When “public health” loses the plot

Content note: dieting, weight loss surgery, fat-phobic healthcare

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A colleague just shared the following tweet from the International Critical Dietetics conference with me:

She noted:


So it would seem. This is not the first time I’ve come across this very skewed view of what is important in health, and in life. I wrote about something similar back in 2013 when I had just had the misfortune to attend an ‘obesity’ conference, chock to the brim with this stuff. The following is a slightly modified version of a post that was originally blogged on the sadly now-defunct Fierce Freethinking Fatties blog. I’m reposting it here for posterity.

Notes from a Conference

I study weight stigma. For some reason, this is considered to fall under the umbrella of obesity research — a problem in itself. Well, they’re both about fat people, of course. But one is about affording fat people their basic human rights, whereas the other is about wiping them off the face of the planet. A couple of weeks ago, the European Association for the Study of Obesity (EASO) held its annual European Congress on Obesity (ECO) conference in Liverpool, UK, fairly close to where I live and study. My supervisor wanted me to go. After looking at an early version of the programme, I wasn’t keen. She insisted; it was a major international conference right on my doorstep and she wanted me to go. Oh well, methought — know your enemy.

So off I toddled to Liverpool for three days of fat bashing, having paid £200 of my own money for the privilege. The conference was actually four days long, but I was running my own conference on weight stigma the day after it ended (one that EASO, and its British counterpart, ASO, had refused point blank to notify their members about), and I was just too busy to attend the last day. This was a bit of a disappointment because it meant that I missed the session on successful dieting after breast cancer — something that I have long felt should be high on the list of medical priorities. Also missed, for a different reason, was the session on preventive bariatric surgery in adolescents. Sadly, the speaker had to pull out at the last minute for personal reasons, so I never got to see whether he had horns and reeked of sulphur. Almost the entire event was an exercise in weight stigma, although not a single session over the four-day event was dedicated to that subject.

There were moments of hope. The sessions on exercise were consistently sensible, and the experimental studies were of a significantly more rigorous standard than those I witnessed in other areas of study. These people clearly showed that even with supervised, intense exercise, weight loss was minimal, highly variable, and often didn’t happen at all, with some people even gaining weight. But they noted the health improvements that occurred in all participants. People who had worked in the field for longer were even more forthright — we need to stop focusing on weight and start promoting physical activity in its own right. Steven Blair was so righteously pissed off, it was almost comical. Except it wasn’t. Nearly 20 years of high-quality, high-volume data showing that fitness matters as much, if not more, than weight for health outcomes, and yet papers are still being published showing oh-my-god-obesity-will-kill-us-all without taking factors like fitness into account.

There were, literally, dozens and dozens of posters (summaries of people’s scientific research) showing that programme X, Y, or Z resulted in “effective” weight loss of a few kilogrammes in 12 weeks. Wahoo. Obesity crisis solved. Talk about junk science. How people still get funding to conduct such meaningless research is beyond me.

I also spent a happy 15 minutes haranguing the lady on the Slimming World stand for the strapline in their advertising: “Because you’re amazing.” Why, I asked them, if we were so amazing, did we need to come to Slimming World to change? Oh, they said, because you’re amazing on the inside. So, your outsides aren’t amazing? No, no, no — this isn’t what they mean at all. It’s an accepting, non-judgmental environment where all people are welcomed and supported, apparently, because all people are amazing. Clearly not amazing enough. In the end, I felt a bit sorry for the poor woman. Her company’s advertising is hardly her fault, but maybe I at least made her think a little.

Bariatric surgery, or metabolic surgery as some are now trying to brand it (seeing as how bariatric surgery is developing a bit of a bad name), was well represented. Everyone was careful not to mention the words “weight loss surgery.” Perhaps because, again, the weight loss from weight loss surgery often does not even bring people into a “healthy” weight range; correlates with significant post-surgical health problems, increased rates of depression, substance abuse and suicide; and often isn’t permanent anyway. “Barbaric surgery” (as one reader likes to call it) clearly needs a new image. Watch this space for the rise of “metabolic surgery.”

Despite this, a large proportion of the presentations at the conference were about surgery. I chatted to one scientist who was looking at people’s expectations of BS and was planning on following them afterward to see how that affected long-term outcomes. A small study, but interesting enough if people are going to have the procedure anyway. I think the more we know about the psychological and long-term issues, the better. It’s not just about cutting out the unacceptable bits of your body and Bob’s your uncle, something that most of the medics seem to be almost willfully unaware of.

Not that they’d care if they were. Fat people need fixing, after all. It’s a public service. Much like lobotomies in the 1940s and 50s for the treatment of psychosis (over 20,000 performed in the US alone), or removing children’s healthy thymus glands because in autopsies they seemed enlarged. It was a leap of non-logic: enlarged thymus causes illness and death; let’s rip ‘em out prophylactically. Pity the kids needed them to be large to help develop their burgeoning immune systems. If the history of medicine teaches us anything, it’s that we really need to be more careful before destroying bits of people and then saying “whoops.”

But getting back to the lady with the small study. She mentioned the varying levels of family support for the surgery. She said that one older woman was facing a lot of resistance from her husband about the surgery. I suggested that maybe this was a good thing — that he was okay with her as she was and didn’t want her to risk going under the knife. “But but but,” said my well-meaning new friend, “Her weight is seriously impacting her health and quality of life,” absolutely incredulous that anyone could object to her being helped in this way.

“Oh, what’s wrong with her?”

“Well,” she replied. “It’s really affecting her mobility. She struggles to get into her car because the gearshift is in an unusual place; she can’t paint her own toenails, that kind of thing — she’s really distressed by it.”

Her toenails? Given that there were only 18 people being studied, the poster actually listed all of the participants: gender, age, BMI etc.

“Which one is she.” I asked.

“That’s her.” She was 67, female, with BMI of 46.

Me at the Fattylympics. BMI 40. This is “morbid obesity”

“Forty-six? For Pete’s sake, my BMI is 40,” said I, doing a little twirl. “Forty-six is hardly cut-off-the-side-of-the-house mobility issues. And she’s 67. Perhaps she might benefit from some kind of physical strengthening and flexibility training,” I suggested. “Has she done that?”

“Oh,” said my friend. “I don’t know.”

This is the world of obesity research. We have completely lost the plot. If it were me, I’d suggest that this woman could increase her movement capacity through some fairly basic training, and possibly suggest she get the occasional pedicure. But clearly that’s just me.

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