Friday, January 09, 2009

Obesity problems--true and faux

An anonymous reader posed a question to me on another thread, which I thought deserved its own thread. He or she wrote:

I've been reading your blog on and off for about 8 months now. Do you ever recognize that there is an obesity problem in the States? Though I am on board with the message that 'fat' does not equal 'unhealthy,' and I am certainly opposed to pathologizing a group of people who have nothing wrong with them, I still believe there is an obesity-related health problem in this country.

In public, I feel I need to be an advocate for fat acceptance (or maybe, Health at Every Size), but I also want to find a way to acknowledge and distinguish the obesity-related health problem that does exist. I'd love to hear your thoughts about how to address this with an even hand.

I'm not an epidemiologist; I haven't done any studies on this question. I've read extensively, I've thought about it, I've talked to people. I'll tell you what I think, personally, and then I'd like to hear from other readers who may know more than me.

What I've read suggests that there is no obesity explosion in this country. That in general Americans are a little heavier than they were, say, 50 years ago. They are also a little taller. Some of what I've read suggests that these two go hand in hand. I know that there was a surge in obesity statistics about 10 years ago, when BMI cutoffs were changed overnight. People who went to sleep merely overweight woke up obese, and an alarming new statistic was born.

I've read research suggesting that weights went up in the late 1980s, after several years of the low-fat craze. Which brings me to the point here: While I don't think we can say with any certainty that people are fatter now and/or why that might be, what we do know is that we can't make them thinner. So let's set assume for a moment that yes, people are fatter now. Let's take it a step further and proclaim that this rise in weight is a Serious Health Problem (and I'm not saying it is; as others have pointed out very well, fat is not equivalent to poor health, and thin does not correlate good health).

Here's the thing: We can't change what people weigh. Some people lose weight for a short time by dieting. But 98 percent of them gain it back, and then some.

So diets don't work for adults. They don't work for children, either. School interventions are notoriously ineffective when it comes to making kids thinner.

Now let's go back to that assumption, that weight is a serious health problem. There is little to no evidence of this. There is a correlation between obesity and diabetes, but it's a correlation, not cause and effect. We don't know that obesity causes diabetes; maybe whatever malfunctioning metabolic shift causes diabetes actually causes obesity. In which case, trying to "cure" obesity would be like trying to "cure" OCD by, I don't know, strapping someone's hands to their sides so they can't obsessively wash them. It would be treating the symptom rather than the cause.

When it comes to other measures of health, the statistics don't bear out the notion that obesity is a serious health issue. In fact, Katherine Flegal's now-famous mortality study points to modest advantages to being "overweight," especially as people age.

So in answer to your question, Anonymous, no, I don't know that obesity is a serious health problem in the U.S., and neither do you, or anyone else, for that matter. We don't have enough information; we don't even really understand the information we've got. Losing weight sometimes raises people's risk of dying from cardiac disease, in fact. We just don't know.

While we don't really understand all the implications of weight, we do know that fitness is good. Eating a varied diet that includes (but isn't necessarily limited to) fresh fruits and veggies is good. Exercising (but not to the point of obsession) is good. Feeling good about yourself is good (and feeling bad about yourself is bad for you).

So until I know more, really know more, I'm going to stick to my guns on this one. Eat well. Live well. Move your body. And, most important, love yourself as you are right now. Not 20 pounds from now but today, this minute. Self-loathing--the kind that is a natural consequence of the current anti-obesity hysteria--is far worse for people than extra pounds. As far as we know.

Tuesday, January 06, 2009

The Maudsley Institute

It's not really called that, but that's how I think of the new training program for Maudsley therapists, organized and run by Drs. Daniel le Grange and James Lock, co-authors of Help Your Teenager Beat an Eating Disorder. Its official name is the Training institute for Child and Adolescent Eating Disorders, and it aims to do something incredibly important: train therapists to do true family-based treatment.

Right now, many families in the U.S. who want to use family-based treatment to help their children recover from eating disorders face the unhappy choice of trying to go it alone, drive many hours to see a Maudsley therapist, or go with a different treatment. FBT is hard--the hardest thing most families will ever do. They need support. But at the moment, there just aren't enough true Maudsley providers to go around.

Maybe more important, families have no way to tell the faux Maudsley providers from those who truly practice and believe in FBT. There's a surprising number of therapists out there who say they practice Maudsley but who've given it their own unfortunate spin, like this one. And there are outpatient and inpatient programs who claim the same. Too often, what they're doing is NOT true FBT.

Lock and le Grange's new institute will put the seal of approval, as it were, on professionals who not only train with them but actually practice true FBT. This is good for everyone: Providers will get more training from the folks who know the treatment best, and families will have a measure by which to judge quality and competence of potential therapists. It's win-win.

The first training will be held February 27-28 in Palo Alto, California. It will take some time to "graduate" the first group of Maudsley therapists. Personally, I can't wait. Thanks to Drs. le Grange and Lock for doing this.

Monday, January 05, 2009

What do YOU do?

So I'm sitting at brunch with some neighbors--new neighbors, people I don't yet know very well but whom I like a lot--and the subjects of eating disorders and weight come up, as they inevitably seem to do. It is just after New Year's, after all, and we are sitting at brunch--a feast of a brunch, actually, with omelets and homemade waffles, a big bowl of whipped cream, berries, lox, roast potatoes, clementines. Everything is delicious and there's plenty of it.

So of course the conversation turns to dieting and New Year's resolutions, obesity and anorexia. And in the space of about 5 minutes I hear pretty much every myth about eating and weight there is:

"Children are much much fatter today than they've ever been and we have to do something about it."
"There's an explosion of diabetes among children today."
"Anorexia--that's all about control, isn't it?"
"Anorexics are doing that because they want to be thin. It's a cultural pressure kind of thing."

As I've said, these are people I like but don't know very well. But I can't just keep my mouth shut. I can't. I try to maintain a reasonable facade but within minutes I'm arguing, spouting statistics and opinions, trying to keep my voice friendly, hearing the urgency in my own words. I explain that one reason for the so-called explosion of obesity in America (among adults as well as children) is that the cutoffs for overweight and obesity changed overnight, so millions of people woke up one morning and were suddenly considered overweight or obese. That while more children are diagnosed with diabetes now than, say, 30 years ago, some of that number is certainly due to increased awareness and earlier diagnosis, which is a good thing. That the numbers don't differentiate between cases of Type 1 diabetes, which is largely genetic, and Type 2, which is linked to diet and activity.

I tell them about Health At Every Size, and try to conjure as many of Deb Burgard's talking points on size acceptance as I can remember. I tell them that Tom Cruise has been considered obese according to the BMI charts.

I tell them that no, anorexia is not about control, that it's not "about" anything except having the shitty luck to be genetically vulnerable. I tell them that for a person with anorexia, eating is like--oh, I don't know, maybe jumping out of a plane without a parachute. Covered in writing snakes. Giving a lecture on the way down. That for some people, restricting (aka dieting) sends them straight down the rabbit hole, that anorexia distorts thoughts and perceptions and feelings, that it's not a question of just picking up a fork and eating.

One of my new neighbors is in medical school. She's particularly interested in these subjects because she will have to adopt a professional attitude about them sometime soon. She'll have to figure out what she thinks and how to talk to people on all parts of the weight and eating spectrum--her patients. She listens. Everybody listens. We actually have a lively and interesting conversation. I think.

But I lay awake last night replaying it in my mind, wondering if I should have taken a different approach to the discussion. It's not so much that I think I was obnoxious (though maybe I was, a little) as it is the fact that I find these conversations exquisitely painful. Every time I hear the words It's all about control, isn't it? it's like some synapse in my brain starts overheating. How do I offer my knowledge and opinions without being obnoxious or driving myself beserk?

What do YOU do when the conversation turns to subjects like this?

Sunday, January 04, 2009

OT: Clearing the air on Kawasaki Disease

My heart goes out to John Travolta and his family for the loss of their 16-year-old son, Jett. What a devastating nightmare to lose a child. Any parent who's faced a child's mortality can empathize, I'm sure.

The Travolta family blames Jett's childhood bout with Kawasaki disease. We won't know for sure what happened until the autopsy is complete. But I'd like to clear up a few misconceptions about KD, as it's called, in the meantime

Kawasaki disease is a full-body vasculitis, meaning that blood vessels all over the body become inflamed. That's why the whites of the eyes turn red, along with the the soles of the feet and palms of the hands and the tongue. The heart, of course, is vascular, and it, too, becomes inflamed and can suffer permanent damage. KD affects mainly babies and toddlers of Japanese descent, and is often not diagnosed quickly. Children can indeed wind up with scarred and damaged hearts.

My younger daughter, Lulu, had KD when she was 8 years old. Luckily, a pediatrician recognized and diagnosed it promptly. Lulu spent 5 days in the hospital on intravenous gamma globulin and months convalescing at home. Today, at 13, her heart is fine.

No one knows what causes KD--and believe me, people have speculated galore. The Travoltas have been convinced for years that Jett's KD was caused by carpet cleaners. That's one of the theories that's circulated about it. I don't buy it, partly because hey, we never clean our carpets. KD is statistically more common in the winter and early spring (Lulu came down with it in January); maybe there's a correlation because people clean their carpets more in winter. I wrote a piece on KD for the New York Times and talked to all the leading researchers on it. They don't buy the carpet cleaners theory, either. It's more likely to be related to Staphylococcus aureus (Staph A) or toxic shock syndrome.

There is absolutely no evidence that KD causes autism. Repeat: KD does not, to the best of our knowledge, cause autism.

Of course there's a lot we don't know. We don't know that Jett Travolta was autistic, and frankly, it's none of our business. But we do know that kids who have had KD do not typically wind up with seizure disorders or autism.

I'm thinking of the Travolta family in their grief and loss, and hoping that Jett's death doesn't add to the misconceptions around Kawasaki disease. Maybe this well-publicized incident will inspire some researchers to get on the stick. There's been very little research done on KD. How about it?