Last week was the Cardiometabolic Health Congress, an annual event for which experts from around the world convene in Boston to discuss the latest developments and treatments for cardiometabolic conditions, such as diabetes, high blood pressure, and high cholesterol.
This was my third year attending the conference, and while I found the first two experiences to be largely interesting and pleasant, this time I had moments of anger and disgust so heightened that I occasionally considered getting up and leaving. If I want to fancy myself as having an open mind though I actually have to live it, not just pay the concept lip service and then bolt as soon as a presenter says something with which I disagree. I stayed, listened, and considered what the speakers had to say.
Following this paragraph is my list of key moments from the conference. By default, I was going to group them by disease state, but given the circumstances perhaps it is more appropriate to categorize them by the emotional state they created.
• Gut Microbes A presentation on gut microbes revealed the immense impact they seem to have on body weight. Linda Bacon addresses this topic in Health at Every Size, and I found it interesting to learn more from a professor who made research in this realm the focus of his PhD work. In experiments he did on mice, he found that animals colonized with the microbes of an obese donor developed twice as much body fat as those colonized with microbes from lean donors, even though the recipients consumed the same diets and had the same initial weights and body fat percentages. Gut microbes seem to be so closely related to weight that he said he can predict one’s body mass index based solely on his or her gut microbes with 90% accuracy. He stressed that this is a developing field and nobody knows for sure yet how to take these research findings and clinically apply them.
• Eating Pattern A presenter stressed that overall dietary pattern is what matters for cardiometabolic health and that no individual foods should be considered “good” or “bad,” a point with which Joanne and I completely agree. All-or-nothing approaches may be popular, but balance and moderation are typically the keys to long-term success.
• “Diet can be so rarely effective in maintaining weight loss.” During his presentation, a bariatric surgeon acknowledged, “There is weight regain in every intervention,” even after surgery, and that body fat seems to have a set point just like red blood cells and the liver, both of which will regenerate to their original masses after partial removal. For that reason, he explained, “Diet can be so rarely effective in maintaining weight loss.” We already know this latter point, but it was interesting to hear a doctor say it. He seems to be moving the focus of his surgery away from just weight loss and instead focusing on the metabolic benefits that can occur after bariatric surgery even in the absence of weight change.
• Effects of Sleep Deprivation on Hunger A doctor who specializes in sleep presented research indicating that the risk of developing cardiovascular disease inversely correlates with sleep duration. In other words, the more sleep one gets, the less likely one is to develop cardiovascular disease. He also presented epidemiological data showing that the less sleep people get, the more likely they are to have a higher body mass index. He debunked the theory that people who get less sleep eat more simply because they are awake for a longer duration. Rather, people eat more when deprived of sleep because leptin and ghrelin levels change and increase appetite. His research found that people consume 35 calories/hour more when sleep deprived compared to when they are adequately rested.
• Aspiration Therapy A novel bariatric surgery of sorts, known as aspiration therapy, was presented. The procedure involves implantation of a tube through the abdomen and into the stomach, sort of like a PEG tube that is used for nutritional support. In this case, however, the tube is not used to feed the person, but rather to empty the person’s stomach soon after he or she has eaten.
It’s interesting, if I diverted food back outside my body soon after eating in order to keep it from being properly digested and absorbed, I would probably be diagnosed with the serious and sometimes-fatal eating disorder known as bulimia nervosa, but I guess if the behavior is performed via an implanted device and endorsed by a doctor in the name of weight loss then everything is cool, right?
• FDA Oversight On the conference’s second day, the woman sitting at the table next to me struck up a conversation at lunch time. Turns out that she works for the U.S. Food and Drug Administration (FDA) and part of her job is to keep an eye on the messages that drug companies are using to endorse their products. She explained that when she went into the exhibition hall to speak with vendors, she kept secret that she works for the FDA because if she revealed it then the drug company representatives would “shut up” and warn the other reps to keep quiet because the FDA is there. If the drug companies are telling the truth and not doing anything improper, then why do they care that the FDA is present? Reminds me of how I reflexively hit the brake with my lead foot when I spot a police car on the highway.
• “I just push them all to surgery. I don’t know if that’s a good thing.” During a break, I approached one of the doctors who had presented on hypertension and asked her a question about the effect of sodium lost through sweat. The conversation segued to sports nutrition and then ultimately to weight. She brought up the supposed benefits of losing weight for cardiometabolic health, to which I responded by sharing how dismal the odds are of keeping off intentionally-lost weight. While I expected resistance, instead I got agreement. “It’s biology,” she said, “The body is really good at gaining weight, but not very good at losing it.” While I was pleasantly surprised to hear her acknowledgement, this anecdote ends up in my Disappointing category because of what she said next, “I just push them all [my patients] to [bariatric] surgery. I don’t know if that’s a good thing.”
• Success? Two doctors presented on lifestyle interventions for weight loss. Every single graph they presented for each intervention showed sharp initial weight loss followed by slow and steady regain. With the exception of one four-year study, all of the others lasted two years at most. As the study timelines came to a close, the graphs showed that subjects were still regaining weight, yet the presenters called the interventions successful because the subjects weighed less as the studies ended than at baseline. But the subjects’ weight trajectory was still upward; aren’t they at least a little bit curious about what happened to their weight after the studies ended?
Apparently not, for one of the doctors continued, “As long as you keep the diet and exercise going, you will maintain the weight loss.” But we know that is not true! People often regain weight even as they maintain the behaviors that lost it. Even the doctor I mentioned earlier, the one who pushes everybody to bariatric surgery, acknowledges this.
• Medical Recommendation or Disordered Behavior? The presenters advocated people weighing themselves daily, knowing exactly how many calories they are consuming, and burning at least 2,500 calories per week through exercise. They also suggested that people get together in weight-loss groups for the “healthy competition” of inspiring each other to lose more weight. You know, if lean people did these same things we might describe their behaviors as disordered.
The above point reminded me of an excellent piece that Ragen Chastain wrote about how behaviors that are considered dangerous for thinner people are routinely recommended for heavier people. Trying to keep that open mind I mentioned earlier, I thought to myself that plenty of medical interventions exist that would be cause for concern if someone without a warranting condition began to utilize them. For example, if I prick myself with a needle until I bleed people will probably be concerned about my emotional well being, but a diabetic who does the same thing in the name of checking his blood sugar is taking good care of himself.
The crux of the issue, therefore, is whether or not obesity in and of itself is really a disease. Despite all of the evidence to the contrary, much of the medical community still sees it as one so they advocate treatment for it. We could debate obesity’s place as a disease state all day long, but even if it is one, the problem is the “paradigm blindness” that I mentioned in an earlier blog entry: The presumed solution, dieting, actually exacerbates the condition so they keep adding more of the supposed solution to the ever-worsening issue not realizing they are caught in a feedback loop.
• Can’t See the Forest Through the Trees A doctor presented some research that looked at the influence of lifestyle behaviors (eating patterns, physical activity, stress management) on cholesterol and blood pressure. Researchers controlled for weight by screening out subjects whose body weight increased or decreased by more than 3% over the course of the study. They made this decision based on the presumption that excess weight itself is harmful and would confound the data. What the research showed, however, is that the lifestyle interventions themselves improved blood pressure and cholesterol even when no significant weight change took place. I would have thought the researchers would use these results as a basis for reconsidering the generally-held assumption that being overweight/obese is harmful, but interestingly they did not.
• Yay, Surgery for Everybody! The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for obesity. “Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent interventions.” The presenter who shared this continued that USPSTF’s recommendation is a grade-B level. He was excited because he said that the Affordable Care Act mandates that all grade-A and grade-B recommendations be covered, meaning that the USPSTF’s recommendation opens the door for individuals to receive pharmacotherapy and bariatric surgery based solely on their weight. The presenter continued that he looked forward to a day when everybody with a body mass index over 30 kg/m2 could get bariatric surgery.
And there it is. Ever since obesity was officially declared a disease, I have heard people talk about how this controversial decision was about finances. Although I did not know enough about the decision-making process to have a solid opinion, I always leaned away from conspiracy theories and figured that those involved in the decision had not fully considered the overall body of research. Given this statement though, I must acknowledge that it sure does seem likely money played at least a part, if not a large part, in the decision. While other moments from the conference made me more angry, as you will soon read, no other instant made my stomach drop like this one.
• Is Weight Cycling Funny or What!? One of the presenters who discussed lifestyle interventions for weight loss concluded his presentation with what I guess was supposed to be a joke, “Better to have lost and regained than to never have lost at all.” That offensive and ignorant comment garnered huge laughs from the audience. Weight cycling (“yo-yo dieting”) is associated with everything from diabetes to depression. Hilarious! Association is not causation, but he should have at least acknowledged the potential dangers of weight cycling and shown some respect for the people who have gone through it. Instead, he literally used it as a punch line.
• It’s All About the Money During a break between sessions, I visited the exhibition hall and wandered over to a table where sales reps were pitching a medically-supervised weight-loss program that physicians can license for use in their clinics as a way to make more money. One of the reps told me that the patient’s first visit is with a “salesman” (Yes, that is actually the term he used.) who asks the patient how much weight he or she would like to lose and then tells the patient how many visits and injections he or she will have to receive to achieve it. Injections? Those would be phentermine injections, which the Mayo Clinic cautions, “Phentermine may be a way to kick-start your weight loss. But once you stop taking it, you’re likely to regain the weight you lost . . . . Although phentermine is one of the most commonly prescribed weight-loss medications, it has some potentially serious drawbacks,” and then continues on to list its side effects.
Presumably the program also includes dietary counseling, so I asked the rep who is responsible for helping patients with their eating. “Dietitians are too expensive,” he said, not knowing that I am one myself. He said they recommend using “lower level” workers, like “nutritionalists.” I have never even heard of a nutritionalist and have no idea what one is. So far, everything the rep had told me was about sales and finances, so I asked him about outcomes. He had no data to offer me about how patients fare on the program and said he would email me some, but he never did. The rep could not even anecdotally offer any information regarding results. My impression was that little consideration was given to health and patient welfare in this program that seemed to be all about making money.
• Question Dodging This year, the conference organizers diverted from the normal format of having attendees verbally offer their questions through stationed microphones and instead invited us to submit our questions via text. The last event of the conference was a panel discussion on obesity, so I texted in the following question, “Research compiled by Linda Bacon in her book Health at Every Size and Ellen Glovsky in her book Wellness Not Weight show (1) long-term research that looks at least five years out shows that only 5% of people who intentionally try to lose weight keep it off and 60% of them end up heavier than at baseline (2) research that controls for behaviors indicate that these are better predictors of health than is weight. Given this, ethically how can we be prescribing weight loss to our patients?”
The moderator never presented my question to the panel. I could give him the benefit of the doubt that perhaps a technical glitch kept my question from entering the cue, but I received a reply confirming that they received my text. I could give him the benefit of the doubt that perhaps they ran out of time, but in fact the question-and-answer period ended earlier than scheduled.
Perhaps the moderator did not want to address my question because one of the conference’s industry sponsors is launching an anti-obesity drug that is pending final FDA approval? There I go with conspiracy theories of my own. Perhaps the moderator had a legitimate reason for not fielding my question, but it was hard to escape the feeling that he was dodging it.
MADE ME WANT TO THROW SOMETHING
• A Seed Is Planted Fortunately, somebody with a little more clout than myself raised a similar concern. A member of the panel, a bariatric surgeon, interjected the proceedings with a question of his own. “Sometimes we do surgery too much,” he began, and cited obese patients who are metabolically healthy, yet have bariatric surgery anyway. He continued that over the course of the conference, research had been presented indicating that lifestyle interventions that address eating, physical activity, and sleep can improve cardiometabolic health even when no weight loss occurs, that even bariatric surgery can have positive metabolic effects independent of weight loss, and people who are overweight tend to fare better than leaner counterparts when battling certain diseases. Given that, he asked, “Are we overemphasizing weight?”
I heard a couple of chuckles, but otherwise the room went silent. Crickets. Nobody on the panel wanted to touch the question. Sensing the uncomfortable silence, the moderator said we would come back to the question and moved on to other topics. The surgeon reiterated his question, this time rephrasing it so as to suggest that the presumed link between weight and health might be inaccurate. Fellow panel members trickled out answers: The exercise specialist said that excess weight can make movement difficult, the surgeon himself said that surgery can be more challenging in the context of obesity and specifically mentioned transplant operations, and another doctor offered, “Some individuals are genetically predisposed to have more adipose tissue . . .” before trailing off. Another surgeon on the panel, who seemed angered by the question, emphatically called attention to the association between obesity and cardiometabolic disease.
At that, the moderator cut off the discussion and moved on to other questions. There it was, one of the most important questions of the entire conference, a question of which I had tried to raise a different permutation myself without success, offered by an open-minded panel member, yet the moderator quickly dismissed it before it received the full attention that it deserved. I found myself literally shaking my head at the missed opportunity.
The upside though is that at least the question was raised. Even if it did not receive a proper discussion in response this time around, the seed was planted, and in that action exists the potential for growth.
“Can’t see the forest for the trees” – this type of study has been done before and with the same result. Here’s one of the earliest ones that used obese patients who were not allowed to lose weight: http://www.nejm.org/doi/full/10.1056/NEJMoa020194#t=article There are others.
Whenever I see a bariatric surgeon talk about how “diets don’t work” I have to pause. Perception bias makes me want to believe them, as there are studies that back this up. But it’s important to remember that bariatric surgeons depend on patients believing that their surgery is the “only cure” to obesity. While it’s good to see some of them admitting that the surgery isn’t a magic bullet, the recent changes to Medicare and the AMA’s decision to classify obesity as a disease mean that weight loss surgery has gone from a gold mine to a diamond mine.
It’s important to remember perception bias and to pay attention to when money is involved. Getting the ‘right’ answers for the wrong reasons does not move things forward in a proper way.
All excellent points, Moose, especially your last one. Thanks for your comment.
Slightly off topic — I’m currently working on collecting links to studies that show that nutrition is far more complicated than “food eaten + exercise = your weight”: that a wide variety of things can affect fat storage (such as smoking, sleep quality, diseases like insulin resistance, etc) and modify how efficiently food is burned (or not), that for reasons ranging from genetics to current and past health the same calories and exercise can have different results, and such. [Frankly, I’m fed up with people telling me that “food eaten + exercise = your weight” is based on the laws of physics, which of course cannot be changed, and any other belief is wrong, stupid, and only quoted by lazy fat people who just don’t want to bother dieting.]
Ahem. Sorry. Am bitter. Anyway, my point was that, given that you are an RD, I was hoping you had written something about this and/or had linked to stuff like this, but trying to look for posts by tag on your site leads to a lot of grey-on-black text that is unreadable. Might there be (a) post(s) here? .
Those sound like really important topics to address, but unfortunately the closest blog I have written is probably http://www.soolmannutrition.com/2014/06/health-focused-weight-management/. Ragen Chastain wrote an excellent piece on http://danceswithfat.wordpress.com/ in which she included links to a bunch of primary source articles. I wish I could point you to the exact blog entry that she wrote but I do not know where in her site archive it is buried. Anyway, I have a bunch of articles that may be of interest to you and I am happy to share. Your email address does not display on this site for privacy reasons, but behind the scenes I can see what it is so I will shoot you an email with some articles. Hopefully they will help. If I can be of any further assistance, just let me know. Thanks again.
Today, you are my hero. Thank you.
You are very welcome. I just emailed you a handful of articles. They may or may not be exactly what you are looking for, but hopefully they will at least be of some use. Thanks again, and please let me know if there is anything else I can do to help.
Excellent essay, Jonah. Thank you for writing this. I am speaking at a medical conference in London this weekend. I hope I can muster your professional restraint. I shall keep a copy of your story close at hand for company. I’ll be debating the head of the National Obesity Forum. The title of the debate? Incredulously, “Parents of Obese Children Should Be Prosecuted.”
Thank you so much, Marsha! Ugh, that is quite an inflammatory title for a debate! I admire you for having the courage to take that on. Best of luck, and I look forward to hearing how it goes!
I’m not surprised by the laughter in the room after the “better to have lost weight” comment. Years ago I learned that doctors have a worse view on their fat patients than the patients had of themselves. That’s a hard level to top, but doctors (in general) seem to race each other in their willingness to see fat people as a source of income and not to see fat people *as people*.
Russell Williams said, many years ago, that the Pledge of Allegiance ends in “with liberty and justice for all”. It doesn’t add “except fat people”.
As a fat advocate and activist, I’ve had to deal far too often with the medical community. There have been only two (!) doctors who haven’t harassed me about my weight, and that was only after I used Hanne Blank’s letter to her doctor as an example.
A Mayo Clinic orthopedic surgeon tried to talk me into weight loss surgery five times before he consented to talk to me about what I was there for, a new knee. He later admitted that he knew nothing about diets or weight loss, he just automatically tried to get me to have surgery for my weight.
I applaud you for giving us a behind-the-scenes look at how the medical community thinks about fat people – and money.
Thank you, I appreciate that. Much like my conference experience, stories like yours conjure a variety of emotions, including disappointment, sadness, and anger. It seems that many people have similar stories, which is so unfortunate. I have had doctors make incorrect assumptions about me and/or decline to perform tests because I am lean and, in their minds, must therefore be healthy. While our stories may be different, weight stigma negatively impacts all of us, no matter our size or shape.
Just as we discuss stereotypes and stigma, we need to be careful not to turn around and do the same to doctors. I am not saying you did in your post, Mara, but I am just making the overall point because an unintended consequence of my own post is that it seems to have triggered some doctor bashing. Although some practitioners (Let’s not single out doctors when the truth is that there are practitioners of all disciplines – dietitians, therapists, etc. – who engage in weight stigma.) who get into the field do so for the wrong reasons, many chose this career path because they want to help people. Unfortunately, for a variety of reasons, they just do not know how to do it. As a consequence, they unintentionally hurt instead of help. Through education and continued discussion, hopefully we can change this.
Thanks for this report! I know from experience how intensely distressing it is to attend an event like this one. I once sat next to Mal Fobi, with the word “butcher” ringing in my head the whole time.
i was surprised that a bariatric surgeon (aka stomach amputator) would raise such questions. Perhaps he is actually paying attention to the effect of what he does to people? It reminds me of a story that longtime fat activist and former NAAFA board member Lynn Meletiche tells.
She attended a medical conference on so-called “obesity” years ago in Florida. After a presentation about so-called weight-loss surgery, she stood up during the Q&A and asked, “How many people here would perform one of these surgeries on a loved one or close family member?” There was an uproar of protest and indignation. After that went on for quite a while, one surgeon admitted — grudgingly — that he would be willing to perform weight-loss surgery on his brother-in-law. Wankers.
I, too, was surprised that a bariatric surgeon called into question the very procedures that he offers. Doing so took both an open mind and courage. He seems like a well-respected doctor in that community so I hope that people took seriously the question that he raised, even if they were not ready and willing to address it at the time.