Blobs of Fake Fat

Doctors in the UK are getting plastic models of fat blobs to show their patients. (Yes, seriously).

When I was 10 or so, I recall my family doctor showing me one of these plastic models. It was very hurtful. I really don't understand how the message can be anything other than "This is disgusting. This is part of you. Thus, you are disgusting." I already wanted to lose weight; it had been my New Year's Resolution for years, and part of my daily life for even longer. This experience just added more shame and more pain to being a fat child.

Experiences like these with doctors are a big part of why I chose to study medicine. There are better ways to motivate people, and better ways to promote health. One of my dreams is to one day open a multidisciplinary primary care health clinic based around Health at Every Size principles. Fake fat won't be allowed on the premises. :-)

Obesity Guidelines

I was recently looking through the Canadian Guidelines on Obesity Management. This is a monster of a document: 24 chapters and over 100 pages. It's also infuriating. A few choice quotes:

"In addition, the medical profession is failing to counsel young, disease-free adults and those in lower socioeconomic groups" [to lose weight]. Because if you haven't yelled at healthy fat people, you just aren't doing your job!

"Overweight and obese people, especially those with binge-eating disorder, lack self-efficacy. Self-efficacy refers to confidence in one's ability to do what is required to produce the desired outcome." I was pretty angry when I read this. Just because I'm fat doesn't mean I am lacking in the ability to Get Things Done. So I went and looked at the abstracts for the three articles they use to reference this statement (1, 2, 3).

The first two articles refer specifically and only to weight self-efficacy -- which, apparently, is confidence in one's ability to do what is required in order to get to a socially-sanctioned weight. That is, fat people are pretty sure that they can't diet to become permanently thin. I would describe that as "fat people have a good grasp on reality" rather than "fat people have low self-efficacy".

The third article is the only one that refers to self-efficacy in general, and it finds that fat individuals with binge-eating disorder have lower self-efficacy than fat individuals without binge-eating disorder. Which, obviously, says nothing about fat people as a group.

Good News, For Once!

First, apologies to anybody who is still reading this blog for my several-month-hiatus! Over that period, I gave two talks about HAES topics: one to my medical student peers, and one to some philosophy grad students. Both went over very well! It was nice to find a receptive audience for these ideas.

Third Day Back

We managed to get through two whole days of school this semester without mention of the Scary Obesity Epidemic. On the third day, our final lecture about health care spending and cost analysis was nearly over when the professor decided to use an example of how fat people are going to bankrupt us. After all, the obesity epidemic is no doubt going to cost a fortune because of diabetes and other necessary interventions. And just to make sure that our evidence-based-medicine week had some not-remotely-evidence-based comments, he added that exercise programs for kids that reduce obesity later are likely to have a great return on investment these days.

He really ought to read Junk Food Science occasionally, where he could learn things like childhood obesity prevention programs don't work, or that there's really no evidence that fat people are going to cost more, and being fat may actually save the health care system money.

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

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.

---

Background:

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.