October 27, 2014

Can We Just Stop it Already? (a.k.a. Obesity is "Associated With...")

If you follow health-related news in the mainstream media or regularly read peer-reviewed scientific literature on obesity, weight loss, or health and nutrition and in general, you can confirm my observation that the phrase, “Obesity is associated with…” is bounced around so frequently, it gets more action than a metal pinball in a 1980s arcade. And in place of that ellipsis (the three little dots), feel free to put just about anything you like, because I can pretty much guarantee someone’s established an association between obesity and whatever that other thing is: heart disease, diabetes, cancer, depression, a flat tire on your way to work, and rain on your wedding day. (With apologies to Alanis Morisette.)

Note that word: association. Unless and until a firm chain of causation between two things has been established, researchers have to be very careful with their language. (Believe me, I know. In my other professional capacity, writing for a supplement company that is committed to sticking to the science, I have to get pretty creative with ways to stay safely within the confines of FDA regulations regarding the mechanisms of action of certain products. For example, I can never say something like, “This vitamin formula is specifically designed to help manage diabetes.” Instead of making that kind of “disease claim,” I have to stick to what is known as “structure/function claims,” which are super boring and tepid -- as in, “May help support healthy blood sugar levels,” or “Contains taurine, a compound required for healthy liver function.”) My point is, because no one wants to get sued, everyone has to skirt the legal edges of nutritional rhetoric.

But here’s the thing. Between you and me—just us friends here—we all know that when obesity researchers say “association,” they’re implying causation. They want to say causes. Obesity causes [insert-awful-and-expensive-health-condition]. But they can’t. Because it doesn’t.

That is, not usually.

Is obesity associated with many awful and expensive health conditions? Yes, of course. We know some of these things cluster together. But that doesn’t necessarily mean that one—just one—of those things that cluster together is causing the clustering of the others. What if some other thing—above and beyond any of those little, individual things—is causing all of them to cluster together? What if multiple other things are causing it?

With this in mind, can we just stop it already? Please? Can we stop seeing obesity as “THE THING” that is associated with causes all the others? Because when we get stuck in this simplistic view, we take something complex—the biochemistry and physiology of body weight regulation—and reduce it to a moral debate. An ethical dilemma. Instead of focusing on scientific facts, we revert to snap judgments based on nothing but visual observation. Instead of looking at scientific facts about how the human body works, and giving people concrete advice that can help them correct the imbalances that are most likely leading to excess body fat accumulation, we can bandy about words like discipline and willpower, and lob insults at overweight people because their problem is obviously that they are weak-willed and lazy. It couldn’t possibly be that the nutritional guidelines they’ve been advised to follow for several decades are ruinous.

I am starting to get very angry about this. And it’s no fun keeping anger to one’s self, is it? It’s so much more fun to share it with other people, so you can get them riled up too. So here we go. What I’m talking about today will figure largely into the early posts of the OECD (Other Effects of Crap Diets) series I mentioned in the post where I gave a preview of where I’ll be taking things with this blog.

I’m angry about a lot of things in nutrition and health research, and possibly even more, the way this research is conveyed to the public by various news outlets. But the thing I am most angry about is that people who don’t know any better—a group that actually includes some researchers, themselves, who should know better!—still see obesity as character flaw. It’s still a moral judgment, in which overweight people are seen as willing participants in, and eager contributors to, their own adiposity, rather than what they actually are: victims of severely misguided—yet firmly entrenched and institutionalized—dietary recommendations, the loyal following of which has made them unwitting hostages to their own physiology. (In most cases. For clarification, see this post. People do need to accept some degree of personal responsibility for their health, but it's not quite what you think. Just know that I am not saying obese people are completely hapless and bear no responsibility whatsoever for whatever complications their excess weight causes is associated with. I’m just saying that that’s not the case for all of them. After all, many highly disciplined people do "all the right things," and still don't see the results everyone says they will. Not to mention, my chosen words, "victims" and "hostages" aren't really that great. They bring a lot of connotations I don't mean to imply, so please don't come lobbing tomatoes and hate speech at me. I am aware they leave a lot to be desired. I'm just making a point is all, and the language can get pretty squirrelly.)

The question is, WHY do so many of us still see obesity as a behavioral issue—something to be fought on the psychological, rather than the physiological, battle field? I think it’s because obesity is something we can see. And a picture is (sometimes) worth a thousand words. If you are overweight, then you DO eat too much and move too little. How do we know? Because we can see it, plain as day. It’s right there, on your thighs, in your double chin, in your gut, on your love handles, your cankles. Don’t even try to deny it. Don’t tell us that you live on Lean Cuisines, fat-free, high-fiber cereal with skim milk, and salads with low-fat dressing, and that you spend two hours at the gym every day. We know you don’t. WE KNOW IT, because if you did those things, then you wouldn’t be overweight. Post hoc ergo propter hoc. Or, not, in this case. We are assuming a chain of causation that doesn’t exist. Or, if it does exist, we are oversimplifying it to the point of rendering it ridiculous, counterproductive, and useless as a contributor to the national conversation on health, regardless of body size.

We have assumed the chain of causation works like this:

As you can see, because you are a lazy, greedy pig, who lounges on the couch all day eating chips & dip, and downing 64oz sodas, you are obese. And because you are obese, you are more likely to have the conditions mentioned above. (Because obesity is “associated with” those conditions [and more!], but between us “experts” and government policymakers, really, obesity is causing them [wink, wink, nudge, nudge].) And because you are a fat, lazy slob with a ton of health problems, you are a gigantic (pun intended) drain on society as a whole. See, because of lazy, fat people like you, the rest of us virtuous, righteous, “clean eaters” and regular exercisers pay insurance premiums that are higher to cover the zillions of extra dollars YOUR fat fannies cost the whole system. When YOU miss work because you’re too tired/in pain/depressed/uncomfortable to drag said fat fannies to the office, WE have to pick up the slack. Thanks a lot. Hope you enjoyed the Fritos & Mountain Dew… 

But here’s the deal. IT DOES NOT WORK THIS WAY. At least, not always. (And I would argue not most of the time.) Here’s how we know: there are plenty of people with [insert-scary-and-expensive-health-condition] who are at a “normal” or “healthy” BMI. (Whatever that even is. Nothing but height and weight? Congratulations on your morbid obesity, every muscular NHL star on the ice!) Ask a bunch of cardiologists about their patient populations, and they will confirm for you that not everyone with one foot in the grave in terms of heart health is overweight. Ask a bunch of endocrinologists, and they’ll tell you that plenty of their diabetic patients are at a “healthy” weight. OB/GYNs? Lots of women who can’t conceive or who have massive hormonal imbalances “look fine” on the outside. (Read: are not overweight.) And walk into a cancer treatment center sometime and take a look around. You will see patients of all shapes and sizes. So even if obesity does contribute an extra amount of risk for any of these things, it’s certainly not the only thing causing associated with them.

It’s not easy for people to wrap their heads around this. It’s easy to deal only with the things we can observe with our senses—sight, in particular. Because we can see a person’s size. We can see that they are larger than we think they “should be” (if we can see them at all, that is, looking down at them from the vantage point so far up on our high horses). And maybe we also happen to know that this person experiences sleep apnea, mood swings, indigestion, severe PMS, and is taking medication for acid reflux, anxiety, and hypertension. And because we can see that they’re “overweight,” it is (probably) our natural human inclination to assume that there’s a causative process there, and it works like this: OBESITY --> All those other problems.

And let’s make no mistake: adipose tissue is an endocrine apparatus. No question about that. It is not physiologically inert. It doesn’t just sit there. It secretes and absorbs things, sends and receives. So yes, once excess adipose tissue has begun to accumulate, it can wreak plenty of havoc on health all throughout the body. But what is causing it to accumulate in the first place? In some cases, yes, eating too much and moving too little (whether that’s too much fat, protein, or carbs; eating too much of anything for one’s metabolic constitution can do this). But what about all the other things that might be causing the storage of nutrients in adipose tissue? What about hormones? What about the primary hormone that is chronically elevated in many people as a direct result of the nutrition guidelines the American population, as a whole, has received for the past several decades? (We have been told to literally base our diet on starchy, acellular carbohydrates, which some researchers speculate might even be the primary driver of obesity.)

What about the myriad other inputs whose inclusion or exclusion are likely playing a causative (not just associative!) role in the accumulation of excess adipose tissue? What about THIS:

Do you see how different this looks from the previous chart? Here, obesity is not a cause, but an effect. And it’s just one among many other effects it is so commonly cited as causing being associated with. Yes, of course it’s associated with all these other gnarly issues, because the same things that are causing the accumulation of excess adipose tissue are also causing the other gnarly things. (And the people who experience some of those gnarly things without accumulating excess adipose tissue are simply lucky. They are what "Jane Plain," a registered nurse who is the smartest blogger you're not reading calls "constitutionally obesity resistant." These are the people who eat total crap diets but for some magical reason don't become obese. That doesn't mean they're healthy. Most of them will eventually experience some of the gnarly things above, whether or not they ever become overweight. Actually, those people do accumulate excess fat tissue; they simply lose muscle at the same time, so their body weight [and therefore BMI] remains "normal." They are "skinny-fat," or what medical researchers have termed "normal weight, metabolically obese." More on this in future posts.) Why are more people not beating this drum? Why do I feel like a lone voice in the wind?

Like I said, it’s difficult for people to wrap their heads around this. Because we can’t see how much someone sleeps. And we can’t see how much fresh air they get, or what kind of diet and lifestyle their great-grandparents had. We can’t see what’s going on with their gut flora, or how well they handle stress. (Maybe we can see and know some of these things if we are especially close to this hypothetical person, like, say, a spouse or best friend, but for strangers we observe in passing, or even coworkers, with whom we spend a relatively limited amount of time? Not so much.) Yet, people who don’t know how these pieces fit together feel free to pass judgment based on the one visual observation they can make: the size of someones rear end.

My mother, who had her share of health problems, and therefore saw a lot of doctors, far too often had her questions and concerns disregarded and dismissed with advice no more sophisticated than, “You need to lose weight.” She would come back to these healthcare professionals [and I use the term loosely] with, “Okay, fine. I’ll do that. But now, please tell me what you’d say to someone with this same condition who weighs 125 pounds.”  

I’m going to be talking a lot more about this issue in OECD, and I hope you’ll come along and chime in. I think it’s long past time to change the tone of our national discourse on obesity. I also think it’s long past time to change the focus of our national discourse entirely. Rather than the size of our butts and bellies—which, in most cases, is not the cause of our health problems, but rather, just one more of the cluster of outcomes of our diet and lifestyle (the former of which was recommended by the very agencies and organizations now insisting it’s all our own fault), lets shift the focus to the diet -- and maybe its time to recognize that the diet the experts have been recommending for a while now ISNT WORKING. (Lets also focus on the lifestyle factors, but diet is the one the authorities have standardized and institutionalized the most.)

Let’s remember: we can see the size of someone’s body. We can’t see their elevated triglycerides. Or their sky-high fasting blood glucose. Or their low HDL count, their high blood pressure, or the extensive calcification of their coronary arteries. We can’t see their lack of menstruation, their brain fog, or their loss of libido so severe they haven’t even thought about sex in 18 months, let alone had any. And yet, all of those things are Other Effects of Crap Diets that people of any size can experience. And they do drain our healthcare resources, and they are a huge burden on the economy as a whole. And they rob millions of people of something far more important than money: quality of life. Time with their loved ones. But they aren’t the direct results of being fat.

So really, can we please just stop already?    

Remember: Amy Berger, M.S., NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition.


  1. Thanks for reminding me. I am often guilty of having these very judgemental thoughts about people who are overweight - especially when they get in my way, block the footpath, spill over onto my seat in an aeroplane/train/tram/bus; when I hear the government bemoaning the escalating cost of health care; see them walking into a doctor's surgery, struggling to carry out everyday activities etc. I should know better as I have friends who are obese despite doing everything right (right in our book that is; not CW) but their adrenals are shot to pieces from past stress, and their thyroids stop working the day they hit menopause. These ladies are really hurting inside, at the end of their tethers trying to work out what to do, which ends up in a vicious cycle....and I have the arrogance and ignorance to criticise those I don't know; under my breath, and sometimes it doesn't stay under my breath, but sneaks out to the surface. When I see these overweight people in future, I will remember your article, smile and say hello to them.....it might just help them to feel a little better about themselves.
    Many thanks for your article.

  2. It was nice to see that Mark's Daily Apple shared a link to this post saying it was a great piece :)_