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Doogie Howser, M.D. —

February 16, 2012
by

Trigger warning for weight loss science talk.

Once again, a reply to a comment has become a post unto itself. This time, I’m responding to a certain Dr. Peter, who has posted comments here and here and here. Oh, and who could forget this fun chunk of condescension.

Seeing as how I’m still waiting for the “medical team” of Children’s Healthcare of Atlanta to respond to our evidence-based alternative to Strong4Life’s Shame and Salvation campaign, I think it’s fair to see you, Dr. Peter, as a proxy for CHOA and the traditional weight-based view of health.

You have a few advantages over me. You’re clearly qualified to comment on the subject of obesity and health, while I am not. You have years and years of medical training and an advanced degree, while I have my GED. I’ve only been doing this for two years, while you’ve been in practice for who knows how many years. Your opinion certainly holds more water than mine.

And I say this with all sincerity: I have the utmost respect for the medical profession and the people who serve our communities in the service of human health and welfare. I’ve seen first-hand how dedicated and selfless our doctors, nurses and medical professionals are across the board, and I am nothing but grateful for your service.

That being said, some of you are just plain wrong on the subject of obesity, health and weight loss.

And you don’t have to believe me. Why would you? You’re in the trenches every day trying to help people improve their health and their lives. You are on the front line in the War on Obesity. I get it.

But the thing is, I didn’t make this shit up. I didn’t just wake up one day and say, “Hey Shannon, let’s start a medical revolution that will put you at odds with mainstream medical opinions!” Everything I’ve learned about obesity, health and weight loss is from the work of other equally dedicated doctors who have studied this subject much more intensely than you have, I assure you.

Like Dr. Stephen Blair who has run what may be one of the most exhaustive studies on fitness with tens of thousands of patients for multiple decades at one of the most respected fitness organizations, The Cooper Institute (although he recently left Cooper for the University of South Carolina’s Arnold School of Public Health). Blair’s research unequivocally finds that cardiorespiratory health is by far the best indicator of metabolic health, not BMI and not weight loss.

And while we’re on the subject of weight loss, even the CDC says that a 5-10% weight loss will have a profoundly positive impact on your health.

For example, if you weigh 200 pounds, a 5 percent weight loss equals 10 pounds, bringing your weight down to 190 pounds. While this weight may still be in the “overweight” or “obese” range, this modest weight loss can decrease your risk factors for chronic diseases related to obesity.

So, I’m curious about this comment, when you say, “We advise a 200 calorie deficit per day… A pound of human fat is about 3600 so this is moderate weight loss.”

Let’s assume your patient is compliant (and your attitude on the compliance is not surprising considering the tendency among medical professionals to assume non-compliance by their obese patients (PDF), which is why fat patients stay away from doctors… fat patients tell their doctors that they are sticking to the diet and because the diet has failed, the doctor labels them non-compliant, rather than trying to understand why weight loss doesn’t work), and he adheres strictly to a 200 calorie deficit.

In fact, let’s use me as your theoretical patient. I’m 5’7″, 265 pounds. Let’s say I make this change permanently. Approximately how much weight do you believe that I would lose as a result of this reduced calorie diet after one year, two years, five years? I agree that a 200 calorie deficit is not much. In fact, it sounds rather low in terms of weight loss. I’ve done one of those classes where they check your metabolic rate and recommend a caloric level for your desired body weight, and I put in a modest goal of 250 pounds and they recommended a 500 calorie deficit. So, in terms of weight loss only, I’m just curious what you think a 200 calorie deficit is going to do for a person.

Also, I’m curious if you can find a single, decent-sized, well-controlled study that demonstrates that weight loss of greater than 10% can be achieved by more than, let’s say, 25% of the population for longer than two years. And those are generous figures. Unless we’re talking Very Low Calorie Diets of 800 and below, or bariatric surgery, then two years is when the backslide begins to creep into the data. And if you can find one study meeting these criteria, I can give you 20 that show exactly the kind of failure rates I’m describing.

My understanding of weight loss failure comes straight from Dr. Jeffrey Friedman, the man who discovered the hormone leptin in 1994, and whose lecture series at the Howard Hughes Medical Institute in 1994 can transform even the staunchest cynic into a skeptic like me. Because of the response that leptin and ghrelin have to even modest caloric deficits, sustained weight loss becomes an uphill battle of increasing difficulty.

Finally, I’d like to know how familiar you are with the research on weight cycling and the strong correlation with cardiovascular disease and major weight gain, and I’m leaving out the mixed studies on abdominal obesity, hypertension, hyperlipidemia, type 2 diabetes, and any other “obesity-related” disease you can think of. But the cardiovascular correlation is the most disturbing by far, and fairly well-established and accepted in the literature. Even Dr. Walter Willett has a hard time spinning the results of his own research into saying that weight cycling isn’t a big deal.

Between 1993 and 1999, we documented 418 new cases of type 2 diabetes that were confirmed by supplementary questionnaire. The crude incidence rate was 313 cases per 100,000 person-years. As expected, BMI in 1993 had a strong association with the risk of developing diabetes. Compared with women with a BMI <22 kg/m2, those who were overweight, but not obese (BMI 25 to 29.9 kg/m2), were approximately eight times [risk ratio (RR) = 8.29; 95% confidence interval (CI), 4.14 to 16.62] more likely to develop diabetes. Women who were obese class I (BMI 30 to 34.9 kg/m2) were 29 times more likely and those who were obese class II (BMI greater than or equal to 35 kg/m2) were 84 times more likely to be diagnosed with type 2 diabetes. Weight cyclers were significantly heavier than noncyclers; therefore, when BMI was not controlled for in the statistical model, weight-cycling status in 1993 seemed to be a strong risk factor for developing diabetes (mild cyclers: RR = 2.57, severe cyclers: RR = 5.56). After adjustment for BMI, however, neither mild (RR = 1.07; 95% CI, 0.87 to 1.32) nor severe (RR = 1.46; 95% CI, 0.98 to 2.17) weight cycling predicted diabetes. Further adjusting the model for physical activity, inactivity, and dietary intake further attenuated the severe-cycling effect. Adjusting for total activity instead of vigorous activity did not materially change the results (data not shown). Both BMI and recent weight gain (data not shown) predicted the development of diabetes; therefore, adjusting the model for recent weight change further attenuated the effect of severe weight cycling. [emphasis mine]

But that doesn’t stop Willett et. al. from trying. It’s right there in Willett’s own work: severe weight cyclers are significantly heavier than non-cyclers; severe cyclers have twice the incidence of a recent weight gain of more than 15 pounds; and BMI and recent weight gain predicted the development of type 2 diabetes. And somehow, in the midst of all of this information, the authors have the temerity to say, “But this has nothing to do with weight cycling.”

You cannot disentangle the effects of weight cycling (weight gain and high BMI) from the diseases correlated with those effects. It’s like there’s this mental block with anti-obesity advocates that make them completely unable to accept that weight loss, as a medical prescription, is more complicated than the dual, flawed axioms of “calories in/calories out” and “3,500 calories in a pound.” Although these assumptions may be roughly true when someone puts on weight, the research does not support these theories regarding weight loss.

And advising a patient to “keep trying” a prescription that fails the vast majority of the time in the vast majority of patients, all the while ignoring evidence that the prescription is not only a failure, but may even contribute to cardio-metabolic damage… well, that’s borderline malpractice.

Now, as to the information in this comment, which is the one that I’ve pondered the most. In particular, your questions about Insulin Resistance (IR).

Once again, I’m essentially ignorant on my own. I’m not a medical person, I’m a creative person. But I’m intelligent enough to understand the medical basis for my beliefs, as well as your own, based on all of the books and research I have read. By relying on the experience and education of others, I’ve been able to educate myself on these subjects, most recently in a conversation with a friend who is both a nurse practitioner and diabetes educator.

When I asked her about the correlation between obesity and IR, she initially agreed with you that in her 20 years, she has never seen a thin person with IR (although the research you cited certainly found a small risk factor for those in the normal BMI). But it’s more complicated than just reaching a cutoff point and suddenly you’re IR.

Not all people who are obese are insulin resistant.  There are other causes of obesity such as thyroid disorders, leptin deficiencies, etc.  Also you can be diabetic and not IR. Some have more of an insulin production problem rather than an insulin usage problem. You can have hypertension and hyperlipidemia and not be insulin resistant.  There are other causes of all of these.  But when you are IR, it generally causes you to have hypertesnion, hyperlipidemia, obesity and eventually diabetes.

Our inheritance determines where your IR range is. You inherit a range and can go up and down based on the environment and choices.  In other words if you choose to follow a healthy diet, exercise regularly, sleep well, be happy, not depressed… you will be less IR and if you do the opposite you will be more IR.  But not everyone gets the same effect with the same activity or starts at the same place due to genetics.  If you have “uncontrolled IR” ( you are more IR ) you are more likely to have everything that goes along with it.  But you can be extremely IR and not have diabetes as long as the pancreas can produce a lot of insulin.  Some people who are overweight, but do not have  hypertension, hyperlipidemia, or diabetes (are usually not IR) but then do not have the bad effects of being overweight.  The ones that are IR usually have all the above, but as long as we control the sugar, BP, cholesterol, they spend their children’s inheritance.  So it is not the fat that gets them, it is the effects of the IR.

We had a lengthy phone conversation last night where she gave me an example of her boyfriend, who is thin and frequently asserts his own right living as the cause of his thinness. Yet he drinks sugar-sweetened beverages and other sweet treats and, as a result, has high blood pressure and high cholesterol. But because his genetic inheritance gave him an IR range on the lower end, he would not technically qualify as IR.

So, let’s say his IR range is from 1-5, but because of his lifestyle choices, his IR level is around 5, which is bad for his particular range. Then you take someone who has a genetic IR range of 5-10, but this person is eating healthy and exercising, so her IR level is also around 5. She is doing the best she can within her given range and will reap the benefits of living a healthy lifestyle, while he may appear healthy, but his lifestyle habits are causing metabolic damage nonetheless.

In short, this nurse practitioner and diabetes educator agreed that IR is the problem and obesity is a red herring. Everyone can benefit from improving their insulin sensitivity, and focusing so many resources on obesity is a waste of time and money.

As far as the other research you presented, you claim that “NHANES clearly DOES demonstrate that obesity prevalence has increased over the last two decades” and you cite this study as proof. First of all, NHANES is an awesome research project led by Dr. Katherine Flegal, an epidemiologist and Distinguished Consultant with the CDC’s National Center for Health Statistics, who shattered the dubious research which said that obesity causes 400,000 or 365,000 deaths per year.

The study you cited does indeed say that obesity rates increased over the past two decades… problem is, your study was publish in 2002 and gave results for 1999-2000. For some reason, you’ve completely ignored the 2010 study published by Flegal et. al., which covers adolescent obesity trends for 2007-2008. These results showed no significant increases, except among the heaviest boys:

Among 6- through 19-year-old boys, however, there was a significant linear trend at the highest BMI cut point (BMI for age ≥97th percentile) but not at the lower cut points, nor was there a significant trend in the younger age groups. The categorical analysis of survey period suggests that among 6- through 19-year-old boys the difference is only significant between the 2 time periods 1999-2000 and 2007-2008, so it not possible to tell if the 2007-2008 estimate is the continuation of a trend or not.

And while we should be investigating this trend and how to ensure the health of these heavier boys, the fact that every other category has remained level is worth keeping at the forefront of our minds while we are discussing whether stigmatization is an appropriate response to a leveled “epidemic.”

You can continue to point to studies like this one that show a correlation between BMI and all-cause mortality, but as Dr. Blair told me in an interview, if these studies do not control for cardio-respiratory fitness, then they are bunk. Too many confounders contribute to obesity and poor health, such as poverty, education, genetic susceptibility to IR, and the social determinants of health. Simply pointing to a correlation does not impress me much.

This 1998 study in the Journal of the American Medical Association looked at the influence of socioeconomic status in relation to four behavior risk factors draws a telling conclusion:

Our results suggest that despite the presence of significant socioeconomic differentials in health behaviors, these differences account for only a modest proportion of social inequalities in overall mortality. Thus, public health policies and interventions that exclusively focus on individual risk behaviors have limited potential for reducing socioeconomic disparities in mortality. While reducing the prevalence of behavioral risk factors is an important and critical public health goal, socioeconomic differentials in mortality are due to a wider array of factors and, therefore, would persist even with improved health behaviors. Increasing health promotion and disease prevention efforts among the disadvantaged is not a “magic policy bullet” for reducing persistent socioeconomic disparities in mortality. [emphasis mine]

And simply focusing on obesity, rather than behavior, makes even less sense within the framework of our understanding of the effects of SES on health. If three-fourths of fat people will never be diabetic, then why treat all fat people like they’re a donut away from an amputation?

There is an alternative to your highly flawed approach to healthcare, Dr. Peter, and it is Health At Every Size®, and when we say that it’s an “evidence-based alternative,” we don’t just mean that our claims of disease prevalence are based on clinical evidence (as you have done), we mean that the success of our prescription is also found in the literature.

Now, I have just provided you a 2,600 word response to your challenge of our beliefs. I’ve done so multiple times for several people. I do so by citing my sources and providing ample evidence that the approach I advocate is both effective and sustainable. When you, or CHOA, can do the same for your beliefs by providing evidence that weight loss works for more than two years, then I might start taking you seriously.

Until then, you’re just another medical professional mired in magical thinking and unfounded axioms.

28 Comments leave one →
  1. February 16, 2012 11:09 am

    Damn! Well-done! I can’t even imagine how much work went into this post. XO

    • February 16, 2012 11:51 am

      Thanks Stacy. I spent quite a bit of time last night on it, but much of the week time mulling it all around in my head. :)

      Peace,
      Shannon

  2. February 16, 2012 11:47 am

    Speechless.

    Well done, Shannon.

    Bookmarking this post for what I anticipate will be many, many, future uses.

    Thank you so much for your dedication to this cause.

    Theresa
    The Fat Personal Trainer
    http://www.biggirlsworkout.com / http://www.bigguysworkout.com

    • February 16, 2012 11:52 am

      You’re welcome. And thank you for being right there in the fight too, Theresa. :)

      Peace,
      Shannon

  3. Laura Jennings permalink
    February 16, 2012 12:51 pm

    Nice work, Shannon!

  4. Duckie Graham permalink
    February 16, 2012 1:30 pm

    Bravo! I’m so glad you have the knack for research wrangling and can so eloquently feed it to the sad souls who haven’t found HAES yet. Belly bumps to ya!

  5. February 16, 2012 3:32 pm

    Shannon for President!!!!!

  6. vesta44 permalink
    February 16, 2012 3:48 pm

    And when is your book coming out? This is definitely a must-read for anyone who thinks calories in/out is gospel and works for permanent weight loss and health improvement. Too bad that CHOA and S4L won’t be reading it or accepting it :(

  7. Amy Hays permalink
    February 16, 2012 6:00 pm

    Excellent! I am very happy to see this kind of research based article. I grew up heavy. I could be considered a severe cycler because I lost 60 to 80 lbs several different times in my life to be “healthy”. But I had to go to unhealthy extremes to do that. While growing up not one single doctor addressed my thyroid or the fact I had all hypothyroid symptoms. And even though my maternal grandmother had had thyroid cancer and her identical twin died of it 3 yrs before her diagnosis in the 1960’s. I was discriminated against along with my mother. Until 2010, when they had to remove my thyroid as it was swelling (even with a year of treatment), full of cysts, changing my voice and hurting severely. I had thyroid cancer. I had lived all my life with Hashimoto’s and hypothyroidism until I found a doctor who checked it and then treated it. He saved my life because he did not discriminate against me. I was 38. This really opened my eyes to the fact that our medical doctors are discriminating on size. I even had one doctor blow raspberries at me when I told him what happened to me.

    And as far as diabetes goes. My husband is normal sized with type 2 diabetes. Yet people think I am the diabetic when we are together. It is so frustrating.

    The questions I have for those scientists. Did they just look at statistics or did they actually do some hard core science? Because you cannot figure out what came first, the chicken or the egg, by just looking at statistics. You need research it further and do some real science and think about the problem without biases. If they did that, they would find they are severely lacking in their conclusions.

    • February 18, 2012 11:39 pm

      It amazes me as I read your comment that I felt like I was reading my own story in a way. Obviously some differences. My mother and sister are both taking 300 mcg of sythroid. My niece is on 100 mcg. My paternal grandmother and paternal aunt both had their thyroid removed my aunt’s being cancerous. My mom has two sisters. The youngest sister’s daughter has graves disease her son is fine as far as I know. Her oldest sister’s kids ALL have thyroid disorders there are 4 girls and one boy the youngest have Graves. I have told this history to numerous doctors who checked my TSH which was normal and dismissed my symptoms. (Lowbody temp, missing parts of my eyebrows, dry skin, lone atrial fib, fatigue, dry skin, etc) I asked one doctor about further testing and he flat out said “Fa people like to try to look for an excuse for their weight let’s not go down that road”.
      32 years I have been dealing with these symptoms and feeling like crap and getting fatter and fatter and less energetic to the point of having to rest after getting dressed. In Sept I finally have abnormal TSH and was put on 100mcg of thyroid and went to see an endo who diagnosed me with Hashimotos. I have lost about 15 lbs since Sept without making any changes. I have more energy and my eyebrows are growing back. IT amazes me how any doctor could look at my family history and my symptoms and ignore them based on one thyroid test. I am actually really angry right now. Angry for me and angry for you and angry for all of us that are doomed to suffer because of the prejudice and ignorance that doctors have towards and about fat people.

      • February 23, 2012 10:22 am

        I took my temperature every morning to try to convince my doctor that I had thyroid problems. My waking temperature was typically in the mid 94 range, and he told me my morning temp didn’t matter. Since starting thyroid meds, my waking temp is now in 96s to 97s.

        I’m also very, very angry, and I can’t seem to let go of the anger.

  8. Len permalink
    February 16, 2012 7:19 pm

    Wow, that was some seriously interesting reading Shannon. Seriously, thank you.

    I look forward to Dr Peter’s reply, or any other medical practitioners who happen to be reading.

    Len

  9. Jackie permalink
    February 16, 2012 7:37 pm

    Thanks for this post Shannon. I’m wondering if we scared Dr. Peter off, and sent him running back to the comforting arms of a medical practice based upon sizeism.

  10. LittleBigGirl permalink
    February 17, 2012 11:11 am

    I am really glad you talked about IR. I have PCOS, a hormone imbalance which is linked to IR and a side effect of which is weight gain. The medication prescribed to help treat my hormone imbalance also carries the side effect of weight gain. In fact there are a ton of medications with the possible side effect of significant weight gain.

    Which means for many people obesity is the symptom and not the disease.

    No self respecting, ethical doctor should waste their time and their patients health insurance treating a symptom instead of the underlying health problem causing the symptom.

    Thank you for all your hard work researching Shannon!

  11. February 18, 2012 12:26 pm

    I’m blown away by this article. You did a magnificent job across the board. Well done!!

  12. Peter permalink
    February 18, 2012 7:59 pm

    “I think it’s fair to see you, Dr. Peter, as a proxy for CHOA and the traditional weight-based view of health…you’re just another medical professional mired in magical thinking and unfounded axioms.”

    I’m a member of the American Medical Association (among other professional organizations) that holds the widely accepted scientific view that obesity is an independent risk factor for poor health outcomes. ‘My’ view is just a reiteration of said experts.

    Has a group of doctors ever been wrong before? Of course. I freely admit that the sum of my medical knowledge is based on faith; faith that my colleagues don’t lie or cheat on their research towards some nefarious goals. I learn things that were discovered by someone else, hopefully verified by other parties, and this entire system relies on high standards and ethics which I believe we have.

    It may be that you and your devout followers are actually right in that obesity’s nothing to worry about. However, your brief periods of humility are just that -brief- and accusing me and the likes of the AMA of Schizotypal-like ruminations hardly advances your goals. In fact, your rhetoric matched with the over-whelming evidence we have suggests your foundation is not as solid as you believe

    “even the CDC says that a 5-10% weight loss will have a profoundly positive impact on your health.”

    Exactly, obesity is a dose-dependent risk factor for your health. As i said before (and as the research shows), the more obese you are, the worse the outcomes. Depending on your weight, you can start to see a difference at 5% loss, but you see a more improvements with better BMIs.

    Simply put, some weight loss= good. More weight loss towards ideal BMI = better.

    Again, think of some other dose-dependent activities, like smoking. There’s great evidence to show that decreasing the amount you smoke will improve your outcomes, even if you continue with your bad habit. That doesn’t mean that smoking a little is good for you. And it doesn’t matter what amount of exercise you do, smoking will always be bad for you. That’s what being an ‘independent risk factor’ means.

    “I’m just curious what you think a 200 calorie deficit is going to do for a person.”

    Look up the laws of thermodynamics; they are the laws of the universe as we understand them. The 1st law states that matter and energy can neither be destroyed nor created.

    If you worked out your metabolic needs, and ate your daily caloric requirement minus 200 calories, you would absolutely lose weight over time. That’s not an opinion, that is a fact. Leptin and other things can make you want to eat more, but it doesn’t just make fat appear. so, to answer your question: eating less calories than what you burn will result in weight loss, albeit gradual at 200 calories/day. But gradual is OK, I don’t recommend stopping tobacco cold turkey either.

    The Lancet article you referenced only said that it will take longer for the more obese to reach a steady state and that we need better math models to find basal rates. Ok.

    “Also, I’m curious if you can find a single, decent-sized, well-controlled study that demonstrates that weight loss of greater than 10% can be achieved by more than, let’s say, 25% of the population for longer than two years.”

    This is where I think you have some confusion. Think back to smoking. Can you show me a single study that shows that at least 25% of long-term smokers are able to quit successfully within 2 years? Is it realistic that all smokers will stop smoking? If only a small amount of smokers actually quit, should we bother trying to convince them?

    Certainly people like Dr. Stephen Blair think not, and he (and you) may be right. Many clinicians (myself included) have realized that few obese people will be compliant with their weight loss programs. Much like how in residency I would put 12 year olds on birth control, perhaps we should just accept peoples’ poor lifestyle choices and try to cope with the aftermath the best we can.

    That is a legitimate pubic health view, BUT, let’s get a few things clear. (1) The likes of Dr. Blair et al DO believe we are experiencing an obesity epidemic and acknowledge it is behavior, not genetics, that took us to where we are today: an overweight nation. Read your own sources if you disagree. (2) They also believe obesity to be an independent risk factor for poor outcomes. They DO NOT believe that being obese is a good thing. So, when it comes to the medical opinions on obesity, Dr. Blair agrees with the ‘traditional’ view that you despise so much. He just disagrees with me on the best way to tackle it.

    What Dr. Blair, HAES, etc, are saying is: let’s be realistic with non-compliant obese people and switch to damage control because they are incapable of change.

    I disagree. As an advocate for my patients’ health, I want the very best for them, and while I will congratulate a person for a 2 lb weight loss, a reduction in smoking, etc, I also continue encouraging them to improve their habits until they at the best health they can be. That is my professional mission in life. It is also one of my core beliefs that all people have the ability to change, no matter their condition, and it’s this belief that keeps me going as a physician.

    As a doctor, trying to tell a person that they need to lose weight is difficult. As this forum shows, people can be extremely sensitive about their weight, and many see it as a legitimate condition attributable to a lifestyle choice or genetics, akin to sexuality. They think it’s who they are. I could not disagree more with this position. There is NO, I repeat, NO evidence to suggest that America is obese because of genetics. It’s been awhile since I referenced Hardy–Weinberg, but I’d be interested to see an explanation as to how fat-promoting genes could have increased in prevalence by this sort of magnitude in only a couple of generation.

    “Finally, I’d like to know how familiar you are with the research on weight cycling and the strong correlation with cardiovascular disease and major weight gain”

    I am familiar with it. Yes, it’s bad to lose and then gain weight. So don’t do that.

    I am not saying that losing weight is easy. In fact, I would say that my obese parents have a more difficult challenge then my patients addicted to drugs: both are addicted to a substance, but one person can walk away the substance; the other can not.

    Losing weight is hard, and those knockout mice from the 1990s did show that leptin seemed to be the culprit to overeating. We’ve been waiting on a pharmacological intervention for ages, but so far they don’t work. I doubt drug companies haven’t been trying. Rather, from what I understand, it’s a lot more complicated than what we thought. The pathway of addiction is not as clear cut, and we don’t know the mechanisms fully behind the compulsion to overeat.

    Until we have a drug that’s akin to the patch for smokers, the obese have it tough. But let me tell you, i’ve seen some pretty dramatic things in my career: gang members giving up crime, heroin users breaking their habits, etc. These are all highly unlikely things. But they can happen, and to deny people the opportunity to change is to debase the most wonderful quality that makes us human: the ability to improve upon ourselves.

    I am confused about what you were demonstrating with the discussion of your NP friend. Not all obese people get DM2, obviously. Her boyfriend has a poor diet. He should not do that. Ok. The point is: regardless of your activity level, genetics, and all other factors, being obese is an independent risk factor for insulin resistance, and hence diabetes. Again, this view is hardly controversial, and it’s well proven. You keep attempting to shift the focus to other bad habits. Don’t do that.

    Life is about self-improvement and challenging yourself. Take some responsibility and make a change in your life. Start with exercising through HAES and gradually working towards weight loss. And if you don’t want to, that’s fine. Just be informed and know that in the future you’re much more likely to meet us condescending, magical-thinking doctors in the hospital.

    Good luck to you all

    • February 18, 2012 10:43 pm

      Again, I’ll have a more thorough response in the near future, and I’m going to invite HAES-proponents, and particularly medical professionals to chime in. I get the impression that I’m not going to make much more headway than getting you to admit that weight loss doesn’t work for most and that weight cycling is bad. You’ll continue to insist upon non-compliance because you aren’t satisfied with any other answer than fat people are gluttonous sloths who refuse to change their lives.

      I pity your patients because your complete and utter lack of empathy is disgusting. Your patronizing comment that “the obese have it tough” is beyond ignorant. You dismiss the role of leptin and genetics as though you know what the hell you’re talking about. Genetics does not mean that people weren’t capable of getting fat in the ’50s and some genetic trigger was flipped in the ’70s and suddenly we’re fat. Monumental changes have been taking place since the ’70s, including the advent of the modern weight loss driven culture (again, weight loss leads to significantly higher long-term weights), the swapping of strenuous manual labor for relatively sedentary office work, the gradual diminishing of personal time, urban sprawl, and about 50 other cultural transformations that have ensured that staying thin is not built into our daily lives, we have to choose to spend additional time getting fit.

      And on top of all that, we tell people that if they eat the right foods and exercise X number of hours, that they will get, and stay, thin. We make Biggest Loser-style transformations seem plausible without following up five years later to see the long-term success. And that is because the overwhelming number of studies on long-term weight loss say exactly what I described and rather than provide for me evidence that even the most motivated dieters can achieve the kind of success that you’re promoting. Instead, you misdirect and challenge me to find proof of smoking cessation.

      I think you’re a coward for ducking my question, but I will take your challenge and then repeat my request for a single study with the weight loss success rates I described above. You asked, “Can you show me a single study that shows that at least 25% of long-term smokers are able to quit successfully within 2 years?” I say, yes, I can:

      A 14.5-year study from 2005 on the mortality rate of smoking cessation programs found that “at 5 years, 21.7% of special intervention participants had stopped smoking since study entry compared with 5.4% of usual care participants.”
      In a 1997 study (PDF) on predictors of successful quitters, researchers found a successful cessation rate of 24% at five years after completing a 10-week smoking cessation program.
      A 2002 randomized study of 4,517 smokers found that 22% of participants who received an “intensive 12-week smoking cessation intervention” remained smoke-free 11 years later.

      And that’s just short-term smoking cessation programs. Researchers find even better results using Nicotine Replacement Therapy (NRT), whereby smokers use nicotine patches or gum to ease nicotine withdrawal symptoms.

      For example, a 2004 five-year study on nicotine patches found that 33.1% of smokers had abstained for the past than 12 months. And in a meta-analysis study of 132 trials of NRT, including over 40,000 people, the authors found that all forms of NRT increased a person’s chances of quitting by 50 to 70%. Individual products had various odds of success, including 43% for nicotine gum, 66% for nicotine patch, 90% for nicotine inhaler, 100% for oral tablets or lozenges, and 102% for nicotine nasal spray.

      We are not denying anyone anything. We are giving them hope for the first time in their lives that by eating right and exercising, they can be healthy even if they don’t get as thin as Dr. Peter thinks they can.

      And yes, I am saying that you and the AMA are wrong if you believe that obesity is an independent risk factor. Again, I don’t expect you to believe me, so I will be asking those who have a medical background and a knowledge of contemporary research to step in and explain to Dr. Peter exactly why his outlook on obesity and health is completely and utterly wrong. If you would like to write a guest post, I invite you to contact me at atchka at hotmail and I will allow you to publish a refutation of Dr. Peter.

      Thank you very much for allowing us to demonstrate the complete and utter disrespect that many medical professionals have toward their fat patients. It is people like you who make the experience of their fat patients so humiliating and degrading that they stop seeing any medical professionals rather than to deal with your condescension and presumptions.

      Peace,
      Shannon

    • LittleBigGirl permalink
      February 18, 2012 11:52 pm

      What if someone “takes responsibility” for their life, makes “healthy changes”, eats nutritiously, exercises, etc….and is still fat? What about people who never overeat, and eat healthy, and are still fat?

      What about all the drugs doctors prescribe that have a side effect of weight gain?

      I really find it difficult to respect your medical opinion when you insist on comparing obesity and smoking. The first is a highly complex issue with countless internal and external factors. The second is an addictive specific lifestyle choice. No one is genetically predisposed to be a smoker. You can go your whole life without cigarettes but you can’t live without food. Smoking has never been shown to be anything but unhealthy, while health experts cannot agreed on what role weight plays in a persons health. I suppose smoking and obesity are similar in that a person can smoke like a chimney and never get lung cancer while a person can be obese and never get diabetes. Other than that, I find it highly irresponsible to keep trying to parallel the two when they are world’s apart. Are you actually saying you would rather someone smoked than be obese???

      I think it is also extremely biased and irresponsible to suggest that people are only obese who eat junk food and don’t get enough exercise; that people are only fat because they aren’t “trying hard enough” to be thin. To write every case of obesity off as a result of food addiction is ridiculous. If that is true how do you explain fat athletes? There are fat dancers and fat marathon runners who do way more than the average amount of physical activity recommended by health professionals. And yet they are still fat, even though they are doing what you say people should do to “work towards weight loss.” Are you seriously saying that since they are fat, these athletes are just not exercising enough? Or do you just assume that they are secretly scarfing junk food because “eat right and exercise” is the magic weight loss bullet? I was hoping for a bit more insight from someone in the medical field than “(I know it’s hard but) put down the cheeseburger.”

      There are so many health variables in people’s lives it is insulting and dangerous to try and simplify by saying fat = bad and people would be healthier if they just lost weight. Fat activists object to what you still insist on doing: focusing on weight like it’s the alpha and omega of health. We want the focus to shift from obesity to health because the two are not mutually exclusive. You keep insisting that fat is unhealthy, but our obsession with fat as being unhealthy and unacceptable has led to very unhealthy methods of weight loss. From unbalanced diets to dangerous drugs, people have been led down unhealthy, even life-threatening roads by (however well-meaning) doctors who tell them they need to lose weight to be healthier. I have absolutely no trust in the BMI system when recent changes arbitrarily make people who were previously healthy ‘obese’ and make it practically impossible to reach a ‘healthy’ BMI without either developing an eating disorder or getting gastric bypass surgery.

      There are unhealthy thin people, unhealthy fat people, healthy thin people and healthy fat people. Can you show me the scientific study that proves unequivocally that out of those four groups, unhealthy fat people are a) the majority, b) all equally unhealthy and c) all unhealthy *only* because they are fat and d) fat *only* because they *all* ate unhealthy food and did not get enough physical activity?

      Even if obesity is a legitimate health concern, it has been blown out of proportion and used as a boogie man. It is a scapegoat for every ailment a person with a high BMI comes to their doctor with. The FA community is filled with horror stories of legitimate health concerns with no relation to obesity whatsoever being dismissed by doctors who just told their patients they needed to lose 20-50 lbs. It is *this* condescension and magical thinking that angers us, Dr. Peter because we actually care about our health. We exercise and we eat “right” and we do every thing you tell us to do and we are still fat and you are telling us we are risking our health. Are we? Or are you just unable to reconcile the fact that we can be fat and healthy?

      You can smugly throw in your vague future health threat of how we fatties will inevitably end up in your office if we don’t tow the weight loss line if it makes you feel better. In the mean time, we will be improving ourselves, living full lives, exploring nutritional and physical activity options, letting our bodies find their natural weight, and fighting for the right to be treated with dignity and respect regardless of what that weight happens to be at the moment. Because we are more than our BMI number Dr. Peter, and health comes in all sizes.

      • Fab@54 permalink
        February 21, 2012 8:37 pm

        :::applauds:::: Loudly and enthusiastically.

    • Theresa permalink
      February 19, 2012 12:04 am

      “Also, I’m curious if you can find a single, decent-sized, well-controlled study that demonstrates that weight loss of greater than 10% can be achieved by more than, let’s say, 25% of the population for longer than two years.”

      That was an excellent question that Shannon asked. I know that you couldn’t answer it, because there is not a single study that shows that weight loss works in the long term for anywhere near that percentage of people (as you know, in reality it’s more like 5 percent).

      So instead of acknowledging this fact, you change the subject, and blithely attribute the abject long-term failure of weight loss programs to “non-compliance.”

      How absurd. How condescending.

      I’m not sure if you are a real M.Deity, as you have not shown your actual credentials, but here’s a cautionary tale, just in case you are:

      A friend of my Mom’s was a fat lady named Vivian. She went to see her doctor one day about her unrelenting back pain. The doctor said, “You’re too fat! Lose weight!” and sent her on her way. She joined a weight loss group, lost a small amount, and still her back hurt. She returned to the doctor, and he said, “You’re still too fat! Lose more weight!” and sent her on her way again. Lather, rinse, repeat, for two years. Vivian trusted her doctor. Why would he steer her wrong? Tragically, she did not get (or possibly could not afford) a second opinion. Finally, after two years of futile weight loss attempts and continually worse back pain, the doctor sent Vivian for an x-ray and wouldn’t you know, there was a TUMOR pressing on her spine. Doctor says, “Just kidding about being too fat! It’s actually cancer! Too bad the tumor is too big to operate on now!” Vivian soon died of her cancer.

      Cause of death: Cancer, exacerbated by her physician’s unwillingness to look beyond his preconceived notions about his fat patient.

  13. February 19, 2012 10:19 am

    Loved your post, Shannon. What gets to me all the time in responding to people who are resistant to these notions is that it’s really not about data – it’s about a lack of consideration of data. Conventional ideas about weight are so built in to the structure of our belief system, that assumptions are considered fact and not even recognized as something that can muddle our interpretations. We just have faith in our predecessors and don’t stop to reconsider. It’s impossible to ever change the paradigm, if we just keep reiterating the same old stuff. As an example, consider how we interpret the studies showing that when research participants lose 5% of their weight, health improves. Because conventional experts expect weight loss to be beneficial, they attribute the health improvement to the weight loss, never even noticing that the study participants did something to lose weight – like changed their eating or activity habits – and that this might play a role in the health improvement. When we don’t challenge our assumptions, they just serve to keep reifying the old paradigm. But those studies alone certainly don’t provide evidence that small weight loss is valuable. Anyway, I have compassion for why people get so entrenched in their anti-obesity world view. It takes a lot of guts and independent thinking to go beyond the “everyone is saying it so it must be true” argument. I’ve posted an open letter here, to try to challenge people to do the necessary critical thought: http://lindabacon.org/HAESbook/pdf_files/HAES_Message%20for%20Those%20Who%20are%20Resistant.pdf. (It’s an excerpt from my book, Health at Every Size (www.haesbook.com).

    • February 19, 2012 9:59 pm

      Thank you, Linda. It’s an honor to have you give your support, and although I love the Final Words, I doubt since Dr. Peter wouldn’t even entertain the ideas of HAES, there’s no point in trying to convert him, specifically. Instead, I hope that others may be learning about HAES for the first time here and compare traditional medical opinions on obesity and health to what HAES has to offer and see just how futile the traditional approach is. Especially if you’re a fat person who has weight cycled your entire life, despite being perfectly compliant, and faced a medical professional who treated you as non-compliant.

      And how can any medical professional do their job credibly if they disbelieve their patients and assume noncompliance when the only indication of noncompliance is a body type that he believes is the problem. But the incredible work that you and so others are doing is spreading acceptance of HAES to areas we’ve never thought were possible. You’re having conversations and raising questions and dismantling the existing paradigm brick by brick.

      Thank you so much to you, and to everyone, who works so hard to spread the message of Health At Every Size®. It’s because of HAES, and it’s tireless advocates, that fat people don’t have to suffer the indignities of Dr. Peter any more.

      Peace,
      Shannon

      • February 20, 2012 11:19 am

        “And how can any medical professional do their job credibly if they disbelieve their patients and assume noncompliance when the only indication of noncompliance is a body type that he believes is the problem.”

        This is absolutely the crux of it, Shannon.

        At the Natural History Museum in London there’s a long-standing Human Body exhibition with a bunch of interactive stuff. One of the games is the ‘Homeostasis Booth’. You basically enter a bunch of your details (age, gender, height, weight), it programs you into the computer, then you come up on screen as a ‘virtual’ person, and you choose an activity (say, running), and then you get to push a series of switches to regulate your own heart rate, blood pressure, sweating and so forth. I’ve been there a few times and watched people try this thing, and the vast majority of people who give it a go are ‘dead’ within 30 seconds – because that’s what happens when we, with our conscious brains, try to control an artificial, vastly simplified version of the bodies we actually live in. Thankfully, the real versions do this all by themselves, and pretty efficiently most of the time considering just how complex they are.

        The point being, that you can do what you like to a human body, but the exact way it responds is outside both you and your doctor’s control. If your doctor tells you to restrict sodium and you do just that, and your blood pressure doesn’t go down, that’s not non-compliance – you complied, but for one reason or another, your blood pressure doesn’t respond to sodium levels. (Not everyone’s does.) If your doctor tells you to exercise more and restrict calories, and you do that, and your weight fails to go down as expected – that’s not non-compliance either.

        Really, the issue is one of trust. If the doctor trusts the patient to tell the truth, and doesn’t shame them for it, the patient’s that much more likely to trust the doctor, and they can work together to find what will make that particular person as healthy as they can be. Win-win all round. Once you start accusing someone of lying when they’re actually telling the truth, that’s the short slippery slope to the end of any relationship, medical or otherwise.

        (PS: Yes, this is the regular Emerald commenting here. I have my own WordPress account now, is all.)

  14. Len permalink
    February 22, 2012 5:11 am

    I think Shannon put his finger on the nail, as always, by pointing out that Peter represents a lost cause. He is clearly focussed on his own identity as the Big Doctor Man who swoops in wearing the +4 White Coat of Magnificence and expects instant, fawning respect because, people, he is ADVOCATING FOR OUR HEALTH which means, of course, to treat each and every one of us as lazy, worthless liars.

    What Peter seems to have forgotten is that medical professionals, in this century, need more than the Big White Hunter mentality. He has forgotten the importance of trust, of mutual respect and of communication, and he has clearly decided that he is too important to do anything as mundane as listen, or exchange information that might just be of benefit in diagnosing and treating illness.

    If I seem particularly bitter, it’s because I am. I have had about as much as I am prepared to tolerate of people like this who are so unprofessional that they have already diagnosed and condemned before they even meet a person. I have had puh-lenty of doctors like Peter who condescend, insult and lie. I have had enough doctors who injure.

    What Peter doesn’t appreciate is that being fat is. Not. A. Problem. in my life. I am privileged enough to be able to afford to eat well and purchase clothing that fits, and that sure makes a difference to me. I hope that I can share my privilege with others for as long as I have it.

    My life right now is probably exactly what Peter thinks it COULD be if only I was thin. I work, I manage a successful business, I exercise, I have many hobbies, I have brilliant friends and family. I live with the love of my life. I laugh a lot and eat three meals a day and stare at my wardrobe every morning for ten minutes trying to decide which of three almost-identical outfits to wear and I get stressed at deadlines and I go to the cinema occasionally and every dratted winter I catch the flu because I work with kids. I give and receive compliments and I love what I see in the mirror. I sometimes don’t exercise enough because I’m tired and grumpy, and sometimes I’m on top of the world and hardly stop moving.

    In fact the only thing wrong in my life is idiots like Peter, who give me way too much space in ther heads trying to fit me into pointless boxes labelled ‘unhealthy’, ‘stupid’, ‘greedy’ and ‘non-compliant’.

    Peter I have news for you. You do not – thank heavens – represent the medical community. There are others out there who are actually willing to work with people who look like me to try and maintain optimum health with whatever nature handed us. Yes, people who are fully trained and read articles and have clinical experience and all.

    Stop throwing the word ‘responsibility’ around Peter, unless you are prepared to live and die by it too. Take some responsibility for your inability to miraculously turn fat people into thin people. Take some responsibility for the fact that you injure people, that you are hurting people with your intolerance. Take some responsibility for the fact that you have the capacity to work with people towards their health but instead you choose to condemn and blame. Take responsibility for the fact that you cannot change nature, and that for some reason I cannot understand, you still claim to be an advocate for the very same people you deny, insult and injure.

    I will go on living my fat life: fatly, responsibly and without any ‘help’ from the likes of you.

  15. James permalink
    June 21, 2012 9:56 pm

    Anecdotal stories are not evidence, but they do sometimes shed light on problems. In the case of physicians and preconceived notions of illness, sloth, or laziness where none exists, they can be exasperating, dangerous, or even deadly.

    I have followed this blog but never posted to it before. My wife was once (before I met her) thin (but not a waif), but after she was in a car accident and in a coma for six weeks where she gained 25# (who ever heard of gaining weight in a coma?) her weight climbed to about 260# and leveled off. I have only seen pictures of her thin; I have only known her at her present weight.

    She is far more energetic than me; she works outside in the garden much more than me, yet she eats precisely the same portions of food I do, almost all made at home from scratch (this place is a long way from a restaurant). Her physicians determined after her coma that some sort of brain damage must have occurred that altered her metabolism; by no stretch is she an “over-eater.”

    But from some people, the commentary she gets, looks, and treatment would make you believe she was a pariah. “Some people let themselves go . . . some people are lazy . . .” I have heard all of them, and anytime I do, I am equally well-mannered in informing them of their rude gossip (and make an effort to find a shortcoming of theirs to humiliate in turn).

    I am neither fat (male, 52, 5’10”, 120#), nor a physician. But the good doctor’s post smacks of the logical fallacy of “appeal to authority” if I ever saw one; moreover, there is no evidence the poster actually -is- a physician, nor an authority.

    In my experience with physicians, though, ofttimes they already have a preconceived notion of (name a condition) and will work very hard to fit a patient into that notion.

    A case in point: it took three different doctors a few years ago to diagnose I had scarlet fever. For my second time. Yes you can get it twice, and I did.

    It took four doctors to diagnose mumps last December, which was also my second time (and you can get mumps twice as well, and it is very dangerous as an adult male).

    Another case in point: I was at a Veterans Administration hospital last year (I will not name the hospital to prevent its humiliation), for a drug level test for my epilepsy medications. The doc at the VA decided to throw in a cholesterol test.

    Pointing out to the doc I had just eaten in the VA canteen about two hours before (something that resembled deep fried pizza), I cautioned the cholesterol test mighn’t come out correctly.

    He pooh-poohed me and ordered the lab anyway.

    A trip to the Internet after I got home to the VA’s Website clearly indicated that a fasting lab must include the fast. The results are otherwise invalid. This is in the VA’s own medical rules.

    Not surprisingly, when I went back two weeks later for an adjustment to the epilepsy medications, I was told my cholesterol numbers were too high (duh), and I needed to take a statin medication (not a chance).

    I asked for a second opinion (my right in the VA). Denied. I asked for a second cholesterol test (I had fasted the evening before in anticipation of this result). Denied.

    I told him no thanks to the statin. As I left across the waiting area he literally ran out of his office, screaming across all the heads of other veterans and their families waiting, “If you don’t take it you’ll die.”

    Aside from the likelihood that we all will die, that particular display was unprofessional and clown-posse insane. My trip then took me to the Patient Advocacy Office, to lodge a complaint over violations of my privacy (screaming at me across the lobby), The office took the complaint, and round-filed it. No response (which is required).

    Using my own money as a disabled veteran (because the VA had already done the test they wouldn’t pay for a civilian to do it), I went to my wife’s civilian physician and explained the problem. He recommended a repeat of the test (after an appropriate fast).

    The numbers were marginally high, but not like they were after the deep-fried pizza. He recommended instead reviewing my diet and exercise (that was easy, I don’t exercise at all), making appropriate adjustments to lower cholesterol intake, and return.

    I did, and the numbers were fine. They have been ever since. I have recently moved; the VA here did a cholesterol test recently and found nothing alarming. They were curious as to why a physician had entered into my record I was refusing treatment for cholesterol, though, and removed the remark.

    I once had surgery at another VA clinic on my hand. The physician prescribed a narcotic for pain relief, not checking first to see that it is contraindicated for my epilepsy medication, a barbiturate.

    Having seen many pompous physicians in the past (and bear in mind Business Week magazine rated the Veterans Administration the -best- health care system in the United States, government or commercial), I was already armed with a list of such black-listed meds.

    He accused me of making up the list. He would not even look in his own PDR. He also refused any pain medications (and if you have ever had surgery in the palm of your hand, you’ll understand why they are necessary) -because I had challenged his authority-.

    Of course, all physicians are not like this. The vast majority are truly concerned about the best outcome for each and every patient they see. But a significant minority are concerned only for their own ego, and if you don’t defend yourself against such people, no one else will.

    And the doc with the statin prescription? He is no longer amongst us, though he was younger than me when he died. Probably stress.

    • June 22, 2012 3:35 pm

      Geez James, that statin doc was a quack. What kind of doctor gives a cholesterol test without an overnight fast? That is textbook stuff. At my last physician visit, the only thing I had that morning was a swig of skim milk, and the doctor still gave it some thought before giving me the test. But you’re right about the VA being the best healthcare in the country because if anyone deserves excellent healthcare, it’s veterans.

      And you are right: all people consider themselves to be the expert on any opinion they hold. The wise ones recognize this bias and try to compensate for it. Physicians are no different, they just have the documentation to confirm their arrogance. Just keep in mind that at every medical school, some doctors had to graduate at the bottom of their class.

      Thanks for stepping out of the shadows. It’s always nice to hear from our many silent readers.

      Peace,
      Shannon

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