehensive data on health service use.
Furthermore, for a number of indicators, the higher rates were only evident for those at particularly high BMI values. For example, the Obese group had more physician visits per year than others, but only about 15% more overall...
...Causal modelling of health service use rates indicated that illness level was by far the strongest predictor of health service use, followed by sex, and then other factors including BMI, age, and socioeconomic status.
On the relationship between BMI and mortality:
Initial analysis of death rates by BMI value (and BMI group) revealed no systematic relationship between BMI and mortality, though the follow–up period for most participants was less than 10 years. Multivariate analysis including age, sex, and other variables confirmed that obesity does not have a significant direct association with mortality.
On the relationship between BMI and disease:
Among the diseases studied in this project:
- Diabetes prevalence and incidence were strongly related to BMI group, especially for females. Among males, diabetes prevalence was 2.6 times higher in the Obese group than the Normal group; the incidence rate was 4.4 times higher. The corresponding values for females were 4.4 and 7.5, respectively.
- Hypertension prevalence and incidence were also strongly related to BMI group in both sexes. The Obese group had rates nearly double those of the Normal group.
- Heart attack (AMI) incidence rates were strongly related to BMI for males, but not for females. Conversely, total respiratory morbidity (prevalence and incidence) was modestly related to BMI among females but not males.
- A number of indicators revealed no statistically significant associations: dialysis initiation, heart attack prevalence, ischemic heart disease prevalence and incidence, stroke incidence, and hip fracture rates...
- Cancer incidence rates were also analysed and revealed few significant associations with BMI groups...
Got that? High blood pressure is associated with being heavier, but heavier people do not have a higher prevalence of heart attacks. Could this be because of white coat syndrome or because many medical professionals measure fat people's blood pressure with cuffs that are too small? Or perhaps fat people naturally have slightly higher than normal blood pressure? All of those would result in higher brood pressure readings that wouldn't translate into a higher heart attack rate.
We've been seeing alarmist "studies" (and I use that term loosely) in recent years, purporting to show that fat people are going to bring down the world's health care systems with our high demand for services. These papers are based on wild conjecture and statistical manipulation, but a lot of people take their claims for granted. Other papers have suggested that fat people have shorter life expectancies and will therefore use healthcare for fewer years, and that may cancel out our higher rate of health care use. Nobody, as far as I know, has challenged the idea that fat people use more health care resources than smaller people. Even I would have guessed that we use more resources on average, if only because of weight loss treatments. Weight loss treatments could certainly explain the 15% higher health care use by fat people in this report.
When the Flegal study revealed that people classified as overweight are at the peak of the life-expectancy bell curve, some people suggested this was because heavier people are being kept alive through the extensive use of advanced, modern medicine. This report makes that seem doubtful, as heavier Manitobans are not using significantly more healthcare resources than lighter ones.
The real news here is that when you look at the actual statistics that are produced by a public health care system, fat people are not using significantly more health care than anyone else, and are not dying earlier either. These are notable facts, as they demolish pretty much all of the common wisdom about weight, health, and life expectancy. Not only that, they expose as myth the idea thin people's taxes and insurance premiums are disproportionately being used to treat fat people's health problems. This is important.
* note: "15% more" means that, for example, people whose weight is in the obese range visit the doctor 23 times for every 20 times so-called normal weight people visit the doctor. Not such a big difference, especially considering the fact that fat people are constantly being told that we're inherently diseased and at increased risk for this or that health problem, which would make almost anyone paranoid about their health.
Tomorrow: a look at the news coverage of this report.
Earlier this week, the Globe and Mail, arguably Canada's newpaper of record, published an article called Canadian MDs consider denying fertility treatments to obese women.
Canadian doctors are considering a policy that would bar obese women from trying to have babies through fertility treatments – provoking debate over whether the fat have the same reproductive rights as the thin.
One obvious issue is, of course, Polycystic ovary syndrome (PCOS), which according to Wikipedia, affects 5-10% of women of reproductive age. PCOS is associated with fatness and also tends to make women infertile. As is the case with every health concern associated with fatness, many people assume that fatness causes PCOS. Having known several women with PCOS, I think it's pretty clear that the causation runs in the other direction; PCOS causes women to gain weight and makes weight loss extremely difficult.
We have a discriminatory (and proud of it!) jerk in Ottawa:
“We’ve had many angry patients say to us, ‘This is discriminatory’ and I say, ‘Yes, it is’ But I still won’t do it,” said Arthur Leader, co-founder of the Ottawa Fertility Centre. The facility where he works will not treat women with a Body Mass Index (a measurement of weight relative to height) of more than 35. A BMI of 30 meets the clinical definition of obese.
...and we have a voice of reason in BC:
“You’d be denying half the reproductive population access to fertility treatment,” said Anthony Cheung, a fertility expert at the University of British Columbia and Grace Fertility Centre. “These people already know they have a problem – are you going to make it worse, add to feelings of social injustice, low self-worth, depression?”
“We don’t say, ‘Oh sorry you smoke, so we can’t treat you – it could result in pre-eclampsia, or small babies.’ It doesn’t mean we have this blanket policy where we say we can’t treat (smokers)”
Dr. Cheung says it makes him wonder about the “biases of our own society around treating women with high BMI…if it reflects a paternalistic view around obesity.”
Evidently, this is a worldwide debate:
The Canadian Fertility and Andrology Society, which recommends practice standards for the country’s fertility doctors, is not the first professional body to consider a treatment ban based on weight. The British Fertility Society recommended a ban in 2006, as has New Zealand, and it was the hot topic of debate at the European meeting on assisted reproduction in Sweden this summer.
Wow. A treatment ban. No exceptions. No case-by-case evaluation. Instead, a BMI cutoff for fertility treatments.
Arya Sharma, Canada's obesity czar, is with us on this one. However, he doesn't mention PCOS in his short post on the topic.
I think that one thing we can do to fight this is to tell our stories. I changed my mind about whether or not fertility treatments should be considered basic health care (for anyone) because a friend of mine shared the story of her and her mother's struggle with PCOS and fertility, and the fact that she wouldn't have been conceived without fertility treatments. Maybe we can change others' minds, too.
National Geographic. Did anyone else here have a vast collection of this magazine - too visually stunning and informative to throw away - on bookshelves in their basement as a kid? I used to love to read this back when my parents had a subscription, but I haven't seen one in years.
Well, they've published an article on Health at Every Size that's largely based on an interview with Linda Bacon. Health at Every Size, Live Healthy Without Dieting, by Mary Schons.
If you're already familiar with Dr. Bacon's work, then there's nothing new here. However, maybe this will help spread the word: weight does not equal health.
A press release from the ASDAH:
August 1, 2011, San Francisco, CA--The Association for Size Diversity and Health (ASDAH) is pleased to announce that they have been granted a trademark for Health At Every Size® services and materials This is the culmination of many months of patient work and planning on the part of the ASDAH Board, who are careful to stress that the trademark registration is part of an ongoing effort to keep the term from being “borrowed” by diet and weight-loss programs not in keeping with the original intent of the phrase.
“This is not about keeping the Health At Every Size® approach exclusive to ASDAH,” said ASDAH President, Deb Lemire. “Through the diligent work of many people both within and allied with our organization, the Health At Every Size® principles have come to mean something very important to people of all sizes who want access to compassionate, relevant and rational health care. We simply want to protect this phrase from individuals or large corporations who would seek to co-opt the phrase to hawk their latest diet or weight-loss program.”
The new trademark is just one in a series of proactive responses to the continued misguided public and political approach to health and weight. In June, ASDAH launched healthateverysizeblog.com featuring outspoken advocates for the Health At Every Size® paradigm. ASDAH also recently responded to a commentary in JAMA suggesting the removal of higher weight children from their homes. While the removal was proposed as a last resort, “the option should not even have been on the table,” says Lemire “when the Health At Every Size® approach is a viable and compassionate alternative.” ASDAH has drafted a policy response which can be downloaded from its website.
There's a new study that fails to support the theory that weight loss surgery cures type II diabetes. MedPage Today published an article on it, entitled 'AACE: Bariatric Surgery May Just Mask Diabetes.'
A larger study was posted on the same topic in 2009, there were earlier studies with the same conclusions, and I've always suspected that these studies are right; that WLS doesn't cure diabetes.
We all know what kind of money and influence is behind the people promoting weight loss surgery; the surgeon's groups and the drug companies that manufacture the devices. Surgery candidates want to believe that WLS is worth the risks, because they want the social rewards that come with being thin. If they have or fear getting diabetes, then the claim that WLS "cures diabetes" can be a powerful influence.
But it doesn't really make sense that WLS cures diabetes, does it?
This is how I see it. No doubt it's an oversimplified way of looking at things. I'm not a medical professional, but there are people in my family with type II diabetes and I'm at risk of getting it myself, so I've done a lot of reading.
Type II diabetes is primarily a genetic syndrome, although the easiest way to diagnose and track it is to measure blood sugar. However, if someone can't eat a normal meal - if they're basically starving - then their blood sugar is not going to be high even if they're diabetic. If a diabetic is constantly running a calorie deficit (as they would after WLS), then the fact that their cells aren't responding to insulin - which tells the cells to store fat - isn't really going to matter, because they're losing fat stores, not adding to them. Does that mean that the diabetes is cured? No. As soon as their weight stabilizes and they go back to sometimes using energy and sometimes storing it, then the diabetes will once again become easy to detect.
From the Medpage article:
The researchers also cited flaws in the 621 studies involved in a meta-analysis by Buchwald et al, which concluded that bariatric surgery was a cure for diabetes.
They said most of the studies were retrospective, single-armed, and made up of relatively young women. Also, only 1.6% of them provided Class I evidence.
Marina concluded that HbA1c and fasting blood glucose measurements aren't sufficient criteria to establish a "curing" of type 2 diabetes after gastric bypass surgery.
- The new study-
American Association of Clinical Endocrinologists, Marina AL, Trence DL "Is diabetes mellitus really cured by gastric bypass surgery?" AACE 2010; Abstract 210.
- The older study-
Roslin M, et al "Abnormal glucose tolerance testing following gastric bypass" Surg Obesity Related Dis 2009; 5(3 Suppl): Abstract PL-205.
From the Associated Press, via Yahoo News: US life expectancy surpasses 78, a new record.
This is in spite of the fact that, according to the Centers for Disease Control, 34% of Americans are classified as overweight and an additional 34% are classified as obese. And it's a horrible, scary, deadly EPIDEMIC - an epidemic that is now affecting 68% of us. Why are we not dying earlier? Where, I ask, are the piles of dead fat people?
Despite decades of hand wringing over how increasing rates of overweight and obesity are going to decrease life expectancy in the U.S., life expectancy keeps stubbornly increasing.
Is it because fat people are benefitting from advances in medicine? If we are, it's being mitigated by a lot a societal forces that would tend to damage our health.
Fat Americans are charged more for or refused health insurance. Medical professionals tend to want to treat our body size rather than caring for our health. We are more likely than average to be poor and/or members of ethnic minorities that are discriminated against. We, as fat people, are discriminated against. Large numbers of us continue to subject ourselves to unhealthy and ineffective weight loss methods. Given this, it's a miracle that as a group, we aren't causing the national life expectancy to decrease.
Aren't we fat people wonderfully resilient?
Oh! And the same thing is happening in the U.K.
There are two fat and health items in the news right now.
The first - the request from lap band manufacturers to the FDA to lower the BMI where lapbands are allowed - was covered by AndyJo in the previous post.
Another study, published by New England Journal of Medicine with Amy Berrington de Gonzalez as the first author, is being reported on in articles such as ABC New's "Higher Body Mass Index Linked to Greater Mortality Risk" and touted as "proof" that people in the 25-30 BMI ("overweight") and the 30-35 BMI (obesity type one) categories are at increased risk of death because of their weight. This study is a data dredge, that is, it's built on data from older studies that could have been cherry-picked to get the desired results. It's obviously meant to refute Katherine Flegal's 2005 study and a recent Canadian government study, both based on population-level mortality statistics and both of which indicate that people in the the 25-35 BMI range have an average or above average life expectancy.
The flaws in the new de Gonzalez study? Well, I haven't read it myself, but I'm hearing from medical professionals who have read it that it doesn't control for level of physical activity - or health insurance status (!!). It's interesting that it was published shortly before this request to expand the market for lapbands. Lucky for the lap band manufacturers, eh?
There's a great post on both studies on Suethsayings: Push for weight loss surgery even if you have a lower BMI follows study about obesity.
Health and science reporters? If any of you are reading this, please look at the quality of the research before suggesting that a data dredge invalidates large, comprehensive and well designed studies like "BMI and mortality: results from a national longitudinal study of Canadian adults" (Orpana et al, 2009) and "Excess Deaths Associated With Underweight, Overweight, and Obesity." (Flegal et al, 2005)
The Atlantic Monthly has published an interesting article in it's November issue: Lies, Damned Lies, and Medical Science. It's part of a series called Brave Thinkers, 2010 and it features an interview with Dr. John Ioannidis, who leads a team that specializes in critiquing medical studies, both qualitatively and quantitatively.
“Maybe sometimes it’s the questions that are biased, not the answers,” he said, flashing a friendly smile...
That question has been central to Ioannidis’s career. He’s what’s known as a meta-researcher, and he’s become one of the world’s foremost experts on the credibility of medical research. He and his team have shown, again and again, and in many different ways, that much of what biomedical researchers conclude in published studies—conclusions that doctors keep in mind when they prescribe antibiotics or blood-pressure medication, or when they advise us to consume more fiber or less meat, or when they recommend surgery for heart disease or back pain—is misleading, exaggerated, and often flat-out wrong. He charges that as much as 90 percent of the published medical information that doctors rely on is flawed.
We've discussed poorly designed studies before on Big Fat Blog. Studies and surveys in the social sciences are especially sensitive to design bias and data manipulation, and medical studies aren't far behind. They may have biases built into their design, and their data may be manipulated and interpreted to support the conclusion that will make continued funding most likely. Glenn Gaesser's Big Fat Lies and Paul Campos's The Obesity Myth (or the Diet Myth) do an excellent job of exploring how this has happened in the study of obesity, in particular. The dodginess of obesity research is referred to somewhat obliquely in the Atlantic article as well:
On the relatively rare occasions when a study does go on long enough to track mortality, the findings frequently upend those of the shorter studies. (For example, though the vast majority of studies of overweight individuals link excess weight to ill health, the longest of them haven’t convincingly shown that overweight people are likely to die sooner, and a few of them have seemingly demonstrated that moderately overweight people are likely to live longer.) And these problems are aside from ubiquitous measurement errors (for example, people habitually misreport their diets in studies), routine misanalysis (researchers rely on complex software capable of juggling results in ways they don’t always understand), and the less common, but serious, problem of outright fraud (which has been revealed, in confidential surveys, to be much more widespread than scientists like to acknowledge).
Now, Dr. Ioannidis's assertion that up to 90% of medical studies produce flawed conclusions seems very dire indeed, and I'm not sure what to think about it. I wonder about the details of his methods and about the scope of the analysis. Is he talking about a particularly error-prone subset of studies? Where does he draw the line between medical research and hard science?
I like data and believe that collecting and analyzing it is useful. I believe that the scientific method - hypothesis to experimentation and observation to theory- is the best way we have of understanding the universe, our world, and our biology. But Dr. Ioannidis's work really illuminates the way science can be warped by economics, by biased assumptions and methods, and by individual egos.
When journalists cover scientific studies they usually serve them up uncritically, based on press releases, often with a dash of sensationalism. And, they bring their biases to the table as well. Qualified scientific and medical journalists that look deeper, like Sandy Szwarc of Junkfood Science (currently on hiatus, but still well worth exploring) are rare and valuable. Science, especially medical science as reflected in the press, is far from infallible. It is always wise to look closely at the studies that concern you most, and at their context.
...and here's a great post on how to do the best you can with nothing but a news article to work with. Thanks, MichMurphy!