For something different…

First of all, I have been taking pictures of food, but not as often as I used to. I’m thinking about doing VeganMoFo, so I guess I’m kind of saving up for that. We’ll see! I’m in my last year of grad school right now, so I’ve been pretty busy- but of course, I do eat. That brings me to what I’m really posting about today. I’m actually thinking about setting up another blog for this, but I’m not sure that I’d have enough content, so I thought I’d try it out here.

This will be rather lengthy, so feel free to skip over this post, because it’s not about veganism. It’s about weight. Weight of course being related to eating. Actually, it’s really about “fat acceptance,” which on its face, I think is an awesome idea. Everyone should be treated with respect and dignity without regard to their size, and people should not have to hate themselves because they don’t fit into what the media says we should look like. I’m all for that. I’m also all for being healthy at whatever size you are. That’s what I strive for- and I’m most certainly not at a BMI below 25. Never have been, relatively speaking to childhood (children’s BMIs are calculated the same way as adults, but are scaled by percentile for age and sex. A BMI of 17.5 in a 5-year-old girl would be overweight, while in an adult, would be underweight).

The problem that I see with the “fat acceptance” groups on the internet is that way too many people have blinders on. I get the point that you can be healthy at any size. It’s great to realize that not every health problem we have is related to weight, as some would have us believe, but it’s wrong to think that none of them are related to weight, either. The First Do No Harm blog is a great example of the really good things and the bad about fat acceptance. There are many very sad stories about people who had a medical problem, went to see their health-care provider, and were told that the problem was their weight, and to lose 100 pounds before coming back (or something similar)- all without a physical exam or taking a history or any of those other important things I’ve been learning to do in my nurse practitioner training. Then often, the problem turns out to be something very serious that needed to be treated right away, and something bad happens to the patient. That’s malpractice. It’s awful, it’s unacceptable, and unnecessary.

It’s not all that happens, though. Everyone who submits to that blog has been at least treated rudely by a provider in direct response to their size, and that’s really the issue. Again, not okay, especially when it scares someone away from seeking future treatment. A lot of the time, the problem those writers have gone in for had nothing to do with their weight. But the other problem is, some of the time, it does, despite their continued protestations. I’ve never once seen a writer to that blog acknowledge that. The attitude is that the provider is a jerk (true) and whatever is wrong had nothing to do with weight (not true). Weight might not have been the proximal cause, but it is almost certainly what caused the proximal cause (otherwise known as a secondary cause :-), in quite a few of those stories. That gives the provider absolutely no excuse to say “don’t come back until you’ve lost 100 pounds”- the proximal cause needs to be treated, and the patient needs to be treated with dignity and respect, no question. A provider assuming that anything wrong with a patient has to do with their weight is one wrong; a patient assuming that anything wrong with them can’t have to do with their weight is another. As the expression goes, “Just because you’re paranoid doesn’t mean they’re not out to get you.”

Fat acceptance groups sometimes cite an article published in The Lancet as to why it is “crap” that doctors and other health professionals associate overweight and obesity with mortality. Indeed, this article finds that in a statistical meta-analysis, overweight patients have the lowest risk for overall mortality, and obese patients have no increased risk, relative to people at a “normal weight,” and people with a BMI below 20 had the highest risk of mortality. This information can be found by reading the abstract- but you have to read the whole article to get the whole story.

People in this study were already identified as having cardiovascular problems. Results in this study are relative to the population studied, not the population in general. The patients who had a BMI below 20 also tended to be older than the other patients in the study and tended to be smokers; they also had a higher rate of cancer. Everyone in this study had either a heart attack (MI), an angioplasty (PCI), or coronary bypass (CABG). Nowhere in this study does it say that obese people are less likely to have heart problems. It says relative to all the people who do have heart problems, those who are normal weight (defined as a BMI 20-24.9), overweight (BMI 25-29.9) or obese (BMI 30-34.9) are less likely to have died overall in the time frames studied (at least six months after the event). It also states that people who are severely obese (BMI 35 and over) are much more likely to die of a cardiac-related event than anyone else in the study, though are not at an increased risk of dying overall, relative to the population studied.

Notice I keep saying relative to the population studied.

So what does this boil down to?

People in this study at a BMI below 20 who are also more likely to smoke, have cancer and be older than people with a BMI above 20 are more likely to die within six months of their cardiac event than the other groups. That’s not a ringing endorsement for saying that obesity is protective. Remember, everyone in this group actually had a cardiac event; it is not comparing to the general population. What it does say is that if you do have a cardiac event, being overweight may be somewhat protective (think of how awful recovery is from open-heart surgery- it would make sense that having some extra mass would be helpful), and that being obese makes you no worse off than someone at a BMI of 20-24.9. It also says that if you’re severely obese, you are way more likely to die of a cardiac event, if you’re in this population. If you’re at a low BMI (and again, in this group, you’re more likely to be older, a smoker and have cancer)- you’re more likely to die in general, and less likely than the severely obese people studied for that death to be from a cardiac event. Heart disease + cancer + smoking + advanced age = greatest likelihood of death. I’m thinking that makes sense, regardless of BMI. Now, they don’t say that the low BMI group had an increased risk of death because they are likely to be older, smoke and have cancer. They can’t because this is an analysis of 40 different studies with different protocols; they don’t have that information available to them consistently.

With their statistical analysis, they can’t say why people at a BMI of 25-29.9 fared the best, while those at a BMI below 20 fared the worst. Readers are left to draw their own inferences. It does speculate that there is truth to the “BMI is crap” theory, as BMI makes no differentiation between lean muscle and adipose tissue.

They speculate that indeed, those who have less or no increased risk probably have a higher proportion of lean muscle mass than those in the low weight group. They suggest this an area for further study. On a side note, this article makes no mention of quality of life for those who live after a cardiac event.

My father was in the overweight – mildly obese BMI category. He was diabetic, and had his first heart attack and coronary bypass at age 52. He died at 62. He was hospitalized for cardiac related problems close to 100 times in that 10 years, I kid you not. He was in the hospital almost once a month. He couldn’t walk up a flight of stairs. For the last couple of years of his life, he looked like death. Just an anecdote, you say? Not representative? I’m fairly certain that he was actually in one of the cohort groups analyzed in this study- one of the very people for whom being overweight may have been a “protective factor.” Well, if your only criteria is “not technically dead,” then I suppose it’s true.

So what does this study mean for those of us who are overweight or obese?Kate Harding’s BMI project, a commenter mentions that only the abstract is available through PubMed, but that’s “usually all you need.” If what you need is the whole story, that’s not true. You should always read through the whole article- at least focus on the discussion section if the methods/statistical analysis don’t mean much to you. Find out who the article is studying, and what they’re studying against. This isn’t a study that is matched with a control group, as it’s not that kind of study. For a major publication like The Lancet, you can probably get access through your public library, and if that doesn’t work, any local community college’s library would probably have access, or ask a friend that works in a hospital or college/university (or a student) and has access to online resources. Don’t rely on the abstract to give you all the information.

References

Romero-Corral, A., Montori, V.M., Somers, V.K., Korinek, J., Thomas, R.J., Allison, T.G., Mookadam, F., & Lopez-Jimenez, F. (2006). Association with bodyweight and with cardiovascular events in coronary artery disease: A systematic review of cohort studies. The Lancet, 368:666-678. doi:10.1016/S0140-6736(06)69251-9

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One Response to For something different…

  1. Katherine says:

    thank you for this post, jodie – your analysis of the lancet article was brilliant. i will definitely read anything else you write about weight.

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