American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, November 12, 2012

Why I can't quite be okay with 'Okay at Any Size'

There has long been a movement to defend the overweight from a prevailing lack of understanding. And, alas, that defense seems to be needed.

The evidence of obesity bias in our culture is abundant and pervasive, and can be found from playground to boardroom. We have historically done a poor job of attacking the problem of obesity without attacking those burdened by the problem of obesity.

The defense has come in the form of professionals who highlight the pernicious effects of bias. It has come in the form of organizations, such as NAAFA, the National Association to Advance Fat Acceptance. In my own case, it comes in the form of the National Exchange for Weight Loss Resistance, which I launched to help spread the word that some people can eat well, be active, and still never get too thin.

There has long been some okay-at-any-size support from Hollywood and Madison Avenue, as well. The Dove ads for women with "normal" curves are already classics. Oprah has emoted on the topic. Plus-size models can do quite well. And Queen Latifah has brought her inimitable "what you see is what you get, if you're lucky" brand of gumption to the issue.

Apparently, though, we've entered a new stage of evolution on the topic. The New York Times recently reported that a whole new cadre of celebrities prone to the same obesigenic influences as the rest of us are simply shrugging their shoulders, and letting it all hang out. In some cases, quite literally, by exposing the expanding epidermis in question.

So "okay at any size" seems to be gathering pop culture momentum. And I regret to say, I can't be entirely okay with that. It's not the size I'm not okay with, it's the consequences.

Epidemic obesity is not just a reason we have epidemic diabetes, it is the reason. It is the reason why the CDC is projecting that as many as 1 in 3 of us may be diabetic by mid-century, at a cost the nation is unlikely to find manageable.

It is the reason why what used to be "adult onset" diabetes is now a disease of children as well, and called "Type 2." It is the known reason for a proliferation of ever more cardiac risk factors in ever younger people. It is the reason behind a triple coronary bypass in a 17-year-old boy whose case I know. And it is the likely reason for a 35 percent increase in the rate of stroke among 5-to 14-year-olds.

And the toll of this menace continues to rise. Not so much now because of more people becoming overweight, although that continues to happen. Rather, since most of us vulnerable to becoming overweight or obese are already there, the relevant trend at present is the degree of overweight, which is worsening fast. A recent report indicates that the prevalence of severe obesity has "skyrocketed" in the past decade. We can probably no longer gauge this epidemic by noting how many are overweight; we now need to monitor how overweight the many are.

These, then, are the stakes in play. It's true that people can be fat and fit, but few of us are. More and more of us are fat to one degree or another, and most of us are unfit as well. These can be unbundled, but in the real world they seldom are. And when they are unbundled, it's because thin people can be unfit, too. In general, the behaviors that cultivate genuine fitness offer the best defense we have against fatness.

And this points to a message residing more than skin deep. Whether fat or thin, what we eat matters. Food is the fuel that powers the human machine. It is the one and only construction material for the growing body of a child. It is the construction material on which adults rely to replace spent cells and enzymes and hormones every day. Junk is a poor choice all around, no matter your size.

And exercise matters. It is the vital, conditioning work of the body, whatever its proportions. The "okay at any size" message does not explicitly say that junk food and lounging on the couch are fine, but it doesn't tend to say explicitly that they aren't, either. We could be more okay at any size if we took good care of ourselves, large or small. But if one of the reasons for larger size is lesser attention to health, that's not really okay. And frankly, what we know about prevailing dietary and physical activity patterns suggests that's just what's going on.

Along with helping many patients lose weight over the past 20 years, I have talked some out of the enterprise. I have told them they were healthy, and as far as I was concerned, looked great as well. I encouraged them to love the skin they were in, and not obsess for the rest of their lives with themselves 10 pounds lighter, or a size or two smaller. Sometimes they listened to this advice, sometimes not. Those that didn't listen might well have benefited from a bit more cultural emphasis on the "okay at any size" message.

So I am not only okay with "okay at any size" up to a point, but an active proponent. I oppose obesity bias, and reject the notion that widespread obesity among children and adults alike is somehow due to an inexplicable, global outbreak of personal responsibility deficiency syndrome. If you have evidence of such an outbreak, it would be the first I've heard of it.

I am more than okay with the notion that weight and waist circumference do not measure human worth. I will gladly stand shoulder-to-shoulder with others inclined to fight in defense of this proposition.

I am not just okay, but adamant, that we should be able to attack the problem of obesity without attacking those dealing with the problem of obesity.

And I can be okay with "okay at any size" if it includes a proviso: okay at any size as long as health is not adversely affected.

But when weight imperils health, as it clearly does all too often, I am not okay with it. In this context, bold displays of burgeoning flesh, and "flab is fab" bravado may do more harm than good. We do not, as a society, want to normalize ill health or the factors that impose it. Fewer years in life, and less life in years is not an acceptable endowment to the next generation.

We could choose to give our children a future in which 80 percent of all chronic disease goes away, because we commit to making tobacco avoidance, eating well, and being active our cultural standard. Or we can be okay with the trajectory we are on, and give them ever more serious illness starting at ever younger age.

When the bigger we are on average, the harder and younger we fall victim to serious chronic disease, I am not okay with it, and don't think anybody else should be, either. It's not the size that inspires my opposition; it's the consequences.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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