Is Obesity a Disease?

Is obesity a disease? This is a question I ask myself regularly and have many internal debates in my efforts to answer.

On the one hand, I want the health consequences of obesity to be taken seriously. In the spirit of The Obesity Society's "I Treat Obesity Seriously" campaign, I want people needing treatment to have access to it. I want people to have access to evidence-based, sound treatments, with plenty of options between the extremes of "just eat less" and bariatric surgery.

On the other hand, obesity is currently defined as a size. As Dr. Sharma told us at this week's Your Weight Matters Convention, anatomical descriptions of obesity don't tell us anything. By using definitions--even if they can be calculated with numbers--that ultimately rely on visual cues, I worry we further stigmatize people who have obesity.

In order to think of something as a disease--and treat it seriously, we (1) need a definition that demonstrates health impact, (2) we need ways to screen and identify individuals with a disease, and (3) we need treatments to offer them.

The CDC, and pretty much everyone else, defines obesity based on BMI. Of course, BMI doesn't distinguish fat from muscle, subcutaneous fat from visceral fat, healthy people from unhealthy. There have been some good attempts to "score" obesity in terms of health, including the Edmonton Obesity Staging System. They are huge improvements, but we don't have enough evidence to define obesity using them alone. Does my BMI-defined obesity remain "obesity" because I think Prevacid is the best drug ever invented, or do I need to have actual GERD? Is a tight airplane seat enough functional limitation, or does it have to reach the point I buy velcro shoes?

For that matter, how we are we going to implement and screen any sort of health-based measure like this? Do I have to have a high BMI? I could have high percent body fat and a low BMI. What about all of the people who have a low BMI and conditions associated with obesity? If we use size as the fundamental requirement for defining obesity, how do we get past the stigma of the current societal perceptions of size? BMI is used because it's so easy to calculate. Really identifying when a high BMI is problematic requires more effort--a fasting lipid panel, for example, along with many other assessments.

One of our greatest challenges is that there are too few treatments for obesity. Intensive lifestyle interventions can work, but they don't always, and they aren't readily accessible to everyone. There are a few new drugs, but pharmaceutical treatment continues to struggle to overcome the black mark of Phen-Fen. Obesity treatment research is painfully hampered by the perception that obesity is the fault of the person with the obesity. The unremarkable success of current treatments has led to a focus on prevention, assuming treatment will never work. But we don't know that treatments won't work--we just haven't found them yet. What if we stopped trying to find cancer treatments because early efforts were not successful?

The "obesity epidemic" is not something that we can solve overnight. Prevention is a key element, but until we regularly use health-focused definitions, recognize the complex factors underlying obesity, and develop effective treatments, we will never succeed. Paraphrasing Ted Kyle, we are "writing off an entire generation, perhaps two generations." And we are doing this because of our unwillingness to accept that the failure is actually our own. We researchers, clinicians, and policymakers have failed people who have obesity because it's easier to say "people just need self-control" than "we have done a terrible job defining this disease and developing treatments."

Passing the blame is simply unfair. We will only ever be able to "Treat Obesity Seriously" when we take responsibility for developing serious health-focused definitions, step away from body size stigma, and focus our energy on real, effective treatments.

The Researcher's Promise

I've had one of those days where I'm questioning whether researchers should even be allowed to present their findings to the general public.

It started with the report on the increase in autism rates. I don't want to minimize the devastating effects of autism on families. But it reaches a point that it defies credulity. A jump from 1 in 88 to 1 in 68? In two years? And with a nearly fourfold variation between the lowest and highest states? (Alabama and New Jersey. Can you think of some differences between Alabama and New Jersey to explain that?)

Another study reported that a third of school-age kids have borderline or high cholesterol. These were kids between 9-11, a time we know cholesterol increases naturally--and is probably a necessary increase. And we have no clue how or if this affects them as adults. (By the way, this was just a meeting abstract, not a peer-reviewed paper.)

And, of course, there's the study showing that toddler obesity plummeted, one with significant issues I've already written about. Another writer posted about it recently, raising a different set of (equally valid) problems. An interesting tidbit there was that the author of that piece was not giving media interviews. (And I'm trying to not be bitter that no one cared when I made my arguments a month ago!)

As a researcher, I've had to learn to understand the media, and learn to understand how to present my findings. I'm sure I've stumbled. But this is something we, as researchers, absolutely HAVE to learn--how to explain what we've found. And we have to be absolutely sure what we are presenting is accurate, not just statistically, but in how it gets presented.

Why is this so important? These three studies tell me 1) autism is increasing at a rate that will eventually make it the scourge of the US, 2) a third of kids need intensive cholesterol interventions, and 3) obesity is all better. None of these things are true. Autism prevalence is still a mystery tied up in diagnosis rates and societal norms for "disorder". The only kids who really have cholesterol problems are a small group with genetic hypercholesterolemia--the rest are probably just growing. Obesity, or whatever we want to call this increase in body size, is pretty much unchanged.

Our studies, when promoted in the media, are the foundation of public discourse. They determine the policies that get developed, the programs that get funded, how the public perceives health problems. Carefully putting information in the public domain is our responsibility. We work so hard to do good work and get it into the journals. But that is only the first step. Of course we don't have complete control over the media--but too many of us denigrate journalists as not understanding researchers. That's not true at all, in my experience. We, the researchers, seem to not understand the rest of the world.

I think we need a researcher's promise (with some inspiration from the Girl Scouts).

"On my honor, I promise to always try to ensure my work serves the people of this world, to take an active role in translating the message to non-researchers, and to generously offer my knowledge and time in making research have only a positive impact."

I'm willing to consider edits on that promise!

Be Wary of the Headlines: Has Toddler Obesity "Plummeted"?

Yesterday, a study was published showing the prevalence of obesity in children and adults over the last decade.

The headline that was commonly seen was "Toddler Obesity Plummets". This insinuates that the main story out of this study is that we are winning the "battle against obesity".

Let's look at two things: What the study says about toddler obesity and what it says overall.

First, the study did indeed find that toddler/preschool (ages 2-5) obesity in 2011-2012 is much lower than it was in 2003-2004. However, what it also showed is that the drop happened right after--in 2005-2006. In fact, if you look at the authors' previous work, you can see that it was much lower in 2001-2002. For some reason, 2003-2004 was anomaly in NHANES, or in obesity rates. The rates went from ~10% to ~14% to immediately back down to about ~10%.

To say that toddler obesity has plummeted in the last decade in disingenuous at best. It has only decreased when making the very specific comparison of one two-year cycle. The trend over the last decade is not significant. The authors do acknowledge the importance of the comparison, but do not discuss the very important difference in 2003-2004.

Second, although obesity in young children dominated the headlines, the paper actually examined children and adults at all ages. The real story of this paper, in my opinion? Nothing has changed. It hasn't changed for young children or teenagers, for young adults or older adults.

Don't let a shocking headline distract you.

Love Song of the Headless Fatty

So, I got a paper published today, one I'm quite proud of. It's a viewpoint in JAMA Pediatrics, and is accompanied by a contrasting viewpoint from Daniel Callahan.

My basic premise is that we must stop stigmatizing children, even in small ways, because the thing that can be seen--the fat--is not what we should hope to change. Callahan, on the other hand, argues that "the main and simple message is that obesity is bad, not to be accepted or delicately evaded or minimized".

I would never argue that we should minimize the health effects of obesity, but we can not shame anyone into thinness. And we should never view obesity as solely the result of individual decisions, an (unstated) assumption that we know is faulty. 

I'll let everyone read them and make a decision for themselves. If you are at an academic institution, you likely have full access. If you are not (and are not on a mobile device), you will get to see a first-page preview, which is the majority of both articles. Shoot me an email at asheley@unc.edu, and I can share a full PDF if you like.

(The titles below link to the JAMA Pediatrics page.)

The Love Song of the Headless Fatty and Other Observations

Children, Stigma, and Obesity

The Stigma of Childhood Obesity

Some colleagues and I recently received a rejection of a letter to the editor of JAMA. When we saw this cover, we were immediately struck by the child in the middle, and decided a letter was needed. I guess I shouldn't be surprised by the rejection, given that JAMA recently rejected another piece of mine on how stigma pervades the medical and scientific communities that work on childhood obesity. (That piece, however, was accepted by another in the JAMA family, JAMA Pediatrics, and will be published July 1.)

The refusal to engage in the discussion is as informative as the original point we were trying to make. Below is the image on the cover, which should link you to Dr. Zylke's description--my apologies to those who can't access it freely. I think our letter was appropriate and true.
 



 

Dear Dr. Zylke,

It was with great excitement that child health researchers came across a special issue of JAMA focused on child health last week.  Unfortunately we found this issue’s cover alarming.  The illustration promotes the stigmatization of obesity that has not only pervaded popular culture, but, as so clearly demonstrated here, the research and medical communities, as well.
   
On the cover, we instantly saw a portrayal of an obese child with a large soda-an image that managed to meet all three criteria for defining pejorative images from the Yale Rudd Center for Food Policy and Obesity at Yale University media guidelines.¹  While you say this image tried to portray “problems stemming from social or environmental issues,” the use of a picture of an individual child with a large soda to reflect the high prevalence of obesity among children is stigmatizing in that it recognizes the individual behavior without also recognizing the larger environmental roots.  

Far more disturbing are the subtleties apparent in the image.  The fact that so many people in the scientific community must have looked at this obese girl—with an awkward facial expression, unflattering clothing, and avoiding the world—as an honest representation of childhood obesity is truly disheartening.  Social constructs of disease place responsibility on different individuals, assigning blame in ways that portray children as either victims or perpetrators.² On this cover, nearly all these children are either promoters of their own health or “victims” of their diseases, except this child, who is shown as a perpetrator of hers.  

In your description of the cover’s more idyllic images, you quote Norman Rockwell: “I paint life as I would like it to be.” We would like to offer up another of Mr. Rockwell’s quotes: “Right from the beginning, I always strived to capture everything I saw as completely as possible.” The narrow, incomplete and negative view of the obese child so painfully portrayed on the cover demonstrates the narrow, incomplete view that many people have of obese children and obesity itself. 

If we only focus on the doubt and difficulty of changing individual behaviors, we will not reduce the prevalence of obesity as significantly as if we address systemic factors.  Continual perpetuation of stigmatizing images of obese children reinforces beliefs that obesity is a problem driven only by individual behaviors. Such stigma serves to dehumanize obese people, and may even serve to perpetuate obesity itself.³





Asheley Cockrell Skinner, PhD

Stephanie E. Hasty, BA

Eliana M. Perrin, MD MPH 

References

1.         Yale Rudd Center for Food Policy and Obesity. Guidelines for the Portrayal of Obese Persons in the Media. 2012; http://www.yaleruddcenter.org/resources/upload/docs/what/bias/media/MediaGuidelines_PortrayalObese.pdf. Accessed May 9, 2013.

2.         Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology. Sep 2003;22(5):533-540.

3.         Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. Psychological Bulletin. Jul 2007;133(4):557-580.

The Political Destruction of Health Research

The Washington Post has a fabulous interview with Elias Zerhouni, a former NIH Director, about the effect of the proposed NIH cuts in the federal budget.

The projected cuts are 8.2%. Zerhouni does a great job explaining why this is particularly devastating to an organization that functions on long-term research.

I hear lots of arguments about why this is really not so bad.

1) "Research should be in the purview of the private sector."

Rely on market forces for medical research, and you get research that produces all sorts of new hormone treatments, but not the research that shows how the hormone treatments harm women. What you will get is research that is profit-driven, not health-driven.

2) "Some of that research is so dumb anyway."

Hear about the study that used recovery funds that had people mail in toenail clippings and measure nicotine exposure? It might sound crazy, but it actually aims to determine people's risk for lung cancer--and understanding risk is critical to protecting health. Believe me, I've gone through the grant-funding process. I'm sure a few crazy things slip through the cracks, but I can assure you most things that sound crazy are probably actually pretty important.

3) "We need to spend money on 'real' jobs."

I'm a puny little researcher, with very little grant funding, in comparison to those around me. But even I have--in addition to what I like to pretend is some half-decent research, in the world of incremental findings--created two jobs. Created two jobs with (sort of) decent wages for bachelor's-level individuals--not "fancy scientists". Huge portions of grant funding goes to personnel--and much of that goes to creating jobs at many levels. Researchers, for sure, but also the assistants, administration workers, project managers... 8.2% cuts won't just be felt by "researchers" but by people who work in all sorts of jobs.

Cuts in medical research hurt everyone. And they will continue to hurt everyone even if funding is restored, because researchers like me won't be able to stay in research, and will have already left. If I'm not funded, I don't have a job. My "cushy faculty job" is entirely dependent upon my success with funding--which is largely government-based. I'm still fighting the fight, but it's not something I can do forever. Many of the bright minds--the person who could find the proverbial "cure for cancer"--will leave the field, and that gap in brainpower will be felt for generations to come.

Do we really know the best nutrition policy?

If it's possible to reblog from wordpress to here, I don't know how. But here's the link to an amazing blog post from Laura Schoenfeld, about nutrition policy in the US.

I'm not even going to try to write much more about it, because she does such a great job. All I can say is that we really take for granted that our nutrition recommendations are based on science and evidence.

A New Approach to Data?

We all know that new technologies are changing how we do research. One of the most interesting was first introduced to me several years ago by a student of mine, who was particularly interested in how social media spread information about health-related issues. The first goal was to see how accurate the information was, but I think it's becoming more and more obvious that social media can be used to identify things more quickly than traditional research methods.

A post by kottke shows a fascinating result of using Google to identify disease breakouts. This picture is the interesting point:

The Orange is US data, Blue is Google-based data.

The tracking of certain Google search terms is very, very close to CDC data. What appears to be happening, though, is that Google identifies the trends a couple of weeks before CDC data.

Potentially more interesting, though, is what this could mean for other types of disease outbreaks. The US has a good system for tracking certain infectious diseases, particularly flu. But what about for diseases or problems that are newly emerging? Can we use Google, or other social media, to identify problems before we even know there is a problem we should be looking for?

We haven't even begun to understand how we can make use of all of the data that are being generated by millions of individuals across the world. This is the true "new frontier" of research.

Inertia

A Forbes article from earlier this month tries to dispel the myth that doctors will only increase their (uncompensated) work burden if they are willing to communicate with patients via email. Personally, I communicate with my physicians via email--I actually go so far as to nearly use that as a criteria when choosing a physician. But I think this form of communication is important for a far greater reason.

The power differential in the doctor-patient relationship is a key factor in how a particular patient's care will proceed, as I've written about before. Email has the benefit of being a low-pressure method of communication, one that doesn't require confident, direct interaction. Many individuals, no matter their background, find it difficult to speak openly with their physician, to ask questions, to be sure they are sharing all of the information and history they should. But email provides an opportunity for the patient to carefully consider what they want to say, and to do outside the pressure of the exam room. Patients may share information--some which might be critical to providing the best care--that might otherwise be left out or simply overlooked.

As technology becomes more and more integrated into all aspects of life, including medicine, health care will have to embrace these changes. People are embracing them. We can't let inertia prevent improvements in care.

Dangerously Stubborn

I stumbled across this article in Slate today, where a leading environmental activist professes he was wrong about opposing genetically modified crops. In and of itself, it's an outstanding, and seemingly courageous thing to do.

I say "seemingly" because, in truth, this is how science should always be. The steadfast adherence to a particularly belief is one of the most dangerous things in science, and one that far too many scientists are guilty of. I understand, I really do. It's difficult to write something and then go back later and say that maybe you were wrong. But the point is, barring truly poor or fraudulent science, studies aren't ever wrong--they just all provide different results. The entire point of the scientific method is to replicate until the preponderance of the evidence suggests a particular hypothesis to be true.

Unfortunately, we live in a scientific world where novelty is valued over replication, regardless of what it means for a particular hypothesis. I do believe we are making some strides, particularly with the advent of journals whose purpose is publish either negative findings, or to publish other things that might not get much interest but are still scientifically sound.

As I have begun to pay more attention to this phenomenon, I've become more determined to not allow myself to fall prey to this pressure. I hope, throughout my career, that I will be able to recognize and admit when I am wrong, and that I will always work towards doing the right things, as a scientist. I probably won't have a very storied career, but at least I'll know I've done well.

No child left behind in recess?

Earlier this week, the American Academy of Pediatrics issued a new policy statement on the importance of recess during school for kids. Recess is NOT the same as physical education, the statement makes is clear that both are needed.

This certainly isn't the first time that we've been told that kids need more recess. As childhood obesity has become a mainstream issue, many parents and policymakers have argued that recess is critical for kids to ensure they are active during the day. However, many schools continued to focus on classroom instruction time, particularly with regard to the standardized testing required as part of No Child Left Behind. My personal experience has been one of frustration with the seemingly endless amount of class time and homework for my children, but I'm also sympathetic to the administrators and teachers who are so dependent on successful testing scores.

One thing the policy statement makes clear (and this is not new information, but it's always nice to see it in an actual policy statement) is that recess is not good just for children's bodies, but their social, emotional, and cognitive development. In short--if you replace class time with recess, you get kids who are more successful in class.

Will this make a difference? I just don't know. I think the culture of testing has become the axle around which all of public school instruction turns. A policy statement is a start, but schools have rarely heeded the advice from non-educational professionals. I don't think it's because they don't want to, but because the risk of poor test scores is too great. We've created a monster that, in its effort to hold teachers and schools accountable to children's educational success, is not held accountable for the damage it does to children's overall health and success.

Is obesity really a health issue?

I've long had concerns about how we measure and define overweight and obesity, and what it means for health. The entire reason to wage a "war" on the "epidemic" of obesity is because we want to improve the health of individuals and the population. Many studies have demonstrated previously that being overweight and (in some cases) obese is NOT a risk factor for mortality. Obesity only becomes an issue at levels of "Grade 2 Obesity". However, I've always found it difficult to reconcile the data with the message. These studies--and I've been involved in a few related to child obesity--are difficult to publish, precisely because they go against the paradigm, and when they are, they receive little attention.

Yesterday, a study was published that should have helped bring the matter to a close. In a meta-analysis of 97 studies, representing nearly 3 million people and 270,000 deaths, Flegal and her colleagues demonstrated that being in the overweight category (so, a BMI of 25-30, the lowest of the overweight groups) was associated with lower mortality than being "healthy weight". Grade 1 obesity (BMI 30-35) was associated with no difference in mortality.

This is not an inconsequential finding. Meta-analyses have their own set of critiques, but, at least in my opinion, this one addresses to the extent possible most of them. They appear to have a rigorous a clear protocol for selecting the included studies, and perform the analyses in several different ways (presenting all of the findings). Indeed, Dr. Flegal herself is a well-known obesity researcher at the National Center for Health Statistics and has played an important role in development of obesity-related research. If she has any subconscious bias, I would expect it to be in the direction of demonstrating overweight obesity are bigger problems.

The authors make very little comment on the meaning of these findings. They do, however, note that possible explanations include earlier presentation to health care for heavier patients (meaning more screening for risks), and higher metabolic reserves (a fancy way of saying that when you get cancer or other severe illness and lose a bunch of weight, heavier people can tolerate that better). An accompanying editorial (which, unfortunately, can not be accessed for free) extends the discussion a bit, but discuss whether BMI is a good measure of obesity (in terms of fat tissue) and that, of course, weight alone should not be the only factor a physician considers when estimating a patient's risk.

What no one is willing to come out and say is this: Maybe overweight and (moderate) obesity are just not a big deal? Maybe we defined these "diseases" all wrong, and maybe we're creating problems that don't really exist. Maybe we let social perceptions of what someone "should" look like effect these definitions? Maybe we have been unwilling to consider the possibility that overweight is not a health risk because we are so invested in the paradigm of obesity = really, really bad that we are unwilling, as a field, to step outside that paradigm.