A Hypothetical Doctor’s Visit

Jasmine is waiting in the exam room and her chart shows that her weight today is up five pounds from her last visit two years ago, putting her BMI at 32. Her blood pressure was borderline high in contrast to the normal readings in previous visits. Although Jasmine’s labs were normal in past visits, they are out of date. When Dr. Johnson greets her today, Jasmine seems anxious and tells Dr. Johnson, “I almost did not come in today knowing my weight is up from the last time I was here and you suggested a diet. I feel like such a failure. However, I need help for my migraines, so here I am.” Dr. Johnson and Jasmine look at each other, there is a beat of silence, and they both sigh.

Dr. Johnson says, “You know, Jasmine, I have been reading the research on weight loss interventions and weight-cycling and I’m realizing that if the same thing happens to almost everyone, it probably is not the fault of the person, it is probably more about the process itself. So, instead of focusing on weight loss, I’m encouraging my patients to think about what makes them feel better in their everyday lives; emotionally and physically. For example, do you feel better when you eat more fruits and vegetables, drink more water, take a walk with a friend, meditate to relieve stress, and get enough sleep? There’s good evidence that those behaviors are going to make you healthier and feel better even if your weight does not change.”

Jasmine is a bit surprised by Dr. Johnson’s shift and says, “Well, typically, when my weight loss slows down or stops completely, I stop doing any of those things you mentioned that would help me feel better and be healthier.” Dr. Johnson says, “I understand, but we’re going to turn the focus from your weight to your health. Because those behaviors are linked to health, why not do them anyway?”

Jasmine smiles at Dr. Johnson and says, “It sure would be easier to come back and see you the next time I’m supposed to if I did not have to lose weight first.”

Dr. Johnson replies, “I do not want anything to stand in the way of you getting your medical care, including worrying that I might scold you. Now that we have a better plan, I am going to have the nurse retake your blood pressure.” Jasmine and Dr. Johnson then discuss treatment options for Jasmine’s migraines.

— from The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss published in the Journal of Obesity.

2013 at Living 400lbs

Most-read posts / pages:

  1. Day in the Life
  2. About
  3. Barefoot Contessa
  4. How Do You Comfort Sore Muscles?
  5. Fat Clothing Catalogs…
  6. Day in the Life: Shower, Chafing, & Jock Itch
  7. But…!
  8. Disney World
  9. What If You’re Too Big For Lane Bryant?
  10. Exercise

Some more amusing search terms:

  • unicorns are real they’re just fat and gray and we call them rhinos
  • rhetorical question about obesity
  • what size is 30/32 plus size
  • cyberspace mountain weight
  • 400 hundred pounds woman sex lessons while dancing

Some that have me rolling my eyes at the denial involved:

  • what do you eat in a day morbidly obese  — people’s eating habits vary. 
  • do all obese people have diabetes — no 
  • why don’t super obese people have diabetes — genetics, stress, luck? 

Those are outliers though.  Most people find this blog by searching for a variation of the blog name -or- on something to do with Ina Garten.  (Seriously, I don’t know why.  Maybe I need to post more about Dawn French?)   Others find this blog from links on other sites.  In the past year Shakesville, Reddit, The Fat Nutritionist, Twitter, a HuffPo post, and Fat Heffalump sent a lot of people here.

Whether you’re new here or just found this site recently, relax and be welcome.  :)

Fat Bias Isn’t Just About Rapport

As noted on Twitter, the article Tara Parker-Pope wrote for the New York Times about a study in Obesity looking at how fat patients aren’t always welcomed by doctors. Not news, though I suppose it’s good to have quantitative research supporting it.

Really, though, this is just the tip of the iceberg.  Here’s some more.

For patient stories on health professionals, check out the crowdsourced http://fathealth.wordpress.com

ASDAH is collecting videos on weight bias in healthcare.

The Yale Rudd Center is not a fat-accepting organization, but they do research on weight bias and their publications page can be very useful.

Naafa on weight discrimination.

Things to Read

A clear explanation of why  New York’s fat hatred is much more harmful than the soda ban from Melissa McEwan:

People do not die of “obesity.” Some fat people die from complications of what are commonly known as “obesity-related diseases,” like heart disease and diabetes, but those diseases have only been shown to be correlated with fat, not caused by fat. (Which is why thin people have them, too.) So it’s not even accurate to assert that obesity kills indirectly.

This, however, is a thing that is accurate to say: Fat hatred kills people all the time.

And speaking of correlation, an explanation of causation vs correlation at The New York Times makes use of a correlation between ads for junk food and fatness:

The problem is that their policy recommendations rest on a crucial but unjustified assumption: that any link between obesity and advertising occurs because more advertising causes higher rates of obesity. But the study at hand showed only an association: people living in areas with more food ads were more likely to be obese than people living in areas with fewer food ads. […] In fact, it is easy to imagine how the causation could run the opposite way (something the article did not mention): If food vendors believe obese people are more likely than non-obese people to buy their products, they will place more ads in areas where obese people already live. […]

This is not an arcane statistical point or a mere technical criticism of one academic article. Too often, relationships that are far from being understood are assumed to reflect a particular, strong causal connection, leading to no end of regulatory mistakes. 

(Emphasis added)

And from a woman’s story of getting fat after marriage:

I missed the husband who loved me no matter what, not the new anti-fat crusader he had changed into. But he felt the same way: he’d fallen in love with a plump-but-not-fat woman who wanted to be thin, and now he had a fat wife who’d “given up on herself.” And Ihad given up: given up on dieting, given up on the idea that my body needed to be fixed.

 I already wished I hadn’t spent so many years beating myself up for being fat; I wasn’t going to stay in a marriage where my husband did it for me.
The article is good, and bonus points for a photo of the author in scuba gear with the caption “Cage diving with great white sharks: more fun than dieting”.

Fat Demographics

I ran across some interesting US data from the CDC recently.

Obesity and Socioeconomic Status in Adults

It might add some illumination to the assumption that fat people are all poor.

Related:

Things to read

I think a lot of people look to exercise to help them lose weight, and when they don’t lose weight immediately with exercise, they quit. They return to the couch, and they basically never move again. What is lost in that is that fitness is almost certainly more important than fatness. — Gretchen Reynolds, promoting her new bookThe First 20 Minutes.

On the one hand, this is a bit of aduh“. On the other hand, there are clearly a lot of people who don’t get it.  From the same article:

Ms. Reynolds makes a clear distinction between the amount of exercise we do to improve sports performance and the amount of exercise that leads to better health. To achieve the latter, she explains, we don’t need to run marathons, sweat it out on exercise bikes or measure our peak oxygen uptake. We just need to do something.

“Humans,” she writes, “are born to stroll.”

While I’m writing about exercise, you may have seen references to the recent study which concluded “[h]ealthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.”  If you’re interested, the full text is here.  (I also realize that not everyone cares ;)

On a different note, Seanan McGuire has a great “Dear girls of the world today” post on her blog:

Collect dolls or knives or books or interesting rocks. Watch horror movies or romances or cartoons. Run races; go to spas. Eat cake or lettuce. Buy yourself a toy light saber and make your own wooooom noises while you wave it around; build a cardboard castle and chuck plush mushrooms at your would-be rescuers. Live your life, the way you want to live it, and understand that no one can kick you out of “the girl club” for doing it wrong, because you’re not.

May is Mental Health Awareness month:

Mental health is about more than mental illness. Please don’t hear “mental health” and just think “crazy people”, or even, more enlightenedly, “people with mental illnesses”. Health isn’t only a topic for sick people, and that’s just as true in the psychological as the somatic. — Siderea

I found this lesson in illustrating wheelchairs from someone who uses one rather illuminating.

Also: May the Fourth be with you!

Rebecca Puhl on Chris Christie & Weight Bias

Rebecca Puhl is the director of research at the Rudd Center for Food Policy & Obesity at Yale.  The Rudd Center is pro-weight loss, which can be disconcerting to run across on their website. Nonetheless, they do useful research on weight discrimination and health, not to mention writing articles for CNN on how weight discrimination affects the news coverage of NJ Gov Chris Christie.

How common is [weight discrimination]? It may seem less significant compared with discrimination on the basis of gender or race, but it is rapidly increasing and no less important. Research shows that weight discrimination in the United States has increased by 66% over the past decade. It is now the third-most common type of discrimination reported by women, and the fourth most common among men. Recent estimates even show that weight discrimination is comparable to prevalence rates of racial discrimination.

Weight discrimination is especially common in the jobs setting. Decades of research have shown that overweight and obese employees are much less likely to be hired than thinner employees (even with identical, or better qualifications), they receive lower wages, are less likely to be promoted and are more likely to be fired from their jobs, compared with thinner employees.

Criticism of Christie’s weight suggests this prejudice exists even if the job under consideration is at the highest levels of government — and it isn’t the first time. Surgeon General Dr. Regina Benjamin’s excess weight was publicly censured and critiqued in the media discussion over her appointment, often eclipsing consideration of her impressive credentials, awards and accomplishments. […]

Dr Puhl also attacks the “but what about his health” worries:

We cannot make assumptions about Christie’s health status, let alone the health status of other thinner political candidates. There are many overweight individuals who eat a balanced diet and exercise regularly; there are many thin individuals who smoke cigarettes, drink too much alcohol, eat poorly, have high blood pressure and are sedentary. Being thin is not an automatic indicator of health, and neither is being overweight. If Christie’s health status is to be scrutinized, then the health status of his political peers should be scrutinized as well.

To be clear: There is no reason to assume that a person can’t be an effective political leader simply because of his or her body weight. Discounting an individual’s credentials, training, abilities or accomplishments because of body weight is discriminatory. And it communicates an unfair, harmful message that a person’s talents and contributions to society have lesser value if that person is obese.

As a bonus, I was pleased to see that Dr Puhl did NOT say anything about whether Gov Christie should attempt weight loss  — quite refreshing in an article of this type.  Whether an individual, including Gov Christie, chooses to attempt something as risky as weight loss is nobody else’s business.  

(Even if Gov Christie attempted weight loss, he would not necessarily have immediate or noticeable results, so guess what?  Other people might not notice … and again, it’s not any of their business. )

US Obesity Rates Level Off Again?

Oh, not again.  Still.  They’ve been level for years, but this time the Journal of the American Medical Association noticed. There’s discussion as to why, such as “people are getting healthier”.  Given how dieters often gain weight in the long term, I thought this perspective a bit more realistic:

Dr. Ludwig said the plateau might just suggest that “we’ve reached a biological limit” to how obese people could get. When people eat more, he said, at first they gain weight; then a growing share of the calories go “into maintaining and moving around that excess tissue,” he continued, so that “a population doesn’t keep getting heavier and heavier indefinitely.”

That’s not what my mother told me.  She was convinced that if I wasn’t actively dieting I would continue to gain weight for the rest of my life.  Yet when I finally quit dieting my weight … leveled off.  Huh.

Furthermore, Dr. Ludwig said, “it could be that most of the people who are genetically susceptible, or susceptible for psychological or behavioral reasons, have already become obese.”

Gee, y’think?

Way Outside the Bell Curve

Per the US CDC’s Anthropometric Reference Data (PDF) 5% of adult, non-pregnant women in the US weigh less than 111lbs, and 95% weigh less than 250lbs.   90% of US women weigh between 111 and 250lbs.

This is why I consider myself a statistical outlier, weight-wise.  As I’ve noted before, in some ways I’m a freak of nature — most humans simply can’t weigh as much as I do.   And most adults can’t weigh less than 111lbs.

This article from the German newspaper Der Spiegel profiles a woman who is also far outside the average, but on the other side.   Lizzie Velasquez weighs 62lbs and was born with neonatal progeroid syndrome (NPS); she has zero body fat.   Not low body fat – zero.  Most children born with the NPS die within the first year or suffer mental retardation.  In Lizzie Velasquez’ case, her brain developed normally.  The lack of fat reserves affects her appearance, but also her stamina — she gets hungry much more frequently than other people, and shows starvation symptoms (listlessness, immune resistance) if she doesn’t eat when hunger pangs hit.  Ms Velasquez reportedly averages 8,000 calories throughout the day.

I don’t envy Ms Velasquez her NPS.  Nor do I think it’s something to joke about, any more than anorexia.   But I am glad that she seems comfortable with herself, not pining for a cure.

Deciphering studies: Absolute vs Relative Risks

I thought this example Lisa Martinez made in the comments at the Well blog was one of the clearer examples I’ve seen for absolute vs relative risks.

100 women took ABC pill and 100 women took a placebo, which is not an actual medication. Of the 100 women who took ABC pill, 2 developed cancer and of the 100 women in the placebo group, 4 got cancer. It is reported that this clinical trial showed a 50% reduction in cancer and another report states that the same clinical trial showed a 2% decrease in cancer. Both percentages are accurate and that is because the data are being reported in two different ways.

The 50% reduction was reported using relative risk reduction. The 2% decrease was reported using absolute risk reduction. It is extremely important that you understand the difference between the two when making decisions about your care. So when presented with options for chemotherapy or any treatment, make sure you ask your healthcare provider to give you the relative and the absolute risk reduction percentages.

Many publicists and news articles on the risks of weight use relative risks not absolute. As you can see, this can be a BIG difference!

Perspective: Use It Or Lose It

I recently discovered that the CDC has Anthropometric Reference Data (PDF), otherwise known as various body measurements (height, weight, waist, etc) broken down by age, gender, and percentiles.

Personally I find this data fascinating.  The height tables, for example, were a wake-up call. At 68″ tall I know, intellectually, that I’m on the tall side for a woman.  But unlike, say, jr high, I feel that I’m about average height.

Looking at the data on women age 20 and older, measured in inches (table 10) tells a different tale:

50% are shorter than 63.8
75% are shorter than 65.6
95% are shorter than 68.2

Huh? I’m taller than 95% of women?  Since when?  (And why are “regular length” women’s pants aimed at someone 67″ tall and “petite” for someone 64″ tall?)  My brain was actually boggled by this.  Do women grow taller here?  Then I realize: I work in … software. I work mostly with … men.  Men tend to be taller.  Oh.  I skipped down to the  data for men  (table 12) and realized that’s where I usually compare myself:

25% are shorter than 65.6
50% are shorter than 69.4
75% are shorter than 71.5

Oy.

There’s the weight table.  Again, all US women age 20+ in pounds (table 4, pregnant women excluded) shows that 85% of women weigh less than 207lbs.  (95% weigh less than 250lbs.)

Of course, the census estimates that the US also has a population of 304 million and that by 2010 there will be over 120 million women age 18 and over (PDF).   Even if there’s only 100 million adult women that’s still 15 million women, which means that Oprah is not alone.  But it does help me understand why she freaked out about weighing 200lbs.  Or why people have no idea what 300lbs looks like.