Obesity – Primary vs. Secondary prevention

I will never forget the very first patient history I ever took. Part of medical school training is they send you onto the wards to gather patient histories and physicals so you learn to gather information effectively as a clinician. My first patient history was on a woman about 35 years old on the orthopedics ward, who was a triple-amputee. She had her legs removed below the thigh, and one arm amputated below the elbow. The cause was imminently preventable. She had type II diabetes that was poorly controlled. She was obese, weighing about 180 lbs despite the removal of large parts of her body. A common problem with diabetics is that they are susceptible to infection in their bones. Diabetics have have poor pain perception from diabetic neuropathy and poor blood supply, the result is that cuts on their extremities go unnoticed, heal poorly, and ultimately result in infection that frequently goes into the bone. The result, osteomyelitis, is persistent infection of the bones from these infections, and, if antibiotics are ineffective, the only treatment is to surgery to remove the infected tissue and often amputation. Such was the case with my patient. She was poor, from Appalachia, had inadequate control of her diabetes, and as a result lost multiple limbs from infection (she was hospitalized for yet another infected bone).

The major reason for the increase in Type II diabetes rates is obesity and lack of exercise. Disturbingly, younger and younger people are presenting with diseases often only seen with age, like type II diabetes and gout. This is unquestionably due to increasing rates of obesity in the US population. Thus, it is with dismay, that I read Sandy Szwarc’s blog Junkfood science, that seems to exist for the sole purpose of denying the health risks of obesity and of being overweight. Sandy, who is on CEI’s staff, routinely writes about obesity as a health-scare, that is not harmful as doctors and health scientists suggest.

To illustrate the problems with her analysis, let’s go through one of her more recent posts on the Obesity Paradox – the apparent decrease in mortality in studies of the obese.

Sandy starts with the startling assertion that fat does not cause heart disease or premature death.

What is most amazing is how long it has been known that body fat doesn’t cause heart disease or premature death, yet how vehemently people hold onto this belief. “The notion that body fat is a toxic substance is now firmly a part of folk wisdom: many people perversely consider eating to be a suicidal act,” wrote Dr. William Bennett, M.D., former editor of The Harvard Medical School Health Letter and author of The Dieter’s Dilemma. “Indeed, the modern belief that body fat is a mortal threat to its owner is mainly due to the fact that, for many decades, the insurance companies had the sole evidence, and if it was wrong they would presumably have had to close their doors.” That can still be said today, although the obesity interests have since grown considerably larger.

One already notes the intimation of a conspiracy in “obesity interests”, but let’s leave that aside for now. But what is this evidence that fat is harmful? For one, obesity is known to be a risk factor for hypertension and other morbidity in children (1,2,3,4,5,6) and increases the risk of diabetes (1,2,3,4,5,6) In adults obesity increases a number of cardiovascular and other morbidities (1,2,3,4) and the health burden of obesity is recognized as a critical public health problem (JAMA free full text) as well as a cause of decreased quality of life (1). Further the statement that obesity does not increase morbidity or mortality based on the book Bennet wrote in 1982 simply can no longer be sustained (1,2,3,4,5,6)

Let us continue.

Ancel Keys and colleagues, for example, examined 16 prospective population studies in seven countries, as well as actual angiographic and autopsy examinations of 23,000 sets of coronary arteries which found no relationship between body fatness and the degree or progression of atherosclerotic build-up. And the most careful studies ever since have continued to support these findings.

This is may be entirely true, but one of the lessons of cardiovascular medicine over the last few decades is that the issue isn’t size of atherosclerotic plaques but rather their stability. Heart attacks and strokes aren’t caused by gradual narrowing and then closure of vessels. Rather, atherosclerotic plaques which form in reaction to inflammatory reactions in the vessel wall suddenly rupture, exposing the the necrotic cores of these plaques to the bloodstream, resulting in pathological activation of the clotting cascade, and then infarction. Size of lesions is largely meaningless with regard to acute coronary and cerebrovascular events. Either way, the evidence is in from epidemiologic studies, obesity, discounting other risk factors, greatly increases risk of cardiovascular disease, some cancers, diabetes, dyslipidemia, joint problems, etc. Continuing:

“Before we delve too far into the possible connections between overweight and heart disease, we should look at the evidence to see whether they are as closely linked as they are conventionally assumed to be,” cautioned Dr. Bennett. “Again, we can use major statistical trends to reassure ourselves that fatness cannot be a very important cause of cardiovascular death….”

He wrote that back in 1982, pointing out how the age-adjusted rate of deaths from heart attacks and strokes since the early 1950s had dropped while weights had increased. Biological truths cannot be reversed. These very same findings continue today. As was reported just last month, the health of Americans continues to improve, and heart disease and cancer rates are dropping as weights increase; and the CDC now estimates that today’s children will live longer than ever in our country’s history.

Again, we’re assessing irrelevant information. Heart disease and cancer rates decrease because of screening, smoking prevention, and better drugs, but the evidence is clear of a link between obesity and morbidity/mortality. This is assessed independently of innovations in medical care, and is an independent factor for increased death rates.

“Detailed epidemiological studies, too, show no impressive connection between obesity and cardiovascular disease,” Dr. Bennett wrote. By that he meant credible, carefully done studies. Junkfood Science readers regularly see how such studies can be manipulated to give the false impression of correlations seeming to show causation by, for example, ignoring confounding factors (like stress, social-economic factors, dieting, and prescription drugs) or using false surrogate endpoints rather than actual clinical disease or deaths. Also, he emphasized, “it cannot be said that fatness in itself causes hypertension…[and] being fat does not, in itself cause diabetes.” Again, those findings continue to hold true today.

This information is so patently false as to be offensive. There is no question of a link between obesity and diabetes, and obesity and hypertension. I have no doubt, that if my first patient had not been morbidly obese, she wouldn’t be losing limbs to type II diabetes before age 40. I know of no responsible physician that would deny these links. But let’s go onto the latest study showing the harmlessness of obesity in Sandy’s eyes.

Which brings us to a study in the current issue of the American Journal of Medicine, led by cardiologist Dr. Seth Uretsky, M.D., at St. Luke’s-Roosevelt Hospital in New York. By now, we should not be surprised that the media is not reporting on this study, like all the others that go against popular groupthink. These researchers set out to see if the “obesity paradox” of lower morbidity and mortality with increasing body mass index exists with heart disease patients.

The patients were from the INVEST trial, a prospective, randomized international study of 22,576 patients age 50 and older who had hypertension and coronary artery disease. Their heart disease was confirmed and defined as having had a documented heart attack, coronary angiogram with more than 50% stenosis in at least 1 major coronary artery, angina pectoris, or evidence of ischemia on at least 2 different modalities of stress tests (electrocardiogram, echocardiogram, radionuclide scan) that were consistent. The patients received extensive cardiovascular workups in the clinical setting including BMI calculations, and were followed for an average of 2.7 years. The primary outcomes for this study were all-cause mortality, heart attacks and strokes.

Their findings? Compared to ‘normal’ weight patients, the thin patients had 74% higher risk of both death and having a heart attack or stroke, whereas the ‘overweight’ patients had 29% lower risk. But the obese had the lowest risks of all, nearly half that of ‘normal’ weight patients. Only at the very highest BMIs did the risks begin to creep up but they were still less than the overweight and most notably less than the ‘normal’ weight patients. The reverse “J” curve of their graph was amazing similar to that shown earlier this year in a Stanford University-led study of women. The most significant endpoint, all cause mortality, is where the lower risks with fatness were especially striking.

In contrast with these epidemiologic studies, our analysis…among patients with a history of hypertension and coronary artery disease, overweight and class I to III obesity were associated with a decreased risk of morbidity and mortality compared with normal-weight patients, despite less blood pressure control. This finding is consistent with the notion of an “obesity paradox” that has been described in patients with documented cardiac disease (eg, heart failure), patients undergoing percutaneous coronary intervention, and patients with coronary artery disease referred for single photon emission computed tomography.

Now this study actually is very interesting, even if it does conflict with others that failed to show such an effect. The thinner patients, who had an average age about 10 years higher than any of the other groups, also had a higher mortality after adjusting for co-morbidities.

This is where the issue of primary prevention comes in. It is clear that obesity causes a host of morbidities and mortality, but in older populations in these studies the relationship is less clear, and things like weight loss are associated with a higher risk of mortality. There are many reasons for this. For one, in study groups for evaluating drugs, as in this case, investigators strive to make sure patients get quality care as part of an ethical investigation. The high BMI cohort in this case, even if not perfectly controlled, did have treatment for all the co-morbidities of obesity that the doctors could address. Further, in older patients, you expect a weight gain of about 1lb a year. When weight starts decreasing in an elderly patient, this is what’s known as a bad sign. It is likely the “protective effect” that is observed is from the fact that healthy patients maintain weight, while losing weight is often associated with worsening health in an elderly cohort.

Losing weight therefore appears to be a risk for death, and it is also possible that dieting in an older population simply isn’t a safe proposition anyway. The message you should take home from all these studies of obesity and weight loss or gain is simple. It is very difficult to improve health through making people lose weight, and diets rarely have long lasting effects. Exercise, even in the overweight, is the most likely intervention to improve markers of cardiovascular health. In the overweight, appropriate management of symptoms like hypertension, diabetes etc., is effective in decreasing mortality. And finally, the best way to prevent the diseases of obesity is to avoid obesity in the first place. It’s called primary prevention.

Once people are overweight, it is very difficult for them to return to a normal weight, especially as they age. Clinicians, before diet, should probably stress management of the co-morbidities of high-blood pressure, high cholesterol, and insulin resistance, while encouraging exercise first and foremost. Treatment should not be delayed while expecting weight-loss, which rarely takes.

Especially in children, avoiding obesity is becoming increasingly critical. Diabetes is a serious disease that, if poorly controlled as it is in so many cases, results in terrible outcomes like I saw in my first patient. The best thing we can do for children’s health is emphasize exercise, outdoor activity, and get the damn purified and processed sugars out of their diet, which cause obesity and may independently affect insulin sensitivity. While studies may show that obese patients may experience similar or even better morbidity and mortality to normal weight people, one has to remember these are people who are experiencing control of their blood-pressure, blood sugar, cholesterol etc. Many patients, like my first patient, aren’t so lucky as to have good insurance, regular doctor’s visits, good discipline, or to be enrolled in a clinical trial. The best thing that can be done for them is to prevent obesity and their disease from occurring in the first place.

This constant denial of any negative consequence of obesity is irrational, contrary to the clinical evidence, and is, quite simply, just crankery. While some of Sandy’s skeptical writings do hit the mark (the social-networking study of obesity on the Framingham study being a good example), I have to say she’s more of a skeptic like Steven Milloy of Junkscience (who she links – there’s a bad sign), also a CEI fellow, and noted global warming crank. While they have some capacity to recognize real nonsense, the central message is one denying the rational interpretation of the literature.

Comments

  1. #1 Adrienne
    October 11, 2007

    Thanks for writing about this.

    I used to be involved with the “fat acceptance” movement. But the fat acceptance activists really started to remind me strongly of IDers/creationists with the constant denial of any facts/studies they don’t like while cherry picking the ones that seem to support their cause. So while I still abhor the negative moral assumptions typically made about the obese and I’m still obese myself, I decry strongly the twisting or outright denial of facts by the fat acceptance advocates like NAAFA and Szwarc.

    Then I finally decided to lose some weight too…50 lbs and counting. My blood pressure has gone from 143/92 to 118/72 as a result.

  2. #2 factician
    October 11, 2007

    Adrienne,

    Congrats. Losing weight is very difficult, and you deserve commendation.

    I also know folks who are big into the “fat acceptance” movement. That’s difficult terrain. While I don’t want to stigmatize people for their size, we shouldn’t pretend that it’s not a major health issue. But given how closely weight and self-esteem are intertwined, it’s hard to deliver one message without hurting folks.

    Anyway, very difficult terrain. Nicely written, Mark.

  3. #3 ordinarygirl
    October 11, 2007

    I listened to a SciAm podcast recently about this topic and it was really informative.

    I think for most people diet and exercise is too easy (no wonder pill required) and yet too hard (not as easy as taking a wonder pill).

    The only thing I wonder about that’s not usually addressed is metabolism. Do people really have high and low metabolisms and is it possible to “fix” a low metabolism? Exercise would seem to be key as well as regular meals, but I’ve never really seen a good explanation of how it all works.

  4. #4 Jennifer Ouellette
    October 11, 2007

    An excellent, balanced discussion that manages to avoid the hysteria often associated with this touchy subject. As factician says, too often, weight and self-esteem are so closely intertwined, and being fat is so unacceptable in our society, that it’s tough to separate those issues from the well-established health risks associated with obesity. Those in the “Fat Acceptance” movement have some valid points. They do face public ridicule and sometimes overt discrimination, which is very painful. And the BMI scale is a pretty flawed measure of healthy vs. unhealthy weight, as it fails to account for individual differences in build, bone density, muscle mass, etc. But to make the leap from there to a national “conspiracy” to inflate health risks is ridiculous. Citing the occasional study with ambiguous findings as “evidence” isn’t just cherry-picking — it’s ignoring how science works.

  5. #5 Sandy
    October 11, 2007

    JFS must be doing something right to get this response. This post starts off by scaring readers with an emotional anecdote describing the horrors of diabetes, which are indeed tragic for its victims, while failing to point out that fat people suffer fewer complications than thin diabetics. It also says the increase in type 2 diabetes in population statistics is because of obesity and lack of exercise, rather than the ageing of the population, improved diagnosis and changing the definition parameters. But this piece goes on to repeat age-old myths like refined white sugar causes diabetes, obesity and other chronic diseases; and that processed foods and our Western diet cause obesity and diseases. Quackwatch and the National Council Against Health Fraud would be recommended reading to help with these misconceptions. The post even throws in a few zingers, such as claiming the reason rates of cancer and heart disease are going down is because of better screening — but screening brings the reverse in the stats of any disease, increasing the cases being diagnosed.

    But the biggest fallacy of logic, is failing to understand what risk factors are and equating them with causes of disease. It’s that old “correlation does not equal causation” thing.

    The ad hominem attacks, especially given they are false, are beneath any credible scientist or medical professional, so that classic fallacious argument does not even deserve a response. Neither do many of the logical fallacies in this piece (arguing from authority, personal incredulity, false continuum, post-hoc ergo propter hoc, and tautology).

    The author, while overstating concerns over an obesity epidemic, does admit that no effective intervention exists to reduce long-term weight in fat people, but goes on to repeat the popular suggestion that, therefore, the answer is to prevent obesity — but provides no evidence of any intervention that has been shown to be safe and effective in preventing obesity…because there is none. And this has been documented by the top expert reviews of the evidence, such as the USPSTF, as has been discussed at JFS. In contrast, we have decades of evidence that this suggestion — and endless admonitions to count calories, eat “right,” and exercise — does not work and is causing harm. Also ignored are the decades of research into the causes of obesity that show it is not simply a matter of calories in-calories out. The author repeats the myth that a healthy “normal” weight for everyone is the same arbitrary BMI range, ignoring the natural diversity of sizes that has been part of recorded human history. There is no money in telling people that they are not doomed to die “of fat,” that the few pounds increase in population statistics over recent years is not a major public health crisis, that their food is not killing them, and it might actually be the healthiest thing for people to stop worrying so much. People who feel less afraid and better about themselves are considerably more likely to take care of themselves and be healthier, too.

  6. #6 Adrienne
    October 11, 2007

    The ad hominem attacks, especially given they are false, are beneath any credible scientist or medical professional, so that classic fallacious argument does not even deserve a response. Neither do many of the logical fallacies in this piece (arguing from authority, personal incredulity, false continuum, post-hoc ergo propter hoc, and tautology).

    LOL! He didn’t have any ad-hominem attacks in his post. None. As for the other accusations…can you say “projection”, anyone? Wow. Arguing from authority is one of Szwarc’s favorite tactics.

  7. #7 Greta Christina
    October 11, 2007

    I think this is actually a very hard issue to manage, and to think about.

    As a fat adult myself, what am I supposed to do with the information that obesity is harmful… but there probably isn’t very much I can do about it anyway? (“Once people are overweight, it is very difficult for them to return to a normal weight, especially as they age… Treatment should not be delayed while expecting weight-loss, which rarely takes.”)

    Yes, prevention in childhood would probably have been good. Too late now.

    So the data I focus on is this: I’ve read studies (sorry, can’t find them now to cite) showing that many of the health differences between thin and fat adults diminish greatly, in some cases almost to the point of disappearing, with regular vigorous exercise. (Eating a diet of actual food instead of junk doesn’t hurt, either.) And I focus on that: the improvements in my stamina, my strength, my libido, my mood, my mental health, my ability to sleep, my bum knee, my asthma, etc., that I get from exercise. When I focus on my weight, instead of all those other things, I just get frustrated and miserable.

    For me, that’s what fat acceptance is about: not pretending that there aren’t health problems associated with being fat, but accepting that even when I exercise vigorously and eat well I still don’t lose weight… and accepting myself anyway. (And exercising vigorously/ eating well/ generally taking care of my health anyway.)

    I think one of the problems that the fat acceptance movement has with society (and it’s a problem I share) is that the obsessive fixation on weight loss over any and all other health co-factors is actually counter-productive. (Not to mention the counter-productive moral judgments that get laid on fat people — we’re lazy, undisciplined, self-indulgent, self-hating, etc.) This is anecdotal here, so my apologies for that; but it seems to me that people get so fixated on weight loss that, when it doesn’t work, they give up entirely on lifestyle improvements like exercise and improved diet — even when those changes are improving their lives in other areas. And many of the things people to do lose weight and keep it off are actually harmful, like crash diets and smoking.

    My point — and I do have one — is this: With adults, a public health message of “Being fat is really really dangerous and bad, but there’s probably not a lot you can do about it, so too bad for you” isn’t very helpful. We’d be a lot better off with a public health message of “Exercise and eat right — there are lots of good reasons to do it, even if you don’t lose weight.”

    With kids, it’s a whole different matter. I think a point that Sandy is missing is that Americans are getting fatter over the decades, and American kids are especially getting fatter… and something has to be causing that. And if something is causing it, then something could almost certainly be done to prevent it. Getting sugared soda mahcines out of schools; re-funding phys. ed. programs that have been gutted due to budget cuts; encouraging parents to limit TV time and play physical games with their kids; making high fructose corn syrup a Class 1 Prohibited Substance… all of that would be a good start.

    But we do have this basic problem, which is that our society is largely structured around sedentary schools/ workplaces/ forms of entertainment. It’s structured around cars and car travel. It’s structured with grossly underfunded schools that don’t have money for science and English teachers, much less phys. ed. And for lots of people, it’s structured so that parents work such long hours, often at two jobs, that they don’t have time or energy to do anything with their kids except feed them processed food and plop them in front of the TV. And short of a glorious worker’s revolution, after which we will all be eating strawberries and cream and dancing in the streets every night (kidding!), I don’t know what to do about that.

  8. #8 MarkH
    October 11, 2007

    It also says the increase in type 2 diabetes in population statistics is because of obesity and lack of exercise, rather than the ageing of the population, improved diagnosis and changing the definition parameters.

    Well, that may apply to the elderly but there is simply no explanation for the increase in diabetes in the young except for excess obesity. As any one of the citations I listed shows, obesity is rapidly increasing rates of type II diabetes in the young. You are just listing irrelevant information to distract from the main point, that you are wrong to say that obesity does not cause diabetes, and has created a new young population with the disease.

    But this piece goes on to repeat age-old myths like refined white sugar causes diabetes, obesity and other chronic diseases; and that processed foods and our Western diet cause obesity and diseases.

    Again, a statement inconsistent with the literature. While it’s not clear yet if they have an independent effect on diabetes incidence – which is why I qualified the statement originally – it’s clear refined sugars are partially responsible for overweight and obesity.

    Quackwatch and the National Council Against Health Fraud would be recommended reading to help with these misconceptions.

    I searched quackwatch and found no information debunking the idea that obesity causes health problems, or that refined sugar products may be unhealthy in excess. Nor do I find contradictory information at the NCAHF searching for obesity, refined sugar, or western diet. I’ve contacted Dr. Barret and hopefully he’ll give his opinion.

    The post even throws in a few zingers, such as claiming the reason rates of cancer and heart disease are going down is because of better screening — but screening brings the reverse in the stats of any disease, increasing the cases being diagnosed.

    Some screenings that identify pre-cancerous disease actually do prevent serious cancers. I also mentioned prevention in that sentence as a cause of decreased rates.

    But the biggest fallacy of logic, is failing to understand what risk factors are and equating them with causes of disease. It’s that old “correlation does not equal causation” thing.

    True, risk factors may not be the cause of a disease, but exactly what is increasing the rates of diabetes in kids? Why are they getting gout – the classic disease of excess usually only seen with age? What is the variable that we are missing if not obesity and a sedentary lifestyle – eating crap, drinking soda and playing video games – that has emerged in the last few decades concurrent with all these other problems? Yes, if we want Aristotelian perfection we have to acknowledge there may be another cause, but that doesn’t mean that obesity isn’t the best explanation, or that there is a significant amount of science that provides a reasonable biological basis for obesity being the cause of CVD from an endocrine, inflammatory, and physiological perspective.

    The ad hominem attacks, especially given they are false, are beneath any credible scientist or medical professional, so that classic fallacious argument does not even deserve a response. Neither do many of the logical fallacies in this piece (arguing from authority, personal incredulity, false continuum, post-hoc ergo propter hoc, and tautology).

    My ad hominem attacks are not part of the argument I make, and don’t invalidate the argument. They are tacked on to describe what I think of your site, and my arguments are not dependent on them. As far as arguing from authority, what, the literature? I explained the post-hoc ergo propter hoc, but can’t identify the tautology. You’ll have to help me there.

    The author, while overstating concerns over an obesity epidemic, does admit that no effective intervention exists to reduce long-term weight in fat people, but goes on to repeat the popular suggestion that, therefore, the answer is to prevent obesity — but provides no evidence of any intervention that has been shown to be safe and effective in preventing obesity…because there is none.

    This is true, which is why I suggest the goal should be primary prevention. And just because we don’t have a good treatment yet doesn’t mean one can’t be discovered and wouldn’t be helpful. That’s just fatalistic.

    And this has been documented by the top expert reviews of the evidence, such as the USPSTF, as has been discussed at JFS. In contrast, we have decades of evidence that this suggestion — and endless admonitions to count calories, eat “right,” and exercise — does not work and is causing harm.

    Eating right and exercising causes harm? Now who’s dropping a zinger?

    Also ignored are the decades of research into the causes of obesity that show it is not simply a matter of calories in-calories out.

    So our bodies violate the laws of physics? We produce more energy than we take in?

    The author repeats the myth that a healthy “normal” weight for everyone is the same arbitrary BMI range, ignoring the natural diversity of sizes that has been part of recorded human history.

    I do not repeat this myth at all. In fact the BMI is an imperfect scale. I think the results would be strengthened with more current metrics like waist:hip ratios and measurements of visceral and belly fat. But on average they describe the problem adequately.

    There is no money in telling people that they are not doomed to die “of fat,” that the few pounds increase in population statistics over recent years is not a major public health crisis, that their food is not killing them, and it might actually be the healthiest thing for people to stop worrying so much. People who feel less afraid and better about themselves are considerably more likely to take care of themselves and be healthier, too.

    Are you suggesting I have a financial stake in this? I own no stock in nutraslim or whatever, I assure you.

    Sandy’s arguments remind me of the classic cigarette-company arguments against the link between cancer and smoking. Denigrating epidemiological evidence, and obvious correlative associations between the product and cancer was the classic strategy. You see the same occurring here. Yes, these are correlative and epidemiological studies, but there is no variable that describes the increasing rates of diabetes, or that explains the morbidities better. Further it ignores the biological and physiological bases for these hypotheses that show that fat has endocrine properties, increase inflammation, and increases load on the heart.

  9. #9 MarkH
    October 11, 2007

    Greta,
    I realize now my post seemed doom and gloom, but it is true that medical studies of weight loss interventions haven’t been largely successful. That doesn’t mean that some people don’t successfully lose weight, or that it isn’t worth trying. It’s just not the usual experience.

    As far as what the literature would recommend, it emphasizes exercise as it ameliorates most of the risks of obesity, as well as treatment of the so-called co-morbidities of high cholesterol, high blood pressure, diabetes etc.

    I realize there is a lot of judgment of people based on weight, and part of the health concern comes across as more value-laden judgment, and that is unfortunate. One of the good aspects of the fat-acceptance movement has been to make doctors address this behavior, and not treat obese patients as if their weight is their only problem. Many of the studies cited in this article show that most of the negative health consequences of obesity can be countered with good preventative medicine,( BP control, cholesterol good sugar control,etc) and regular exercise. The bad aspect of the fat-acceptance movement, is of course the denial of science to push their objectives. While their motivations are pure, their reading of the science is not. It is clear that obesity increases risks of morbidity and mortality.

  10. #10 minimalist
    October 11, 2007

    The “no money to be made” whopper is exactly the tactic taken by many global-warming deniers, too.

    ‘Cuz, as we all know, university research scientists are just raking in the dough, while those poor, poor CEI hacks are forced to scrabble for a few hard-earned pennies from oil and sugar interestes.

    The mendacity is staggering.

  11. #11 Orac
    October 11, 2007

    The ad hominem attacks, especially given they are false, are beneath any credible scientist or medical professional, so that classic fallacious argument does not even deserve a response.

    What ad hominem attack? Even if there were, Mark extensively cited the medical literature.

    Actually, I have to be honest here. Mark’s post crystallized nagging concerns I had had about JFS for a several months now but hadn’t taken the time to investigate further. Perhaps it is time that I did so. I also have to admit that I’ve seen a few articles from JFS submitted to the Skeptics’ Circle over the last several months that I had serious qualms about. Your response to Mark did not reassure me that he didn’t make a good point.

  12. #12 Dave C
    October 11, 2007

    Apart from the conspiracy theory feeling on Sandy’s blog, the fact that does make me think that the blog is really just a propaganda machine is that there is no room for comments on it.
    You are just supposed to take what she says at face value, there is no need for clarifications or questions.
    Not quite the censorship practiced at Uncommon Descent but it similar has a similar feel to it.

  13. #13 Brendan S
    October 11, 2007

    We need to add the following to the quack/woo/denialism handbook:

    ‘State that your opponent is using fallacious arguments. Use the Greek terms for these so that you feel important. It doesn’t matter if they actually did it or not. If they claim they didn’t, accuse them of not know what they’re talking about.’

  14. #14 G Felis
    October 11, 2007

    Part of the problem is that the definition of obesity has been reshaped in ways that seem to be more about popular culture’s obsession with thinness than based on careful epidemiology centered on concrete and measurable health outcomes. Thanks largely to distortions by epidemiologists at the Harvard School of Public Health, people who are carrying a few extra pounds are now defined as “obese,” and people who are unhealthily lean are classed as having an ideal healthy weight – even when they suffer worse health outcomes on average than otherwise comparable people with slightly higher BMIs. While Paul Campos of The Obesity Myth fame sensationalizes and expands the scope of this problem beyond all reasonable bounds, the refusal of the Harvard folks to respond appropriately to legitimate scientific criticisms of the basis for their weight categories feeds the crankery of the Campos and the CEI and their ilk: There is SOME demonstrably bad (or at least questionable) science involved in the precise definition of obesity, which gives the fringe people all the reason they need to decide that ALL medical science regarding obesity is bad.

    Of course, having already descended into crankery on the subject, if you show them that study after study of obesity risks shows the same general health risk trends when the Harvard categorization is tossed out in favor of raw height/weight or BMI data, they won’t believe it. Which doesn’t change the fact that the Harvard asses need to just ‘fess up to their errors and fix the damned numbers already.

  15. #15 Brian
    October 11, 2007

    ‘State that your opponent is using fallacious arguments. Use the Greek terms for these so that you feel important… ‘

    Jumpin’ Jiminy! What’s the point of arguing with someone if they refuse to even learn a new PHRASE, much less any relevant new information?

  16. #16 minimalist
    October 11, 2007

    Good question. I, too, hope Sandy learns what it means someday, and as a result is more careful about slinging it around in the future.

  17. #17 Lab Lemming
    October 12, 2007

    Adrienne:
    “Then I finally decided to lose some weight too…50 lbs and counting. My blood pressure has gone from 143/92 to 118/72 as a result.”

    You ROCK!

  18. #18 Adrienne
    October 12, 2007

    Why thank you! :-)

  19. #19 Brian
    October 12, 2007

    Adrienne,

    As a fellow ‘loser’ (lost 50lbs too, gained like 15 back, and recently re-lost those 15), one thing I noticed is how good I felt when I lost weight, but how my actual weight didn’t seem to matter, emotionally.

    I felt worse going from 175 to 180 than I did from 195 to 190, even though I’d have killed to be back at that lower weight. I think that’s partly why people gain weight back (hence the warning here): There’s a bit of a disappointment when you reach your target weight, because the thrill of losing weight is gone. As long as the goal is always to improve your health overall, you’ll be buffered from that.

    Keep up the good work, I know how hard it can be! :)

    ps: also, dietfacts.com helped me a lot… it’s crazy to see nutritional info for restaurant foods. Never would’ve suspected that Hardees was better for you than any burger at Ruby Tuesday ;)

  20. #20 Adrienne
    October 12, 2007

    Thanks, Brian. I know about losing and regaining. In both 2001 *and* 2002 I managed to lose 40 pounds in 4 months, then regained it both times. What happened? Both times I “fell off the wagon”, then just gave up. And my bulimic urges from long ago always come back when I diet, so I had to fight that each time too.

    This time with the weight loss, I’ve learned to forgive myself and move on if I eat off plan, which I could never really do before. I’ve “cheated” more than I did previously when I tried to lose weight, but I’ve also been able to get back on track each time. I’ve also been able to conquer the bingeing and purging demon (after a few lapses, naturally) and keep it away. Go me!

  21. #21 Adrienne
    October 12, 2007

    Oh, one more thing: I read somewhere that it takes the average smoker five quitting attempts to finally quit smoking for good. So that made me feel better about trying to lose weight again.

    Also, I think the successful losers in the National Weight Control Registry on average took a few tries to finally lose a significant amount of weight and keep it off.

  22. #22 Dano
    October 12, 2007

    I don’t know if Tech Central Station still posts Sandy’s disinformation there, but I created the Dano character partially out of a response to her mendacious posts at TCS.

    And the use of ad hom is a clue to a signature reaction by a particular ideology.

    HTH.

    Best,

    D

  23. #23 PalMD
    October 12, 2007

    Jeez, i just gave my “energy in, energy out” speech not 2 hours ago to a fat patient.
    It’s not a matter of “blame” but physics. You cannot maintain your weight if you consume insufficient calories. Now, that’s hard as hell, but there is no “fair” in science.

    We are not designed to starve ourselves, but if you restrict calories, you will lose weight. Period. You may feel like you are not eating (because your body sends signals to your brain that you are starving–you are) but any time you are gaining weight, you are consuming more energy than you are expending.
    No magic, no woo, no politics, just science.
    BTW, weight watchers works.
    Other obesity-related health problems often overlooked–if you are very obese, you don’t fit into many diagnostic devices, can’t get a cardiac catheterization, ct scan etc. We used to have to humiliate people by sending them to the friggin ZOO for MRIs.
    Obesity is horrible–socially (society can fix that) and medically (individuals can fix that).
    To make ridiculous statements about fat diabetics being healthier–well, to quote Orac again, “The stupid, it burns!”

  24. #24 ChrisC
    October 13, 2007

    “There is no money in telling people that they are not doomed to die “of fat,” that the few pounds increase in population statistics over recent years is not a major public health crisis, that their food is not killing them, and it might actually be the healthiest thing for people to stop worrying so much.”

    Wow! What an insight that sums up the quality of your argument perfectly.

    Of course, there is no money to be made SELLING junk food. It’s not as though Coca-Cola and Coors, have donated generously to the CEI (an organisation Sandy is a member of http://www.sourcewatch.org/index.php?title=CEI#CEI.27s_Budget). An of course, there would be no possible advantage to large food corporations, such as Coca-Cola who have been vocal in attempting to silence criticism over obestiy, in delaying action to reduce childrens intake of its products. (http://www.sourcewatch.org/index.php?title=Coca-Cola_Company#Countering_Criticism_Over_Obesity)

    No, the whole thing is a conspiracy by those of us who would like to see kids eating “right”, who have “obesity interests”. Think of all the money that can be made by scaring kids into eating… VEGETABLES! Mwwwhahahaha!

    There is obviously no money to be made telling people it’s okay to eat as many twinkies as they would like.

  25. #25 PalMD
    October 13, 2007

    Don’t forget an agricultural subsidy structure that favors corn syrup and other grain based products over fruits and veggies.

  26. #26 Adrienne
    October 13, 2007

    Yah, and it’s not like McDonalds and other fast food and junk food manufacturers aren’t the main contributors to Tech Central Station, the website that routinely features Sandy Szwarc’s writing or anything. It’s not like she’s essentially a shill for the food industry. Oh, wait….

  27. #27 ChrisC
    October 14, 2007

    You can follow the money that McDonalds has spent on lobbying at this website:

    http://www.opensecrets.org/lobbyists/clientsum.asp?txtname=McDonald%27s+Corp&year=2006

    For such a large company, their lobbying expenses are actually quite small. However, according to Source Watch, Mickey Ds has made substantial political contributions ($123,000 in 05/06), with 90% of the cash flowing to the Republicans.

    This obviously proves that there is a large vegetable lobby, out there to terrorise children into eat spinache and broccolli, rather than good ol’ quater pounders. All for personal gain of course.

  28. #28 sea Creature
    October 14, 2007

    Greta Christina, thanks for a wonderful post. I am close to someone who is overweight but has taken up exercise for the first time and is loving the effects – better sleep, better stress management, better mood swing management, more stamina and strength. But the body image stuff is huge. I can only get a glimpse of it. This person works as a teacher and has seen over the last 20 years the fattening of the students and believes that increased food insecurity of the poor is part of the problem. The kids sometimes go without much in the way of food for a few days then a paycheck comes and the family binges.

  29. #29 Justin Moretti
    October 14, 2007

    it is with dismay, that I read Sandy Szwarc’s blog Junkfood science,

    I read it with dismay too, mostly because (as Dave C said) she’s turned off all commenting for the entire blog and there’s no easy way to call her on things that don’t look quite right.

  30. #30 Az
    October 16, 2007

    I used to be a regular reader of Sandy’s Blog, until I actually had time to start going through some of the studies myself and found that there was a lot of cherry-picked information filling its pages.

    I understand the draw though. When gradschool slapped an extra 30 lbs on my ass (you NEVER imagine what spending 14 hours a day in a desk is going to do to you) my doctor stopped being helpful and started sending me home in tears. It happens. There are good docs and bad docs, and people who’s physicians only have enough time with them to give them the standard “you’re going to die before you’re 30″ lecture leave feeling hopeless and are infinitely more suceptible to woo.

    I really like that you addressed how difficult weightloss is and that the best option is to treat comorbidities first. I finally found a decent doc now who works with me to maintain my health. Keeping my cholesterol and blood pressure at a constant level is mandatory. Daily exercise is used as a means to reduce stress, and to stop thinking about monkeys. Weight loss is not mandated, but has been happening as a result of lifestyle changes. In my experience, this has been a better approach than focusing on weight loss alone.

  31. #31 Adrienne
    October 16, 2007

    Yeah, I in agreement about going to doctors who aren’t mean to fat people. It’s one thing to be told that losing weight will improve your health, but quite another to be humiliated by a doctor who obviously regards you as “lesser than” because of your weight. And having been overweight since age 9 (then officially obese since 17), I’ve had more bad experiences with doctors than I’d care to recount. Left at least two doctor’s offices in tears. I’m glad a “fat friendly health professionals” list exists now: http://www.cat-and-dragon.com/stef/fat/ffp.html

  32. #32 Moxiequz
    December 20, 2007

    I’m a bit behind the times – I just found this post today. Thank you MarkH for your excellent analysis and rebuttal to Sandy’s comments. I’m overweight and – even as I struggle with getting my daily diet on a healthier track – I maintain no illusions on the negative health effects this extra weight brings. I wish it weren’t so but there’s nothing to be gained by ignoring reality.

    I’ve found excercise to be the best thing to focus my energy around. It makes me feel better, it builds endurance, it’s relaxing (I generally take long walks and do steep-hill walking when I can) and it reduces blood glucose levels and blood pressure. It also gets you up and out of the house and away from the temptation of snacking/grazing.

  33. #33 Anonymous
    March 20, 2008

    “what am I supposed to do with the information that obesity is harmful… but there probably isn’t very much I can do about it anyway? (“Once people are overweight, it is very difficult for them to return to a normal weight, especially as they age… Treatment should not be delayed while expecting weight-loss, which rarely takes.”)”

    You don’t have to go far to find example of people who have lost weight and keep it off. Check out your local weight watcher meetings. Statistically most people who try to quit smoking don’t succeed either, but we all know people who have quit smoking and people who have lost weight.

  34. #34 moldau
    September 27, 2008

    Thank you SO much for this! I consider myself a feminist, and frequently run into the Fat Acceptance thing on blogs. I think it is absolute junk, and if I say so I’m accused of “fat shaming.” I also take offense at women “of size” making remarks about women who are slim, talking about our “toothpick” legs, assumed lack of breasts, calling us anorexic and talking about our “boyish” figures. You made the argument better than I ever could. I work in rehab and am so frustrated when I’m dealing with obese people who aren’t willing to accept that their obesity contributed to the knee replacement they just had, and that their size is making the rehab process harder and longer.

    Change is so hard for some people that they will make all sorts of arguments to avoid it.

  35. #35 HappyChappy
    January 16, 2009

    It saddens me to hear a doctor(?) say that eating sugar causes diabetes. Please don’t do that it immediately identifies you as ignorant.

    Diabetes is genetic. There are some things you can do to prevent it or at least put it off for years and losing weight and excercising will help. If you are not genetically predisposed to get diabetes then gaining weight or lack of excercise will probably not increase your chances of getting it.

    Obesity is primarily genetic. You can diet, excercise, starve yourself and make temporary changes but your body will win.

    When you look at the data it is no suprise that obesity and diabetes tend to corrolate. But this is a result of your genetics and not one factor causing another. I am guessing they don’t make doctors take enough statistics classes in college and this would explain their lack of understanding of it’s weaknesses. By the way, it is carrots that cause obesity and diabetes!! There is a clear statistical correlation between eating carrots and getting diabetes and being obese. With few exceptions fat people have eaten carrots and ditto for obese people. After all statistics don’t lie…

  36. #36 Fraser
    February 3, 2009

    Happy, to be statistically relevant, you’d have to show that fat people eat more carrots than thin people, that weight increases with carrot intake, that sort of thing. I know you’re making a joke, but still.

  37. #37 yvonne
    July 7, 2009

    Hi,

    Great site!!!! Obesity is the cause of many diseases. There are a lot of American’s that are over weight. We have to stop eating FAST FOODS it is killing us. Good health is our greatest asset without good health we are doomed to die. We need to eat right, exercise and drink plenty of water to help maintain good health and well-being

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