New York Times Gets it All Wrong

BMI Graphic FinalA fairly terrible article appeared recently in the New York Times. The article, which I’ll not be linking to lest I give them traffic I don’t think they deserve, asked the question “should obesity be considered a disease.”

Now, I would be thrilled if the authors were asking questions like – “how can [weight in pounds] x 703  divided by [height in inches]2 be a diagnosis for a disease?  Or, if that does constitute a disease diagnosis, how will we be treating Tom Cruise, Mel Gibson, people of above average height (since a squared equation in a three dimensional world skews toward “diagnosing” tall people as obese) and a good chunk of the NFL?  Or how about, “How can a body size constitute a disease diagnosis when people of that size have extremely varied health outcomes and when studies show that health outcomes are changed by behavior regardless of body size?”  Or, “How can we diagnose a group of people with a disease just because their physical appearance is correlated (without causal relation) with a higher incidence of diseases?” Or, “Why did the AMA ignore the recommendation of their Council on Science and Public Health who they themselves commissioned to study this question for a year, and who recommended that obesity should NOT be categorized as a disease?”

But no, alas they aren’t asking those questions.  They are predictably worried that a disease diagnosis might convince the big fat fatties not to try to lose weight. “Suggesting that one’s weight is a fixed state — like a long-term disease — made attempts at weight management seem futile, and thus undermined the importance that obese individuals placed on health-focused dieting and concern for weight.”

I think they do raise an important point, but not in the way they think.  To say that weight loss attempts are futile would suggest that people end up at the same weight.  While that is the experience of some, many people who make intentional weight loss attempts actually gain back more weight than they lost. So if obesity is a “disease” and weight loss is the “treatment,”  than we are prescribing something that results in the exact opposite of the intended effect for the majority of patients, with no proof that even the small majority who succeed will be healthier for it.

Here’s where someone will jump in and say that this is because people “go back to their old eating habits.”  First of all, let’s get real with the fact that intentional weight loss (whether you call it a lifestyle change, or a diet, or something else) is about feeding our body less fuel than it needs, in the hope that it will consume itself and become smaller, with the additional separate hope that greater health will come along for the ride.  I think there is good research that shows that the body has a number of reactions to this that are created with the express purpose of regaining and maintaining weight, even if the dieter maintains their habits.  I also think that in this case we have to realize that “going back to their old eating habits” actually means no longer feeding the body less fuel that it needs to complete its daily tasks.  I think that the research shows that almost everyone can lose weight in the short term, and almost everyone gains it back in the long term, with a majority of people gaining back more than they lost.  I think that the diet industry has done an excellent (and profitable!) job of taking credit for the first part of a biological response and blaming their clients for the second part.

But even if we employ enough willful suspension of disbelief to suggest that it’s true that it’s the dieter’s fault that they gain back the weight, the “treatment” for the “disease” of obesity still fails to meet the guidelines for ethical medicine  – if almost everyone with a disease who attempts an intervention is unsuccessful (with the majority actually making their disease worse)  then medical science needs a new intervention regardless of the reason.  For example, if a protocol of prescriptions is so complicated that only a tiny fraction of people is able to engage in it successfully, and the majority of people actually exacerbate their disease state by trying to follow it, then the proper course is to look for new interventions, not blame the patients and just keep prescribing it knowing that it will make the disease worse for the majority of patients.

In the meantime, if the doctor isn’t telling the patients that their “prescription” is likely to have the exact opposite of the intended effect, then they are not meeting their ethical requirements for informed consent.  Since the earliest studies on weight loss, there has not been a single study in which more than a tiny fraction of participants have succeeded at long term weight loss. Not a single study.  There is also not a single study of successful long term dieters showing that their dieting lead to better health (in fact, a study by Mann and Tomiyama showed that there wasn’t a strong connection at all.)  So, even if we buy the idea that obesity is a disease and that making obese people smaller will make them healthier, we still run smack into the fact that we don’t actually know how to get that done and that the thing that we’ve been prescribing for decades actually has the opposite of the intended effect the majority of the time.

So even if we think that being obese is, in and of itself, a disease state (and I don’t think that it is), knowing that the majority of weight loss interventions  end by making the subjects fatter than when they started, would lead to the conclusion that the NYT authors’ concerns are completely unfounded and, actually the BEST that we can hope for is that classifying obesity as a disease leads to obese people not taking part in weight loss interventions.  Not because those weight loss interventions are futile, but because they are actually far worse.

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43 thoughts on “New York Times Gets it All Wrong

  1. In the past week, I’ve had one dieting friend complain about stressing out about what to eat, one feel bad about eating an entire 10″ pizza, which was the majority of her food that day, and one (who had bariatric surgery) mention she’d lost muscle mass.

    I can’t help worrying about these people. Only two of them has lost weight, and one of them has plateaued. The surgery friend I don’t think has lost anything.

    This stuff makes me sad.

  2. If weight loss dieting were merely futile, I wouldn’t have a bee in my bonnet about it because ultimately it would do little harm to those who engage in it. But it does actively make the condition it is supposed to cure even worse, while fobbing all the stigma off onto the poor sod who thought it was going to solve all their problems.

    And yes! we need to make sure people understand that Mel Gibson is obese, Johnny Depp(!) is overweight, and most of the NBA is obese. It’s not just people who are clearly and visibly fat like me, but seasoned athletes who look like the popular perception of a fit body, too. Is anyone bewailing the impending death of Tom Cruise due to fatness? In a pig’s eye, they are! But he is obese.

    BMI = Bullshit Masquerading as Information.

    1. OOOOOH I love that definition of BMI. I wish I could put that up in my classroom… LOL.. Boy would that get me in trouble.

    2. Don’t forget NHLers and Olympic athletes. The Olympic shot putter I know (family friend) would be considered “dangerously” obese.

      And I hope you don’t mind me using your definition of BMI 🙂

  3. “BMI = Bullshit Masquerading as Information.” Thanks for that Twistie, I like it! Isstrout, that is so sad about your friends and reminds me of something that happened to me last week. I was at a monthly Fibromyalgia get together where we meet around lunchtime in the restaurant of a garden centre on the outskirts of the city. By the nature of meeting there, most of us have some kind of food/lunch, including lovely, quite large different flavour scones. There are some newer women that I don’t know that well and while standing in the queue to get food and coffee, one turned to me and said if I didn’t mind, the tag of my top was showing and could she put it back in? I said I didn’t mind either way and she then commented, “It’s ok, the size isn’t showing”, didn’t take too much notice, but was a little surprised, so i said, “I’m past caring”, but what I really meant was, “why does it matter who sees it”. It was only on the way home that I wondered if she was being bitchy as she is tall and fairly slim, whereas I’m the opposite!! I then sat down and was talking to an almost 70 year old retired nurse, who I’d got friendly with the previous month, she was sitting next to me, when she suddenly said, “Oh dear, around my middle has got a lot fatter, especially since I moved here a few months ago”. I had no idea what I was supposed to say or if I was expected to empathise/agree, so I said nothing and changed the subject!

    So even a very intelligent, outspoken ex-nurse is falling for all the crap, I give up? Here in the UK, we seem to be more and more going down the road of your country as most days,weeks there seems to be news stories, newspaper articles, TV programmes, etc., going on about “The War on Obesity”, The Obesity Epidemic” and “Changing people’s bad eating behaviour”, driving me crazy. This is on top of all the usual dieting, covering your flab/body parts, slimming you down, presuming your health/well-being is all about size/weight. It must be some big conspiracy, convinced of it?!

    Marion, UK

  4. “Go back to their old eating habits” is one of the most frustrating and untrue things I hear defenders of dieting say. I am one of those people who regained weight after two years on a commercial well-known diet plan even though I diligently kept up with the “lifestyle changes.” I was astounded that eating moderately and healthfully, while exercising 5 days a week could result in regain. No one was more surprised than me. It was devastating and really sent me into a tailspin of self-loathing, despair and hopelessness. The whole entire dieting industry is based on deceit and the fitness industry isn’t much better. They peddle a load off bull dung too.

    Thanks for this article!

    1. I also regained while still restricting. The Women’s Health Initiative, which Linda Bacon references a few times in her book Health at Every Size, showed that participants regained whether they dropped out of the program or not… and that was in a controlled setting, so there’s no falling back on “they underestimated their calories,” another favorite of the Defenders of Restriction. Their calories were being counted *for* them, by professionals, *and they still regained.*

  5. I think that the most irritating thing I deal with is how I cannot go to a gym to workout and NOT see information about weight loss/control groups, plans and such. It’s just stupid. Even when I am on the eliptical machine and watching the t.v. for distraction, there are ads all the time for diet programs. Home is no better… the couch calls to me and then I’m stuck with the ads again. I LIKE going to the gym. I LOVE the change of space and location that allows me to separate all the work junk and household chore junk that mocks me when I try to excerise at home. I just want it to be less pushy about weight loss.

  6. ON the danger of repeating mysel (I may, I am getting old as my hair shows) – yes, yes, and yes. YES – the BMI is not the ultimate standard of measuring health. YES – diets and the yo-yo-effect are not separable and YES – even fat people may not be on their way to a heart attack
    I am sorry to read that a quality paper like the NYT gets on the boulevard-bandwaggon …

    1. NYTimes is a bastion of fat-bashing. It’s Mark Bittman’s gravy train (pun very much intended) and the commenters jump right on board. One commenter actually suggested in today’s Bittman column that obese people be treated as “outlaw.” I went right for the jugular with that one, telling her that people like her are the reason why there’s been such a big jump in children under 12 being hospitalized with eating disorders. I added that people like her won’t be happy until the “outlaw” fatties are segregated out of society and into camps.

      1. When I was in college, I loved reading the book review, but loathed how much trendy hipster posturing I had to put up with to get to it. One editorialist wrote a tearful piece about the inhumanity of dogfighting one day, and the very next, a scathing condemnation of a then-current reality TV show that dared to show *fat women going on dates,* of course on the premise that little fat girls might see fat women going out, having boyfriends, exercising as a means towards ends that aren’t weight loss, and living their lives, and realize they don’t have to hate themsel… er, I mean stay in their place and accept that thin nobility gets first dibs on everyth… er, I mean “get healthy.” WON’T SOMEBODY THINK OF THE GROSS FAT CHILDREN???

        I still read the book reviews, but as a NEWSpaper, they had zero credibility in my eyes after that.

        1. PS – Oh, and this was when I was still restricting, so that’s how egregious said editorial was, that it not only failed to convince me but managed to offend me in even in my then-credulous state of mind.

            1. Because fat people are just like smokers. They have to be treated as “outlaws” to serve as a lesson/warning to others. For the children, public health, and all that other horseshit.

              1. We do not endanger the children – fat is not contagious. We do not endanger public health – it can even be debated if fat alone is endangering our own. And my manure is not clogging up somebody elses toilet, I can assure that NYT-author …

                1. Another commenter suggested: “In addition to these welcome measures, there has to be a social, cultural and psychological change that starts regarding huge portions as obscene, obesity as unsightly, and sugar- and fat-laden food as disgusting.”

        1. My comment was finally posted:

          “What crimes have fat people committed to justify their being treated as “outlaw?” To use your comparison to smoking, smokers smoking in public spaces subject others to breathing polluted air. Fat people being fat in public … what? Forces skinny people to mainline bacon drippings?

          “And what does being treated as “outlaw” mean? Discrimination in employment, shaming and bullying by condescending and bigoted know-nothing elitists, mistreatment by the medical community? All that already goes on, and, by your own admission, it hasn’t worked because there are still fat people out there.

          “Ignorance and bigotry like yours are part of why there has been a more than 100 percent increase in children under 12 being hospitalized with eating disorders in the last 15 years. Because self-appointed body police like you would rather see kids dead or emotionally hobbled for life than have them be fat.”

  7. I was very depressed by the NYTimes article.

    Last week I went to a new endocrinologist to try to get some answers about my thyroid. Three years ago another endocrinologist (who wouldn’t listen to any of my questions) reduced my thyroid medication. Since then I’ve felt increasingly lethargic, my hair has become noticeably thinner, my voice is hoarse, my skin is rough etc etc etc. And incidentally, I’ve gained 30 pounds in that same time despite eating healthily and exercising. I’d held steady–fat, but stable!–for several years previously. For all these reasons, I think my thyroid is under medicated and the reviews I read online of this doctor said he would listen, is willing to look beyond one blood test, etc. I’d like to get this evaluated and treated so I can recover my energy, so my voice will be normal again, etc. I do not care if I lose weight or not.

    So I went to the new endocrinologist (a 50-mile drive away — I live in a small town). He did listen, and he seemed to take my questions seriously, and he took blood for a full thyroid panel. So far, so good. He also wants to evaluate me for pre-diabetes, since my glucose is high (about 112, fasting). I commented that I found it strange that I have been steadily gaining weight although eating my normal amount and exercising. “The difference now”, he said, “is that you’re insulin-resistant.” (In other words, insulin resistance can cause weight gain — right? Not that fat causes insulin resistance, but vice versa. Good doctor, I thought.) He said he wanted to do several blood tests (okay) to check my glucose and see if I’m truly “pre-diabetic.” I responded, “If I *am* pre-diabetic, what should we do?”

    His answer: “We will get you on a weight loss diet.”

    Okay, my friends, I admit I didn’t play this right. I should have said “Wait one goddam minute right there, buster!” but I was so taken aback–and slipped so easily into old habits–that I didn’t. When he started telling me details I did push back– “Added sugar is the main culprit.” Me: But I don’t add sugar to ANYTHING I cook.” Him: “Watch out for packaged foods.” Me: “I don’t eat them. I’ve cooked almost everything for myself for nearly 4 years now, to control my sodium, and I cook from scratch.” Him: Watch out for simple carbohydrates. Me: I don’t eat white bread, I have a potato about once a month, etc. Him: You may be eating too much fruit. Me: I actually eat very little fruit, about two apples per week.

    At that point, he said, “Well, let’s wait and see what the blood work says and then we’ll try to identify the problems in what you’re eating.” So now I’m waiting to hear the results.

    What I’m thinking I’ll do, if he tells me I am indeed pre-diabetic and need to get the glucose down, is to say something like this: “Doctor, I am completely behind getting my glucose levels down. I am very willing to work on that in any reasonable way you can suggest. But as YOU YOURSELF SAID, fat doesn’t cause high glucose levels but is a SYMPTOM of insulin resistance. And I am just NOT going to approach this through a “weight-loss plan.” I don’t freaking care if I lose weight or not. I care about not becoming diabetic. And hey, how about telling my what my thyroid is doing, since that’s what I came to you to talk about in the first place?”

    I’ll also give him the history of my weight cycling (don’t want to go into it here through fear of triggering) and how “dieting” has always, inevitably, left me heavier three years out than I was when I began.

    Sorry this is so long. But it is SO discouraging to hit the same old brick wall with a doctor I had high hopes for — and it was discouraging to hear myself not immediately having the strength to fight back. I’ll be very grateful for any suggestions for how to deal with this if he does “prescribe” a “weight-loss diet”.

    1. When my doctor’s nurse suggested weight loss and physical therapy to treat my arthritis, after arguing that diets don’t work, I finally said, “If you can find me a diet plan where a large majority of the participants lost over a hundred pounds AND kept it off for the rest of their life, I will stick to that diet… but there isn’t one, so stop talking to me about my weight.” “Then you won’t do physical therapy, fine.” Uh… sorry, starving my body has nothing to do with physical therapy, I’ll do that until the cows come home. And she kept taking me saying no dieting to mean no physical therapy. She just couldn’t resolve the idea that someone was willing to do exercise but not willing to starve themselves at the same time.

      I was amused my doctor tasked her nurse with talking to me about it though, because when I first met her, I put my foot down about it and told her I never wanted to hear a single comment about my weight and that I insisted on being treated as she would treat her thin patients, and she has actually gone out of her way to do so for 6+ years.

    2. When I bring up the subject of fat oppression I often get told that its not really happening, that I’m being too sensitive or engaging in confirmation bias. But then I read this and, yeah, it’s real, it’s happening, and no I won’t shut up about it. I hope this doc will be willing to work with you in the way you need. It’s not about special treatment, its about equal treatment. In any case and for what it’s worth, you have my support and well wishes.

    3. *HUGS* Did up Ragen’s article about talking to your doctor. I recall she had some really good advice.

      As a diabetic, I’ve been lucky that my doctor has said little about my weight. He’s always encouraging exercise though, because it is the most effective in maintaining blood sugar.

      Also, I took a class about diabetes, and in addition to watching carbs etc, it discussed making sure you have a bit of protein with meals/snacks to help keep your blood sugar stable.

      I know you already exercise and eat in ways that are best for you, so please don’t think I’m trying to tell you that you aren’t, I’m just telling you what I’ve been told.

      Insulin resistance/diabetes are both genetically based. What’s more insulin resistance definitely does make it harder to lose weight (not that you are trying to do that) so this doc’s weight-loss advice is even more silly.

      Good luck with the medical stuff. I hope you can get the help you need.

    4. I’d recommend insisting the doctor address one hormone imbalance at a time. You *know* you have low thyroid, which can cause insulin resistance ( so there’s no point in trying to manage your blood sugar via weight loss until your thyroid levels are stabilized.

      There’s a possibility that increasing activity level might help with the blood sugar thing, but the known hypothyroidism is the first thing to tackle.

      1. Thank you, everyone, for the sympathy and support. Amber, your suggestion is exactly what I’d independently decided today, thinking about it. I came home to a message from the doctor on my answering machine (yes, I’m old enough to still have one of those) saying that yes, my thryoid is low and we should treat that, but pre-diabetes blah blah blah. When I call him back tomorrow I’m going to say exactly what Amber suggests — let’s treat the thyroid, stabilize those levels, and recheck in a few months to evaluate the glucose levels.

        Again, thanks to all of you — this blog is such a wonderful resource. I realized when I was writing my earlier message that never in my life before would I have been able to say, honestly, that I don’t care if I lose weight or not, I just care about my health. But now I can say it and mean it. This is a wonderful place.

    5. Pre-diabetic, is that like being pre-pregnant? Because people who do not have diabetes are not “pre” anything. They are people without diabetes. Full stop. Just like pre-pregnant means a woman is not pregnant. These doctors and their drug-pushing lingo.

      It is great for the medical and drug industries that we are all “pre” something. They’re raking in the bucks with that con.

    6. Everyone is different in the way they react to starchy foods. I can eat potatoes in moderation with no problems, but rice spikes my blood sugar and causes me to be hungry again very soon after eating it.
      Like you, I yo-yo dieted. I yo-yo dieted up until I was 45 years old and discovered size acceptance. It took me a long time to learn that I was not the failure, the diets that I went on failed.
      Many weight reduction plans (i.e. Special K, Slim Fast) are actually very high in simple carbohydrates, which cause blood sugar spikes. It’s no wonder that people are ravenous an hour after consuming this garbage.

  8. Brilliant, as always. I’m one of those people who never even lost weight in the short term but always gained after a restrictive period anyway. I guess it’s actually good that I never yo yo’d and never experienced false hope (probably thanks to my thyroid disease). anyway, i’d love to see you also cover the article that said obese women get less than one hour of exercise in a year.

    1. That would mean we sleep day in-day out, never moving, since getting up and going the bathroom counts as exercise. It also means we are homeless, never work, and have no money.

  9. OT: Does anybody know where I can find a chart of reasonable serving sizes for children of different ages that is not saturated in the neurotic terror of making children “obese?” I am about ready to go dig up those books on day care and school lunch planning from World War II that I saw online once. Isn’t there anything more recent than that online that isn’t full of fat talk?!

    BTW, apropos to the current weather in the contiguous U.S.: If you’re stuck without heat due to utilities going down, you know what you need to do? You need to eat. Eat whenever you are hungry, and don’t stop until you are full. All of the other measures for staying alive in a modern house without heat–double-dressing, making a nest on the bed, etc.–are for conserving the heat you generate by eating as soon as your body signals the need for more fuel!

      1. Well, yes; I’m looking more at the grocery shopping end of the situation, because I generally shop only once a week and I’m tired of running out of some things while others spoil.

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