Monday, May 9, 2011

What Obesity and Nicotine Addiction Do Have in Common

Ok, this post is not about comparing overeating to smoking. It is also not about borrowing obesity prevention or management policies from tobacco. And it is most definitely not about even suggesting for a moment that obesity solutions are even remotely related to the way we have dealt with with smoking by making it socially unacceptable, inconvenient, or unaffordable.

This post is about something very different. It is about how, in my experience, many “obesity deniers” often use the very same strategies and arguments used by ‘Big Tobacco’ to discredit even the suggestion that there may be an obesity epidemic out there and that, even if it did exist, it has any impact on population health.

These strategies, that could have been directly gleaned from Big Tobacco, include the following:

1) All scientific studies are flawed and inconclusive – associations do not prove causality.

This is a very common strategy used by interest groups to discredit any unwelcome research findings. Thus, despite experimental proof of carcinogenicity (biologic plausibility) and overwhelmingly consistent associations between smoking and health risks (coherence of data), critics and activists argue away all such evidence with the following tactics:

a) findings in animal studies or cell culture cannot be extrapolated to humans.

b) smokers have poor health not because they smoke but because they also don’t exercise, eat poorly, lead stressful lives, are risk takers, have lower socioeconomic status, etc, etc, etc.

Indeed, anyone even suggesting that tobacco may be unhealthy and smoking cessation may be a good idea is accused of not understanding the literature, jumping to conclusions, ulterior motives, promoting the nanny state, inability to see the big picture, being a ‘health nazi’, and countless other ‘personal’ accusations (if you can’t discredit the science, you can always discredit the scientist).

2) Present anecdotal evidence and personal stories and testimonials:

These arguments fall along the lines of pointing to people who smoked all their lives and died after falling out of bed at age 104 or the fact that most people who die of heart attacks, strokes or cancer never smoked a cigarette in their lives. I have heard the quote, “you only have to look at me to see that smoking does not kill people”.

3) The need for nicotine is a ‘natural’ condition

Here the argument is that some people (not everyone, but many) are genetically (or otherwise) predisposed to addictions and that for them smoking is simply a natural way of dealing with this ‘condition’ – in fact they will point out out that smoking is perhaps one of the lesser of the many evils that such people could turn to, so trying to get people to stop smoking would simply be driving them to overeat, drink or use illicit drugs and can even result in severe depression or suicide.

Very closely related to this ‘tactic’ is the statement that tobacco cannot really be all that harmful, as it has always been around, has been part of traditional ceremonies, and serves an important social function. This also implies that ‘medicalisation’ of smoking is simply Big Pharma wanting to sell you smoking cessation pills, gums or patches (with all of their risks and side effects) or doctors wanting to make money with smoking cessations programs.

4) Trying to get people to stop smoking is pointless because recidivism is so high and there are so many negative consequences of actually quitting.

According to this line of argument, because quitting is tough, risk of relapse is high, and negative consequences (see above) cannot be ruled out, it is perhaps better to simply let smokers smoke and focus more on helping them improve other aspects of their lifestyles – better to be a healthy smoker than an unhealthy non-smoker!

I have long given up even arguing about this issue with ‘deniers’ because I never sense that I am dealing with people, who are even open to discussion. No amount of data or arguing will change strongly held beliefs and convictions, so it is pretty much a waste of time trying to expect rational discourse.

Fortunately, I can generally chose to ignore this issue, because I find it a far better use of my time to help those, who actually want and value my advice. Those, who believe my advice is wrong or misguided, are more than welcome to ignore it.

I have never approached medicine with the goal to change the world – my goal has always been to understand what each of my patients wants and give them the best advice I can, based on my understanding of their needs, issues, and circumstances and on my experience and knowledge of the science and art of medicine.

In the end everyone is welcome to take it or leave it, like it or not – I learnt a long time ago to never take rejection or opposition from patients personally.

On the other hand, I do love a serious discussion – i.e. one where the discussants do not have firmly held beliefs, unchangeable ideologies, or axes to grind – all other discussions, are largely a waste of time.

When evidence changes, I change my opinion – I am never locked into any view or opinion for any reason other than what my knowledge or understanding of a topic convinces me is current best knowledge.

I am happy living with uncertainty and ambivalence – I will be the first to admit that I do not have all the answers.

Indeed, having all the answers would be pretty boring. As I;ve said, before, I certainly prefer the uncertainly of knowledge to the certainty of ignorance.

AMS
Ottawa, Ontario

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20 Responses to “What Obesity and Nicotine Addiction Do Have in Common”

  1. fredt says:

    Thanks for your post. It is more evidence that we “easy to fatten” have been marks to the food industry for a lone time. They do not have public health uppermost in there minds. The food industry is corrupt, with corrupt marketing, and much is owned by old tobacco money. How do we know what information to trust?

    Overcoming addiction is tough. Tobacco was the easiest of the three that I overcame. Sugar was next, and next easiest. Wheat was tough, I craved for about a severely for about year. Withdrawal included bad headaches, different from low glycogen headaches. Both wheat and sugar creep into my food occasionally, and result is intense cravings. Both are everywhere. With sugar and wheat generally gone, I dropped 55+ kgs. Manufactured oils, or Omega 6 oils also appear to be addicting, or hyperpalatable, but it is difficult to cut to 2 gm/day as it is everywhere.

    Keep up the good works.

  2. Ellen says:

    What medical school did you go to where they taught you that associations do prove causality? There is increasing amounts of evidence that shows that disease, discrimination, and dieting may be causing obesity, not the other way around. We are doing more harm than good by going after what maybe a symptom in some, and maybe a natural body type in others. These efforts are in large part either causing more weight gain at best or trying to cure a symptom and ignoring the disease at worst.

    It is disingenuous to say that people who question the panic surrounding obesity discount ALL scientific studies. It is important to understand that you need to look at a body of evidence, not particular studies, because they each have their limitations. You absolutely cannot take a study and treat it as definitive proof. This is especially true when you are dealing with observational studies. It is also equally important to understand how biases and stereotypes influence the interpretation of these studies. To say that people should not critically look at the interpretation of scientific data does not add to your argument.

  3. Marilyn Wann says:

    This analogy is total bullshit and seems motivated by deep discomfort with the possibility that a genuine commitment to scientific method (rather than the usual weight-based stereotypes treated as fact) might produce a result different from the one you like.

    Correlation can only suggest direct causation with a very high correlation, if then. People who smoke tobacco are 300 times more likely to die from lung cancer alone. Even the fattest people barely have a doubling of morbidity/mortality risk and that correlation is even weaker for subpopulations. If you can’t see the significant difference between the number 2 (doubling of risk) and the number 300 (300 *TIMES* the risk), then that’s even more reason why a self-respecting fat person like me would question the ethics and efficacy of someone like you, who insists on believing in the failed, weight-based paradigm.

    You insist on treating BMI as if it is a behavior. I refer you to setpoint range, a concept that was clearly supported by the data and becoming popularly familiar in the 90s until the diet drug and weight-loss industry interests killed it.

    As a fat rights activist, I do not have a death wish. Quite the opposite: I’m opposed to attempts to “cure” me of my difference that are only likely to endanger my health and/or my life. I am not an activist on behalf of laziness or gluttony. Anyone who imagines that I am is engaging in the sorts of stereotypes that fuel weight-based prejudice. In fact, I believe that early data suggest a Health At Every Size approach does a vastly better job at supporting people in maintaining health-enhancing eating/exercise behaviors for life. (Unlike a weight-focused approach, in which people clearly only maintain improved behaviors for brief periods of time.)

    If we care about health and about health-enhancing behaviors, a weight-neutral approach is clearly the better option. If we care about weight conformity and don’t mind encouraging poor health, mental distress, and other ills, then a weight-focused approach is what one would choose.

    If everyone ate “perfectly” and exercised “perfectly,” weight diversity would still exist and your work — Mr. Sharma, you’re not any sort of doctor to me! — would still be suboptimal for goals of public health and social justice.

  4. DeeLeigh says:

    On the other hand, I do love a serious discussion – i.e. one where the discussants do not have firmly held beliefs, unchangeable ideologies, or axes to grind – all other discussions, are largely a waste of time.

    Really? Because this entire post seems designed to discredit people who think critically and/or who disagree with you. It even implies that medical professionals and activists who believe that health can be addressed independent of weight (HAES) are somehow analogous to big tobacco.

    However, in the case of obesity, it’s the people selling the “solutions” who are making the money. The people who are questioning the weight based paradigm have very little money or authority behind them. And these “solutions?” They’re like smoking succession aids that independently raise the risk of lung cancer.

    When I read a study – any study, even one I think is probably right – the first thing I do is ask “where could this have gone wrong?” Unfortunately, critically thinking is rare these days, even among well educated and successful people.

  5. NewMe says:

    Dr. Sharma,

    I can only assume you are still coming down from the “high” created at the Obesity Conference where no doubt everyone was on the same obesity epidemic wavelength.

    I think DeeLeigh sums up my opinion of this appalling post of yours when she says:
    [...] this entire post seems designed to discredit people who think critically and/or who disagree with you. It even implies that medical professionals and activists who believe that health can be addressed independent of weight (HAES) are somehow analogous to big tobacco.

  6. Deb Burgard, PhD says:

    Dr. Sharma,

    I agree that the tobacco industry made such arguments, but there were RCTs and plenty of empirical studies that show a causal link. This is not the case with fat tissue. An industry that stands to make money clearly has a motive to ignore empirical data. It is disingenuous to compare ignoring data to demanding data when it is not there, especially when it is a grassroots movement challenging the healthcare, pharma, food, and weight loss industries.

    I have not seen any evidence that trying to quit smoking and failing leaves a person with negative psychological or physical sequelae, but I have seen plenty of evidence that trying to lose weight and regaining it is quite a different story. I know that this is the doubt that beats at the heart of every ethical healthcare provider’s discomfort with suggesting yet another diet that is so much more likely to end in a worse outcome for the patient you care for.

    Ironically, the tobacco industry must be thrilled by the focus on obesity these days – the money that went to combating smoking has been diverted to the ineffective and harmful anti-obesity campaigns, and smoking rates are up among young people who are trying not to be fat.

    People who are criticizing the anti-obesity public healthy campaigns are using plenty of evidence to make their arguments, while the people who are running the campaigns have not had to prove they have effective interventions that do no harm before their are foisted upon the public – because “we all know fat is bad.” It puts people who are asking for evidence before implementation in the role of “proving they don’t work” – rather than regarding the burden of proof as lying with the people who are intervening. A very strange state of affairs, one which is common when it is culture rather than science running the show.

  7. DebraSY says:

    Sigh. Dr. Sharma, I am sad. I sense you’re exhausted from parsing differences with the HAES crowd and you are cutting bait. And, in fairness, the HAES crowd has not been entirely measured and patient in its engagement here recently. (Grrrrrr.)

    Here’s what I know, as a failed HAES practitioner and long-term weight-loss maintainer: HAES is not a form of denial, anymore than the three-dimensional approach you take is. Neither you nor the HAES people have all the answers. I don’t have the answers. However, many people/corporations/moneyed interests CLAIM to have the answers, and they create a vocabulary and set of assumptions that is unhelpful but defines all of our discourse.

    In the grand scheme of things, I’m sure you live comfortably, but you are not a serious moneyed interest along the lines of General Mills, Kraft, Pepsi, Allergan or Johnson and Johnson. You’re just trying to help people. HAES is not a moneyed interest at all. They’re just trying to help people.

    No one in the HAES movement denies that obesity exists, nor do they deny that it can create complications (physical and medical) for fat people. (They have a different approach to dealing with it, yes.) Most HAESers also acknowledge that obesity is getting more prevalent. We’ve always had a bell curve that expresses the distribution of our weight in society. Most people in the HAES movement also acknowledge that the center has shifted, and that the curve has morphed and flattened. Yes, we have grown taller, but our weight has shifted upward more dramatically in the past four decades, and especially the past two.

    Now, why is this? And what should be done about it? Normally, you are closer to HAES on these answers than you are to diet culture and the moneyed interests. On your more peaceful days, you agree that science needs to be questioned, tested. You have written about weight bias among those who should know better (the Kelly Brownell studies). On your better days, I think you wouldn’t call people who ask questions “obesity deniers.” I’d like to think you’d use more measured language.

    The divisive vocabulary of diet culture and othered moneyed interests, includes, for example, “portion control” (which, because of big food, only refers to quantity and actually boosts profits). ELMM street was built by big money, and you have taken a sledge hammer to it in the past, but now you’re attacking your fellow hammer-weilders.

    Last week’s posts were hard to watch. Big processed food endeavors to “build trust” with the medical profession at obesity conferences, and HAES isn’t even invited to participate in the discussion. You come home to a blog page under attack, as it were, because you have been open to HAES in the past, and are showing other colors now.

    Last week that flare up between you and Linda Bacon made me go, “Hmmmm. The fecal matter is really hitting the oscillator.” I was saddened by both Linda’s words and yours. My first shock, however, happened when you accepted the Alberta Money-Scare study without guile or questions. Is it useful to portray fat people as a financial drain on society? (Big money interests, such as the insurance industy, think it is!) Is it accurate? Really?

    I hope you will take time, breathe, cogitate. Come back to the center, as you define it. And open the discourse, again, even though it’s exhausting (and you won’t even get a conference goody bag with coupons and other prizes).

  8. Jennifer says:

    Hi Dr. Sharma,

    I love this post, and I think that the analogy is apt. Thanks for posting it!

  9. Rachel says:

    I think using the analogy of the tobacco industry is provocative. I can see why some readers are offended. The biggest difference being motivation: tobacco companies care only about financial profit while “obesity deniers” do appear to care strongly about people’s wellbeing.
    Having said that I do think there is a risk to politicizing obesity more than it already is. I agree with Dr. Sharma that there is a very worthy scientific debate to had that will help people in the end. Polarizing the debate on the basis of social values and politics is not helpful. I’d like to see science debates clearly distinguished from values debates, recognizing that there is a relationship between the two. We need to debate science with science and values with values but not science with values. When the two are blured noone wins.

  10. Susan Koppelman, PhD says:

    “To smoke” and “to be fat” are not grammatical parallels. To compare them is fallacious. It’s sort of like comparing “walking” with “blue-eyed.”

    “Smoking” is a behavior. “I smoke, you smoke, she/he/it smokes.” To smoke is a verb.
    “Fatness” is a state of being. To say, “I fat, you fat, she/he/it fats” is ridiculous. What, Dr. Sharma, are you suggesting is the parallel verb?

    I heard a brilliant presentation on this fallacy at the recent Popular Culture/American Culture Association conference by Jay Solomon. (Jay Solomon, More of Me to Love,
    Size Doesn’t Matter. You Do., O: 267.882.7169, M: 888.MOMTL.29,
    Jay@moreofmetolove.com) He suggests that the grammatical parallel to smoking is “obesing.”

    Most people of good faith, good sense, and without financial vested interests, agree that calories in/calories out is an inadequate explanation of different embodiments. They agree that there are many reasons why some people are fat, some thin, and some in between. They agree that those reasons are complex, not yet well understood, and, in general, not necessarily relevant to health, longevity, or general well-being (except insofar as being the object of discrimination, blame-laying, hatred, etc. leads to extreme stress which is, as everyone knows, unhealthy!). They further agree that although we think we know lots of reasons why people are or get fat, there are probably other reasons we haven’t yet begun to guess at. There are some fascinating speculations going on in the area of species studies, eg. What survival value to the species is it that some of us are fat, some thin, and some in between?

    I wonder where Dr. Sharma stands on the issues of good faith, good sense, and financial vested interests. I wonder what would lead him to write such a logically fallacious article. I wonder what kinds of grades he got on his middle school grammar tests.

  11. Arya M. Sharma, MD says:

    @susan: note the use of the word “addiction” (I am guessing ‘noun’?) in the title. Since when is addiction a behaviour (he/she/it addicts?!?) :)

  12. HopefulandFree says:

    With this kind of inflammatory rhetoric over-taking discourse (“obesity deniers”), I can’t help but wonder how long it will be before “obesity epidemic” is socially constructed as the obesity holocaust–but then in many people’s minds, it appears, the toll on society (and innocent non-fat people) supposedly resulting from obesity (well, from fat people) is already being measured in how much it is costing “our nation and our world.” Gee, WWIII, anyone?

    Fat people are being attacked and blamed and vilified for a condition (however one defines it and understands it) over which, once it is established in human bodies, there exists little individual ability to control through individual efforts, at least not on a permanent basis. And certainly not without risks, and questionable long-term benefits. You’re right. This isn’t quitting smoking we’re talking about here, as you noted in the beginning. So why inflame the issues with rhetoric that compares denial about the benefits of quitting smoking (tobacco) with valid concerns about the health benefits/risks of losing (and regaining) weight–without acknowledging the risks of repeated weight re-gain, including mental health risks, and, perhaps especially, without acknowledging the very real harm that results throughout society when fat people are expected to change a physiological condition, as individuals, which doctors and scientists are unable to tell them HOW to do, safely and effectively?

    What has happened to “First, do no harm”?

    Can you NOT see the harm being done to fat people–and to people in general when they are handed a professionally-sanctioned free pass, an excuse, to inevitably view fatness as a sickness? (Or even a self-caused sickness.)

    Can you not see the harm that results when professionals, such as yourself, continue to hold individuals responsible (yes, by medicalizing obesity) for illnesses that are often correlated with obesity, but are far more strongly correlated with social status and social conditions?

    I keep searching in mass media sources for signs of a medical doctor who truly understands and takes seriously the complexity of these issues, in relation to social conditions and social determinants of health (and health risks). I now suspect that the medical paradigm itself–focused so exclusively on individuals and individual behaviors–makes use of a rhetorical lens, a socially constructed kind of communication, which simply cannot be used to actually VIEW problems, or solutions, other than those focused on individual bodies. I suspect that the medical paradigm constructs a kind of rhetorical lens which cannot effectively create research or analyze research data except when it focuses at the level of individual patients.

  13. Rachel says:

    DebraSY’s reference to Linda Bacon got me curious so I went back to last week’s blogs. Here’s my 2 cents worth: I know the obese have no reason historically to listen to the medical profession. I know as much as anybody they’ve had nothing helpful to offer. But things are changing both in the medical profession and in the wider community. I think its worthwhile listening to what Dr. Sharma has to say. He’s the most promising ambassador we’ve ever seen from the medical profession and I think what he has to offer is of value.

  14. Jim says:

    I’m sorry, but HAES is pure B.S. Period.

  15. Fenella says:

    Wow, what a can of worms you’ve opened up here.

    I lurk around the fringes of the Fat Acceptance movement. They’re right about so many things, including the fact that it’s very difficult to shift weight, and trying to do so is usually counterproductive and worse for your health than just leaving well alone.

    But you’re right, too. The movement IS in denial about the many health problems that excess fat brings. And yes, I’m saying excess fat brings those problems, all by itself, and not that fat is just running concurrently with other problems.

    The question is, what can be done? That’s the big question. Shaming, blaming etc don’t work. Diets don’t work. WLS brings its own problems, and often doesn’t work.

    As far as I can see, the only answer is prevention: don’t get fat in the first place. But for that to happen, there has to be fundamental changes at a policial level. For as long as Big Ag is subsidised and it’s worth while for them to produce cheap, crappy food, obesity is going to be a problem. For as long as people are being forced to work crappy jobs with low status and pay that mean their lives are chaotic, obesity is going to be a problem. For as long as cars are prioritised in the urban landscape over good public transport, obesity is a problem. For as long as it’s socially acceptable not to be able to cook and care for yourself, eat on the streets, eat in your car and otherwise engage in extremely unhealthy behaviours, obesity is going to be a problem. While kids don’t learn domestic sciences in school any more, that can’t be fixed. What’s the chance of public policy tackling any of those fundamental problems? About none.

    So the medical system has to pick up the pieces, while the people suffering from all of the above are vilified.

    If the Fat Acceptance movement can give people a bit of self esteem back, in the face of all of the above, then good on it.

    And good for you for being the best, most balanced commentator on these issues around.

  16. Observer says:

    Agree or disagree with Dr. Sharma, this is an interesting collection of comments. Interesting that so many make it a personal attack, and not a debate of evidence or science. That says a lot about certain people here, and certainly taints any arguments they may have. My four year old is smarter and more professional (read: polite) than that.

  17. Anon1 says:

    Fenella, you’re still assuming that obesity is always created by behaviours. This is often true, but there are exceptions. Sometimes a person can do everything right and still pack on the pounds.

    The idea that people can choose not to be fat that is beyond aggravating for those of us who feel we pound our heads against this endless concrete wall called weight loss.

  18. Antigone says:

    Completely agree with Observer #1.

    I am appalled at the rude, ignorant and incredibly unprofessional comments.

  19. zarzamora says:

    Completely agree with Jim. HAES is complete BS. I was a proponent for years, lost years. I wish it had not taken me so long to see it, but when I did, my life turned around. Provocative post, yes, but unprofessional? Hardly! The usual quality standard.

  20. Razwell says:

    To various commentors:

    HAES is NOT B.S. at all. In fact, Linda Bacon is peer reviewed and her HAES research was successful in making participants improve their health to a very large degree. Dr. Judith Stern was her mentor- she is extremely respected in the field.

    You can lose substantial weight applying HAES. Linda Bacon is very familiar with the body fat regulation literature. HAES is weight neutral. They do not deny that you CAN lose weight following the principles, but that simply is not their main goal to do so.

    Only 26,000 people die every year of obesity related causes, NOT 400,000 like the CDC claimed. That was a computer error.

    I find it interesting that some of the commentors on here are so eager to proclaim what science says, while never even reading it.

    Dieting is a DEAD END completely. Genuine science demonstrates this. The Internet is NOT a valid source of information about obesity .

    Dr. Sharma, Dr. Jeffrey Friedman and Dr. Linda Bacon ( all who are featured on the Internet) ARE VALID sources of information.

    OVER 10 % of morbid obesity cases are caused by a GENE DEFECT. Keep this in mind when you look at obese people . Internet commentors need to REALIZE this FACT from Dr. Jeffery Friedman – perhaps the foremost expert on obesity in the world. ( Internet diet book authors are beyond laughable).

    Meanwhile, I support the above mentioned people. My blog is the BEST layman blog on the Internet. It is valid because it features the work of reputable scientists and fetaures GENUINE science.

    Sincerely,

    Razwell

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