4.06.2015

But, do you like, *know* know?
Food Issues Book Club - Weighing In, Chapter 2

Hello all!  Welcome to the NOiG Food Issues Book Club, wherein I read books about food stuff, summarize each book by chapter, and then attempt to apply that book chapter's ideas to the New Orleans food environment and my own experiences.  Fun right?!  Check out previous installations here.  I'd love it if you'd read along and join in!  And now, without further ado...

Weighing In, Chapter 2: How do we know obesity is a problem?

Summary:

The so-called obesity epidemic has been framed "in ways that tend to overdramatize some elements and underspecify others, especially those that might lead to different conceptualizations of the problem."  The result is that we are more concerned about size (appearance) than actual presence of illness.  "The term obesity reflects a medicalization of fatness."  While this approach can open avenues to treatment, it also insists that there is in fact an illness to treat.  Even in the World Health Organization definition of obesity, there is an inference that anyone who is fatter than they "should be" is automatically ill - whether or not there is any other indication of illness.

The average national Body Mass Index (BMI) began to rise in the late 1980s, and leveled off again in the 2000s.  BMI is the most frequently used measure in studies of obesity, simply because it is the easiest to measure, requiring only a few pieces of personal information to calculate.  This measure, though, tells researchers only about the size of a person (height relative to weight) and nothing about actual healthfulness.  It is in fact not even particularly accurate at determining excessive adiposity, given that it "makes no allowances for variations in bone mass and density, or somatic differences more generally."  It also fails to account for differences in body type or fat deposition patterns.

Where do you fall?  Does it matter?
A good illustration of the problem
with BMI (if a bit fat-shaming)
Calculations of the rates of obesity based on BMI are misleading for several reasons.  Because of the absolute cutoffs used in its calculation (for instance, a BMI of 24 is normal but 25 is overweight), a person who is two pounds over the line of "obese" is reflected identically to a person 100 pounds or more over the line.  Second, in 1998, the BMI value for "overweight" was changed from 27 to 25.  As a result, millions of people went from normal to overweight without any actual change in weight.  These relatively arbitrary cutoff points are assigned meanings that are overstated, often to the point of inaccuracy.

The use of the word "epidemic" is catastrophising and even cruel, "simultaneously minimizing the violence of serious plagues and overstating the association of corpulence with death."  Determining whether fatness is a causal factor in deaths has been greatly oversimplified.  Prominent studies claiming to show higher morbidity and mortality in the obese assume that all obesity stems from poor diet and too little exercise, "letting the condition stand in for the behavior."  A 2005 study actually showed lower mortality among most categories of overweight people when compared to those of "normal" weight.  Other studies have shown an increase in mortality among the very thin.  Of course, in all cases, association does not mean causality.

The methods used to determine obesity rates and risks of associated illnesses are, then, prone to the shortcomings of all statistical analysis.  For example, those who go to doctors for treatment are more likely to be ill - and those who are willing to be studied are more likely to be healthy - than an unbiased cross-section of the population would be.  As such, studies based on information from either of these groups is a poor representation of broader trends.

"The use of size as an indicator of risk appears to be blunt at best, and possibly much more damaging."  While there is in fact an increase in body size, "[t]he issue is how we interpret these changes, how we treat them, and the consequences of both."

Discussion:

As I discussed last month, the City of New Orleans supports a fitness initiative called FitNOLA.  It aspires to a goal of becoming one of the top ten "fittest" cities in the US by 2018.  Its homepage very clearly indicates that its fitness goals relate directly (and seemingly only) to obesity: "The City of New Orleans Health Department is leading an effort designed to shape a shared vision for our own city as it addresses obesity, one of its major public health challenges... Together we can turn the tide to win the battle against obesity and create a more fit city."

But is a lack of obesity the same as presence of fitness?  I believe that answer is a resounding no.  While an association can be drawn between "normal" body weight and health for some individuals, there are overweight people who are healthy, and thin people who are quite ill.  How do we unfurl the concepts of weight and health, now that they are so intertwined in the minds of most?  This conflation reminds me of the insistence that only meat contains protein and other such nutritional fallacies.

Nola's favorite Fat(s)
New Orleans certainly hosts its fair share of people who are overweight.  And yet it also homes people who are food insecure (a lot of them), and people diagnosed with cancer, and people with addiction problems, and people of "normal" weight who suffer from diabetes and high cholesterol and hypertension.  Certainly people who are starving, dying, or drug dependent are not "fit" - even if they are thin.  Why, then, focus so exclusively on fatness?

Perhaps the city chose to focus on it because it places all responsibility - and all blame - on individuals, and deflects completely away from the city for, say, failing to make sure that all of its citizens have safe outdoor spaces in which to exercise and a non-toxic food environment and clean air.  Perhaps it's because we can look at people and know they're fat, and can't do any such thing with the other issues mentioned.  Perhaps it's just because Michelle Obama said so.

Whatever its cause, this obsession with the idea that fatness is sickness and thinness is health is both incorrect and also potentially dangerous, even beyond the inevitable psychological trauma of the fat-shaming it fuels.  Since thin people have been told that they are healthy, they may opt not to visit the doctor - why should they? - and as such miss diagnoses of potentially life-threatening illness.  Even more frightening, since doctors are also prone to the "thin is healthy" bias, they may overlook developing health problems in thin people.

To the credit of the FitNOLA program, its homepage also lists free exercise classes held each day at different parks around the city.  Attending them may or may not help you lose weight (if that's what you want to do), but getting some good exercise can make all of us more fit.  In the end, it's fitness - not fatness - that matters.  Also check out Heath at Every Size, whose name pretty much says it all.


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