Wednesday, June 24, 2009

Should we keep talking about obesity in public health?

Dr. Dinosaur has a good post on Why Obesity is NOT a Disease. Unfortunately, I think this is news to a lot of people, including many health care professionals. In public health, obesity=disease is accepted as a given and this often makes me uncomfortable. I feel fortunate that I have been exposed to the writing, speaking, and work of fat activists and research from scientists who are questioning the “obesity epidemic” - but only in a limited way. I don’t really feel confident enough to fight a lot of the generalizations that are made about overweight/obesity in class lectures and discussions. In public health, at least, while the outcome focus may be on reducing obesity, the methods are generally not focused narrowly on weight loss. Public health tends to go for more walking paths, better food options, and other interventions to help people lead overall healthier lifestyles.

On the other hand, continuing the data collection focus on overweight/obesity concerns me. I’m running some data for my internship right now on preconception and prenatal risk factors for women who have experienced a fetal loss or infant death. I noticed that while prepregnancy weight BMI data gave us all 4 categories (underweight, normal weight, overweight, obese) last year’s report only reported percent of women who were overweight and obese. Yet 10% of our sample had been underweight, which seemed like a pretty big number. I decided to do a little literature search on risks of prepregnancy underweight and found that they were not insignificant – and included increased risks of preterm birth and low birth weight, which were two of the main causes of infant death in the group we’re looking at. It’s moments like this when our lopsided obsession with BMI really becomes clear, and I feel like I should speak up more in class. As it is, I added a sentence to this year’s report discussing underweight. Of course, I couldn’t have a nice little box comparing it to the Healthy People 2010 goals (the way I did for obesity) because wouldn’t you know it – there is no HP 2010 goal regarding underweight.

For great posts on what this focus on weight means to pregnant women, and resources to educate yourself more on pregnancy and women of size (along with great posts on other topics like cesarean prevention) check out The Well-Rounded Mama (the list of “Top Posts” to the right of her current posts is a good place to start).

(P.S. Nursing bra post coming soon!)


Nickey said...

Great post! This is something that really isn't getting talked about enough.

I'm also curious on your thoughts about the BMI in general. I'm sure you know that it's a poor measure of health for people on the high end of it, since it takes absolutely nothing into account, besides height and weight. So wouldn't that hold true for the low end, too?

Another critique of the BMI that I've heard from fat activists is that it is a very outdated tool, having been invented in the mid-1800's. Activists say that there is so little medical knowledge we still rely on from those days, so why the BMI?

publichealthdoula said...

I wish I had more BMI-in-general thoughts...this is where I need to do some more self-education. I could see it being a poor measure for both unerweight and overweight, but the focus on the overweight end by people who accept BMI's legitimacy to me says something about our national obsession with the "epidemic". I would like to do more reading and research in this area...maybe there's some way I can work it into a class next year.

Susan said...

Just came across this, and it really interested me since I'm working as a corporate (telephonic) health educator and deal a lot with people who are overweight. It's a pretty interesting post by Dr. Dinosaur, and I'm not quite sure how I feel about it as an educator. On the one hand, I don't feel that BMI is an accurate representation of individuals (although like other things in public health, it works well for populations), and I would agree that not having any current health issues would imply no current cause for alarm. However, primary care and health education both are (or should be) concerned with PREVENTION. While there may be no symptoms or other diseases to treat in the moment, I don't believe this means that the topic of weight management should go unaddressed with patients/clients. If a patient/client clearly is overweight because of body fat (and not because they're a well-muscled athlete), something needs to be discussed, because down the road there can be all kinds of issues that crop up that could have been averted simply by having a conversation about weight management early on. Whether this means obesity should or shouldn't be classified as a disease or epidemic is not even a relevant point to me here - the point is that overweight and obesity, as the doctor pointed out, are risk factors for health problems down the road - but I have to disagree with the doctor and say that it is still worthwhile to discuss the health implications of too much body fat. Why wait until there are chronic conditions present, that may need to (at least temporarily) be treated with expensive medications, when they could have very well been avoided through preventive measures?

Well-Rounded Mama said...

Hey there, Public Health Doula! I had no idea you had linked to my blog until today when I saw this post, but thanks for the shout-out!! I appreciate it.

Susan, the problem is that there is no good way to treat "too much fat." It's not just a matter of eating less and exercising more for a lot of fat people.

If you really look closely at the evidence, research shows that weight loss methods simply don't work long-term. They work for a little while and then the body works to reassert its norm. The long-term success rate for really significant weight loss is extremely low, and not because the people involved are weak-willed or not working hard enough.

Pushing clients to lose fat in order to lower their risk for problems later on often actually makes things WORSE, not better.

One of the strongest risk factors for GAINING weight is trying to lose weight. And there is some evidence that really significant weight loss actually increases mortality instead of decreasing it. We have to be careful that the "cure" isn't worse than the "problem."

A better approach is the HAES approach, Health At Every Size, which emphasizes increasing healthy behaviors without tying them to weight/fat loss.

It's beyond some people's genetic destiny to achieve a "normal" weight long-term. But a lot can be done to lower the risk for health issues by increasing exercise, focusing on reasonable eating habits, and maintaining a more stable weight.

I would invite you to explore some of the various HAES links there are out there. Google it, and be sure to read Linda Bacon's book. You don't have to agree with everything you read, but it would be good to learn about the damage that is often done in the name of "preventing problems" later on.