Obesity: not a 'self image' problem – Greg Stevens – The Kernel

My recent article, You eat too much, elicited strong emotional reactions from many readers. The letters and comments still flooding in that express outrage and anger at the article follow two main themes I think are worth addressing.

The first is what I will call “special cases”. What about people who are on medication that cause weight gain? What about people who are injured in an accident? What about people who binge-eat in their sleep and don’t even realize it? Does it really make sense to blame them them for being overweight?

The people who point out these special circumstances are doubtless very well-intentioned. But I think the reflexive tendency to focus on these anecdotal stories is unhelpful.

Look at the numbers for a moment. Over 35 per cent of Americans are obese. Do you really believe that all, or even most, of these individuals fall into these “special case” scenarios? Are they all sleep-eating, or on special medications that cause weight gain? Is it not more likely that even when you factor out people with such “special circumstances”, there are still a large number of people left over who simply have bad habits?

I understand that the people who focus on special cases mean well, because they are trying to introduce nuance into the conversation. They are trying to say: “Don’t paint with a broad brush!”

But by chronically focusing on special case exceptions, rather than personal responsibility, these stories become the excuses that every obese person can latch on to. Every person then imagines him or herself as a “special case” and declares: “Why even bother? It’s out of my control!”

For most people, that is simply not the case.

The second theme is “I struggle with being pudgy”. Many people shared their own stories about growing up as pudgy kids, and always trying to eat right and exercise, and yet nothing seemed to help. These were sincere and emotional stories from people who have battled their entire lives to “lose that last 10-20 pounds”.

They were offended by statements in my article such as: “If you want to make a change, put down the ice cream scoop and pick up a gym membership. It really is that simple.” They wrote to tell me from their own experience: they know it isn’t “that simple”.

I completely understand the frustration that many people feel, battling their entire lives to get into better shape, and often never seeing the results that they want. Many people I know – perhaps most people I know – have lived their entire lives with the quiet desperation of not being completely satisfied with their physical self-image.

But let’s be clear: that is not what this article is about.

The article “You eat too much” is about obesity. Obesity is not “feeling a little fat”. It is not the pudgy little girl who can’t seem to lose that last 10 pounds. It is not the person who works out every day, and counts calories, and still just can’t fit into those 32-inch waist jeans.

There is a huge difference, both psychologically and literally, between someone who “can’t lose that last 10 pounds” and someone who is obese.

When talking about chronic dissatisfaction, seeing yourself as “slightly overweight”, then all of the complexities of issues like self-acceptance and cultural standards of beauty become very important. But that’s not the case with obesity.Obesity is not about self-image, and it is not about whether one can be both “round and sexy”.

It’s about being dangerously, medically overweight.

Perhaps this issue is so sensitive that no amount of clarity would be “clear enough” to prevent this misunderstanding. If that is the case, then that is part of the problem with our culture.

But if we allow people to conflate obesity with “being a little overweight”, then we will never be able to have a serious conversation that addresses obesity for what it is: a serious medical issue that requires changes in behaviour before and above all else.

NOW READ: You eat too much

Beyond Obesity: Reframing Food Justice with Body Love « Oakland …

Oakland has been at the forefront of what many would call the food justice movement – a movement to ensure that disenfranchised communities have power over they foods they produce, sell and eat.  Organizations like People’s Grocery have led the way in identifying the intersections between race, income and health.  Phat Beets Produce and City Slicker Farms have been innovators in community-led urban gardening.

Being in one of the centers of food justice work has been exciting but as someone who has also been involved in body acceptance movement, I find myself increasingly uncomfortable with the frame of obesity prevention as a justification some use to enter this great work.  Many groups doing this work have to apply for funding (such as Michelle Obama’s Let’s Move) that frames food access as obesity prevention.  Researcher Linda Bacon coined the term “Health at Every Size” to challenge ideas that weight loss is desirable for everyone and I wanted to think further about the impact of the framework of obesity prevention of food justice and communities of color.  That’s when I read Sonya Renee’s post  Weight Stigma in Diverse Populations.

Sonya-Renee-Taylor-2

By stating “Our society tells us fatness is not beautiful.  Blackness is historically, not beautiful.  So even while battling weight stigma and reclaiming size diversity as beautiful, the presence of Blackness complicates the narrative,” Sonya Renee names the very real intersection between marginalization of women of size and black women.  Performance Poet, Activist and transformational leader, Sonya Renee is a National and International poetry slam champion, published author, and change maker.  As the founder and CEO of the The Body is Not An Apology, she is working to promote an international movement focused on radical self love and body empowerment. I asked Sonya more about the impact of the obesity prevention frame on food justice work.  Her responses are eye opening.

There are a lot of well-meaning people trying to do right by their communities by working on “food justice.”  Does that have relevance to size acceptance and body love?  Where do you see the intersections?  

I think food justice absolutely has relevance to size acceptance and body love or what The Body is Not An Apology calls Radical Self Love.  Radical Self Love is about being an advocate for your own well-being, your body and then allowing that advocacy to demand those things that aid well-being.  Asking for healthy food and access to nutrition is without question an element of radical self-love.  Also, when we think about who has access to good grocery stores, nutritious choices in their communities; we must look at the ways body impacts that.  There is a racial aspect that must be named which is about what bodies are valued and cared for systemically and which we do not. Those observations lead us directly to the way we further disenfranchise bodies of color, fat bodies, poor bodies.  Food justice is about ensuring all bodies have access and autonomy over their bodies.

How do community activists combat the obesity frame in public health, especially related to black communities?  There’s some real dollars attached to doing food justice as “combating obesity.”

I think it is essential to talk about the intersections of discrimination.  Asking how is a framework that makes someone’s body “wrong” an act of public health? We must ask who benefits from a war against people’s bodies.  Does it benefit communities to be at war with their bodies?  Does it benefit large people to view their bodies as a thing they must fight?  If the benefit is not to the communities we serve then what makes the model a justice movement?  Given that there are actual health indicators that can be assessed without size and size actually is not valid indicator of health unto itself, it is completely possible to talk about health without pathologizing bodies.  I also challenge public health professionals to be honest about the mental health aspects of having society be at war with your body or teaching people to be at war with themselves which is the translation of “combating obesity.”  Anything that reinforces inequity, bigotry, prejudice or shame IS NOT a justice movement.  Food justice work that does not include dismantling weight stigma in my opinion is not a justice movement.

There’s a lot of momentum around promoting health in marginalized communities (i.e. Michelle Obama’s work) but with the frame of ending obesity.  What frame would you recommend using to address what are real problems of accessibility for food and recreation? 

I often just sit with the idea that the “ending obesity” paradigm is actually saying “we want to end Fat People.”  There simply is no health promotion in that framework.  The Body is Not An Apology operates from the framework that says injustice starts in many ways from the inability to make peace with the body, our own and others.  From that premise, the issue of promoting health is not about the failure of the body but the failure of our society to protect and care for EVERY BODY equally and the ways in which we as individuals and communities have internalized that lack of care.  If we cared for each person in our society we would have those things that are required for basic human sustainability in all communities.  We would have grocery stores with affordable healthy options; we would have playgrounds and recreation in all communities.  If we did not have recreation due to community violence we would be addressing and healing community violence.  We would be ensuring our media replicated images of all members of society in nuanced, dynamic, psychological healthy ways.  If we were using an intersectional community care model we would be addressing the myriad ways we could better care for each other and for ourselves.

How do we incorporate the historical analysis of the commodification of black bodies into our work as food justice advocates?

Understanding the commodification of black bodies helps understand why there is little investment in our community’s well-being and health.  I think it would also help black people understand how their demand to be treated humanely via Food Justice is as vital as the Civil Rights movement, abolition movement etc.  The value of black bodies was directly tied to unpaid labor.  When that unpaid labor was no longer a resource, we saw a complete divestment in the lives of black people.  Now that the commodification of black bodies comes via the criminal justice system there is an absolute necessity to foster the disrepair of black communities. The commodification depends on us growing up in such a way that increases our likelihood of engaging in criminal activity.  That is shown time and again to be directly tied to poverty and not having one’s basic needs met.  Food justice is about ensuring that all communities have their basic needs met so that they might thrive. The treatment of people in such communities is an illustration of the difference between commodifying bodies and valuing bodies. Food Justice is about demanding our bodies be valued!

Finally, how do we make the shift from shame and blame to love?

The question I ask that gets me to the answer of that question is always about who does blame and shame serve?  How does blame and shame make a world that creates positivity and possibility?  I reject the notion that there is some way that my body can be wrong.  And if there is nothing wrong with my body then there is no place for blame or shame.  From this space I can focus on how I can better LOVE my body and how I can better advocate that the world support me, my family, and my community in growing that love.

The Five Stages Of Living With Obesity | Dr. Sharma's Obesity Notes

stages-of-grief-300x282Some readers may be well aware of the five stages of grief, the natural process of grieving, which, according to Kubler-Ross, move from denial to anger to fear to grief and finally to acceptance.

As others have pointed out, the same five stages apply to virtually every serious life event, including being diagnosed with a chronic or severe illness.

Now that we have come to appreciate that obesity is a chronic disease (for which we have no cure!), it should come as no surprise that these five stages also apply to obesity.

First comes denial: not denial that I am gaining or have put on weight – that is obvious enough. Rather, denial that this may be a real problem or may have serious consequences down the road. A normal response in this stage is to not want to know about it. I don’t see a doctor because I don’t want to hear that I have a problem. I don’t listen to advice because it doesn’t apply to me. I don’t weigh myself because I don’t want to know. Pseudoacceptance – it may be as it may, but if that’s the case, then that’s the case – don’t tell me I have a problem and don’t tell me I need to do something about it – leave me alone!

Second comes anger: often it is the anger that fuels the denial. Anger at my body. Anger at myself. Anger at the people around me (including those offering help or understanding). Anger at life in general. Why me? Why this? Why can I not stop myself? Why can I not stick with my diet or exercise plan? Nothing works!

Third comes depression: this phase is characterized by sadness, a sense of loss, despair, anxiety, fear of what is to come. What if this weight gain continues? What if my health problems get worse? I don’t want to be the “fatty” that people make fun of. I don’t want to be ridiculed in public. I don’t want my pains to get worse. I don’t want to end up in a wheelchair or have diabetes or sleep with a CPAP machine. There will be restrictions – giving up things I love. It will mean effort – doing things that I don’t care for. No longer can I live like I used to or like others continue to – lucky them!

Fourth comes bargaining: OK, I get that I have a problem but really, there must be some simple way out of this. If I can only find the right diet or right exercise or maybe cut my carbs or go vegan or get myself tested for food allergies. How about I just give up the white stuff, or the fat, or the pop? What if I buy a treadmill and religiously used it every day? How about I just share my story ? May be someone will help me – or I will find the strength. I have been successful in every other aspect of my life – so really – how hard can this be?

Fifth we reach acceptance: This is where I finally accept that I have this problem and reach the point where I am ready to move on. Once I accept that this problem is not simply going to go away, nor will it be fixed by another quick diet or weight-loss supplement, I reach the stage where I accept that I need to become more realistic about the solutions. I am now ready to find and accept the help I need (and fight for it if I have to) or I am ready to accept that this is what I will have to live with for the rest of my life – so let’s make the best of it and move on.

Research shows that these stages are not perfectly sequential – often they occur in parallel and even regress or sometimes flip-flop from one stage into another. That is perfectly natural. Some folks may never move beyond denial or anger, some may be stuck forever in depression or bargaining. Even those, who have accepted their situation may occasionally regress (e.g. the surgical patient who is in denial having to take his vitamins).

At this point it is important to point out that acceptance does not simply mean accepting the status quo.

Rather, acceptance means accepting the fact that I need to now deal with this problem the best I can. If I need to become a marathon runner to conquer this weight, so be it. If I need to open my soul to a psychologist to work through my childhood trauma, then that’s what I have to do. If in the end the only solution is bariatric surgery – bring it on. If this is what it will take – I am now ready to accept it, embrace it, use it to my advantage. I am now ready to stand up to bullies and the “wise guys” who have all the answers.

As health professionals, it is important that we recognise what stage our patients is at. The denial and anger stage are not the best time to discuss diet plans. Nor is the depression or bargaining stage the best time to bring up the topic of surgery or lifelong medication.

With true acceptance comes hope and a positive change that sets the foundation of whatever is to come next. This is no longer the time to point fingers, assign blame, nurse regrets,  hide in shame, dissolve in despair.

Things are as they are and I accept them. But, as they say, when life throws you lemons, reach for the tequila!

If you have experienced or can relate to these stages – I’d love to hear your story.

@DrSharma
Edmonton, AB

The Five Stages Of Living With Obesity , 10.0 out of 10 based on 4 ratings

Labels: ,

25 Responses to “The Five Stages Of Living With Obesity”

  1. EC says:

    I am slightly confused on the denial part where you say “that this may be a real problem or may have serious consequences down the road.” Do you consider it denial if someone is overweight or obese (by the BMI chart), is weight-stable, has good health measures, exercises and eats a mostly healthful diet? Or are you specifically referring to someone a little higher on the Edmonton Obesity Scale by this? That would be more in line with my understanding of your general message, but it’s not clear to me here.

    I guess I feel a little touchy on this one, because this smacks of the “Vague Future Health Threat” a lot of people get hit with by their doctors and pretty much all of society the instant they get above BMI 25.0. Any argument that says “really, I’m healthy,” is countered with the idea that we’re in denial.

  2. Nanette says:

    You hit the nail on the head every single time. This blog is full of win. Thank you!

  3. Arya M. Sharma, MD says:

    EC – if your weight is not really a problem then this is not a question of denial – after all there is nothing to deny. But, let us be honest, the vast majority of people with excess weight do have a problem – people who don’t, make up a rather small healthy minority of fat people. If this is where you belong, good for you.

  4. Dagny Kight says:

    I’ve gotten a lot of response to a section in my book where I write about how going on a diet takes a person through stages of struggling with a sense of control.

    You pick a day to start a new diet and make a plan. The planning gets you all motivated and excited.

    At first, you stick to the plan very specifically and it makes you feel proud of yourself. You have a sense you’re “doing something” to solve a problem and you’re being good at it.

    The diet plan imposes changes on your regular routine and lifestyle that are difficult to maintain so little by little, it starts to break down. The breakdown usually begins with a temptation to eat something off the diet plan so you bargain with yourself that you’ve “been good” up to this point so you deserve a treat and it’s OK.

    The diet plan becomes more difficult to maintain over time so the bargaining gets bigger. You fall off the diet one day so you consider that day a total loss, you might as well eat whatever you want. You do it because you bargain with yourself to be back “on” the diet tomorrow.

    Eventually you consider the diet a complete failure. You bargain with yourself to be “off” the diet and decide it’s over. You eat whatever you want in an “off” a diet manner until the day that you decide you will start your new diet. You feel OK about what you’re eating as long as you stick to the terms of the bargain you make with yourself.

    You start the cycle over again.

    People have written to me that they do this all the time and they realize they’ve used up months and years of their lives living like this. I know I did.

  5. DebraSY says:

    I would like to share a little correction to your premise, based on my limited time as a lay chaplain. These are the Kubler-Ross stages of death. They are what people go through from diagnosis to final chapter of life as they confront their own mortality (and, as you rightly point out, the order is not set — though bargaining is usually listed before depression). The stages of death are frequently confused with stages of grief, and often misapplied, especially in early grief. The first stage of grief — when one learns that someone dear has died — is chaos. The grieving person may bounce back and forth from feeling numb to feeling profound sadness to feeling uncharacteristic emotions. Often friends see the numb stage or an uncharacteristic emotion and inform the poor griever that he or she is in denial and must move on. This is unhelpful. It makes the grieving person feel guilty for something that is natural.

  6. Kelly. Proulx says:

    This is awesome Dr Sharma. Thank you for putting this together. As a Dietitian I see people battling with their weights all the time and some days I struggle to help them. I use the stages of change, but this is excellent. Thank you.

  7. Linda Fair says:

    I wrote this a couple of years ago and your article reminded me of it:
    The Many Layered Cake of Obesity

    1. The bottom layer is the pain that started it all. Whatever drove us to seek comfort, solace, numbness in food, over and over again. Most of this probably started very early in our lives and was not our fault.

    2. The next layer contains the real physical effects of being obese: diabetes, cholesterol, heart disease, fatigue, joint deterioration, etc.

    3. The next layer contains the self-loathing that we cannot control this thing that eats at us.

    4. Another layer is all the unkind judgmental things that others have said to us, well intentioned or not.

    5. …all the times and ways that others have tried to “help” or “fix” us by controlling us.

    6. …all the misinformation and unhelpful advice that we have received directly or indirectly.

    7. …the isolation we seek in order to avoid being hurt again.

    8. …all our other needs, wishes and desires that cannot be fulfilled because of our obesity and/or others’ attitudes.

  8. Melinda Munro says:

    I’m with EC. I am super healthy and fit but with a BMI over 30. So am I in denial? No, actually bargaining, most of the time and sometimes acceptance. But EC is right, there is a constant pushback to doctors that the BMI does not mean I have any illness which I am denying.

    But I am curious about your comment about numbers, Dr. Sharma. What is the percentage of EOSS 0 or 1 in the population of people who have BMI’s over 30? Are we a tiny minority or are we sizable enough to warrant attention to what genetic factors drive our ability to be fit, strong and fat?

  9. Pierre Trudel says:

    Pierrette I live with these steps everyday.We have “been there,done that”.When we talk to others that are still in denial we no longer try to convince them.
    Until they reach the other factors, we are talking for nothing.
    I know of “no” people that are obese and exercise regularly and eat properly.
    Those that say they do are full of it and are in real strong denial.
    People that are obese simply eat all the time because they are always hungry.I know.I did also.
    When I changed my lifestyle and realised that I can eat healthy foods and be totally satisfied, then and only then did I really join “my fight” to become healthy.
    My wife is 62 and I am 61 and we are both in the best health of our lives…..Wow
    Pierre Pierrette Trudel

  10. Arya M. Sharma, MD says:

    Melinda: The exact numbers based on NHANES III for population with BMI 30 to 35 is Stage 0 = 8%, Stage 1 = 19%. For BMI greater than 40, the numbers are Stage 0 = 5% Stage 1 = 14%

  11. Arya M. Sharma, MD says:

    Linda: The Layered-Cake of Obesity – interesting idea!

  12. Arya M. Sharma, MD says:

    DebraSY: You make an important point – all of these stages are “natural” and even “healthy” as part of the process. Thus, for e.g., although it sounds negative, “denial” is a very healthy initial response, so is “depression”. The problem is when people get stuck in one of the other stage or fail to eventually progress to acceptance. The notion of thinking of this as a staged process (not always linear) is for the professional to recognise where your patient is at and counsel appropriately. As I said, trying to talk someone, who is in the denial stage into addressing the problem will only create defensiveness.

  13. Arya M. Sharma, MD says:

    Dagny – you perfectly describe someone stuck in the bargaining stage. This person has not yet fully accepted that changes have to lifelong and that the expectations have to be realistic. I know hundreds of people (probably most people trying to lose weight), who are stuck in the bargaining stage and never make it to full acceptance.

  14. Valerie X Armstrong says:

    This is so much like a blog post I made on 11/13/12…great minds, you know

    http://thesurvivalofthefattest.blogspot.com/2012/11/the-five-stages-of-accepting-myself-as_13.html

  15. Elina Josephson says:

    As usual, I find myself offering a contrary voice. I believe from experience, that these stages are better understood as interwoven threads. Rather than experiencing them one at a time, a person who is gaining weight cycles through them often on a moment by moment basis. All the threads exist in the same time and space but the person is more focused on one or the other. This is not nearly as true for grief, but it is true for weight management. What this means for a qualified and caring CBT is that you are not required to wait for the client to transition into acceptance, you can help the client shift focus and change perspective. You can help the client find motivation, strength and purpose. We are complicated and powerful. Within each one of us, at every single moment,lives the potential to simply make another choice.

  16. Arya M. Sharma, MD says:

    Elina – you are bang on that these stages are interwoven (which is why I chose the image of the ribbon for the illustration). I also agree all all these stages can co-exist from minute to minute, from day to day. A skilled CBT counsellor will recognise this and provide the necessary support.

  17. DebraSY says:

    Pierre: you no of NO ONE who is obese and exercising regularly and eating properly? All obese people are “full of it” and “in real strong denial”? Wow, that’s harsh. Is Diana Nyad in denial? What about 75% of the Kansas City Chiefs (my team) or, for that matter, 75% of other people’s football teams. What about Oprah (also proof positive that no amount of accountability and resources can assure permanent weight-loss maintenance). What about Janet Cook, the first person to swim the Berring Straight? There are also many non-famous obese people who quietly exercise and eat well with no fanfare. I knew quite a few when I belonged to the YMCA.

    Please reconsider your judgments. Weight bias hurts people.

  18. Dagny Kight says:

    I don’t deal with weight because of “pain that started it all.” I don’t allow people to treat me like I am some weak, broken emotional wreck or to label me in that way. Some of us can have bodies that manage energy very efficiently and brains that want to think about food and connect it to everything in our lives. Fighting that to manage your weight in an intensely obesogenic environment is VERY DIFFICULT. Even if you think certain situations triggered certain habits, the struggle with weight itself becomes the difficulty.

    We have to get rid of this paradigm that says every fat person is a screwed up mess of emotional issues and “pain that started it all.”

    Food is its own driver.
    Weight is its own stressor.
    Fighting to control your body and mind is immensely difficult and can feel endless

  19. Benedetta says:

    Dagny, well said. Thank you!

  20. Sharon says:

    Very wise words. So how can one move on to that stage of acceptance, or help a client or loved one to do so? I find myself cycling between denial, depression and bargaining–and would love to be able to move to acceptance, so I can fix my weight and my life.

  21. Arya M. Sharma, MD says:

    Sharon – that’s a great question. I am not a counsellor but there are many who read this – they may wish to chip in with some advice.

  22. Elina Josephson says:

    This is at Sharon- You might just not be done cycling yet. Acceptance often comes when all the other possible versions of reality have been exhausted. When you get tired of running in circles and the reward of one more bite does not seem worth it. When the payoff from the denial and the depression and the bargaining no longer works for you. When that times comes, find a great CBT counselor, come in with a willing heart and and an open mind. Walk in to work, do not expect to be fixed, but rather to be empowered to fix yourself. When that day comes, your counselor will help you open the door and you will have found acceptance.

  23. EC says:

    Pierre’s comment is exactly why I brought up the “denial” issue, because this is the kind of thing I hear over and over. Thank you, Debra and Dagny, for pointing out the flaws in assuming that every fat person is an emotional wreck, or a lazy glutton, or “in denial” — an attitude I find frustrating and insulting.

    While the numbers of obese in EOS 0 or 1 are small, it is still enough that it’s not a total anomaly. I would guess that for people in overweight BMI (where I am — high side of it), those numbers are a bit higher. It needs to be addressed instead of doctors having the knee-jerk reaction of prescribing intentional weight loss to everyone above BMI 25, even if those folks are healthy and weight-stable with good enough habits.

  24. Melinda Munro says:

    You go Dagny!

    If we aren’t being judged as being lazy and deceitful (Pierre), we are judged as being broken emotional wrecks with childhoods laden with abuse.

    The reality is our bodies are hyper efficient and in some of our cases, due to external drivers to be thin, we engaged in behaviours, like yo-yo dieting, that made our bodies even more efficient.

    However, thin friends of mine face some of the same labels – if you are skinny, you must be anorexic with an unaccepted history of abuse.

    How about we agree that we can be healthy people whose genetics and body morphs are different from someone else’s.

    If we are struggling with mental illness that impacts our physical health, then focus on that and not make stereotypical judgements.

  25. Diane says:

    Dr. Sharma, I have bounced back and forth through all of these stages, spending lots of time in denial. It took a lot of work with an addictions counsellor to get me to the stage in which I was willing to go to any lengths to get healthy again. I am on the waitlist for surgery in BC and have been for 4 1/2 years. I don’t have a date yet but I have reason to believe I will have one soon. I appreciate that you recognize that it is sometime a battle to get what we need to get healthy. Thank you for all the work you do on our behalf.

Leave a Comment

Examining the link between bacteria and obesity

We have, it seems, moved on from acknowledging it takes a village to raise a human being. We are well into the realm of realization that it takes a village just to be one. More and more studies are demonstrating the importance of the germs that outnumber our cells by an order of magnitude at least, to virtually every aspect of physiology. But while epiphanies of this sort are redolent with promise, they can be dizzying as well, and pose a threat of disequilibrium and distraction. If we can miss the forest for the trees, there is, I think, a comparable risk of missing the importance of lifestyle for the Lactobacilli. My motivation here is the hope that we will not.

While I can no longer readily recall what life was like before email, I certainly do recall medical practice before the widespread popularity of probiotics. Only very recently did the use of ingestible bacteria transition from the realm of far-fetched to all-but-standard, and from “you must be kidding!” to “where to do I get mine?” Not all that long ago, the only good germ was a dead germ.

Progress since the initial uptake of the probiotic concept has been astounding. The now well-established potential to prevent and treat C. difficile colitis, a dire complication of antibiotic therapy, with probiotics is a considerable advance all by itself.

The more we’ve learned about the importance of our resident microbes, the more we’ve learned about the need and opportunity to learn more. The process may be likened to climbing a hill, and then gaining a view of the higher hills and mountains beyond. There is a lot of climbing left to do.

One peak now within view involves the important relationships among our immune system, cohabiting bacteria, and other organisms. In An Epidemic of Absence, Moises Velaszquez-Manoff makes a thorough and compelling case for the unintended consequences of sanitizing our environments and the eradication of parasites. How best to apply such lessons to the management of allergy and autoimmune disease is a work in progress, but that it’s vitally important work now seems abundantly clear.

The other peak before us is the one that worries me a bit. It beckons with tantalizing new findings related to weight control.

We have known for quite some time that commensal microbes play a vital role in digestion. In fact, we surmised this about bacteria living in our guts before we knew much else about them; after all, what else would they be doing there? More recently, we have come to learn that bacterial colony counts influence our energy efficiency and the number of calories we can extract from food. Differences in the microbiome can make it harder or easier to lose weight, and may account for more flagrant cases of weight loss resistance. In some instances, when all else fails, the wholesale transplantation of gut microbes may allow for weight control.

This provocative tale is further embellished by a cluster of recent papers in preeminent scientific journals. An article published in Nature Reviews in early August explores the causal pathway from intestinal microbes to obesity risk. A study published in late August in Nature compared the microbiota in 123 lean and 169 obese Danish adults. The authors report greater genetic variety among gut microbes in lean individuals than obese. A brief report of an intervention in the same issue of the journal reported an increase in the genetic richness of gut microbes when obese and overweight individuals were put on a weight-reducing diet. And even more of Nature’s rarefied real estate has been allocated to this topic to accommodate commentaries and editorials.

And a report in Science indicated that the gut microbes from obese adult twins could make germ-free mice get fat, while the gut microbes from their lean siblings had the opposite effect.

Why does this all worry me?

I fully acknowledge the almost certain importance of our microbial diversity to energy balance and weight regulation. I accept that indelible links are being forged among genes, germs, and resultant girth.

But we are all too easily distracted from the accessible means of both losing weight and finding health, by new and exotic theories. Excessive preoccupation with the microbiome could lead us into our next great boondoggle.

Consider that behaviors we control directly, as opposed to microbial colonies we may not, explain 80 percent of the variation in the risk for all major chronic diseases. Consider that overwhelmingly, when people eat well and exercise, they lose weight — and if the behaviors persist, so does the weight loss. Consider that obesity was rather uncommon a half century ago in the days before drive-through fast-food restaurants, a vast proliferation of junk foods, and a comparable proliferation of labor-saving technologies.

In other words, while scrutiny of our microbes may help account for enigmatic cases of weight gain, they are, for most of us, the trees that may cause us to overlook the forest. The fixable causes of obesity and chronic disease are on prominent display, all around us. Most of us will gain weight when we take in too many calories, even if from wholesome sources. Most of us will lose weight if we restrict calories enough, even if those calories come from Twinkies. Energy balance does not seem to require a bacterial referendum.

For the most part, people who exercise diligently and eat very well are both leaner and healthier than others who don’t. What a remarkable coincidence it would be if those who best attended to calories in and calories out just happened to be those with the genes and germs conducive to trim guts.

This does not mean the germs and genes in our guts are not germane to weight and health; they clearly are. But the available evidence suggests they are at least as much effects as causes.

In other words, the same adverse exposures that tend to make us sick and fat appear to do much the same to our resident bugs. It doesn’t much change the relevance of junky diets and physical inactivity to poor health and weight gain to note that along with all of the other adverse effects of such behaviors, they disrupt and distort the microbiome. All this really means as that we, and our germs, are in this together — we flourish, or founder, together.

For a quick analogy, imagine if we had just discovered atherosclerosis and reached the conclusion that it is the “real” cause of heart disease. That would be true, but it would be a serious mistake to toss out what we knew about tobacco, physical activity, and diet as a result. Those factors influence atherosclerosis, which in turn influences the likelihood of heart attack. Similarly, shifts in our bacterial colonies may be part of the pathway by which behaviors translate into changes in both weight, and health. This is in no way an invitation to jettison anything we already knew about the importance of those behaviors.

There may well be some opportunities to address the microbiome directly, from probiotics to fecal transplant. There are, analogously, ways to address atherosclerotic plaque directly with angioplasty and coronary bypass surgery. But just as lifestyle can keep arteries healthy in the first place, or even restore them to health, so too, it seems, can the very same lifestyle practices that protect our health do the same for our inner menagerie.

Over the years, we have heard about many “obesity genes.” But these genes were around long before obesity was a salient public health concern. Genes that haven’t changed recently can’t really account for recent changes in epidemiology. Similarly, while our understanding of our intimate codependence on gut microbes is fairly recent, the codependence is not. The bugs were there all along. If they have suddenly become complicit in epidemic obesity, it might be tempting to pass the buck to the bugs, but it begs the question: What changed them?

This, in turn, offers the silver lining of insight within the dark clouds of potential diversion. One of the prevailing mistakes about obesity is to pin it all on personal responsibility. There is, clearly, a case for personal responsibility; but the choices we make are in turn governed by the choices we have. It never made sense to presume that the current generation of 7-year-olds was less endowed with personal responsibility than every prior generation of 7-year-olds; but they sure are fatter! It makes even less sense to ascribe less personal responsibility to the current generation of Saccharomyces.

Of course, the “fault” lies not in our Saccharomyces! The explanations for what is awry within us are all around us; the very factors of lifestyle, environment and culture that have changed us have changed our resident flora as well. The behaviors that lead to better health and healthier weight may do so in part by moderating the expression of genes, and favorably shifting the populations of gut microbes.

It takes a healthy village within, it seems, to be a healthy human being. It still takes healthy choices by that human being to tend the village.

David L. Katz is the founding director, Yale-Griffin Prevention Research Center. He is the author of Disease-Proof: The Remarkable Truth About What Makes Us Well.

Blood test hope in the battle to beat obesity | Health | News | Daily …

The major discovery could lead to quick and effective ways of curbing Britain’s spiralling obesity problem.

It was made by researchers at the University of Copenhagen who discovered a number of genetic links to over-eating. Once people become aware of these traits they could make lifestyle changes to help prevent themselves gaining weight, the researchers believe.

Professor Haja Kadarmideen, who led the research using 1,200 pigs, said they have confirmed that genetics play a huge role in both how much we eat and who is more likely to pile on the pounds. For some pigs with certain genes, overeating was normal behaviour.

Targeting Weight Gain in Pregnancy to Reduce Childhood Obesity …

Targeting Weight Gain in Pregnancy to Reduce Childhood Obesity A new study suggests pregnancy may be an especially important time to prevent obesity in children.

Investigators followed 41,133 mothers and their children in Arkansas and discovered that high pregnancy weight gain increases the risk of obesity in those children through age 12.

The findings, published in the journal PLoS Medicine, suggest pregnancy may be an especially important time to prevent obesity in the next generation.

“From the public health perspective, excessive weight gain during pregnancy may have a potentially significant influence on propagation of the obesity epidemic,” said the study’s senior author, David S. Ludwig, M.D., Ph.D.

Childhood obesity is especially worrisome as the condition is harmful in many ways including an increased risk for diabetes, high blood pressure, breathing and sleep issues. Obese kids are also more likely to be obese adults.

“Pregnancy presents an attractive target for obesity prevention programs, because women tend to be particularly motivated to change behavior during this time,” said Ludwig.

Researchers have previously observed a familial tendency toward obesity. Children with mothers who are obese, or gain too much weight during pregnancy, are more likely to be obese themselves.

However, this relationship may be due to associated factors such as shared genes, common environmental influences and socioeconomic and demographic considerations, rather than any direct biological effects of maternal over-nutrition.

Ludwig, together with coauthors Janet Currie, Ph.D., and Heather Rouse, Ph.D., used a novel study design to examine other causes of childhood obesity.

They linked the birth records of mothers with two or more children to school records that included the child’s body mass index (BMI) at an average age of 11.9 years, and then made statistical comparisons between siblings.

Researchers comparing siblings to minimize the influence of outside factors because on average, siblings have the same relative distribution of obesity genes, the same home environment and same socioeconomic and demographic influences.

The current study extends results of an earlier study that Ludwig led, which showed that excessive weight gain in pregnancy increased the birth weight of the infant.

The effect of maternal weight gain apparently continues through childhood and accounts for half a BMI unit, or about 2 to 3 lbs., between children of women with the least to the most pregnancy weight gain.

“Excessive pregnancy weight gain may make a significant contribution to the obesity epidemic,” said Ludwig. “Children born to women who gained excessive amounts of weight, 40 pounds or more, during pregnancy had an 8 percent increased risk of obesity.”

This risk, though relatively small on an individual basis, could translate into several hundred thousand cases of excess childhood obesity worldwide each year.

Source: Boston Children’s Hospital

Pregnant woman sitting on a couch photo by shutterstock.

<!– Related News Articles
–>
<!– Related Clinical Articles
–>

 

 

<!–

Advocacy and Policy, General, Health-related, LifeHelper, Obesity and Weight Loss, Parenting, Professional, Psychology, Research, Stress

–>

Pregnancy Weight Gain Linked to Childhood Obesity | WebProNews

Pregnancy Weight Gain Linked to Childhood Obesity

Though recent data has shown that childhood obesity numbers are falling in a number of U.S. states, health officials in the country are still referring to obesity as an epidemic. This week, a new study has shown that expectant mothers may have more direct, biological influence on the size of their children than previously thought.

The study, published Monday in the journal PLoS Medicine, shows that high weight gain during pregnancy is directly linked to an increased risk of obesity for the children up until age 12. The study’s authors believe that helping women limit their weight gain during pregnancy could have an impact on the fight against obesity in the U.S.

“From the public health perspective, excessive weight gain during pregnancy may have a potentially significant influence on propagation of the obesity epidemic,” said Dr. David Ludwig, lead author of the study and the director of the Boston Children’s Hospital’s Obesity Prevention Center. “Pregnancy presents an attractive target for obesity prevention programs, because women tend to be particularly motivated to change behavior during this time,”

The study looked at 41,133 mothers and children in the state of Arkansas over 12 years, cross-referencing birth records and school BMI records. Statistical comparisons were then made between siblings, ruling out demographic, genetic, and environmental influences. Excessive weight gain in the study was defines as 40 or more pounds, which correlated to an 8% increase in the risk of a child being obese.

Though the difference in BMI from mothers who gained the least weight during pregnancy to those who gained the most is only one-half of a BMI unit, Ludwig and his colleagues believe this effect could contribute to hundreds of thousands of obesity cases nationwide.

Overweight and healthy: the concept of metabolically healthy obesity …

Plus-Size-Woman-Lifting-Weight

Carrying too many pounds is a solid signal of current or future health problems. But not for everyone. Some people who are overweight or obese mange to escape the usual hazards, at least temporarily. This weight subgroup has even earned its own moniker—metabolically healthy obesity.

Health professionals define overweight as a body-mass index (BMI) between 25.0 and 29.9, and obesity as a BMI of 30 or higher. (BMI is a measure of weight that takes height into consideration. You can calculate your BMI here.)

Most people who are overweight or obese show potentially unhealthy changes in metabolism. These include high blood pressure or high cholesterol, which damage arteries in the heart and elsewhere. Another harmful metabolic change is resistance to the hormone insulin, which leads to high blood sugar. As a result, people who are overweight or obese are usually at high risk for having a heart attack or stroke, developing type 2 diabetes, or suffering from a host of other life-changing conditions.

But some people who are overweight or obese manage to avoid these changes and, at least metabolically, look like individuals with healthy weights. “Obesity isn’t a homogeneous condition,” says Dr. Frank Hu, professor of nutrition and epidemiology at the Harvard School of Public Health. “It appears that it doesn’t affect everyone in the same ways.”

Dr. Hu and three colleagues wrote a “Personal View” article in Lancet Diabetes and Endocrinology reviewing what is known about metabolically healthy obesity. They identified several characteristics of metabolically healthy obesity. These include a high BMI with

  • a waist size of no more than 40 inches for a man or 35 inches for a woman
  • normal blood pressure, cholesterol, and blood sugar
  • normal sensitivity to insulin
  • good physical fitness

BMI isn’t perfect

BMI is not a perfect measure of weight or obesity. It often identifies fit, muscular people as being overweight or obese. That’s because muscle is more dense than fat, and so weighs more. But muscle tissue burns blood sugar, a good thing, while fat tissue converts blood sugar into fat and stores it, a not-so-good thing.

“Further exploration of metabolically healthy obesity could help us fine-tune the implications of obesity,” says Dr. Hu. “It supports the idea that we shouldn’t use BMI as the sole yardstick for health, and must consider other factors.”

Genes certainly play a role in how a person’s body and metabolism respond to weight. Some people may be genetically protected from developing insulin resistance. Others are genetically programmed to store fat in the hips or thighs, which is less metabolically hazardous than storing fat around the abdomen.

The concept of metabolically healthy obesity could be used to help guide treatment. Currently, exercise and a healthy diet are the foundation for treating obesity. When those efforts aren’t enough, weight-loss surgery (bariatric surgery) is sometimes an option. Such surgery is appropriate for people with metabolically unhealthy obesity, the authors suggest, but for people with metabolically healthy obesity it might make more sense to intensify the lifestyle approach rather than have surgery. This idea, however, needs to be tested in clinical studies, says Dr Hu.

Don’t rest easy

Metabolically healthy obesity isn’t common. And it may not be permanent, warns Dr. Hu. Just because a person has metabolically healthy obesity at one point doesn’t it will stay that way. With aging, a slowdown in exercise, or other changes, metabolically healthy obesity can morph into its harmful counterpart.

It’s also important to keep in mind that obesity can harm more than just metabolism. Excess weight can damage knee and hip joints, lead to sleep apnea and respiratory problems, and contributes to the development of several cancers.

Bottom line? Obesity isn’t good, even if it’s the metabolically healthy kind.

<!–

–>

Share

Print Print

Antidepressants may raise diabetes risk

People taking antidepressants are at a higher risk of type 2 diabetes, a new study has warned.

A number of studies have been carried out to establish whether antidepressants are linked with diabetes but results have varied depending on the methods used, type of medication and the number of participants.

In a systematic review, researchers at the University of Southampton found that people taking antidepressants are at a higher risk of type 2 diabetes.

However, the study cautioned that it is not certain whether the medication is responsible for the condition.

Researchers assessed 22 studies and three previous systematic reviews that looked into the effects of antidepressants on diabetes risk. Overall, people taking antidepressants were more likely to have diabetes.

However, the researchers warned that different types of antidepressants may carry different risks and long-term prospective randomised control trials are needed to look at the effects of individual tablets.

The team said that there are “several plausible” reasons why antidepressants are associated with an increased risk of diabetes.

For example, several antidepressants are associated with significant weight gain which increases the risk of type 2 diabetes.

However, they also said that several studies which explored this association still observed an increased risk of diabetes after adjustment for changes in body weight, implying other factors could be involved.

“Our research shows that when you take away all the classic risk factors of type 2 diabetes; weight gain, lifestyle etc, there is something about antidepressants that appears to be an independent risk factor,” said Dr Katharine Barnard, Health Psychologist from the University of Southampton.

“While depression is an important clinical problem and antidepressants are effective treatments for this debilitating condition, clinicians need to be aware of the potential risk of diabetes, particularly when using antidepressants in higher doses or for longer duration,” said Richard Holt, Professor in Diabetes and Endocrinology at the University.

New Inquiries into Eating Disorders and Obesity

 

stethoscope1

Last week, there was some media coverage of a new study, published in Pediatrics (the journal of the American Academy of Pediatrics), that highlights the concurrence between obesity/overweight and eating disorders. The study sheds light on the fact that a significant number of young people who seek clinical treatment for eating disorders come from a history of overweight or obesity. At the Mayo Clinic Children’s Center, where Dr. Leslie Sim, one of the authors of the study, works, 45% of adolescents seen for ED treatment in the last year came from a history of obesity. The study makes a case for recognition of obesity as a common precedent to disordered behaviors. It also illuminates the very tendency of primary care providers to overlook symptoms of disordered eating in people with history of obesity. It highlights two case studies: a fourteen-year-old boy and an eighteen-year-old girl whose eating disorders were misdiagnosed in large part because they had previously been obese.

As I read this article, I felt an enormous sense of disappointment at the way both obesity and eating disorder treatment are failing young people in this country. Because our emphasis is on weight loss at all costs (rather than the fostering of healthy habits), obese adolescents often transition directly into anorexia, bulimia, binge-eating, and EDNOS. At least half of the men and women I know who have struggled with eating disorders were overweight or obese growing up, so it comes as no surprise that what I’ve observed is borne out in the 45% statistic. Still other individuals who have shared their stories with me say that the eating disorder began when they were advised to lose weight by a health care provider or school nurse. In their dutiful attempts to obey that mandate, they quickly turned to extreme forms of restrictive eating or exercise.

Sim, Lebow, and Billings’ study details the history of a fourteen-year-old boy who had lost over 87 pounds. Possessed of a significantly higher than average BMI through childhood, he’d begun dieting at the age of 12, first by eliminating sweets, fats, and carbohydrates, and ultimately resorting to eating 600 calories per day. He developed hallmark symptoms of an eating disorder: difficulty concentrating, low moods, bloating, constipation, social withdrawal, fatigue, and intolerance to cold. His health care providers tested him for a number of GI disorders (celiac sprue, GiardiaH. pylori), and thyroid abnormalities. In spite of the fact that he began to show heart irregularities and dehydration, eating disorders weren’t suggested.

The study states,

In spite of having lost over half of his body weight, the medical documentation associated with the evaluation stated, ‘there is no element to suggest that he has an eating disorder at this particular time.’ At the request of his mother, however, Daniel was referred for an ED evaluation. Of note, Daniel’s weight was a focus of discussion at all medical appointments throughout his childhood. However, during the 13 medical encounters that took place when he was losing weight, there was no discussion of concerns regarding weight loss.

Italics are mine.

The next case study is equally disturbing. An eighteen year old girl was sent to an ED evaluation because she was demonstrating extreme fear of weight gain, amenorrhea, intolerance to cold, stress fractures, excessive exercise, food restriction, and binge eating. She, too, came from a history of obesity. She had begun dieting at the age of fourteen, ultimately going from 97th percentile for weight to the 10th percentile in only three years. After the first year of her weight loss, she developed amenorrhea, but the suggested explanations were PCOS or her long distance running, and she was put on birth control pills. She was referred to a dietitian after her stress fractures developed. The dietitian didn’t suggest ED treatment or express concern over her severely low fat diet, even when the girl’s mother suggested that she might have an ED. According to the study, the girl’s physician noted, “‘given that her BMI is currently appropriate, it is reasonable to do a trial off the birth control pill and see if her menses resume.’”

Italics are mine again.

In our green recovery discussions, we have often touched on how flawed BMI is as a marker of health. The USA Today coverage of the new study discusses this problem. It notes that many of the people who need ED treatment aren’t immediately identified as being at risk because they aren’t underweight:

It’s a “new, high-risk population that is under-recognized,” says Hagman, medical director of the eating disorders program at Children’s Hospital Colorado, who was not involved in the new report.

The kids she sees in this condition “are just as ill in terms of how they are thinking” as they are in terms of physical ailments, she says. “They come in with the same fear of fat, drive for thinness, and excessive exercise drive as kids who would typically have met an anorexia nervosa diagnosis. But because they are at or a even a little bit above their normal body weight, no one thinks about that.”

These cases are no surprise, says Lynn Grefe, president of the National Eating Disorders Association. “Our field has been saying that the more we’re pushing the anti-obesity message, the more we’re pushing kids into eating disorders” by focusing on size or weight instead of health and wellness.

Medicine is not a perfect science. BMI can help physicians to quickly identify someone who is very overweight or underweight, but like any diagnostic tool, it has limitations. One way to circumvent these limitations is to use multiple diagnostic criteria when it comes to complex conditions like EDs. Weight may be telling, but it doesn’t tell the whole story. Listening to a patient’s symptoms, history, and habits is equally, if not more, crucial. It’s time for treatment providers to stop equating eating disorders with the state of being underweight. People who are not underweight by the books can have eating disorders, and–as one of my commenters noted–people who are underweight don’t necessarily have them.

What struck me most about this study was the bias it unearthed. It is the idea that there are two types of people– people who have been overweight, and people who are, or could become, restrictive– and that those two types of people are not and cannot be one in the same. This is the bias that leads a primary care physician to miss overwhelmingly evident ED symptoms in a kid who used to be obese. It is the bias that, left uncorrected, may allow countless adolescents and adults who are in need of care to go unnoticed.

US News and World Report interviewed Dr. David Katz as a part of its coverage. Katz is the Editor-in-Chief of the journal Childhood Obesity, President-Elect of the American College of Lifestyle Medicine, founder and President of the non-profit Turn the Tide Foundation, and the founding director of Yale University’s Prevention Research Center. He has devoted much of his career to combating childhood obesity through education about healthy eating and a comprehensive approach to patient care. He echoed the dangers of treating obesity and disordered eating as mutually exclusive phenomena, and underscored the fact that there is quite a bit of fluidity between them:

“First, obesity itself is a risk factor for eating disorders,” Katz said. “This link is well established for binge-eating disorder, where obesity is potentially both cause and effect…Second, while weight loss in the context of obesity may appear beneficial, there is a point at which the methods used — or the extremes reached — may indicate an eating disorder,” Katz said.

“Effective treatment of obesity cannot simply be about weight loss — it must be about the pursuit of health,” Katz said. “An emphasis on healthful behaviors is a tonic against both obesity and eating disorders. By placing an emphasis on diet and activity patterns for health and by focusing on strategies that are family based, we can address risk factors for both eating disorders and obesity.”

Just as weight restoration alone cannot remedy anorexia, neither is weight loss, in and of itself, an adequate treatment for obesity. In both cases, changes in weight should be accompanied by an emphasis on the importance of nourishing foods and an attempt to foster lasting, positive body image.

✵          ✵          ✵

Between the ages of eight and ten, right after my parents’ divorce and during a turbulent moment in my childhood, I gained some weight. My pediatrician remarked on it during an annual checkup when I was eleven–he wasn’t overly worried, he said, but a diet might help me get back to a more “appropriate” weight for my frame. He left it at that, and I took matters into my own hands. This was that summer that I discovered rules and restriction. It was the summer I realized that I could make my body “behave” itself. It was also the year that my weight took its first major plunge, and the roller coaster in and out of my ED began.

In bringing up my own story, I don’t mean to draw a direct or easy comparison between what I remember and what the two individuals profiled in the study experienced. Nor am I putting all of the blame on my physician, because he was acting in good faith, and there were many, many factors involved with my ED. But I couldn’t help but feel a sense of recognition as I read, an empathy that having comes from having once felt as if someone–someone who was supposed to be taking care of my health–had given me the message that I ought to reject my body. While I recognize the seriousness of childhood obesity, and support all healthful measures undertaken to treat and prevent it, I believe that the onus is upon health care practitioners to do so in a way that will encourage children to embrace their bodies, rather than renounce them. I’m hopeful that it can be done.

As always, I’d love to hear your thoughts on the study, which can be found here (Sim LA, Lebow J, Billings M. Eating disorders in adolescents with a history of obesity. Pediatrics. 2013 Sep 9. [Epub ahead of print]).

In the meantime, I wish you a happy Sunday, and a great start to the week ahead.

xo



Print Friendly