Saturday, February 09, 2008

If I had a (smaller) hammer . . .

To a hammer, everything looks like a nail. And the proverbial hammer we often talk about is the BMI, a simple height/weight ratio that's more and more being used to identify and punish everyone from schoolchildren to the lederly for being fat.

Of course, BMI is a crude tool, a hammer, if you will, because it doesn't take into account muscle mass, or percentage of body fat, or anything beyond height and weight. So most athletes fall into the overweight if not obese category, according to BMI charts. Tom Cruise's BMI makes him obese, because he's short and densely muscled.

Now, finally, someone somewhere is paying attention. In a study published in Nutrition Journal, researchers at the University of Pavia in Italy did a small study looking at how weight loss recommendations would change for a group of people when they applied different measures of overweight:

The researchers obtained each person's BMI as well as body-fat measurements including waist circumference and total percent body fat. The also calculated a measurement similar to BMI that identifies fat mass called body fat mass index. The investigators then compared the percentage of the study group that would be told to lose weight according to each calculation.

BMI calculations, they found, identified 11 percent of the group as needing strong recommendations to lose weight and 41 percent as needing basic recommendations to lose weight. By contrast, waist circumference measurements indicated about 25 percent would need strong recommendations to shed pounds and 36 percent would need basic weight loss recommendations, Colombo said.

Moreover, 29 percent and 48 percent would have received similar weight loss recommendations according to total percent body fat measurements, while 21 percent and 54 percent would receive the same, according to body fat mass index.

The lead researcher, Dr. Ottavio Columbo, concluded, "Using criteria based on body adiposity (fatness) rather than body weight would result in a much greater proportion of the study population receiving recommendations for weight loss."

Yeah. We coulda told you that. But hey, it's a start.

Friday, February 08, 2008

Under-reporting eating disorders?

This study, just out from Rhode Island Hospital and Brown University, is not only interesting, it's important. And timely. And has implications for the way eating disorders are both diagnosed and treated.

Researchers went back through data collected from some 2500 psychiatric patients and looked at the incidence rates of various diagnoses of eating disorders. They found--unsurprising to anyone familiar with eating disorders--that the vast majority of diagnoses were for ED-NOS, or "eating disorders not otherwise specified."

This is a catch-all diagnosis for those who don't meet the strict diagnostic criteria for anorexia or bulimia. The study authors intelligently suggest that the fact that ED-NOS is the most common e.d. diagnosis (at least in their sample)

suggests that there is a problem with the clinical applicability of the diagnostic criteria in the DSM-IV eating disorder category.

Yes! Too true. Why does it matter? Let me tell you a story.

When my daughter became ill, at age 14, our pediatrician diagnosed anorexia. It was clear to all of us that that's what she had. Her weight was down to 75% of what it was supposed to be; she was in ketosis, she was afraid of all food and drink, she'd withdrawn socially--in short, she had a classic case.

Following good medical procedure, the pediatrician referred my daughter to a psychiatrist. Our insurance would cover only a shrink-in-training, a very nice woman without a lot of experience. My daughter spent our first visit, and most subsequent visits, with her head in my lap, sobbing.

I'm not sure which of the diagnostic criteria for anorexia the psychiatrist felt my daughter did not meet:

DSM-IV Criteria for Anorexia Nervosa

1. Refusal to maintain body weight at or above a minimally normal weight for age and height (eg, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected).
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
4. In postmenarchal females, amenorrhea ie, the absence of at least three consecutive cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, eg, estrogen administration.)

My daughter definitely had #1 and #2 (though more on the wording of #1 in another post). She wasn't expressing #3, partly because by then she wasn't expressing much of anything, other than intense anxiety and fear. And she hadn't begun menstrual cycles yet, so #4 wasn't applicable.

In any case, the psychiatric fellow diagnosed her with ED-NOS--and you will be surprised to learn, as I was, that because they're classified as mental health disorders and appear in DSM-IV, only a psychiatrist can truly diagnose an eating disorder. The pediatrician's word counted for nothing.

The diagnosis informed our daughter's entire treatment with the psychiatrist, most of which consisted of useless attempts at anti depressants. The psych was convinced that if we treated the depression, my daughter's eating "issues" would magically improve or even resolve.

Why does it matter? Because we wasted a lot of time, and most of our precious mental health benefits, dicking around with this stuff. If the diagnosis had been anorexia, the psych could have looked up research showing that antidepressants are ineffective during acute malnutrition, and that depression is a symptom of anorexia, not a cause. She probably could have looked this stuff up anyway, but since she was never convinced my daughter had anorexia, I assume she just didn't go there. I don't know for sure what she was thinking, and it stopped mattering after a while.

Back to the study, which hypothesizes that many of the ED-NOS diagnoses are true cases of anorexia or bulimia that for one reason or another don't meet 100% of the clinical criteria. And that psychiatrists should take another look at the criteria and the cases.

I agree. And there's another implication, too: I'm convinced that the low incidence rates are one reason so few research dollars have been spent on anorexia and bulimia. Where are you going to spend your money, on a disease that affects 2 percent of the population or on one that affects 30 percent?*

So three cheers for the Rhode Island researchers, whose work, if somewhat obvious, is long overdue. I look forward to seeing how it might begin to change the clinical picture in eating disorders.

*I refer, somewhat sarcastically, to the proposal that obesity be classified as a psychiatric illness in DSM-V.

Thursday, February 07, 2008

It is too genetic

Check out this new study, just published in the American Journal of Clinical Nutrition, in which British researchers looked at more than 5,000 pairs of identical twins and determined that

genes account for about three-quarters of the differences in a child's waistline and weight.

Here's the quote of the day:

"Contrary to the widespread assumption that family environment is the key factor in determining weight gain, we found this was not the case," said Jane Wardle, director of Cancer Research UK's Health Behavior Centre, who led the study.

So what does this mean? It means that maybe we can stop obsessing over children's BMI and focus instead on their OH--their overall health. It means that families can go back to making sure their children are healthy without all the woohoohoo about them being fat. Most important, it means that maybe, just maybe, we can start ditching some of the blame and shame about fat and pay attention to what really matters.

As the Dressing Room Project folks like to say, Worry about the size of your heart, not the size of your body. Amen, sisters.

Here's a PDF of the entire study. Have fun with it.

Wednesday, February 06, 2008

News flash: Oprah's gaining weight

Though I despise the culture of celebrity obsession, I found this story from the Orlando Sentinel to be of interest (well, most of it) because it raises in a public and visceral way the question at the heart of the weight-loss "debate."

To wit: If Oprah Winfrey, with all her money and personal chef and personal trainer, can't keep the weight off, who can?

According to the story,

Oprah, by her own admission, has tried everything.She tried the Atkins diet, she tried diet pills. She tried the Scarsdale diet, the banana, hot dog and egg diet. She tried a 1,000 calorie a day diet. She tried Weight Watchers, Diet Work Shop and Diet Center. She tried Nutri-System.

Yep, and still her weight goes up and down.

The story quotes a dietitian who says, "The longer you do this over the years and get into this classic yo-yo dieting syndrome, the more likely you are to end up with metabolic chaos." Thank you, thank you. It's nice to see the truth in print occasionally.

The reporter goes on to say

But the key to losing weight permanently, experts say, is to figure out why you overeat. Do you eat junk food when you're depressed? When you're stressed out from work? When you break up with a boyfriend or girlfriend? To figure out what triggers your overeating, keep a journal.

(For the record, Oprah has kept a journal for years -- and opined publicly about how you need to understand how emotions play into your eating habits. It's not clear how much it has helped.)

Maybe that's because fat people are no different from thin people when it comes to emotional eating. Show me a thin person who never takes comfort from a plate of warm mac and cheese or a slice of chocolate cake, and I'll show you someone who's lying--to themselves or to you.

Emotional eating is no different from emotional sex, emotional TV watching, emotional long-talks-with-a-friend. They're all part of life.

There's a difference between emotional eating and binge eating. I know, because I've done both. It's been about 10 years since I binge-ate, and in that time my weight has come down maybe 25 or 30 pounds. But I'd still be considered obese by the BMI charts.

It would have been nice if the reporter followed up on the ideas she raised--that very few people can lose a lot of weight and keep it off, that dieting is part of the reason. It would have been nice if the word genetics was mentioned anywhere in the story.

But it's a start. Of sorts.

Tuesday, February 05, 2008

Mississippi 282, RIP


A state lawmaker on Monday promised a quick death for a bill that would prohibit Mississippi restaurants from serving obese people.

House Public Health and Human Services Committee Chairman Steve Holland announced his intention to kill House Bill 282. The proposed legislation has outraged advocacy groups critical of the legislation and intrigued the national media.
"It's dead on arrival at my desk," Holland, D-Plantersville, said in a news release. "While I appreciate the efforts of my fellow House members to help curb the obesity problem in Mississippi, this is totally the wrong approach."

The bill filed by State Reps. Ted Mayhall, R-Southaven, John Read, R-Gautier, and Bobby Shows, D-Ellisville, would make it illegal for restaurants with more than five seats to serve people who are obese. The criteria for obesity would be set by the state Department of Health, and restaurants that do not comply would have their permits revoked.

The legislation has been referred to a subcommittee, where Holland said he will use a "pocket veto" to kill it. It would have advanced to his committee if it had survived.

Mayhall said Monday he wouldn't vote for the bill. He said he and his colleagues filed it to bring attention to the state's obesity problem, but he never expected to hear from so many people. Media from New York, Australia, London and Ireland have called him since The Clarion-Ledger reported on the bill Sunday, he said.

"You take food away from fat people ... my gosh," Mayhall said.

Obesity makes people more susceptible to diabetes, which puts a further strain on the state's financially-challenged Medicaid program, he said.

A 2007 report put the state's obesity rate at 30.6 percent - the worst in the nation.

Dr. Ed Thompson, state health officer, has previously said Mississippi's obesity rate cost Medicaid alone $221 million each year.

But the National Association to Advance Fat Acceptance issued a news release Monday blasting the bill as "a clear and shameless violation of (Mississippians') human and civil rights."

The group described itself as a "nonprofit human rights organization dedicated to improving the quality of life for fat people," and urged voters to boot the lawmakers who filed the legislation.

"These men are wasting their time, which is your money, and could potentially bankrupt your state. Are these the kind of men you want to continue to represent you?" the news release said.

In a separate news release, the Coalition of Fat Rights Activists president Paul McAleer said the bill would "have substantial and negative side effects on Mississippi's economy and health."

"Anyone who supports human rights and freedoms should be opposing this bill - and any subsequent bill," he added.

Cheryle Evans of Clinton said the legislation is "very short-sighted." She said restaurants should be required to provide details of calories, fat grams and carbohydrates on their menus instead. Evans also said more bike paths and sidewalks should be made available.

Holland, who has described himself as obese, said, "I am working on my own health issues, and I need to do that. I think (Gov. Haley Barbour's) take on this is a good idea. Let's all go walking instead of trying to tell restaurants who they can serve."

Barbour appears in television commercials that promote physical activity. Last session, state lawmakers mandated exercise and health education for students in kindergarten through middle school.

One Reason I'm not Voting for Obama

"Reducing obesity to 1980 levels will save Medicare $1 trillion." -- Barack Obama

Now a new study, as reported by Junkfood Science, calculates that reducing obesity actually costs governments more money in the long run.

What the study really points out, says JS, is the ridiculousness of coming up with such estimates in the first place. And I would add, the moral sledgehammer of using them in sound bytes, to make points that truly do not exist.

We've already had a president who fudges with spectacular ease and seeks to impose his own moral code on all of us. Please, let's not have another.**

**Oh, wait, do any of the candidates pass this test?

Quote of the Day

The "serious problem" [House bill 282] clearly calls attention to is the erosion of basic civil and human rights as war is continually waged against a segment of our population.

From the Association for Size Diversity and Health, in a response to Mississippi House Bill 282, which seeks to bar restaurants from serving food to anyone considered obese by the Mississippi state department of Health. For more, visit ASDAH's website.

Sunday, February 03, 2008

For God's sake, repeat after me: There are no bad foods

That's what I feel like saying to the idiots who now want to "salvage" the ridiculous Mississippi bill that would prohibit restaurants from serving food to people considered obese.

Who will be labeled obese, and by whom? Let's not even go there. For now, let's stick with a higher power of absurdity, worthy of Beckett, and talk about the latest twist on this bill: Use it to Save the Children.

Forget about saving the adult fatties, according to this latest spin; let's stick to saving the innocent children. Under the new provisions, children would not be allowed to eat in certain fast food restaurants without a parent present. (Sounds like the concept behind R-rated movies, doesn't it? Do you know the danger you child is able to be exposed to?)

According to John Banzhaf, the idiot behind this new spin,

obese children would still be permitted to order most of the items on a fast food menu. "For example, at McDonald's, even a Double Cheeseburger and Quarterpounder, or a Filet-O-Fish or McChicken, has fewer than 500 calories. Those food items the child should not be served include: the Double Quarter Pounder With Cheese (740 calories), Premium Crispy Chicken Club Sandwich (660 calories), several deserts [sic], etc.

What's the cutoff here? 500 calories = OK, 600 calories = instant obesity?

Banzhaf, a professor of public interest law at George Washington University, needs a lesson in psychology. Actually he needs lessons in a whole lot of other fields, but let's start with psychology. Does the term forbidden fruit hold any meaning? How about banned books? See, we humans are constructed to always want what we cannot have.

And when it comes to food, that goes double. The biggest reason why 95% of diets do not work is that depriving yourself leads to later cycles of binging. You tell your body it can't have chocolate, and watch your chocolate cravings soar. Whereas if you tell your body, Chocolate's fine, no big deal, work it into your day if you really want it, well, your chocolate consumption will over the long term drop. A lot.

Do we really want a double quarter pounder with cheese to become the Holy Grail of a generation of children? Cause that's what will happen should your ridiculous plan come to fruition.

Here's another pearl of wisdom: The more we try to micromanage our metabolisms, the more badly we fuck them up. Dieting leads to eating disorders and even more weight gain. How about, instead of banning foods like they were chapters of Lady Chatterley's Lover, we invest in teaching children the joys of intuitive eating?

Oh, yeah, that would take a complete cultural paradigm shift. And it wouldn't make for such a great sound byte.

P.S. I don't eat at McDonald's; I don't like their food. My kids have never eaten there. I'm not a shill for the fast-food industry. I'm a reasonable human being who believes that people come in all shapes and sizes, that you can be fat and healthy, and that discriminating against and humiliating fat people seems to be the new national sport. Whatever happened to baseball?