Is Obesity Really a Problem? Two Decades of Questionable Treatment

Article Contributed By: Christopher D. Keiper, M.A. at River Centre Clinic

As a person who has struggled with dieting and weight loss, I know the stigma that can be placed on people who do not seem to live up to what Western society purports as the norm for human body shape. It is now almost trite to point out that endemic images of fashion and television celebrities are unattainable social expectations so that many strive to reach a lower weight and feel ashamed when they cannot. We tend to think there is something wrong with us when we fail and assume that when someone does not reach a “healthy” BMI it is a deficit of personal willpower or poor life choices. Moreover, the overweight are led to internalize negative stereotypes about themselves.

But, the stigma of being overweight does not exist merely in avenues of social desirability. We have come to believe that overweight and obesity are almost unquestionably linked to risks for developing chronic, preventable illnesses. Health is equated to having a thin physique. This “fact” appears almost indisputable in popular media: even when weak data are used, science journalists rush to the foray to reaffirm the notion that fat people cannot be healthy [1]. What is more, individuals who are overweight are encouraged to seek out treatments in the belief that their supposed “illness” can be permanently reversed. Both of these assumptions are far from certain in the scientific research literature.

Flimsy Evidence: Two Decades Has Not Changed Much

The assertion that it is possible to lose large amounts of body fat and successfully keep weight off is questionable at the very best. Large-scale research studies have shown the lack of long-term efficacy of obesity weight loss treatment by dieting [2]. Even in the most successful intervention for weight loss – expensive surgical intervention – 50% of weight loss is regained, and the procedures come tied to a lifetime of restricted food choices, dietary supplements, and risk for gastrointestinal complications [3].   But what is perhaps most alarming about the belief that obesity can be successfully “treated,” is that researchers have know about the lack of evidence for efficacious treatment for over two decades. As early as the 1990s, Susan Wooley and her colleague David Garner -President of the River Centre Clinic in Ohio- stated:

“The purported benefits of weight loss are so well known that to question them is to defy almost unshakeable beliefs. An especially telling sign of this …is the continuing willingness of professionals to provide, and consumers to participate in, programs known to have only a small chance of success. Even if one’s chances of losing and keeping off weight are better than one’s chances of winning the lottery, the motivation is much the same: winning, although unlikely, promises transformation.”

Instead, Wooley and Garner showed that people who use dietary methods to lose large amounts of weight may find themselves experiencing phenomena that are familiar to those who have self-starved to below a normal weight: high rates of bingeing; lower calories maintaining the same weight; depression; preoccupation with food, weight, and body image; and no guarantee of an improved quality of life [4].

Despite these observations, research on weight loss methods and treatment of obesity treatment have steadily increased, with 220,000 individuals in the U.S. receiving gastric bypass surgery in 2009, at around $28,000 a pop [5].

Why are we spending so much energy on treating obesity with only moderately effective methods? If the evidence suggests dieting is not effective in the long-term, and weight-loss surgery is hardly an easy route, certainly there must be huge health consequences to obesity?

How Bad is ‘Excess’ Body Fat?

Although health professionals tend to disagree about the most effective ways to treat obesity, rarely do they question whether obesity needs to be treated. Saguy (2013) notes this fiat method of the prevailing social frame of obesity-as-problem, “…If we perceive obesity to be unhealthy, it is because it is. In other words, facts speak for themselves.” (p. 26, italics added). Because obesity has been linked to cardiovascular risk, diabetes, hypertension, cancer, and stroke, body fat is perceived as adding undue risk of illness, regardless of contradictory evidence that at times higher weight may prevent premature deaths.

Most of us would recognize the popularized “obesity epidemic” language that pervades health policy and news outlets. It has been over a decade since the term was introduced into medical vernacular in a special issue of the Journal of the American Medical Association [6]. Despites its widespread use (consider First Lady Michelle Obama’s “Let’s Move” campaign), there are many problems with portraying fatness as a medical issue [7]. In fact, it is fair to say that the negative health outcomes of obesity are drastically overstated.

So perhaps before you go rushing into your next diet or weight loss routine, consider the following evidence we have gathered about the relationship of body fat to health:

1.     It’s Not Just Your Sweet Tooth – The causes of being overweight are multi-faceted, and cannot be attributed to solely individual will-power and life choices

• Popular media, nutrition and fitness programs, and government awareness often point to obesity as an individual choice. If you are larger than social expectations, it is portrayed as consequences of diet and exercise decisions. However, up to 70% of BMI is explained by genetic variation [8]. This means that for some, perhaps telling someone they are “too heavy” would be like suggesting their shoe size is too large.
• Non-genetic biological factors also seem to affect human body size. In the Dutch Famine Study, individuals were deprived of nutrition as a consequence of a WWII commercial blockade. Women who were born during this time had significantly higher BMIs than those not exposed to famine, suggesting prenatal malnutrition may increase risk of obesity [9].
• Public health campaigns that stigmatize obesity and put a large emphasis on individual choice are no more likely than others to increase motivation to lose weight, and such campaigns actually reduced self-efficacy of participants [10].
• Health professionals are taught, sometimes inadvertently, to treat patients’ inability to lose weight as a failure of personal compliance with treatment. Health professionals with higher weight bias have more frustration with patients [11].

2.     We’ve Known for 20 Years that Obesity Treatments Are Overstated – Obesity treatment by dieting is widely shown to fail in the long term, and bariatric surgery has unknown health sequale while incurring substantial financial cost

• Behavioral and dietary treatments for obesity almost always fail in the long run (5+ years) after the initial weight loss period. David Garner and his colleagues pointed out this research in the 1990s [12], and it still is true today [2]. Yet, dietary treatments are still advocated for weight loss as a pathway to health.
• When dietary treatments market themselves as “successful,” they are usually defined in short-term follow-up studies. A large review of weight-loss treatments for obesity found that 1/3 to two-thirds of participants return to their original weight [2].
• The same study also showed that, on average, dieting itself was a significant predictor of weight gain when controlling for baseline weight and other factors. Dieting at baseline predicted an average of 22 lbs. of weight gain.
• Treating and managing obesity -a non-medical condition- with bariatric surgery and weight loss medication cost U.S. health consumers, insurance companies, and health-care providers an estimated $1.3 billion in 2005 alone [13]. Likely, obesity treatment costs are significantly higher than this.
• Despite improvements in bariatric surgery techniques, the leading centers for obesity treatment admit to many potential complications, such as bowel obstruction, ulcers, and nutritional deficiencies [14]. Additionally, there is no guarantee that people who receive bariatric surgery will decrease their risk for conditions such as CVD and Type II diabetes simply due to weight loss.
• Post-surgery, there is only a 50% success rate for maintaining weight loss for bariatric treatment with stringent adherence to diet and exercise regimens [15]. It is additionally impossible to tell if the resultant health benefits post-surgery may actually be due to diet and exercise changes adhered to after the surgery.

3.     The Negative Health Outcomes of Obesity are Overemphasized – While there is sound research suggesting that overweight may be protective from certain chronic illnesses, it is not cited in popular media and is met with skepticism.

• Estimates from the U.S. government changed the death rate associated with obesity from 400,000 in 2000 to less than 30,000 in 2001, yet this went largely ignored in popular media and print [16].
• Although certain risks are associated with greater body fat, evidence suggests that there is a high prevalence of cardiometabolic abnormalities among “normal” weight individuals and a large number of overweight and obese individuals who are metabolically healthy [17]. Thus, cardiometabolic risks are not just about weight!
• BMI standards of “overweight” have changed to be more in bias of thin physique: In 1998, following a WHO inquiry, the NIH altered “optimal” weight so that 29 million Americans became overweight in an instant when BMI cutoff categories were changed to rounded numbers [18].

4.      Being Fit and Being Slim are Not the Same – Recent evidence shows that cardiovascular fitness, more than weight, is indicates longevity and lowered risk of certain disease.

• Obese and cardiovascular fit older adults have less mortality risk than any other group (obese and inactive, normal weight and active, normal weight and inactive) suggesting fitness and obesity combined may be protective [19].
• A recent study suggests that exercise- and not weight- predict longevity and lowered risk of mortality [20]. Overweight individuals who were physically fit had lower risk than “normal” weight participants who did not exercise frequently.

Looking Forward

Labeling obesity as a medical problem- a disease- has produced questionable treatments and may have unnecessarily led tens of thousands down a journey to failure, treatment complications, and stigmatization. Moreover, we’ve know this for a very long time, and new evidence suggest it is likely possible to be overweight and still be medically fit. Maybe its time, as a health conscious society, that we ask ourselves: Is obesity really an illness worth our current mental, physical, and economic efforts? Perhaps we’ve been viewing fatness wrong all along. And perhaps as our paradigm of body size begins to change, so too will our advances in sustaining long-term public health.

Need Help Now? Please call us at 1-800-957-4802 to speak with an eating disorder specialist at River Centre Clinic.

Resources:

[1]: http://www.latimes.com/science/sciencenow/la-sci-fat-healthy-myth-20131202,0,5532717.story#axzz2nIAjZJ7z
[2]: http://www.ncbi.nlm.nih.gov/pubmed/17469900
[3]: http://www.ncbi.nlm.nih.gov/pubmed/23235396
[4]: http://www.ncbi.nlm.nih.gov/pubmed/1918744
[5]: http://www.bloomberg.com/news/2013-02-20/weight-loss-surgery-fails-to-reduce-costs-study-finds.html
[6]: http://jama.jamanetwork.com/Issue.aspx?journalid=67&issueID=4709&direction=P
[7]: http://www.letsmove.gov/learn-facts/epidemic-childhood-obesity
[8]: http://www.nejm.org/doi/full/10.1056/NEJM199005243222102
[9]: http://ajcn.nutrition.org/content/70/5/811.full
[10]: http://www.yaleruddcenter.org/resources/upload/docs/what/bias/PublicPerceptionsObesityCampaigns_AJPM_6.13.pdf
[11]: http://onlinelibrary.wiley.com/doi/10.1002/oby.20637/abstract
[12]: http://www.indiana.edu/~k536/articles/behavior/failure%20Garner%201991.pdf
[13]: http://www.sciencedirect.com/science/article/pii/S0277953610001784?np=y
[14]: https://my.clevelandclinic.org/Documents/Bariatric_Surgery/schauerbest.pdf
[15]: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096273/
[16]: http://jama.jamanetwork.com/article.aspx?articleid=198357
[17]: http://archinte.jamanetwork.com/article.aspx?articleid=770362
[18]: http://www.washingtonpost.com/wp-srv/style/guideposts/fitness/optimal.htm
[19]: http://cardiology.org/recentpapers/VETSpdf/McAuley%20Fitness%20Fatness%20Elderly.pdf
[20]: http://www.huffingtonpost.com/2013/11/20/fat-but-fit-fitness-weight-death-risk_n_4305622.html

Chris Keiper is a 6th year PhD candidate in clinical psychology at Fuller Theological Seminary and a research consultant to the River Centre Clinic. His research focuses on eating disorders, spirituality, and psychological assessment. For more resources on opposing obesity stigma, see:
Abigail Saguy: What’s Wrong with Fat
Health at Every Size Blog
Rebecca Puhl: Yale Rudd Center for Food Policy and Obesity

 

Page Last Reviewed and Updated By : Jacquelyn Ekern, MS, LPC on
February 21, 2014
Published on EatingDisorderHope.com, Eating Disorder Information Help & Resources