Research about dieting never changes...

Every few weeks, I get together with some friends who are also interested in fat acceptance and HAES and we discuss a relevant journal paper. The first paper we discussed was a meta-analysis of dieting studies. It's a good paper, published in 2007, in the Journal of the American Dietetic Association. It reviews what we all know: all diets work pretty well at first, then you gain the weight back. In the end, after a year or two, dieters in studies end up about 5 kg lower than they started. Given that this doesn't include the 1/3 to 1/2 of the people that drop out, and also given that initial weights tend to be inflated as people binge before their initial weigh-in, and given that this isn't nearly enough to make any fat person thin ... those 5 kg are pretty meaningless.

Still, this month's Journal of the American Medical Association published a paper called Comparison of Strategies for Sustaining Weight Loss. This study has -- I counted them -- 27 authors! It's published in a top medical journal! It involves over 1500 participants! And can you guess what it showed? Yup, they all lost weight at first, and then regained to end up about 5 kg below where they started.

I really don't get it. Why do they bother? Why does this stuff keep getting published? (And in major journals!) It's all the same.

Fat, Female, Forty, Fertile

We had a lecture about gallbladder surgery this morning. The phrase "Fat, Female, Forty, Fertile" describes the patient most commonly affected by gallstones. The prof simply explained this without moralizing, and even mentioned that rapid weight loss is a substantial risk factor for gallstones. You can discuss fat as a risk factor for specific diseases in an inoffensive way.

Plastic Surgery

This morning we had an hour lecture on plastic surgery. The cases shown were pretty amazing -- individuals recovering from burns, cancer and accidents whose lives have been dramatically improved by plastic surgery.

It was all well and good until the lecturer tells us we have five minutes left, and do we want to see a "really gross case" before the end of class. Of course, the class says yes. So he pulls up a slide that says "Morbid Obesity". He then described and showed images of a panniculectomy. That's an operation to remove a large pannus (basically extra tummy fat that can hang down over the pelvis in fat people). This was an unusually large pannus in an unusally large woman.

I jotted down a few comments, verbatim, from the lecturer:

• "next time you go to the chip truck" (that is, remember this case, because if you eat too many chips you'll get like this)


• "she works at the post office" (just to reinforce other random fat-person stereotypes, I guess)


• "I'm not making fun of her, this is a horrible disease" ... but ... "this disease is from eating"


• "she's still huge! look at the size of her!" (that is, she's still a giant fatty after we've removed the pannus)

This was a whole lecture of cases that could be considered 'gross'. It's gross to see someone's abdomen ripped open, it's gross to see someone with half their face missing, and it's gross to see a hand with no skin on it. Nevertheless, the panniculectomy was the only item in the lecture that was explicitly described as gross. The part that really gets me is that the prof wasn't describing the surgery as gross, rather, he was describing this woman's body as gross. That's the part that really is not okay.

Afterwards, I was pretty upset about this. Over the next couple of days I asked a few classmates for their impressions. The response was pretty uniform. Mostly, they didn't recall the panniculectomy slides at first. Then they agreed that there would have been a less offensive way to say it -- but on the other hand, there's a lot of black humour in medicine, and I'm being a overly sensitive.

I don't think I'm being overly sensitive. This matters. Fat people don't seek medical care because they worry that doctors will think their bodies are "gross".

References

Some basic first resources to point people to when learning about HAES:

"Diets Don't Work" list of blog posts
Penn & Teller Video Clip
Gina Kolata on dieting
A good summary of dieting myths

The right way to talk about fat

Recently we had a lecture about various gynecologic cancers. There were several mentions of weight as a risk factor and it was as simple as that. Not in a condescending way, not in a "they deserved it" kind of way, not in a "and by the way they need to diet NOW" kind of way. Just simply explaining. The lecturer also pointed out that women with ovarian cancer are often told that they're just getting fat when, in fact, they have tumors growing. Not surprising to me, but good to mention to our class, I think.

Smoking and sedentary means fat?

Today in tutorial we considered the case of a post-menopausal woman and her risk for osteoporosis. The case described the woman as a sedentary smoker, but made no mention of her weight. The tutor then made a comment along the lines of "And is she also obese? Probably!" I responded, "Probably not, because obesity is protective for osteoporosis and this woman already has low bone density." I don't even know what the association was in this case, it seemed totally random. Is it simply because people assume that sedentary = fat?

Other than that, the gynecology resident who taught the session was an excellent tutor. He explained the material well, shared career advice, and was generally friendly and helpful. I'm adding this bit because I don't want to generally complain about this tutor -- he wasn't bad. The stereotypes about fat patients seem to hold for just about every physician I meet through school, no matter what they are like otherwise.

Another BMI Chart

Today in tutorial we were handed another BMI chart. That's either my third or fourth since starting medical school. I can't quite remember, partly since I throw them out right away... The claim was made in this tutorial that a BMI of 27.3 increases the risk for endometrial carcinoma. I was pretty skeptical. Flegal's 2007 JAMA paper shows that in the BMI 25-30 range the risks of "obesity-related cancers" are not significantly different from the BMI 20-25 range.

I don't have time to look into this carefully right now, but I'll try to check out the following article when I have some time.

Authors Full Name	Chang, Shih-Chen. Lacey, James V Jr. Brinton, Louise A. Hartge, Patricia. Adams, Kenneth. Mouw, Traci. Carroll, Leslie. Hollenbeck, Albert. Schatzkin, Arthur. Leitzmann, Michael F.
Title	Lifetime weight history and endometrial cancer risk by type of menopausal hormone use in the NIH-AARP diet and health study.
Source	Cancer Epidemiology, Biomarkers & Prevention. 16(4):723-30, 2007 Apr.
Abstract	Obesity and menopausal estrogen therapy are established risk factors for endometrial cancer. However, the joint effects of obesity and menopausal hormone therapy on endometrial cancer risk are incompletely understood. We addressed this issue in a cohort of 103,882 women ages 50 to 71 years at baseline in 1995 to 1996. During a median of 4.6 years, which contributed to a total of 455,304 person-years of follow-up through 2000, 677 cases of endometrial cancer were ascertained. (...)
Date of Publication	2007 Apr