The third option.

Cross-posted to Shameless.

break50

Two days ago, there were rumblings. First, I heard that the American Medical Association’s science council had advised them against declaring “obesity” a disease.

My initial feeling was one of mild surprise – hadn’t they declared it a disease already? I honestly didn’t know, but given the way our culture and our doctors treat fat people – as diseased, as a burden on society, and possibly doomed to explode of sheer fatness – I would’ve assumed they had.

My second feeling was lack of surprise that the science council, after examining the evidence, was recommending not to declare “obesity” a disease, because everyone knows that the diagnostic tool used for defining “obesity,” the Body Mass Index, is too blunt to be used in the absence of other health indicators, right?

And because everyone knows that there is a sizable population of healthy – by any definition – fat people, right?

And because we also all know that illness is largely socially constructed, right?

No, not right. Wrong, in fact, because the next day the AMA went ahead and did exactly what their science council had advised them not to do, and declared that “obesity” – measured solely by a height-weight measurement, and defined by an imaginary line in the sand – to be a disease.

Here is why I have a problem with that.

First, what is a disease? Why do we define certain physical conditions as “diseases” and not others? You would think the answer would be “incontrovertible scientific evidence!”…and you would be wrong.

Diseases are defined partly on the basis of evidence that they impact a person’s ability to function, or cause suffering and death, but also partly (perhaps mostly) due to social and economic reasons.

What counts as a disease also changes over historical time, partly as a result of increasing expectations of health, partly due to changes in diagnostic ability, but mostly for a mixture of social and economic reasons…This has consequences for sufferers’ sense of whether they are…’ill’, but more concretely for their ability to have treatment reimbursed by health service providers.

(Emphasis mine.)

And, from the New York Times article on the AMA decision – see if you can spot the similarity:

Still, some doctors and obesity advocates said that having the nation’s largest physician group make the declaration would focus more attention on obesity. And it could help improve reimbursement for obesity drugs, surgery and counseling.

(Emphasis mine again.)

Imagine red, blinking, reindeer lights circling that quote. This is what I believe this new definition is about: defining a market (fat people who don’t want to be fat) and making it easier to sell things to them (drugs and surgeries and diet programs that promise to make them not-fat.)

If you can label a condition as a disease, it naturally follows that someone is going to develop a treatment for it, and people who suddenly realize they have an honest-to-goodness disease, and not merely a quaint variation on the human theme, are going to want to buy it. In this case, “people” represents a full third of the U.S. population. That’s over 100 million people, most of whom desperately do not want to be fat.

If you truly believe, in your heart of hearts, that “obesity” is a disease, then this is not a bad thing. In fact, it would seem to be a very, very good thing. I mean, fat is killing people! There’s an epidemic on, people! We’ve got to do something! Besides, people desperately want weight loss drugs, and they want them now. Pharmaceutical companies are simply trying to give people what they want. Capitalism in action. The system works!

And that might even be all well and good, provided the treatments actually work and do not harm people, and provided there are regulations in place to ensure that before releasing them to the public. But let’s look at a little history, shall we?

Historical medical treatments for fat include:

-Thyroid hormone given to fat people with normal thyroids around 1900 – stopped being used for this purpose after causing hyperthyroidism
-2,4-Dinitrophenol – withdrawn from the market in 1938 due to causing fatal hyperthermia
-Amphetamines – addictive, with many unpleasant side effects; brand name Obetrol was removed from the market in 1973
-Fen-phen – withdrawn from the market in 1997 after it was suspected of causing heart problems
-Redux – withdrawn from the market in 1997 after it was suspected of causing heart problems
-Meridia – withdrawn from the market in 2010 due to risk of cardiovascular events and strokes
-Orlistat – still on the market; causes oily butt leakage, kidney damage, vitamin malabsorption, and modest weight loss

Maybe someday someone will come up with a safe, effective weight-loss drug, but since this experiment has been going on for over 100 years now, I’m not holding my breath.

In announcing their decision, the AMA offered up two seemingly reasonable options: either we define “obesity” as a disease so that fat people are no longer blamed for their condition and can receive appropriate medical care…or we don’t, and the stigma and lack of treatments continue.

This is a false dichotomy. There is a third option that has been conveniently left out of the discussion, though a vocal minority of fat people have been arguing for it since the late 1960s: what if fatness is neither a disease nor a cause for blame and stigma?

What if there are so many different reasons people are fat that it’s impossible to boil it down to “personal responsibility” and moral failure?

What if being fat is just the way some of us are, and while we deserve appropriate medical care for whatever actual diseases we might have, we don’t need blame, shame, or a cure for our very existence?

What if fatness is not a disease, let alone an epidemic? What if fatness is part of human biodiversity – yes, a trait that intersects and interacts with disease, just as other traits like sex, skin colour, and height do – but not something to be eradicated at all costs?

Well, then we might have trouble selling things to people. For the weight loss industry, this would be a very big problem indeed.

Though I don’t share their goals, I would prefer that, for people who want to lose weight, safe and effective weight loss approaches were available. But those treatments should be optional, not mandatory, and they should not be the only treatments offered to fat people who go to the doctor for a medical issue. Losing weight should not be a prerequisite to receiving medical care.

Another problem is that we’ve been trying, with increasing desperation, to find those approaches for the last hundred years, and we have failed. People are not thinner. Attempting to lose weight may even cause some to get fatter over time. And the stigma attached to being fat has gotten worse.

I don’t think this stigma will be helped by calling fatness a disease. The doctors who seem to believe it will apparently don’t live in the same world I do, where HIV, Type 2 diabetes, mental illness, and lung cancer – to name only a few – are all officially recognized as diseases, and have all been incredibly stigmatized.

They also don’t seem to think doctors are taking “obesity” seriously enough, despite numerous reports from fat people of health care providers providing weight loss advice over and above actual care, and evidence of considerable weight bias among those who treat fat patients. Again – apparently the AMA doesn’t live in the same world I do.

In my world, my body and I are an indivisible unit. I am an embodied self, not a problem to be solved – and I happen to be fat. My fatness is part genetic heritage, part cultural identity, part vital organ. And it is not going anywhere, no matter who decides to call it a disease.

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61 Comments

  1. Kelly H.
    Posted June 21, 2013 at 10:36 am | Permalink

    Treating fatness like a disease seems somewhat like treating homosexuality as a disease, you think? Not a perfect comparison, but the similarities make me wonder what will come of all this.

    • Posted June 21, 2013 at 10:58 am | Permalink

      I’m not sure how to feel about this comparison yet. I understand the reasons for wanting to make it, and I thought of it too when considering the issue, but I still don’t know how I feel about it. It feels potentially appropriative of the experiences of LGBTQ people, but I do think there are plenty of examples through history of some trait being considered a disease and leading to devastating stigma, that was later rethought. There are similarities but also differences, and I don’t wish to borrow anyone else’s history of suffering, which is unique and horrible in its own way.

      • Kelly H.
        Posted June 22, 2013 at 9:44 am | Permalink

        I agree, and struggled with the wording of my comment. I don’t want to offend anyone who would disagree. What I wonder, and hope, is that the great strides and successes the LGBTQ community has made will equal successes made for the fat community in terms of acceptance of reality with this new definition. I worry that there will be further discrimination against fat people, but perhaps, as a disease, and with the right laws to support it, this “pre-existing condition” will be treated. I’m lucky enough to live in a state where pre-existing medical conditions are legally protected against insurance discrimination.

        • Posted June 24, 2013 at 9:24 am | Permalink

          I really do hope that is the case, but the way “obesity” has been addressed by public health and health care practitioners in general does not give me much reason to hope that this will result in anything positive for fat people. What I believe we will see is continued punishment of fat people through insurer and employer-based “wellness” programs that give discounted rates to people who maintain a certain BMI, and a new slate of wondrous FDA-approved weight loss pills and surgeries that will continue to harm people until they are taken off the market. Sorry to be so dark, but I’m using history as my teacher in this case. And history has not been good to fat people in the past century or so – especially the last decade.

      • Posted June 22, 2013 at 11:03 am | Permalink

        I too thought immediately of homosexuality while reading about the AMA’s decision – because the comparison fairly leaps out based on its former definition as a “disease” until 1973. The story is interesting: that year, a reluctant American Psychiatric Association (APA) was forced to acknowledge that homosexuality is not and never had been an illness.

        Until then, however, the ‘shrink’s bible’ known as the Diagnostic and Statistical Manual of Mental Disorders had included homosexuality as a mental disorder.

        That was before the APA decided (what were they thinking?) to hold their 1970 convention in San Francisco, where the gay liberation movement was at its peak after the Stonewall Riots. Gay liberationists stormed the convention and shouted down speakers in order to make their voices heard.

        Next thing you know, homosexuality was quietly removed as a form of mental illness from the next edition of the DSM – as if it had never even been there in the first place.

        So this comparision leaped out out at me merely because it shows how “diseases” can be “un-diseased” by the stroke of a committee chair’s gavel at any given moment. The new DSM5 now includes normal bereavement grief as a medical condition (more good news for antidepressant-sellers).

        Consider too that alcoholism was named by the AMA as a “disease” in 1956 despite ongoing concerns ever since from many critics in the addictions field who still refer to this decision as the “myth of the disease model”.

      • jj
        Posted June 24, 2013 at 1:24 am | Permalink

        Michelle, I must say your response really organizes well what I have been trying to put into thought lately. Especially when aquantences of mine make comparisons to weight bias, the LGBTA community and different cultural struggles.

  2. Jackie
    Posted June 21, 2013 at 10:45 am | Permalink

    Thank-you!

  3. Twistie
    Posted June 21, 2013 at 10:53 am | Permalink

    The weight cycling industry might as well set up cash registers in every doctor’s office in the US after this.

    You know, when homosexuality was declared a psychiatric illness in the mid-twentieth century, it was seen as a leap forward by a lot of people because at last there was a school of thought that it wasn’t deviant criminal behavior, but something to be fixed with compassionate treatment. We’re still dealing with the holdovers from the wicked deviance approach, as well as the psychiatric illness model, but more and more people every day are realizing that gay is just another naturally occurring variation in nature.

    I firmly believe that one day fat will be seen the same way. It won’t be overnight, it won’t be easy, and it will continue to be a frustrating struggle… but if we keep fighting, it will happen.

    My armor is on and I’ve taken up my arms, fat and all. I’m going to keep fighting for justice.

  4. Posted June 21, 2013 at 11:50 am | Permalink

    Thank you for this. My response is on my site.

  5. ksol
    Posted June 21, 2013 at 12:08 pm | Permalink

    Thank you. I have been distressed over this development, and you have put into words my objections. Keep in mind, too, that it’s not one-third of the population — it’s two-thirds, since that’s the proportion out of “healthy weight” range. My fear is that even more people will be overtreated, and every medical treatment has complications. By defining obesity as a disease — even in a weight-stable person with good habits and no cardiovascular or insulin resistance — the pressure will be on to “treat” it with ineffective methods that can cause more harm than good.

  6. Posted June 21, 2013 at 2:43 pm | Permalink

    I hesitated to do a post on this topic because I’m quite conflicted for the very reasons you identify. The one positive, though, is that those who do need help will able to get it with reimbursement (which requires recognition as a medical condition). Obesity has been covered as a medical diagnosis for decades in MA and gets reimbursement, and it has allowed individuals who truly struggle with binge eating, with prediabetes, with mobility issues, etc to get help. No, not with pills and surgery, but with sensible, practical supportive guidance–to learn to work on mindful eating, to get assistance with organizational aspects of meal planning and normalizing eating patterns, and to correct the wealth of misinformation about Paleo, and low carb and good foods/bad foods that keep them overwhelmed. It allows patients to see RDs to help them set realistic goals based on their history and to stop blaming themselves.

    Lori Lieberman, RD, MPH, CDE, LDN
    food-2-eat.com

    • sannanina
      Posted June 23, 2013 at 5:22 am | Permalink

      Lori – just out of curiosity: Is there also openness about the possibility that fat people might have eating disorders other than binge eating? And are RDs free to treat fat patients in weight neutral ways, i.e., set goals with them that don’t involve any weight loss at all and possibly not even weight maintanance as one of the main goals where you are from? How many would actually be comfortable to do so?
      These are the problems I run into during eating disorder recovery. (I am a recovering binge eater who also went through quite long stretches of extreme dieting and/or fasting and most health care professionals – doctors, RDs and therapists alike – tend to ignore the second part of the problem completely, even the well-meaning ones). Granted, I am very easily triggered by ANY focus on my weight, and weight changes in either direction are very stressful for me even if I am neither praised nor admonished for them, but in my experience more focus on weight and on obesity as a disease in itself has always been incredibly counterproductive.

      • Posted June 23, 2013 at 2:52 pm | Permalink

        I have been in treatment for an eating disorder for a year now. And the dietitian and the whole program have the attitude that we need to eat intuitively — eat when hungry and stop when full. They don’t discuss weight with us, although they track it, mostly because if the anorexic and bulimic folks are losing even more weight, then there is something wrong, and they need to find out what’s going on. They encourage a healthy attitude toward food, which means you CAN have anything you want, but eat moderate portions — don’t binge to the point where you feel ill. And figure out what causes binges, so that you can address the source of your distress, and not go into robot mode and binge without thinking. They also encourage eating responsibly, which means establishing a routine, and eating a variety of foods. And not under-portioning, either, because while that may FEEL virtuous, it isn’t. You have to nourish your body, no matter what your weight is. So I think it’s a very good program, although I know that very few dietitians seems to realize this; the dietitian in this program is exceptional in her understanding of all food issues. I guess I’ve been lucky! :-)

  7. Elodie
    Posted June 21, 2013 at 4:15 pm | Permalink

    I have no patience with anyone defending this. Calling fatness a disease is a lie. No good ever came from lies. Nor does any good ever come from rejecting science in medicine. It’s snake oil.

  8. Posted June 21, 2013 at 4:28 pm | Permalink

    There is a novel, called Big Brother, about a woman whose brother is down on his luck and has become enormously fat — he’s portrayed as a continuous-binge eater. I haven’t finished the book, so can’t tell you if it’s good or bad, but I was struck by the quote at the beginning: (something like) “The weight-loss industry is the only successful business with a 98% failure rate.” That certainly says something.

    My second observation is that we, as a society, have become obsessed with changing our appearances: hair dye, hair styles, clothes sizes, and make-up are VERY important to eating-disordered young women, and I think it’s because they can’t stand living in their own bodies. Air-brushed pictures of models on magazines don’t help, but these young women consume them avidly. So is it any wonder that we’re obsessed with obesity? I think the revulsion factor is because they’re afraid that they might come to look like that. The obesity blame and shame game is more a result of OTHER people’s fear and revulsion than anything else.

    • E
      Posted June 21, 2013 at 11:57 pm | Permalink

      Natalie, I’m sorry, but your comment is offensive and false. I don’t mean to discount your personal experience, but I object to the generalizations you’re making. Where is the evidence that “hair dye, hair styles, clothes sizes, and make-up are VERY important to [all or most] eating-disordered young women”? Where is the evidence that “these young women” consume fashion magazines “avidly”? Is there evidence that teenage girls with eating disorders are more likely to read Vogue than their non-eating-disordered peers? And although adolescent girls are more likely to be diagnosed with an eating disorder — for various reasons — than are members of other groups, there are plenty of children of both sexes and plenty of older men and women who suffer from eating disorders, too.

      I was going to try to write a thoughtful critique of your statement that “the revulsion factor is because they’re afraid that they might come to look like that” . . . but I’m too tired and annoyed to compose a response. I’ll just say that that statement does not ring true AT ALL for me, with regard to my own experience or that of people I know, and I don’t think there’s any evidence that there’s a greater “revulsion factor” toward obese people in people with EDs. Frankly, I find your central position — that people with eating disorders are responsible for “the obesity blame and shame game” — utterly puzzling. If it’s true that eating-disorder sufferers “can’t stand living in their own bodies” (another generalization…), then shouldn’t they be more focused on their own bodies than on the bodies of other people? I really don’t follow your logic.

      • Posted June 24, 2013 at 8:55 pm | Permalink

        I’m sorry, but what I was trying to say is not what you inferred. I, having been diagnosed with an eating disorder myself, spent almost a year, including 3 months in a residential setting and 6 months in an intensive outpatient setting, in a treatment program with almost entirely anorexic and bulimic young women (only one had binge eating disorder, and she herself agrees with the diagnosis). So I had PLENTY of opportunities to observe their behavior. They spent HOURS getting their makeup JUST right, doing their hair and changing their clothes throughout the day. Why would they do that unless they were obsessed with their appearance? Why do they drive themselves to sickness and death (yes, anorexia has the highest death rate of any mental illness) unless they are terrified of being “fat”? Why did a young woman burst into tears because she could no longer fit into her size zero jeans? And another one methodically turn fashion magazines on the rack backward to prevent herself from seeing them and being triggered? Yes, they ARE terrified by the thought that they are fat and going to get fatter, and yes, more so than the general public. And one of the things they do is constantly compare themselves with others, too — it can become a competition: My lowest weight was lower than yours! Or OMG, did you see that FAT lady at the store? I’m never going to be like HER!

        In truth, there ARE men and older people who have eating disorders, but they tend to express them in different ways.

        However, I did NOT say that people with EDs were responsible for the blame and shame game directed at fat people. I should have paragraphed it differently, because I meant to say that the general public is responsible for it.

        I am sorry that I cannot come up with study references; I can only give you the evidence of my own observations. I know that studies are finally being done more frequently, and that the DSM5 is defining eating disorders differently than previous editions. Of course, MOST fat people DON’T have eating disorders, nor do thin ones, but ED is real.

        • Erin
          Posted August 1, 2013 at 4:36 am | Permalink

          I think the conclusion you’ve drawn doesn’t necessarily have to be correct. The answer to “Why would they do that?” that comes to mind is: Because they strive for perfection, control. You don’t have to think fat is repulsive (on others) to want to maintain a certain wait. It’s possible you just want to have it 100% in your hands. The same goes for make-up: If you do it just right, then you … did it right. One thing that is in place. I don’t negate what you’ve seen, but unless you have talked to all of these girls/women to find out what motivates them, you cannot know for sure how they feel about the reasons.
          (I’m not saying that the reasons I mentioned have to be correct. They were supposed to illustrate that there are other possible explanations.)

    • Emerald
      Posted June 23, 2013 at 5:13 am | Permalink

      Natalie, off topic but, I heard Lionel Shriver talking about that novel on the radio when the novel came out – as you may be aware, it’s semi-autobiographical, in that she did have a very fat brother who died a few years back. This Telegraph article:
      http://www.telegraph.co.uk/women/womens-life/10003135/Fear-of-fat-Novelist-Lionel-Shriver-on-her-fascination-with-flab.html
      makes it clear that her own relationship with food has always been, to say the least, fairly screwed up. But even while she recognizes that, she can’t countenance FA because ‘my fat brother is dead, being fat kills you’. It’s all very sad.

      Anyway. What Michelle said about defining a condition as a disease not stopping stigma – yes. As someone diagnosed with depression and anxiety, I can definitely relate to that. When I heard about the suggestion of obesity as a disease, I did wonder whether it might have any effect on legal protection, such as in the workplace. Then it struck me that in my own case – and mental illness is protected under employment law in the UK where I live – certain people where I was working back in 2004 had fought tooth and nail, against every kind of evidence up to and including an independent medical, to, firstly, deny that I was depressed, secondly, deny that it was a medical condition, and thirdly, deny that I had any kind of legal rights on those grounds. Unless there’s a general sea-change in society’s attitude around fat (and there have been substantial changes in attitude around mental illness here over the last decade or so, and yet people still struggle to get the law enforced), I can’t see that it’ll be much help to anyone.

      • Posted June 23, 2013 at 2:45 pm | Permalink

        Thanks for the reference to the article, Emerald. I read it, and it clarifies what’s happening in the book. It seems to me that Lionel Shriver still has a very conflicted relationship with food and her body, which is very sad.

        I’ve been thinking more about this subject, and it seems like there is quite a difference between someone like me, who is packing a few extra pounds, and someone who is bedridden and can’t take care of themselves because of extreme obesity. When obesity becomes disabling, I WOULD like to see insurance compensation for treatment. But it is NOT disabling for a lot of people, and they shouldn’t be hounded and shamed for the genetic attributes of their fat storage. I’m apple-shaped, and while there are a lot of dire stories about how bad storing fat around your abdomen is, what in the world can I do about it? I can’t CHOOSE where I store my fat, so I do get more than a little pissed by the supposed virtue of the pear-shaped, and the obvious gluttony and sloth of the apple shaped. I know there will always be controversy among academics, but I am struggling to just live my life!

  9. Posted June 21, 2013 at 9:23 pm | Permalink

    I adore this. So lucid.

  10. Erin
    Posted June 22, 2013 at 11:24 am | Permalink

    Glad to have you back. I missed your posts.

  11. Posted June 22, 2013 at 6:31 pm | Permalink

    Maybe someday someone will come up with a safe, effective weight-loss drug, but since this experiment has been going on for over 100 years now, I’m not holding my breath.

    If this ever happens, I would expect it to come from people like Jeffrey Friedman and Arya Sharma, who at least understand that weight is complicated and affected by homeostatic mechanisms. Not the Nightmare on ELMM Street people. I think there’s a lot of basic research that needs to be done to understand these mechanisms before it’s possible for anyone to come up with an effective drug (unless they basically do so by luck).

    When I think about such a drug, I can’t help thinking of the end of X-Men 3 (where mutants have to choose whether to be “cured” of their mutations). :)

  12. emlev
    Posted June 23, 2013 at 1:55 am | Permalink

    I appreciate hearing your take on the issue and agree with you. And yet, here’s another tidbit: I pay a huge amount of money for individual “health insurance” every month because of the laws that say that a company with which I’ve had continuous insurance since I was on a group plan must offer me a policy, but that there’s no limit on what they can charge me. No other company will insure me, using my weight as the reason. I am healthier than nearly everyone I know in my age group. With “obesity” defined in a way that includes me and classified as a disease, it seems to me that the insurance companies would no longer be able to discriminate against fat people because discrimination on the basis of pre-existing conditions is no longer permitted.

    Of course, I would much prefer that the discrimination end, and that we have single-payer health insurance for all. In the meantime, though, there could be some advantages to this situation. And everything you write is still also true.

    • Posted June 24, 2013 at 9:11 am | Permalink

      I have these hopes as well, but given my experience with the way the “War on Obesity” has gone over the past decade and a half, I do not have much reason to believe that this will actually happen. The minority of people who are in your exact position re: insurance may benefit from lowered rates, sure. But many fat folks will continue to pay higher insurance rates, I think (and that’s not even counting the wellness program approach which is a relatively recent innovation that essentially punishes fat people for having a higher BMI) – that’s my guess anyway. I could be wrong. I hope so. I will be very interested to see how this shakes out in practice. If you remember in a few months from now, come update us on any changes that happen to your insurance, if they do happen.

  13. Erin
    Posted June 23, 2013 at 7:32 pm | Permalink

    http://www.drsharma.ca/why-recognising-obesity-as-a-disease-is-only-fair-to-those-affected-by-this-condition.html

    Canada’s top obesity expert is defending this. Please take a read for the other side of the story.

  14. Mich
    Posted June 23, 2013 at 7:45 pm | Permalink

    Michelle, could you give me some info on Dr. Bernstein. What are his tactics? Do his “successes” live happy lives or neurotic ones? Where’s he from, when did he get started? I ask because there’s this one commercial on tv now, that I see 10 times a day, where this one guy has diabetes, and a handful of other “scary” diseases and he lost 196 pounds, kept it off (doesn’t say how long though, 1 yr? 10 yrs?), and he’s running marathons. The guy they got is obviously an actor because he doesn’t have hanging skin or sunken eyes. Looks like he was never fat.

    • Posted June 24, 2013 at 9:08 am | Permalink

      His tactics are, if I’m not mistaken, a Very Low Calorie Diet (is it a liquid diet?) perhaps supplemented with vitamin injections or even appetite suppressants. I haven’t read in-depth about his approach – just heard of it and seen the ads – but I am betting it is some combination of those things. These diets usually result in rapid weight loss, follow by rapid regain of the weight lost, and sometimes gallbladder disease on the side. These programs have been around for decades, so Dr. Bernstein is nothing new. As with any weight loss program, there will be exceptional cases who lose lots of weight and keep it off, and those will be used as testimonials while the masses of people who regain the weight will never be heard from. (And even some of the testimonial cases will regain weight, but of course you don’t get updates on their cases after the commercial ends.) Same old, same old. It also would not surprise me if actors are used for testimonials who may have never lost weight. I don’t know if that is legal or not in Canada, but I do know that in the US, some of the worst offenders for violating FTC rules on advertising claims are weight loss businesses much like Dr. Bernstein.

      • Canadian Doc
        Posted June 24, 2013 at 11:57 am | Permalink

        Canadian family doc here. Bernstein offers a very very low calorie diet with multiple weekly visits with his nurses, lots of regular bloodwork, and vitamin injections. And potassium supplements. Everybody loses weight thanks to the low calories and lots of support; hardly anybody keeps it off. He neither publishes nor reveals his long-term success numbers to clients. He does have a maintenance program but very few can afford to keep going to it. The program removes all the pleasure and much of the nutrition from eating, IMHO.

        As a physician and by-the-numbers obese myself (a pregnancy at 44 followed promptly by menopause followed promptly by major surgery pushed my genetically sturdy body far beyond my best weight) I’m not sure what I think about this. On the one hand I dislike “medicalizing” the range of human experience; on the other if obesity is seen as a chronic condition to be managed with an eye to preventing complications, that’s not a bad thing. “Management” of a health problem doesn’t have to include medication and surgery, and I suspect most of us who are both obese and fit figured that out a long time ago.

        • Posted June 24, 2013 at 12:38 pm | Permalink

          Thank you for the details!

          I don’t necessarily think that helping fat people manage their risk of disease is a bad thing, in theory – but in practice, I think we live submerged in so much weight stigma, pharmaceutical profiteering, and ableism that this definition will only reinforce and add to those things, rather than merely making for better “management.” I hope I am wrong, but I don’t see a good reason not to believe it, as yet.

          Health at Every Size has been completely left out of this discussion by both the AMA and the media, even though it does precisely what you describe – helps people of all sizes to manage risk without surgery and medication. And yet it is completely marginalized as an option, both in the practice of medicine and dietetics, and in the discussion overall. This really bothers me.

          • Canadian Doc
            Posted June 25, 2013 at 11:43 pm | Permalink

            I’m a little out of the loop, not being American, re the “Health at Any Size” program, shall look it up. I do like Dr. Sharma’s definition of obesity as “having excess body fat which is causing harm or has the potential to cause harm to one’s health” (not an exact quote). As he points out that point, at which fat causes harm, is different for everybody and not discernable through BMI — or looking at someone — alone; it requires knowledge of a whole slew of other risk factors. By that definition I’d agree it should be a disease. I’ve learned that the AMA is using BMI and only BMI in their definition, though, and I think that’s a real shame.

            Bernstein, BTW, has franchised his diet clinic across Canada. Quelle horreur.

          • Posted June 26, 2013 at 1:56 pm | Permalink

            Yes, you would probably enjoy reading about Health at Every Size. Here are some resources:

            http://www.amazon.ca/Health-At-Every-Size-Surprising/dp/1935618253/

            http://haescommunity.com/

            https://www.sizediversityandhealth.org/

            https://www.msu.edu/user/burkejoy/?pagewanted=all

            Don’t get me wrong – Dr. Sharma is the lesser of many, many evils. But I’m a touch radical, you could say, so I’m likely to be unimpressed by people who are paid consultants to weight loss pharmaceutical companies, no matter how compassionate and reasonable they sound.

    • Posted June 24, 2013 at 9:04 pm | Permalink

      Which Dr. Bernstein are you talking about? I know a lot about Dr. Richard K. Bernstein, but don’t know whether there is another one.

      At any rate, Dr. Richard K. Bernstein is a Type 1 diabetic, who advocates a low-carb, moderate-protein, high-fat diet for diabetics. He advocates eating a lot of low-carb vegetables and nuts, and a moderate amount of meat products. He does not advocate vitamin injections or supplements, and while he studies each individual who comes to his office intensely, there are lots of people who have bought his book and followed it, and used it to successfully control their diabetes, be it Type 1 or Type 2. So far as I have ever heard or read, he only works with diabetics, not the general public.

      People do tend to lose weight on the diet he recommends, but the goal is not ketosis; it’s eating in such a way as to control blood sugar. If you don’t have diabetes, it’s not necessary for you to limit yourself in this way, but if you do, it can really make a difference. And it’s been abundantly proven that good blood sugar control diminishes the likelihood of complications later.

      • Posted June 25, 2013 at 6:59 am | Permalink

        No, it’s a different guy. We’re talking about Stanley K. Bernstein who runs a diet clinic in Toronto. The diet you describe actually sounds really healthy for people with diabetes, though I can also imagine many people might find it a difficult change to make.

      • Mich
        Posted June 26, 2013 at 12:32 pm | Permalink

        I don’t know the first name, but it sounds like the one Michelle names. The Canadian doc said that he’s franchised his clinics out to the rest of the country, I’ve seen one in a mall.

        I suppose regular doctors would be cleaning up the mess of rapid weightloss and accompanying complications. This is nothing new, during Victorian times they knew of the dangers of weightloss.

  15. Lauren
    Posted June 24, 2013 at 8:04 am | Permalink
    • Posted June 24, 2013 at 9:17 am | Permalink

      This post is incredibly simplistic and actually glosses over several important points. Needless to say, I disagree with Dr. Freedhoff’s overall conclusions.

  16. Posted June 24, 2013 at 12:43 pm | Permalink

    Just a general note: I do believe that human size variation is both an expression of genetic diversity and also a trait that is influenced by environmental and social issues, many of which lie outside direct individual control. This is true for almost every human trait in existence, by the way – learn to biology.

    Nowhere in this post, or anywhere on this website, do I argue that human body weight is 100% genetically determined (though it is highly heritable – http://ajcn.nutrition.org/content/87/2/275.full )

    Do not construct strawmen when commenting, or your comment will be sent to spam.

  17. Posted June 24, 2013 at 3:31 pm | Permalink

    Talking about weight loss drugs epic fail – here’s a post I did on my other blog about the new ones that were approved a year ago, and all their lovely side effects and research that shows you barely lose weight on any of them. They might kill you though.
    http://bignoises.wordpress.com/2012/07/19/obesity-has-gotta-be-healthier-then-this/

  18. Linda Strout
    Posted June 24, 2013 at 7:35 pm | Permalink

    Lately when I think of the outcry to ‘do something about obesity’ I keep flashing on that scene from the movie 1984 where the man is required to stand in front of his TV to do exercises and gets yelled at by the person who is watching him through the screen.

    • Mich
      Posted June 26, 2013 at 12:34 pm | Permalink

      I was thinking the same thing (but I haven’t seen the movie, just read part of the book). They watch us and yell when we fail at something. This whole “medicalization” is yet another attempt to micro-control our lives. Karl Marx in action.

      • Linda Strout
        Posted June 28, 2013 at 11:28 pm | Permalink

        People need to pay attention to their own lives. I was raised by parents who spent a lot of time talking about other people (including their children) but less time talking to them and trying to really find out what any given person was like.

        I had to break myself of the same thing

        Now I have a lot more spare time. Also, I’m still trying to learn how to talk about myself to others.

    • Mich
      Posted August 13, 2013 at 6:50 pm | Permalink

      Another article from a sane man in this haze of chaos: http://www.spiked-online.com/newsite/article/exploding_the_myth_of_the_obesity_timebomb/13919#.UgrDJ5KTif4

      He writes often on spiked, he’s worth checking out, and his book called “Panic on a Plate: How Society Developed an Eating Disorder” is being ordered by my library. I originally found spiked through the Junk Food Science blog.

      • Posted August 14, 2013 at 9:53 am | Permalink

        I’ve been meaning to read this book, but haven’t gotten around to it yet.

        • Mich
          Posted August 14, 2013 at 2:09 pm | Permalink

          Great, now I know I’m not the only one who likes his writing.

  19. Erin
    Posted July 18, 2013 at 1:53 am | Permalink

    My mother, 47, has been categorized as obese for quite a few years now. She is beautiful and radiant just as she is, but she’s hoping to lose some of her weight just to improve her overall comfort, as she works long hours at an active job. She fed me whole grains and fresh vegetables growing up. She taught me to eat healthily and adventurously, but also to enjoy indulging in the pleasure of rich foods. She, like everyone, knows how to eat.
    She was recently diagnosed with high cholesterol for the first time in her life. Not crazy high, just a little too high. She was immediately prescribed a statin drug and a weight loss pill, against her request. She read their side effects to me: memory loss. dementia. schizophrenic behavior (WHAT?). heart damage (isn’t this what we’re trying to AVOID?). kidney damage. Astounded, she did not fill either prescription. Equally astounded, I wondered what would drive a doctor to give such poorly tested, dangerous pills to a generally healthy woman. Why not discuss alternatives when she TELLS you she’d rather not take medicine?
    I feel there is a general impatience in the medical field with overweight people. I am not one of them, but I’ve seen my smart, informed mother glossed over by trained medical professionals so many times that it makes me sick. Three doctors have prescribed three different weight loss pills to her over the last year, none of which she asked for. She wanted a solution based on her lifestyle, goals, and needs. Even a referral to a more qualified person would have been nice. But that is too much work, apparently.
    What kind of “disease” is obesity, anyway? Its “victims” are FINE. Doctors should help them improve their health, not their appearance. That is the patient’s prerogative and no one else’s.

    • Mich
      Posted July 21, 2013 at 12:56 am | Permalink

      Kinda sounds like what parents go through, but they lap it up, being total believers. They joined this new-ish diet fad called Pure North Synergy Foundation (only in Calgary, AB so far) and they take your blood and test it for all the vitamin levels, and then they give you these pill packets of fish oil, probiotics and some vitamins that are in non-bioavailable forms or unproven ingredients (they give the pills on the first visit without having received the test results).

      Anyway, after the results came back, my mom sent hers to her doctor and she has extremely high HDL and extremely low LDL, plus low B12 among other things. What does the doctor do? Prescribes Crestor. Even though there’s no evidence that statins are beneficial for women of any age. My dad’s been taking Lipitor for over a decade, and acts like a teenager again. They both also have chronic dumping syndrome too (gross I know), which I think is caused by these prescription drug cocktails that they take, plus the pseudo-science pills from this centre.

      I think they both have early onset dementia already. My mom keeps getting more confused everyday, and can’t understand simple sentences sometimes. And I don’t think calling their doctor (who sent me to a nutritionist to treat “arthritis”) will do anything. He’s obviously in it for the money.

    • Posted July 23, 2013 at 10:23 am | Permalink

      I agree with you that there is an impatience on doctors’ parts to deal with their fat patients. There is documented weight bias among health care practitioners, and it would not surprise me if that’s one way it manifests.

      Regarding the prescriptions, there is also the dangerous problem of drug manufacturers purposely burying clinical trials that do not reflect favourably on their products – leading doctors to only have access to studies that seem to indicate the drugs are safe and effective, even if those favourable outcomes reflect only half the studies undertaken. As a result, doctors who try to keep up on the research to guide their patients do not have the best data on hand because half of that data has been disappeared.

      http://www.alltrials.net/ is a response to this problem.

  20. Posted July 24, 2013 at 12:06 am | Permalink

    Ugh, ugh, ugh.

    There’s already a tremendous stigma about weight. Do they think this is going to solve any problems? Really?

    I’ve been seeing specialist after specialist for over a year now… Last summer I was diagnosed with a hindbrain malformation. Every single doctor I’ve seen has tried to pin my symptoms (symptoms from the physical size and position of my skull relative to my brain) on my weight. My double vision? Weight. Severe headaches, especially after coughing/laughing/straining? Weight. The fact that I don’t have diabetes, heart disease, high cholesterol, or any other “fat” disease is irrelevant. A dozen “professionals” have told me surgery is risky because of my weight, but then encourage me to look into gastric bypass. Unfortunately, surgery is the one and only possible cure for my symptoms.

    I’ve been seeing a podiatrist for a couple of months and every. single. appointment. she asks if I’ve been diagnosed with diabetes yet. I’m running out of patience, but also running out of doctors to try. It’s heart breaking.

    -Katrina
    http://www.gofundme.com/39hoes

  21. Mich
    Posted July 31, 2013 at 3:09 pm | Permalink

    This issue made some news in England, and just recently a fat chef in New Zealand was expelled back to his home country for being “unhealthy”.

    http://www.spiked-online.com/newsite/article/too_fat_for_new_zealand/13865#.UfluApIsmf4

    http://www.spiked-online.com/newsite/article/13739/#.Uflu6JIsmf4

    • Posted July 31, 2013 at 5:50 pm | Permalink

      There was an earlier case of a doctor, and I believe a nurse as well, being refused immigration to NZ because of their BMIs. In the midst of a medical personnel shortage. SMRT.

      • Mich
        Posted July 31, 2013 at 11:58 pm | Permalink

        That whole policy reeks of eugenics. I think Australia is the same. There’s some scary stories about it on Do No Harm blog. That whole site gives me the creeps.

  22. Mich
    Posted August 2, 2013 at 12:09 pm | Permalink

    Not really much news, but the world is up in arms about Princess Kate’s post-baby bump. The height of arrogance and ignorance.

    http://news.nationalpost.com/2013/07/25/kate-middletons-post-baby-bump-sparks-debate-over-what-normal-women-look-like-after-giving-birth/

    Many other links in article and to other related news.

  23. Mich
    Posted August 25, 2013 at 1:34 am | Permalink

    A plus-size model joined CTV News online for a chat on June 20. I just found it today while looking for another story. http://www.ctvnews.ca/ctv-national-news/replay-newsmaker-noon-obesity-as-a-disease-1.1333983

    At the end there is a poll asking if you agree with the AMA’s decision. If you can’t vote and see the results, the results are: yes 36%, no 64%. Some of the comments are reflective of what we’ve gone through and commented here, others are fat bashing.

  24. Linda Strout
    Posted September 5, 2013 at 7:51 pm | Permalink

    Two thoughts:

    1) Has anyone been reading the news about the microbes in our guts and the fact that certain ones may contribute to fatness?

    2) I was idly looking up nutrition for a mango lassi (I am craving Indian food) and the couple of places I looked put the emphasis on the fat/carbohydrate/sugar content, not the giant pile of vitamins in the drink. Clearly healthy eating has nothing to do with getting actual nutrients into your body.

    I need samosas.

    • Mich
      Posted September 8, 2013 at 3:34 pm | Permalink

      I work in a library and the current issue of Scientific American just came in. It’s a food issue, with an article by Gary Taubes. I didn’t read any of them, but from the cover and the titles, it’s all about how fat we are getting.

      I recently found I enjoyed luncheon meat (aka spam, prem), and vienna sausages. the walmart brand of luncheon meat, Great Value, has 15% RDI of Calcium, and over 6% RDI of iron. The “name” brands of the same stuff have no calcium, and less than 2% of iron. same goes for the vienna sausages where the walmart brand has vit. A, vit. C, calcium and iron, but the other brands have a smidgeon of iron and nothing else. I’ll stick with the extra vitamins.

      Like you I look for the vitamins and other important factors (protein, fat), rather than calories.

  25. Erica
    Posted September 7, 2013 at 4:14 pm | Permalink

    Nice piece. Just ran across this belatedly, and I want to have my students read it during our unit on metabolism and obesity. We hit the end result of an inactive lifestyle and poor diet very hard as if A. All people who are fat are inactive junk food guzzlers, and 2. All inactive junk food guzzlers are fat. It’s a lot more complex than that, and I try to tell my students they should focus more on having a healthier lifestyle and less on how much they weigh. It’s hard, though. We’re so inundated with images of “physical perfection” and everyone, women especially, are cultured to believe that they have an obligation to be attractive at all times and in a very narrowly proscribed way. I sure as heck wish I had my 25 year old (thin) body back.

    I ran across something recently that suggested tall people get more cancer than short people. Of course, correlation does not mean causation. But what if it turns out that something about tallness really does increase cancer risk? Will tallness be declared a disease and a scourge to be cured or prevented at all costs (even if it means giving kids with tall parents growth hormone inhibitors or something)?

  26. Linea
    Posted September 8, 2013 at 3:43 am | Permalink

    Yes, I definitely fall into the third option area. For the first 50 years of my life, I was thin, with little effort on my part. (I’m 5’8″ & I weighed between 125 & 135 most of those years.) And then a psychiatrist decided to try a different medication on my intractible clinical depression. I was told it “might cause a little weight gain.” I gained 10 lbs a week for the 10 weeks that I was taking it. At the 100 lbs gained mark–2 1/2 months later–I told the Dr that she needed to find me something else. I went from a size 34AA bra to a 46DD bra in those short 2 1/2 months. It was like I’d been given an entirely new body that I had no idea how to operate. I tried everything to lose it, including diet & exercise & the most I’ve ever lost was 40 lbs, which came right back as soon as I stopped Weight Watchers.

    I was with a woman at the time who told me often that I’d never find anyone else who would want me now that I was fat. I was still so depressed that I believed her & stayed with her for several more years because I was so afraid of public opinion. And so, I had to come to love myself all over again & to love the new body that I was wearing. It took a good long time, but now I am happy with the me that I am today. I truly do love me & this body is just my exterior. You might be amazed at how many people one can find to love one no matter what their body looks or feels like. In order for me to continue to enjoy this body, I did have to be more selective of who I allowed to say what to me. My sister, to this day, is convinced that I overate my way to those hundred pounds. Even when I presented her with the mathematics of that type of eating & weight gain, she firmly believes what she learned when our parents put her on her first diet at the age of 6 months: overeating is the only way that one can ever get fat.

    So here’s to me & all the other fat girls who are loving & accepting of themselves & healthy despite what that stupid BMI chart says. Which, by the way looks suspiciously like the “normal” height weight charts of my girlhood; it’s just got a fancy acronymous title now.

    • Mich
      Posted September 11, 2013 at 7:28 pm | Permalink

      That’s an awful experience. I don’t know how one could gain 100 lbs in 2 months naturally. You’d have to monkey with your immune system and metabolism. So the psych. made you more depressed after your new pills and weight gain. Nice. (not)

  27. Mich
    Posted September 17, 2013 at 2:35 pm | Permalink

    Has anyone else seen the new Sobey’s commercials with Jamie Oliver in them? He’s paired up with the grocery store chain to get “healthy” foods more widely available.

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