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Unamerican Activities —

November 15, 2012

Trigger warning: Discussion of a weight loss study.

Judging from the media coverage, Americans love a brutal fatty story.

Doesn’t matter what kind: reports confirming that all fatties are on the brink of type 2 diabetes, serious stories on government proposals to fight back the lipotide, examples of fatties being publicly humiliated. Take your pick, the 24-hour networks, the newspapers, and the blogs are gonna make sure you hear about it.

But what happens when a story doesn’t fit the popular narrative about fatness, health and government intervention? What happens when our best and brightest reach an unavoidable conclusion that the slimstream media really wants to avoid?

What happens then?

Radio silence.

For example, did you hear that Denmark had a fat tax?

You may have seen a story about it back in 2011, when it passed. CNN covered it. So did ABC, Fox, and The Huffington Post. You’ll notice that none of those sites have any story about how Denmark has now repealed the fat tax.

Why?

Well, those desperate for a positive spin say the tax wasn’t ended because it didn’t work, it was ended because of economic difficulties. With saturated fat being taxed at $1.25 per pound, people were crossing the border into Germany to buy groceries, according to WGBH in Boston.

Danish butchers sued, saying the tax violated European Union trade rules. Some consumers accused supermarkets of using the tax as a screen to inch prices even higher. Other skeptical residents saw it as just one more way for the government to line its coffers.

Despite the public outcry over the tax, the author goes on to speculate that were it not for the angry hordes, the program would have finally, FINALLY, solved the Obesity Epidemic:

Did it needle any butter-hungry Danes into cutting back?

The answer just might be yes. Just as the government was announcing its decision to abolish the tax, the newspaper Information printed a story about an as-yet unpublished study by the Institute of Food and Resource Economics at Copenhagen University. According to the institute’s report, Danes’ consumption of butter, margarine and oil did, in fact, fall by 10-20 percent in the three months after the fat tax went into effect, as compared with the same time the year before. But it’s unclear whether the credit should go to the law or the poor economy.

Wow! You mean that when you tax something, it reduces consumption? You don’t say!

Well, I’m so glad that we have definitive proof that the fat tax is still a viable strategy for stopping the fatness.

Oh, wait, it didn’t say that, did it?

And if you ask your run-of-the-mill low carber, they’ll claim that abolishing saturated fat will result in even greater Danes (ha, get it!). As a result of the failed fat tax, the sugar tax they planned is also being scrapped.

The fact is, all the best theories on food taxes say that it has to actually hurt the consumer in order to change behaviors. According to The Washington Post, which has been the primary source for the story of the Danish tax, one study said the government would have to “increase the price of unhealthy food by as much as 20 percent in order to cut consumption by enough to reduce obesity, and they should be paired with subsidies on fruits and vegetables so consumers don’t swap out one unhealthy habit for another.”

Folks, the problem isn’t just that unhealthy foods are cheap and healthy foods aren’t (though that plays a role access to healthy foods). The problem is that most households are stretched thin for time and money, and many just don’t have the time to prepare fresh, wholesome meals like Mom used to make. Namely because Mom’s job used to be homemaker and chef, whereas now it’s homemaker, chef AND breadwinner. In short, it’s complicated, and making convenience foods prohibitively expensive doesn’t change the behavior. It just adds another burden onto already stressed families.

Denmark is learning its lesson now, but America is charging headlong toward futility if the fat tax ever gains traction. In the meantime, the media is doing a bang-up job defending its consumers from any hint of trouble with clever-sounding solutions to obesity.

And not just the clever-sounding ones, either. They’re also protecting the common sense-sounding ones too.

For example, there’s the common sense-sounding advice that if you have type 2 diabetes, you just need to get off your fat ass and lose some weight. But as common sense-sounding as that advice is, the long-term efficacy of weight loss has never been proven for any but a sliver of the population. Of course, that doesn’t stop them from trying.

Eleven years ago, the Look AHEAD trial sought to prove that an intensive diet and exercise program would reduce the risk of heart disease in people with type 2 diabetes. Guess what happened

In September 2012, the NIH stopped the intervention arm, acting on the recommendation of the study’s data and safety monitoring board. The independent advisory board, charged with monitoring the study data and safety of participants, found that the intensive lifestyle did no harm but did not decrease occurrence of cardiovascular events, the primary study goal. At the time, participants had been in the intervention for up to 11 years.

On the plus side, the weight loss improved sleep apnea, reduced dependence on diabetes medications, increase mobility, and improved quality of life. These are all admirable improvements, but who’s to say that it takes weight loss, as opposed to healthy lifestyle changes regardless of weight loss, to achieve these goals.

Few, if any, studies of this size and duration have had comparable success in achieving and maintaining weight loss. Participants in the intervention group lost an average of more than 8 percent of their initial body weight after one year of intervention. They maintained an average weight loss of nearly 5 percent at four years, an amount of weight loss that experts recommend to improve health. Participants in the diabetes support and education group lost about 1 percent of their initial weight after one and four years.

So, after four years of the “intensive diet and exercise program,” subjects slipped from a peak of 8% down to 5% of their starting weight. Using myself as an example, I would have gone from 265 pounds to 244 pounds, then back up to 252 pounds. That data point alone is disheartening information for readers, but what makes it downright depressing the fact that this intensive lifestyle change that resulted in negligible weight loss did absolutely nothing to protect diabetics from heart disease.

Of course, this doesn’t negate the health benefits of healthy diet and exercise for all people. It merely says that diet, exercise and weight loss aren’t the magic pills we’ve been promised.

Dr. David Katz (whom I have previously referred to fondly as Dr. Dickhole) tries to spin the results of the abandoned Look AHEAD trial in US News and World Report, saying it’s a case of too little, too late.

Consider that famous space mission analogy: A mission to outer space is running just a bit off course. If you fix it now, it’s a minor adjustment—a small effort for an excellent outcome. The longer you wait, the more magnified that small diversion from the planned course. The later the correction, the larger the correction needs to be—and the less likely it is to be enough. Once you are in the wrong solar system, the show is over.

It’s the Jim Fixx scenario: sometimes even the most rigorous health fanatic can’t undo a lifetime of self-inflicted damage. If that’s the case, then it’s difficult not to draw the conclusion that it doesn’t matter what we do, as we are all fucked in the end. But I believe it’s more a case that for those with diabetes, sometimes exercise and diet isn’t enough.

But Katz draws a different conclusion by citing a previous study by the same team that was successful:

The Diabetes Prevention Program (DPP)—the precursor to AHEAD, in fact, and based on the very same lifestyle intervention—showed that diet, exercise, and modest weight loss could prevent the development of diabetes in 58 percent of high-risk adults. The best drug we’ve got, metformin, was only half that good.

Katz’s message: if only you had taken better care of your body sooner, you wouldn’t be such a lost cause! Except subjects in the DPP all had “prediabetes,” defined as “a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes.”

Except prediabetes is not a predictor of insulin resistance, according to Dr. Gerald Reaven, the man who discovered insulin resistance in 1988. Prediabetes is measured through impaired fasting glucose (IFG), but according to Reaven, IFG itself is not enough to determine whether a person is insulin resistant:

Although there is substantial epidemiologic evidence that the higher the plasma glucose concentration, the more likely an individual is to develop type 2 diabetes, it is not as clear that the use of IFG provides a particularly effective way to identify either the presence of insulin resistance or to predict CVD risk.

So it’s not actually prevention if you don’t know for certain that subjects are on the cusp of type 2 diabetes. Some of those prediabetics may have been healthy to start with before the intervention began. Making healthy people engage in healthy behaviors will result in — surprise, surprise — healthy people.

Both the Danish fat tax and the Look AHEAD trial don’t make for gripping headlines. When you’re building a media narrative that fatties are the bane of our existence and that the solution is as simple as eating less and moving more, then it’s completely natural to avoid stories that refute that narrative. I mean, if they were up front about these kinds of stories, then who’s going to patronize their sponsors that promote weight loss as the Great American Imperative?

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15 Comments leave one →
  1. vesta44 permalink
    November 15, 2012 11:21 am

    At heart, it’s not about health at all. If it was about health, these studies would be shouted from the rooftops. It’s about the fact that people have been brainwashed into thinking that fat people are ugly and have no right to exist, period. It’s about punishing fat people for daring to exist, for daring to want to be treated with the same respect and human dignity as their thinner peers. How dare we think we’re human beings worthy of life, liberty, and the pursuit of happiness at our current weights? We’re not entitled to any of that unless and until we get thin. And all of those punitive measures that are taken to ensure that that happens – those fat taxes on sugar/fats, those limits on sugared drinks sizes, etc? Those don’t just hit fat people, they also hit thin people and just fuel the resentment/hate toward us. After all, thin people think “Why should I have to pay these taxes or limit the size of my sugared drinks? I’m not fat. those damned fatties are making my life miserable again. Not only are they driving up the cost of my insurance, now they’re driving up the cost of my food.”

  2. November 15, 2012 11:30 am

    A group of doctors in Ontario was just calling for a similar plan, the fat foods tax, as well as graphic warning labels on junk foods. UGH.

  3. Kala permalink
    November 15, 2012 11:47 am

    Ugh, David Katz. Hey Katz, I’ve got a tidbit for you. Perhaps Look AHEAD didn’t reduce the incidence of it’s outcomes (cardiovascular death (including fatal myocardial infarction and stroke),
    non-fatal myocardial infarction, hospitalized angina, and non-fatal stroke), because these are all cardiovascular outcomes that go hand in hand with both age and family history, along with other factors that may or may not be preventable given the situation. Working out and eating 1500 calories a day isn’t going to change one’s age or one’s family history.

    I’m not sure how the risk numbers pan out, frankly, I haven’t read into it. We put a lot of focus on the preventable causes of things like cardiovascular diseases because it’s something you can do something about. Sucks to say to someone, oh well you’re probably going to get this, so, here’s some Rx and let’s hope for the best. So instead we put a lot of pressure on people to whittle down their risk fro preventable causes, but depending on the person, that might be a lot of hardship and stress for a very small whittling of risk.

    It’s like breast cancer, the public narrative on that one may very well be more fucked than it is for obesity. But I won’t rant about that one now.

    But back to Dr. Katz. I’ve read some of his articles on different topics that he’s put on the net, and frankly I’m surprised that someone who writes so stupidly is in the position he’s in. Maybe he’s actually competent if you don’t let him write opinion pieces, I’m not sure.

  4. November 15, 2012 5:10 pm

    Folks- the veil of cyberspace invites rudeness that most decent people would never perpetrate face to face. You might consider that people at whom you choose to hurl insults are real people, whether or not you can see them when you press ‘post.’ I’ll let that go, but simply note that if you make enemies of your friends, you wind up with fewer friends:

    http://www.huffingtonpost.com/david-katz-md/obesity-of-blame-and-sham_b_834937.html

    All best,
    DK

    • vesta44 permalink
      November 15, 2012 7:12 pm

      Dr Katz – I read the article at the link you provided, and that’s a backhanded apology if I’ve ever read one. I’m in the same boat as the woman you saw, and I’ve now settled for seeing a doctor that I don’t really care for because I do at least get decent care for everything except my back pain. He’s like every other doctor I’ve ever seen – the problem is caused by my weight and if I’d just lose weight, the problem would go away. When I ask him “What part of multiple diets haven’t worked, and a failed WLS 15 years ago didn’t work don’t you understand? Why do you think it’s possible for a person who has dieted her way from 250 lbs to 400 lbs to suddenly be able to go on a diet and lose the weight and keep it off forever? It’s never worked in the past, why, why do you think it’s suddenly going to work this time?” I’ve had to tell him that the subject of my weight is not up for discussion unless I bring it up, and I’m not bringing it up unless I lose or gain an appreciable amount of weight in a short amount of time.
      Personal responsibility has nothing to do with whether someone can lose weight and keep it off forever. What does matter is if the person has the stubbornness required to stick to a starvation diet forever and exercise like a hamster on speed forever in order to lose weight and maintain that weight loss. Most people aren’t disordered or obsessive/compulsive enough to be able to do that for a lifetime. Apologizing for the way doctors have treated fat people in the past, and are still treating them today, and then turning around and saying that weight loss still needs to be addressed negates your apology. There is no way to tell a fat person that zie needs to lose weight for hir health when there is no proven way to turn a fat person into a thin person, permanently. If you can’t offer anything better than another diet that’s going to fail, or WLS that’s going to give them complications that are worse than being fat, why are you even a doctor? Because believe me, that doesn’t meet the criteria of first, do no harm. Address their health, give them ideas on how to eat healthier meals, get more or better exercise, and leave weight out of the conversation. Your patients will feel a lot better, and their health will probably improve, even if they don’t lose weight.

    • November 15, 2012 7:21 pm

      Sure, but isn’t that predicated on the assumption that you are my friend — and/or that you’re the friend of any posters or commenters to this blog?

    • November 15, 2012 8:18 pm

      Dr. Katz,
      You lost any claims to civility when you began using (and reusing) your airplane anecdote to compare two complete strangers who are cheesepuffs in front of a child to a parent who would give their kids drugs or alcohol. You have repeatedly wrote articles that stereotype and degrade fat people as if the underlying health problem is the size of our asses and not the behaviors that day and thin people alike engage in. In short, you have enthusiastically and unapologetically waged a war on fat people in an over-simplified attempt to discourage bad behavior. You don’t reduce smoking rates by insulting people with yellow teeth, and you don’t reduce the rates of insulin resistance by insulting fatties. So I’m not too concerned about which friends of yours I might lose because you have never been a friend to people like me.

      Peace,
      Shannon

      • Kala permalink
        November 15, 2012 11:05 pm

        Oh man, the cheesepuffs article on Huffpo. I remember that, that one was grand.

        It’s hard to take the article he linked us to with even a shred of sincerity with that kind of context.

    • November 15, 2012 10:19 pm

      Hey, Dr. Katz, here’s something I’d say to your face: go fuck yourself.

      You cannot come in here and pretend you are some kind of all-knowing oracle about my life, about all fat people, when all you see is data which you and your ilk cherry pick and manipulate. You talk about civility in cyberspace – why should I give you any when just about every word you write is an insult to me and mine?

    • bj1980 permalink
      November 16, 2012 10:25 am

      “We do not, as a society, want to normalize ill health or the factors that impose it.” What are you saying, doctor? ‘Obesity bias is wrong, except when it’s used to promote good habits?’

      Dr. Katz, by calling obesity a pandemic you’re calling me — a fat person — a plague carrier. I can’t make people fat by touching them, sharing space with them, or swapping fluids with them. I’m not Typhoid Fatty. The public is safe from me.

      I do apologize– no, you know what? I *don’t* apologize. Anti-obesity rhetoric from providers is counterproductive and discourages people from getting medical attention THAT CAN SAVE THEIR LIVES; you think a single apology makes it all okay? With all due respect, what were you expecting?

  5. November 15, 2012 7:05 pm

    Dr. Katz, As long as one of your main goals in life is to rid the world of fat people you will be an enemy and not a friend of those fighting for fat acceptance.
    Warmly,
    Rhonda Simon

  6. JeninCanada permalink
    November 16, 2012 12:18 pm

    Blergh. Am trying not to get drawn into a debate about ‘just eat good food and get off the couch!’ on a friend’s facebook wall where he posted about the Denmark fat tax being withdrawn.

  7. lifeonfats permalink
    November 16, 2012 4:45 pm

    Hey Dr. Katz,

    If shame and degradation worked, than all fat people would be thin. Since we’re not, you need to pick some more compassion, take a hard look at genetics, socio-economics and ethnicity, and stop treating your fat patients as diseases on two legs and start treating them as HUMAN BEINGS. Is that really so hard for you?

  8. pyctsi permalink
    November 16, 2012 5:42 pm

    Gotta love a guy who basically says, ‘waaaah you were mean to me, I’m a real boy,’ when his writing career is – as far as I know – based on removing the humanity from fat people and making them abstract examples, denying them their right to be real.

    As someone who has be told to lose weight by several doctors who said it would magically cure my back ache (caused by having large breasts and improperly developed back muscles – ’cause I wasn’t told I needed to work them out, just lose weight) and generally ignored by doctors who fob me off with prescriptions I don’t want and possible don’t need – doctors who didn’t bother examining me to determine the cause of my pain, I do not feel that his apology is acceptable especially as it appears to be half assed and trying to distance himself from other doctors.

    The current doctor I am seeing has given me treatment for problems, suggested I increase my exercise and improve my core strength and actually touched me to complete the examination. Even if she doesn’t agree with me totally she is working with me to improve my health and has enough empathy to make me trust her and actually willing to see a doctor when needed rather than just hoping I’ll get through it.

    TL/DR This guy comes across as two faced and untrustworthy as a doctor and I’m glad there are a couple who aren’t.

    • November 19, 2012 1:19 pm

      It is kind of sad that he recycles this anecdote that he compares to drug pushers, then says, “Hey, don’t be mean. I’m a person!” Ah, okay, I see how that works.

      Peace,
      Shannon

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