Disease

[liv]

So apparently the American Medical Association decided to classify obesity as a disease.

The fatosphere has lots of opinions about this, as you'd expect. Michelle, the Fat Nutritionist, is not impressed. Living ~400lbs has a comprehensive link roundup of evidence against trying to cure obesity through diet, exercise and surgery.

I also enjoyed this piece by David Berreby at Aeon who takes a balanced yet skeptical view. He takes as read that obesity is a medical problem (so he wouldn't be popular with committed fat activists like those in the first couple of links) but he challenges the discourse of obesity being caused by bad lifestyle choices, viz eating too much and moving too little. Really thought-provoking.

On the other side, pw201 linked to a piece by Karen Hitchcock, an Australian obesity doctor who absolutely does believe, based on her medical training and experience, that being fat is caused by eating too much. The thing that's interesting about this piece is that, unlike a lot of the stuff that uncritically repeats the dogma of overeating-makes-you-fat and fatness-makes-you-die, Hitchcock displays empathy rather than disgust for her fat patients.

Comments

[jack]

I'm forcibly reminded of http://lesswrong.com/lw/2as/diseased_thinking_dissolving_questions_about/, not so much for what it says about weight, but for the concept of "what counts as a disease" in general being a question that sounds factual, but carries a heavy implication that it is, or isn't, your fault.

[liv]

Very useful post, yes. If I had lots of time I might have expanded this post into a discussion about what exactly it means philosophically to decide that obesity is a disease, but I wanted to just dump some relevant links and see what people come up with in response. It is absolutely an inextricable combination of moral and scientific questions, and that's important in how we discuss the issue.

[ptc24]

On the subject of disease categories:

From one of the links there's this paper, which I'm in two minds about. It's a social constructionist paper, and I find the way social constructionists use language to be rant-inducing, particularly the way they equivocate between things and ideas of things. With that particular paper, if they did a search-and-replace, to turn every occurrence of "illness" into "illness-concept" or "illness-label", then IMO it would be vastly improved. ETA, oops, no, you can't do a search-and-replace job like that. "Stigmatized illness can make an illness much more
difficult to treat and manage." - I'm pretty sure the second "illness" isn't being used to refer to an illness-concept.

[liv]

Thank you, that's a pretty nice introduction to the orthodoxy of medical sociology. I'm slowly getting used to constructionist jargon but it still kind of grates on me too.

[ptc24]

You know, up until now I had never thought of armour-plating my PhD thesis to improve its effectiveness and chances of survivability when hitting people over the head with it, but Geoffrey Miller (see the balanced yet skeptical piece) has changed all that.

I'm mildly surprised the article didn't mention tributyltin chloride; that's the first compound I'd heard of as a suspected obesogen - in Linda Bacon's book Health At Every Size, which I must finish reading some time.

A hypothetical I've pondered: Supposing the obesogen hypothesis turned out to be true, and that stricter emissions controls on those substances, at a low but non-negligible economic cost (maybe a few people would have to be laid off), would substantially decrease the incidence of obesity, could implementing those controls be the right thing to do? I tend to think "yes", and I tend to think this makes my views incompatible with some of the more radical fat acceptance activists.

I did like the Living ~400lbs link. "Weight cycling industry" is such a good term, I'll have to remember it. The Fat Nutritionist link... jars with me, but I'm sure everyone's fed up with me complaining about that sort of stuff.

[liv]

Geoffrey Miller is a complete waste of space, and really the sort of person who gives evo-psych an atrociously bad name! It's not quite as satisfying as an armour-plated thesis, but Tumblr has him about covered.

I am a fan of Bacon, but I am worried by how much the whole fat activism world relies on her (along with Paul Campos). I respect the pioneering work they've done, but intellectually... I think they're like a lot of people who make major breakthroughs challenging the accepted views in their field, and then fall a bit too much in love with their alternative theory and see everything in the world ever in the light of that.

I am not surprised you find Living ~400lbs congenial. I like her style a lot, she's very much the sort of person who will bombard you with evidence to try to convince you to her point of view. So she always comes across as caring about the truth more than identity politics, somehow. The Fat Nutritionist is in some ways the exact counterpart of Dr Hitchcock: she is very much pragmatic. FN sees many people who have been psychologically harmed by anti-fat prejudice and pressure to follow ineffective diets, and she wants to make life better for those people, just as Hitchcock sees many people who have been medically harmed by carrying too much excess fat, and she wants to make life better for them. In some ways neither of them really cares what the underlying causes are for obesity (in individuals or in the population), they are not very willing to adapt their beliefs to new evidence because they just want to get out there and fix people. I think this makes it less likely that they will make arguments that will look convincing to anyone who isn't already on side.

Interesting hypothetical, too. I think you're right that some fat activists would be against this intervention because they think there's nothing wrong with being fat, so why try to fix it? But others I think would support emissions controls because they believe obesity is primarily environmental anyway, and are much more comfortable with trying to fix society than trying to fix individuals.

[rmc28]

Ironically your post on my reading page is just below one from a friend celebrating substantial weight loss.

*sigh*

[liv]

There's pretty much always someone celebrating substantial weight loss, because weight cycling is socially valued. Have you seen catvalente's posts? In some ways you maybe don't want to, because they're all about how great it is that she lost lots of weight. But also she's a really good writer, and she really has some hard-hitting things to say about how fraught the whole issue is and how much misery is caused by trying to make everybody go on reducing diets.

Re: *sigh*

[jae]

Even if you don't want to celebrate your weight loss, there's no shortage of people stepping up to do it for you. I'm not naturally a very big person, so on me "substantial" was much less than it tends to be for someone else, but it was enough that people I barely knew kept coming up to me and trying to get me to talk about it by complimenting me, asking for my "secret" and policing what I ate to see if it was something they could duplicate (!). I could only react to their questions and comments by saying "yes, I weigh less than I did the last time you saw me" with a neutral look and then changing the subject. (And then of course they all thought I was the weird one.)

-J

Re: *sigh*

[hunningham]

Yes, my partner lost some weight a couple of years back and I don't think there's anything else he could have done with his life (Queen's silk, Nobel peace prize, whatever) which would have gotten him so much praise and positive comment.

[liv]

There's a depressing thought. How about praising people for their achievements rather than their body shape!

[liv]

Good on you for responding neutrally, but it sounds like a whole annoying situation. I've been getting compliments on my supposed weight loss recently, to the point that I went and weighed myself (which I never do) and discovered that I've lost a single digit number of kilos in the past year (and I'm still in the obese category for BMI). I've got a lot fitter in that period though, so I think what people are actually seeing is that I'm more muscular. Weight has nothing to do with it, and anyway, I'm not working on fitness in order to change my appearance in the first place.

[jae]

Yeah, that's it, really. I mean, I did lose weight when I got fitter, but it wasn't weight loss I was going for--it was an incidental. I'm okay with it (size acceptance to me means accepting your body at whatever size), but it's certainly nothing to compliment me on. If near-strangers have to compliment me on something personal (a dubious practice at the best of times), I wish it could be, like, my increased walking endurance, which I actually I am very pleased about and proud of.

People are so screwed up about this, it's so exhausting.

-J

[liv]

*solidarity* I am really proud of getting fitter, but the only way I get direct compliments on it is by banging on about my fitness regime which seems kind of intrusive and self-centred. In some ways I'm kind of lucky that my weight isn't very responsive to lifestyle changes. I mean, it's unfortunate in that doctors tell me to improve my habits, and I do, and I'm still fat, so not deserving of esteem. But it's positive in that I don't have this visible marker on my body of how healthily I'm living for annoying people to misinterpret. I'm absolutely with you on accepting bodies at whatever size, including if they change.

[redbird]

Several years ago, I completely threw people's scripts because they would say, in a cheerful/complimenting way, "You've lost weight." I would tell them that no, I hadn't (because I got curious enough to check, using the scales at the gym). That's really not in the set of accepted answers. There were times when it was because I had built muscle by exercise (and was in some literal sense of the word thinner, but not lighter) and times when it seemed to mean "Hi, you are a woman who looks good and/or is moving comfortably."

I don't recall whether you were part of the discussion in which I concluded that it would be appropriate to answer what they seemed to actually mean with "thanks, you're looking good too."

[liv]

I think thanks, you're looking good too is a really brilliant idea, and thank you for coming up with that. I sometimes get "wow, you've lost weight" when I'm wearing something that particularly suits me, not in the sense of making me look thinner, not that I can perceive, but that fits my body well and lets me feel comfortable, and I'd almost rather get a direct compliment on my clothing choice, but responding to what people actually mean rather than their literal words is, well, a useful social skill sometimes.

Some of the time I actively want to challenge the weight = health = virtue thing, but sometimes I do want to just smooth social interactions and this is a good technique, without requiring me to put myself in an uncomfortable position.

Re: *sigh*

[wildeabandon]

I actually find it quite upsetting if someone appears to be celebrating my apparent weight loss*, so I have no qualms about responding to such praise with "Really? Oh dear. I hope I'm not getting ill."

*I was ED in my teens/early 20s. I'm mostly comfortably fat now, but the headweasels never completely go away.

Re: *sigh*

[liv]

Ugh, that one's really hard. I try never to assume that the people I'm talking to are all safe from ED history and potential triggers, but I'm sure I slip up sometimes. It must be tough to navigate the world bearing those particular headweasels.

[redbird]

On a separate note, it's worth remembering that the American Medical Association is not governmental, nor focused on any specific disease or set of symptoms or patients: it's a lobbying group, and does not represent all or even almost all practicing doctors in the United States. That fact is likely relevant to questions of motivation: the AMA seems to have shifted from defending the independent/small medical practitioner from the perceived dangers of socialized medicine, to trying to defend/support physicians in their conflicts with insurance companies' attempts to tell them what tests, procedures, etc. they may or must do, while demanding ever-more paperwork.

I am much more sympathetic with the latter goal. I don't want to be buried in paperwork any more than my doctor does, and time a doctor is filling out forms is time when she is neither seeing patients nor keeping up with medical advances. Doctors should be able to take time to talk to patients about their health; but it still seems relevant that one possible outcome of this proclamation is that doctors will now be able to bill not just for weight-loss surgery or desired nutritional counseling, but for time spent lecturing a patient about weight loss when s/he has come in for an unrelated reason.

[liv]

That's actually particularly helpful, because I didn't know that about the AMA; all the articles I've read on the issue assume the reader knows what sort of institution it is. A medical lobbying group that represents some medical practitioners, good to know.

And yes, there are so many ramifications to this in a system of private health insurance. (There would be ramifications if the NHS made a similar decision, of course, just different ones.) I'm surprised that doctors don't already bill their patients for weight loss lectures, but it would definitely be undesirable if that got worse.

[damerell]

I feel a strong need, reading some of those links, to get a Goldacre "I think you'll find it's a little more complicated than that" t-shirt.

[liv]

Yeah, it's always more complicated than that. I particularly liked Berreby's piece because he seems to do quite well at acknowledging complexity rather than seeking a soundbite answer. But this stuff is seriously complicated, for sure.

[jack]

Ironically, my major objection to those T-Shirts is that they're too simplistic :)

[ironed_orchid]

I felt that Hitchcock may have displayed empathy, but disgust was there too. Right from the beginning with the descriptions of the fat American family and their greasy pizzas. Also the bit where she associates being fat with being unwashed and poorly dressed, as if fat people who don't fit into her stereotype are special unicorns.

[liv]

You may be right. I probably have too low expectations of reading articles by medical people talking about fat people, sad to say, that Hitchcock's piece seemed relatively good. I could definitely find flaws in it; when she claims that she's never seen a patient who put on weight because of a hormonal problem, that's patently bullshit. I know people who have experienced sudden, extreme weight gain due to hormonal issues, and I don't work in an obesity clinic! And in the end her empathy is a lot like pity, really, she feels sad that these people have such terrible lives that they eat too much and become hugely fat. I don't know if I would want to be treated by Dr Hitchcock or not; it's not like she has loads of competition from doctors with good attitudes.