Friday, August 7, 2009

Who Are You Calling Fat?

"I have a certain alacrity in sinking."


A survey suggests that the majority of Americans are not convinced that they are as fat as health experts say they are, or at least, they don't seem very alarmed about it. 82 percent said that obesity is either no problem or only a mild problem for themselves or their families. I don't know if they were asked whether obesity is a problem for other people and their families; my guess is that the numbers in that case would come out differently. But clearly this is out of step with the near-panic of many health experts over the epidemic of obesity.

This is the perennially interesting question of who gets to define what an illness is. Obviously opinion polls don't settle purely scientific questions. I believe I've seen multiple polls suggesting that the majority of Americans do not give full credence to the theory of evolution. While this fact is fascinating on cultural and sociological grounds, it detracts nothing from the validity of evolution itself.

The question with obesity is whether the poll in question reflects mere denial of the prevailing metabolic state, disbelief in the alleged health effects of obesity, or a declaration that whatever those effects might be, most folks don't care enough to tackle the problem. It hasn't helped, of course, that there has been significant ambiguity about health effects; while morbid obesity clearly hastens mortality, it is far from completely settled, so far as I know, that obesity in the moderate range shortens life span.

Obviously there are other ways obesity may be detrimental, primarily through increased morbidity, that is, suffering related to arthritis, diabetes, or other secondary conditions. These complications arguably increase health care costs. Obesity is problematic in other miscellaneous and logistical ways, for instance, even by increasing consumption of jet fuel for higher passenger payloads. None of this is to comment in any way on the causes of obesity, or the locus of responsibility, merely the consequences.

So the poll results may just reflect ignorance--people just don't understand, or don't want to understand, the social impact of obesity. But what if, at some level, they do, but they don't deeply care enough to label it a problem? Certainly in psychiatry, lack of insight is a common predicament--individuals with alcoholism or schizophrenia often enough can't or won't grant that they have a problem. But in those cases we stipulate that if they were placed before a jury of their peers, so to speak, or before a hypothetically rational person, they would be found to have a problem.

Alcoholism and schizophrenia do not reach epidemic status; it is easier to see the outlier as "disordered." But what happens when the outliers become the majority--can they define their putative disorder out of existence, or at least redefine it so that it again becomes a minority state? For instance, one could imagine a redefinition of morbid obesity as obesity, period, and what we now call moderate obesity, within a new and broader normal range. Even if such a change reduced average life span, the majority consensus would be a repudiation of the designation "illness" or "problem." There are, after all, values other than health-related values.

Yes, maybe technically the doctor makes the diagnosis, but if the "patient" doesn't consult the doctor, or even if he ignores the doctor's advice, is there still an "illness" or a "problem?" If the majority of patients were to do this, maybe not. In the country of the blind, the seeing man is king. But in the country of the overweight, the lean man is...malnourished. In a patient population of the contentedly curvaceous, the alarmed doctor is...alarmist.


Anonymous said...

An illness is only a problem when it kills you.

Most people have an astonishingly good ability to tolerate each tiny incremental infringement on the integrity of their health status; the slow chipping away teases their capacity to function in micro-ways: first indetectable, then remotely nagging but otherwise tolerable, until they get to a stage where they've reached a supposed point of no return in terms of maintaining their existing detrimental lifestyle - the logic seems to be: 'I've come thus far, I can't go I'll go on' until death. It's a lot simpler to concede defeat and yield to the inevitable arbiter of life...

A subconscious submission to punishment for the bodily wrongs committed? Or just laziness...

fraise said...

This writeup might interest you:

Money quote: "The risks associated with the most 'morbidly obese' (BMIs 35+) — the uppermost 3% of this Canadian cohort— were statistically the same as those with 'normal' BMIs. [RR=1.09 (0.86-1.39, 95% CI) versus RR=1.0.]"

Glad to see you mention the "quality of life" point though. I have an uncle who's morbidly obese, age 65, and it's a constant battle for him not to go past the weight at which his bones would no longer support him. Certainly, he's lived longer than non-morbidly-obese people I've known who have been in fatal car accidents or died of, say, leukemia, but it's hard to argue that he has a good quality of life to show for it.

Retriever said...

Very good post. I particularly love the "In the country of the blind..."

I am glad you are thinking and writing about this, altho it's one of those areas where angels fear to tread.

I don't like the current overuse of the addiction paradigm to overweight, but both are physical problems with spiritual and emotional origins (as well as consequences). Hungers that cannot be satisfied moderately. Aches salved desperately. Disordered appetites. Good gone to excess. And both addictions and overweight defy rational advice.

In my experience around people suffering from both, it seems that reawakening hope, finding one positive step a person can take that will immediately improve their life, is more effective than alarmist predictions (even those that spring from genuine concern). Thus, for example, I was able to help (in a very small way) a massively overweight friend begin to lose weight and get healthier by cajoling her to walk with me some at lunch by trailing tantalizing gossip. We would yak with each other, as friends of ten years, and she got some healthy color from being outdoors, and these seemingly small steps helped her take more.

I also think it helps people if their doctor commiserates with them a little. That, yes, life is unfair. That if you the MD are in good shape, it is not because you are the Kwisatz Haderach but simply the result of blind genetic luck, plus a fitness freak spouse (or whatever else contributes to it that you can be cheerful and not brag or seem superior about). It wouldn't motivate a person to have a physician who said "Ve vill now to develop some discipline. I have it, so vy do you not also??"