Measured Against Reality

Monday, May 28, 2007

The war on obesity

This is LaDainian Tomlinson (LT). He's a running back for the San Diego Chargers. He broke several records this year, including touchdowns in a season and rushing touchdowns in a season. He is one of the best players in a very, very difficult athletic game. And he is obese.

No, I am not joking. According to the CDC, LT is obese. That particular calculator doesn't say the exact number, but another one has him pegged at 31.6 BMI. The CDC has the following to say to LT:

People who are overweight or obese are at higher risk for chronic conditions such as high blood pressure, diabetes, and high cholesterol.

At a minimum, anyone who is obese should try to avoid gaining additional weight. In addition, anyone who is obese should try to lose weight. Even a small weight loss (just 10% of your current weight) may help lower the risk of disease. Talk with your healthcare provider to determine appropriate ways to lose weight.

Why am I talking about this? I mean, calling LT obese is clearly insane, even if he does technically have a BMI over 30, the cutoff for obesity. He's an exception, an extremely muscular and athletic man.

But that's precisely my point, BMI is a ridiculously crude tool. It doesn't account for any number of things, all of which can affect how healthy you are. LT is definitely healthy, but is technically obese, and the same is likely true of many athletes (and people).

But this is how our "obesity crisis" is defined. How on earth can we be certain that we really are getting fatter given that BMI is such a blunt tool? It has so many variables in it, it's nearly meaningless.

So are we getting fatter? It seems so, but based solely on BMI measurements I don't buy it. Not to mention getting fatter doesn't necessarily mean getting less healthy. For example, take this tidbit from Wikipedia:

In an analysis led by Lopez-Jimenez of 40 studies involving 250,000 people, heart patients with normal BMIs were at higher risk of death from cardiovascular disease than people whose BMIs put them in the "overweight" range (BMI 25-29.9) Lancet. 2006 August 19;368(9536):666-78. Patients who were underweight or severely overweight had an increased risk of death from cardiovascular disease. The implications of this finding can be confounded by the fact that many chronic diseases, such as diabetes, cause weight loss before the eventual death. In light of this, higher death rates among thinner people would be the expected result.

Health is a very tricky thing, and I'm not convinced that we should be in as big of a weight scare as we are, especially given that it can be extremely difficult to lose weight and keep it off, and that humans have natural weight variability that depends on dozens of factors (for instance, how much your mother eats during pregnancy can affect your tendency to put on fat: if she eats little your body prepares for starvation conditions).

All I'm really trying to say is that if you're happy with your body and you're reasonably healthy, then your weight is probably fine. It's when people start to have trouble doing mundane things that they should start really looking at their weight.



  • Yes, you are right. Obesity and BMI are not the issue.

    Body size is not a behavior!

    As long as we define obesity as the problem, we are eliminating the possibility of a solution. We need to re-define the problem so that it CAN be solved. We need a definition that allows anyone, of any size, to succeed in the short term and in the long term. First, I will clarify some of the harm and dangers of defining obesity as the problem. Then, I will propose a new definition of the problem that we can solve as health professionals, as individuals, and as a society.

    Instead of a “war on obesity” that often feels like a war on obese people, there is a new peace movement: “Health At Every Size” (HAES).

    As a lifestyle coach, psychotherapist, and personal fitness trainer, I work with people of all sizes, especially large size. In the years since I started in 1980, I have had the pleasure of watching hundreds of people make substantial changes in their lives. I have seen people improve many measures of their health: lowering cholesterol, lowering blood pressure, improving blood glucose levels, increasing exercise stamina, and improving functioning in daily activities. I have also seen many people lose weight as a side effect of their healthy living actions.

    Unfortunately, I have also seen the harmful results of a focus on weight or body size. With this focus, large people are seen as the walking embodiment of “the problem”. They are seen as wrong, bad, even villainous … and they internalize these feelings. Let’s look at how this prevents large people from taking better care of themselves. Consider how feeling like this can discourage large people from participation in an exercise or fitness program.

    Think about fitness:

    When a large person walks into a traditional fitness facility, they are often scorned or taunted by patrons. Instructors frequently talk down to them and provide exercises that do not accommodate the unique biomechanics of a large body. What is a warm up to the 110 pound instructor is quite an aerobic activity for the 280 pound exerciser. Without a warm up, the large person simply cannot succeed at the workout. Everybody needs a warm up. Without basic physiological needs being met, the large person has even more difficulty with the workout. They feel like a failure when they have difficulty with the exercises. Often, large people are traumatized by their experiences with fitness rather than helped.

    If the problem is defined as “obesity”, then it seems like having a large body size is the obstacle to fitness. Actually, some of the real obstacles to fitness for large people are the hurtful attitudes and lack of information about exercises for diverse body types. Defining obesity as the problem inhibits development of fitness for people of all sizes and reduces fitness opportunities for large people. Without comfortable, enjoyable, effective fitness opportunities, how can large people find health? How can we, as a society, as health professionals, and as individuals provide health for all sizes?

    Think about medical care:

    Even if a large person were taking really good care of themselves, on any given day, they would still be large. Therefore, if the problem were defined as obesity, then the large person would still have “the problem”. One of my clients who weighed 320 pounds went to her doctor’s office and was seen by his associate, who was unfamiliar with her case. It was not surprising that the doctor took one look at this very large lady and gave her an extensive lecture on the dangers of obesity and chastised her for her large size. She felt completely wrong, like a failure, like she could never succeed … she felt awful.

    She was not awful. She was wonderful. For over a year, she had been focusing on healthy eating, regular exercise, and positive thinking independent of weight. She had learned to eat when hungry and stop when satisfied. She was meeting her needs without over using food. She stopped measuring her happiness by the numbers on the scale. She did not even know what she weighed. Her life was blossoming, her health was improving, and she had the spring back in her step. As it turned out, she had lost 60 pounds as a side effect of her healthy lifestyle (NOT as a primary goal, but as a side effect).

    But none of that mattered. On that day at the doctor’s office she was still a very large person. With one glance and the assumption that obesity is the problem, this doctor robbed her of all her feelings of success. Because he saw obesity as the problem and she was obese, this doctor defined her as wrong, unhealthy, and in jeopardy.

    Think of a new approach:

    We need a new definition of the problem so that people of diverse sizes can feel successful when they are participating in the actions of healthy living. It is inaccurate to assume that all people who are obese have poor eating habits and are sedentary. It is inaccurate to assume that all people who are lean eat healthy and participate in fitness activities.

    You can no more tell the healthy lifestyle of a person based on their body size than you can tell how hard someone works based on the balance in their bank account.

    There are many reasons why an individual may have a specific body size. Frequency of dieting, genetics, medications, and much more affect our body size and weight. Since we do not have complete control over body size or weight, it seems logical to focus on something over which we have more control. We can affect our actions. Both as individuals and as a society, we can build systems that encourage the actions of healthy eating and fitness activities.

    We can make our GOAL healthy living actions, rather than choosing a goal of some specific weight.

    When we consider the problem of “childhood obesity”, there is great focus on how to get large children to lose weight. Again, body size is the focus and the definition of the problem. Often the result of this concern is harmful to large children as they are targeted for special programs (that stigmatize them), bullied by peers, even traumatized in gym class by teachers who want to make examples of the “fat kid” in order to deter others from becoming obese. Any adult who ever was a “fat kid” or had a friend or sibling who was large can tell many painful stories of these hurtful experiences. A focus on weight and body size during childhood is often the beginning of a lifetime of low self-esteem, yo-yo dieting, or eating disorders.

    But what can we do? We cannot just ignore all these obese children! Moreover, we cannot ignore the small and medium size children either. When we focus on “childhood obesity”, we are giving the small and medium sized children the message that they do not need to focus on healthy eating and fitness activities they do not have “the problem”. When we define the problem as obesity, we are telling our children that if they are thin, then they are the ‘correct size” and they don’t have a problem. We are implying to thin children that only the “fat kids” need to focus on health. This is not what the health professionals intended to happen. This is not a message likely to promote the actions of healthy eating and fitness for children of all sizes.

    Let’s understand how the “War on Obesity” CAUSES health problems instead of solving them. So, it seems like we must solve the problem of obesity, yet in trying to solve this problem, additional difficulties are actually being generated.

    I would like to look at another health issue to demonstrate how this might happen.

    • The behavior or action: smoking

    • The associated characteristic: yellow teeth

    • The associated health issues: Lung cancer, emphysema

    What would happen if we tried to reduce the incidence of lung cancer and emphysema by focusing on the characteristic of yellow teeth instead of focusing on the behavior of smoking? What if we launched a “War on Yellow Teeth” to prevent lung cancer and emphysema? What if we defined the problem as yellow teeth? People who had yellow teeth would worry about their health and be made to feel bad about their yellow teeth. They would be told how their yellow teeth were costing billions in health care and insurance premiums. Many smokers would be targeted in this war as needing intervention. They would be given teeth whitening potions and creams, programs to whiten teeth, even surgical removal of the offending yellow teeth. After all, missing teeth and the resulting health problems are not as dangerous as lung cancer or emphysema.

    What about those smokers who do not happen to have yellow teeth even though they smoke? Since their teeth are white, they would not be defined as having a problem. They would be ignored by the “War on Yellow Teeth” because they do not possess the characteristic that has been defined as the problem. They would not get support or education on reducing lung cancer and emphysema.

    What about those people who did not smoke and just have yellow teeth due to genetics, medication, or other reasons? They would be targeted. As they worked to whiten their teeth, they would face frustration because they could not get their teeth white enough. They may damage their teeth with more and more extensive efforts to whiten them. And all along, they would be encouraged to continue. They would be pressured, and chided, and even have recommendations to have their offending teeth surgically removed in order to save them from the awful impending lung cancer and emphysema.

    Now, let’s get back to the “problem of obesity” and consider it in a similar way.

    • The behavior or action: Poor dietary habits and sedentary lifestyle

    • The associated characteristic: Large body size, obesity, or high BMI

    • The associated health issues: High blood pressure, high cholesterol levels, metabolic syndrome, other cardiovascular risks, increases the likelihood of developing type 2 diabetes.

    We are experiencing similar results in the “War on Obesity” as would occur in the above scenario about yellow teeth. In both cases, by targeting the characteristic instead of the behaviors and actions, we prevent a solution from being found. The resulting policies hurt the people with and without the unhealthy behaviors. The assumption that the associated characteristic causes the health issues skews research design and results in conflicting scientific conclusions.

    We need to re-define of the problem in a way that promotes a solution for adults and children, of all sizes. I think that the real problem is: We need healthy eating and fitness activity for everybody of every size.

    I propose that we end the “War on Obesity”, and begin a “Campaign for Healthy Eating and Fitness for Everybody of Every Size”. The new peace movement is Health for ALL Sizes (HAES)!

    This new definition of the problem has a solution built right in. This solution is based on the ACTIONS of the individual, rather than on the characteristic of body size. Notice the inclusive nature of this new definition of the problem and solution. If someone had poor dietary habits and a sedentary lifestyle, they would get support and encouragement to improve their lifestyle, Independent of their weight. Likewise, if someone is participating in the actions of healthy eating and fitness, they would get support and encouragement to continue their healthy lifestyle. Nobody is stigmatized. Nobody is ignored who needs help. Everybody can be successful. Whether someone is small or large, the moment they participate in the actions of healthy living, they are in the process of succeeding. One success motivates another.

    This constructive process of healthy living actions has the opposite effect of “weight watching”. When the numbers on the scale are the measure of success, the patient or client is doomed for frustration. Have you ever known anyone who lost weight as fast as they wanted? Has anyone ever participated in a weight loss program without hitting a plateau? Not in my experience. However, when the goal is NOT weight loss, but rather eating well and exercising, then success is one action away. Everybody of every size can succeed.

    Let’s end the “War on Obesity”, and begin “Campaign for Healthy Eating and Fitness for Everybody of Every Size”. Let’s participate in the new peace movement: “Health At Every Size (HAES)”.

    Body size is not a behavior!

    By Anonymous Kelly Bliss, at 6:14 AM, October 28, 2007  

Post a Comment

Links to this post:

Create a Link

<< Home