A Slim Chance?

They are as sick that surfeit with too much as they are that starve with nothing

Although the word ‘obesity’ was not used until the beginning of the 17th century, the suspicion that there was something distinctly unhealthy about it has been with us for millenia –certainly long before Shakespeare’s The Merchant of Venice was written. There was a time, of course, when food was scarce and so its acquisition and display was considered a sign of wealth and power. Only the more extreme examples of over indulgence seemed to stand out as unhealthy and undesireable. But it’s true that our standard of acceptance has varied over the centuries; our idea of what is normal is very much influenced by what we see around us (as I have commented in a previous essay: https://musingsonwomenshealth.wordpress.com/2015/04/02/nudging-childhood-obesity/)

There seems little question as to the adverse health problems associated with obesity, but I suppose the most worrisome aspect of its increasing prevalence is what is to be done about it. There have been those who have felt that to condemn it is to discriminate unfairly –unjustly attributing fault (and guilt) where there should be none. The International Size Acceptance Association (ISAA) for example was founded in the USA in 1997 to promote acceptance of excessive weight and end weight-based prejudice. But, by and large, there has been a general realization that unless something is done about it, the burden of obesity will result in a parallel but undue burden not only on health itself but also the facilities necessary to deal with its consequences.

So the challenge is staying abreast of the problem: treating it, or better yet, preventing it. There was an interesting article in a July 2015 BBC report about some of the problems with our approaches to the issue so far: http://www.bbc.com/news/health-33551498 Using UK data, ‘The research tracked the weight of 278,982 men and women between 2004 and 2014 using electronic health records.’ And the findings from this huge data base were disappointing: ‘For obese people (with a Body Mass Index of 30 or more), the annual probability of slimming down was one in 210 for men and one in 124 for women.

This increased to one in 1,290 for men and one in 677 for women with morbid obesity (BMI 40 to 45)’. In other words, ‘Current strategies that focus on cutting calories and boosting physical activity aren’t working for most patients to achieve weight loss and maintain that.’ http://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2015.302773

There are, of course, other strategies –bariatric surgery probably the most successful of these. This is an approach that attempts either to restrict the amount of food that can access an adequate amount of bowel to be processed, or conversely to restrict the amount of processing (absorption of nutrients): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3470459/

Quite apart from the fact that it is a surgical –ie invasive- approach, and requires both facilities and trained surgeons to perform, is expensive, and would not be scalable to the requirements of a large and increasingly needful population, it is not without problems. Depending on the study, there are complications in as many as 17% of cases, and even a need for re-operation in 7-10%. New data will emerge as methodologies improve, no doubt, but even if complications dropped to zero –an almost naïve fantasy- it would still not serve the needs of the vast majority of obese people.

No, it seems to me that the only viable option is that of primary prevention –establishing a culture of healthy eating, and an expectation of a more healthy weight spectrum. But even to say that, courts another naivete, namely that wishing it were so –knowing that it makes sense- is a view held by everyone. Were it not for the stigma of weight, how many would realize there was even a need for change? And is the stigma itself more of an impediment than an incentive to weight reduction? I found another study, this one with more of an emphasis on social justice than answers: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009.159491 And as the authors suggest in their abstract –again in the American Journal of Public Health: ‘On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity. Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.’

So, clearly the solutions must come from within –much as you have to want, say, to quit smoking before you will even hear the message. Maybe Shakespeare again, hinted at this when, in his play Julius Caesar, he has Cassius say to Brutus:

And since you know you cannot see yourself
So well as by reflection, I, your glass,
Will modestly discover to yourself
That of yourself which you yet know not of.

It’s a thought, anyway…

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