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Speaker: The system's pretty good, the expectations are crazy

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  • BenWilson,

    Sorry for characterising obesity as a disease/disability that language isn't ideal but in the terms of the discussion it seemed appropriate.

    It's a way of seeing it that seems more empowering than considering it 'inbuilt'. Whether it's true is another matter. Indeed, if it's not true, it's a false sense of empowerment. But I guess we either keep looking for a magic bullet or accept obesity for some. And that's always going to be a personal choice, if such an idea really makes any sense.

    Auckland • Since Nov 2006 • 10633 posts Report Reply

  • George Darroch,

    Can we not turn this into a fat fight?

    I happen to have a strong opinion, but I think that there are plenty of other issues that deserve attention from this article, and the debates about fat/obesity/weight are more heat than light in the great majority of places, including here.

    WLG • Since Nov 2006 • 2264 posts Report Reply

  • andin,

    Obesity is the modern world's take on the mind-body problem.
    I always say it's a glandular problem. The pineal gland, to be precise.

    Some people think the pineal is the seat of the soul.
    So is it, either get fat, or find god. Now those are bleak choices, luckily there is nothing binary about it.
    I've seen examples of people who do both.
    But thats not what I wanted to say either...I'll get my coat.

    raglan • Since Mar 2007 • 1881 posts Report Reply

  • Bart Janssen,

    there are plenty of other issues that deserve attention from this article

    Agreed

    However like many writers talking about health there is an underlying assumption that things can be improved by political changes. IMO the problem is always political involvement in health.

    In short if spending the health budget was left to those who actually have the knowledge and experience to make the best use of the money, specifically the doctors, then there would not be all that much wrong with the system.

    It is only when politicians and treasury insist on giving control to MBAs instead of MDs that you start to see waste and stupidity. Even more waste occurs when politicians start to directly interfere (eg with pharmac).

    There is nothing in what the speaker says that isn't well known by actual medical professionals the problem is that over the past couple of decades fewer and fewer medical experts are involved in the decisions. Instead those decisions are placed in the hands of managers who in the end have no clue. Bitter moi?

    Auckland • Since Nov 2006 • 4450 posts Report Reply

  • Danielle,

    Can we not turn this into a fat fight?

    George, I'm afraid that once someone says 'it's not rocket science' I have been programmed to respond. ;)

    But yes. This conversation is, nine times out of ten, totally judgeypants and dispiriting and I'd probably prefer not to have it again either.

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

  • Bart Janssen,

    'it's not rocket science'

    duh it's biology bro :)

    Auckland • Since Nov 2006 • 4450 posts Report Reply

  • dyan campbell,

    This conversation is, nine times out of ten, totally judgeypants and dispiriting

    I'm afraid I'm considered one of the main offenders on that count, but my point of view and intention could not be farther from a position of judgement.

    My involvement in sci/med conferences concerning obesity - as someone who has both attended and organised the damn things - and having had my Mum die of diabetes (or rather with diabetes at 83) is far from judgemental.

    There is no point delivering penalties in the form of withholding access to necessary medical care. There is a complex (only now being unravelled) epigenetic component to complications from obesity- or metabolic syndrome - same thing. In other words our maternal grandmother's health may have almost as much impact on our health as the choices we make ourselves.

    This is especially evident in populations where the rise and fall of access to decent nutrition can be traced with records over time (India, post war Holland, England to name a few places) - and the reverb that can be felt in subsequent generations health - clearly show how we are not entirely in control of our health outcome over time.

    In short if spending the health budget was left to those who actually have the knowledge and experience to make the best use of the money, specifically the doctors, then there would not be all that much wrong with the system.

    I would agree with most of this assertion, except doctors are far from the only experts that should have any input here. Most of them know shockingly little about epigenetics, or the hormonal drivers of obesity or metabolic syndrome. So I think some endocrinologists, epidemiologists, geneticists, and numbers geeks should also be included. As well as urban planners, food industry scientists, social scientists - and the general public - all need to have input into the solution to the sharp rise in obesity and the attendant diseases.

    The biggest factor that could change public health would not be related to food or exercise in the specific go to the gym kind of pursuit. The most efficacious thing that can be done in a community is to provide access to green spaces, easy and safe and pleasant routes for pedestrians, skaters, cyclists, skateboarders, those in wheelchairs and those on walkers. If you look at populations that live in areas where these needs are recognised and provided for, the population will be healthier and happier. It's interesting that rural kids (in Australian stats anyway) suffered greater rates of obesity to urban kids - and I think that is direct reflection of access to safe, sociable, non-exercise oriented exercise. That is a turn on the Nevsky Prospect - the Seawall - Cornwall Park - whatever your city offers.

    Auckland offers very little in the way of parks and greenspaces where you can escape cars, and what is available is not well integrated for use by different ages and pursuits. The best urban plans are those where every demographic can enjoy the space but not intrude on each others' pursuits.

    There are physiological, psychological, social and habitual drivers behind any bad health choice - cigarettes, heroin, overwork, overtraining, overeating. There are trends in food industry (high fructose corn syrup, trans fats) that result in what one poster described - children whose growth is stunted while they are also obese. There are calorie dense, nutrient poor foods that are causing a kind of starvation that can be accompanied by adipose tissue. No one chooses to be in this state of health, and it usually associated with poverty.

    Actually George Orwell wrote (in The Road to Wigan Pier) interesting stuff about choices made by those actually experiencing poverty, as opposed to those who knew what to do to remedy poverty. He talked about how the miners knew that fried food, candy, alcohol, tobacco and sugary tea was not as good for them as salads, but that after a hard day and given a hard life, people seek comfort food. He pinpointed the fact that drivers that are in one part of our brain that is most emphatically not the conscious logical part, and that when stressed, we are most likely to give in to the unconscious drivers - whatever the poor choice.

    auckland • Since Dec 2006 • 595 posts Report Reply

  • Danielle,

    I'm afraid I'm considered one of the main offenders on that count

    I wasn't thinking of you at all, Dyan! Seriously.

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

  • Evan Yates,

    Once you are a fat person it is HUGELY unlikely (perhaps 95% unlikely?) that you are going to lose large amounts of weight and keep it off permanently.

    Bugger...
    So I'm 95% likely to remain a Foxtrot Bravo * for the rest of my shortened miserable life.... And I just blimmin' spent $300 getting my poor bike un-mangled...

    Ever thought of becoming a motivational speaker?

    Sod it. I'm off to deep-fry a Mars bar.


    *NATO phonetic code for Fat Bastard

    Hamiltron, Te Ika-a-Māui • Since Nov 2006 • 197 posts Report Reply

  • Islander,

    Good post Dyan- there is that whole ancestral/genetic component that does determine what & who you are - *and how you react to varying circumstances.* And all the rest of your post is also excellent reading.

    I have a heavily-built strong Polynesian frame (which I am happy to have) -and osteoarthitis from (probably) the Scots side of my ancestry (one of my brother's has gout from both! Unjoy!) I am overweight (even including the weightier Polynesian bones) but I can no longer walk as often or as long as I used to be able to - nor fish in the strenuous ways I did. Catch (heh)-22-

    Big O, Mahitahi, Te Wahi … • Since Feb 2007 • 5643 posts Report Reply

  • BenWilson,

    I'm sensing no one wants a fat fight, which is good, I sure don't. There's plenty more issues in public health to chew on, which I think would be more mentally nutritious.

    Auckland • Since Nov 2006 • 10633 posts Report Reply

  • Islander,

    BenWilson - it isnt a fat fight. The genetic component also applies to gout/osteoarthritis/shortsightedness(and susceptability to early cataracts & retinal tearing etc. etc. etc. (I am just talking about my family's lot.)) It also applies to diabetes and certain kinds of heart disease.

    And *ignoring the genetic componenents* in any discussion about Public Health issues (as in taxpayer monies being involved) is just bloody stupid.

    Big O, Mahitahi, Te Wahi … • Since Feb 2007 • 5643 posts Report Reply

  • Peter Ashby,

    Much the same way people who exercise <b>too much</b> become addicted to the endorphins.

    Ahem, I get my endorphin hit after a mere 30min of running, and it doesn't have to be hard. I dont' call that 'too much'. It only seems so to people who exercise inadequate amounts.

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • Peter Ashby,

    I am well aware of the hormonal cross talk adipose tissue sets up with hunger signals from the stomach and squashing satiety signals. However none of that makes it biologically impossible to lose significant amounts of weight once you are obese. People do it all the time without even a stomach stapling. Which doesn't make it easy for everyone of course, but it does mean it is not biologically impossible as some have claimed.

    I agree that it is more than about food, that even basic activity levels are part of the problem. Activity monitors show that those who are not fat are so in part because they fidget, they pace, they are unable to sit for hours in a chair.

    The thing is we know all this stuff, we are just not good yet at working out how to build all that into programs people can follow. And even if we get that good there is the problem I have described earlier that the signals from advertising, from the specials in the supermarket and from what tastes good conspire against such programs and they are all pervasive.

    It is why people get morbidly obese in the first place, if empty calories were taxed heavily only the rich could afford to be fat. Which is how things were in the past. It's why in China the Buddha is fat and happy and why being fat is a proxy for wealth.

    Our society is inverted from that, being slim, tanned and groomed are signs of wealth and being morbidly obese is a sign of being poor.

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • Islander,

    And you're still ignoring the genetic propensities Peter-

    Big O, Mahitahi, Te Wahi … • Since Feb 2007 • 5643 posts Report Reply

  • Peter Ashby,

    @Islander

    What you describe is all part and parcel of Type 2 diabetes, and you are right having Polynesian ancestry makes you highly prone to developing it. When exposed to a modern western diet. The two are inextricably linked.

    Jared Diamond reckons that the fact that non European peoples are like that is not the issue. The issue is why Europeans have significantly lower levels of Type 2 diabetes when exposed to the same diet.

    He thinks it is because, due in part to Feudalism, Europeans have had food security for a long time. Sure there have been famines, but they are remembered because of their rarity. If you were genetically predisposed to develop Type 2 in that milieu then you will likely be insulin dependant before you turn 20. Which is a death sentence. So susceptibility has been bred out of Europeans.

    For the rest of the world the normal situation was much more precarious. In the Islands cyclone season hits before the staple crops are ripe, so when one hits, every few years or so you need what is called a thrifty phenotype, the ability to pack away the calories efficiently. But what is good in the Islands traditionally is not good in Mangere or Porirua or anywhere else with a MacDonalds and supermarkets packed with cheap white bread, packets of chips and cheap nasty sausages.

    Life is too easy for most of us, so unless you have the drive and enjoyment that I have it is hard to keep your weight under control. It takes some determination to come home after work, in the dark here and make yourself go out into the rain and exercise. I do it by reminding myself of how I will feel if I wimp out and because experience has taught me that once I'm warmed up I don't care about the weather. I grew up running in West Auckland and when it rains like it does in Auckland you are soaked inside of 30s. My philosophy was firstly that I am not soluble and secondly that it was better than sweating buckets in high heat and humidity.

    The weather forecast says it will be raining, lightly then heavily and 5C on my run tonight. I will not wear any water proof gear, it won't be cold enough for that. Experience tells me that, provided I keep moving at a good rate, I will generate enough heat that being wet won't be a problem. I am not soluble.

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • Peter Ashby,

    @Dyan

    Great post.

    I liked your pointing out that we need more than doctors to set health priorities. This is largely because when all you see are sick people (yes, okay and the worried well), you get a warped view of how prevalent ill health is. Which is why we have epidemiologists, to measure the incidence and run the stats. Etc, etc. It's why those who work in A&E are the most vocal against alcohol, because they see all the problems (and their drinking is never problematic). But they don't see all the alcohol use that doesn't cause problems, so they are not good people to get to determine the whole policy.

    I agree with your point from Road to Wigan Pier too. Allotments have been an antidote in part for those bad diets. Giving people who don't have anything even approximating a garden somewhere to grow a few vegetables. In NZ it is assumed everyone has a quarter acre paradise for that, but many don't.

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • Islander,

    Peter- I have a character in a novel (ongoing, ongoing) who says, "I've learned you do not dissolve when wet" and "I am walking in the rain and, would you know, I havent melted-"

    History, intermingling of peoples, changed dietaries, a deep ancestral desire for (within my whanau) fat - which used to be bird/seal/cetacean/human fat (because that was the gamut)- means the easy choices get chose.

    I have taken a dinghy out in a hailstorm (there were pots to be got up): I have fished in ridiculously violent weather - because that was the time 'the bait would run (they did) and Family needed a feed...

    I truly *love* that kind of exercise, and resent the narrowing - through, majorly, osteoarthritis- of my prowess-

    Big O, Mahitahi, Te Wahi … • Since Feb 2007 • 5643 posts Report Reply

  • andrew clive,

    I'm from the old school of thought & know in many cases obesity is down to a lack of self discipline .Over eating , a lack of will power ..If we keep blaming everything else except ourselves all we become is a brain washed society that says " its everyone elses fault that im fat".
    I try & exercise about 2 to 3 times weekly , jogging mostly: like Peter i enjoy it because i feel good after it.
    My local neighbor is an overweight Pom & a big drinker . His immigration visa status is seriously under threat, all to do with liver problems indicated from his medical results.He has been given an ultimatum to lose weight & have another medical test done in 4 weeks time. His whole family , wife & 2 kids are here as well . There future in NZ is totally determined on whether Immigration will allow him an extension on his work visa.I tried to help him by suggesting an exercise pattern & giving up the booze. I offered to go jogging around a local reserve with him. He was all keen & committed to come the next day . But he never showed up, he just can't be bothered to do the right thing for himself & his family.
    So who can he blame for his condition ? Only himself.
    Gareth Morgans article seems to point to the fact that the NZ health system will become broke by the epidemic obesity problem we have if it keeps escalating.Too many people are waiting for a magic pill or have resigned themselves to a stomach stapling operation.
    The key word here is moderation.

    auckland • Since Feb 2008 • 37 posts Report Reply

  • TracyMac,

    And to continue the fatness discussion, there is actually a difference between eating disorders, metabolic disorders, and simple fatness.

    With the genetic component, some people are simply going to be overweight/fat no matter what they do. Someone like me, who is fit enough, strong, healthy and has a hip/waist ratio of .76 (supposedly near the "ideal" for a woman) is within two kilos of being "obese" according to the bullshit of the BMI.

    Then you do get the people who are eating disordered or who genuinely are completely ignorant about good eating, and who eat themselves into a unhealthy physical state. That is what should be treated. As too the conditions that cause the unhealthy weight gain - PCOS being one. Although there is plenty of medical opinion that opines that PCOS is caused by women becoming overweight. It's a sad state when medical researchers can't agree on which is the cart and which is the horse.

    One of the things that bothers me about singling out "obesity" as a health issue is that, as in the case of PCOS, cause and effect are incredibly vague. And too often, peoples' health issues are blamed on the fact of their fatness, when much of the time the causation is not at all demonstrated. A friend was refused knee surgery because her knee pain was supposedly due to her obesity. When they finally did an MRI (two doctors later) and found the torn meniscus that had resulted from the fall she'd had (and told the doctors about), then suddenly surgery was back on the cards. After 6 months of pain and vastly reduced mobility.

    I have a problem with gastric reflux, and they wanted to check out if there was an ulcer or helicobactor infection. Nothing was found, and the doctor performing the gastroscopy told me - after looking at my chart and seeing the BMI written down - that losing weight might help in the case of no apparent cause. See above where I discuss my hip/waist ratio as a size 14 - there is barely any weight on my stomach! It certainly didn't help modify my impression that weight is often used as a diagnosis of convenience.

    Sure, treating the fat, and the underlying syndrome or eating disorder, if it's causing a health issue is an important step in primary care. But I bitterly resent that I'm deemed as overweight when I am actually average for my height and age (and not a "modern fat" average either - does no-one look at pre-70s pictures of women any more?). And too often that cause is not positively identified.

    To get back onto the broader issue, when do you stop handing out health care? Sure, the pie is not unlimited. But do you not treat someone who is "too fat"? Do you tell George Best to piss off with his liver? Do you give the 90-year-old spinster the hip op that lets her spend her final 5 or so years of life mobile, or do you leave her stuck in that wheelchair? Where do you draw the lines?

    Canberra, West Island • Since Nov 2006 • 701 posts Report Reply

  • Peter Ashby,

    @TracyMac

    You are right about basic BMI scores which is why they should by now be modified by the hip/waist ratio correction factor. I am overweight on strict BMI since I have big muscles and dense bones yet I have very little body fat.

    However you say you are 'fit enough', does that mean you take regular exercise or not? By that I mean more than a brisk walk as walking is insufficient, you need to get breathless for at least half an hour several times a week. If you are not doing that and you have some subcutaneous fat then chances are you have internal fat packed around your viscera and it is this which is not helping your gastric condition.

    The good news is that internal fat is the first deposit to go when you lose weight by exercise. This is one reason why it takes time to perceive a weight loss in terms of loss of girth after starting exercise. In men the last deposit to go is spare tyre, even on my exercise regime I still have my remnant and it is proving stubborn. There's a six pack under it, I'm sure ;-) For women the last deposit to go is usually the hips and the bust.

    So it might help if you take your doctor's advice and get some proper exercise while watching your diet. It fixed my problems and they have not returned. I have a half tube of bisodol that has sat unused beside the bed for months now, just in case. Must check if they are still in date.

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • Danielle,

    You know what's awesome? Having the unmitigated chutzpah to attempt to 'diagnose' people we've never met. Over the INTERNET.

    However none of that makes it biologically impossible to lose significant amounts of weight once you are obese. People do it all the time without even a stomach stapling.

    And are unable, generally, to keep it off for longer than two years. And will usually gain it all back *even if they keep eating the same low-calorie diet*. As I noted. In my original post. Which referenced a review article. Which summarised the results of pretty much every *long term* (not short term, anyone can drop significant weight in the short term) clinical trial of weight loss programmes over the last twenty years. Additionally, there are significant health risks to 'weight cycling' or yo-yo dieting, including cardiovascular issues. But there are lots of happy benefits associated with exercise and better eating. Which is why concentrating on weight loss as the main object of improving health is not actually all that helpful. Which is what I said in the first place.

    Seriously, this conversation is *always* like a brick wall headbanging. It's just uncanny.

    weight is often used as a diagnosis of convenience

    'Oh, you have a bleeding gash to the head? Yeah, it must be because you're overweight. Ever thought about fixing that, fatty fatpants?' (I exaggerate only slightly.)

    And we're all going to die no matter what we do (she says, cheerfully). Hey Evan, I think I *am* going to become a motivational speaker! :)

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

  • Peter Ashby,

    Sigh, Danielle I'll say it again. I do not deny any of what you say. I am only pointing out that some people have managed to lose significant amounts AND keep it off. I make no claims for this for universality, as I make clear. Neither do I say it makes it easy, which I also make clear. The one and only thing which it says, is what I claim for it: that there is no biological imperative against it per se. To be crude how many obese corpses do you see on the piles and pits on the footage from the liberation of Belsen? Or do you deny that no obese people were ever sent there? Now can we stop being silly?

    I have been at this for over two years now and I have not put the weight back on. Granted I was not obese, but reading you I get the impression that nobody ever successfully lost weight on their own. Peddling this myth just infantilises people and removes their sense of agency, which is not helpful.

    You will also find me out on the net opining that weight is not the issue, fitness and not being insulin resistant are more important. Both of these are possible for the overweight. You cannot get morbidly obese people to exercise for the sake of their health though. They have to lose some weight first until it is safe for them to exercise.

    Because numbers are small we do not know that it is, or always is, unhealthy to be significantly overweight providing you also exercise. Plenty of overweight people exercise by cycling or swimming (for obvious reasons they prefer non weight bearing exercise) and they maintain their weight by eating lots. I have talked online to people who fit that category who undertake epic cycle journeys for eg.

    The problem is that for the majority of people who are overweight they are also deeply sedentary so the dogma that it is overweight that leads to insulin resistance has taken hold and we actually know no such thing.

    When the muscles have too much lipid in them they actively refuse to take up glucose when signalled to do so by insulin. Thus it is lipid in muscle that underlies insulin resistance, not subcutaneous fat. So if people are regularly burning the lipid in the muscles through sustained aerobic exercise the muscles will be glucose sinks and insulin resistance will be averted. None of that is incompatible with overweight.

    Now can we stop with the PC manning of hysterical barricades for political reasons and talk about reality, please?

    Dundee, Scotland • Since May 2007 • 425 posts Report Reply

  • steven crawford,

    My friend in Christchurch, one a biggest looser commutation. He maintains his lean physique by eating well, not drinking gallons of beer and putting ten times as much energy into physical exercise as I do. It's a bit like, I take ten times longer to read a book than him. Thats the way the cookies crumble, I guess.

    Atlantis • Since Nov 2006 • 4306 posts Report Reply

  • Danielle,

    Peter, you managed Godwin *and* 'hysterical' in one post. Rad.

    So you're saying that... people can totally lose a lot of weight if they just put their minds to it, as long as we don't infantilise them... except for the people who can't... but even if they don't, they could still be healthy even though they're fat... as long as they do some regular exercise and eat 'right'... uh, I don't even get what you're arguing with me about, at this point, because you appear to agree with me by the end of your post. :)

    I don't agree with 'infantilising' people either. Unfortunately, I think medical professionals - and others - often infantilise fat people (I've been in the room when this happens) by assuming all sorts of things about their diets and behaviour. Tracy noted this in her post. PCOS affects one in ten women and their bodies will hold on to every single calorie like grim death. If you believe in giving people 'agency' you should try to avoid assuming that they're constantly lying to themselves and others.

    Charo World. Cuchi-cuchi!… • Since Nov 2006 • 3828 posts Report Reply

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