Point Sizing up Health
by Catherine Kraus M.Ed, RD, CHES.
Counterpoint Health at Every Size
by Michelle Allison
How many times have you heard someone say, “I have a weight problem because I have a slow metabolism?” People blame their weight on all sorts of things, and it is true that diet, exercise, genetics, and environment all play a role in a person’s ability to manage weight. Understanding obesity is a complex issue that we will not solve overnight. But the truth is the obesity epidemic is a serious public health problem in America, one we cannot afford to ignore.
Before we can discuss the implications of weight, we have to understand that obesity is defined as having a BMI of >30, whereas the “overweight” category covers BMIs between 25 and 29.9. The terms are not interchangeable. There are many exclusively obesity-related co-morbidities, including diabetes, hypertension, sleep apnea, heart disease, joint pain, and acid reflux.
But these aren’t the only difficulties facing the obese. As a dietitian working in a weight management setting, I see and hear about the struggles my patients experience on a regular basis. People of average weight might never think to worry about seat belt extenders for cars and planes, a chair’s ability to withstand their weight, discrimination in the workplace, inability to find clothing in any department store, crossing their legs when they sit or difficulty with bathing, dressing, and chores. Many obese people, however, must confront these difficulties daily.
These are serious problems, and they affect a large slice of the population. According to the CDC, the prevalence of obesity in the United States is 32.2% among adult men and 35.5% among adult women. Childhood obesity is also on the rise: 17 percent of children ages 2-19 in the United States are obese. Many pediatricians and parents shy away from using the term “obese” when referring to children, but parents may not take their child’s health seriously if the pediatrician sugar-coats the situation with statements like “your child is a little overweight.” Children face the same health risks as adults as well as many psychosocial issues such as bullying and low self-esteem. These obese children often grow up to become obese adults, and the vicious cycle continues.
It is essential that we break this cycle. Motivation, or lack thereof, can affect a person’s ability to make changes in their lifestyle. But, at a fundamental level, weight gain is linked to excessive calorie intake. The diets of individuals with limited resources or limited access to healthy food tend to consist largely of refined carbohydrates, saturated fat, and sodium. All of these promote diabetes, hypertension, dental caries—and, of course, obesity. Some of the best ways to improve a poor diet include increasing fiber intake via fruits and vegetables, decreasing overall calorie intake, choosing non-sweetened beverages, and making healthy choices while dining out. But individual diet choices alone aren’t the answer.
So, what is the solution? Many people believe we should invest in preventative programs. However, this would require either 1) all insurance companies to cover these programs (an unlikely prospect) or 2) all participants to pay for these programs out of pocket. Given the medical costs associated with adult obesity ($2.9 billion in 2003) and the current state Michigan’s economy, the latter is not really an option for most individuals.
Obese individuals should also avoid non-surgical weight loss programs that guarantee drastic weight loss in a short amount of time. A safe, healthy rate of weight loss for an adult is about 1-2 pounds per week, and for children that number can be 0.5 pounds or less. People can achieve these goals by reducing their daily caloric intake by 500-1,000 calories while increasing energy expenditure. Pharmacotherapy can supplement these practices in some cases, and bariatric surgery is an option for adolescents and adults who qualify based on the requirements of their insurance company—typically, having a BMI of greater than 40 and at the presence of serious weight-related illnesses. But even those who undergo surgery must still change their lifestyle significantly.
Obesity is a serious health care issue, and we must take concrete measures to address it. Most people probably recognize that it is not healthy to be obese, but they may not know what steps to take in order to lose weight. Though healthcare providers ought to be sensitive when discussing a patient’s weight, they have an obligation to educate their patients about the consequences of obesity and effective ways to improve their health. Working with a multidisciplinary team (dietitian, physician, exercise specialist, therapist, pharmacist) provides the most well-rounded approach by addressing all areas of the patient’s life. Trying to change several behaviors at once can also feel overwhelming, and initially, patients can change their habits in small ways, such as consuming a high calorie beverage every other day instead of daily. Long-term clinical follow-up may also be necessary to ensure weight maintenance. But these steps do lead to successful and lasting weight loss, and if patients continue to develop and solidify positive lifestyle habits, they can go on to lead healthier and happier lives.
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The link between weight and health is not as straightforward as we’d like to believe. We commonly assume that to be fat is to be unhealthy and that fat people are personally responsible for their weight “problems,” but the scientific literature on weight and health tells us a different story. Fat and health are not mutually exclusive categories, and the promotion of dieting and weight loss as the only routes to good health can actually harm much more than it helps.
Studies of metabolically benign obesity show that more than half of “overweight” and nearly a third of “obese” US adults are metabolically healthy. At least two population studies in the US and Canada show that the lowest risk of all-cause mortality exists in those labeled “overweight” on the BMI scale, a risk that climbs only for the 6% of US adults whose BMI exceeds 40. Being “underweight” carries increased risk as well, and in older adults, the correlation between obesity and increased mortality risk breaks down altogether. Clearly, it is not just possible to be fat and healthy—at least 40% of the fat people in the US already are.
Exercise studies have shown that aerobic fitness has a more significant effect on health than weight alone, and that fat, fit people are healthier than thin, unfit people. In addition, a “health at every size” approach to diet and exercise has been proven to improve health parameters without weight loss, and people who pursued this approach were more likely to change their habits for the long term, compared to a weight loss approach.
But the most important point is that even if there were a direct, causal association between fat and ill health, there is no safe, effective, and permanent method of weight loss that works for more than a tiny percentage of those who try.
Even the most optimistic obesity researchers estimate the failure rate of weight loss at around 80%. The National Weight Control Registry, designed to highlight the effectiveness of weight loss, actually proves the opposite. Despite relatively lax inclusion criteria, the registry of people who have “successfully” lost weight comprises only 0.001% of all who attempt weight loss in the US. By all standards of medicine, this approach would not be considered to an acceptable treatment. For the treatment of overweight and obesity, however, we seem willing to suspend such standards.
Why? An extensive body of research from the Rudd Center suggests that weight bias—prejudiced beliefs and attitudes about fat people, often leading to discrimination—is prominent among health care practitioners. The willingness to promote questionable treatments to fat patients may be the result of the tendency to view their weight and health issues as the result of laziness, gluttony and lack of discipline, rather than the complex biological puzzles they are.
You’ll notice that these biased beliefs are couched in moralistic terms: “ lazy,” “gluttonous,” “undisciplined.” In social psychology, such global assessments are hallmarks of the fundamental attribution error, wherein a person attributes another’s behavior (or, in this case, appearance—a proxy for behavior) to inherent aspects of their personality, rather than the result of circumstances beyond their control.
This, in turn, reveals the presence of a “just-world hypothesis,” where it’s easier to believe that a person is fat due entirely to their own behavior and immorality—in other words, they got what was coming to them—and that thin people, in contrast, have an inherent moral superiority that grants them the self-discipline to control their weight. But research in both human and animal models show that not only is weight diversity natural, it is also very difficult to permanently lower or raise one’s body weight through changes in diet and activity.
Moralizing is not only common around weight but also affects our beliefs about food. Despite having arguably the safest, most plentiful food supply in human history and enjoying a longer lifespan and better health than any previous generation, our anxiety about food and health has only increased in recent decades.
Not only are we anxious, but the foods we deem “healthy,” and therefore desirable, map in a curiously neat way onto foods that are “classy” or trendy: organic, heirloom fruits and veggies, free-range eggs and meat, whole grains, etc. High-class food, in other words, becomes “healthy” food. And since people with higher BMIs tend to have lower socioeconomic status, high-class bodies—thinner bodies—become “healthy” bodies.
In the early 20th century, when poor people tended to be thinner and adiposity was a sign of economic success, a fatter frame was considered more attractive—and healthier—than a skinny one. Whole grains were still the fare of poor people, including immigrants, and more expensive white bread and refined cereals took on an aura of wholesome healthfulness.
What I’ve learned from my training and my practice, however, is that how one eats is just as important as what one eats. A healthy relationship to food underlies good nutrition. After all, a wide variety of different diets exist around the world that support people in good health. I believe ours could, too, if we would let go of our panic about weight and learn to eat and live well just as we are.
About the Issue
Point author: herine Kraus is an LSA senior majoring in Communications and Linguistics. Perry is a lifelong Michigan fan and laments the fact that his four years at UM have been some of the worst four years in Michigan football history.
Counterpoint author: Michelle Allison is a sophomore at the University of Michigan majoring in history and anthropology.
Edited by: Aaron Bekemeyer and Leslie Horwitz
Cover by: Rose Jaffe