Not All Obese People Die From Fatness. Well, Duh

Aside

Most of us know how inaccurate the BMI is as a measure of fat & health. A 16-year prospective study just released shows that obesity alone does not determine mortality down the road.The study followed 29,533 volunteers from the Cooper Clinic in Dallas over an average of 16.2 years; 6,224 were considered obese; the obese folks were categorized into a 4 point classification system based on fatness-related illnesses – Edmonton Obesity Staging System (EOSS) levels 0-3.

One of the things I did in my former life was to critique scientific articles. I won’t do that in detail here but will point out a few limitations and summarize. Plus, I encourage you to read the results in the abstract plus look at Table 1 to see the EOSS classification system of health that they used rather than BMI and Table 2 to see the characteristics of the participants.

Bottom line: the more obesity-related diseases at the start (for example, diabetes, heart disease, hypertension, sleep apnea, limitations in daily activities, even mental health issues), the higher risk of mortality over follow-up in  EOSS groups 2 & 3. Those in the EOSS classes 0 or 1 actually had lower risk for heart deaths. All EOSS categories had higher risk of cancer. (See Figure 1 from the article below for a picture of risk of death at the end of the study.)

The participants were highly educated, White men (sigh), which means this is not representative of most of us. Not all participants were available for follow-up over the entire study, and the length of time the participants were followed varied by group. (For example the normal weight people were followed for an average of 17.6 years, EOSS 0 and 1 for 18.4, EOSS 2 10.2, and EOSS 3 11.9) I don’t see that the authors attempted to account for this statistically. (But I didn’t read it that closely in my attempt to get this on the blog quickly.) Weight or fat measure was not analyzed over time, so fluctuations could have occurred differentially among the groups.

This doesn’t mean stay fat. This lends credence to the saying, “fat and fit” (If you are a wealthy, educated White male living in Texas…) But the cancer risk is hard to ignore. More importantly it provides a measure for other studies to use rather than BMI for measuring risk in fat folks. Also, if I were a practicing doc, I would start incorporating this scale to assess risk and advise patients. (Because BMI sucks so badly.)

A final caveat. Although this study shows increased risk of death among those with more fat-related (my words) conditions, it does not prove that treatment of fatness or the related conditions will decrease the risk of dying or dying from cancer or heart disease. This study does not address that question. But it is always tempting to extrapolate…

HR=hazard ratio. How much more at risk than the normal weight group. NW=normal weight. CVD=cardiovascular disease

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National Coming Out Day

Those who have read my blog (and between the lines) probably realize that I am a lesbian – big deal. That hardly defines who I am, but my life partner certainly defines my chosen family. So, on “National Coming Out Day” just to be sure anyone who reads the blog knows, I am happily partnered to another woman, and we would be married for the past 20 years if it were legal in the United States.

Why spend time on a weight-loss blog discussing my sexuality? Several reasons. First, I am distressed about the teen suicides resulting from bullying and want parents to know that it is beyond OK for their kids and relatives to be gay, and it is far from acceptable to tolerate bullying. It is also beyond difficult to grow up gay. I spent years struggling with my sexuality, especially as the daughter of an evangelical minister, and then entering a profession (medicine) that did not look kindly on gay physician’s in the late 70’s. I did not come out publicly while actively seeing patients. I hid – from my family, my friends, my colleagues, myself.

Second, I think hiding had much to do with gaining weight (100 pounds!)  during my residency, which is when I admitted to myself that I was gay. Did you know lesbians are 2-3 times more likely to be obese than straight women? This might be a generational phenomenon as homosexuality becomes less of a stigma, but given that gay kids are killing themselves and gays are brutalized for just for being gay, it’s still a stigma.

Third, I want to remind people that gay folks just want to be treated like anyone else – like any other American human. We want to be loved and respected for who we are – not because of our sexuality or in spite of it, but because we are humans in need of connection. We are your neighbors, your teachers, your housekeepers, your lawyers, your doctors, your congressmen, your clergy, your children.

If you do anything today, help to stop bullying of kids – bullying for any reason. Teach your children well.

 

Me, Dad and Sue at the Grand Canyon last week

 

Movin’ Through Manhattan

What a difference a year makes! Last March I could barely lumber my way to taxis as we navigated the Big Apple, and forays through musuems, shopping, sight seeing excursions, etc. were cut short by my lack of stamina and aching joints. Yesterday we walked miles (my knee says it was miles) through lower Manhattan, popping in and out of subways (stairs and more stairs), laughing as we ended up heading to Brooklyn rather than Central park, refusing to give in to food unless we were hungry. I had a blast!

We went to Zabar’s to gather edibles for a dinner in, and I fell fast asleep watching “Shutter Isle” while icing my knee.

Now I am wide awake at 2 am planning our day so we won’t be too pooped for this evening’s 4-hour opera at The Met. I am wearing HEELS!

(Pic is outside The Met at Lincoln Center taken two nights ago when we saw South Pacific at the Vivian Beaumont Theater in the complex)

Lincoln Center in New York

Come Fly With Me

After the angst of preparing for our week in NYC and feeling wretched from trying on clothes, I experienced almost childish glee as we settled aboard the small jet on the first leg of our trip.

We had to sit side-by-side because all of the 1-seat portions on the regional jet were full. My love never complained about my hips impinging on shared arm rests, but I always felt bad for taking up more room on our trips. This time there were inches to spare around me as I plopped down, and the seat belt had way more (see childish) than 6 inches left after buckling. Just last February I still required an extender. She was completely unsurprised, “You still expected to not fit after loosing 70 pounds?” Another body re-check for me.

Small victory – wait no it isn’t. No more carrying my extender (I have 2 that I’m willing to give away); no more trying to make myself invisible as I lumber down the aisle; no more glances from other passengers that imply, “Please, god don’t put her next to me”; no more avoiding flight attendants’ disapproving glares; no more fear of flying.

Monitoring My Obesity Hormones – Yeah, Right

The beauty of self-monitoring one’s behavior is that — if you bother to go back and read — you have a chance to watch your self (“self” intentionally left separate), maybe even catch yourself before you slip. Well, I might be regressing, not sure though. Using the Livestrong website (I have no commercial interest) allows me to keep complete track of my nutrient intake and physical activity. An interesting discussion with a wonderfully ancient woman in the grocery store made me go back and check my sodium intake, which is well below 2 grams per day. I noticed, however, that I have been lumping my calories in “gulps”.  Breakfast – check. Usually a banana, half-n-half in my coffee (yummy fat and protein), then nothing, nada, zilch until dinner and even later when I eat the remainder of my allotted 1200 calories – if I even eat that much. Hmmm.

Why am I doing this? Does it matter to my weight loss?

Part of the reason that I don’t eat after breakfast is that I have no hunger mid-day, even though I am listening to my body for physical hunger. When it is time for the family dinner and I start eating then I want to eat more. As the Germans say, “The appetite comes at the eating.” I’m concerned that my evening appetite is not hunger but something old, primitive, anxious, and eating is a way to sooth the feelings. Or, maybe there is more to it.

The impact on weight loss… Current data seem to suggest that when you eat (time of day) really doesn’t matter – throw out that “no food after dark myth.” Now, how often you eat just might be crucial to regulating hormones that control appetite and metabolism, such as leptin, ghrelin, insulin, growth hormone, god knows what else. Unfortunately, I cannot find anyone who agrees on the exact mechanism of how these hormone interact – except that they are screwed up in obese people. For example, leptin suppresses hunger but us fat folks have an excess of leptin. Also, no one agrees on how one should adjust the timing of meals to best manipulate these endogenous chemicals to help with appetite and thus weight loss – eat every 3 hours, 5 hours, don’t eat after 7, wait 11 hours between evening meal and breakfast, yada, yada, (and no scientific evidence, i.e., WAGs). Oh yes, there is a link between ghrelin and sleep and obesity – enough evidence that I can say – GET YOUR EIGHT HOURS!

I am convinced that eating the majority of my calories in one setting is bad for my weight loss. Why? Who the heck knows the exact mechanism? I will be looking at this with a scientific eye and getting back to you. For now, I’m spreading out my calories, getting back into a routine, and with the help of my physical terrorist, walking again!

Mad scientist cartoon juggling hormones

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Plateau Obsession

You know you’re obsessed with plateaus when you start to label them on your weight loss chart. No, really. I call my last one the “WTF Plateau” because after reviewing my records there is NOTHING that indicates why my weight loss was stalled for one month except that it happened — until 2 days ago when I dropped 4 pounds overnight. (And, no, I don’t have those female fluctuations in hormonal water retention any more.)

I have been reading about these pauses while dropping significant poundage – perusing forums, various “expert” websites, even tried searching the medical literature. Everyone seems to have the same basic answer, which I loosely interpret as: “Your guess/suggested reasoning is as good as mine.” In medicine, we call these WAGs or “Wild Ass Guesses”. If there is the faintest bit of evidence behind the proposed answer then it gets a SWAG, “Scientific Wild Ass Guess”.

I know you are holding your breath waiting to find out my discovery as to the nature of weigh-loss plateaus (I won’t bother with the ridiculous theories on how to break them – time seems to cure all):

  • The recent medical literature on weight loss plateaus all relate to post-op obesity surgery – not much help here (thanks guys & gals)
  • Plateaus are reported universally (among those writing about weight loss) and vary in length of time
  • Loss of lean body mass (muscle) before fat = decrease in metabolism. Makes for a good SWAG.
  • One can get into “starvation mode” eating too few calories and shut down metabolism – hard to buy since obesity surgery works so well so quickly and for so long
  • Your body adapts to whatever diet/exercise regimen you are on – show me some data. I want to see that obese people who are losing weight drop their metabolic rate significantly. This does happen once you reach goal and start maintaining , and I will be happy to deal with that burden once I get there.
  • Fluid retention – well, duh, ask any woman, but fluid retention for a month in a post-menopausal woman?
  • A calorie is NOT a calorie (just ask those who do low-carb eating) and getting stuck is from the relative consumption of too many carbs. Another SWAG, this one based on the thermogenic properties of macronutrients (takes more calories to burn up proteins and fats). In fact, there is evidence in healthy subjects that this is true. Does this apply for us really fat folks? Who knows – we don’t get studied much unless someone wants to operate on us.
  • Your exercise regimen is making you gain muscle mass, which weighs more than fat. DO NOT MAKE ME LAUGH. Maybe if I were losing from 130 pounds to 125 this might be the case, but losing 140 pounds, nope.
  • The scale is a sh!tty measure of weight loss efforts. I am beginning to believe this one from personal experience. Body fat percentage is probably what we are really shooting for here. The scale just cannot accurately assess body fat. Waist circumference is as close as one can come at home.

Bottom line. Weight loss as measured by a digital scale is not predictable over a prolonged period of time. Since BMI relies on weight, it also is a flawed measure.

So, why aren’t I deleting my weight loss goals and replacing them with body fat percentage? Good question.

Age-Adusted Body Fat Percentage Recommendations

Women

Age Underfat Healthy Range Overweight Obese
20-40 yrs Under 21% 21-33% 33-39% Over 39%
41-60 yrs Under 23% 23-35% 35-40% Over 40%
61-79 yrs Under 24% 24-36% 36-42% Over 42%

Source: Gallagher et al. Am J Clin Nut 2000; 72:694-701

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Six-month Check In

Time flies when you aren’t gaining weight. Daily self monitoring sometime becomes a “losing the forest for the trees” kind of thing, thus, time to reflect and see how I have been doing with behavior changes and remind myself and the vast (cough) number of readers what is working, what I’ve thrown out, and what my latest doctor visit revealed.

As a summary, my plans for weight loss were kick started by a laparoscopic cholecystectomy September 16, 2009. Resulting complications left me unable to eat much for over a month. My surgeon, Dr. Katie Artz, performed a superb procedure using only one incision, and she was amazingly tolerant of me. During my pathetic attempt to play patient through unexpected pain, numerous tests and ridiculous GI side effects, I resolved to make permanent lifestyle (ah, that word) changes and worked hard to outline clear behavior goals and get my partner on board to support me.

Defining goals in terms of behavior change, not just how much weight one wants to lose, is a crucial component of being successful. Ask me, I’m a behavior change expert – no really, want to see my research publications? I consider weight “goals” to be long-term outcomes of behavior. I do know it is  important to establish those long-term and intermediate weight outcomes (as I have posted on the sidebar), but without knowing how you are going to get there, it’s impossible to just go out and lose 140 pounds. Holy shit that’s a lot of weight to lose! Another reason for breaking down the goals into behavior change components is that individual behaviors are much more doable than just dropping an entire person off your body.

Knowing what has worked for people who have successfully lost weight and maintained that loss, knowing from scientific data what people do to change health habits (on their own or with help), knowing my own stumbling blocks from prior losses and regains, here is how I started: I chose a ultimate weight outcome, intermediate weight outcomes, a physical activity outcome and then listed what behaviors I needed to do to get there. January 8th I posted these. Now time to revisit.

I have done stellar at self-monitoring my weight and food intake. I’m still eating a higher percentage of carbs than I would like, but they are complex carbs, so I will live with the current balance between carbs/protein/fat. I still do not eat any protein from animals with eye lashes (go figure – it’s some aversion that occurred postop). No sweeteners – check.  All food within my reach is something on my plan because I still have such low impulse control. The only refined products are Lean Cuisine© and Eating Right© frozen dinners plus the occasional protein shake + skim milk to supplement protein and calcium intake. Fruits and veggies easy now with huge salads, fresh fruit with lunch or breakfast, and low sodium V8 as a treat. And, I have not even looked at ice cream. Breakfast, ummm, sometimes after my morning coffee it’s already time for lunch, so that needs improvement. Although I do not indulge in late night eating any more, I do eat dinner after 7 pm frequently. I need to rethink my time limit or buckle down and cut off eating by 7 pm.

I have continued to keep my family and partner in the loop of what I am doing. Sue and I have effectively blocked her mother subverting my eating plan this winter (perhaps another post about family sabotage later). I stay connected to online support groups because that is the only place where I have been comfortable getting and receiving support in this effort. When I feel a bit edgy, usually in the evenings, I appease my other senses by lighting candles, having an abundance of herbal teas, luxuriating in my therapeutic tub with exotic mineral salts, playing non-violent video games (a change in my gaming pattern), holding the pets, listening to music more, and trying to write more.

My physical activity long-term outcome of walking a 5k is on hold because of a knee injury. An appointment with orthopedic surgeon scheduled since walking around the block is almost impossible at this point.

Having lost 61 pounds and eating so healthy, I proudly presented myself to my PCP for a routine visit, a recheck of cholesterol, and follow-up on liver enzymes that were out of whack for months after surgery. I had gone off my cholesterol lowering med because of its effect on the liver and the fact that I was eating so damn healthy. Good news, my blood glucose is low, low, low; liver enzymes are back to normal. Bad news, my total cholesterol is higher than it has ever been; HDL cholesterol (the good kind) is high; but LDL (the bad kind) is very high. So back on medication. Rats! Also, my blood pressure was elevated even though I am on a beta-blocker for another condition. WHAT THE HECK?

So now… Nothing to change on the diet front. I satisfied that my salt and fat intake are not contributing to my cholesterol and BP problems. In fact, I’m giving myself a huge pat on the back for keeping my behavior changes going although I have so much more to accomplish and a lifetime ahead of me. There are other ways that I can be physically active that do not involve my knee – looking for a pool (we must be the only people in our Tucson neighborhood without one) where I don’t feel too self-conscious showing so much flab. Checking blood pressure 3 times a week for now. Starting on new cholesterol med.

I do allow for special occasion eating. Life goes on, and it’s OK to have a romantic 5-course dinner that includes a few bites of desert – as long as I plan for it.

Oh yes, I am enjoying buying new clothes but still disgusted with my body. Fodder for another post.

Peace.