If you haven't noticed yet, obesity and the treatment of fat people in general is one of my causes. Not everything I post here will be on that topic - I generally have a lot to say about a variety of things and sometimes just like to be silly, too. But because of my personal experiencing dealing with being obese, it is a subject that I care about quite a bit and hope that maybe others can learn from some of the information I offer, so that other who are also obese may have an easier time of it than I have. So, here's the latest entry in what's likely to become a series on obesity issues. I hope you'll take time to read through it and give it some thought. Kathy J. Kater, a psychotherapist who specialises in the promotion of body image, eating, fitness and weight, recently sent a letter to the BMJ (British Medical Journal) in response to an article it had run regarding the "obesity epidemic" and questioning the effect it has on fat people when obesity is treated as a behavioural problem and they are subjected to constant shame and scare tactics to try and get them to lose weight. She notes that in many ways, focusing on obesity as a behavioural issue is counterproductive in that when people start focusing on their weight and attempt to change it by dieting (with or without exercise,) they will most likely wind up heavier than they started out, and feeling worse about themselves than they did - which typically leads to yet another round of dieting, failure and self-flagellation. Here's what she had to say:

The debate over whether the health risks of obesity are exaggerated seriously detracts from the real question: what should we prescribe for our health in any case? Weight loss or management is constantly recommended—disregarding the fact that weight is not a behavior, and as such it is not ours to “control.” Weight results from a multitude of factors, some of which are in our power to chose—how we eat, how active or sedentary we are—but many of which are internally regulated, and thus are not. A host of studies have now eliminated the age old mystery about why some sedentary folks can eat like horses and remain lean while their neighbors consume moderately, train for triathlons, and stay fat. If we limit ourselves to healthy means, the best anyone can hope for is to influence weight, not control it. Genetic predisposition aside, it turns out that the most common advice for reducing fatness has made things worse. Research published over fifty years ago demonstrated how and why even a moderately restrictive diet is counterproductive for long term weight loss. New studies bear this out: weight can be lost on virtually any contrived plan to restrict calories or food groups, but between 85% and 95% of this weight is predictably regained, with over half of all dieters gaining more weight than they lost. If you doubt this, check the National Institute of Health for the data, then check your own observations to consider how many people you know who have gone on a diet once. If dieting was effective why would it be a perennial activity, and why would most dieters be fatter today than before their first diet? Aside from weight loss, what other unpleasant recommendation with a 90% failure rate would still be prescribed? Even so too many health authorities persist in the belief that if we can make people feel bad or afraid enough about their weight they will “do something” about it. This flies in the face of new studies that document what many of us working in the trenches to reverse disordered eating have known for years: body dissatisfaction does not serve as a motivator for healthy behaviors. To the contrary, unhappiness about weight is a catalyst for disordered eating, weight gain, and poorer overall health. Worry about weight is a self-fulfilling prophesy. In light of this, how can we persevere like Sisyphus in unrelenting talk about the risks of fatness and the need for weight loss as if this will make people repent? In four decades the thinner we have tried to be the fatter we have become. But if fat phobia and efforts to lose weight contribute to the problem, what is the solution? The way out of this spiraling and dangerous problem requires the courage to ask the right question: fat or thin, what should we be doing for our health in any case? Few will dispute the evidence showing that fatter people who are well fed and fit are at lower risk for health problems than thin people who eat poorly and are sedentary. In light of this, what if instead of fear and loathing of fatness, health initiatives pushed the value, ways and means for wholesome eating and fitness for everyone—irrelevant of size? If instead of size or a BMI a sustainable, healthy lifestyle were the goal, then some people would remain fat, some would be thin, but virtually everyone would be healthier. Isn’t this the point? It is troubling that so few leaders in health care cannot see the forest for the trees: that shifting the focus to how we live rather than what we weigh is an effective solution that empowers all people of every size and shape to be the best they can be. Who could argue that a fit and well-fed populous of diverse sized people would not be preferable to the status quo. Campaigns to support the development of healthy, realistic body images, wholesome, stable eating, and lifetime fitness habits regardless of shape, size, or weight could eliminate much of our population’s “weight problem.”

Earlier this week, CitizenSugar posted an article entitled "Fatism is the new racism? Do we need need a law against it?" Several people responded from both sides of the issue, and there was some really good discussion taking place. One thing that I, being a fat person, appreciated is that while there was some of the usual "Fatties would be just fine if they'd stop stuffing their faces and get their fat asses off the couch" comments, they were balanced out by posters who either understood that the situation isn't anywhere near that simple or found themselves feeling more compassionate about the situation after reading the stories about what some of us who are fat have gone through. I've mentioned this statistic a few times already, but it tends to bear repeating - and in this case, its important to understand because it has a great deal of relevance to the comments below. There have been a great number of studies done on the viability of intentional attempts at losing weight. They "intentional" is included to differentiate people who are wanting to lose weight from those who lose weight from sickness or other such factors. These studies have consistently shows than 95% to 98% of the time, when someone attempts to lose weight intentionally, they will fail to lose as much weight as they intended and/or even if they *are* successful in reaching their goal, they will regain all of the lost weight - generally with more added - within 5 years. This takes into account all types of diets, diets-and-exercise programs, weight loss surgery, weight-loss maintenance programs for people who have met their goal, and any other methods people use to try and lose weight intentionally. Only 2% to 5% of the people who try to intentionally lose weight will reach their goal and keep it off for 5 years or more. Statistics also show that people who repeatedly diet and regain the weight they lose or end up even heavier than they were when they started, are much more likely to suffer a shorter life-span than people who are fat but do not repeatedly dieting. The "yo-yo" dieting syndrome is harder on the body than just being fat is. Think about that for a moment. Imagine that you had an illness, and the doctor came in and told you that they only had one treatment option, but that it's only effective 5% of the time, and each time the treatment fails, there's a very strong chance it will make your illness worse not to mention that using the treatment repeatedly, hoping that *this* time it'll work, increases the chance that you'll have a shorter lifespan. Just how eager would YOU be to try and treatment time after time? And how would you feel if people kept trying to push you into using the treatment, or started discriminating against you because you've decided you're better off dealing with the illness itself than the risks of the treatment? That's the situation that we face. A blog I frequent is Junkfood Science, run by Sandy Szwarc, RN, BSN, CCP. Her blog focuses on research and studies done about obesity, examines the way some studies can be distorted or "spun" when they're made public, researches who financed studies and what - if any - financial interest they might have in the outcome, and trends that can result from a misunderstanding of what some studies actually show. Prior to starting her own blog, she frequently posted at TCS Daily, which has a biography page about her, her background in both health and food, along with a list of publications she has written for. Her current blog is rated as the top health blog at Wikio, and she notes that her blog adheres to the Medblogger Code of Ethics. I'm telling you all this, because I want you to know that this is not some fly-by-night flake with a personal hang up or a wild conspiracy-theorists or anything else like that. Szwarc is a long time health and food professional, with a solid reputation. It's this last aspect that she recently posted about in an article called House to House searches -- for twinkies and guns?. She begins by commenting on recent efforts in Boston and Washington DC to enact programs where the cops can go from door-to-door and search peoples' homes for guns as part of a "Safe Homes" program. The officers would not need warrants for these searches (though they may need to get the homeowner to sign an "informed consent" statement) and homeowners found to have illegal guns would be given amnesty from illegal-weapons charges. If the guns are tested and found to be tied to a crime, however, they homeowner could be investiged and charged with that (if appropriate) and it's unclear what happens if they find evidence of other crimes while doing the search. Sandy then poses the question of what other kinds of things might authority figures be sent door-to-door to look for - and notes that it's not all that far-fetched to think that they might come and want to look at your pantry, since that's already happening in the US. Below is the portion of her post related to that issue - any emphasis is mine:

A knock on our door

What other reasons might public officials use to convince people to allow them to search their homes and private lives, and believe that such intrusions are for their own benefit? Might we get a knock at our doors asking to go through our pantries and refrigerators to make sure we’re eating the prescribed “healthy” diet; to assess our weights, exercise and smoking habits; and to monitor our compliance with health prescriptions and report us if we’re not being good? Incredibly, it is not a far-fetched idea that agencies might want to make such door-to-door searches in the name of public health — because they already have! As part of the plans of Health Secretary Patricia Hewitt, “unfit and overweight Britons will get doorstep visits from NHS staff to track those at risk of future illness.” As the Observer reported, “staff could ask people in certain streets about their lifestyle — and invite those at risk for a health 'MoT' with their GP, after which they could sign agreements to lose weight or stop smoking...” Sec. Hewitt said the government had to start going to people and not wait for them to go to the doctor. She said those with “genetic inheritance” need especially intense interventions to “ditch bad habits.” “At least two primary care trusts were already getting staff to knock on doors in streets they had identified as high risk for disease, often in low-income areas,” she said... The approach will be highly controversial, prompting charges of snooping on people's private lives and interfering in their freedom, the Observer reported. Comparable programs have been suggested or already instituted here in the United States. Proposals were made by the California Department of Health for door-to-door searches of young Latina and African American women in low-income neighborhoods to assess their health risk behaviors, purportedly to tackle HIV and STDs. A program funded by the National Cancer Institute, targeted 350,000 families of preschoolers in St. Louis, Missouri, who received a knock on the door asking them about their eating habits, going through their pantries and reviewing their grocery shopping lists. It was part of a “High 5 Low-Fat” program to address childhood obesity by telling parents how to feed their children “healthy” by cutting fat, getting fruits and vegetables, and reducing “bad dietary choices.” A similar anti-obesity initiative was introduced last summer by Dr. Mehmet Oz, author of the You on a diet diet book and an Oprah regular. Funded by $250,000 from the New York City Council, the program he founded is called HealthCorps. Modeled after the Peace Corps, it pays college graduates to go around the city and council kids on diet and exercise. Another initiative to fight obesity proposed by economists at Brookings Institution, called for establishing a “Retired Healthcare Professionals Corps.” Retired physicians and nurses would be mobilized into “cadres of community healthcare workers” to go door to door and to give residents information about common diseases and “monitor compliance with prescribed regimens, and communicate with healthcare providers about the needs and circumstances of neighborhood residents.” Citing Robert Wood Johnson Foundation extensively: “My idea is to mobilize retired physicians and healthcare workers to serve their country by joining in a crusade to combat childhood obesity, especially in those communities and among the children where the problem is most acute.” The authors said it was necessary to make “lifestyle medicine” a credentialed clinical specialty and part of basic medical training because of the “serious health threats confronting our nation” and that these Corps were necessary because primary doctors didn’t have time to do “the extensive counseling on nutrition, exercise, and lifestyle changes that is required to treat obesity.” They also noted that genomics will soon bring the ability to identify those at risk for chronic diseases and in need of intervention.

While the articles from which the examples were drawn talk about the programs being voluntary, there's still something unsettling about the prospect of someone coming to your door and saying they want to poke around in my kitchen and review my grocery lists to make sure I'm eating right (or that the children in the home are being fed properly.) We've already seen situations where parents have had - or were threatened with having - their children removed from their homes because they children were obese. Who's to say that these people coming into homes to check your pantry won't decide to call your local CPS if they think your kid is too fat? In the article about the Brooking's Institute suggestion of using retired doctors to help monitor patient compliance, it also notes the following:

Finally, the federal government as well as insurers and employers are beginning to flex their muscle by prodding Medicaid patients and employees to take better care of their health. For example, the State of West Virginia plans to reward responsible patients with significant extra benefits and punish those who do not join weight loss programs where indicated. Medicaid recipients who sign and abide by the agreement with the state would be eligible to receive enhanced benefits, including mental health counseling, long-term diabetes management and cardiac rehab, prescription drugs, and home health visits as needed, as well as antismoking and anti-obesity classes. Those who do not sign up will get the federally required basic services, but they would be limited to four prescriptions a month and be denied other enhanced benefits.

So, the lucky 5% who are actually able to lose the weight they want and keep it off for 5 years or more get better care, and to hell with the other 95%! What I find ironic, though, is that if losing weight is supposed to cure or control diabetes, improve your heart health and maybe even reduce your depression, that why would you need the mental house counseling, long-term diabetes management and cardiac rehab? Should those pretty much fix themselves? And if losing weight increases your mobility, what do you need home health care visits? And on the flip side, given the intertwining of obesity and depression, denying someone mental health care because they can't lose weight seems counterproductive, as does denying them long-term diabetes management and cardiac rehab. If the recalcitrant fatties who can't lose weight don't do the state of West Virginia the favour of dropping dead, thus no longer needing *any* health care, won't denying them these services - in addition to limiting their access to medications just end up making them sicker - and thus even more expensive down the line? Someday - and it'd be nice if it were sooner rather than later - society is going to need to truly comprehend that diets, diets-and-exercise, weight-loss surgery and other intentional weight loss methods simply do not work for the vast majority of people who are overweight or obese and that continually losing and regaining weight is much harder on the body than not losing weight at all. Once that happens, maybe - just maybe - people will stop trying to punish fat people for being fat. I doubt it'll happen in my lifetime (especially since it's supposedly going to be so much shorter,) but one can always dream...