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.