The Weight of the Nation: Part One, Consequences

I decided to watch the HBO/NIH series The Weight of the Nation despite being very put off by the lead up to it. With so many people sure to watch, I wanted to know what it was all about, not just go off my first impression. Here’s my review of the first episode.

Consequences

The first obvious problem is the title: “Consequences.” Consequences of what? Oh yeah, “Obesity and Overweight.” When you get into the meat of the series, you learn that the many health problems they’ve tied together under the shadow of a fat person ready to squash the nation are actually consequences of sedentary lifestyles and the industrial food system. These things are also wrecking havoc on thin people’s health, but that’s not how they’ve framed it.

They set out with the argument – “Obesity and Overweight” are on the rise in both adults and kids. Diabetes has never been so common. Fat kids have heart disease, high blood pressure, and high cholesterol. If you’re fat, your risk factors for all sorts of health problems are through the roof. Oh, and it sucks to be fat, too.

They showed a couple interesting studies, but I was disappointed in the conclusions drawn. The Bogalusa Heart Health Study followed a population of school kids from the time they were in elementary school all the way through adulthood, and looked at their obesity rates and heart disease. Autopsies of children who died from other causes showed that heart disease had already begun. They said that kids who were obese were more likely to be obese adults, and people who were obese were more likely to have heart disease.

Heart Disease

The show implied the cause of this heart disease and obesity was that people ate fat and were fat. The presence of lesions in children does not mean the cause of their illness was their weight. The idea that saturated fat from red meat and full fat milk is the cause of heart disease has been debunked. Yet when we see a problem: heart disease in children, what’s the recommendation? Stop feeding them fat.

Now, I’ve been browsing the peer reviewed scientific papers on the subject. Interestingly, an analysis of the Bogalusa Heart Study itself1 says right there in the abstract:

Of the 813 overweight schoolchildren, 475 (58%) were found to have at least one risk factor. Furthermore, the use of overweight as a screening tool could identify 50% of schoolchildren who had two or more risk factors. CONCLUSIONS: Because overweight is associated with various risk factors even among young children, it is possible that the successful prevention and treatment of obesity in childhood could reduce the adult incidence of cardiovascular disease.

Details in the paper itself made it even more clear that obesity was not the cause of all the disease or a good predictor of any particular risk factor, but kids who had multiple risk factors were more likely to be overweight than kids with one or no risk factors. This means that there were fat kids without risk factors, and kids who had risk factors but were not fat. Obesity was not the cause of the risk – rather it was correlated with the risk.

Changes in percent of total fat consumed, by food groups, by 10-year-old children in the Bogalusa Heart Study during 1973–1994 vs. 1992–1994.

Changes in percent of total fat consumed, by food groups, by 10-year-old children in the Bogalusa Heart Study during 1973–1994 vs. 1992–1994.

In the Bogalusa study, diet was tracked in a consistent way (using 24 hour recall) since 1973. While it’s clear that heart disease can start in childhood and that children with more fat showed a higher risk in the long run, what’s not clear is how they came up with that recommendation, or how other foods they had eaten may have played a role in the health problems documented. In the early years of this study, the lipid hypothesis was gaining traction. It is only recently that the mainstream is starting to look at it skeptically. Could this have biased the researches when they were interpreting the data?

Over the course of the study, the percentage of calories children got from fat actually declined while the carbohydrate and increase in sugary drink consumption rose. Additionally, the quality of the fats that they ate changed – fat derived from snackfoods dramatically increased, while fat from all animal products except for cheese and poultry declined. I believe it’s a huge mistake not to note that transfats increased and natural fats decreased and sugar consumption went up! There are no grounds to state that the problem here is red meat.

They also showed arteries hardened with cholesterol. There was no mention of the new science showing that these accumulations are not due to obesity or the consumption of fat, but rather caused by the reaction of the body to inflammation. This inflammation can be caused by sugar, which can lead to accumulation of fat. Again, the cause and effect mixed up.

Size and Insulin Resistance

But what about the scourge of diabetes? Surely that is caused by obesity. After all, they told us all about the metabolic processes that go on in fat cells… and that having more fat leads to greater insulin resistance. Surely the answer is to lose weight.

A fellow who had lost a foot to diabetes and his wife were interviewed. They realized that you don’t have to be huge in order to have a health problem. Their takeaway was that just a bit of fat could mess you up. When talking about their diet they sang the praises of fish and chicken and said they no longer eat red meat. Last time I checked, cutting out red meat was not the recommended dietary change for dealing with diabetes! The implication was the the reason he’d lost his foot to diabetes was the few extra pounds he carried, and that losing weight by reducing saturated fat was the answer. His other foot looked to me like it was headed for trouble, too.

But let’s get back to obesity and diabetes. The Pediatric Obesity Epidemic: Causes and Controversies makes some very interesting points. So many, in fact, that it’s really hard to choose just one. Please go read the whole thing!

In 32 patients with advanced coronary disease, 4 wk of a low-glycemic diet reduced the glucose and insulin response to an oral glucose tolerance test compared with a high-glycemic-index diet without any change in body weight (83).

This quote jumped out at me, because it talked about the fact that the way the body deals with insulin can be changed with diet rather than with weight loss. Other studies cited showed that the low glycemic and low carb diets that had these kinds of effects also ended up in resulting in weight loss – much more (and more sustainable) weight loss than could be gained with low calorie and low fat diets. Could it be that most people who are successful with their diets and in improving their diabetes have lost weight as a side effect of a diet that helped them regulate their blood sugar?

1000 Extra Calories A Day?

For more on the effects of fats in the body, check out Put Your Heart in Your Mouth

For more on the effects of fats in the body, check out Put Your Heart in Your Mouth

Continuing with fallacies about fat, the film showed a study where a woman had to add 1000 calories a day to her diet in the form of fast food. Not surprisingly, she ended up both much sicker and somewhat bigger at the end of this experiment. They talked about the saturated fat being the problem with this food – no mention of the sugar, no mention of the difference between transfats and saturated fats. Actually, they were lumped into the same category. This lady got the message that all fat is bad and that the reason she was having health problems was that she gained weight.

We eat loads of fat and haven’t gained weight or developed the health problems she had. Our fat comes from grass-fed animal products, coconut oil, nuts, and avocados, not a frier with rancid, highly processed soybean oil!

I’d say she had problems because of the kind of fat she ate. What if she’d just had a lot of the kinds of fats we eat, and hadn’t bothered counting calories? We’ll never know, because they didn’t think to draw that distinction.

Mechanical Effects

This episode actually did change my thinking about correlation and causation a little bit. I’ve had a knee jerk reaction against anything that tries to say size is the root cause of a health problem. I still strongly believe that most health problems blamed on obesity are problems in their own right, and that blaming health issues on weight alone is a dangerous and misguided approach. But I will acknowledge that some health problems may result from obesity.

When they showed the effects of obesity on the heart’s mechanics I was swayed a little. The walls can thicken and the systolic and diastolic function become impaired. The question of which came first does seem a bit more sensical in this case than in the case of arteriosclerosis. While many people suffer heart failure due to other causes, in some cases it appears that simply being overweight can be the cause of heart failure for some people. According to the New England Journal of Medicine article Obesity and the Risk of Heart Disease:

The population attributable risk of heart failure due to overweight was 14.0 percent in women and 8.8 percent in men. The corresponding population attributable risks due to obesity were 13.9 percent in women and 10.9 percent in men.

Interestingly, the same study showed lower mortality for obese people who suffered heart events!

They also talked about the stress on the frame of the body and joint pain. I couldn’t shake the feeling though, that they were perpetuating the myth that if you hurt, it’s the fat causing it. I happen to know that many people who suffer joint pain as fat people can relieve that pain by cutting out gluten. Food intolerance is just one of many potential problems that could cause pain. While fat and pain may be related for some, it’s not the only or best explanation for the pain many people experience.

Fat, the Endocrine Organ

The show also gave a quick overview of the ways in which fat cells themselves can harm the body’s functions. For example, they showed fat deposits in the liver and talked about the function of fat cells changing as the body accumulates more fat, leading to greater insulin resistance. I started to question my previous ideas and wonder if maybe fat was the root cause of these issues. But when I did more reading, I again found that chicken and egg problem cropping up. Pediatric Obesity and Insulin Resistance: Chronic Disease Risk and Implications for Treatment and Prevention Beyond Body Weight Modification2 talks about these very issues, based on the analysis of many independent studies. While they maintain high correlations between fat, metabolic syndrom, fatty liver disease, diabetes, and more, it’s clear that the fat itself is not the cause of these issues. Here’s one interesting tidbit:

Furthermore, in multivariate regression analysis, insulin sensitivity, but not fat mass, was independently and negatively related to triglycerides and blood pressure and positively related to HDL-C. These results suggest that the effect of adiposity on lipids and blood pressure control is mediated via insulin resistance.

and another, regarding fatty deposits in the liver:

In addition to IMCL, fat deposition in the liver has also been associated with insulin resistance and hyperinsulinemia in both nonobese normal subjects (122, 133, 161) and in obese subjects with type 2 diabetes (102, 122), and this association seems to be independent of total body adiposity.

I don’t want to give you the wrong impression though… this paper does corroborate a point made in the film:

Since the discovery of leptin in 1994 (191), it has become evident that adipose tissue is not an inert tissue but instead is a critical tissue involved with metabolic regulation (103). Adipocytes produce and secrete several important mediators related to insulin resistance, cardiovascular disease, and type 2 diabetes.

Indeed, it would be foolish to assume that such a large number of our cells had no function other than to affect how we look. As we change our adiposity, we affect our fat cells in number and in size… and in function as well. That doesn’t change my main problem with the film, though: That fat people are viewed as the problem, and that fat loss is considered the solution. One more quote from the pediatric obesity article says it well:

However, there are very few examples of intervention studies designed specifically to address the underlying metabolic abnormalities. Most typical “weight management” programs for youth have been based on the traditional “energy balance” model and used restrictive diets, behavior modification techniques, physical activity, and/or drugs, but these approaches have generally not been successful and don’t necessarily address insulin resistance and the underlying risks beyond weight loss. In addition, a recent study shows that dieting approaches are generally ineffective in children and adolescents and may actually promote weight gain (57). Thus, as was concluded in a recent Cochran review, conventional approaches targeting weight management in children have not been effective (173)

The People

Overall, I was pleasantly surprised at the treatment of the people interviewed. They were shown respect, and I didn’t see a lot of blame and shame going around. There was even some acknowledgement that dieting generally has done more harm than good for most people. Unfortunately, they went back to the point that people need to lose weight to be healthy, and that it needs to be done by portion control and exercise. Calories in, calories out. Who does that work for, anyway? There also wasn’t a lot of diversity of perspective represented, and being fat was represented as a universally negative experience.

Conclusion

Correlation means things are related… if you see one, you are more likely to see the other. I’m willing to buy that being fat is related to some health conditions. But a risk factor involves risk. That means there is chance involved – one does not always indicate the other. Often, correlated things have the some of their underlying causes in common. One is considered a risk factor for the other only because it is more readily seen and measured. On top of that, for every disease that is corrolated with obesity, there are plenty of obese people who do not suffer from it, often the majority.

The whole premise that we have an obesity epidemic which is the root cause of our health problems seems backward to me. We have a whole lot of other problems, which sometimes lead to obesity. Even when they don’t, they are bad news. If we found a magic pill or surgery that could make all people permanently skinny, we would not solve the health problems we are facing as a nation.

Coming up, my review of Part Two: Choices – in three parts.

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Unlinked Sources

Put Your Heart In Your Mouth

Put Your Heart In Your Mouth

1. Freedman, D. S., Dietz, W. H., Srinivasan, S. R., & Berenson, G. S. (1999). The relation of overweight to cardiovascular risk factors among children and adolescents: The bogalusa heart study. Pediatrics, 103(6), 1175-82.

2. Cruz, M. L., Shaibi, G. Q., Weigensberg, M. J., Spruijt-Metz, D., & al, e. (2005). PEDIATRIC OBESITY AND INSULIN RESISTANCE: Chronic disease risk and implications for treatment and prevention beyond body weight modification. Annual Review of Nutrition, 25, 435-68.

This post is part of Sunday School.

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