Sunday, February 10, 2008

Saturday, February 9, 2008

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.

Tuesday, February 5, 2008

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.

Monday, February 4, 2008

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 NameChang, Shih-Chen. Lacey, James V Jr. Brinton, Louise A. Hartge, Patricia. Adams, Kenneth. Mouw, Traci. Carroll, Leslie. Hollenbeck, Albert. Schatzkin, Arthur. Leitzmann, Michael F.
TitleLifetime weight history and endometrial cancer risk by type of menopausal hormone use in the NIH-AARP diet and health study.
SourceCancer Epidemiology, Biomarkers & Prevention. 16(4):723-30, 2007 Apr.
AbstractObesity 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 Publication2007 Apr

Balancing Evidence and HAES

I am a second year medical student. I am fat. I believe strongly in Health at Every Size: the idea that everyone, regardless of size, can improve health through enjoying physical activity and eating well and pleasurably. I do not believe that dieting or intentional weight loss are healthy or desirable activities.

I started this blog because situations and school get me so angry when obesity is discussed. This is my space to vent.

My lecturers and tutors and classmates mean well. They are certain that encouraging patients to lose weight is positive and will improve health. And beyond that, I wouldn't deny that there is an association between (some) disease and weight. But it's not as strong as is commonly thought. And as Sandy and others point out repeatedly, correlation continues to be different from causation.

A Morning of Gynecology

This morning, we had three gynecology lectures. The first two were about menopause and the third was about PCOS. The menopause lectures were bearable; the PCOS lecture was not.

Some points that bothered me:
  • An example used in lecture was, "This week, I am treating an 11-year-old girl with PCOS who weighs (pause for effect) TWO HUNDRED KILOGRAMS!" (The class responds "Ooooooohhh".) Yes, this child is unusually fat for her age. No, we don't have to present her as a freak. Let's keep in mind that the vast majority of 11-year-olds couldn't weigh that much no matter how hard they tried.
  • The oft-repeated statistic that "even a 5% reduction in body mass improves ovulation and fertility" was used. That always seems to me to be evidence that your behaviors matter more than your absolute body mass.
  • A slide quoted "Obese women (BMI > 27 kg/m2)" I guess this is a typo, but it seems to me that more often than not the typos classify people as fat when they are not. For the record, the current cutoffs define BMI of 30 as obese, and before the cutoffs were changed about ten years ago a BMI of 27 was considered the cutoff for overweight (ie BMI of 26.9 was considered normal.) So, in this slide we present a weight that a few years ago was on the cusp of normal as "obese". Sigh.
The part that bothered me most was when I spoke to her after class. I asked whether she uses metformin as a first-line treatment for PCOS. I was particularly curious about this given the recent NEJM review that recommends metformin as a first line treatment. The lecturer responded that she doesn't use it as first line treatment. She gave several good reasons: the evidence is unclear, there isn't yet a consensus, patients could end up taking the medication for decades, etc. I generally agree with all that.

Her last reason, though, was along the lines of: "If we give metformin to teens with PCOS, then we negate the importance of lifestyle changes." That really gets me. If the medication is effective at treating PCOS then teens should have access to it! The alternative, telling teens that their facial hair and acne is because they are fat, just leads to a lifetime of yo-yo dieting and self-loathing.


PCOS stands for Polycystic Ovarian Syndrome. It is a common condition where women have varying symptoms that might include irregular periods, excess facial and body hair, acne, and type II diabetes. Many women with PCOS are fat.

Metformin is a medication that is mostly used for diabetes that makes the body more sensitive to insulin. Insulin resistance is currently thought to be the main mechanism causing PCOS. Metformin, then, is often helpful in reducing symptoms for women with PCOS.