We need to stand up for common sense in medicine
Either you didn't read the NYT piece, or you're being purposely obtuse. The author states, correctly, that our current measures for weight loss (for everyone, including kids) don't work. She also states, again correctly, that the BMI is not a reliable measurement when used in kids. And yet, the new AAP guidelines focus on BMI for *two year olds*.
Is obesity in kids a problem? Maybe. Should we treat it as aggressively as the AAP suggests? Heck no. As Emily Oster writes in her piece (https://www.parentdata.org/p/new-aap-guidelines-on-childhood-obesity) on the new guidelines, "There is a link between childhood obesity and adult obesity, but the predictive power is not 100%. About half of children with obesity go on to have obesity in adolescence, and about 70% of adolescents with obesity go on to have obesity at age 30."
Yet we have the AAP recommending weight loss medications and bariatric surgery - permanently altering the bodies of children as young as 13. Whose ideas are deranged again?
Rats. I really think diving into the data on obesity would be your jam Vinay. That being fat is bad for us is just the kind of thing that’s so obvious to us that we don’t need data to believe it. The kind of thing I know you are keen to investigate further. When I’ve gone back and looked at the highest quality data we have I’ve been left with the impression that the downsides of obesity are far overstated, especially for the BMI 30-35 group (the vast majority of “obese” people). I’ve come to wonder if fat bias isn’t more detrimental than fatness itself. It’s certainly true that telling folks to lose weight, which we’ve been doing for decades, hasn’t done anything to move the needle (or perhaps it has, and it’s backfiring!). I worry you’re not taking your usual approach to this issue. Yes, we need RCTs, but the question should be “do people live better and/or longer if they lose weight with X intervention?” And we must be open to the possibility that our interventions may lead to weight loss without improvement in morbidity or mortality, because perhaps being fat per se isn’t bad at all.
The people responsible for the article are tragically absorbed in bad ideas. But they are right (on accident, probably) when they asked if it were possible to eat more healthy foods, rather than restrict calories. It's what people are eating (sugar and refined seed oils) that's at the root of the problem, not the quantity (the quantity is driven by the what). Saying excess calories is the problem with obesity is like saying gravity is the problem with plane crashes. Technically true, but totally useless. It's insane to argue that obesity isnt a problem or is racially motivated, but it's also insane to continue to attempt the same strategy (eat less, exercise more) that has failed for 40-50 years.
Wow. Absolutely wild.
The bingo comment was sort of a joke. I did spend my career working in small rural communities and ran a very large practice and heart hospital. No one told us how to practice and as managing partner of over 50 cardiologists it’s like herding cats with machine guns.
No one is saying obesity is fine. Even the examples given don't say that.
What the examples show is that the way we talk about obesity isn't working in certain populations. As we see plainly, our public health efforts around obesity over the last 20 years have failed completely.
In both minority populations and in kids, we can't just scream "eat better and eat less!" Our advice has to match the environments they live in and, for kids, the impulses they have.
The author of this piece seems to have completely missed those points.
Okay, I will grant that the entire U.S. landscape is nutritionally racist.
How does that eliminate the health consequences of obesity?
The Mt. Sanai people could link any number of adverse U.S. health profiles to poverty. Basically all of them. So how is "ignore it" supposed to help?
Being a doctor at this point would not be worth the combined hassle and expense. Those of you already there and with your loans paid off have a different problem than the people being churned through medical schools right now and expected or even required to believe or feign belief in loads of horseshit about obesity, reproductive physiology, and vaccines.
I'm going to start consulting that one permanently unshowered local chiropractor every town has for all of my medical needs.
The thing is ... even if you live in a "food desert", you can still control your eating habits and exercise more. People in prison can be in fantastic physical shape despite terrible prison food.
Even Walmart carries fruits and vegetables. Even if you primarily get them from frozen bags, it's better than eating fast food. Nothing is stopping these "poor" people from exercising, even if it's just going for a walk. Nobody is forcing them to eat fast food, ice cream or drink high-calorie drinks. Water is (mostly) free from the tap.
By cutting out fast food I dropped about 15 pounds in a few months with no change in exercise routine. I dropped more weight through portion control. When eating out, once I stopped feeling hungry and noticed I was eating for "pleasure", I would put down my utensils and ask for a take-home box or bag.
"Deranged" is exactly the correct term. What kind of alternate universe have we entered?
It is 100% about treatment not preventing obesity. Treatment makes the medical complex money.
Dr. Prasad, I highly respect you, your education, knowledge, and experience. Your insistence on paying heed to legitimate studies, as well as your ability to “ see things from all sides” and take into consideration the nuances that exist in most everything. The evidence is clear: obesity, being overweight, is bad for one’s health. If you live on planet earth, it is hard to imagine that you have not heard this message. And you did mention that you should address an overweight person carefully and compassionately. You wrote that poor people and minorities need extra support. Good on you! But honestly, if we are going to tackle this thing that is bad for health and humanity, I implore you that this is not the way to do it. Obesity is an incredibly complex issue. The person that wrote about suggesting eating more healthy foods instead of restricting calories was simply coming to the problem from a different, more nuanced perspective. You can see that in the context of that paragraph. Know this: people who are overweight know they are overweight. Most have been on every diet known to mankind. They have lost and gained their body weight a dozen times. Don’t you think if it were clear and easy that they would have lost weight long ago and kept it off? Do you think they enjoy being overweight? Make no mistake: when you come at people/patients with obesity as their problem, it is not the same as saying someone has hypertension. Or gout. Or an ear infection. No, it says to them that they are the problem. You are trying to fix them because they are the problem.
I ask just this: how is this working for us? How is this working for the “problem” we have with obesity in the US? I would like to suggest that it is not. Obesity is hugely complex and we need to talk about and offer much more nuanced ways of trying to help and expand our research to see what can help and why some people struggle with it and some never will. We need more information.
I’ll leave with just one of a myriad of nuanced possibilities as to why the “calories in, calories out, excercise more, come back for a weighin to see if we have corrected your problem (that is you),” isn’t working. How about the young girls who at age 10 or 11 have a bit more “meat on their bones” (NOT obese) and are comparing themselves to what they see in every media place? Whose daddy (totally immersed himself in what screens say female beauty is) pinches her arm and says that she better skip dessert because she’s getting a little pudge and you don’t want the boys not to like you, do you? Please know, these examples and so many more are at the root of obesity, at least in part. There is much shame involved so much of the time. Obesity is not just about what and how much we eat and what and how much we excercise. And the number on the scale.
Dr. Prasad, thank you for listening, I so hope that this has made some kind of sense to you and others. Perhaps you might reread the paragraph referenced here and see that they are trying to take a different approach to help a patient, an approach that leaves shame out of the picture,
So true, as a prior doc in the USN...we had standards of physical readiness....had nothing to do with race or sexuality...and of course it's for good health to not be obese
Watching kids doom scroll says a lot. Thinking how little physical activity they get suggests that we will see an explosion of broken bones and osteoporosis about 50--60 years from now. Those teens glued to their gaming consoles are another reason for worry.
There are three threads on display here that should not be confused:
One: social norms that indeed can be stigmatizing, but for different things in different cultures and for different things at different times. Questioning of norms and customs is very prominent in modern industrialized societies where change has been accelerated.
Two: medical knowledge that certain practices are better than others in terms of promoting health. So here it is important both not to stigmatize obese patients or clients - something that has been a part of medical practice as long as I can remember (I am a retired RN) - while pointing out real and potential health problems. But it is probably impossible to completely cleanse such discussions of any normativety, and the question is if this would even be desirable. Being saddled with health or mobility problems down the line is not empowering, but what risk any individual is at must rely on best population and individual data both.
Three: the contribution of an ideology that sees racism and colonialism in everything, and want to problematize any established association between heath and obesity (as far as I can see).
It is therefore important which of these points of view one is arguing from, for clarity: Yes, there are all kinds of contributing factors to obesity and ideally one should be able to address all - but that is still presuming that there is something to be addressed.
Another example of American medical leaders becoming futile in their speculations with their foolish hearts being darkened to the truth. Up is now down; left is now right; fat is now healthy. They are professing to be wise, and yet they are quickly diving head-first into foolishness.
So the NY Times publishes a opinion piece from a guest author, suggesting obese people eat more healthy foods, and they're "pro-obesity?"