PSA

Hey, you all should check out the interview with the awesome Health at Every Size advocate Linda Bacon over at Med Journal Watch. (And let’s all take a moment to appreciate the blog’s author, Christian Bachmann, for being willing to examine his own biases and change his mind about obesity.)

I particularly liked this bit of the interview:

CB: If people are fat and sick and if they lose weight and get cured, this could be a proof that fatness causes disease. Has there been any such outcome in a study?

LB: That seems like an impossible study to conduct. You would have to control to make sure that nothing changed other than their weight. They would have to be doing something differently to lose weight. For example, suppose they exercised more – you couldn’t attribute the health improvement to the weight loss as it might have come from the activity changes.

Bacon goes on to say that although gastric by-pass surgery has been shown to cause an immediate reversal of diabetes, the fact that it’s immediate suggests weight loss is not the cause of that reversal; furthermore, a study that examined the effects of liposuction on diabetic women showed that, shockingly enough, sucking out the fat did not improve their metabolic profiles.

I think these are such important points, and I need to remember to make them more often. I actually wasn’t aware that there was a liposuction study, but I know I’ve wondered many times why doctors don’t advocate liposuction for health reasons — it’s a hell of a lot less invasive than gastric by-pass surgery — if they really believe fat is the problem. If being “overweight” is the big health risk, and liposuction is a reasonably efficient way of removing fat, why isn’t it being touted as a cure-all? Why don’t insurance companies cover it for anyone with a BMI over 25? Wouldn’t it save money in the long run, by removing the scourge of fat, which we all know is going to leave our health care system in tatters? (Insert big huge eyeroll.) Wouldn’t it be cost-effective, according to the Fat Is the Enemy belief system, even if it had to be repeated frequently — since regain is a problem with lipo, just like with dieting and bariatric surgery? How come I’ve had doctors hand me Weight Watchers pamphlets, but they’ve never once recommended liposuction?

Well, there are two reasons I can think of off the top of my head. One is that, as that study showed and anyone who’s read a bit about Health at Every Size could easily guess, lipo won’t cure jack. Because most of the health problems traditionally associated with fat can be prevented and/or improved by increasing exercise and getting more fruits and veggies and fiber and whatnot, regardless of whether weight loss occurs. It ain’t the fat causing the health problems, it’s the sedentary lifestyle and lousy diet that sometimes but not always go hand in hand with fat.

The other reason, of course, is that if you believe fat is a moral issue, then liposuction seems like a cop-out. Where’s the punishment? Where’s the atonement? Where’s the humiliation?

Sadly, I’m not at all sure that the first reason is the primary influence on doctors’ deciding not to recommend lipo to their fat patients.

Now read that first line of Bacon’s again. That seems like an impossible study to conduct. Ding ding ding! Weight loss is sometimes a side effect of other intervening factors — diet changes, exercise changes, surgery, illness, going on or off a particular medication — but it is not an intervention in itself. You can’t just decide to lose weight and magically do it, without making some other specific changes in your lifestyle.

Which means there is no real way to measure whether weight loss itself has health benefits. You can prove that eating a balanced diet and exercising have health benefits, or even that bariatric surgery does (though I don’t believe for a second those benefits come close to outweighing the risks), but any weight loss in those cases might very well be incidental — and the one thing we do know is that, even with the surgery, any weight loss is likely to be temporary. The fat will probably come back, but must the health risks?

No, not necessarily. As I’ve said a kabillion times, the Health at Every Size approach has shown terrific results in terms of improving health, but not in terms of keeping weight off of people who are predisposed to be fat. In light of that, and the fact that liposuction doesnt improve health, WHY THE FUCK ARE WE STILL BLAMING THE FAT?

17 thoughts on “PSA

  1. Fat is still being blamed because it’s somethng visible. Rather than keep looking for what is not easily visible, lead with what you’ve got.

    Kind of pathetic, really.

    I was watching a show about 700 lb. people the other night and it showed that the fat isn’t just stored in easily accessible outer areas below the skin, but within muscle and all around organs. Some of them have so much pressing on their heart and lungs that they can’t breathe and need assistance. So, liposuction isn’t going to address any of those medical concerns. Also, insurance doesn’t cover liposuction, so I can’t see doctors recommending it when they know that most people can’t afford the whole hospital bill for it. Sometimes I think about the doctors who go into the specialities that insurance won’t cover (most plastic surgery, fertility, and others I can’t think of right now) knowing full well that they will only be “helping” a select portion of the population. It really gets away from the notion of becoming a doctor in order to serve humanity.

  2. I was lectured by someone recently; a mutual friend of ours had found some ways to improve her chronic health problems, and had lost some weight. The person lecturing was trying to say that the weight loss was responsible for the health improvements, when in fact, it was her health improvements that caused her to lose weight.

    When I pointed out that her feeling better was due to acknowledging and treating her celiac disease and hypothyroidism, I didn’t get any response. I guess it’s hard to swallow when someone challenges long-held beliefs like that.

  3. Iirc from The Beauty Myth, nine French women died during lipo surgery trials. The risks are huge and not talked about. If I have time to dig out my copy, I’ll post the details. Of course, the book is old now. So maybe the situation has improved.

  4. Lucy, to clarify, I am not remotely in favor of liposuction, or any unnecessary surgery. I was just trying to point out that if it were really about fat, lipo would be an obvious solution — so the fact that it’s not recommended suggests this is not really about fat.

  5. The lipo surgery thing is my new favorite study. If there were some health benefits directly due to losing fat, liposuction would be where these results are found, right? Because that’s where you can kind of isolate other factors (though of course there are factors like the risks of the surgery itself to take into account). But is it a coincidence that I’ve never heard of this study before? I think not.

  6. In a way, that study has been done. It just got interpreted as diet justification. There have been studies on the benefits of adopting a healthy lifestyle change and the health improvements are considerable while the weight change was nominal. Still, it gets reported for the weight change and the media showcases the extreme minority who lost a lot of weight. Paul Campos discusses this in Obesity Myth but my copy is still packed away somewhere so I can’t say exactly where. It shows that when a study really does try to look at health irrespective of weight, it will still get spun differently but the authors and especially the media. That weight loss was shown to be incidental and inconsistant gets completely disregarded. I very slight average reduction carries the day.

  7. I guess one reason lipo isn’t touted to be a cure-all (as WLS is) because there is such high rate of regain. I think doctors and the media are convinced that WLS is more effective because it’s “treating” the “problem” from the inside out, and not just cosmetically addressing the “issue” (as lipo would do).
    I’m no doctor, so i cannot rightly say, it’s just my two cents.
    I also think it has to do with insurance and of course the benefits that Big Pharma reaps. Lipo is still categorized as cosmetic surgery, paid out of pocket by the patient. WLS is being covered increasingly more so by insurance companies, IMO, in collusion with companies like J&J who have a vested financial interest in the lap band etc. Additionally, gasstric bypass post ops have lifelong reliance on medication, correct? At least on b-12, no? Certainly some drug company is standing at the end of that line, ready to take the money every month for that ‘scrip. As always, follow the money.

  8. As far as I know, (not that I’ve delved very deeply being violently opposed to such measures), lipo can only be carried out on relatively small deposits of fat, (i.e. you can use it to syphon off a little cellulite on an otherwise average-sized arse but you couldn’t transform an arse of epic proportions into Kate Moss’s using lipo), which is why it’s regarded as a cosmetic procedure compared to full-on bariatric surgery.

  9. I think doctors and the media are convinced that WLS is more effective because it’s “treating” the “problem” from the inside out, and not just cosmetically addressing the “issue”

    Haha, right… the underlying problem is that sometimes you eat food! We can fix that for you!

    But people do claim that FAT is the problem — not habits, just FATNESS — and so lipo would be addressing the issue. The fact that they do “weight loss” studies on enforced anorexia through gastric bypass shows that they don’t really think adipose tissue is the problem, and all the “fat causes this” and “fat increases your risk for that” talk is just disingenuous. (Madge’s theory, that WLS sells pills, is a perfectly reasonable one; I’d add to that that it’s easier to market a procedure or a pill than it is to market HAES.)

    I was frustrated with the interview because I felt like Bacon wasn’t really answering the questions, but at least her talking points should make people think.

  10. When I was younger, I watched a video that said for every pound of fat you gain, you have to grow X amount of new blood vessels through that pound of fat. When you are fat your heart has to work harder, and thats bad. Makes it weak.

    So, to counteract this, you need to exercise. Exercise makes your heart work harder. Makes it strong!

    Now, I’m sure there are many medical reasons why this seeming contradiction is so, and why an enlarged heart in Lance Armstrong is amazing and good and an enlarged heart in an obese person is going to make them keel over and die, but thats not my point.

    Fat cells are part of our bodies, and they must be oxygenated and nutritionated (yes, those are scientifical terms :). You can’t suck it out all at once because you’d be damaging those blood vessels, probably causing some one to bleed to death. I can’t imagine how they do it at all, since from operations I’ve seen they don’t really look like they’re watching what they are doing, so to speak.

    I wonder if 100 years from now, rubenesque women will be the fashion again and people will say, oh those 21st century losers were so stupid!

  11. I should jump in here to say that Fillyjonk read me right; I’m not suggesting it’s possible to lipo your way from fat to thin. I’m saying if, as so many claim, even a modest reduction in weight has tremendous health benefits, why not recommend a modest reduction in weight via lipo?

    It’s a rhetorical question, basically. As I said above, I don’t WANT anyone recommending more lipo. The real question I’m getting at is: is fat the problem or isn’t it? Is a 10% reduction in weight a major health boon or isn’t it? I have a BMI over 30, and I could definitely have 10 percent of my weight liposucted away. Would that make me healthier?

    No, of course not. But if I lost 10 percent of my weight by exercising more and suddenly had a better health profile, there are many who would claim I was healthier because of the weight loss, not because of the exercise. There are also those who would claim I was automatically healthier for being 10% thinner regardless of whether there was any measurable change in my health.

    There’s a big disconnect there.

  12. Exactly, Fillyjonk! Treat the problem by limiting the patient’s ability to eat food. All of the other psychological and physiological factors involving a person’s weight are completely irrelevant and ignored.
    It’s like we’re in the middle ages all over again, except we’ve gotten rid of that big wheel and the rack.

  13. On the other hand, Madge, they are bringin’ back leeches! Yep what goes around comes around alright. Me, I’m just sitting tight waiting for Yellowhammer’s “what the hell were we even thinking?!” scenario to come to pass.

  14. Christian just sent me a heads up that the interview he did with me attracted a lot of attention – hits that were directed from the New York Times topped the list, and this site came in second. Congrats for building such a large community. I’m glad to have been introduced to the site and have enjoyed wandering around. As painful as it can be living in an obesity war zone, its also heartening to see oases of safety like you have here.

    Someone had commented that I didn’t appear to answer the questions. Yes, Christian composed this posting from a much longer interview, so my responses didn’t always appear to flow from the questions. Nonetheless, he did an excellent job of maintaining the integrity of the overall message I was trying to deliver (which I find rare in reporting) and I’m sure it was much more accessible in this more concise format.

    Anyway, the main reason for my posting is to congratulate Kate and others for this community you’ve created. This is a large aspect of how change occurs: people speaking their truths and spreading the word.

    I’m slowly building resources to educate people on HAES and size acceptance. If supportive material is helpful for you, please check out my website (www.lindabacon.org) – in particular you’ll find a (free) educational download there called the HAES Manifesto, which lists some scientific resources that support HAES and size acceptance. I’ve also written a book for laypeople on this topic, but it will be a long time before it makes it to bookstores.

    Anyway, keep up the good stuff here. All my best,
    Linda Bacon

  15. Sorry not to include in earlier posting, but Kate, you were interested in the lipo study I referred to. Here’s an excerpt from a work in progress of mine about surgery, weight loss, and diabetes, along with the citation in case you want to do further follow up:

    On a short-term basis, weight loss is very effective at improving control of blood glucose. However, it is difficult to determine whether this means that it is improving the diabetes – even skipping one meal will lower blood glucose, but this doesn’t mean that the diabetes is being cured. A 1995 review of all of the controlled weight loss studies for type 2 diabetics showed that the initial improvements were followed by a deterioration back to starting values 6 to 18 months after treatment, even when the weight loss was maintained1.
    Surgical studies allow us to see the effects of weight loss without changing other factors, like eating or activity habits. Gastric bypass surgery appears to reverse diabetes within days, before significant weight is lost, suggesting that it is not the weight loss that brings about the improvement, but probably some other factor (such as a change in the release of gut hormones).
    Liposuction studies provide further support that it is not the weight itself that is problematic. For example, in one study researchers examined obese women (half of whom were diabetic) before and 10-12 weeks after an average of about 20 pounds of body fat was removed2. Despite the weight loss, their metabolic profile did not improve, including their fasting glucose and insulin levels or their insulin sensitivity.

    1. Ciliska, D., et al., A review of weight loss interventions for obese people with non-insulin dependent diabetes mellitus. Canadian Journal of Diabetes Care, 1995. 19: p. 10-15.
    2. Klein, S., et al., Absence of an effect of liposuction on insulin action and risk factors for coronary heart disease. N Engl J Med, 2004. 350(25): p. 2549-57.

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