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Obesity: Lies, Damned Lies and Statistics

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With the CDC still wiping egg off their collective faces and the “size-acceptance” caucus shouting huzzahs to every media outlet that will listen, it is clearly time for something to change in our proselytizing about the risks (or, lack thereof) of being overweight. You know that an issue is unclear when even the plaintiff bar cannot seem to pick a side in the ever-growing controversy. One group of lawyers are salivating over the prospects of making the food industry the next tobacco class-action suit; the others have proclaimed the only thing to fear about obesity is obesity treatment and are still counting their booty from the “Fen-Phen” fiasco.

And make no mistake, there are some very powerful industries involved in the controversy. The restaurant industry is funding an advertising campaign even now, through their favorite non-profit – Consumer Center for Freedom – ridiculing the CDC’s flip-flopping statistics on the “obesity epidemic.” But the CDC, with long and strong ties to the equally well-healed pharmaceutical industry, refuses to silence the sirens of the impending doom. The medical insurance industry seems to be straddling the fence and remaining quietly in the background. They certainly don’t want to have the CDC to make any more rash statements like “obesity is a disease” lest they have to pony up some coverage for yet another disease.

And then there is the U.S. Department of Agriculture. Along with dealing with the awesome specter of Mad Cow Disease, they have for nearly 15 years, continually revised and redistributed our “Food Guide Pyramids” and at what cost? As far as I can see, they serve no one (save the dieticians whose audience is extremely limited) and they are not of any help to the single, working mother of 3 in Des Moines. If the money directed to sustain these “scientific advisory panels” and to print and publicize their recommendations were directed at actual research, perhaps we would be farther along toward resolving the issue.

The CDC, as it has proven, is not the appropriate agency to spend its precious resources crunching statistics and, depending on which statistical method they use, predicting that we are either doomed or, well, never mind. They are crunching numbers from an orange orchard and trying to determine how the apples will taste – it just does not work. The only thing one can say about the CDC’s humiliating flip-flop is a familiar refrain of the digital era: garbage in-garbage out. Their statistics speak only to the penultimate end-point: namely, death. They do not (and cannot) comment on the multiple comorbid medical problems that those who are obese may be faced with as they age. I will not list them here as we all have read the problems (supposedly) associated with excess adiposity in susceptible people but, as the bigfatblog.com advocates are quick to point out, correlation does not prove causation.

As a physician, (I think) I know the following:

1. Significant adiposity is a health risk to the majority of people affected.
2. Measuring morbidity from obesity, per se, cannot be done in a clear, statistically-valid way.
3. Yes, the food industry carries some of the blame for our expanding girth but there are many other pressures that also contribute to the problem
4. Yes, obese people are discriminated against but to compare this to other discriminatory struggles (racism, homophobia) is inflammatory
5. Obesity is not a problem a flawed personality and gluttony, sloth, etc. as some uninformed pundits have suggested. It has very strong genetic, sociological and economic influences, among others. The corollary being: most overweight people cannot and will not permanently achieve a “normal” weight (whatever that is this week) by simply “pushing away from the table and getting more exercise.” It is naive and unrealistic to espouse this viewpoint.
6. We are only dealing, economically, with the tip of a very large iceberg. When our ever-plumping children get into their 20s and 30s, that is when the economic burden on our society will become overwhelming.

So, what’s the solution? Just as the Framingham Study, initiated 50 years ago, we need a long-term observational study of a specific “captive” (non-transient and geographically stable) population to see what risks, over the life of a person, that obesity might pose. Just as Framingham definitively proved that cigarette smoking and hypertension shortened lives – can you believe that 50 years ago we did not know this for sure? – a longitudinal study of diet and obesity would answer our quandary once and for all. But, until the USDA stops spending money on pyramids and the FDA stops kowtowing to the pharmaceutical and food industries (as the Public Health Service once did to “Big Tobacco”) we will continue to rail against the wind.

The fundamental question – and the problem that makes obesity is so difficult to study – is that it is rarely a problem with just excessive body fat. When Framingham studied smoking risk, it was simpler. Do you smoke or not? Matched smokers and non-smokers of equal weight and height, age and sex, and watch what happens. They died sooner than non smokers. Risk found.

With obesity, excessive body weight leads (in genetically-susceptible people) to a myriad of physiological changes that compound and obscure the contribution of “fatness,” per se. For example, take 100 women who weigh less than 150 pounds and 100 women who weigh more than 250 pounds. You cannot simply watch them for 20-25 and see who dies first, as Framingham did. What is the effect of their diet? What is their effect of the activity (exercise) level? How long have they been overweight and how has their weight changed over the years? Do they go through weight cycles? Have they dieted extensively or have they been medically treated for weight loss? Do they smoke? What is their family history? What is their blood pressure? What is their blood sugar, leptin, and insulin levels? What are their lipid levels?

We know adiposity can influence all these physiological factors (and many others) which, by themselves, can effect morbidity. But, if an overweight study members develops high cholesterol, high blood pressure, hyperinsulinemia, diabetes, atherosclerosis, or dies of a heart attack, exactly what contribution did excessive body fat have on these conditions? We just don’t know.

It will require the long-term commitment that I suggested earlier if we will ever be able to answer the debate. Until then, fat-advocates (size acceptance seems to be, at least currently, more PC) will continue to rail that “obesity doesn’t kill; obesity treatment does!” and they will be partially right. The medical profession, based on still-incomplete knowledge and anecdotal experience, will continue to advise diet modification, increased activity and, yes, weight loss to control HBP, diabetes, hyperlipidemia, and other comorbid conditions. We, also, are partially right. At this juncture in time, we are all right but we are all, clearly, also wrong.

While we hurl stones at each other at this point, we all need to advocate a long-term observational study and find out the truth. All sides of the argument that are willing – the NAAFA, AOA, Council on Size and Weight Discrimination, the International Association of Size Acceptance, and other advocacy groups along with doctors, epidemiologists, sociologists, and others – should stop, at least long enough to be heard by Congress and work together to have a definitive study funded and carried out. I wouldn’t wait to be joined by the pharmaceutical, insurance, and restaurant industries or the trial lawyers in this coalition of the willing. I suspect they will prefer to abstain.

In 1948, the newly-formed National Heart Institute had strong enough public opinion (in no small part due to the death of the beloved FDR from a malignant hypertension-induced stroke in 1945) to take on big tobacco and other powerful special interest and changed forever the way we live our lives. I think nothing less will need to be done to change our opinions, strong as they are on all sides, about the possible risks of obesity and its impact (or, to be fair, lack thereof) on the lives of our citizens. Taking on the food industry, the pharmaceutical industry and others with a vested interest in this problem will not be easy, but it is high time the government started looking for answers to, at least to my eyes, what is going to be the most important health problem of our generation.

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  • http://www.elitistpig.com Dave Nalle

    Great article. What I’m curious about is the phenomenon of people who exercise and are physically fit, but still technically qualify as overweight or obese. I know a lot of people like this – mostly men – who live relatively active lifestyles, are generally healthy, are not generally what one would call fat – no significant fat on other parts of the body – but still carry substantial belly weight – enough to push them over the limit into technical obesity. These guys can run, play sports and use exercise machines with no significant shortness of breath, but no matter what they do – unless they do truly impractical amounts of running or the equivalent – they cannot get rid of that baseline 25-30 pounds of gut weight. Are these people truly at risk, because the phenomenon seems very common, and from my observations they seem to be as healthy as anyone and live just as long too.

    Dave

  • http://www.docofdiets.com dietdoc

    Dave writes: “Are these people truly at risk, because the phenomenon seems very common, and from my observations they seem to be as healthy as anyone and live just as long too.”

    Reply: Dave, you have hit the proverbial nail right on the head. No one has a clue! My guess would be that the “normal” weight (or BMI, or whatever measure we care to use) does not have anything to do with fitness. I think what we will find is that body weight is not nearly as important as fitness and aerobic capacity. I suspect that – and until we get what we need for data – our lifestyles will be a better predictor of risk than a number on a scale. But, our society being what it is, everyone focuses on that damned number. Until something definitively tells us otherwise, I am afraid we are focusing on the wrong thing. And I am quite sure we are not going to focus on anything else until something proves us wrong.

    Cheers,

    Ron

  • Nancy

    On this one I have some authority also, not as a doctor, but as one who has been morbidly obese almost from infancy. I’ve been thru every diet, drug, and procedure known to man – and then some. Had my jaws wired shut, lived on nothing but cows’ hooves (liquid protein) for weeks at a time – and nothing else – even had my stomach stapled. None of it worked. Nor was it a matter of pushing away from the table. I’ve probably spent less time eating, and eat less, than most other persons would ever consider in their worst nightmares. I’ve followed diets made out by a slew of dietitians and metabolic specialists, from private practice to NIH. None of that worked, either. On top of all this, I’ve been goaded to exercise to the point I’ve developed problems from physical overdrive. Nada. In fact, at one point I was swimming 2 olympic miles a day. I lost half a size, but gained 18 lbs. So even after 4 years, that didn’t work, either. To add insult to injury, I constantly have to bear the deliberate rude remarks of the ignorant, and the kindly meant but equally rude suggestions of the ignorant on the other end of the spectrum – including not a few insensitive idiot physicians (no slur to present company intended) who have suggested my only problem is I need to go on a ‘serious’ diet. Oh? I would have thought stomach stapling and my med. history indicated some pretty serious efforts, but I may have missed something there. Anyway, there’s my credentials.

    Obviously in my case, whatever is wrong is genetically sourced. I can say this pretty confidently, because while I suffer socially from the effects of my lifelong obesity, I am mercifully free of problems with diabetes, high blood pressure, or cholesterol. My arteries are clear as a baby’s. No family history on either side of heart, cancer, or the myriad of other problems endemic among most people. In terms of gross chemical health, I am in stunning condition, as opposed to a friend of mine, an average weight woman who is within the insurance variables for her age, height, and build, who had troubles with all of the above, just about, and family medical history to prove it.

    All that said, I must absolutely agree with those who urge weight reduction: I would almost sell my soul to be a “normal” weight – or even just 1/2 of what I am now. Not only because of the personal suffering involved of being fat in a thin-obsessed society (especially if you’re a woman), but because time and gravity – yes, gravity really does work! – ended up being the worst enemies I had. My ticker is fine; my knees are shot. Even knee replacement is not a very good option, since recovery and p.t. will be difficult if not outright impossible, as they involve physical effort I can not manage, due to my weight. I can’t breathe well because of my weight, which means walking and normal means of exercise are out of the question. Swimming might help … but we already tried that when I was young and my metabolism was a lot swifter and that wasn’t very helpful either, except to the extent it kept my muscles toned. I really had wanted to spend my life as a biped, not a bivalve. But I don’t tell all this for pity or sympathy. Forget that. That’s not the point.

    Take my word for it, as the possible ultimate authority, someone who’s lived with it all my life, fought it, and will to the very end: I have no axe to grind, I get no subsidies from the government, CDC, or any other party with an agenda; just my own personal experience and a hope that I can possible help someone else decide to avoid the eventual pain and problems overweight engenders … and don’t kid yourself that a ‘mere’ 10 or 20 or 50 lbs can be carried. Those pounds become exponential with each year you age. That pizza, that chocolate, that beer, that McBurger, that extra day of lounging in bed or convenience of taking the elevator instead of using the stairs – none of them are worth it. In my rather odd case, diet hasn’t helped much, nor exercise, but I suspect (she said sarcastically) I’m in a class of my own along with a very few other unfortunates, and nothing short of DNA therapy will help us, if that. But for everyone else out there who DOES respond to moderated diet and exercise, which is the majority of you: DO IT! Do it, do it, do it! Don’t do it for your loved ones, your enemies, or society in general: do it for YOU! Don’t wait! You don’t want to look like Kate Moss, but you sure as hell don’t want to carry a pound more than you must, either. There’s no hype about that.

  • http://www.webspawner.com/users/outwit2/index.html ConsumerAvenger

    I hope people will check out my webpage on how fast food and soda’s are formulated to be addictive and how this has increased obesity.

    I was about ten to twenty five pounds over the fashionable weight of time throughout my adolescence and adulthood. Since I was a teenager in the seventies, this means I was a normal weight but was considered to be a “fat cow” by the standards of that time. Later when I was heavier, I was more accepted after 1986 when people were glad to see you weren’t wasting away, if you remember. I suffered a lot for a normal weight not socially accepted and less for a slightly high weight later. All during that time I was fit and exercised for hours each day. I was seldom given credit for this and was scoffed at regularly if I tried to take credit. People who, for instance, went hiking with me would call me an athlete (as they struggled to catch up). I guess my point is that you cannot separate a discussion of weight from asthetics and social conditioning. I don’t feel that doctors do. All those years when I had perfect vital signs and good muscles they only focused on the fact that I was taking up more space than alloted for a woman in our society. I would never accept what the medical and scientific community say about weight at face value. “Science” and “medicine” have often been used as a means of social control.

    Now, unfortunately, I am obese due to reasons beyond my control. Having been all weights, normal to obese and spend years at each weight, I feel that if a person who is somewhat “overweight” by today’s standards (we have to specify since it changes so often) but exercises, eats right and doesn’t smoke, they can be quite healthy, probably healthier than a thin person who does everything wrong. Once you get to true obesity, it would be less likely to be healthy but it is possible. The problem is that it may be a health condition that makes you fat in the first place, that makes it hard to exercise or whatever. Or the problem could be that your unhealthy habits are making you, as an individual, fat. Or you could be fat but healthy, or kind of healthy, or partly healthy, as a thin person could be.

    The dietdoc person was deriding the size acceptance movement. I, for one, am grateful to it. I would not choose to be this weight but I deeply value the activists who went before me and made a way for me to be in this world and not be hated or hate myself, and get clothes and other stuff that I need. Thanks to everyone that did that. I did my share.

  • http://www.docofdiets.com dietdoc

    ConsumerAvenger writes: “Science” and “medicine” have often been used as a means of social control.

    Now, unfortunately, I am obese due to reasons beyond my control.

    Those are two very argumentative statements in a row! Then you go on to close with:

    The dietdoc person was deriding the size acceptance movement. I, for one, am grateful to it.

    As to the first statement, I think in earlier times, you were absolutely right; science was used as a control. But, with today’s more open society, I don’t think it can used as such a powerful control without the contrarians shouting to the hills “what’s up!” It (science) may still influence opinion – the CDC studies on onesity threat being one excellent example – but it is not nearly as effective and unquestioned as it once was.

    Your second statement, about your personal control of your weight, I am also in partial agreement. There are some very strong and very complicated psychological, physiological, and sociological factors that wrench your control away from you. It is a tough fight to achieve and maintain a lower body weight. I, from a first hand view, know the stuggle and understand, I think, the pressures involved.

    Now, I have to take issue with the third statement. In point of fact, I was calling on the size acceptance movement to voice in favor of a long term study on the real risks of having excessive adipose tissue. I attempted to poke a little fun, good naturedly, with all factions concerned – at least I tried to be good natured. They are all (science, medicine, lawyers, and size acceptance) deserving of a measure of proding. I understand, I think, the battles of the obese population and see them every day.
    I just wanted to make the point that we need to work together to get the government and medical communities to approach the problem definitively and together. Not with inuendo, junk statistics and bad science, but with a study we can all agree with. Without a definitive study over a long term observation, we – all groups – will continue to shout and slander each oither with the present cacophony. All the shouting and suspicions will do little to resolve the issue, one way or the other. We just need to know the impact of excess weight. We did it with tobacco and we can also do it, working together, with weight.

    Cheers, Ron

  • http://www.docofdiets.com dietdoc

    Nancy writes: You don’t want to look like Kate Moss, but you sure as hell don’t want to carry a pound more than you must, either. There’s no hype about that.

    Reply: Thank you so much for saying, more eloquently than I, the plain facts about carrying extra weight. We can shout (usually) useless statistics about excessive adiposity from the rooftops but, hearing from someone who is there and “living the life” makes a much greater impact. I understand size acceptance and the battles fought for acceptance and against discrimination due to size. But the movement loses me when they say that nothing really proves obesity is harmful. In my opinion, that is niave and dangerous. I personally think it is and you, clearly, do as well. The exact impact on the body might not be predictable, but the effects are there, as you so clearly describe.

    Also your point on appearance was quietly powerful. We need to stop trying to “look like” anyone, other than ourselves. We should just strive to live a healthier life. If we do that, usually (clearly not always) the other trivials will take care of themselves. I wish you well and a long life. You sound like someone who deserves one.

    Cheers,

    Ron

  • Eric Olsen

    best wishes to you Nancy, I am truly sorry about your trials and tribulations, which strike me as extremely unfair and arbitrary. Your attitude is much better than mine would be.

  • Nancy

    Even with the problems I’ve got I’m still way better off than a lot of people I know, therefore I’m not crying for me at all. But I DO want to warn off those who think that an extra few lbs now is nothing to worry about. Yeah, it is. I know it’s like talking into a black hole to try to tell this to most people, who always figure ‘well, that won’t happen to ME’. Yeah, it will. Trust me: GRAVITY WORKS. There’s no bucking the laws of phyics, and cartilege (sp?) does not renew itself or heal, unlike most other body tissue. The nice thing is, losing even a few lbs, eating correctly, and getting a little gentle exercise (one needn’t turn into Lance Armstrong) is beneficial even when you’re older and decrepit. Every little bit helps. So park your car at the far end of the row at the grocery store, instead of looking for a space next to the door. A friend of mine lost 10 lbs in one year just doing that. For most of us, it truly doesn’t take much, and healthier really is happier!

    This writer is not subsidized by the CDC, jeans designers, airline seat mfg. companies, or Weight Watchers. ;)

  • http://paperfrigate.blogspot.com DrPat

    The big difference between smoking and dieting is that you don’t need to smoke to stay alive. You DO need to eat.

    We all have powerful built-in motivations to eat the exact types of food that are bad for us, developed during aeons when these comestibles were rare and filler-food (low in nutrient value, high in fiber) was what we could find daily.

    How ironic that drives we evolved with as survival mechanisms are now killing us!

  • http://www.elitistpig.com Dave Nalle

    Breatharians would disagree with you, Dr.Pat. Apparently they have no need to eat at all. See http://www.breatharian.com for information on their crazy philosophy and photos of some astonishingly thin people.

    Dave

  • http://paperfrigate.blogspot.com DrPat

    Lots of loons out there! I actually met a breatharian once in Boulder, CO. He had just “converted” a few months before.

    Did I mention I met him the hospital? He was flat on his back. Apparently a vein-fed sucrose solution was within his precepts; but a Big Mac was not.

  • http://www.docofdiets.com dietdoc

    DrPat writes: How ironic that drives we evolved with as survival mechanisms are now killing us!

    Reply: I find it equally ironic that the same genetic mechanisms that allowed our ancestors to survive times of famine are now, in the “target rich” food-on-every-corner environment of today, causing us to gain weight. Our bodies are only responding to what generations have selected out as a favorable gene, i.e. the gene(s) of metabolic efficiency. Mother Nature does have a distinctly wicked side to her. And, additionally, genetics can be a cruel taskmaster.

  • http://murasaki.blog-city.com Purple Tigress

    Evolution is one thing, but scientific progress is going so fast, I don’t think humans have evolved or changed their lifestyles to compensate.

    In my mother’s or grandmother’s time, you could eat a lot more because you walked a lot and my mother worked on a farm. Judging from the sewing machine my grandmother had, women of those times used a lot of energy sewing. Likewise, women used a lot of energy making food (beating, kneading and chopping by hand), cleaning and doing other chores–even letter writing.

    In a hundred years, modern machines have saved us time and also saved us from using calories.

    In my current medical state, I cannot drive. So I walked about five miles (round-trip) on Sunday to go to a flea market and cabin-fever.

    A simple trip to the market is more time consuming but also consumes more calories.

    Of course, I hesitated to comment before because by BMI standards, I am underweight and weigh myself almost every day. I’m not anorexic. But I have watched other people eat and see them make bad choices or rationalize bad choices.

    There’s a certain amount of discipline required to stay fit and at an ideal weight. Body metabolism helps, but life choices (eating habits and exercise) make the biggest difference IMHO.

  • Brian

    Good article.

    One thing that is completely ignored in most articles is the use of steroids, growth hormones and other “agricultural aids”. Ever notice that when farmer brown started injecting his cattle and they got big really fast that our cancer incidence skyrocketed, the fertility rates declined and all kinds of unusual things like 6-10 inches of increased average height and big weight problems started?

    Pesticides on fruits, vegetables and in our ground water. Contamination from the fertilizers made with chemicals that kill — They all contribute to the problems.

    McDonalds might be bad for you, but it is the most affordable meal for the poor. Where did obesity come from? The big corporations forcing the poor to eat the garbage they make lrage amounts of money from and then offering them “supersized for a nickel more”.

    Poverty is creating obesity. Lack of time for the poor working 2 jobs to pay the rent means McDonalds for the kids, breakfast, lunch and dinner. Don’t criticize people for bad choices that are advertised down their throats by corporations wanting to increase their bottom lines and wallets.

  • http://www.docofdiets.com dietdoc

    Purple Tigress writes: “In a hundred years, modern machines have saved us time and also saved us from using calories.

    Reply: Hopefully, my last irony: in order to get more exercise, we will have to reverse engineer our cities and suburbs. We will have to make stairwells more inviting, build bike and walking paths, and make walking and other forms of exercise more convenient.

    No, our genetics has not changed – our activity levels and food access (and choices) have. We have engineered our lack of activity – our “lifeless lifestyle” – and, with it, changed the human dynamic – for the detriment of our health. Such is mankind – one big trial-and-error experiment. And the leisure lifestyle just ain’t working!

  • Nancy

    Brian’s comment is something I’ve been mulling over for some years now: the corporate conglomerates’ wholesale and reckless use of additives of sundry sorts in any and all food products. I would be very interested to know if anyone has ever done a study of persons raised and living on strictly ‘natural’ (i.e. not necessarily organic, but not having additives or antibiotics added) foods, if there are such people, vs. the average consumer: weight stats, disease and morbidity stats, etc. I’m pretty sure there would be a correlation, as Brian surmises. All this junk created by megabusiness and shovelled onto a willing public must have some influence on the rising adverse figures regarding public health. Any of you docs hear anything about studies like this? Have there been any done by any organization without an agenda of some kind?

  • http://www.docofdiets.com dietdoc

    nancy writes: I would be very interested to know if anyone has ever done a study of persons raised and living on strictly ‘natural’ (i.e. not necessarily organic, but not having additives or antibiotics added) foods, if there are such people, vs. the average consumer: weight stats, disease and morbidity stats, etc.

    Reply: Probably be hard to find someone – anyone – who would be the control subjects in that, Nancy. But, you’re quite right, as is Brian. We ain’t eating food as it was intended to be, that’s for sure.

  • http://murasaki.blog-city.com Purple Tigress

    If you are looking, you can find lovely walks. If you get out your bicycle, you can take a lovely ride when you just need to pick up a few items.

    Having lived in London, Tokyo and Los Angeles and visited NYC and Paris, there are plenty of lovely walks–even in downtown Los Angeles.

    Some of us don’t mind stairs and even find it a challenge. Of course, if you live in an area where there is an extensive subway system, you do have to walk.

    I don’t think cities necessarily need to be re-engineered. I think people need to take responsibility for their lifestyle and choices.

    I take the stairs. I don’t have a weight problem.

    As for the other comment, let’s not blame McDonald’s for obesity. Why take a double quarter pounder with cheese when a cheeseburger would do? Why eat so much meat at all?

    Not everyone who is poor is obese and not all the obese are poor.

    At my work places, I’ve often seen people choosing a donut over a bagel or taking two donuts when surely one would do or choosing fried food over baked or having a lot of butter instead of none or a little.

    I just came back from a walk. I’m not permitted to do stairs until sometimes later this month though.